Westminster Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Illinois.
- Location
- 2025 East Lincoln Street, Bloomington, Illinois 61701
- CMS Provider Number
- 145400
- Inspections on file
- 21
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Westminster Village during CMS and state inspections, most recent first.
Two residents with CHF had physician orders and care plan interventions for daily weights, but staff failed to obtain and document these weights on multiple days and did not consistently record reasons when weights were not taken. One resident experienced notable weight gain along with swelling, shortness of breath, and altered mental status before being sent to the hospital, with no documented provider notification of the weight variance. Another cognitively intact resident with leg swelling reported being weighed only weekly despite a daily weight order. Nursing staff, the NP, and the DON all acknowledged that daily weights, documentation of refusals or missed weights, and timely provider notification for significant weight changes were expected under facility policy, but these practices were not consistently carried out.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
The facility failed to provide adequate feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two residents. This resulted in severe weight loss for both residents, with one losing 16.65% of their weight over six months and the other losing 15.6% in two months.
The facility failed to label opened prepared foods with the date and time in the refrigerator, potentially affecting all 90 residents. The Dietary Manager could not determine how long the items had been in the refrigerator and decided to discard them.
The facility failed to obtain orders for oxygen, store, change, and label oxygen and nebulizer tubing per policy, and provide routine cleaning of a humidifier for several residents. Observations revealed uncovered and undated nebulizer equipment, outdated humidification bottles, and oxygen tubing on the floor, with no proper documentation or adherence to facility policies.
The facility failed to implement enhanced barrier precautions (EBP) as recommended by the CDC, affecting five residents. Staff did not wear gowns during urinary catheter care and wound treatments, and there was no EBP signage or PPE available in the rooms of affected residents. The Director of Nursing/Infection Preventionist admitted that the facility did not have an EBP policy in place.
The facility failed to assess the ability of three residents to self-administer medications, resulting in unauthorized medications being found at their bedsides. None of the residents had documented orders or assessments for self-administration, despite the facility's policy requiring such measures.
A resident experienced a fall and was later found to have multiple rib fractures, but the facility failed to investigate the cause of the injuries as required by their Abuse Policy. The DON and Assistant DON were unaware of the fractures until weeks later, indicating a lapse in communication and policy adherence.
A resident's care plan meeting was missed, with the last meeting documented several months ago. The facility's staff acknowledged the oversight, citing a large caseload as a contributing factor.
A resident reported swelling in their right elbow, but the facility failed to document the condition or ensure the resident was evaluated by a physician. Despite the resident's complaints and a nurse's observation, there was no follow-up or proper documentation in the medical record.
The facility failed to complete comprehensive wound assessments for two residents with new pressure injuries. Both residents, who required substantial assistance, had physician's orders for wound care but lacked proper documentation and timely updates to their care plans. The facility's policy did not specify staff responsibilities for initial wound assessments, leading to a lack of awareness and proper care.
The facility failed to secure oxygen canisters and properly implement fall interventions for two residents. Unsecured oxygen cylinders were found near a resident's doorway, and the resident's bed and chair alarms were not consistently connected to alarming devices. Fall investigations were incomplete, lacking documentation on the resident's activities prior to falls and staff interviews.
The facility failed to perform complete urinary catheter care, prevent cross-contamination, and maintain dignity and infection control for three residents. Issues included incomplete cleaning, improper glove use, and uncovered urinary collection bags touching the floor.
The facility failed to complete or accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for two residents. One resident's medical record lacked proper assessments and behavior quantification, while another resident's record did not include nonpharmacological interventions or responses.
The facility failed to document and offer/administer Pneumococcal and Influenza vaccines for three residents, despite having a policy in place. The Assistant Director of Nursing confirmed that the required consent/declination forms were missed.
The facility failed to offer and document COVID-19 vaccination boosters for two residents. One resident's record showed no documentation of education or booster administration, while another's record lacked any vaccination history or status. The Assistant Director of Nursing confirmed that the required documentation was missed for both residents.
The facility failed to use the appropriate assistive device for a resident at high risk for falls, resulting in the resident slipping from a sit-to-stand lift and sustaining a dislocated shoulder. Despite the care plan indicating the need for a sling type mechanical lift, staff used a sit-to-stand lift, leading to the injury.
Failure to Obtain and Document Ordered Daily Weights for Residents With CHF
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document physician-ordered daily weights for residents with congestive heart failure (CHF), and to document reasons when weights were not obtained. One resident with an active diagnosis of heart failure had a physician order for daily weights related to CHF, but the Medication Administration Record showed no weights documented on multiple specified dates. The weight summary showed a significant increase in weight over two days, yet there was no documentation in the electronic medical record that the physician or NP was notified of this variance. Progress notes later documented increased shortness of breath, increased swelling, and altered mental status, leading to transfer to the hospital. The resident’s family member reported concern about fluid retention, swelling, and shortness of breath, and stated the resident was supposed to be weighed daily but was not. The NP and DON both stated the resident should have been weighed daily and that staff should notify the provider for specified weight gains. Another resident with an active diagnosis of heart failure and a care plan focus on ongoing CHF treatment had a physician’s order for daily weights, but the Treatment Administration Record showed that weights were not obtained or documented on multiple dates. The resident, who was cognitively intact, reported leg swelling due to CHF and stated staff weighed them once a week. Nursing staff confirmed the presence of bilateral leg swelling, the use of ace wraps, and that daily weights were an intervention in place, noting that the resident sometimes refused but that refusals should be documented. The DON and other nursing staff acknowledged that daily weights were required per physician order, that reasons for missed weights should be documented, and that nurses are expected to notify the provider for specified weight gains. The facility’s policy on Acute Change in Condition and Clinical Monitoring required daily weights per physician order, documentation in the TAR/MAR, documentation of reasons when weights cannot be obtained, and a nursing assessment of fluid status, which was not consistently followed for these residents.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two residents. Resident R5 experienced a severe weight loss of 16.65% over six months. Despite documented interventions in R5's care plan, there was no evidence of new nutritional interventions after 12/18/23, and significant weight loss was not reported to or evaluated by a physician. Observations showed R5 often struggled to eat without assistance, and staff did not consistently offer the prescribed nutritional supplements or provide necessary feeding assistance. Resident R21 experienced a 15.6% severe weight loss in two months. The facility did not document that R21's significant weight loss was reported to or evaluated by a physician. Additionally, R21 was not consistently provided with the prescribed nutritional supplement, receiving a less nutritious version instead. This discrepancy was not identified or addressed by the dietitian or nursing staff, contributing to R21's continued weight loss. Both residents' care plans included interventions to address their nutritional needs, but these were not consistently implemented or monitored. The facility's failure to follow through with dietary recommendations, provide necessary feeding assistance, and communicate significant weight changes to physicians resulted in severe weight loss for both residents. Observations and interviews with staff and family members highlighted the lack of consistent assistance and monitoring, further contributing to the residents' nutritional decline.
Failure to Label Opened Prepared Foods
Penalty
Summary
The facility failed to label opened prepared foods with the date and time in the refrigerator, which has the potential to affect all 90 residents. On 4/08/24 at 9:00 AM, cole slaw, whipped topping, and sour cream were observed in the refrigerator without labels indicating the date and time they were opened. The Dietary Manager stated that they could not determine how long these items had been in the refrigerator since they were not labeled and decided to discard them. The facility's midnight census as of 4/8/24 was documented as 90.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to obtain orders for oxygen, store, change, and label oxygen and nebulizer tubing in accordance with facility policy, and provide routine cleaning of a humidifier for several residents. Specifically, a humidifier was found in a resident's room without documentation in the medical record or routine cleaning/care. The resident was unsure of the machine's use, and the Director of Nursing (DON) was unaware of its presence, stating that the family brought it in and maintained it. Additionally, nebulizer equipment for another resident was found uncovered and undated, with droplets of medication still present, and there were no documented orders for routine changing of the equipment. Another resident was observed wearing oxygen with an outdated humidification bottle and unlabeled tubing, despite physician orders to change the equipment weekly. Lastly, another resident's oxygen tubing and nasal cannula were found on the floor, with the tubing dated but no storage bag provided, and there were no orders for oxygen administration or routine changing of the equipment in the medical record. The facility's policies for oxygen and nebulizer therapy were not followed, as evidenced by the lack of proper labeling, storage, and routine changing of equipment. The DON confirmed that oxygen and nebulizer tubing should be changed weekly, labeled with a date, and stored in a bag when not in use. However, the observations and interviews revealed that these practices were not consistently implemented, leading to deficiencies in respiratory care for the residents involved. The facility's failure to adhere to its own policies and obtain necessary physician orders contributed to the identified deficiencies in respiratory care management.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as recommended by the CDC, affecting five residents reviewed for EBP. Certified Nursing Assistants (CNAs) V11 and V15 provided urinary catheter care to Resident 31 without wearing gowns and without EBP signage on the door. Resident 31's care plan indicated the need for contact isolation due to MRSA colonization. Similarly, Resident 97, who had an indwelling urinary catheter, did not have EBP signage on the door, and CNAs V11 and V15 did not wear gowns during catheter care. The Director of Nursing/Infection Preventionist admitted that the facility did not have an EBP policy in place yet, although EBP signage was available. Residents 149, 150, and 33 also did not have EBP signage on their doors, and no PPE was available upon entering their rooms. Resident 149 had a urinary catheter and a pressure area on the right buttock, while Resident 150 had Stage II pressure ulcers on both buttocks. In both cases, the staff did not wear gowns during wound treatments. Similarly, Resident 33 had open pressure ulcers on both buttocks, and staff did not wear gowns during wound treatments or catheter care. The lack of EBP signage and PPE availability, along with the staff's failure to wear gowns, were consistent across all observed cases.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of three residents to self-administer medications. During observations, surveyors found bottles of saline nasal spray and artificial tears at one resident's bedside and bathroom, two tubes of Diclofenac on another resident's nightstand, and a bottle of Flonase and three tablets of medication on a third resident's overbed table. None of these residents had documented orders to self-administer these medications or to keep them at the bedside. Additionally, the residents' medical records lacked assessments of their ability to self-administer medications, despite the facility's policy requiring such assessments and physician orders for bedside medication storage. One resident had moderate cognitive impairment, another had severe cognitive impairment, and the third had moderate cognitive impairment. Interviews with staff confirmed that the residents did not have the necessary orders for self-administration or bedside storage of the medications found. The facility's policy mandates that residents must be assessed and deemed appropriate for self-administration, have a written physician order, and store medications in a manner that prevents access by other residents. The policy also requires that unauthorized medications found at the bedside be reported and returned to the resident's representative, which was not followed in these cases.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident (R16) who was reviewed for accidents. According to the facility's Abuse Policy, injuries of unknown source should be investigated within two hours of notification, and the results should be reported to the Illinois Department of Public Health within five days. R16 experienced a fall on 3/14/2024 and was later found to have multiple rib fractures on 3/17/2024 after being transferred to the hospital. However, there was no documentation that the cause of R16's rib fractures was identified or investigated by the facility. The Director of Nursing (DON) and Assistant DON were unaware of R16's rib fractures until 4/9/2024, indicating a lapse in communication and failure to follow the facility's policy. The DON confirmed that an investigation would have been conducted if they had been notified. The Assistant DON speculated that the rib fractures might not be related to the fall since a chest x-ray on 3/14/2024 did not show any fractures, and suggested that the fractures could be due to R16's coughing. The Administrator began an investigation into the rib fractures on 4/9/2024, but this was after the deficiency had already occurred.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for a resident (R21) as required. R21 stated that the facility does not have care plan meetings with her or her family. The medical record shows that R21 was admitted to the facility and had Minimum Data Sets completed on two occasions. However, the last documented care plan meeting for R21 was on 12/28/23, and no subsequent meetings were held within the required quarterly timeframe. The Social Services Director (SSD) and the Assistant SSD confirmed that R21's care plan meeting was missed and was only scheduled after the oversight was realized. The MDS/Care Plan Coordinator admitted to having a large caseload of 95 residents and acknowledged that R21's care plan meeting was overlooked. The facility's policy mandates care plan reviews and updates at least quarterly, but this was not adhered to in R21's case.
Failure to Document and Follow Up on Change in Condition
Penalty
Summary
The facility failed to document and follow up on a change in condition for one resident who reported swelling in their right elbow. The resident, who is cognitively intact, stated that the swelling started about three weeks ago and had informed the nurses about it. Despite the resident's complaints, there was no documentation in the medical record regarding the swelling or any evaluation by the physician. A registered nurse noticed the swelling and left a note for the physician but did not document the condition in the resident's medical record. The Director of Nursing confirmed that any changes in a resident's condition should be documented in the progress notes, which was not done in this case. The facility's policy on changes in a resident's condition requires that significant changes be reported to the physician and documented in the resident's medical record. However, in this instance, the resident's complaint and the nurse's observation were not properly recorded, and there was no follow-up to ensure the resident was evaluated by the physician. The physician was eventually contacted and ordered an elastic bandage wrap, but this was after the surveyors identified the deficiency.
Failure to Complete Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete a comprehensive wound assessment for two residents with new pressure injuries. Resident R150, who was cognitively intact and required assistance for ADLs, developed two Stage II pressure ulcers. Despite having physician's orders for wound care, there was no comprehensive wound assessment documented. R150 expressed discomfort and reported being left in a wheelchair for extended periods, which exacerbated her condition. The staff did not assist her in moving to a more comfortable recliner, as she requested. Similarly, Resident R149, who was also cognitively intact and required substantial assistance for transfer and toileting, developed a pressure ulcer on the right buttock. The treatment was initiated, but no comprehensive wound assessment was documented, and the care plan was not updated until a week later. The facility's policy did not specify the staff responsible for initial wound assessments, leading to a lack of proper documentation and awareness of the residents' conditions. The Assistant Director of Nursing and the Care Plan Coordinator were unaware of the pressure ulcers until much later, indicating a communication breakdown within the facility.
Failure to Secure Oxygen Canisters and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure oxygen canisters were secure and to thoroughly investigate falls, care plan, and implement fall interventions for two residents. On two separate occasions, unsecured, free-standing oxygen cylinders were observed near a resident's doorway. The Director of Nursing confirmed that the oxygen cylinders were not stored appropriately and should have been placed in the oxygen storage room. The facility's policy on oxygen therapy mandates that oxygen be used and stored safely to ensure resident and staff safety. Additionally, the facility did not properly manage fall interventions for a resident who was at high risk for falls. The resident's bed alarm was not connected to an alarming device on multiple occasions, and the chair alarm was inconsistently used. The resident had a history of falls, including unwitnessed and witnessed falls, but the fall investigations were not thorough. The investigations lacked documentation on the last time the resident was checked on, toileted, or if alarming devices were in place during the falls. There was also no evidence that staff were interviewed regarding these falls. The Assistant Director of Nursing confirmed that the fall investigations could be improved and acknowledged that the bed and chair alarms should have been documented in the resident's care plan and tasks. The facility's policies on falls and fall risk management require staff to identify causes and resident-centered interventions to prevent falls and minimize complications, as well as to monitor the efficacy of alarm use. However, these protocols were not adequately followed in this case.
Deficiencies in Urinary Catheter Care and Infection Control
Penalty
Summary
The facility failed to perform complete urinary catheter care, prevent cross-contamination during catheter care, and maintain the urinary collection bag in a dignity bag and off the floor for three residents. For one resident, the CNAs did not check or cleanse the creases between the thighs and genitals after a bowel movement, despite performing other aspects of catheter care. Another resident's catheter care was compromised when a CNA did not change gloves after removing the resident's shoes and failed to retract the foreskin and clean the penis. Additionally, a resident's urinary collection bag was observed uncovered, touching the floor, and without a dignity cover in the dining room and during transport out of the dining room. The facility's Nursing Patient Care Policy & Procedure requires hand hygiene, glove application, cleansing of the suprapubic and pubic area, and retraction of the foreskin for uncircumcised males during catheter care. The policy also mandates that urinary drainage bags be kept off the floor and covered for dignity and infection control. The Director of Nursing/Infection Preventionist confirmed that the observed practices did not align with the facility's policy, indicating a failure to adhere to established protocols for catheter care and infection prevention.
Failure to Complete Psychotropic Medication Assessments and Nonpharmacological Interventions
Penalty
Summary
The facility failed to complete or accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for two residents. Resident R5 was admitted with diagnoses including Anxiety Disorder, Major Depressive Disorder, Delusional Disorder, and Paranoid Personality Disorder. The medical record for R5 documented multiple psychotropic medications but lacked proper assessments, behavior quantification, and nonpharmacological interventions. Additionally, there was no assessment for the increased dose of Escitalopram. The Assistant Director of Nursing confirmed these deficiencies during the review. Resident R14 had diagnoses of Anxiety, Depression, and Dementia and was prescribed multiple psychotropic medications. The psychoactive medication assessment for R14 documented behaviors of anxiety and constantly yelling out but did not include any nonpharmacological interventions or responses to such interventions. The Care Plan Coordinator confirmed the absence of documentation for nonpharmacological interventions or responses. The facility's policy requires specific behavior documentation and assessments on admission and quarterly, which were not followed in these cases.
Failure to Document and Administer Vaccinations
Penalty
Summary
The facility failed to maintain documentation of immunization status and offer/administer Pneumococcal and Influenza vaccines for three residents out of five reviewed in a sample of 31. The facility's policy, dated April 2024, mandates that residents be offered these vaccines based on CDC guidelines, with the Nursing Department responsible for ensuring administration and documentation. However, the records for three residents (R31, R21, R26) did not show that these vaccines were offered or administered. Specifically, R31's record showed previous vaccinations but no documentation of recent offers, R21's record lacked any immunization information, and R26's record showed an outdated vaccination with no recent offers documented. During an interview, the Assistant Director of Nursing (V3) confirmed that the process involves offering vaccines on admission and reviewing hospital records for immunizations. V3 acknowledged that the consent/declination form was missed for the three residents in question and could not provide documentation showing that the vaccines were offered on admission. This lapse in following the facility's policy and CDC guidelines led to the deficiency noted in the report.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer and administer COVID-19 vaccination boosters to two residents, R31 and R21, as required by their policy. R31's medical record showed that they received a COVID-19 vaccine on 5/3/2022 and were admitted to the facility on an unspecified date. However, there was no documentation that education regarding the COVID-19 vaccination was provided to R31, nor was there any record of a COVID-19 booster being offered or administered. Similarly, R21's medical record did not document that COVID-19 vaccinations were offered or given, nor did it include any vaccine history or status. R21 was admitted to the facility on an unspecified date and had diagnoses of Pneumonia, Anemia, and Cerebral Infarction. During an interview, the Assistant Director of Nursing (V3) stated that Flu, Pneumonia, and COVID vaccines are offered upon admission and that hospital records are reviewed for immunizations. V3 acknowledged that the form for documenting consent or declination of vaccinations was missed for both R31 and R21. The facility's policy, revised in January 2024, mandates that the latest COVID-19 immunizations be made available to all residents upon admission unless medically contraindicated or already immunized. The policy also requires documented consent or refusal of the COVID-19 vaccine, which was not provided for R31 and R21.
Inappropriate Use of Assistive Device Leads to Resident Injury
Penalty
Summary
The facility failed to utilize the safest assistive devices for a resident (R1) who was at high risk for falls. R1, who had multiple diagnoses including chronic kidney disease, congestive heart failure, muscle weakness, and unsteadiness on feet, was moderately cognitively impaired and dependent on assistive devices for mobility and hygiene. Despite R1's care plan and physical therapy notes indicating the need for a sling type mechanical lift for transfers, the staff used a sit-to-stand lift, which was not appropriate for R1's condition. This inappropriate use of the sit-to-stand lift led to R1 slipping from the device and sustaining a dislocated shoulder, which required medical intervention in the form of a closed reduction at the emergency room. On the day of the incident, the registered nurse (V6) and two certified nurse aides (V8 and V9) attempted to clean R1 after a bowel movement using a sit-to-stand lift, despite R1's documented need for a sling type mechanical lift. During the process, R1, who was too weak, slipped out of the sit-to-stand lift and was eased to the floor by the CNAs. R1 complained of pain in the right shoulder, which was later confirmed to be a dislocation requiring emergency medical treatment. The incident was corroborated by interviews with the involved staff and a review of R1's medical records and care plan, which clearly indicated the necessity of using a sling type mechanical lift for all transfers due to R1's high fall risk and physical limitations.
Latest citations in Illinois
A resident with severe mental illness, cognitive impairment, and a well-documented history of elopement and exit-seeking was placed on 1:1 monitoring but was allowed by a CNA to be behind a closed bedroom door and out of direct visual supervision, contrary to facility expectations for 1:1 status. During this lapse, the resident exited through a window, climbed a fence, and was later found outside with a displaced foot fracture. In a separate incident, a cognitively intact resident with a history of substance abuse, whose family visits were supposed to be supervised, had an unsupervised visit with grandparents known to bring contraband, was later found unresponsive with signs of overdose, received naloxone, and tested positive for oxycodone despite having no order for it, while his roommate had an active oxycodone prescription and staff found a white powdery substance and related items in the room, indicating a failure to prevent resident access to an unprescribed opioid.
A resident with multiple chronic conditions and severe cognitive impairment was found unresponsive and not breathing, with no documented code status, POLST, or DNR in the medical record. Nursing staff verified the absence of respirations and pulse but did not initiate CPR or call 911. An LPN reported she proposed starting CPR due to the unknown code status, but an RN declined. Leadership and clinical staff stated in interviews that facility practice and expectations are that, when a code status is unknown or no POLST is on file, the resident is to be treated as full code and CPR should be initiated.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident with extensive traumatic fractures, internal injuries, and a long history of chronic pain management was admitted on existing orders for ibuprofen PRN and Percocet for pain, with hospital discharge instructions indicating scheduled Percocet three times daily. During the first night after admission, staff administered only ibuprofen, documented as ineffective, and did not provide any Percocet because the hospital had not sent written narcotic prescriptions and the DON did not obtain a timely verbal order to access Percocet from the emergency kit. The resident repeatedly complained of severe, escalating pain, used the call light frequently, yelled out, and ultimately called 911, signed out AMA, and was transported to the ED, where she reported uncontrolled pain and opioid withdrawal symptoms and received Percocet.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
Surveyors identified multiple unsanitary conditions and ineffective sanitization practices in the kitchen, including a non-functioning, leaking garbage disposal with rotting food, leaking pipes near the ice machine, and a dirty HVAC unit shedding debris onto surfaces. The kitchen door to the dining room was damaged and improperly hinged, and staff reported it had recently been cut and sanded as part of a replacement. The wall-mounted chemical dispenser lacked compatible sanitizer bottles, and when staff prepared sanitizer solution, test strips showed no chlorine present; staff instead used dish soap and multipurpose cleaner from housekeeping to clean food contact surfaces. These failures affected the sanitation of food preparation and service areas for all residents in the facility.
A resident with dementia and behavioral disturbances consistently kept her TV volume excessively loud, to the point it could be heard from the nurse’s station and the end of the hallway, disturbing nearby residents who reported difficulty sleeping and ongoing disruption. Multiple residents stated that the loud TV had been a problem for some time, especially at night, and one reported needing headphones to block the noise. Staff, including an LPN and a CNA, confirmed frequent complaints, noted that the resident became verbally aggressive when asked to lower the volume, and reported that she insisted on keeping her door open and held the remote to prevent staff from adjusting the sound, despite a care plan indicating an agreed-upon lower volume level.
A resident with a known history of aggressive behavior deliberately kicked another resident while residents were lined up for a smoke break, causing the victim to fall onto his hip and later report ongoing left hip pain requiring an X-ray. Multiple witnesses, including another resident and CNAs, described the act as intentional physical abuse. Although an LPN, the DON, and the ADON all recognized the event as reportable abuse under facility policy, facility staff did not call the police or an ambulance for the victim despite his repeated requests, and the Administrator confirmed the incident was not reported to the state surveying agency.
Failure to Supervise High-Risk Resident on 1:1 and Prevent Access to Unprescribed Opioid
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and ensure adequate supervision for residents at high risk for elopement and substance misuse. One resident with schizophrenia, psychosis, major depressive disorder, severe cognitive impairment, and a documented history of wandering, elopement, and exit-seeking behaviors was identified as an elopement risk and placed on an elopement care plan and 1:1 supervision. Nursing and psychiatry notes documented repeated attempts by this resident to use keypads, push and kick exit doors, set off alarms, hover at exits, attempt to climb through windows, and a prior incident of exiting the building and being returned by social services. Despite this, while on 1:1 monitoring, the assigned CNA allowed the resident’s bedroom door to be fully closed and the resident to be out of direct line of sight, contrary to the facility’s expectations that residents on 1:1 remain in continuous visual contact with the aide and that doors not be shut. On the morning of the elopement event, the night-shift CNA reported that the resident had been up visiting, eating, and sleeping, and that at 5:45 AM the resident was in her room on the floor. Shortly thereafter, the resident stated she wanted to use the bathroom; the CNA reported seeing her enter the bathroom with the bedroom door left open so the bathroom door could be observed. When the day-shift CNA arrived to assume the 1:1, she found the bedroom door completely shut, opened it, and was told by the night-shift CNA that the resident was in the bathroom. After briefly leaving to put away her belongings and returning, the day-shift CNA found the resident no longer in the room and the window open. The nurse initiated a headcount and search, and the resident was found outside near a tree, holding herself up due to foot pain. Investigation and hospital records showed the resident had exited through her window, climbed over a fence approximately six feet high, and sustained a displaced fracture of the left metatarsal bone after landing on the ground while attempting to escape. A second deficiency concerns the facility’s failure to ensure a resident with a history of substance abuse was protected from access to an opioid medication not prescribed to him. This resident, cognitively intact with diagnoses including schizophrenia, anxiety disorder, bipolar disorder, and major depression, had a care plan noting behavior problems and a history of returning from family outings intoxicated or under the influence of unknown substances, with instructions that family visits be supervised in common areas. On the day of the incident, the resident, who lived on a locked behavior unit, had an unsupervised visit outside with grandparents known by staff to have previously brought contraband into the building. Later that day, staff observed the resident stumbling in the hallway wearing sunglasses and then becoming unresponsive in his room, with slow, abnormal breathing and no response to sternal rubs. Nurses recognized signs consistent with drug overdose, administered naloxone, and the resident was transferred to the emergency room, where a urine drug screen was positive for oxycodone, despite no oxycodone order for this resident. Further review showed that the resident’s roommate at the time had an active PRN order for oxycodone 5 mg for pain related to a right tibia fracture, and both residents had histories of substance abuse. Staff reported finding a white powdery substance and empty bags with white residue in the overdosed resident’s dresser drawer, and another resident on the unit was found snorting a crushed substance with paraphernalia on his dresser. The DON acknowledged that the overdosed resident had an oxycodone overdose diagnosis from the emergency room and that it was plausible he had taken the roommate’s medication, although the exact source of the oxycodone could not be confirmed. Facility policies required that medications, including controlled substances such as oxycodone, be administered only to the resident for whom they were prescribed and be securely stored in locked compartments inaccessible to residents and visitors, but the events showed that the resident was able to obtain and self-administer oxycodone that was not prescribed to him.
Failure to Initiate CPR for Resident With Unknown Code Status
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) and call emergency medical services for an unresponsive resident whose code status was unknown. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, hypertension, and dysphagia, and was documented as severely cognitively impaired and dependent on staff for several activities of daily living. The resident’s medical record did not contain any documentation of a code status, POLST, DNR order, or other advance directive limiting resuscitative efforts. In the early morning hours, a nurse entered the resident’s room to assist the roommate and observed that the resident was not breathing but was still warm to the touch. The nurse then obtained a second nurse to verify the absence of breathing. The facility’s final investigation report states that the nurse assessed the resident and noted absence of respirations, absence of a palpable pulse, and physical findings consistent with post-mortem changes, and determined the resident had expired. Despite the lack of any documented DNR or advance directive in the record available for review at that time, CPR was not initiated and 911 was not called. Interviews with staff confirmed that the resident’s code status was unknown at the time of the event and that no resuscitative efforts were made. The ADON stated that if a resident’s code status or POLST form cannot be found, the resident is considered a full code, and that when in doubt a resident is a full code. The DON reported that the LPN who found the resident did not know the code status and did not initiate CPR or call 911, even though the resident was a recent admission and no POLST form was on file. The LPN stated she suggested initiating CPR because there was no POLST, but the RN present told her not to start CPR. Other staff interviewed stated that if a resident’s code status is not known or cannot be found, CPR is supposed to be initiated.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Provide Ordered Opioid Analgesia for Resident With Severe Traumatic Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered opioid pain medication to a newly admitted resident with extensive traumatic injuries and a history of chronic pain management. The resident was admitted following a serious motor vehicle accident that resulted in multiple fractures (thoracic vertebrae, ribs, pelvis, sacrum, humerus, ilium), lung contusions, traumatic pneumothorax, liver and spleen lacerations, and hemoperitoneum. Hospital documentation showed that prior to admission the resident had been on Percocet 5-325 mg three times daily as an outpatient and was discharged from the hospital with instructions to continue Percocet 5-325 mg one tablet three times daily (scheduled) and ibuprofen 800 mg every 8 hours as needed for pain. The facility’s physician orders on admission included ibuprofen 800 mg every 8 hours as needed and Percocet 5-325 mg every 8 hours as needed for pain. On the evening and night following admission, the facility administered only ibuprofen and did not provide any Percocet, despite the resident’s repeated complaints of severe pain. The MAR documented that ibuprofen 800 mg was given late in the evening for a pain level of 4 and was noted as ineffective in controlling the pain, with no documentation that Percocet was ever administered. The DON documented that the hospital had not sent written prescriptions (“hard scripts”) for the narcotic pain medication, that the pharmacy reported not receiving such scripts, and that the facility was unable to access narcotics from the emergency kit without a prescription. The DON contacted the pharmacy and the hospital but did not obtain an order that would allow access to Percocet from the emergency kit, and she did not contact a provider at the time she first realized the resident had arrived without the necessary narcotic prescriptions. The DON later stated she was not aware that a verbal order could have been used to access the emergency kit and acknowledged there was a discrepancy between the facility’s PRN Percocet order and the hospital’s scheduled Percocet order, of which she had not been aware. Throughout the night, the resident continued to report uncontrolled pain, which she later described as escalating to 10/10, and she reported yelling out in pain and repeatedly requesting Percocet. CNAs reported that the resident was constantly on the call light, complaining about needing pain pills, threatening to sign out AMA, and yelling out. The DON documented that the resident complained of pain and inability to sleep, had received PRN ibuprofen, and that vital signs were within normal limits; she also noted that the resident had two loose stools but did not associate them with opioid withdrawal. The pharmacy director confirmed that the correct dose of Percocet was available in the emergency kit and that it could have been accessed with a provider’s emergency verbal order. The medical director stated that, had he been contacted sooner, he could have given a verbal order to access Percocet from the emergency kit or ordered transfer to the ER. Instead, after the resident called 911 requesting transport for pain management, the medical director eventually ordered transfer to the ER at the resident’s request, and the resident signed AMA paperwork stating she would not return. In the ER, the resident presented with complaints of pain all over, nausea, vomiting, diarrhea, and reported opioid withdrawal symptoms, with documentation that no pain medication had been administered between the time of admission to the facility and arrival at the ER, approximately 12 hours later. The ER administered Percocet and discharged her with a prescription for Percocet. The facility’s own pain management policy stated that it was the policy of the facility to respect and support the resident’s right to optimal pain assessment and management, and referenced an opioid use policy and procedure. Despite this, the record shows that the facility did not provide the ordered opioid medication, did not resolve the lack of a written prescription in a timely manner through available mechanisms (such as obtaining a verbal order to access the emergency kit), and did not adjust its actions when ibuprofen was documented as ineffective. The combination of the resident’s extensive injuries, documented chronic pain management history, hospital discharge instructions for scheduled Percocet, and the facility’s failure to administer any Percocet or secure timely prescriber authorization led to the resident experiencing uncontrolled pain, reporting opioid withdrawal symptoms, and ultimately signing out AMA and calling 911 for transport to the ER for pain management.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Unsanitary Kitchen Conditions and Ineffective Surface Sanitization
Penalty
Summary
The facility failed to maintain effective sanitizer levels for cleaning food contact surfaces and to keep kitchen equipment in a safe and sanitary condition, potentially affecting all 64 residents documented on the census. During a kitchen walkthrough, surveyors observed a non-functioning garbage disposal containing chunks of food and clotted milk with water leaking from the seals, pooling on the floor, and draining into a floor drain, accompanied by a strong odor of rotting food. The sprayer above the disposal had hard water buildup that caused water to spray outward onto the wall, floor, and surrounding area. Pipes to the ice machine were leaking water down the wall and pooling on the floor. The HVAC unit in the kitchen had a large amount of brownish dirt and debris, including brown fuzzy lint-like material, with some pieces falling onto the surface below. The kitchen door to the large dining room had a broken top hinge, loose bolts, and a jagged, splintered knob-side edge. Staff interviews and observations further showed improper sanitation practices and lack of appropriate chemical supplies. The cook reported the garbage disposal had been leaking and non-functional for about a week and that maintenance staff were aware but unable to fix it. The cook also stated that maintenance staff had been sawing and sanding a replacement door in the kitchen while food was being cooked and served, although the maintenance director later stated the cutting and sanding were done outside. The wall-mounted chemical dispenser above the kitchen sink had no sanitizer bottles attached. When the dishwasher and assistant dietary manager prepared sanitizer solution using the dispenser, test strips showed no chlorine color change, and the dishwasher was unsure what color the strip should turn. The assistant dietary manager stated the facility did not have compatible chemical bottles for the dispenser and that staff were instead using dish soap in sanitizer buckets and multipurpose cleaner from housekeeping. The administrator stated the facility did not have an environmental policy for maintaining equipment.
Failure to Control Excessive TV Noise Affecting Nearby Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain environmental noise at a comfortable level for multiple residents due to one resident’s excessively loud television. Surveyors observed that one resident’s TV volume was so loud it could be heard from the nurse’s station and from the end of the hallway, even with other residents’ doors closed. A sign on this resident’s door stated “Do Not Shut Door,” and staff reported that the resident liked the TV volume loud and was non-compliant with requests to lower it. Nursing notes documented that when asked to reduce the TV volume, the resident became verbally aggressive toward staff. The resident’s diagnoses included unspecified dementia with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, hemiplegia and hemiparesis following cerebral infarction, and restlessness and agitation. Other residents on the same hall reported ongoing disruption from the loud TV, particularly at night when they were trying to sleep. One resident across the hall stated that the loud TV had been an issue for a while and affected other residents on the hall. Another resident one room away reported that the neighbor’s TV was really loud all day and especially at night, that staff were asked to intervene, and that the resident with the loud TV would briefly turn it down and then increase the volume again; this resident reported needing to use headphones to cancel out the noise. Staff, including an LPN and a CNA, confirmed that residents complained they could not sleep due to the loud TV, that the resident with the TV became upset and verbally aggressive when asked to turn it down, and that the TV volume could be heard from the end of the hallway. The care plan for the resident with the loud TV identified a problem of turning the volume up excessively, with an agreed target volume level of 40 and instructions for staff to remind the resident of this agreed volume.
Failure to Protect Resident From Physical Abuse and to Report Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident with a known history of antagonistic, verbally and physically aggressive behavior kicked another resident, causing a fall and subsequent pain. Multiple witnesses, including another resident and two CNAs, reported that while residents were lined up for a smoke break, the aggressor resident grabbed the victim resident’s leg in an attempt to make him fall and, when that failed, deliberately kicked the victim’s left leg or knee, causing him to fall onto his left hip. The victim resident consistently reported that the kick knocked him off his feet, that he landed on his left hip, and that he continued to experience left hip and buttock pain rated 5/10 with walking and lying on his back. A behavior note documented that the aggressor resident stood up from his wheelchair and kicked the victim resident in the leg for no reason, witnessed by residents and staff, and a subsequent nurse’s note documented the victim’s complaint of left hip pain and an order for a left hip and pelvis X-ray. Despite staff recognizing the event as physical abuse and a reportable incident under the facility’s Abuse and Retaliation Prevention and Reporting policy, the facility did not take required reporting and response actions. An LPN stated that the incident was reportable and notified the Administrator, and both the DON and ADON acknowledged that one resident kicking another constitutes physical abuse that should be reported to the state surveying agency and to the police. However, the Administrator confirmed that the facility did not report the incident to the state surveying agency and that facility staff did not call the police or an ambulance for the victim resident, even though the victim repeatedly requested that the police and an ambulance be called. Instead, the aggressor resident independently called 911 for himself. The facility’s own policy defines physical abuse as willful infliction of injury, including kicking, and affirms residents’ right to be free from abuse, but these standards were not followed in this incident.
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