Norbert Residential Care Facility.

“Resident reported an allegation of physical abuse against direct care staff to staff person A at approximately 1:45 AM, but this allegation was not reported to the local Area Agency on Aging as required.”

“Resident reported an allegation of physical abuse to direct care staff at approximately 1:45 AM, but this allegation was not reported to the Department until approximately 10:45 AM on 2/7/26, exceeding the 24-hour reporting requirement.”

“The facility was video recording in numerous common areas including hallways with resident bedroom entrances in the personal care and secured dementia care units, and exterior entrances/exits, which violates resident privacy rights. Signage indicated 24-hour video monitoring was in place.”

“At 9:30 AM, there was approximately 6 inches of snow on the sidewalk leading to the gazebo outside 5 emergency exit doors in the personal care dining room. At 9:36 AM, there was approximately 4 inches of snow on the steps and landing leading to the front of the building outside emergency exit door #2.”

“Resident support plan does not include the plan to meet medical needs for diagnoses of multiple fractures of ribs and encounter for other orthopedic aftercare, with these sections marked "N/A." Additionally, the resident's current use of walker and wheelchair for mobility was not indicated on the support plan.”

“A dining room table in close proximity to the emergency exit door obstructed the pathway to the outside courtyard on the third floor of the secured dementia care unit.”

“Resident #1's insulin Lispro Kwik pen did not have the original pharmacy label and did not include the date the prescription was issued, the prescribed dosage and instructions for administration, or the name and title of the prescriber.”

“Resident #1 (admitted in 2021) and Resident #2 (admitted in 2021) had not been educated on their right to question or refuse medication if they believed there may be a medication error.”

“The assessment for Resident #3 did not include diagnoses of wounds, coagulation disorder, vitamin deficiency, insomnia, GERD, depression, skin irritation, seizure control/pain, behavioral disorders, and asthma as indicated on the medical evaluation.”

“The directions for operating the home's locking mechanism were not conspicuously posted near the emergency exit door leading to the outside courtyard in the Secure Dementia Care Unit.”

“Approximately 26 residents did not receive their evening medications as prescribed by their physicians on 4/24/24, including insulin injections, pain management medications, and other prescribed treatments, resulting in failure to follow prescriber's orders.”

“Approximately 26 residents did not receive their evening medications when one medication technician abandoned their shift and the other technician did not administer the medications as instructed. This constitutes neglect as residents were deprived of prescribed medications including insulin, pain management, and other critical medications.”

“Approximately 26 residents' electronic medication administration records (E-MARs) were not updated to indicate that residents did not receive their evening medications on 4/24/24, failing to record the date/time of medication administration or non-administration as required.”

“Resident's significant health decline was not assessed and documented through an additional assessment as required. The resident required increased hospice services (from standard to daily aide visits, plus twice-weekly nurse practitioner and three times weekly LPN/RN care), developed multiple wounds (8 total), became bedbound and nonverbal, and required repositioning every 2 hours, but the Resident Assessment-Support Plan (RASP) was not updated to reflect these significant changes in condition.”