Timbercreek Rehab And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pekin, Illinois.
- Location
- 2220 State Street, Pekin, Illinois 61554
- CMS Provider Number
- 145275
- Inspections on file
- 45
- Latest survey
- March 28, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Timbercreek Rehab And Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain baseboard heaters safely and to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, leading to dangerously hot heater surfaces, missing thermostats, and combustible items and beds placed directly against heaters. One cognitively severely impaired, non-verbal hospice resident with multiple comorbidities became entrapped between the bed and a baseboard heater and sustained extensive, painful second-degree burns from the hand to near the shoulder, requiring ED treatment and ongoing wound care. Another moderately cognitively impaired resident’s bed was positioned directly against a hot heater without care plan measures to prevent burns. The Maintenance Director acknowledged the absence of manufacturer operating and preventive maintenance instructions and confirmed there was no established process to monitor or document heater surface temperatures, contributing to the deficiency that placed all residents at risk.
The facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to its staff. Review of the annual in-service schedule and staff in-service and computer-based training records over more than a year showed no QAPI-related education. The census documented 87 residents in the facility, and the Administrator in Training confirmed that staff had not received QAPI training, potentially affecting all residents.
A resident did not consistently receive or have documented pressure ulcer care and daily skin checks as ordered. Multiple dates were missing documentation for wound care and skin checks, and the Infection Preventionist/Treatment Nurse confirmed that unsigned treatments are considered not completed.
A resident did not consistently receive required nephrostomy and urinary catheter care, and staff failed to document urinary output as ordered. Facility records showed that catheter flushes, catheter care, and output monitoring were frequently missed or not performed as scheduled, and care was not always documented or signed out by staff.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A resident who required pain management did not receive safe and appropriate care as needed, resulting in a deficiency related to pain management services.
A resident with a history of aggression, including schizophrenia and mood disorder, physically struck another resident in the face in a hallway. The incident was witnessed by the DON, and it was documented that the aggressive resident had a known history of both verbal and physical aggression. The facility failed to prevent this physical abuse, as required by policy.
Surveyors found that several resident rooms lacked proper window coverings, had unclean and stained bathrooms, and contained maintenance issues such as a detached heater and missing air conditioning. Staff confirmed that some of these problems had been ongoing and that residents requiring assistance with ADLs were not provided with clean and comfortable environments. The facility's policy requires staff to ensure resident rights, but these deficiencies were observed and verified by staff including an LPN, housekeeper, and the DON.
A resident with severe dementia and a known risk for physical aggression entered another resident's room and struck him multiple times while he was in bed and calling for staff. The incident was witnessed and documented by staff, and the victim reported pain and distress. The facility's abuse prevention policy was not effectively implemented to prevent this resident-to-resident physical abuse.
Staff failed to ensure that several residents consumed their prescribed medications, leaving medication cups unattended at bedsides and tables without verifying ingestion. In one instance, a resident received vitamin gummies without a physician's order. No self-administration assessments were completed, and medications were not administered according to facility policy.
Surveyors found that two residents had inhalers left unsecured at their bedsides, in violation of facility policy requiring medications to be stored in locked compartments. One resident had two unlabeled albuterol inhalers without a current order, while another had a labeled Combivent inhaler at the bedside after administration. An LPN confirmed that these medications should not have been left in the residents' rooms.
A resident sustained fractured ribs after falling from a van during transportation. The incident occurred when the transportation driver mistakenly believed the lift was raised, leading to the resident's wheelchair rolling out of the van. The resident experienced significant pain and was sent to the hospital for evaluation. The driver was terminated for violating safety protocols.
A resident reported not receiving a gift card, leading to an investigation that revealed the Business Office Manager had used the card for personal purchases. The resident had initially consented to the facility opening her mail but later revoked this consent. The Administrator compensated the resident, and the Business Office Manager was dismissed after admitting to the misappropriation.
A resident with a surgical wound on the left stump did not receive daily wound treatments as ordered by the physician. The facility's policy requires daily treatment and documentation, but the Treatment Administration Record showed multiple missed treatments. The resident experienced discomfort and bleeding from the wound, and the Director of Nursing admitted to misreading the order as PRN instead of daily.
A facility failed to follow Enhanced Barrier Precautions and Hand Hygiene policies during wound care for a resident. An LPN entered the resident's room without a gown and did not sanitize hands after removing gloves, despite the resident being under EBP due to an open wound. The Director of Nursing confirmed the need for gowns and hand hygiene in such situations.
A resident with limited mobility and high risk for pressure ulcers developed a new ulcer on the coccyx, which was not promptly assessed or treated by the facility staff. Despite the facility's policy requiring immediate documentation and physician notification, no treatment orders were obtained, and no treatments were recorded for the initial days. The ulcer worsened to an unstageable condition before a wound physician was involved.
The facility failed to implement proper infection control measures for residents with infections and medical devices, as staff did not follow PPE protocols, and necessary signage was missing. This affected residents with conditions like ESBL, MRSA, and those with indwelling catheters and gastrostomy tubes, potentially impacting all 90 residents.
The facility failed to monitor active infections and implement their Antibiotic Stewardship Program, as the DON could not provide necessary logs for the past six months. A change in the DON position contributed to the lack of documentation, potentially affecting all 90 residents.
The facility failed to issue written notifications for hospital transfers upon discharge for several residents. Interviews and record reviews revealed that residents were frequently hospitalized without proper documentation or notification to their representatives. The facility's staff confirmed the absence of a policy and written confirmations for these transfers, indicating a systemic issue in the notification process.
The facility failed to develop comprehensive care plans for several residents, including those with PTSD, heart failure, infections, and those receiving hospice or dialysis services. Care plans were not updated to reflect current diagnoses and needs, such as oxygen therapy and pressure ulcers. The care plan coordinator acknowledged being behind due to heavy admissions, leading to incomplete documentation and potential impacts on resident care.
The facility failed to manage oxygen therapy properly for several residents, lacking physician orders, proper storage of oxygen cylinders, and timely changes of oxygen tubing and humidifier bottles. Observations showed residents using oxygen without documented orders, with cylinders unsecured and tubing undated. Oxygen safety signs were also missing from rooms where oxygen was in use.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS did not document oxygen use, despite continuous use observed. Another resident's MDS lacked documentation of a wound infection, despite confirmed MRSA and other infections, and the resident being in contact isolation. The MDS Coordinator and resident interviews confirmed these discrepancies.
A facility failed to conduct a PASRR Level II screening for a resident with schizoaffective disorder. The resident's Level I screening incorrectly indicated no mental disorder, despite the diagnosis. The Business Office Manager confirmed the oversight, and the facility lacked a PASRR policy.
A facility failed to include necessary oxygen therapy in a resident's Baseline Care Plan. The resident was observed receiving oxygen via nasal cannula, and the Nurse's Note indicated she arrived with nasal oxygen via concentrator. However, the Baseline Care Plan did not document this need. The Care Plan Coordinator confirmed the omission and noted there was no designated place to mark it, suggesting it should have been manually added.
The facility failed to update care plans for three residents, reflecting changes in their conditions. One resident's care plan did not include changes in gastrostomy feedings or significant weight loss. Another resident's care plan lacked a new diet order, and a third resident's care plan was missing updates for significant weight loss and fall interventions. These deficiencies were confirmed by the MDS and Care Plan Coordinators.
A resident with multiple medical conditions and pressure ulcers did not receive consistent weekly wound assessments or proper hand hygiene during dressing changes. The facility failed to adhere to its policies, resulting in missed wound measurements and improper infection control practices by staff.
A facility failed to investigate a fall and conduct a root cause analysis for a resident identified as high risk for falls. The facility's policy requires an incident report and investigation for all resident accidents, but documentation for the resident's fall was incomplete. The DON confirmed the lack of additional documentation, and the Nurse Manager could not provide further details or evidence of an investigation.
The facility failed to communicate dietician recommendations to the physician and document daily weights for two residents. One resident experienced significant weight loss without the recommended nutritional support being implemented, while another resident with CHF had no daily weights recorded despite a physician order. This lack of documentation and communication compromised the residents' nutritional care.
A facility failed to provide proper gastrostomy tube care and feeding for a resident. The resident's feeding pump was not in use, and the gastrostomy tube dressing was soiled and undated. The LPN admitted to not changing the dressing as required and stated that the resident had not been receiving feedings or flushes since she began eating, pending physician clarification. Documentation inconsistencies were found in the resident's feeding orders and care, with numerous blank entries in the MAR and TAR, and no physician order to discontinue the gastrostomy tube feedings.
A facility failed to comply with its Medication Administration policy by allowing a resident to keep medications at the bedside without a physician's order. The resident had a Stiolto Inhaler and Ipratropium Nasal spray on the overbed table, and a LPN confirmed the practice was based on verbal reports, despite the absence of a documented order.
A resident with known wandering and exit-seeking behaviors left the facility unsupervised and was found three days later on a park bench, requiring hospital evaluation. The facility failed to implement its elopement prevention policy effectively, as there was a lack of documentation and communication regarding the resident's risk. Staff were not adequately informed or trained, and the incident was improperly treated as an unplanned discharge against medical advice.
A facility failed to develop a comprehensive care plan for a resident at high risk for elopement. The resident's care plan lacked documentation of their elopement risk, G-tube, and cervical spine collar care. Despite frequent exit-seeking behaviors, these were not communicated to the care plan nurse, resulting in missing interventions. Staff reported multiple instances of the resident attempting to leave the building, but the care plan was not updated to reflect these needs.
A resident with a history of falls was injured during a transfer when a CNA, who lacked proper training, misjudged the position of a recliner, causing the resident to slide to the floor. The facility failed to ensure adequate supervision and training for staff, leading to the incident and increased pain for the resident.
A resident experienced increased pain and a decline in daily activities due to the facility's failure to provide physician-ordered pain medication and alternative pain management strategies. The resident's pain was exacerbated following a fall, and the facility did not transcribe hospital-recommended pain control measures onto the resident's records.
The facility failed to follow its Abuse Prevention policy by not conducting a background check on a dietary aide with disqualifying criminal offenses. The aide, involved in direct resident care, had convictions for assault and battery, which were not discovered until years after hiring.
Failure to Maintain Safe Baseboard Heaters and Bed Placement Resulting in Severe Resident Burns
Penalty
Summary
The deficiency involves the facility’s failure to maintain baseboard heaters in a safe manner and to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks. During a tour, all resident rooms were noted to have six-foot baseboard heaters beneath the windows, with measured surface temperatures as high as 172°F. In one room, a stuffed animal pillow was resting directly on top of the heater and a bag was positioned immediately adjacent to it; in another room, a window curtain was draped over the heater. In multiple rooms, thermostats were missing from the heaters, and one resident’s bed was positioned directly against the heater, with the resident’s hand and arm within reach of the hot surface. The resident, who was hard of hearing, stated that the heater gets very hot. The surveyor found the heater surface too hot to safely touch. The facility’s Maintenance Director confirmed that the facility did not maintain the manufacturer’s operating and preventive maintenance instructions for the baseboard heaters, including the parts list with component descriptions and the air-balance report, and that a complete set of these documents was not available on-site. He also stated that he had not previously monitored or documented the surface temperatures of baseboard heaters or heater covers and was not aware of any established process for doing so. Following a burn incident involving a resident, he reported conducting only a visual inspection of all heaters to identify units needing repair or replacement and measuring the surface temperature of only four heaters, confirming that no formal process for routine temperature monitoring had been implemented. The Administrator-in-Training verified that curtains, personal items, and residents should be kept approximately 12 inches from the heaters to prevent burns and fire hazards and acknowledged that the facility did not have the manufacturer’s operating and preventive maintenance instructions. One resident involved in the incident was an older adult with diagnoses including hemiplegia, convulsions, respiratory failure, type II diabetes mellitus with diabetic hemiplegia, chronic kidney disease stage III, depression, and dementia with anxiety. This resident was cognitively severely impaired and dependent or required extensive assistance for all ADLs, received hospice care, and had no signs or symptoms of pain prior to the burn incident. A CNA reported that around midnight she was unable to turn the resident because the resident’s arm was stuck between the bed and the baseboard heater; when she moved the bed, she observed a large burn up and down the resident’s left arm and immediately notified the nurse. Progress notes and emergency room documentation describe partial-thickness, second-degree burns with blistering extending from the pinky finger up the arm to near the shoulder, requiring emergency treatment and ongoing painful wound care. The coroner stated that the resident was non-verbal and could not have yelled for help when being burned and characterized the situation as neglectful of the facility to have allowed the burns to reach that severity. Another resident whose room was observed during the survey was moderately cognitively impaired, with a care plan that did not include measures to keep the resident at a safe distance from the baseboard heater or to protect from burns. This resident’s bed was positioned directly against a heater with a missing thermostat, and the resident’s right hand and arm were within reach of the heater surface. Across multiple rooms, the combination of high heater surface temperatures, missing thermostats, lack of manufacturer guidance, absence of a monitoring system for heater temperatures, and unsafe placement of beds and combustible items near heaters constituted the actions and inactions that led to the identified deficiency. These failures resulted in a resident becoming entrapped between the bed and a baseboard heater and sustaining painful burns that required emergency room treatment, and had the potential to affect all 87 residents residing in the facility.
Removal Plan
- Positioned all residents and their beds at a safe distance from baseboard heaters.
- Obtained and documented surface temperatures of all baseboard heaters in all resident rooms and verified all were below 140°F.
- Obtained manufacturer guidelines for baseboard heaters to ensure safe operation and compliance with recommended safety standards.
- Educated the Maintenance Director to ensure baseboard heaters do not exceed 140°F and to routinely monitor and document temperatures for ongoing compliance.
- Educated all department heads to ensure resident beds are never lowered or pushed against baseboard heaters when in use; implemented and posted a visual guide showing the appropriate safe distance between beds and heaters.
- Educated all licensed nurses to ensure resident beds are never lowered or pushed against baseboard heaters when in use.
- Educated all CNAs and unlicensed staff to ensure resident beds are never lowered or pushed against baseboard heaters when in use.
- Implemented a process to ensure room assignments are appropriate for the number of residents in each room to allow safe placement away from environmental hazards, including baseboard heaters.
- Conducted a facility-wide audit to identify additional risks related to heater placement and bed positioning; immediately corrected concerns and updated resident care plans accordingly.
- Implemented environmental temperature rounds to ensure baseboard heater temperatures are 140°F or below.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to all employees as required. Record review showed that the Midnight Census Report dated 3/24/26 documented 87 residents residing in the facility. Review of the facility’s Annual In-Service Schedule revealed that it did not include any in-servicing regarding QAPI. Additionally, review of Staff In-Services and Computer Based Training records dated from 3/1/25 through 3/28/26 showed no evidence that QAPI training had been provided. On 3/28/26 at 9:50 AM, the Administrator in Training confirmed that facility staff had not received QAPI training. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency, only that all 87 residents had the potential to be affected.
Failure to Document and Complete Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to perform pressure ulcer care and daily skin checks as ordered for one resident with a pressure injury. According to the facility's policy, wound care and skin checks must be documented in the electronic medical record when completed. Review of the resident's Treatment Administration Record showed multiple dates where the prescribed wound care for the left heel and daily skin checks were not signed out as completed. The resident reported that wound care was performed at least daily, but the documentation was inconsistent. The Infection Preventionist/Treatment Nurse confirmed that if treatments are not signed out, they are considered not completed as ordered, and any refusals should be documented in the progress notes.
Failure to Provide and Document Required Catheter and Nephrostomy Care
Penalty
Summary
The facility failed to provide appropriate nephrostomy and urinary catheter care, as well as to document urinary output as ordered, for one resident reviewed for bowel and bladder care. According to the facility's policy, catheter care and nephrostomy tube care were to be completed every day and night shift, and urinary output was to be recorded every shift. However, documentation showed that catheter flushes, catheter care, nephrostomy care, and output monitoring were frequently missed or only completed once daily instead of twice, and in some instances not done at all on certain days. The resident was unsure if care was being performed as required. The Infection Preventionist/Treatment Nurse confirmed that if care was not signed out, it was not completed as ordered, and that refusals should be documented in the progress notes, which was not consistently done.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate pain management for a resident who required such services. The report indicates that the facility failed to ensure that a resident in need of pain management received care that met professional standards for safety and appropriateness. Specific details about the resident's medical history, the nature of their pain, or the exact actions or omissions by staff are not provided in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with diagnoses including schizophrenia, mood disorder, anxiety, depression, schizoaffective disorder, and mild intellectual disabilities was identified as having the potential to be physically and verbally aggressive, as documented in their care plan. Despite this known risk, the resident was involved in an incident where they struck another resident in the face with a closed fist while in the hallway near the front lobby. The altercation was witnessed by the Director of Nursing, who confirmed the aggressive behavior and noted the resident's history of both verbal and physical aggression toward staff and other residents. The facility's policy requires that all residents be protected from abuse, including abuse by other residents. However, the incident demonstrates a failure to protect one resident from physical abuse by another, as the aggressive resident was able to physically strike another resident. Both residents were separated and debriefed after the incident, and it was documented that neither sustained injuries. The event was recorded as an allegation of abuse, and the relevant parties were notified.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
Surveyors observed multiple deficiencies related to the maintenance and cleanliness of resident rooms, as well as the provision of a homelike environment. In one room, two residents had a window with no blinds and a curtain that could not be closed, a baseboard heater detached and lying on the floor, and a bathroom floor with a thick brown stain around the baseboards and toilet. Staff confirmed that the window had never had working blinds or curtains and that the bathroom floor had always been stained. Another resident's room was found with two cardboard boxes taped over the window using silver tape, reportedly to block out hot or cold air, as the blinds were ineffective. The Maintenance Director stated that repairs had not been made due to lack of funding. Additionally, a resident's room had a strong urine odor, a full urinal left on the bedside table, no fitted sheet on the bed, and a sticky, dirty floor. This resident had a diagnosis of schizophrenia and required staff assistance with activities of daily living and personal hygiene, as documented in the care plan. Further observations included a resident room without an air conditioning unit, with a recorded temperature of 76 degrees. Staff confirmed that temperature checks were not being conducted and that the room did not have central air conditioning, as the window unit had been removed and not replaced. The resident in this room had a documented preference for a very cold environment and had previously complained about the room being too hot. The facility's Resident Rights policy requires staff to provide services and advocate for resident rights, but these observations indicate failures to maintain clean, safe, and comfortable living conditions for several residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of physical aggression entered the room of another resident who was in bed and began to swat and hit him multiple times on the arm, side of the face, and head. The resident who was attacked had been calling out for staff assistance, as he sometimes does when he forgets to use the call light. The aggressor, who was severely cognitively impaired according to her most recent assessment, left the room after the incident, and staff responded after being alerted by the victim. The incident was documented in multiple records, including incident reports, nursing notes, and interviews with both the residents and staff. The victim reported being upset and in pain from the physical contact, though no visible injuries such as cuts were noted. Staff confirmed that physical contact was made and that the aggressor had a known potential for physical aggression related to her dementia and anxiety diagnoses. The facility's abuse prevention policy prohibits all forms of abuse, including resident-to-resident abuse, and requires staff to protect residents from such incidents. Despite this, the event occurred, indicating a failure to prevent abuse as required by policy. The aggressor's care plan had identified her risk for physical aggression, but the measures in place were insufficient to prevent her from entering another resident's room and causing harm.
Medications Left Unattended and Administered Without Orders
Penalty
Summary
The facility failed to ensure that residents consumed their medications as prescribed and according to facility policy. Multiple residents were observed with medication cups containing their scheduled morning medications left at their bedsides or on tables, with no staff present to verify ingestion. In several cases, residents had not yet taken their medications, were unsure of the contents, or were handling the medications themselves. The facility's policy requires staff to observe residents consuming medications and prohibits leaving medications unattended unless there is a specific physician's order for self-administration, which was not present for any of the residents involved. Additionally, one resident was found with a medication cup containing gummies identified as vitamin/supplement products, for which there was no physician's order documented. The LPN confirmed the nature of the gummies and the absence of a doctor's order. The Director of Nursing acknowledged that none of the residents had been assessed for self-administration of medications, and that medications should not have been left with the residents. These actions and inactions resulted in the facility not following its own medication administration policy and failing to ensure medications were administered and consumed as ordered.
Improper Storage and Labeling of Inhalers
Penalty
Summary
Surveyors observed that two residents had inhalers improperly stored at their bedsides, contrary to facility policy requiring all medications to be kept in locked compartments unless refrigeration is needed. One resident had two albuterol inhalers with over 100 doses each on the bedside table, neither of which was labeled with a name or dispensing date, and there was no current physician order for these inhalers. The LPN confirmed the resident previously had an order for the inhalers but should not have had them in the room at the time of observation. Another resident had a Combivent inhaler at the bedside, which was labeled with the resident's name and pharmacy information, and had been administered earlier that day according to the Medication Administration Record. The LPN also confirmed this inhaler should not have been left in the room.
Resident Injury Due to Transportation Error
Penalty
Summary
The facility failed to ensure the safety of a resident during van transportation, resulting in a fall and injury. The incident involved a resident who was being transported in a handicap van. During the unloading process, the transportation driver mistakenly believed that the lift was raised when it was not, leading to the resident's wheelchair rolling out of the van and the resident falling to the ground. This resulted in the resident sustaining fractured ribs and experiencing significant pain. The resident, who was in a wheelchair, was being transported along with another resident. The transportation scheduler and driver were involved in the unloading process. The scheduler had lowered the lift to unload the first resident and then moved them to a safe location. However, the driver, assuming the lift was raised, proceeded to unhook and roll the second resident, leading to the fall. The driver realized the mistake only when the resident hit the ground, indicating a lack of proper communication and verification between the staff members involved. The resident was sent to the hospital for evaluation, where it was confirmed that they had sustained rib fractures. The transportation driver was later terminated for violating van safety protocols. The facility's Fleet Safety Program outlines the importance of following safety procedures, but in this case, human error and a lack of awareness led to the incident.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds, as evidenced by an incident involving a gift card. A resident reported that she had not received a gift card she was expecting in the mail. Upon inquiry, she discovered that she had previously signed a document allowing the facility to open her mail, which she then revoked. The resident expressed her concerns to the Business Office Manager and subsequently to the Administrator, who apologized and compensated her with cash equivalent to the gift card's value. An investigation was conducted by a business office manager from a sister facility, which revealed that the Business Office Manager had used the resident's gift card for personal purchases. The Business Office Manager admitted to this misappropriation, leading to their dismissal from the facility. This incident highlights a failure in the facility's abuse prevention program, which is designed to protect residents from exploitation and misappropriation of their property.
Failure to Complete Daily Wound Treatments
Penalty
Summary
The facility failed to adhere to physician-ordered wound treatments for a resident with a surgical wound on the left stump. The facility's policy mandates that wound treatments be completed daily and documented on the Treatment Administration Record (TAR). However, the resident's TAR for October and November 2024 showed multiple instances where the daily wound treatments were not completed as ordered. Specifically, the treatments were missed on several dates in October and on November 1st. During an observation on November 4, 2024, the resident's wound was noted to be red, with minimal swelling, and actively bleeding, causing discomfort to the resident. The resident reported that the wound dressing changes were not performed daily, as required. The Director of Nursing acknowledged the oversight, stating that the order was misread as PRN (as needed) instead of daily, leading to the failure in providing the necessary wound care.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) and Hand Hygiene policies during wound care for a resident. The EBP policy requires the use of a gown and gloves during high-contact resident care activities, such as wound care, to prevent the transfer of multidrug-resistant organisms (MDROs). However, an LPN entered the resident's room without wearing a gown, despite the resident being under EBP due to an open wound requiring dressing changes. The LPN performed wound care without following the necessary precautions, including not sanitizing hands or wearing a gown, which are critical steps outlined in the facility's policies. Additionally, the LPN did not follow proper hand hygiene protocols. After removing gloves, the LPN left the room to retrieve supplies and returned without sanitizing or washing hands before donning new gloves. This oversight occurred despite the facility's Hand Hygiene Policy, which mandates handwashing or the use of alcohol-based hand rubs in specific situations, such as after glove removal and before direct resident care. The Director of Nursing later confirmed that staff should wear gowns and gloves in EBP rooms and practice hand hygiene consistently.
Failure to Initiate Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to assess and promptly initiate treatment for a pressure ulcer identified on a resident, leading to the ulcer worsening to an unstageable condition. The facility's Decubitus Care/Pressure Area Policy requires that pressure areas be assessed and documented, with physician notification for treatment orders. However, when a nurse identified a new pressure ulcer on the resident's coccyx, no physician orders for treatment were documented, and no wound treatments were recorded on the Treatment Administration Record for the initial days following the ulcer's identification. The resident, who had a history of cerebral infarction, aphasia, and other conditions, was at high risk for pressure ulcers due to limited mobility and other factors. Despite this, the initial wound assessment and treatment plan were not completed until two days after the ulcer was first noted, by which time the wound had worsened significantly. The wound physician confirmed that the staff did not contact him until the treatment was started, indicating a delay in addressing the resident's condition.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for six residents, potentially affecting all 90 residents. The facility's policies on Contact Precautions and Enhanced Barrier Precautions (EBP) were not followed, as evidenced by the lack of signage and personal protective equipment (PPE) usage. For instance, a resident with an ESBL infection did not have a contact isolation sign on their door, and staff did not wear gowns during catheter care, contrary to the facility's policy. Another resident with a stage 3 pressure ulcer did not have PPE available in their room, and staff did not wear gowns during wound care. Similarly, a resident with an indwelling urinary catheter did not have Enhanced Barrier Precautions signage, and their care plan lacked documentation of catheter care orders. Additionally, a resident with multiple infections, including MRSA, had a contact precautions sign on their door, but staff did not adhere to the required PPE protocols, and there was no soap or hand sanitizer available in their room. Further deficiencies were noted with residents having gastrostomy tubes and urinary catheters, where Enhanced Barrier Precautions were not in place, and staff did not wear gowns or masks during care. The Director of Nursing confirmed the absence of enhanced barrier precautions for any resident in the facility, despite the policy requirements. These failures indicate a systemic issue in adhering to infection control protocols, posing a risk to resident safety.
Failure to Monitor Infections and Implement Antibiotic Stewardship
Penalty
Summary
The facility failed to monitor active infections and implement their Antibiotic Stewardship Program, which is designed to optimize the treatment of infections and reduce adverse events associated with antibiotic use. The facility's policy on Infection Control Surveillance and Monitoring, last reviewed in December 2018, outlines the responsibilities of the Administrator, ICP, and DON in conducting routine surveillance and monitoring to ensure compliance with work practices and the proper use of protective clothing and equipment. However, during the survey, the DON was unable to provide antibiotic stewardship logs or infection control logs for the past six months, indicating a lapse in the facility's infection control practices. Interviews with facility staff revealed that there was a change in the DON position, which may have contributed to the lack of documentation and monitoring. The AIT acknowledged the absence of the previous DON and the challenges faced in tracking infection control and antibiotic stewardship. The failure to maintain proper logs and documentation has the potential to affect all 90 residents currently residing in the facility, as it hinders the facility's ability to effectively manage and monitor infections and antibiotic use.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notifications of hospital transfers upon discharge for four residents who were hospitalized. This deficiency was identified through interviews and record reviews. For instance, one resident's census list documented multiple hospital unpaid leave dates, yet there was no written notification issued for these hospitalizations. Another resident was admitted to a local hospital and returned to the facility, but there were no nursing progress notes documenting the hospitalization. Additionally, a resident reported frequent hospital visits since admission, but no written notifications were provided for these transfers. The facility's social services worker confirmed that no written notices were given to residents' representatives regarding hospital transfers. The administrator in training also acknowledged the absence of a specific policy for handwritten hospital discharge notifications and the lack of written confirmation for hospital transfers or discharges over the past six months. This indicates a systemic issue in the facility's process for notifying residents and their representatives about hospital transfers and discharges.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for eight residents, as required by their policy. The care plans were not updated to reflect the residents' current diagnoses and needs. For instance, one resident with PTSD did not have their condition or triggers documented in their care plan, despite being cognitively intact and expressing the impact of loud noises on their anxiety. Another resident with heart failure and an order for oxygen therapy did not have their oxygen use documented in their care plan, even though an oxygen concentrator was present in their room. Additionally, the facility did not include necessary care plans for residents with specific medical needs. One resident with a left hip wound infection did not have an infection care plan, and another resident receiving dialysis services lacked a dialysis care plan. Furthermore, a resident receiving hospice services did not have a hospice care plan, and a resident with pressure ulcers did not have a pressure ulcer care plan documented. The facility's care plan policy requires a comprehensive care plan to be developed within seven days of completing the resident assessment. However, one resident only had a baseline care plan, and the care plan coordinator admitted to being behind due to heavy admissions. This lack of timely and accurate documentation in care plans indicates a systemic issue in maintaining up-to-date and comprehensive care plans for residents, potentially impacting their care and well-being.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, as evidenced by the lack of physician orders, improper storage of oxygen cylinders, and failure to change and date oxygen tubing and humidifier bottles. Observations revealed that several residents were using oxygen without documented physician orders, and oxygen cylinders were found free-standing on the floor, not secured in a cart or holder, contrary to the facility's policy. Additionally, oxygen tubing and humidifier bottles were not changed weekly as required, with some dated as far back as July, and others not dated at all. Furthermore, oxygen safety signs were not posted on the doors of rooms where oxygen was in use, which is a requirement according to the facility's policy. Specific instances included residents with undated or outdated oxygen equipment, empty humidifier bottles, and unsecured oxygen cylinders. The Director of Nursing acknowledged these deficiencies, stating that oxygen tubing should be dated when changed and that oxygen cylinders should be stored securely, either in a resident's room in a holder or in a locked storage area.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For one resident, the MDS assessments dated March and June did not indicate the use of oxygen, despite the resident being observed with oxygen infusing via nasal cannula. The MDS Coordinator confirmed that the resident's MDS should have documented oxygen use if it was continuous or used during the assessment period, but no documentation was provided to prove otherwise. Another resident's MDS assessments from March and June failed to document a wound infection, despite the resident being in contact isolation for MRSA and other infections since admission. The resident's laboratory culture results confirmed a heavy growth of MRSA, and the resident was on antibiotics for the infection. The resident reported that their wounds were checked upon admission, but no re-testing had been conducted to determine if the infection persisted.
Failure to Conduct PASRR Level II Screening for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure a PASRR Level II screening for mental disorder was completed for a resident reviewed for PASRRs. The resident was admitted with a diagnosis of schizoaffective disorder, as documented in the Physician Order Sheet dated 5/8/23. However, the resident's PASRR Level I Screen Outcome, dated 5/1/23, indicated that no Level II was required, citing situational symptoms and low-level behavioral health symptoms. The facility was unable to produce a PASRR policy, and the Business Office Manager confirmed that the resident transferred with a Level I screening that incorrectly stated no mental disorder was present, despite the schizoaffective disorder diagnosis. This oversight led to the failure to conduct a necessary Level II evaluation.
Omission of Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a resident's Baseline Care Plan included necessary oxygen therapy. The resident was observed in her room with oxygen being administered via nasal cannula. According to the Nurse's Note, the resident arrived at the facility with nasal oxygen via concentrator. However, the Baseline Care Plan did not document the need for oxygen or any related care. The Care Plan Coordinator confirmed that the Baseline Care Plan lacked documentation for oxygen and acknowledged that there was no designated place to mark it on the care plan sheet, indicating it should have been written in manually.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to revise the care plans for three residents, R38, R41, and R43, to reflect their current conditions, as required by their Comprehensive Care Planning policy. For R38, the care plan was not updated to include changes in gastrostomy feedings, pleasure feedings, or significant weight loss, despite a physician's order to decrease gastrostomy feedings and a documented weight loss of 22.86% from June to August 2024. The MDS Coordinator and Care Plan Coordinator confirmed that R38's care plan did not reflect these changes. Similarly, R43's care plan was not revised to include a new physician-ordered mechanical soft diet. Additionally, R48 experienced an 18.37% weight loss and an unwitnessed fall, yet the care plan was not updated to include these significant changes or the fall interventions. The MDS Coordinator and Care Plan Coordinator confirmed that R48's care plan lacked these updates. These deficiencies indicate a failure to maintain accurate and current care plans for residents, as required by the facility's policies.
Deficiencies in Pressure Ulcer Care and Hand Hygiene
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers weekly and did not adhere to hand hygiene protocols during dressing changes for a resident with multiple medical conditions. The resident, who has a history of Spinal Bifida, Paraplegia, and other chronic conditions, was admitted with pressure ulcers on the right buttock and left lateral hip. Despite physician orders for weekly skin documentation and daily dressing changes, the facility did not consistently document wound assessments or measurements, particularly missing entries for specific weeks. Additionally, the facility's staff did not follow proper hand hygiene procedures during dressing changes. An LPN was observed changing the resident's dressings without performing hand hygiene between glove changes, and used the same soiled gloves to handle community use wound care supplies. This practice was confirmed by the LPN as her usual method for dressing changes, and the DON acknowledged that hand hygiene should be performed between glove changes. The resident expressed concerns about the inconsistency of dressing changes and the lack of retesting for infections in the wounds. The facility's DON and Nurse Manager confirmed the absence of some wound measurements and acknowledged the need for improved wound care management. The facility's policies on pressure ulcer care and hand hygiene were not adhered to, contributing to the deficiencies observed.
Failure to Investigate Resident Fall and Conduct Root Cause Analysis
Penalty
Summary
The facility failed to investigate a resident fall and conduct a root cause analysis for a resident identified as R48, who was reviewed for falls in a sample of 37 residents. According to the facility's Accidents and Incidents policy, all accidents involving a resident require an incident report and an investigation by the interdisciplinary team to determine the root cause and implement appropriate interventions. R48 was assessed as a high risk for falls, with a Fall Risk Assessment score of 21. A Quality Care Reporting Form documented an alleged fall for R48, but it lacked details about the incident. Physician Progress Notes did not include any follow-up information regarding the fall. The Director of Nursing confirmed that there was no additional documentation for R48's fall, and the Nurse Manager was unable to provide further details or evidence of an investigation being completed for the incident.
Failure to Communicate Dietician Recommendations and Document Weights
Penalty
Summary
The facility failed to ensure that the recommendations made by the Registered Dietician (RD) were communicated to the physician and documented appropriately for two residents. For one resident, identified as R48, the facility's records showed a significant weight loss of 18.37% from June to August. The RD recommended a Med Pass Supplement (MPS) to support nutrition and weight gain, but this recommendation was not signed or dated by the resident's Primary Care Physician (PCP) and was not included in the Medication Administration Record (MAR). Additionally, the Physician Orders Sheet (POS) did not reflect any dietary supplement orders, and the physician notes did not address the resident's diet or weight loss. Another resident, identified as R41, had a physician order for daily weights due to Congestive Heart Failure (CHF), but the MAR did not document these daily weights. The resident reported only being weighed at dialysis sessions, not daily as required. The Licensed Practical Nurse (LPN) confirmed that the MAR indicated an order for daily weights, which were not documented. This lack of documentation and communication regarding the residents' nutritional needs and weight monitoring contributed to the facility's failure to maintain adequate nutrition and health for these residents.
Failure to Provide Gastrostomy Tube Care and Feeding
Penalty
Summary
The facility failed to provide gastrostomy feeding per order and appropriate gastrostomy tube care for a resident, identified as R43, who was reviewed for enteral feedings. Observations revealed that the enteral feeding pump was not in use, and the resident's gastrostomy tube dressing was soiled and undated. The resident reported that the feeding pump was no longer used as she could eat food now, and she could not recall when the dressing was last changed. The Licensed Practical Nurse (LPN) admitted to not changing the dressing as required and stated that the resident had not been receiving feedings or flushes since she began eating, pending clarification from the physician. The Registered Dietician's notes indicated that the resident was on tube feeding for nutritional needs, with specific recommendations for feeding and water flushes. However, the Physician Order Sheet (POS) and Medication Administration Record (MAR) showed inconsistencies and omissions in documenting the resident's feeding orders and care. The MAR had numerous blank entries, indicating missed feedings, and there was no documented order to discontinue the gastrostomy tube feedings. Additionally, the Treatment Administration Record (TAR) showed many blank entries for gastrostomy tube care. Despite a dietary note suggesting the discontinuation of the G-tube, there was no physician order confirming this action, leading to a lack of clarity and proper care for the resident's gastrostomy tube needs.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were not left at a resident's bedside, specifically for one resident (R17) out of 19 reviewed for medication storage. The facility's Medication Administration policy, revised on November 18, 2017, clearly states that medications should not be left unattended or at the bedside unless specifically ordered by a physician. On August 4, 2024, it was observed that R17 had a pharmacy-labeled Stiolto Inhaler and Ipratropium Nasal 0.06% spray on the overbed table. R17 stated that they were allowed to self-administer these medications. However, the August 2024 Physician Order Sheet for R17 did not include any order permitting medications to be kept at the bedside. On August 6, 2024, a Licensed Practical Nurse (V25) confirmed that R17 was allowed to keep the nasal spray and inhaler at the bedside based on verbal reports, but acknowledged that there should be a doctor's order for it, which was not found in R17's clinical chart.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a resident with known wandering and exit-seeking behaviors from leaving the facility without staff supervision. The resident, who had a history of severe mental illness, brain injury, and was dependent on staff for activities of daily living, was last seen by staff in the facility and was found three days later on a park bench, approximately two and a half miles from the facility. The resident required transportation to a local hospital for evaluation and treatment after being exposed to high temperatures. The facility's elopement prevention policy was not effectively implemented, as evidenced by the lack of a resident information sheet and photograph for the resident in the elopement risk binder. Additionally, the facility's missing resident policy was not adequately followed, as there was a delay in notifying law enforcement and the resident's family, and the facility did not conduct a thorough search or investigation into the resident's disappearance. Staff members were not adequately informed of the resident's exit-seeking behaviors, and there was a lack of documentation regarding the resident's elopement risk and the events surrounding the incident. The facility's failure to maintain accurate and complete records, including nursing notes and behavior tracking sheets, contributed to the deficiency. The resident's care plan did not reflect their exit-seeking behaviors, and staff were not adequately trained or informed about the resident's risk for elopement. The facility's response to the incident was inadequate, as they treated the resident's disappearance as an unplanned discharge against medical advice, rather than an elopement, and did not report the incident to public health authorities.
Removal Plan
- R1's, R2's, R3's and R4's Elopement Assessment and Care Plans were reviewed and updated accordingly.
- All Resident's Elopement Assessments were reviewed and updated, and Residents at Risk Plan of Cares were reviewed and updated.
- All Staff were in-serviced on Elopement Policy and Abatement Plan. (Door Alarm Policy and Elopement Prevention Policy)
- Weekly Door Alarm Testing was initiated.
- Quarterly QA Meeting reviewed.
- Notification of the Allegation of Immediate Jeopardy to the Medical Director was completed.
- The Elopement Binder was reviewed. Elopement Prevention Policy, Missing Resident Policy, Door Alarm Policy, Investigate Report of Missing Resident Form and Emergency Codes were reviewed.
- Continue to monitor R2, R3 and R4 and other high-risk for elopement residents.
- Monitor Residents with potential to be affected by the alleged deficient practice: All residents who have the ability to exit a door without assistance have the potential to be affected by this alleged deficient practice.
- The Facility (V15//Social Services and V16/Care Plan/Minimum Data Set/MDS) will review immediate actions and changes to Facility systems and review/update all elopement assessments on all residents.
- V2 (DON) and V16 (Care Plan/MDS) will review and update all Care Plans for elopement related to supervision and monitoring.
- V3 (Maintenance Director) will check door alarm functionality and review all doors and alarms and ongoing weekly by V3.
- V15 (Social Service Director) will review/update the Facility elopement books.
- V2 (DON) to complete training/educate staff with Staff on the Elopement Policy, monitor the door alarms, and identify Residents at risk for elopement. All staff will complete in-service prior to working the floor to work.
Failure to Develop Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident identified as high risk for elopement. The facility's policies require that the interdisciplinary team initiate a care plan for residents at high risk for elopement, including specific measures to minimize risk factors. However, the resident's care plan did not document the resident's elopement risk, enteral Gastrostomy Tube (G-tube), perineum medicated ointment application, or cervical spine collar care. Despite the resident's frequent attempts to exit the building and setting off door alarms, these behaviors were not communicated to the care plan nurse, resulting in the absence of necessary interventions in the care plan. Interviews with facility staff revealed that the resident had a history of exit-seeking behaviors and had previously eloped from the facility. Staff members, including a CNA and the housekeeping supervisor, reported multiple instances of the resident attempting to leave the building and requiring redirection. The care plan nurse admitted to not being informed of the resident's exit-seeking behaviors and acknowledged that the care plan was not updated to reflect the resident's needs. The lack of communication and failure to update the care plan contributed to the deficiency in providing adequate care for the resident.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to prevent accidents and falls with injury for a resident (R1), resulting in the resident requiring hospital evaluation and treatment for injuries. The facility's fall prevention policy and mechanical lift policy were not adequately followed. Specifically, the resident, who had a history of falls and required assistance with transfers, was being transferred by a single CNA using a sit-to-stand lift. The CNA misjudged the position of the recliner, causing the resident to slide to the floor, resulting in pain and injury. The resident's care plan required two staff members for transfers, but this was not adhered to during the incident. The incident was witnessed by the resident's roommate and corroborated by the resident's daughter and the CNA involved. The CNA did not receive proper in-service training on the facility's mechanical lifts, and the facility relied on staffing agencies to provide such training. The facility's Director of Nursing (DON) admitted that the CNA should not have been performing the transfer alone and acknowledged that the incident was not thoroughly investigated as a fall. The resident experienced increased pain following the incident and had to use a full mechanical lift for transfers, which did not fit into the bathroom, necessitating the use of a bedpan. The facility's failure to provide adequate supervision and training for staff, particularly agency staff, contributed to the incident. The resident's complaints about pain and the lack of timely assistance were documented, but no corrective actions were taken. The facility's reliance on agency staff without ensuring they were properly trained on the facility's equipment and procedures led to the deficiency, resulting in harm to the resident.
Failure to Provide Pain Management
Penalty
Summary
The facility failed to provide physician-ordered pain medication and manage pain for a resident (R1), resulting in increased pain and a decline in the resident's activities of daily living. The facility's policy on pain prevention and treatment was not followed, as evidenced by the lack of administration of the prescribed pain medication Norco on multiple occasions. Additionally, the facility did not implement alternative pain management strategies such as ice or heat application, as recommended by the hospital after R1's fall and subsequent visit to the emergency department. R1's medical history includes a history of falls, hypertension, congestive heart failure, neuropathy, osteoarthritis, hyperlipidemia, diabetes, left hip pain, and dependent edema. After a fall incident involving a sit-to-stand lift, R1 experienced increased pain in the back and legs. Despite the hospital's recommendation for pain control measures, the facility did not transcribe these orders onto R1's medication or treatment administration records. This oversight led to R1 experiencing significant pain without appropriate intervention. Interviews with R1, R1's daughters, and R1's roommate revealed that R1 was in excruciating pain following the fall and that the facility ran out of the prescribed pain medication, leaving R1 without pain relief for an entire day. The facility staff, including the Director of Nursing and a Licensed Practical Nurse, acknowledged the failure to provide the necessary pain management and the lack of communication with the physician to seek alternative pain relief options.
Failure to Conduct Background Checks on Dietary Aide
Penalty
Summary
The facility failed to follow their Abuse Prevention policy by not performing a health care worker background check and not obtaining a fingerprint-based criminal history check for an unlicensed dietary aide, who had two disqualifying criminal offenses. The dietary aide, hired in 2018, had convictions for assault and battery, which were not discovered until a background check was finally conducted in 2024. The facility's policies clearly state that no staff with disqualifying criminal offenses should be employed unless a waiver is granted, which was not the case here. The Administrator-In-Training admitted to not running the necessary background checks, which would have revealed the disqualifying convictions. The dietary aide was involved in direct resident care activities, such as recording food intake and responding to residents' requests, which could have put residents at risk. The Dietary Manager was unaware of the aide's criminal history, highlighting a significant lapse in the facility's hiring and monitoring processes.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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