Thrive Of Fox Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Illinois.
- Location
- 4020 E New York Street, Aurora, Illinois 60504
- CMS Provider Number
- 146194
- Inspections on file
- 23
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Thrive Of Fox Valley during CMS and state inspections, most recent first.
A resident with new-onset cardiomyopathy requiring a LifeVest cardiac monitor was readmitted and later discharged without physician orders or care plan focus for device management, and without documented discharge teaching on cardiac monitoring, device care, complications, or cardiology follow-up. Nursing staff acknowledged forgetting to enter cardiac monitoring orders, assuming other staff changed the battery and that the resident knew how to manage the device. The discharge form only noted that the resident left with the cardiac vest, while facility policies and its cardiopulmonary program description required documented education, equipment management instructions, and discharge teaching for such devices.
A resident with cellulitis, chronic lymphedema, and a documented risk for skin impairment did not receive ordered skin assessments and treatments. Despite an active order for Nystatin powder to treat a fungal rash under the breast and a care plan directing staff to evaluate and treat skin conditions, ETAR review showed multiple missed Nystatin administrations, and the resident had already filed a medication concern about not receiving this treatment. The resident also reported that an RN did not assess or treat a newly developed open wound on the left thigh, which was later identified by the WCN as a facility-acquired abrasion with serosanguinous drainage. The WCN stated that nurses were expected to assess new skin issues, notify the physician, and follow treatment orders in line with the facility’s wound management policy.
A resident with chronic renal failure, high fall risk, and dependence for transfers was being transported in a wheelchair by a CNA after hemodialysis when the CNA suddenly stopped, causing the resident to fall forward out of the wheelchair. A RN witness and the resident reported that the wheelchair had no footrests in place, despite therapy recommendations and facility policy requiring footrests and safe, controlled transport. The resident sustained multiple lacerations and abrasions and was sent to the hospital for evaluation.
A resident with chronic pain syndrome and acute leg pain from cellulitis had an active PRN order for Norco and a care plan requiring staff to anticipate and promptly respond to pain complaints, yet her request for pain medication around the evening meal was not fulfilled for several hours. Call light records and CNA statements showed the resident repeatedly called for assistance and the CNA repeatedly notified an RN, but the medication was not administered until late that evening after another nurse reportedly lacked access to the drug. The EMAR confirmed the delayed administration time, and the DON stated that nurses were expected to provide pain medications as ordered upon request in accordance with the facility’s pain management policy.
Two residents did not receive appropriate care: one with a cholecystostomy drain was not assessed or monitored by staff, and the dressing from the hospital was left unchanged and undated. Another resident did not receive timely assistance with wet bed linens and incontinence care, despite multiple requests and use of the call light system. Staff failed to follow facility policies for wound care and call light response, and documentation did not accurately reflect the residents' needs or interventions provided.
A resident with a history of pulmonary embolism and TIA experienced an unwitnessed fall while on a blood thinner. The facility's policy required regular neuro-checks after such incidents, but records showed only one check was completed after the initial evaluation. The on-call physician noted that checks should have been conducted throughout the night to monitor for head injuries, indicating a failure to adhere to the facility's protocol.
The facility failed to resolve grievances about extended call light response times, as reported by residents during multiple meetings. Despite training sessions for staff, residents continued to experience delays, particularly during night and weekend shifts. Three residents reported significant wait times, impacting their care and comfort. The facility's grievance policy was not effectively implemented, as evidenced by ongoing complaints and inadequate documentation of resolutions.
Two residents in an LTC facility experienced delays in medication administration, contrary to facility policy. One resident, with multiple diagnoses, had medications administered late on consecutive days without prescriber notification. Another resident reported concerns about late pain medication, which was administered over four hours late without prescriber contact. The DON confirmed the expectation for nurses to notify prescribers of such delays.
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition. Expired and unlabeled items were found, and the Dietary Manager admitted to lacking a food storage policy, contributing to the oversight.
The facility failed to accommodate the needs of two residents by not providing a functioning over bed light and an adaptive call/light button. A resident with paralysis and macular degeneration was unable to use the standard call light, and another resident experienced issues with a broken over bed light that could not be turned off. Staff did not follow procedures to ensure call lights were within reach or report maintenance issues promptly.
A resident with multiple health issues, including a fractured arm and malnutrition, did not receive timely incontinence care, resulting in saturated clothing and bedding. The resident, who requires substantial assistance with daily activities, reported not receiving care since the previous night. The facility's policy mandates care every two hours, which was not followed, as confirmed by the DON.
The facility failed to administer medications as prescribed for two residents. One resident did not receive her Trospium for urinary incontinence for eight days, despite it being listed on her hospital discharge documents. The pharmacy sent an alternative medication, which the resident refused. Another resident did not receive his glaucoma eye drops for two days, requiring his wife to bring the medication from home. The DON acknowledged these as medication errors, and the facility's policy lacked a process for timely medication availability.
The facility failed to provide safe respiratory care for three residents. A resident with COPD and asthma had a CPAP mask not stored properly, while another with asthma had a nebulization mask left uncovered. A third resident with COPD and CHF also had improperly stored respiratory equipment. The DON confirmed that equipment should be rinsed, air-dried, and stored in a designated bag, as per facility policy.
Two residents in the facility did not receive their prescribed intravenous antibiotics as ordered, resulting in significant medication errors. One resident, treated for MRSA bacteremia, did not receive the correct vancomycin IV dosage and frequency, while another resident missed several doses of cefazolin IV for a hand infection. The facility's policies on medication administration were not adhered to, leading to these deficiencies.
A resident with an ileostomy experienced frequent leaks from the ostomy appliance, leading to skin irritation and burning sensations. Despite staff awareness of the issue, the wound nurse was not consistently notified, and there were no specific ostomy care orders documented. The facility's standard of care, which includes regular evaluation and documentation of skin conditions, was not followed, resulting in a deficiency.
Failure to Provide Discharge Education and Orders for Cardiac Vest Monitor
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary discharge education and related documentation for a resident using a cardiac vest monitor. The resident was admitted with multiple diagnoses, including new onset cardiomyopathy requiring a LifeVest wearable cardioverter-defibrillator, and was cognitively intact and able to follow instructions. During the resident’s readmission, the RN who routinely cared for him acknowledged she forgot to enter cardiac monitoring orders, even though such orders were needed to ensure the monitor was checked every shift and its battery changed daily. The EMR and order summary for the readmission did not contain orders for cardiac vest care, and the comprehensive care plan, while addressing discharge planning, did not include a focus problem for the new cardiac condition or management of the cardiac vest. The ADON later confirmed that the EMR did not identify which cardiologist was managing the device and that there were no nursing management orders for the device, despite the resident being admitted to the facility’s Cardiopulmonary Program. At discharge, the RN who discharged the resident stated that the resident left with the cardiac vest in place, along with the charger and extra battery, but there were no active orders for device management, and she assumed the overnight nurse had changed the battery and that the resident knew how to care for the monitor. She did not provide specific instructions on cardiac monitoring, device care, cardiac complications, cardiology follow-up, or who to contact for device issues, and the Transition Home discharge form only noted that the resident was discharged with a cardiac vest monitor without documenting any specific discharge nursing instructions. The facility’s own Specialized Cardiopulmonary Program description stated that it would provide education and resources to help patients manage their disease and determine equipment needs and education at discharge, and its Wearable Cardioverter-Defibrillator and Discharges policies required documentation, specific care instructions, and teaching on special tasks at discharge. The resident was later seen in the ER with bilateral lower extremity edema and reported that the LifeVest was not working due to battery complications, and the ER documentation indicated he was educated there on contacting the device company and monitoring for cardiac complications.
Failure to Assess and Treat Resident Skin Conditions as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to assess and treat a cognitively intact resident’s skin conditions as ordered and as care planned. The resident had a care plan identifying actual skin impairment and risk for further skin breakdown related to left lower leg cellulitis and chronic lymphedema, with interventions directing nursing staff to evaluate and treat her skin as ordered. The EMR showed an active order for Nystatin powder to be applied under the breast twice daily and wound consults as needed. The resident reported that on the evening of 3/26/2026 she requested an RN to assess a new open wound on her left anterior thigh, but the RN did not assess or treat the wound, leaving it untreated and uncovered. She also reported that her ordered antifungal powder for a rash under her left breast was routinely not administered. Record review and staff interviews confirmed multiple omissions in the administration of Nystatin powder on several dates, despite the resident’s Medication Concern form documenting her complaint about not receiving this treatment. When the wound care nurse later assessed the resident, she identified a new open wound on the left thigh measuring 3 x 0.4 x 0.1 cm with serosanguinous drainage, and confirmed that the fungal rash under the left breast still required ongoing treatment as ordered. The wound was documented as a facility-acquired trauma wound (abrasion) with 100% bright pink/red tissue and serosanguinous drainage. The wound care nurse stated that nurses were expected to assess new skin alterations, notify the physician to obtain and initiate treatments, and review ETARs to ensure treatments were administered as ordered, consistent with the facility’s wound management policy that emphasizes comprehensive wound care and staff accountability.
Failure to Use Wheelchair Footrests and Safe Transport Techniques Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to safely transport a high fall-risk resident in a wheelchair, resulting in a fall with multiple lacerations. The resident had chronic renal failure requiring hemodialysis, unsteadiness on his feet, reduced mobility, need for assistance with personal care, and glaucoma, and was assessed as cognitively intact but dependent for transfers and lower body care. A fall risk evaluation identified him as high risk for falls. On the day of the incident, after returning from dialysis, a CNA was wheeling the resident down the hallway when she suddenly stopped, causing the resident to fall forward out of the wheelchair. The resident reported that there were no footrests on the wheelchair at the time, and he sustained abrasions and lacerations to his knees, elbows, and scalp and was transferred to the hospital for evaluation. Witness accounts and documentation confirmed that the wheelchair was not used in accordance with facility safety expectations. A RN who observed the event stated that the CNA abruptly stopped while transporting the resident, that the resident then fell forward onto his left side, and that there were no footrests present, which she said should have been used for proper positioning and safe transport. A physical therapist assistant stated that the resident required a wheelchair due to generalized fatigue, needed staff assistance for wheelchair mobility, and required the use of footrests, noting that he had not shown poor safety noncompliance with wheelchair use. The facility’s policies on fall prevention and transfers required that residents receive adequate supervision and assistive devices to prevent accidents, that transfer ability be determined per evaluation or therapy recommendations, and that footrests be used for transport or, if not, that transport be done slowly. The incident occurred when these measures were not followed, leading to the resident’s fall.
Failure to Timely Administer PRN Opioid for Resident’s Reported Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide timely PRN pain medication to a resident with chronic pain syndrome and acute leg pain from cellulitis. The resident’s care plan identified a potential for pain and included interventions such as administering opioid medication as ordered, anticipating her need for pain relief, and responding immediately to any complaint of pain. The resident’s MDS indicated she was cognitively intact, and her EMR showed an active order for Norco 10-325 mg, one tablet every six hours as needed for pain. On the evening in question, the resident reported that she requested Norco at around 6 PM but did not receive it until approximately 9:30 PM. She stated that a CNA responded to her call light multiple times, each time reporting that the RN had been notified, while the resident continued to experience chronic and acute pain. The call light log documented six calls between 6:06 PM and 9:13 PM. The CNA confirmed that the resident requested pain medication around 6 PM and that she repeatedly notified the RN of the ongoing requests. The RN reported that another nurse had attempted to administer the medication but did not have access to it, and she was unsure when she was first notified of the resident’s request. The EMAR showed the PRN Norco was administered at 9:26 PM, and the DON stated that nurses were expected to administer pain medications as ordered upon request, consistent with the facility’s pain management policy.
Failure to Monitor Cholecystostomy Drain and Provide Timely Resident Assistance
Penalty
Summary
The facility failed to properly assess, monitor, document, and care plan for a resident with a cholecystostomy drain. The resident was observed with a cholecystostomy drainage bag and an incision site covered by a hospital-applied dressing that had not been changed or assessed by facility staff since admission. The dressing was undated and showed a dried area of drainage. The resident and her son confirmed that the dressing had not been changed since the hospital, and the LPN on duty was unaware of any dressing change orders or requirements to monitor the insertion site. The resident's admission assessment and progress notes incorrectly documented that she did not have a surgical drain, and her care plan lacked interventions for monitoring or caring for the cholecystostomy drain. Physician orders were unclear regarding site care, and the nurse consultant was uncertain about the specifics of the order, indicating a lack of clarity and follow-through in care planning and execution. Another deficiency involved the facility's failure to provide timely assistance to a resident requiring staff help with activities of daily living and incontinence care. The resident reported that after spilling water on her bed, she used her call light for assistance, but staff did not change her wet linens for several hours despite multiple requests. The call light was turned off without the resident's needs being met, and assistance was only provided after the resident's son intervened. The resident also requested that her roommate, who had an incontinence episode, receive help first, indicating a broader issue with staff responsiveness. The facility's policies require staff to assess wounds, monitor for infection, and respond to call lights promptly, but these were not followed in the cases reviewed. The DON confirmed that staff are expected to answer call lights within 10-15 minutes and not to turn them off until the resident's needs are met. However, documentation and interviews revealed that these expectations were not met for the residents involved, resulting in unmet care needs and lack of appropriate monitoring and documentation.
Failure to Conduct Regular Neuro-Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that a resident's neurological evaluations were completed and monitored following an unwitnessed fall. The resident, who had a history of pulmonary embolism and transient ischemic attack, experienced an unwitnessed fall while on a blood thinner. The facility's policy required neuro-checks to be conducted regularly after such incidents, but the resident's records showed that only one neuro-check was completed after the initial evaluation. The on-call physician stated that neuro-checks should have been conducted throughout the night at specific intervals to monitor for potential head injuries. However, the facility's records indicated that the neuro-checks were not performed as required by the facility's protocol, which could have helped identify signs of a head injury, such as brain bleeding or intracranial pressure. This deficiency was identified during a review of the resident's care, highlighting a lack of adherence to the facility's neurological assessment policy.
Failure to Resolve Call Light Response Time Grievances
Penalty
Summary
The facility failed to address and resolve grievances related to extended wait times for call light responses, as voiced by residents during multiple Resident Council meetings. Despite the concerns being communicated to the Director of Nursing and Administration, and a training session being conducted for nursing staff, residents continued to report dissatisfaction with the response times. The grievances were documented in Resident Council Meeting Minutes over several months, indicating a persistent issue that was not adequately resolved. Three residents, identified as R1, R2, and R4, expressed specific concerns about the timeliness of call light responses, particularly during night and weekend shifts. R1 reported waiting at least 30 minutes, resulting in an incident where she urinated on herself due to the delay. R2 mentioned waiting for an hour for assistance during the night shift, and R4 described a similar experience while needing medication for a migraine. These residents had various medical conditions requiring assistance with activities of daily living (ADLs), making timely responses critical. The facility's grievance log showed that R1's daughter filed a grievance about the call light issue, but the documentation lacked a timely resolution. The facility's policy on grievances emphasized prompt resolution and tracking of grievances for quality improvement, yet the ongoing complaints and lack of documented resolutions suggest a failure to adhere to this policy. The facility's inaction in effectively addressing the grievances led to continued dissatisfaction among residents regarding call light response times.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications timely in accordance with its policy, affecting two residents. Resident R4, who was admitted with multiple diagnoses including Guillain-Barre Syndrome and West Nile virus, was cognitively intact and dependent on staff for activities of daily living. The Medication Administration Audit report showed that R4's medications scheduled for 9:00 AM on two consecutive days were administered significantly late, with no notification to the prescriber about the delays. R4's wife expressed concern about the late administration of medications. Resident R2, who was cognitively intact and had multiple diagnoses including spinal stenosis and diabetes, also experienced late medication administration. R2 reported concerns about the timeliness of her pain medication. The Medication Administration Audit report indicated that R2's scheduled 9:00 AM medication was administered over four hours late, with no documentation of prescriber notification or guidance on the next dose. The Director of Nursing confirmed that it is expected for nurses to contact the prescriber when medications are administered late.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition from the facility. During a kitchen tour, several expired food items were found, including feta cheese, cheese ravioli, chopped spinach, Eggo frozen waffles, various types of bread, pepperoni, pizza sausage, Boston cream pie, frozen cranberries, white corn grits, chicken and herb stuffing, and [NAME] crumbs. These items were either past their expiration dates or lacked proper labeling, such as received or expiry dates. The Dietary Manager, identified as V9, acknowledged that expired items should be discarded to prevent potential harm to residents. However, V9 admitted to not having a policy on food storage, which contributed to the oversight. The facility's census was 57 residents, with no residents on NPO status, indicating that all residents were potentially affected by the improper food storage practices.
Failure to Accommodate Resident Needs and Address Maintenance Issues
Penalty
Summary
The facility failed to accommodate the needs of two residents, R26 and R31, by not providing a functioning over bed light and an adaptive call/light button. R26, who has a range of medical conditions including paralysis of the hands and macular degeneration, was unable to use the standard call light due to her physical limitations. Despite her cognitive intactness, as indicated by a BIMS score of 15, R26 reported that her call light was often out of reach and that she had waited up to three hours for assistance. Her family member confirmed her inability to activate the call light due to neuropathy and macular degeneration. The facility had alternative call devices available, but they were not provided to R26, indicating a lack of awareness or assessment of her specific needs by the staff. R31, another resident, experienced issues with a broken over bed light that could not be turned off, which affected her ability to rest. The light fixture had been broken since shortly after her admission, and staff had placed a sheet over it as a temporary solution, which posed a potential fire hazard. The RN responsible was unaware of the issue, and no repair requisition was made until it was reported to the Director of Environmental Services, who stated that the repair would have been quick if notified. The facility's policies require staff to ensure call lights are within reach and to report maintenance issues promptly, but these procedures were not followed, leading to the deficiencies observed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R26, who was admitted with multiple diagnoses including a displaced comminuted fracture of the right arm, moderate protein calorie malnutrition, and intrahepatic bile duct carcinoma. On the morning of July 23, 2024, R26 reported that she required assistance with all activities of daily living but felt that the staff was not fully aware of her care needs. She stated that she had not received incontinence care since the previous night, and the first staff member she saw was at 10:40 AM. Upon the surveyor's request, incontinence care was provided at 11:56 AM, revealing that R26's gown, disposable undergarment, absorbent bed pad, transfer sheet, and bottom sheet were saturated with urine. Additionally, R26 exhibited pink blanchable skin on several areas and a non-blanchable area on her left buttock. The facility's Director of Nursing confirmed that incontinence care should be provided every two hours and as needed to prevent skin breakdown and urinary tract infections. The last incontinence care provided to R26 was at 7:15 AM, indicating a significant lapse in care. R26's Minimum Data Set (MDS) showed she was cognitively intact and required substantial assistance with toileting due to impaired mobility and weakness. Her care plan specified the need for assistance with toileting and cleaning the peri area with each incontinent episode. The facility's policy stated that care should be provided according to the resident's individualized care plan, which was not adhered to in this instance.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications according to physician's orders and resident preferences for two residents. One resident, who had been admitted to the facility about eight days prior, did not receive her prescribed Trospium 20 mg for urinary incontinence. Despite the medication being listed on her discharge documents from the hospital, the facility did not have the medication available, and the pharmacy sent an alternative medication, Oxybutynin, which the resident refused. The facility's records showed multiple instances where the medication was noted as 'not available,' and the resident continued to go without her prescribed medication. Another resident did not receive his prescribed eye drops for glaucoma for two days. His wife had to bring the medication from home for the facility to use. The facility's records indicated that the eye drops were not available, and the resident's MAR showed the medication was not administered on a specific date. The DON acknowledged that the failure to provide the medication was a mistake on the part of the nurse and classified it as a medication error. The facility's policy on medication administration did not include a process for ensuring medications are available to residents on time.
Failure to Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents, as observed during a survey. Resident 15, who has diagnoses including Chronic Obstructive Pulmonary Disease and Asthma, was found with a CPAP mask and tubing not in use and not contained in a bag on two separate occasions. The physician's orders required the CPAP/BiPAP to be used at bedtime and for the mask to be cleansed and air-dried after removal. Similarly, Resident 20, diagnosed with asthma and anxiety, had a nebulization mask and medication container left uncovered on the bedside table, contrary to the physician's orders for inhalation treatment every four hours as needed. Resident 265, with Chronic Obstructive Pulmonary Disease and Congestive Heart Failure, was also observed with a CPAP mask and tubing not in use and not contained in a bag, and a nebulization mask and medication container left uncovered on the nightstand. The physician's orders for this resident included CPAP/BiPAP use at bedtime and cleansing of the mask, as well as inhalation treatment every eight hours as needed. The Director of Nursing confirmed that the equipment should be rinsed, air-dried, and stored in a designated bag to prevent contamination, as per facility policy.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to administer ordered intravenous antibiotics for two residents, leading to significant medication errors. Resident R3, who was being treated for MRSA bacteremia, did not receive the correct dosage and frequency of vancomycin IV as ordered. The pharmacist, responsible for dosing the medication, noted that R3's therapeutic blood levels were not within the target range, indicating nontherapeutic treatment. Despite recommendations to adjust the dosage, the facility did not implement these changes, resulting in R3 not receiving the appropriate treatment for his infection. Similarly, Resident R44, who was being treated for an acute osteomyelitis infection of the right hand, missed several scheduled doses of cefazolin IV. The EMAR showed omissions on specific dates, indicating a failure to administer the medication as ordered. The facility's policies on medication administration and physician's orders emphasize the importance of administering medications as prescribed, yet these were not followed, leading to the deficiencies observed.
Failure to Provide Adequate Ostomy Care
Penalty
Summary
The facility failed to provide appropriate ostomy care for a resident, leading to skin irritation around the stoma site. The resident, a male with multiple diagnoses including end-stage renal failure and ileostomy status, experienced frequent leaks from his ostomy appliance. Staff members, including RNs, LPNs, and CNAs, reported that the appliance would often leak two to three times per shift, causing stool to come into contact with the resident's skin, resulting in burning sensations and raw skin. Despite these issues, the wound nurse was not consistently notified, and there were no specific ostomy care orders documented for the resident. The facility's standard of care requires documentation of skin conditions around the stoma and notification of the wound nurse in case of skin breakdown. However, these protocols were not followed, as evidenced by the lack of ostomy care orders and the failure to report ongoing skin irritation to the wound nurse. The resident's physician noted problems with the ostomy leaking and recommended adjustments to minimize skin exposure, but these recommendations were not reflected in the resident's care plan or treatment orders. The facility's policy on ostomy care, which includes regular evaluation and documentation of skin conditions, was not adhered to, contributing to the deficiency.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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