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 Tower Hill Healthcare Center during CMS and state inspections, most recent first.
Failure to Protect Cognitively Impaired Residents from Physical Abuse: Two cognitively impaired residents were physically assaulted by other residents with no prior documented trigger or interaction. One resident with dementia, psychosis, and severe cognitive impairment struck a seated female resident in the head and arm, and another resident with severe cognitive impairment struck a female resident in the face in the lounge. Staff witnessed the incidents, separated the residents, and the facility substantiated both abuse allegations.
A resident with multiple sclerosis and dementia sustained a second-degree burn to the inner thigh after spilling hot coffee that had been served in a handle-less Styrofoam cup rather than a handled mug. The resident was in the dining room when the spill occurred, and subsequent wound assessments documented the burn and its measurements. Later observation showed the resident could securely handle a plastic mug with a handle and did not require assistance to drink. An Assistant DON acknowledged that Styrofoam cups were used due to an insufficient supply of handled mugs, despite a facility policy stating that hot beverages must be provided in a safe manner.
A cognitively impaired, incontinent resident who required substantial assistance with toileting was care-planned for peri-care and barrier cream after each incontinent episode and had no documented buttock wounds on recent assessment. During surveyor observation, a CNA found the resident with a wet brief and a large, dried bowel movement adhered between the buttocks, and the resident was not thoroughly cleaned without prompting. A new stage 2 pressure ulcer and redness on the buttocks and scrotum were observed, despite no prior wound documentation and staff being unaware of any wounds. The wound care physician later identified this as a facility-acquired stage 2 pressure ulcer and stated that the resident’s urine incontinence and stool left on the skin could have contributed to moisture-associated dermatitis and the development of the wound.
A resident with severe cognitive impairment, bowel and bladder incontinence, and care plans requiring peri-care after each incontinent episode and use of barrier cream was not kept clean and dry or thoroughly cleansed. A CNA reported last changing the resident several hours earlier and, when later providing care, initially cleaned only the front genital area and did not recognize the presence of stool until prompted to turn the resident. Surveyors observed a heavily urine-soaked brief, extensive dried stool adhered along the buttocks and intergluteal cleft, significant redness and discoloration of the buttocks, and a small open wound. Multiple rounds of wiping were needed to remove layers of fecal matter, and no barrier cream was applied despite redness and an open area. The DON stated incontinence care should occur at least every 2 hours with residents left clean, and the wound care physician documented irritant dermatitis and a stage 2 wound, noting that the described urine and stool exposure could have contributed and emphasizing the need for consistent checks and prompt stool removal.
A resident reported to an RN that clothes and money were missing and complained that nothing was being done, but the concern was not communicated to the social services staff member responsible for investigating missing items and filing grievances. The social services staff member stated she was unaware of the report and therefore did not initiate her usual process of searching for the items, filing a grievance form, or arranging replacement. Review of the grievance log over several months showed no entry for this resident’s missing items, despite a facility policy requiring that grievances be recorded, promptly addressed, and resolved within a specified timeframe.
Two residents were not protected from physical abuse when one resident in a wheelchair was punched in the face by another resident after a dispute over papers, and a cognitively impaired resident with dementia was found with facial bruising and a bloody nose after his roommate, who also had dementia and had repeatedly complained about being kept awake, was observed standing over his bed and making threatening statements. Staff observations, resident statements, and nursing documentation consistently described resident‑to‑resident hitting and unexplained facial injuries, despite the abused resident’s care plan identifying him as at risk for abuse.
The facility failed to prevent resident-on-resident physical abuse involving cognitively impaired residents with known behavioral issues. In one case, a male resident with dementia, wandering, and aggressive behaviors entered a female resident’s room; she attempted to remove him and a CNA witnessed him punch her in the chest. In another case, a confused, behaviorally disturbed resident in a wheelchair demanded a dining table seat and, after being refused, punched another resident in the face, causing immediate bruising and a black eye, as confirmed by an LPN and another resident witness. These events occurred despite a facility abuse policy that prohibits physical abuse such as hitting and striking.
A resident with severe cognitive impairment, poor safety awareness, prior falls with fractures, glaucoma, anxiety, psychotic disorder, and a cognitive communication deficit was transported in a wheelchair without the footrests in place. While being pushed by a restorative CNA, the resident planted her feet on the floor, causing her to fall forward out of the wheelchair onto the floor. Staff later acknowledged they had not ensured the resident’s feet were on the wheelchair pedals, contrary to the facility’s Safe Resident Lifting Policy requiring appropriate leg/footrests for residents using wheelchairs unless they self-propel.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Two residents with severe cognitive impairment were left unsupervised in a hallway, resulting in one physically striking the other and causing visible injuries. The incident was witnessed by a CNA, who alerted two LPNs to intervene. Both residents had no prior history of aggression, and the facility's lack of supervision led to the occurrence of physical abuse.
A resident who fell out of bed and hit their head did not receive neurological assessments according to facility protocol. Although staff stated that neuro checks should be performed for 72 hours post-fall and resumed after hospital return, documentation showed delayed initiation of checks and missed hourly assessments, with incomplete record-keeping of the incident timeline.
A resident with dementia experienced a delay in call light response, leading to her wetting herself and feeling embarrassed. Despite multiple requests for assistance, staff were occupied with lunch duties, resulting in a 40 to 60-minute wait. The facility lacks a system to track call light response times, and the resident's care plan did not address her toileting needs, contrary to the facility's dignity policy.
A resident with multiple health issues, including reduced mobility and dementia, was injured in an LTC facility after accessing an unlocked room labeled as an ice machine room. Inside, the resident attempted to retrieve ice, causing a wobbly IV pole to fall and injure her shin. The room contained unsecured medical equipment, and the lock on the door was broken, allowing resident access. The resident was treated for a contusion, and the facility acknowledged the room should have been locked and not used for equipment storage.
The facility failed to implement protocols for using an assessment tool for residents receiving antibiotics, affecting all 166 residents. The Infection Preventionist did not use an assessment tool or criteria to evaluate appropriate antibiotic use, and the facility's policy lacked a procedure for standardized assessment. The Director of Nursing acknowledged the need for such a tool, indicating a gap in antibiotic stewardship practices.
The facility failed to provide mechanical soft diets as ordered for residents requiring such consistency. The cook, V9, shredded BBQ pork instead of grinding it, resulting in residents receiving food that did not meet their dietary needs. The dietary manager and dietitian confirmed the inconsistency with the prescribed diet.
The facility failed to provide necessary grooming assistance to two residents who required extensive help with ADLs. One resident with cerebral infarction and functional quadriplegia had long, thick fingernails, while another resident with muscle weakness and difficulty walking had long facial hair and unclean nails. Despite care plans indicating the need for extensive assistance, these grooming needs were not met.
Two residents in the facility had their central venous catheter dressings not changed in a timely manner, risking infection. One resident's dressing had not been changed since early January, while another's was loose and detached. The LPN was unaware of the dressing change policy, and the DON confirmed the need for changes every 7 days or as needed. Facility guidelines stress the importance of aseptic technique and timely dressing changes.
A resident with chronic pain and a history of fractures experienced inadequate pain management due to the facility's failure to implement a care plan and administer prescribed medications consistently. Despite orders for Hydrocodone and Hydromorphone every four hours, the resident reported severe pain levels and significant delays in receiving medication. Nursing staff acknowledged the pain but did not follow the facility's pain management policy, leading to prolonged discomfort for the resident.
A resident with end-stage renal disease was repeatedly observed without a dressing over their central venous catheter (CVC) site, contrary to the facility's infection control standards. Despite the facility's policy requiring the site to remain covered, the resident arrived at dialysis multiple times without a dressing, increasing the risk of infection. The facility's staff were aware of the issue, but the deficiency persisted.
The facility failed to ensure timely physician responses to pharmacist recommendations during monthly Medication Regimen Reviews (MRRs) for three residents. One resident's narcotic pain medication was not reviewed despite a recommendation for discontinuation. Another resident did not have MRRs conducted for six months, and a third resident's antipsychotic medication use lacked physician review. The facility's policy requires timely communication and response to pharmacist recommendations.
The facility failed to conduct required gradual dose reductions (GDR) for psychotropic medications for three residents. One resident had not had a GDR since June 2023 despite being on clonazepam and quetiapine. Another resident was on Restoril for insomnia without a documented GDR evaluation, despite pharmacist recommendations. A third resident on multiple psychotropic medications also lacked a documented GDR evaluation. The facility's policy mandates GDR attempts within the first year of admission and annually thereafter unless contraindicated, which was not followed.
The facility failed to use the correct scoop size for serving pureed diets, affecting three residents. The Dietary Manager used a #8 scoop instead of the required #6 scoop, leading to incorrect portion sizes. This was confirmed by the Dietitian, who emphasized the importance of using the correct scoop size to ensure residents receive adequate nutrition.
A resident with a history of stroke and dysphagia was served a regular texture meal instead of the prescribed pureed diet. The ADON confirmed the error, noting the meal belonged to another resident. The resident's care plan required a pureed diet for safety, which was not followed, as acknowledged by the DON.
The facility failed to follow infection control policies for norovirus and enhanced barrier precautions. A resident with norovirus was not isolated, and staff did not use PPE as required for residents on contact isolation and enhanced barrier precautions. The Infection Preventionist was unaware of a positive norovirus case, and staff entered rooms without proper protective measures.
Two residents with cognitive impairments engaged in a physical altercation during dinner, resulting in one resident sustaining scratches and the other being sent to the hospital. Staff intervened after hearing a commotion, but the incident was not directly witnessed, and the facility's investigation could not determine the aggressor. The facility's abuse prevention program was not effectively implemented, highlighting a deficiency in protecting residents from abuse.
A resident with multiple medical conditions and high fall risk fell during a transfer using a mechanical lift due to excessive movement and pain. Despite being assisted by two CNAs, the resident slid out of the sling and hit her head, although no injuries were reported. The facility's policy on safe transfers was not effectively followed, contributing to the incident.
The facility failed to follow infection control standards during dressing changes for two residents. A nurse used hand sanitizer instead of soap and water after handling a C. difficile case, and another instance lacked enhanced barrier precautions during wound care. The DON misunderstood the guidelines, leading to improper infection control practices.
A resident with cognitive impairments was physically assaulted by another resident in the dining room. The incident occurred when one resident attempted to sit at a table reserved for another, leading to an altercation. A CNA witnessed the event and called for assistance, and an LPN intervened to separate the residents. Both residents have dementia-related diagnoses, and the facility's Abuse Prevention Program prohibits such abuse.
A resident with dementia was physically abused by another resident during breakfast, resulting in scratches and a ripped shirt. The incident occurred when the resident with dementia attempted to take food from the other resident's tray, leading to a physical altercation. Staff intervened, and the police were notified, resulting in charges against the aggressor. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse.
The facility failed to serve food at safe and appetizing temperatures for all 154 residents. Observations and interviews revealed that residents experienced issues with cold and unappetizing food. A test tray showed food temperatures below the required minimum, and the acting dietary manager confirmed that temperatures were not checked before serving, violating the facility's policy.
Two residents with mild cognitive impairment were found in rooms with inadequate cleanliness, including moldy curtains and damaged linens. Despite daily cleaning, issues were not thoroughly addressed, and previous complaints were ignored. The facility's policies on maintaining a clean and attractive environment were not followed.
The facility failed to protect residents from abuse, resulting in multiple incidents of resident-to-resident aggression. One resident experienced ongoing pain after being punched by another, while two other residents engaged in a physical altercation despite supervision. The facility's abuse prevention program was not effectively implemented to prevent these incidents.
A resident with dementia and other mental health conditions was involuntarily discharged to the hospital due to aggressive behavior. The facility failed to have a physician document the necessity of the immediate transfer, as confirmed by interviews with the Nurse Practitioner and Psychiatrist.
Failure to Protect Cognitively Impaired Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure cognitively impaired residents were free from physical abuse. R2 was a female resident with dementia, schizophrenia, delusional disorder, auditory hallucinations, hemiplegia, neuropathy, legal blindness, hearing loss, impaired memory, poor judgment, and severe cognitive impairment. The record showed intermittent delusions, paranoia, medication refusal, and periods of tension, but no documented history of physical aggression toward peers or staff. On April 23, 2026, R1, a male resident with Parkinson's disease, dementia, psychosis, Alzheimer's disease, cerebrovascular-related memory deficits, and severe cognitive impairment, was walking in the hallway when he passed R2, who was seated calmly in a wheelchair near the second-floor dining room entrance and was not interacting with him. The incident report documented that R1 unexpectedly struck R2 on the back of the head and left upper arm without any identified trigger, verbal exchange, or physical interaction beforehand. The facility investigation substantiated the abuse based on witness statements. V7, an LPN, stated she saw R1 slap R2 on the back of the head, and V8, a CNA, reported hearing a slapping sound and hearing R2 scream. R2 later reported that R1 slapped her. Both residents were assessed and no acute injuries or distress were identified. The report also documented a second abuse incident involving R4, a female resident with Alzheimer's disease, dementia with anxiety, cognitive communication deficits, and impaired decision-making abilities, and R3, a male resident with severe cognitive impairment, COPD, chronic respiratory failure, and hypertension. R4 was generally pleasant and cooperative with only occasional pacing, verbal agitation, and inappropriate comments, while R3 was consistently documented as pleasant, calm, cooperative, and without significant behavioral disturbances. On May 2, 2026, R3 struck R4 in the face in the resident lounge, and V5, a CNA, witnessed R3 strike R4 on the right cheek. Staff separated the residents, R4 was assessed with no injuries, and the facility substantiated the allegation of abuse based on the witnessed event.
Burn Injury from Unsafe Service of Hot Coffee
Penalty
Summary
The deficiency involves the facility’s failure to provide hot coffee in a safe manner to a resident with multiple sclerosis and dementia, resulting in a burn injury. The resident reported that a few days prior he had spilled coffee in his lap but stated that the area was healed and that he liked the coffee temperature. A wound LPN stated that the resident was accidentally burned when he spilled coffee in his lap while in the dining room, sustaining a second-degree burn to the left inner thigh. At the time of the incident, staff brought the resident to his room, removed his pants, and applied ice, and the LPN later assessed the area as initially red, which subsequently developed two small blisters. Wound documentation shows a second-degree burn to the left inner thigh with specific measurements and wound characteristics over time. On observation in the dining room, the resident was later seen drinking coffee from a plastic mug with a handle, holding the cup securely with no shakiness noted, and he did not require assistance or feeding cues according to the Assistant DON. The Assistant DON stated that on the day of the burn incident, the resident had been served coffee in a Styrofoam cup without handles because the facility did not have enough handled mugs. The facility’s Hot Beverage Policy states that hot beverages are to be provided to clients in a safe manner. The use of a handle-less Styrofoam cup for serving hot coffee to this resident with multiple sclerosis and dementia, instead of a safer handled mug, was the action that led to the burn injury and constituted the failure to ensure the area was free from accident hazards and that adequate supervision and safety measures were provided.
Failure to Provide Timely, Thorough Incontinence Care Resulting in Facility-Acquired Stage 2 Pressure Ulcer
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including muscle weakness, unsteadiness, dysphagia, schizophrenia, and acute kidney failure, was identified as being at risk for pressure sores and skin integrity impairment. Care plans and the readmission assessment documented that the resident was incontinent of bowel and bladder, required substantial/maximal assistance with toileting hygiene, and had no wounds on the buttocks upon admission and on a skin assessment one week prior to the survey. The care plans included interventions to provide peri-care and barrier cream after each incontinent episode and to observe and report any skin alterations. The facility’s skin management policy stated that residents should not develop pressure injuries unless clinically unavoidable. On the survey date, the resident reported not having been out of bed and being unsure when incontinence was last checked. A CNA stated the last incontinence check was approximately two hours earlier. During observed incontinence care, the resident was found with a wet brief and a very large, dried bowel movement adhered between the buttocks, and the resident was not thoroughly cleaned without prompting. A new stage 2 pressure ulcer on the right buttock, along with redness on the buttocks and scrotum, was observed and confirmed by the CNA as previously unseen. At that time, the LPN was unaware of any wounds, and the electronic record showed none documented. Later documentation by nursing and the wound care nurse described a new open area on the right buttock, and the wound care physician’s evaluation the following day identified a facility-acquired stage 2 pressure ulcer. The wound care physician stated that the resident’s urine incontinence and the stool found on the skin could be contributing factors to the moisture-associated dermatitis and the stage 2 wound, and emphasized the importance of consistent incontinence checks because the resident does not recognize incontinence episodes.
Failure to Provide Timely and Thorough Incontinence Care Resulting in Skin Irritation and Wound
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident at risk for skin breakdown clean and dry and to provide thorough incontinence care as care planned and required by facility policy. The resident was an older adult with severe cognitive impairment, muscle weakness, unsteadiness, lack of coordination, acute kidney failure, dysphagia, schizophrenia, schizoaffective disorder, generalized anxiety disorder, and a history of syncope and collapse. The resident’s MDS showed a need for substantial/maximal assistance with toileting hygiene, and care plans documented incontinence of bowel and bladder and risk for skin integrity impairment, with interventions including peri-care after each incontinent episode and application of barrier cream. A recent skin assessment showed no skin breakdown prior to the events observed. On the day of the surveyor’s observation, the resident reported not having gotten out of bed and being unsure when they were last checked for incontinence. The CNA assigned to the resident stated that she had last changed the resident at 10:00 AM. At approximately 12:50 PM, when the CNA checked the resident, she initially cleaned only the front genital area and stated the resident had only urine incontinence. When asked to show the incontinence brief and turn the resident, she then observed stool. The resident’s buttocks were described as red, purplish, and gray in areas, and there was a large, dried, solid stool adhered along the intergluteal cleft, with the brief soaked with urine from the back to halfway up the front. The CNA was unable to remove the stool easily and obtained assistance from another CNA. During the subsequent cleaning, multiple layers of dried fecal matter adhered to the skin around the anus and inner buttocks were removed, filling about one-third of a small garbage bag with soiled wipes. When the CNA indicated she was finished, visible fecal matter remained within the inner buttocks near the anus, and additional wiping removed more layers of stool, with more than four additional wipes still showing fecal staining. The resident then had a small soft bowel movement, requiring further cleaning. No barrier cream or emollient was applied to the red areas of the buttocks despite existing care plan interventions. A small open wound was observed on the right buttock, which the CNA identified as a wound she had not seen earlier. The DON stated that incontinence care should be provided every two hours or more often as needed, that residents should be cleaned thoroughly with visible stool removed, and that residents should be left clean after incontinence care. The wound care physician later documented irritant dermatitis from body fluids to bilateral buttocks and stated that the urine incontinence and stool found on the resident as described could be a contributing factor to the moisture-associated dermatitis and a stage 2 wound, and that consistent checks and timely removal of stool were important. The facility’s incontinence care policy, revised January 2022, stated that incontinence care is provided to keep residents as dry, comfortable, and odor free as possible.
Failure to Log and Address Resident Grievance About Missing Personal Items
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances and to ensure that a grievance regarding missing personal items was reported, logged, and resolved according to policy. Nursing documentation dated 3/20/25 by an RN (V12) recorded that resident R5 stated he had clothes and money missing and that no one was doing anything about it. During a later interview, the RN stated she documented the note on 3/30/25 and indicated that her usual practice when a resident reports missing items is to report them to the social services staff member (V9), but she could not recall whether she actually reported R5’s missing items to V9. In a separate interview, V9 stated that when a resident reports missing money or clothes, she spends 48 hours attempting to locate the items and, if unsuccessful, files a grievance form and replaces the items, but she was not aware of R5’s report of missing items. Review of the facility’s Grievance Complaint Log from January 2025 through October 2025 showed no grievance filed for R5’s missing clothing or money, despite the resident’s report. The facility’s undated Grievance/Complaint Policy states that residents have the right to voice grievances without discrimination or reprisal, that prompt efforts will be made to resolve grievances, that the disposition of grievances will be recorded on the grievance and complaint log, and that grievances will have a disposition within seven working days of being filed. This deficiency centers on the facility’s failure to ensure that R5’s grievance about missing clothes and money was communicated to the appropriate staff, entered into the grievance log, and processed in accordance with the written grievance policy.
Failure to Protect Residents From Physical Abuse by Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse, as evidenced by two substantiated or suspected resident‑to‑resident physical abuse incidents. In the first incident, a resident in a wheelchair (R1) was struck in the face by another resident (R2). Multiple CNAs reported that R1 had papers in her hand that R2 was trying to retrieve, and that R2 then punched or swung and hit R1 in the right side of the face with a closed fist. The nurse on duty heard staff at the nurses’ station saying, “don’t hit her! He hit her!” and, upon assessment, observed a red mark on the right side of R1’s face near her temple and hairline. R1 later reported being hit in the face by a male person, appeared anxious with shaking hands, and described the event as scary. In the second incident, the facility failed to ensure that a cognitively impaired resident (R3), who had a care plan identifying him as at risk for abuse related to behavior problems and dementia, was free from potential physical abuse by his roommate (R4), who also had dementia and resided on the Memory Care unit. A CNA (V13) reported that around midnight R4 repeatedly complained that R3 was keeping him awake and stated that someone needed to keep R3 quiet. Later, around 5:00 AM, V13 observed R4 standing over R3’s bed, heard R4 say that R3 had kept him up all night making noises and that he should hit him, and then found blood around R3’s nose. V13 believed R4 had hit R3 and informed the LPN, who documented discoloration to the bridge of R3’s nose and later a bloody nose that was cleaned and assessed. Subsequent observations by other staff and R3’s wife further documented unexplained facial injuries consistent with trauma. Another CNA (V16) saw R3 shortly after coming on shift and noted bruising to the bridge of his nose, a split lip, and a runny, somewhat bloody nose, and reported being told by V13 that R4 had been standing over R3 and threatening to “kick his ass.” The day‑shift LPN (V17) documented a full body assessment with bruising to the bridge of R3’s nose and right temporal area, while the Administrator and Social Services Assistant both acknowledged bruising and blood on linens without a clear reason for the injury. R3’s wife was informed only that R3’s nose was bleeding and was told they thought he had bumped into something, but she observed a red mark across the bridge and right side of his nose and questioned whether someone had done something to him. These events demonstrate that the facility did not ensure residents were free from physical abuse as required by its Abuse Prevention Program Policy, which defines abuse as any physical injury inflicted upon a resident other than by accidental means, including hitting.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple resident-on-resident altercations occurred involving cognitively impaired residents with known behavioral histories. In one incident, a male resident with unspecified and vascular dementia, severe cognitive impairment, restlessness, agitation, generalized muscle weakness, osteoarthritis, wandering and exit-seeking behaviors entered the room of a female resident with severe cognitive impairment, psychotic disorder, major depressive disorder, generalized anxiety, glaucoma, and cognitive communication deficit. The female resident reported that the male resident repeatedly came into her room and would not leave, and that she scratched and grabbed him while trying to pull him out of her room, after which he punched her in the chest. A CNA responded to screams and witnessed the male resident strike the female resident in the chest, and an LPN later confirmed being informed that the male resident, who had a history of wandering, agitation, and difficulty with redirection, had punched the female resident while she was trying to shove him out of her room. Social services staff acknowledged that the male resident had a history of wandering and aggressive behaviors and that he should be monitored when out of his room, and also noted that the female resident had dementia, confusion, and a history of past abuse experiences. In a separate incident, the facility did not prevent physical abuse when one female resident with vascular dementia with behavioral disturbances, unspecified psychosis, muscle weakness, cognitive communication deficit, and a history of verbal and physical aggression struck another female resident with dementia, anxiety, insomnia, GERD, rheumatoid arthritis, and spinal stenosis. While a nurse was passing medications in the dining room, the victim resident reported that another resident had hit her in the face after becoming upset about wanting to sit at the same table when there was no room. The nurse observed immediate bruising and later dark purple discoloration to the left side of the victim’s face. Another resident at the table corroborated that the aggressive resident approached in a wheelchair, demanded the victim’s seat, and, after being told no, punched her in the eye, causing pain and a black eye. This witness also stated that the aggressor had a “mean streak” and prior verbal altercations with staff and residents. The administrator, serving as abuse coordinator, confirmed that the incident involving the two residents in the first event was witnessed and that physical abuse was substantiated. The facility’s abuse policy affirms residents’ rights to be free from abuse and defines physical abuse as the infliction of injury by non-accidental means, including hitting and similar acts.
Failure to Use Wheelchair Footrests Resulting in Resident Fall During Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport and adequate supervision to prevent a fall for one resident. The resident had a resident assessment indicating she was severely cognitively impaired and a care plan identifying her as at risk for falls due to poor safety awareness and impulsiveness related to impaired cognition. Her care plan also noted glaucoma, prior falls with fractures, anxiety, unspecified psychotic disorder, and a cognitive communication deficit, all contributing to an increased fall risk. Despite these identified risks, the resident was transported in a wheelchair without proper use of the wheelchair footrests. A progress note documented that while a restorative CNA was pushing the resident in her wheelchair, the resident suddenly planted her feet on the ground as the wheelchair was moving, causing her to fall forward out of the wheelchair, landing on her knees and then rolling onto her back. She was sent to a local hospital and was found to have no injuries and returned the same day. Staff interviews later confirmed that the wheelchair foot pedals were not down and in place, and the CNA did not realize the resident’s feet were dragging on the floor under the wheelchair. The facility’s Safe Resident Lifting Policy required that all residents using a wheelchair have appropriate leg/footrests during transfers unless they self-propel, which was not followed in this incident.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent an incident of physical abuse between two residents, both of whom were severely cognitively impaired and had no prior history of aggressive behavior. The event occurred in the early morning hours when a CNA, after providing care to another resident, observed the two residents engaged in a physical altercation at the end of a hallway. The CNA witnessed one resident striking the other in the face and immediately called for assistance. Two LPNs responded, separated the residents, and performed assessments. The resident who was struck sustained a small laceration and redness to the left eye/eyebrow area, as well as a bruise to the left hand and reported forearm pain. The other resident did not have any injuries and denied pain. Both residents were unable to provide coherent accounts of the incident due to their cognitive impairments. Staff interviews confirmed that neither resident had a documented history of aggression, although one was noted to become agitated with care. The incident was witnessed by staff, and the facility's own investigation substantiated that physical abuse had occurred. At the time of the incident, the CNA was occupied in another room, and the LPNs were preparing medications in the medication room, leaving the residents unsupervised in the hallway. The facility's abuse prevention policy prohibits physical abuse, including hitting and striking, and affirms the right of residents to be free from such harm. Despite these policies, the lack of supervision allowed the altercation to occur, resulting in injury to one resident.
Failure to Complete Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to complete neurological assessments as required following a resident's fall. A resident reported falling out of bed, hitting his head, and being sent to the hospital, after which he returned to the facility the same day. According to facility staff, neurological checks are to be performed for 72 hours after a fall involving a head injury or an unwitnessed fall, and these checks should continue upon the resident's return from the hospital. However, the neurological assessment documentation did not begin until late in the evening on the day of the fall, and two hourly checks were missed in the early afternoon after the resident's return. The documentation also lacked an initial incident time, indicating incomplete monitoring and record-keeping as per facility protocol.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity by not responding to a call light in a timely manner, resulting in the resident, who has dementia, wetting herself. On the day of the incident, the resident's great-granddaughter reported that upon arriving at the facility, the resident needed to use the bathroom and had activated her call light. Despite multiple requests for assistance at the nurse's station, staff did not respond promptly, citing that they were busy with lunch duties. Consequently, the resident had to wait for 40 to 60 minutes before receiving help, during which time she wet herself, causing embarrassment. Interviews with the resident's family and facility staff revealed that call light response times varied significantly, sometimes taking up to 45 minutes. The Director of Nursing acknowledged the lack of a system to track call light response times and stated that such delays were unacceptable. The resident's care plan did not include specific provisions for her toileting needs, despite her requiring maximum assistance for mobility and transfers. The facility's dignity policy emphasizes prompt response to toileting requests, which was not adhered to in this case.
Resident Injured by Falling IV Pole in Unsecured Equipment Room
Penalty
Summary
The facility failed to prevent residents from accessing a room where medical equipment in need of repair was stored, leading to an accident involving a resident. The resident, who has multiple diagnoses including cerebral infarction, reduced mobility, and dementia, was able to enter an unlocked room labeled as an ice machine room. Inside, the resident attempted to retrieve ice and accidentally caused an IV pole to fall, resulting in an injury to her right shin. The room contained several pieces of medical equipment, including wobbly IV poles and oxygen concentrators, which were not secured or stored properly. The resident, who is cognitively intact but requires assistance with various activities of daily living, reported the incident to staff, indicating that the pole fell and hit her leg. The Director of Nursing (DON) confirmed the resident's account and observed a bright red area on the resident's shin, consistent with the reported injury. The resident was subsequently treated at a hospital for a contusion, and X-rays confirmed no fractures or dislocations. The Maintenance Director acknowledged that the room was not supposed to be accessible to residents and that the lock on the door was broken. Additionally, the IV poles were identified as wobbly due to loose screws, which had not been addressed. The DON confirmed that the room should have been locked and that storing equipment in the ice machine room was not appropriate, contributing to the unsafe environment that led to the resident's injury.
Failure to Implement Antibiotic Assessment Protocols
Penalty
Summary
The facility failed to implement protocols for utilizing an assessment tool or management algorithm for residents who may receive antibiotics, affecting all 166 residents. The Infection Preventionist (V4) admitted to not using an assessment tool or criteria when evaluating if a resident is appropriately receiving an antibiotic. Instead, V4 reviews antibiotic orders with providers to ensure there is an indication for use. However, V4 did not have an assessment tool for any antibiotics prescribed during December 2024, January 2025, and February 2025, and did not discuss inappropriate antibiotic use at Quality Assurance and Performance Improvement meetings. The facility's policy on Antibiotic Stewardship, dated December 2016, states that antibiotics will be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program. The policy emphasizes monitoring antibiotic use and educating staff on the importance of stewardship. However, the policy lacks a procedure for utilizing a standardized tool and criteria for assessing antibiotic use. The Director of Nursing (V2) acknowledged that V4 should be using an assessment tool to ensure antibiotics are required, highlighting a gap in the facility's antibiotic stewardship practices.
Failure to Provide Mechanical Soft Diets as Ordered
Penalty
Summary
The facility failed to prepare mechanical soft consistency diets for residents who had a diet order for such. On February 4, 2025, the facility's cook, V9, was observed preparing BBQ pork for residents on a mechanical soft diet. Instead of grinding the pork as required, V9 shredded it into small pieces and mixed it with broth and barbeque sauce, believing this would suffice for a mechanical soft consistency. However, the final product was not ground as specified in the facility's menu and recipe for mechanical soft diets. During the tray line service, V9 mistakenly mixed the shredded pork with the regular consistency diets, resulting in residents on mechanical soft diets receiving food that did not meet their dietary needs. This affected four residents who were on a mechanical soft diet. The dietary manager, V8, was informed of the inconsistency, and the dietitian, V12, confirmed that the mechanical soft diets should have received ground meat as per the menu. The failure to adhere to the prescribed diet consistency was a clear deviation from the facility's dietary guidelines.
Failure to Provide Grooming Assistance to Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance to residents who required extensive help with activities of daily living (ADLs). One resident, diagnosed with cerebral infarction and functional quadriplegia, was observed with long, thick fingernails on her right hand, which were curling and rubbing against her palms. Despite being dependent on staff for personal hygiene, her care plan indicated she should receive extensive assistance from one person. However, her fingernails remained untrimmed, and she expressed a desire for them to be cut. Another resident, who required substantial maximal assistance for personal hygiene due to muscle weakness and difficulty walking, was observed with long facial hair and nails with a blackish substance underneath. The resident's Power of Attorney mentioned having previously assisted with grooming but indicated that the facility staff could perform these tasks. Despite the care plan specifying the need for extensive assistance, the resident's grooming needs were not adequately addressed. The Director of Nursing acknowledged that CNAs should provide personal hygiene assistance every shift or as needed.
Failure to Timely Change Central Line Dressings
Penalty
Summary
The facility failed to change the central venous catheter dressings for two residents, R310 and R309, in a timely manner, which is crucial to prevent the spread of infection. R310, a female resident with a history of infection following a procedure and other medical conditions, was observed with a central line dressing that had not been changed since January 8, 2025. The dressing was dingy, loosened, and detached from her skin. Despite the resident's statement that the dressing was only reinforced and not changed, the Licensed Practical Nurse (LPN) was unaware of the facility's policy for changing central line dressings. The resident's care plan required daily checks of the dressing, and a physician's order mandated checking the intravenous site every 8 hours. Similarly, R309, a male resident with multiple sclerosis and other diagnoses, was observed with a central line dressing that was loose and detached from his arm. The dressing, dated February 3, 2025, was not changed despite its condition worsening over time. The Director of Nursing (DON) stated that central line catheter dressings should be changed every 7 days or as needed if they become loose or soiled. The facility's guidelines also emphasized the importance of aseptic technique and timely dressing changes to prevent infections. However, these protocols were not followed, leading to the deficiency.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to manage a resident's severe pain effectively, as evidenced by the lack of a care plan for pain management and inconsistent administration of prescribed pain medications. The resident, a female with a history of fractures, chronic pain, and osteoarthritis, reported severe pain levels of 10/10 on multiple occasions. Despite having orders for Hydrocodone and Hydromorphone to be administered every four hours as needed, the resident experienced significant delays in receiving her medication, with gaps of up to 11 hours between doses. The resident and her daughter repeatedly informed the staff about the inadequacy of pain management, but the facility did not address these concerns promptly. Nursing staff, including a nurse identified as V23, acknowledged the resident's persistent pain but failed to document or administer pain medication as prescribed. The Medication Administration Record did not reflect timely administration of pain relief, and the staff did not consistently assess or document the resident's pain levels. The Director of Nursing stated that pain levels over 5/10 should be addressed with stronger medication, yet this protocol was not followed. The facility's pain management policy emphasizes a commitment to resident comfort and the need for effective pain management strategies, which were not implemented in this case.
Failure to Maintain Dialysis Catheter Site
Penalty
Summary
The facility failed to maintain the central venous catheter (CVC) dialysis access site for a resident, identified as R119, in accordance with infection control standards and their policy. R119, who was admitted with multiple diagnoses including end-stage renal disease, was observed on multiple occasions without a dressing over the CVC insertion site. This was despite the facility's policy requiring the site to remain covered, clean, and dry at all times. On February 3, 2025, R119 was seen manipulating the catheter without a dressing, and on February 4, 2025, the site was again observed uncovered. The facility's staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), were informed of the situation, but the issue persisted. The dialysis RN confirmed that R119 frequently arrived at dialysis without a dressing on the catheter site, which is critical to prevent infection. The facility's communication tool, used to share clinical information between facility nursing staff and dialysis staff, emphasized the importance of maintaining an intact dressing. Despite this, R119's dialysis treatment records indicated repeated instances of arriving without a dressing. The resident had a history of sepsis due to MRSA, highlighting the critical need for proper catheter site management. The Director of Nursing (DON) acknowledged the requirement for the CVC site to always be covered, yet the deficiency continued, indicating a lapse in adherence to the facility's dialysis protocol.
Failure to Address Pharmacist Recommendations and Conduct Monthly Reviews
Penalty
Summary
The facility failed to adhere to its policy requiring timely physician responses to pharmacist recommendations during monthly Medication Regimen Reviews (MRRs). This deficiency was identified in three residents. For one resident, the pharmacist recommended discontinuing a narcotic pain medication due to non-use for over 30 days, but there was no documentation showing that the physician was notified or that the recommendation was addressed. The Director of Nursing confirmed the lack of documentation and that the medication order remained active. Additionally, the facility did not conduct MRRs for another resident over a six-month period, despite the resident's use of multiple psychotropic medications. For a third resident, the pharmacist's recommendations regarding the use of an antipsychotic medication lacked physician review or documentation of action taken. The facility's policy requires that the consultant pharmacist's recommendations be communicated to the Director of Nursing and/or Administrator, and that the attending physician and/or Medical Director be provided with copies of the recommendations for timely response.
Failure to Conduct Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to adhere to its policy of attempting gradual dose reductions (GDR) for residents on psychotropic medications, as evidenced by the cases of three residents. Resident R73, who was admitted with multiple diagnoses including dementia and psychosis, had not had a GDR attempted or documented since June 14, 2023, despite being on clonazepam and quetiapine. The care plan indicated that a GDR was contraindicated in June 2023, but there was no further documentation to support ongoing evaluations or attempts at dose reduction. Resident R91, diagnosed with insomnia and other conditions, was prescribed Restoril for insomnia. Despite recommendations from the consultant pharmacist for a GDR evaluation on multiple occasions, there was no documentation of such an evaluation being conducted. Similarly, Resident R128, with diagnoses including Alzheimer's and major depressive disorder, was on multiple psychotropic medications. The facility's records showed that a GDR evaluation was due, but no documentation was provided to confirm that it had been conducted. The facility's policy requires GDR attempts within the first year of admission and annually thereafter unless contraindicated, but this was not followed for the residents in question.
Improper Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for pureed diets as specified on the menu, affecting three residents. During an observation of the tray line in the facility kitchen, it was noted that the Dietary Manager used a #8 scoop instead of the required #6 scoop to serve pureed chicken and pasta to residents on pureed diets. This discrepancy was confirmed by the Dietary Manager, who admitted to not checking the menu before selecting the scoop size. The facility's Portion Control Chart indicated that a #8 scoop equates to 4 oz, while a #6 scoop equates to 5 1/3 oz, which is necessary to ensure residents receive adequate calories and protein. The Dietitian confirmed that the correct scoop size should be used to meet the nutritional needs of the residents.
Failure to Provide Prescribed Pureed Diet to Resident
Penalty
Summary
The facility failed to provide a resident with a pureed diet as prescribed by the attending physician. On February 4, 2025, a resident identified as R14 was observed in the dining room with a meal tray that contained regular texture food, including barbecue pulled pork, tater tots, and cornbread, instead of the prescribed pureed diet. A Certified Nursing Assistant (CNA) assisted R14 by cutting up the food, and the resident began eating the meal. The Assistant Director of Nursing (ADON) acknowledged that R14 had an order for a pureed diet and confirmed that the tray served was incorrect, as it belonged to a different resident. R14's medical records indicated a history of stroke, dementia, dysphagia, and facial weakness, necessitating a pureed diet for safety reasons. The resident's order summary and nutrition care plan specified a general pureed diet with thin fluids and aspiration precautions, including no straws. The Director of Nursing (DON) confirmed that the facility staff should have provided the correct meal tray to R14, emphasizing that the resident was on a pureed diet for safety precautions.
Infection Control Deficiencies in Norovirus and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, particularly concerning norovirus, contact precautions, and enhanced barrier precautions. Resident R14, who tested positive for norovirus, was not placed in contact isolation as required by the facility's policy. Despite the positive test result, R14 continued to interact with other residents in communal areas such as the dining room and therapy department. The Infection Preventionist was unaware of R14's positive test result, and the Director of Nursing confirmed that R14 should have been isolated upon receiving the test results. Resident R124, who had a physician order for enhanced barrier precautions due to a urinary catheter and wound, was not properly managed according to the facility's protocols. The Wound Care Nurse and a CNA entered R124's room without donning the required gown, despite the presence of a sign indicating the need for enhanced barrier precautions. They proceeded to perform wound care and reposition the resident without adhering to the necessary protective measures. Resident R7, who was on contact isolation for norovirus, was not managed according to the facility's contact isolation protocols. An LPN entered R7's room multiple times without performing hand hygiene or donning the required gown and gloves, despite the presence of a contact isolation sign and PPE bin outside the room. The LPN acknowledged the oversight when questioned by a surveyor. The Director of Nursing confirmed the necessity of following contact isolation protocols to prevent the spread of infection.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent an incident of abuse between two residents, identified as R1 and R2, during a dinner service. R1, who has a history of aggressive behavior and cognitive impairments, attempted to take food from R2's tray, leading to a physical altercation. R2, also cognitively impaired, reported that R1 hit him first, prompting R2 to retaliate. Staff intervened after hearing a commotion, but the altercation had already resulted in R1 sustaining scratches and R2 being sent to the hospital for evaluation. Interviews with staff members, including the Social Service Director and CNAs, revealed that the incident was not directly witnessed by any staff, as they were occupied with other duties at the time. The Director of Nursing acknowledged the incident as physical abuse and emphasized the facility's responsibility to protect residents from such occurrences. Despite the intervention, the facility's investigation could not conclusively determine the aggressor or victim due to conflicting accounts and the lack of direct witnesses. Both residents have documented histories of cognitive impairments and behavioral issues, with R1 diagnosed with dementia and R2 with Alzheimer's disease and violent behavior. The facility's abuse prevention program, which prohibits physical abuse, was not effectively implemented in this instance, as evidenced by the altercation and subsequent injuries. The report highlights the need for improved supervision and intervention strategies to prevent similar incidents in the future.
Failure to Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in a fall. The incident involved a resident who was categorized as high risk for falls and required a two-person assist for transfers. During a transfer from a wheelchair to a bed, the resident, who had a history of pressure ulcers and was experiencing pain, moved excessively in the sling, causing her to slide out and fall to the floor. Despite the presence of two CNAs, the resident's movement was not adequately controlled, leading to the fall. The resident, who had multiple medical conditions including cerebral infarction, muscle weakness, and pressure ulcers, was on a blood thinner, which increased the risk of injury from falls. During the transfer, the resident complained of pain, which may have contributed to her movement in the sling. The CNAs attempted to adjust the sling, ensuring all hooks were secured, but the resident continued to move, ultimately tipping out of the sling. The fall resulted in the resident hitting her head, although no injuries were reported after hospital evaluation. The facility's policy on transfers using a mechanical lift emphasizes the need for safe and comfortable transfers, but the incident highlights a failure to adhere to these guidelines. The resident's care plan included interventions to remind her not to move during transfers and to educate her about safety, but these measures were not effective in preventing the fall. The incident report and interviews with staff indicate that the resident's movement and pain were not adequately managed during the transfer, leading to the deficiency.
Infection Control Deficiencies During Dressing Changes
Penalty
Summary
The facility failed to adhere to proper infection control standards during a pressure dressing change for two residents. In the first instance, a wound nurse performed a dressing change on a resident with C. difficile, a condition requiring contact isolation precautions. The nurse washed her hands with soap and water initially, but after removing gloves, she used hand sanitizer instead of washing with soap and water, which is necessary to kill C. difficile spores. Additionally, after washing her hands, she removed her dirty gown, which compromised hand hygiene, and did not wash her hands with soap and water before leaving the room. In the second instance, the facility did not implement enhanced barrier precautions during a pressure dressing change for another resident. The nurse and an assisting LPN did not wear gowns, and there was no sign indicating enhanced barrier precautions outside the resident's room. The Director of Nursing mistakenly believed that enhanced barrier precautions were only necessary if the wound was weeping, which was not the case. The facility's guidelines require the use of gowns and gloves during high-risk activities involving multi-drug resistant organisms, such as wound care, regardless of wound condition.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse of a resident, identified as R3, by another resident, R2. The incident occurred in the dining room when R2 approached R3's table and attempted to sit down. R3 informed R2 that the space was reserved for another resident, which led to R2 becoming upset and physically assaulting R3. R3 attempted to block the attack but was struck on the left side of the face, resulting in redness and pain. A Certified Nurse Aide (CNA) witnessed the altercation and called for assistance, after which a Licensed Practical Nurse (LPN) intervened to separate the residents. R2, who was not interviewable, has diagnoses of encephalopathy, dementia, and Alzheimer's disease, with moderately impaired cognitive skills. R3 also has Alzheimer's disease, dementia, schizoaffective disorder, anxiety disorder, and delusional disorders, with similarly impaired cognition. The facility's Abuse Investigation Report and nursing progress notes confirm that R2 struck R3 unprovoked. The facility's Abuse Prevention Program, revised in 2019, emphasizes the residents' right to be free from abuse and outlines that physical abuse includes hitting and other forms of corporal punishment. Despite these policies, the incident occurred, and the facility's response involved separating the residents and contacting the police to file a report. The report does not mention any injuries requiring medical attention, although R3 experienced pain from the assault.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent the physical abuse of a resident, identified as R1, by another resident, identified as R2, during a breakfast incident. R1, who has diagnoses including dementia and severe cognitive impairment, was involved in a physical altercation with R2, who is cognitively intact and has a history of a motor-vehicle accident resulting in the loss of a leg. The altercation occurred when R1 allegedly attempted to take food from R2's breakfast tray, leading R2 to hit R1 on the chin and grab his shirt, resulting in scratches on R1's chest and a ripped shirt. Staff, including an LPN, intervened to separate the residents and assess the situation, noting the injuries to R1 and the absence of injuries to R2. The incident was reported to the police, and R2 was charged with a Class A Misdemeanor for Battery. Interviews with both residents and the LPN confirmed the occurrence of the altercation, with R2 admitting to overreacting and hitting R1. The facility's Abuse Prevention Program, revised in 2019, prohibits abuse and outlines that physical abuse includes actions such as hitting and slapping. Despite this policy, the facility did not prevent the altercation, resulting in a deficiency in protecting residents from abuse.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at a palatable, attractive, and safe temperature for all 154 residents consuming meals from the kitchen. Observations and interviews revealed that residents experienced issues with the food being cold and unappetizing. One resident described the food as inedible, while another mentioned that the food was not warm and was often cold. A third resident noted that while the food was generally okay, there were issues with it being cold and not appetizing. During an observation of the kitchen tray service, the pork roast was found to be watery and unappetizing. A review of the food temperature log indicated that temperatures were not checked before lunch service. The acting dietary manager confirmed that the temperatures were not taken before serving, which is against the facility's policy. A test tray showed that the food temperatures were below the required minimum of 135°F for hot foods, with items such as mixed vegetables, pureed meat, and mashed potatoes all below this threshold. The facility's policy, revised in 2017, mandates that hot foods be held at a minimum of 135°F and cold foods at 41°F or below.
Failure to Maintain a Clean and Home-like Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and home-like environment for two residents, both with mild cognitive impairment. During an observation, one resident was found in a room with a bed sheet that had holes, window curtains with mold buildup, and a bathroom plumbing leak causing stains on the floor and wall. The resident reported that although the room was cleaned daily, it was not done thoroughly, and previous complaints to the nursing staff about the mold and stains were ignored. The housekeeping supervisor stated that the staff is instructed not to use linen with holes or stains, and the maintenance director mentioned that room checks are conducted monthly, with issues addressed immediately if reported. However, the mold on the curtains was attributed to air conditioner condensation, and the maintenance director claimed the plumbing issue was previously fixed but not reported again. The facility's housekeeping policies emphasize maintaining a clean, safe, and attractive environment, which was not upheld in this instance.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse as per their abuse prevention program, resulting in multiple incidents of resident-to-resident aggression. Resident 1 (R1) reported ongoing pain in her head, neck, and shoulders after being punched by Resident 2 (R2). R2, who has severe cognitive impairment and a history of aggressive behavior, admitted to hitting R1 after a verbal altercation. Despite staff intervention, R1 continued to experience pain, which required medical treatment and monitoring. The facility's investigation substantiated the abuse, and R2 was sent to the hospital for evaluation and placed under 1:1 supervision. In another incident, Resident 3 (R3) and Resident 4 (R4), both with moderate cognitive impairments, engaged in a physical altercation. R3 attempted to get into R4's bed, leading R4 to yell and subsequently hit R3. Despite the presence of a CNA assigned to supervise both residents, R3 managed to strike R4 in the nose, and R4 retaliated by hitting R3 in the chest. Both residents were sent to the hospital for evaluation, and the facility's investigation substantiated the abuse. The facility's abuse prevention program, which prohibits all forms of abuse, was not effectively implemented to prevent these incidents. The program defines abuse as the willful infliction of injury or harm, and both incidents involved deliberate physical aggression between residents. The facility's failure to protect residents from abuse resulted in physical harm and ongoing pain for the affected residents.
Failure to Document Necessity of Immediate Transfer
Penalty
Summary
The facility failed to have a physician document the necessity of an immediate transfer for a resident. A [AGE] year-old male resident with diagnoses including dementia, anxiety, mental disorder, depression, and Alzheimer's was involuntarily discharged to the hospital due to aggressive behavior towards another resident. A review of the clinical documentation revealed no evidence of physician documentation to justify the necessity of the transfer. Interviews with the Nurse Practitioner and Psychiatrist confirmed that the required documentation was not completed, as the Psychiatrist was unaware of the need to document the necessity of the immediate transfer.
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What surveyors actually found near you
We read the 716 citations issued within 25 miles in the last 12 months — including the 11 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.
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Nursing homes near South Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Elgin Living & Rehab Center | 0.2 mi | ★★★★★ | 6 | 0 |
| The Pearl Of Fox River Valley | 2.6 mi | ★★★★★ | 13 | 0 |
| Crescent Care Of Elgin | 2.6 mi | ★★★★★ | 5 | 0 |
| River View Rehab Center | 2.7 mi | ★★★★★ | 28 | 0 |
| Aperion Care Fox River | 2.7 mi | ★★★★★ | 0 | 0 |
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