Above 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 Pleasant View Luther Home during CMS and state inspections, most recent first.
A RN gave a CNA a cup with physician-ordered pain medication to pass to a resident instead of administering it herself. The CNA said she believed the pills were Tylenol and delivered them because the RN was busy with another resident and on the phone with the pharmacy. The RN also admitted to previously giving a CNA another resident’s pain medication to administer.
A resident with impaired mobility and poor balance, assessed as a moderate fall risk, was left unsupported on the toilet during personal hygiene care after being transferred with a sit-to-stand lift. The CNA removed the lift sling and raised the enabler bar, leaving the resident unable to maintain balance, which resulted in a fall to the floor.
A resident experiencing depression and emotional distress following a separation and impending divorce did not receive psychosocial service interventions. The Social Service Director confirmed that the resident was not assessed for his feelings, was not included in any psychosocial programming, and that no such programs were available, with residents only attending general activities.
Two residents experienced improper handling of a bed bug infestation, with staff failing to consistently bag and remove all clothing and personal items, provide showers before room transfers, or document the incident and treatment. Staff interviews revealed confusion about procedures, and observations showed unbagged items left in affected rooms, contrary to facility policy and pest control recommendations.
A resident with a history of falls and cognitive impairment sustained a C1 fracture after tripping over another resident's wheelchair in a crowded dining area. Staff confirmed that the space was too narrow for safe ambulation and the resident's walker was not accessible, despite care plan interventions requiring its use. The facility did not identify or address environmental hazards or update fall prevention strategies after previous incidents.
A resident with dementia and major depressive disorder had her Zoloft dose reduced without her POA's knowledge or consent. The POA discovered the change after noticing the resident's emotional state and reviewing medication records. Facility documentation did not show consent for the dose reduction, and staff confirmed that notification and consent should have been obtained.
A resident's representative filed a grievance after finding the resident in bed, soaked in urine and not provided breakfast. Despite communicating concerns to a Resource Nurse and Social Service, the representative did not receive any follow-up or notification regarding the investigation or resolution of the grievance, contrary to facility policy requiring timely communication of grievance outcomes.
A resident who was frequently incontinent and required extensive ADL assistance did not receive timely incontinence care, resulting in the resident being found soaked in urine by a family member. Staff interviews confirmed that the resident was not checked or changed for an extended period, despite care plan interventions to keep the resident dry and prevent skin breakdown.
The facility failed to comply with its policies on hair restraints, food storage, and chemical storage, potentially affecting 76 residents. Kitchen staff did not fully cover their hair, and several food items were found unlabeled and undated. A Sanitizer chemical was improperly stored in the Dry Food Storage Room.
The facility did not ensure that its staff were trained in Hospice and End of Life Care for residents receiving hospice services. A RN and an LPN lacked the necessary education, and the administrator admitted the training was not assigned or completed. The RN confirmed she had not received such training since her hire.
A facility failed to follow proper infection control practices during a pressure ulcer dressing change for a resident. An RN did not perform hand hygiene or change gloves appropriately, using the same soiled gloves to cleanse the wound, apply ointment, and handle personal items and surfaces. The RN also disposed of garbage and moved an overbed table without sanitizing hands, contrary to the facility's infection control protocols.
The facility failed to follow its policy for changing and labeling oxygen tubing and humidifier bottles weekly for two residents. One resident had a humidifier bottle dated over a week old and undated tubing, while another had both the humidifier bottle and nasal cannula undated. The DON confirmed the policy requirement.
A facility failed to obtain written physician orders from Hospice providers for a resident with a terminal prognosis. Hospice orders were often given verbally, and facility nurses entered them into the EHR without written documentation. This led to confusion among staff, as one nurse was unaware of the correct method to administer Ativan. The lack of written orders and clear communication contributed to the deficiency in care.
A facility failed to document a clinical rationale for extending a PRN psychotropic medication order for a resident. The policy requires PRN orders to be limited to 14 days unless a rationale is documented. A resident had an order for Alprazolam for 30 days without a documented rationale. An LPN confirmed the extension was made without written justification.
The facility failed to ensure proper coordination and documentation of hospice services for residents, affecting three individuals with Alzheimer's Disease. Necessary hospice care plans, prescribers' orders, and clinical notes were missing from medical records. Communication between hospice and facility staff was primarily verbal, leading to insufficient documentation.
The facility failed to post Ombudsman contact information on resident floors, affecting all 77 residents. Residents were unaware of how to contact the Ombudsman, and the only poster was located on the first floor, where no residents reside. The Community Ombudsman had not visited in over a year and had difficulty reaching the Activity Director.
The facility failed to make the Survey Binder, containing prior survey results, accessible to residents. Residents were unaware of the binder's existence and location, which was found placed out of reach and view behind picture frames on a high ledge. Additionally, the binder lacked recent survey results, affecting all 77 residents.
The facility failed to provide written notifications to residents or their representatives regarding hospital transfers, affecting six residents. The administrator confirmed reliance on verbal notifications, contrary to policy requirements for written communication. This deficiency could impact all 77 residents.
The facility failed to provide the Bed Hold Policy to residents or their representatives during emergency hospital transfers, affecting six residents. The policy requires notification before hospitalization and at the time of transfer, but documentation showed no evidence of compliance. The Social Security Director confirmed that notifications were not provided as required.
A resident with dementia was sexually abused by another resident with a history of problematic behaviors in an LTC facility. The incident involved inappropriate touching and resulted in the victim feeling frightened and requiring hospital examination. Despite known risks, the facility failed to prevent the incident, leading to an Immediate Jeopardy situation.
A facility failed to implement its abuse prevention program, resulting in incidents of inappropriate sexual behavior between two residents. Despite policies requiring abuse screenings and reporting, these were not conducted or escalated, leaving residents vulnerable. The facility's inaction and lack of communication led to a deficiency in protecting residents' safety and rights.
A facility failed to report and investigate potential resident-to-resident sexual abuse involving two cognitively impaired residents. A CNA observed inappropriate behavior and reported it to an RN, who did not escalate the issue to the Abuse Coordinator, believing the residents could consent. The facility's policy on immediate reporting was not followed, and the administrator later confirmed the residents could not consent due to dementia.
A resident with Alzheimer's and other health issues, requiring assistance for ambulation, fell and fractured her femur due to a CNA's failure to use a gait belt as per facility policy. The incident led to a decline in the resident's condition and subsequent death. The CNA admitted to not using the gait belt, which was required for safety.
A facility failed to immediately report an allegation of physical abuse by a CNA towards a resident. The incident was reported the next morning, violating the facility's policy requiring immediate notification to the Administrator or Abuse Coordinator.
Medication Passed by CNA Instead of Licensed Nurse
Penalty
Summary
The facility failed to ensure that licensed staff dispensed physician-ordered medications for one of three residents reviewed for medication administration. The facility’s Medication Administration General Guidelines state that medications are to be administered as prescribed and only by persons legally authorized to do so, and that personnel authorized to administer medications must be familiar with the medication. R1’s physician order sheet showed an order for Tylenol 325 mg, 2 tablets every six hours as needed for pain. Interview and record review showed that a Registered Nurse gave a Certified Nursing Assistant a cup containing medication to pass to residents. The Administrator documented that the RN admitted giving the CNA Tylenol to give to R1 because she was on the phone with the pharmacy and could not get away to administer it herself. The CNA stated that the RN handed her two pills to give to R1 and that she believed they were Tylenol. The Administrator also documented that the RN had previously given a CNA a Norco to give to another resident. The facility verified that both the RN and CNA were terminated for gross misconduct.
Failure to Implement Safety Interventions During Toileting Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement appropriate safety interventions for a resident identified as being at moderate risk for falls. The resident, who had impaired mobility and poor sitting/standing balance, was transferred to the toilet using a sit-to-stand mechanical lift. During personal hygiene care, the Certified Nursing Assistant (CNA) removed the lift sling and raised the enabler bar to provide more room, leaving the resident unassisted on the toilet. The resident was unable to maintain posture and balance, resulting in a fall to the floor. The facility's policies required that the harness safety strap be securely fastened and that the resident be properly supported during transfers and toileting. However, the CNA unhooked the resident from the lift and did not reapply the top harness before attempting to move the resident's feet onto the sit-to-stand lift. The CNA confirmed that the resident was unable to balance or stand without assistance, and that the enabler bars were intended for residents who could stand independently. The lack of proper support and supervision directly led to the resident's fall.
Failure to Provide Psychosocial Services for Resident in Emotional Distress
Penalty
Summary
The facility failed to provide psychosocial service interventions for a resident who was experiencing significant emotional distress due to a recent separation and impending divorce after more than 40 years of marriage. The resident reported feeling very depressed and stated that he would act out at times because he did not know how to handle his personal situation. He also indicated that the only interactions he had with the Social Service Director or other staff were when he was in trouble, and that no one had asked him about his feelings or what he was going through. The Social Service Director confirmed that the resident was not included in any psychosocial programming, had not been assessed regarding his feelings about the divorce, and that there were no psychosocial programs available in the facility, with residents only participating in general activities.
Failure to Follow Bed Bug Infection Control Protocols
Penalty
Summary
The facility failed to follow recommended guidelines for infection prevention and control in response to the presence of bed bugs in the rooms of two residents. Staff discovered bed bugs in one resident's room, and although clothing was bagged and removed on one occasion, there were inconsistencies in the handling of personal items and the timing of room treatment. On a previous occasion, not all clothing or items in drawers were removed, and staff questioned whether proper treatment was performed, as another live bed bug was found later. The pest exterminator did not arrive until several days after the initial report, and during this period, one resident was isolated in the room while the other was moved to a different room. Observations revealed that personal items such as shoes, socks, and toiletries were left unbagged in the affected rooms, contrary to the facility's own policy and the pest exterminator's recommendations. Staff interviews indicated a lack of consistent education and communication regarding the proper procedures for handling bed bug infestations. Some staff were unaware of the need to shower residents before moving them out of infested rooms, and there was confusion about the appropriate steps to take when bed bugs were found. Additionally, there was no documentation in the residents' medical records regarding the discovery of bed bugs or the treatment provided. The facility's policy required that all clothing and personal items be bagged, residents be showered and dressed in clean clothing from outside the room, and that personal belongings not leave the room until deemed bed bug free. However, these procedures were not consistently followed, as evidenced by staff and resident reports, lack of documentation, and direct observation of unbagged items remaining in the rooms. The failure to adhere to established protocols contributed to the ongoing presence of bed bugs and inadequate infection control practices.
Failure to Prevent Fall Due to Environmental Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to identify and address environmental hazards and did not implement effective fall prevention interventions for a resident with a known history of falls. The resident, who was assessed as a high fall risk due to Alzheimer's, vascular dementia, muscle weakness, and other conditions, required assistance with activities of daily living and was supposed to use a walker for support. On the day of the incident, the resident attempted to leave the dining room table, but the space was too narrow due to the placement of another resident's large wheelchair and a water cooler. The resident's walker was not accessible, and he attempted to step over the wheelchair, resulting in a fall that caused a head injury and a C1 (neck) fracture. Multiple staff interviews confirmed that the dining room layout did not provide adequate space for safe ambulation, especially for residents with mobility aids. The resident had a documented history of previous falls, and the care plan included interventions such as ensuring the use of a walker and anticipating the resident's needs. However, the care plan had not been updated with new interventions following recent falls, and environmental hazards in the dining area were not addressed. The facility's fall prevention policy required identification and mitigation of environmental risk factors, but these measures were not effectively implemented, directly contributing to the resident's accident.
Failure to Notify POA of Antidepressant Dose Change
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) regarding a change in the resident's antidepressant medication. The resident, who has diagnoses of dementia and major depressive disorder, had her Zoloft dose decreased from 75 mg to 50 mg without the knowledge or consent of her POA, who is also her daughter. The POA discovered the change after returning from vacation and noticing the resident was tearful and emotional. Upon reviewing the medication record, the POA found the dose reduction and stated she had not consented to it. The medication was later returned to the original dose at the POA's request, and subsequently increased with her consent. Review of the resident's psychotropic consent forms showed that the dose reduction to 50 mg was not documented, nor was there any record of the POA's consent for this change. The facility's resource nurse confirmed that the POA should be notified and consent obtained for any medication changes. The lack of notification and consent for the medication adjustment constituted a failure to follow required procedures for informing a resident's representative of significant changes.
Failure to Notify Resident Representative of Grievance Resolution
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative of the resolution of a grievance. The resident's daughter and Power of Attorney (POA) arrived at the facility and found the resident in bed, soaked in urine, with a strong urine odor in the room, and the resident had not been gotten up or fed breakfast. The POA communicated her concerns to the Resource Nurse via text and in person, expressing her desire to file a grievance and requesting follow-up. Despite this, the POA reported that she did not receive any communication from the facility regarding the findings or resolution of her grievance for nearly a month. The Resource Nurse confirmed receiving the grievance and acknowledged that an update should have been provided within 24 hours, but no follow-up communication was made to the POA. The Social Service staff completed a grievance form and documented the concern, but also did not notify the POA of the facility's response or findings. The facility's grievance policy requires that the resident or their representative be informed of the investigation's findings and corrective actions within seven working days, which was not done in this case.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of urine and required extensive assistance with activities of daily living did not receive timely incontinence care. The resident's facility assessment indicated a need for assistance with toileting and transfers. On the morning in question, the resident's daughter arrived to find the resident still in bed, soaked with urine, and attempting to get out of bed. The room had a strong urine odor, and the daughter was upset that the resident had not been toileted. Interviews with staff revealed that the night shift CNA last offered toileting at 2:30 AM, which the resident refused, and did not check on the resident again before the end of the shift. The day shift CNA reported only peeking into the resident's room at intervals without checking if the resident was wet or offering toileting assistance. The resident was not checked or changed until the daughter arrived and found the resident in a soiled state. The care plan for the resident included interventions to keep the resident dry and prevent skin breakdown, but these were not followed as documented.
Non-compliance with Food Safety and Storage Policies
Penalty
Summary
The facility failed to adhere to its policies regarding hair restraints, food storage, and chemical storage, which could potentially affect the safety and quality of food consumed by 76 of the 77 residents. Observations revealed that several kitchen staff members, including the Culinary Services Director, did not have their hair completely covered while in the kitchen, contrary to the facility's Use of Hair Restraints Policy. Staff members were seen with hairnets or caps that did not fully cover their hair, with tendrils, bangs, and beards left exposed. Interviews with the staff confirmed that they were aware of the requirement to cover all hair while in the kitchen. Additionally, the facility did not comply with its Storage Procedures and Date Marking Policies. Several food items in the Freezer, Walk-in Cooler, and Bakery Freezer were found without labels or dates, including individually wrapped meatloaf portions, a bag of rice, a pitcher of lemonade, sliced potatoes, sub sandwiches, and bags of cookies. Furthermore, a container of Sanitizer chemical was improperly stored in the Dry Food Storage Room, which is against the facility's policy that prohibits storing chemicals in food storage areas. The Kitchen Manager acknowledged the misplacement of the Sanitizer and the lack of labeling on the cookies.
Lack of Hospice and End of Life Training for Staff
Penalty
Summary
The facility failed to ensure that its staff were educated and competent in providing Hospice and End of Life Care for nine residents receiving hospice services. The Hospice Agreement for Nursing Facility, Inpatient and Inpatient Respite Care Services required that employees be familiar with the needs of hospice patients and competent in their care. However, training transcripts for a Registered Nurse and a Licensed Practical Nurse did not indicate that they had completed the necessary Hospice or End of Life education. The facility administrator acknowledged that the training was not assigned or completed for these staff members upon their hiring. Additionally, the Registered Nurse confirmed that she had not received any Hospice or End of Life training since her date of hire.
Inadequate Infection Control During Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the care of a resident with a pressure ulcer. Specifically, a Registered Nurse (RN) did not perform hand hygiene or change gloves appropriately during a dressing change for a resident with a pressure ulcer located in the coccyx area. The RN used the same soiled gloves to cleanse the wound and apply ointment and dressings, and then proceeded to handle personal items and other surfaces without performing hand hygiene. This included retrieving a marker from her pocket, signing and dating the dressing, and placing the marker back into her pocket without changing gloves or sanitizing hands. Furthermore, the RN continued to handle various items and surfaces with soiled gloves, including gathering treatment supplies, wiping scissors, and cleaning the overbed table. The RN also disposed of the garbage and moved an overbed table into another resident's room without performing hand hygiene. The Director of Nursing confirmed that hand hygiene should be performed between soiled and clean tasks and after removing gloves, which was not adhered to in this instance.
Failure to Change and Label Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R25 and R127, by not adhering to the policy of changing and labeling oxygen tubing and humidifier bottles weekly. For R25, the physician's orders required oxygen to be administered at 1-3 liters per minute via nasal cannula, with the tubing and humidifier bottle to be changed and labeled every Sunday night shift. However, on February 25, 2025, the humidifier bottle was dated February 16, 2025, and the oxygen tubing was not dated. Similarly, for R127, the orders specified oxygen at 2 liters per minute with the same weekly change and labeling requirement. On the same day, the humidifier bottle and nasal cannula for R127 were found undated. The Director of Nursing confirmed that the facility's policy mandates weekly dating and changing of these items.
Failure to Obtain Written Hospice Orders
Penalty
Summary
The facility failed to ensure that Hospice providers supplied written physician orders for a resident receiving Hospice services. The Hospice's agreement allowed nurses to receive and transcribe physician orders, which were to be countersigned by the facility's Director of Nursing or another nurse. However, for the resident in question, the facility did not have written documentation of medication order changes, aspiration risk orders, or instructions for administering medications. The resident's care plan indicated they were admitted to Hospice services with a terminal prognosis related to Alzheimer's Disease and Severe Protein Malnutrition, and they expired without the facility having complete Hospice documentation. Interviews with facility staff revealed that Hospice orders were often given verbally, and it was the responsibility of the facility nurses to enter these orders into the Electronic Health Record. The facility's Director of Nursing and Registered Nurses acknowledged that verbal orders were taken without written documentation, and the Hospice nurses did not leave progress notes or plans of care at the facility. This lack of written documentation led to confusion among the nursing staff, as one nurse admitted to not knowing the correct method of administering Ativan to the resident. The absence of written orders and clear communication between the Hospice and facility staff contributed to the deficiency in care provided to the resident.
Lack of Documentation for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to document a clinical rationale for extending a PRN psychotropic medication order for a resident. The facility's policy requires that PRN orders for psychotropic medications be limited to 14 days unless the prescriber provides a documented rationale for extending the order. In this case, a resident had an order for Alprazolam, a psychotropic medication, to be administered as needed for anxiety for 30 days, three times per day. However, the clinical record did not include a documented rationale for extending the order beyond the standard 14 days. A Licensed Practical Nurse confirmed that the order was extended to 30 days without a written rationale, suggesting it was done to prevent the order from dropping off after 14 days.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure that hospice services were properly coordinated and documented for residents receiving hospice care. Specifically, the facility did not have the necessary hospice care plans, prescribers' orders, or clinical/progress notes available in the medical records for three residents under hospice care. This deficiency was identified during a review of hospice care management for a sample of 38 residents, affecting three residents with Alzheimer's Disease, one of whom had a terminal prognosis and expired during the review period. Interviews with facility staff and hospice personnel revealed that communication between the hospice and the facility was primarily verbal, with hospice nurses not leaving their notes at the facility. The Director of Nursing acknowledged that hospice orders were sometimes given verbally, and the Administrator admitted to having insufficient information in the facility's records. The hospice registered nurse confirmed that new orders or changes in care needs were communicated verbally, and there was uncertainty about whether the hospice office provided the facility with the necessary records.
Ombudsman Contact Information Not Visible to Residents
Penalty
Summary
The facility failed to ensure that the Ombudsman contact information was visible to residents on the second, third, and fourth floors. This deficiency was identified through observations, interviews, and record reviews. Residents from these floors attended a Resident Group meeting and expressed their unawareness of who the facility Ombudsman is, how to contact them, and reported not seeing any Ombudsman postings on their respective floors. The only Ombudsman poster was found at the entrance on the first floor, where no residents reside. Additionally, the Community Ombudsman reported not having visited the facility for over a year and mentioned unsuccessful attempts to contact the Activity Director, who did not return calls. The Activity Director claimed that the Community Ombudsman visits periodically but has not attended Resident Council Meetings. This lack of visibility and communication regarding the Ombudsman potentially affects all 77 residents residing in the facility.
Inaccessible Survey Binder and Missing Records
Penalty
Summary
The facility failed to ensure that the Survey Binder, which includes all prior survey results conducted by the State Agency, was easily accessible to residents. This deficiency was identified during a Resident Group meeting where several residents expressed their unawareness of the existence of such records and their location. The facility's policy states that residents have the right to see reports of all inspections from the last five years, but the residents reported not having seen this information or knowing where to find it. Upon investigation, it was found that the Survey Binder was placed on the upper level of the receptionist desk, approximately four and a half feet from the floor, and obscured behind two picture frames. This placement made it difficult, if not impossible, for residents, particularly those in wheelchairs, to see or reach the binder. Additionally, the binder was missing several recent survey results, including complaint or facility-reported incidents from the past year. The administrator confirmed the binder's location and acknowledged its inaccessibility to residents.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the reasons for their transfer to a hospital. This deficiency was identified for six residents who were transferred to the hospital for various reasons, including falls, changes in condition, and medical emergencies. The facility's policy requires that residents and their representatives be notified in writing and in a language they understand before a transfer or discharge occurs. However, in these cases, there was no documentation indicating that such written notifications were provided. The administrator confirmed that the facility does not provide written transfer forms to residents or their representatives, relying instead on verbal notifications. This practice was found to be inconsistent with the facility's own policy and regulatory requirements. The lack of written notification has the potential to affect all 77 residents residing in the facility, as it does not comply with the necessary procedures for informing residents and their representatives about transfers or discharges.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to residents or their representatives during emergency hospital transfers, as required by their own policy. This deficiency was identified for six residents who were transferred to the hospital for various reasons, including falls, changes in condition, and passing a large clot. The facility's policy, dated December 4, 2020, mandates that a Notice of Bed Hold and Readmission Policy be provided before hospitalization or leave, with a second notice given at the time of transfer or within 24 hours of an emergency. However, documentation for residents R1, R5, R6, R11, R31, and R127 showed no evidence that such notices were provided during their respective hospital transfers. Interviews and record reviews revealed that the facility's Social Security Director acknowledged that residents only sign a bed hold contract upon admission and not with each hospital transfer or discharge. This practice contradicts the facility's stated policy and was confirmed by the inability to produce any bed hold notifications for the affected residents. The facility's CMS 671 Form indicated that 77 residents currently reside in the facility, suggesting that the failure to provide bed hold notifications could potentially affect all residents in the facility.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with dementia from sexual abuse by another resident, who also had dementia and a known history of problematic behaviors such as pacing, wandering, disrobing, and aggression. This incident occurred when the second resident placed his hand down the first resident's pants and performed aggressive sexual motions, resulting in the first resident feeling frightened and requiring a hospital examination where a minor tear near her vagina was noted. The incident was observed by a CNA during routine room checks, who then separated the residents and reported the incident. The first resident, who was severely cognitively impaired, had diagnoses including Alzheimer's Disease, Anxiety Disorder, Depression, and Unspecified Dementia with Agitation. The second resident, who was moderately cognitively impaired, had diagnoses including Vascular Dementia, Unspecified Dementia, Anxiety Disorder, and Major Depression Disorder. The second resident's care plan included monitoring for behaviors such as pacing, wandering, disrobing, and aggression. Despite these known risks, the facility did not adequately prevent the incident from occurring. The facility's policy on abuse and neglect emphasized the residents' right to be free from abuse, including sexual abuse, and required steps to be taken to ensure residents' protection when there is a suspicion of incapacity to consent to sexual activity. However, the facility failed to implement these policies effectively, as evidenced by the incident and the lack of prior intervention despite previous similar occurrences. The facility's failure to protect the resident from abuse resulted in an Immediate Jeopardy situation.
Removal Plan
- A head-to-toe assessment was completed on R1 and 1:1 monitoring was initiated for R2.
- Local police were contacted.
- R1 was sent out to the local hospital for evaluation and returned from the hospital with findings of a vaginal abrasion.
- R2 was maintained on 1:1 monitoring.
- Head-to-toe assessments were completed for each female resident residing on the memory care unit with no findings.
- Further staff interviews conducted with those who worked on the memory care unit with no findings of sexual abuse between R1 or R2 or any other residents.
- R1 was moved to a new room on a different floor.
- Care plan training for IDT for care planning requirements for actual/potential resident to resident abuse completed.
- Care plan updates completed on R1 and R2.
- Head to toe assessments conducted on all residents for signs and symptoms of abuse.
- Completion of the trauma abuse screening assessments on all residents to assess for signs and symptoms of abuse.
- Training took place on utilizing the Abuse and Neglect of a resident policy which includes exploitation and the prevention, detection and reporting expectations for all types of abuse. Training of all staff to be completed in person, or a call to that team member. Administrator was in-serviced by Regional Operations Director. Any team member who has not completed the training will not be able to work until training is completed.
- Administrator or designee will randomly interview four residents for any potential abuse allegations.
- Administrator or designee will interview four staff members to verify their understanding of the identification and reporting of abuse requirements.
- Results from the interviews will be reviewed by the QAPI Committee for any additional recommendations.
Failure to Implement Abuse Prevention Program
Penalty
Summary
The facility failed to implement its abuse prevention program effectively, leading to a deficiency in protecting residents from sexual abuse. Two residents, R1 and R2, were involved in incidents where R2 was observed engaging in inappropriate sexual behavior towards R1. Despite R1 being severely cognitively impaired and R2 being moderately cognitively impaired, the facility did not conduct the required abuse and neglect screenings since their admissions. The facility's policy mandates such screenings upon admission and quarterly, but these were not performed, leaving the residents vulnerable. The incidents included R2 attempting to lay in bed with R1 and being found in a compromising position with R1, which was witnessed by a CNA. The CNA reported these incidents to a nurse, but the nurse did not escalate the reports to the Abuse Coordinator as required by the facility's policy. This lack of reporting and follow-up allowed the situation to persist without appropriate intervention or preventive measures, such as room changes or increased supervision. Furthermore, the facility's staff, including the Social Service Director and the Administrator, were not informed of the incidents in a timely manner, which hindered their ability to take corrective actions. The facility's failure to adhere to its own policies and procedures for abuse prevention and reporting resulted in a deficiency, as the residents' safety and rights were compromised. The facility did not take adequate steps to protect the residents during the investigation, and the lack of communication and documentation contributed to the ongoing risk of abuse.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify and report a potential allegation of resident-to-resident sexual abuse involving two residents, R1 and R2, both of whom have cognitive impairments. The incident was first observed by a Certified Nursing Assistant (CNA), V4, who witnessed R2 attempting to undress R1. This was reported to the Registered Nurse (RN), V5, on duty, but no further action was taken to report the incident to the Abuse Coordinator or to investigate the matter further. The facility's policy requires immediate reporting of such allegations to the Abuse Coordinator, which was not followed in this case. A subsequent incident occurred where V4 observed R2 with his hand down the front of R1's pants, which was again reported to V5. Despite this, V5 did not report the incident to the Social Service Director/Abuse Coordinator, V3, and instead believed that the residents could consent to the interaction due to their perceived enjoyment. V5's personal beliefs about the residents' ability to consent, despite their cognitive impairments, led to a failure to follow the facility's policy on reporting and investigating potential abuse. The facility's administrator, V1, confirmed that the incidents were not reported as required and acknowledged that the residents were not capable of consenting due to their dementia. The facility's final report stated that consent could not be determined due to the residents' cognitive conditions, and the facility decided to act as if abuse had been substantiated. However, the lack of immediate reporting and investigation of the incidents represents a significant deficiency in the facility's handling of potential abuse cases.
Failure to Ensure Resident Safety During Assisted Ambulation
Penalty
Summary
The facility failed to ensure resident safety during assisted ambulation, resulting in a serious incident involving a resident who was at moderate risk for falls. The resident, diagnosed with Alzheimer's Disease, General Anxiety Disorder, Chronic Kidney Disease, Muscle Weakness, and a Displaced Intertrochanteric Fracture of the Left Femur, required partial to maximum assistance for ambulation. During an incident, the resident was being assisted by a CNA without the use of a gait belt, which was against the facility's policy. The resident tripped over a threshold and fell, leading to a fractured femur. The CNA admitted to not using a gait belt, acknowledging that it should have been used. Following the fall, the resident was taken to the emergency room and diagnosed with a left hip fracture. The resident underwent surgery and returned to the facility with increased confusion and required cueing, indicating a decline in condition. The resident was later admitted to hospice care and subsequently passed away. The death certificate listed aspiration pneumonia due to congestive hypertensive cardiovascular disease as the cause of death, with the femur fracture due to the fall and chronic kidney disease as significant contributing conditions. The resident's physician confirmed that the fall and fracture exacerbated the resident's decline and contributed to the subsequent death.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report allegations of employee-to-resident physical abuse to the Administrator/Abuse Coordinator for one resident. The incident involved a Certified Nursing Assistant (CNA) who allegedly punched a resident in the stomach. The CNA who witnessed the conversation about the abuse did not report it immediately to the appropriate authorities. Instead, she texted the Clinical Scheduler's phone after her shift ended, which was not checked until the following morning. This delay in reporting violated the facility's policy, which mandates immediate notification of abuse allegations to the Administrator or Abuse Coordinator. The incident occurred during mealtime when one CNA mentioned to another that she had punched a resident in the stomach to stop the resident's aggressive behavior. The CNA who heard this did not report it immediately due to fear and being new on the job. The Clinical Scheduler, who received the text message the next morning, then informed the Director of Nursing (DON) and the Administrator. The facility's policy clearly states that any team member who receives a complaint of abuse must notify their direct supervisor and the Coordinator of Abuse Prevention immediately, which did not happen in this case.
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Illustrative
What surveyors actually found near you
We read the 103 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ottawa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion Of Ottawa | 0.8 mi | ★★★★★ | 11 | 0 |
| La Salle County Nursing Home | 2.6 mi | ★★★★★ | 0 | 0 |
| Goldwater Care Marseilles | 6.6 mi | ★★★★★ | 12 | 0 |
| Parker Nursing & Rehab Center | 13.2 mi | ★★★★★ | 14 | 0 |
| Manor Court Of Peru | 14.4 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.