Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lingenfelter Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and documented behavioral symptoms were involved in a physical altercation in which one resident reported being pushed and struck in the face, resulting in small abrasions to the bridge of the nose. A CNA observed one resident standing in front of the other with hands raised, noted bleeding from the injured resident’s nose, and saw the other resident wiping blood from his hand before separating them. In the days leading up to the incident, behavior notes for both residents documented anxiety, delusions, escalating or combative behaviors, and difficulty with redirection, yet there was no evidence that a provider was notified of these behaviors, including combative actions toward staff earlier the same day. Post-incident psychiatric evaluations identified one resident as the aggressor and described the event as traumatic for the injured resident, while facility leadership acknowledged video evidence of a hallway "tuffle" with the aggressor’s hands up and the injured resident’s wheelchair rocking, though the actual contact to the face was not clearly visible.
Two residents with dementia and documented behavioral issues became involved in a physical altercation over a bedside table, resulting in one resident being struck in the face. Staff intervened after the incident, but the altercation led to a visible injury, indicating a failure to protect residents from physical abuse as required by facility policy.
A resident with cognitive impairment and aggressive behavior attacked his roommate in an LTC facility, resulting in injuries. Despite having care plans and monitoring protocols, the facility failed to provide adequate supervision, leading to the altercation. Staff interviews revealed that limited staffing and insufficient intervention contributed to the incident.
A facility failed to provide adequate supervision, resulting in an altercation between two residents with cognitive impairments. One resident, known for aggressive behavior, attacked another, causing injuries. Despite care plans and monitoring protocols, staff did not prevent the incident, highlighting a deficiency in supervision and resident safety.
The facility failed to include actual hours worked for licensed and non-licensed staff on the daily staff posting, as required by their policy. The Resident Care Coordinator was unaware of this requirement, believing payroll was responsible for tracking actual hours. The Administrator confirmed the oversight and stated the regulation would be reviewed with the coordinator.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital twice, but the facility failed to document a physician order for one of the transfers. Staff interviews confirmed that an order is required for hospital transfers, but the facility could not locate the order for the November transfer. The facility's policy mandates physician documentation for necessary transfers.
A resident with severe cognitive impairment and behavioral issues, including wandering and aggression, had a care plan that was not updated to address ongoing sleep disturbances and behaviors. Despite documented symptoms and a medication adjustment, the facility failed to notify the provider of continued issues or revise the care plan accordingly. Interviews with staff indicated that the care plan should have been updated to meet the resident's needs.
A resident on dialysis with severe cognitive impairment was not maintained on the prescribed fluid restriction of 950 cc, as documented fluid intake exceeded this limit on several occasions. Staff interviews revealed a misunderstanding about the flexibility of fluid restrictions, and there was no evidence of physician notification regarding the excess fluid intake, contrary to facility policy.
A facility failed to appoint a qualified individual to direct recreational activities. The Director of Life Enrichment, employed without the necessary certification or experience, did not meet the job requirements. Interviews confirmed the lack of certification, although the Director was close to completing the necessary training.
A resident with severe cognitive impairment and multiple diagnoses was observed receiving less oxygen than prescribed, with the concentrator set at 1.5 liters instead of the ordered 2 liters. This was confirmed by an LPN and corrected after checking the order. The DON highlighted the risk of under-oxygenation if orders are not followed, as per facility policy.
A resident with severe cognitive impairment and multiple diagnoses exhibited behavioral symptoms such as aggression and wandering. Despite documented sleep disturbances, the facility failed to notify the provider or update the care plan after an initial medication adjustment. Interviews with staff and review of facility policy revealed expectations for provider notification and non-pharmacological interventions, which were not met, leading to a deficiency in care.
The facility failed to properly dispose of medications, as observed during medication administration by an LPN. Medications were improperly discarded in the trash instead of using the designated MedSafe bin, contrary to facility policy. Interviews revealed inconsistent disposal practices among staff, highlighting a lack of adherence to established procedures.
The facility failed to maintain a sanitary kitchen, as observed during a tour with the Director of Nutritional Services. Moldy strawberries, a brown grape, and shriveled peppers were found in the refrigerator. Additionally, cockroaches were seen near the dishwasher. The Administrator confirmed the Director's responsibility for daily quality checks to ensure food freshness, as per facility policy.
The facility failed to properly dispose of garbage and refuse, leading to potential pest attraction. Cockroaches were observed in the kitchen, and a grease trap near the garbage dumpster was leaking grease and food particles, which could attract bugs. The facility's policy requires garbage to be stored in a manner inaccessible to pests and storage areas to be kept clean.
The facility's high-temperature dishwasher failed to consistently reach the required temperatures for proper sanitization, with the rinse cycle often falling short of the necessary 180 degrees. The Director of Nutritional Services acknowledged the issue, and a new dishwasher was ordered. However, the dishwasher/Nutrition Service Worker continued using the malfunctioning dishwasher instead of the alternative three-sink method. The Administrator confirmed the potential risk of infection due to improper sanitization.
Two residents with severe cognitive impairments were involved in an altercation due to inadequate monitoring and intervention. One resident, known for wandering, approached another resident with a history of aggression, leading to a physical confrontation. Despite staff intervention, the incident resulted in a minor injury, highlighting a deficiency in preventing resident-to-resident abuse.
The facility did not adequately protect the rights of two residents with severe cognitive impairments, leading to a physical altercation. One resident with vascular dementia and behavioral disturbances reported discomfort with another resident with Alzheimer's and major depressive disorder. Both residents exhibited daily physical and verbal aggression. An incident occurred where a CNA witnessed a scuffle resulting in physical injuries. The aggressor could not recall the event, indicating memory issues. The incident was not immediately intervened, highlighting a lack of supervision to prevent such altercations.
Failure to Prevent Resident-to-Resident Physical Abuse and Respond to Escalating Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident and to adequately respond to escalating behavioral symptoms prior to a resident-to-resident altercation. A facility-reported investigation documented that an altercation occurred in the evening, during which one resident reported being pushed from behind, telling the other resident to leave him alone, and then being struck in the face. The alleged aggressor stated that the other resident approached him, and he responded by pushing and striking the resident in the neck to push him back. A CNA witness statement described observing the alleged aggressor standing in front of the other resident with hands raised, seeing blood on the injured resident’s nose, and observing the aggressor wiping blood from his hand onto his pants. The CNA reported that the injured resident stated he had been hit in the nose, and the CNA intervened by getting between the two residents to separate them. The injured resident had a history of dementia with behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, agitation, and Alzheimer’s disease, with an MDS BIMS score of 00 indicating severe cognitive impairment. Prior neurologic evaluations documented disorganized thinking, mild impairment with confusion, and severe cognitive impairment, but also that the resident was usually able to make himself understood and understand others. Behavior progress notes in the days leading up to the incident (March 23, 28, and 29) documented anxiety, delusions, and escalating behaviors, with no evidence in the clinical record that the provider was notified of these behaviors. Following the altercation, a skin assessment showed two abrasions on the bridge of the resident’s nose, each measuring 0.25 cm, and a psychiatric consultation described the event as somewhat traumatic for the resident and noted a skin tear to the nose. The resident identified as the aggressor also had significant cognitive and behavioral diagnoses, including Alzheimer’s disease, dementia with mood disturbance, psychotic disturbance, other behavioral disturbance, and post-traumatic stress disorder, with an MDS BIMS score of 00 indicating severe cognitive impairment. MDS and behavior notes documented physical and verbal behavioral symptoms directed toward others, rejection of care, other behavioral symptoms, and wandering. Behavior notes in the days before the incident described repetitive behaviors, restlessness, anxiety, delusional statements, pacing, and only short-term effectiveness of redirection, with no evidence that the provider was notified of these behaviors. On the day of the incident, a behavior note approximately three hours before the altercation documented that this resident was combative with staff, including pushing, hitting, and pinching, and was not easily redirected, again with no evidence that the provider was notified. A psychiatric consultation after the incident identified this resident as the aggressor and recorded that he punched his peer in the nose when encountering him in the hallway. The DON later stated that video footage showed the two residents in a “tuffle” in the hallway with the aggressor’s hands up and the injured resident’s wheelchair rocking back and forth in an uncontrolled fashion, but the footage did not clearly show physical contact to the face. The facility’s Resident Rights policy defined physical abuse as the intentional infliction of physical pain or injury to the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of negative physical behaviors, including hitting, kicking, and pushing, was not protected from physical abuse by another resident. The resident's care plan identified issues with being protective of personal space and exhibiting negative behaviors toward others. On the day of the incident, the resident entered a common area and became involved in a physical altercation with another resident who also had a history of negative physical behaviors and severe cognitive impairment. The second resident, who was known to be territorial and required supervision and redirection due to wandering and pacing, engaged in a dispute over a bedside table with the first resident. During the altercation, the second resident balled up his fist and struck the first resident on the cheek, resulting in a visible red mark. Staff intervened to separate the residents and prevent further escalation, but the initial physical contact had already occurred. Staff interviews confirmed that both residents had documented behavioral issues and that the altercation was witnessed by a CNA, who reported the incident according to facility protocol. The facility's policy states a commitment to protecting residents from abuse by anyone, including other residents. Despite this, the incident demonstrated a failure to prevent physical abuse between residents with known behavioral risks.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, resulting in a resident-to-resident altercation involving two residents. Resident #3, who has a history of cognitive impairment, delusional thoughts, and physical aggression, was admitted to the facility with diagnoses including PTSD and dementia. Despite having a care plan that included interventions for monitoring and redirecting behaviors, Resident #3 was involved in an altercation where he physically attacked his roommate, Resident #4, believing he was an intruder in his home. Resident #4, who also has severe cognitive impairment and exhibits physical and verbal behavioral symptoms, was found on the floor with a skin tear and bruising after the altercation. The facility's staff, including CNAs and nurses, were aware of the residents' behavioral issues and had protocols in place for monitoring and addressing such behaviors. However, the incident occurred during a time when staffing was limited, with only one CNA present while another was on break, and the LPN was occupied with other tasks. Interviews with staff revealed that the facility had procedures for handling new admissions and monitoring residents, including 30-minute safety checks for newly admitted residents. Despite these measures, the altercation occurred, indicating a lapse in supervision and intervention. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, yet the incident highlights a failure to protect residents from harm due to inadequate supervision and response to behavioral cues.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, as evidenced by an incident involving two residents. Resident #3, who has a history of cognitive impairment and aggressive behavior, was involved in a physical altercation with Resident #4. The care plan for Resident #3 included interventions for managing confusion, unsafe wandering, and negative physical behaviors, but these measures were not effectively implemented, leading to the altercation. Resident #3 was found to have been the aggressor in the incident, which occurred during the night when staff presence was limited. Resident #4, who also has severe cognitive impairment and requires supervision for activities of daily living, was the victim in the altercation. The incident resulted in Resident #4 sustaining a skin tear and bruising. Despite the care plan indicating the need for close monitoring and interventions to manage behaviors, the facility did not prevent the altercation. The staff on duty at the time of the incident were engaged in other tasks, and the altercation was only discovered after loud noises were heard. Interviews with staff revealed that the facility has procedures for managing new admissions and monitoring residents, but these were not adequately followed in this case. The facility's abuse prevention policy emphasizes the right of residents to be free from abuse, yet the incident highlights a failure to uphold this standard. The lack of effective supervision and timely intervention contributed to the deficiency, putting residents at risk of harm.
Failure to Include Actual Hours on Daily Staff Posting
Penalty
Summary
The facility failed to ensure that all required information was included on the daily staff posting, as mandated by their policy and procedures. Specifically, the daily staff posting dated April 14, 2024, lacked the actual hours worked for each category of licensed and non-licensed staff. This omission was confirmed during a review of the posting by the Resident Care Coordinator, who acknowledged that the postings did not include the actual hours worked. Furthermore, the facility was unable to provide the daily staff posting for January 1, 2024. Interviews conducted with the Resident Care Coordinator and the Administrator revealed a lack of awareness regarding the requirement to include actual hours worked on the daily staff postings. The Resident Care Coordinator stated that she was responsible for updating and posting the daily staff information but was unaware that actual hours needed to be included, as she believed payroll was responsible for tracking this information. The Administrator confirmed that the purpose of the daily staff posting is to inform residents and visitors of staff ratios in the building, and acknowledged that the regulation regarding daily staff postings would be reviewed with the Resident Care Coordinator.
Missing Physician Order for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident's clinical record included the required information for discharge, specifically lacking a physician order for a hospital transfer. The resident, who was admitted with multiple diagnoses including recurrent major depressive disorder, pneumonia, dementia with mood disturbance, agitation, and psychotic disturbance, experienced two short-term unplanned hospital discharges. While the facility had a physician order for the February 12, 2024 hospitalization, there was no evidence of a physician order for the hospitalization on November 7, 2023. Interviews with staff revealed that there is a process in place for handling discharges, including notifying the doctor and obtaining necessary orders. However, the facility was unable to locate the physician order for the November 7, 2023 transfer. The Director of Nursing acknowledged the missing order and stated that an order is expected for each hospital transfer. The facility's policy requires physician documentation in the clinical record when a transfer is necessary for the resident's welfare or other specified reasons.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to reassess and revise the care plan for a resident with severe cognitive impairment and multiple behavioral issues, including wandering and aggression. The resident was admitted with several diagnoses, including chronic obstructive pulmonary disease, malignant neoplasm, metabolic encephalopathy, dementia, major depressive disorder, and insomnia. Despite the resident's care plan indicating the use of psychotropic medications and the need for regular evaluation and adjustment, the facility did not adequately address the resident's intermittent sleep patterns and associated behaviors. The resident exhibited significant behavioral symptoms, such as physical and verbal aggression, rejection of care, and wandering, which were documented in various notes and assessments. Despite these documented behaviors and a physician's order to increase the resident's medication, the facility did not update the care plan to reflect these ongoing issues. The resident's sleep disturbances and behavioral symptoms persisted, yet there was no evidence that the provider was notified of these continued behaviors after the initial medication adjustment. Interviews with facility staff, including an LPN and the DON, revealed that the care plan should have been updated to address the resident's needs. The facility's policies on comprehensive care planning and behavior monitoring emphasize the importance of revising care plans as residents' conditions change. However, the facility did not adhere to these policies, resulting in a care plan that did not meet the resident's needs.
Failure to Adhere to Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to adhere to ordered fluid restrictions for a resident on dialysis, which could potentially lead to complications such as fluid overload. The resident, who was admitted with diagnoses including congestive heart failure and dependence on renal dialysis, had a physician order for a daily fluid restriction of 950 cc. However, the facility's records showed that the resident's fluid intake exceeded this limit on multiple occasions, with no documentation indicating that CNAs notified nursing staff of the excess intake. Interviews with staff revealed a misunderstanding regarding the flexibility of fluid restrictions, particularly in cases of comfort care. A CNA admitted to providing additional fluids beyond the prescribed limit if requested by the resident, while an LPN confirmed that fluid restrictions should be strictly followed regardless of comfort care status. The DON acknowledged the failure to adhere to fluid restrictions and the lack of physician notification about the resident's excessive fluid intake, which was contrary to the facility's policy requiring physician orders to be followed and any deviations to be reported.
Unqualified Activities Director in LTC Facility
Penalty
Summary
The facility failed to designate a qualified individual to provide recreational activities, as required by their policy and procedures. Staff #95, who was employed as the Director of Activities and later as the Director of Life Enrichment, did not possess the necessary certification or prior experience in recreational activities. The employee record showed that staff #95 had only a high school diploma and lacked both certification as an activities professional and two years of prior experience in a social or recreational program. Interviews with the Human Resource Director and the Administrator confirmed that staff #95 had not completed the certification for activities specialist, although the Administrator mentioned that staff #95 was close to finishing the training. The job description for the Director of Life Enrichment required satisfactory completion of a training course approved by the Department of Health and Human Services or certification by a recognized accrediting body, along with two years of experience in a relevant program. The absence of these qualifications in staff #95's record led to the deficiency.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident in accordance with the physician's order. The resident, who was admitted with diagnoses including epilepsy, severe dementia with psychotic and mood disturbances, and anxiety, had a physician's order for 2 liters of oxygen to be administered continuously via cannula or mask. However, during an observation on June 3, 2024, the resident was found with the oxygen concentrator set at 1.5 liters instead of the prescribed 2 liters. This discrepancy was again noted on June 6, when the resident was observed in the dining room with the concentrator still set at 1.5 liters. A licensed practical nurse confirmed the incorrect setting and adjusted it to the correct 2 liters after checking the order. The Director of Nursing acknowledged that a physician's order is necessary for oxygen administration and emphasized the risk of under-oxygenation if the order is not followed. The facility's policy on oxygen administration, dated June 1, 2020, mandates that oxygen therapy be administered as ordered by the physician and that the oxygen flowmeter be reassessed for the correct liter flow. The failure to adhere to the physician's order for oxygen administration could result in hypoxia for the resident.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe cognitive impairment and multiple diagnoses, including dementia and major depressive disorder. The resident exhibited various behavioral symptoms, such as physical and verbal aggression, rejection of care, and wandering, which were documented in the Minimum Data Set (MDS) assessment. Despite these documented behaviors, the facility did not adequately address the resident's intermittent sleep pattern, which was noted in several evaluation notes over a period of time. The resident's care plan included interventions for psychotropic medication management and monitoring for changes in behavior or cognitive function. However, after an initial adjustment to the resident's medication, there was no further evidence that the provider was notified of the continued sleep disturbances and wandering behavior. This lack of communication and follow-up with the provider contributed to the deficiency in care. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that there were expectations for staff to notify providers and offer non-pharmacological interventions for residents with sleep issues. The facility's policy on behavior monitoring also required documentation of behaviors and interventions, as well as updates to the care plan. However, these procedures were not followed, leading to the deficiency in providing necessary behavioral health care and services to the resident.
Improper Medication Disposal Practices
Penalty
Summary
The facility failed to ensure proper disposal of medications in accordance with professional standards of practice, as observed during medication administration. During a medication pass, an LPN attempted to administer five medications to a resident, who spat out Aspirin and Docusate Sodium into the medicine cup. The LPN then improperly disposed of the medicine cup containing the medications by throwing it into the trash can at the nurse's station. In another instance, the same LPN dropped a Depakote capsule onto the medication cart and disposed of it in the trash can along with another capsule. Interviews with staff revealed inconsistent practices regarding medication disposal. One LPN stated that non-narcotic drugs are typically wasted by throwing them in the trash or sharps container, while another mentioned using a gray box in the conference room for disposal, usually involving two nurses. The Director of Nursing emphasized the use of the MedSafe bin for disposing of expired or unused medications to prevent diversion and ensure safety. The facility's policy indicated the use of Tridecon Healthcare Solutions for pharmaceutical waste management, but the observed practices did not align with this policy.
Deficient Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, as observed during a tour of the kitchen with the Director of Nutritional Services. During the inspection of the large walk-in refrigerator, a box of strawberries was found to contain a strawberry with a fuzzy white mold patch. Additionally, a bag of green grapes had a brown grape, and a box of green peppers appeared shriveled and wilted. The Director acknowledged the presence of mold and the poor condition of the produce, stating that it is everyone's responsibility to monitor and remove old food. Furthermore, during a demonstration of the high-temperature dishwasher, two cockroaches were observed running on the floor, which were then picked up by a staff member using a paper towel. The Administrator confirmed that it is the responsibility of the Director of Nutritional Services to ensure daily quality checks are conducted to maintain the freshness and nutritive value of the food. The facility's policy on Food Storage and Date Marking requires perishable foods to be stored immediately upon receipt to assure quality. The Administrator acknowledged the potential risk of foodborne illness if spoiled or non-fresh food is served to residents, highlighting the importance of proper food storage and handling procedures.
Improper Garbage Disposal and Pest Attraction
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, which could attract rodents and pests. During an initial tour of the kitchen, two cockroaches were observed running on the floor from the dishwasher to under the sink. A staff member used a paper towel to pick up the cockroaches. Additionally, a tour of the garbage/refuse area revealed a large grease trap next to the garbage dumpster, with grease dripping onto the ground and covering a large area. Small particles of food and grease were visible on the grease trap, which staff acknowledged could attract bugs. The facility's policy on garbage disposal requires that garbage containing food wastes be stored in a manner inaccessible to pests and that storage areas be kept clean at all times.
Dishwasher Temperature Deficiency in Kitchen
Penalty
Summary
The facility failed to ensure that essential kitchen equipment, specifically the high-temperature dishwasher, was maintained and in safe operating condition. During an initial tour of the kitchen, it was observed that the dishwasher did not consistently reach the required temperatures for proper sanitization. The wash cycle consistently reached 150 degrees, but the rinse cycle repeatedly failed to reach the necessary 180 degrees, with temperatures recorded at 145 degrees multiple times. The Director of Nutritional Services acknowledged the issue and mentioned that a new dishwasher had been ordered. However, the dishwasher/Nutrition Service Worker stated that he had never used the alternative three-sink method for washing dishes and continued to run the dishwasher until it reached the correct temperatures. The Maintenance Manager attempted to adjust the dishwasher, achieving a rinse cycle temperature of 150 degrees, but this was still below the required range. The Administrator confirmed the potential risk of infection due to improper sanitization if the dishwasher did not reach the appropriate temperatures. The CMA Dishmachines Owner's Manual specifies that the wash cycle should be between 155 to 160 degrees and the rinse cycle between 180 to 195 degrees, indicating that the facility's dishwasher was not operating within these guidelines, potentially compromising the safety of the dishware used for residents.
Resident-to-Resident Altercation Due to Inadequate Monitoring
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, leading to a deficiency. Resident #69, who has severe cognitive impairment due to dementia, exhibited wandering behavior and entered other residents' personal spaces. On multiple occasions, Resident #69 was noted to wander aimlessly, move furniture, and interact with other residents inappropriately. Despite having a care plan that included monitoring and redirecting the resident, these interventions were not effectively implemented, resulting in an altercation with another resident. Resident #25, also with severe cognitive impairment and a history of aggressive behavior, was involved in the altercation with Resident #69. This resident's care plan included interventions to manage physical aggression and anxiety, particularly during interactions with others. However, on the day of the incident, Resident #25 was observed to be anxious and became physically aggressive when approached by Resident #69. The altercation resulted in Resident #25 sustaining a superficial scratch on her arm. The incident was captured on the facility's camera system, showing Resident #69 approaching Resident #25, leading to a physical confrontation. Staff intervened quickly to separate the residents, but the facility's failure to prevent the altercation indicates a deficiency in protecting residents from abuse. The facility's policy on abuse prohibition emphasizes the need for prevention and protection, which was not adequately upheld in this case.
Resident Rights and Safety Concerns Due to Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect the rights of two residents, identified as #520 and #525, to be free from abuse from each other. Resident #520 had diagnoses of vascular dementia with agitation/behavioral disturbances, while Resident #525 had Alzheimer's disease, major depressive disorder, and dementia with agitation/behavioral disturbances. Both residents exhibited severe cognitive impairments and displayed physical and verbal behavioral symptoms directed towards others on a daily basis. An incident on February 24, 2024, involved a scuffle between the two residents, resulting in physical injuries such as abrasions on their bodies. Resident #520 reported feeling uncomfortable with Resident #525's presence in the room, leading to a confrontation where both residents engaged in physical aggression towards each other. The facility's incident report detailed that a certified nursing assistant (CNA) witnessed the altercation between the two residents, with Resident #525 being identified as the aggressor. The report highlighted that Resident #525 was unable to recall the event, indicating potential memory issues. The facility's documentation also revealed that Resident #520 exhibited loud verbal outbursts and physical aggression towards others, while Resident #525 was described as getting easily triggered by loud voices. The report emphasized that the incident was not witnessed by anybody else, indicating a lack of immediate intervention or supervision to prevent resident-to-resident altercations. During interviews with staff members, it was noted that Resident #520 had a history of being verbally and physically aggressive, while Resident #525 was described as easy-going but prone to moments of anger and difficulty in redirection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kingman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gardens Rehab & Care Center | 0 mi | ★★★★★ | 6 | 0 |
| Desert Highlands Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| The Legacy Rehab & Care Center | 29.7 mi | ★★★★★ | 3 | 0 |
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