Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Oakpark Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia, major depressive disorder, anxiety disorder, and an amnestic disorder had hospital discharge and facility physician orders for daily Nuplazid to treat delusions, and a care plan directing that medications be given as ordered and behavioral health consults obtained as indicated. The MAR showed Nuplazid was not administered on multiple days and marked as awaiting pharmacy delivery, while also being signed out as given on other days, and behavior monitoring later documented aggressiveness and resistance to care. Progress notes recorded that the medication could not be delivered due to high cost and that a family member was asked to supply it. Pharmacy records showed only a three-day supply was ever delivered and documented that the DON twice instructed the pharmacy not to send Nuplazid. There was no documentation that psychiatry evaluated the resident in the facility or that follow-up occurred after the noted agitation, despite facility policy requiring medications to be administered as ordered and deviations documented with physician notification.
On several night shifts, the facility did not meet minimum CNA staffing requirements, resulting in delays for resident care such as assistance with personal needs and water. Staffing records and staff interviews confirmed that the number of CNAs present was below both regulatory standards and the facility's own staffing plan, with efforts made to fill gaps using agency staff or by reassigning existing staff.
Several residents with cognitive impairments and histories of falls experienced repeated falls without new or revised interventions being added to their care plans. Despite facility policy requiring individualized updates after each fall, care plans were not modified, and there was no documentation from providers indicating that additional interventions were unnecessary. The DON confirmed that care plans should have been updated but were not, resulting in a failure to ensure adequate supervision and accident prevention.
Missed Skin Checks and Wound Care: The facility failed to complete ordered skin checks and wound treatments for multiple residents. One resident had weekly skin assessments that were not documented as completed, another resident with impaired mobility had repeated missed skin checks and skin prep to both ankles, and a third resident with pressure injuries and cognitive impairment had multiple missed wound care, turning, and monitoring interventions. Staff interviews confirmed several ordered treatments and assessments were not completed as scheduled.
Insufficient staffing in the assistive dining area resulted in residents waiting for eating help while CNAs were occupied with other residents and tray passing. A resident with dementia, dysphagia, and a BIMS of 00 repeatedly spilled food and drink, grabbed food with her fingers, and was left without cueing or feeding assistance for extended periods. Staff confirmed the room had residents needing full feeding assistance and cueing, but there were not enough aides present to assist everyone.
Infection control practices were not followed for PPE, contact precautions, hand hygiene, soiled linen, resident bathrooms, and a heel protector boot. Staff entered a room on contact precautions without proper PPE, left without hand hygiene, handled meal trays without cleaning hands between residents, and brought a resident into a shower room where dirty linens were still present. A bathroom used by two dependent residents was observed with feces on the toilet and floor, and a resident with severe cognitive impairment had a soiled heel boot that staff acknowledged should have been cleaned.
Facility equipment was not maintained in a clean and safe condition. Surveyors observed PTAC filters in multiple resident rooms caked with dust and debris, a PTAC unit with water pooling beneath it, and black bio growth inside the 300-unit ice machine chute. The MDS stated PTAC filters and ice machines were cleaned monthly, but records showed the last documented cleanings were earlier than the survey observations.
A resident with dementia and dysphagia was repeatedly left without timely eating assistance, with meal trays out of reach or untouched and food and liquid spilled on her table and clothing during meals. Another resident with ESRD on hemodialysis was repeatedly observed in a hospital gown with no clothing in his closet, despite telling staff he wanted clothes for dialysis and saying he had asked multiple times.
Failure to notify resident representative immediately of significant change in condition. A resident with chronic respiratory failure, HF, and convulsions had increased WOB and severe hypoxia in the early morning, with the RN documenting a rapid decline and calling the provider for new orders. The resident expired a little over 2 hours later, but the RR was only documented as being notified after death; the RR said he was not contacted during the decline and learned of the death later that morning.
Failure to report alleged verbal abuse involving two residents. A daughter reported that her mother called crying after a CNA yelled at her and her roommate, and one resident later described the staff member coming into the room, getting in her face, pointing a finger, and yelling at both residents. Interviews showed the allegation was not promptly reported as abuse, and the DON and NHA learned key details only later; facility policy required immediate reporting of alleged abuse or mistreatment.
Incomplete PASRR screening was identified for three residents with dementia and mental health diagnoses. One resident’s PASRR incorrectly failed to document dementia, while two others had incomplete Level I PASRRs that did not include all qualifying diagnoses and did not result in Level II submission. The DON confirmed one screen was inaccurate, and the NHA stated the facility did not have a PASRR policy and followed federal regulations.
The facility failed to provide needed ADL assistance for one resident who required supervision, cueing, and hands-on help with eating and for another resident who required a mechanical lift and two staff for transfers. The first resident, who had dementia, dysphagia, and a very low BIMS score, was repeatedly observed without consistent meal supervision while spilling food and drink, using her hands instead of utensils, and taking a tablemate's food and cup. The second resident stated staff did not get her out of bed because a Hoyer sling was unavailable, and staff confirmed she was left in bed when her sling was in laundry.
A resident with HTN, paroxysmal atrial fibrillation, and syncope had a heart monitor ordered to remain in place for 14 days, but staff found the device off the resident and on the bedside table before the monitoring period ended. The LPN believed it had only been on for two days, the DON and RN/UM confirmed the order required it to stay on, and the cardiology NP said she had not been notified that the monitor was no longer on the resident.
Failure to Provide Ordered Psychotropic Medication and Mental Health Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with multiple mental health and neurological diagnoses received ordered psychotropic medication and appropriate mental health services. The resident was admitted with Parkinson’s disease, major depressive disorder, anxiety disorder, dementia, and an amnestic disorder, and hospital discharge instructions showed an order for Nuplazid 34 mg daily. Facility physician orders also reflected Nuplazid 34 mg daily for delusions. The care plan identified alteration in neurological status related to Parkinson’s and dementia, and a mood problem, with interventions including administering medications as ordered, obtaining behavioral health consults as ordered or indicated, and monitoring and reporting significant mood and behavior changes to the physician. However, the MAR for a portion of December showed Nuplazid was not administered on multiple days and was documented as “waiting on delivery from pharmacy” on several dates. Despite this, the MAR also showed Nuplazid as signed out as administered on other dates during the same period, and behavior monitoring documented only insomnia and wandering initially, followed by aggressiveness and avoidance/resisting care on later dates. Progress notes indicated that on one date the resident was agitated, hitting and kicking staff, and that Nuplazid could not be delivered due to high cost, with psychiatry reportedly aware and new orders awaited; a later note documented that a family member was called to supply Nuplazid. Pharmacy records showed only a three-day supply of Nuplazid was ever delivered and that the DON had twice called instructing the pharmacy not to send the medication. There was no documentation that psychiatry actually saw the resident in the facility, and no follow-up documentation related to the progress note about agitation and medication unavailability. The DON and NHA confirmed the resident did not receive the ordered Nuplazid for several days, that psychiatry did not see the resident, and that there was no facility policy related to psychiatry services or mental health care, despite an existing policy requiring medications to be administered as ordered and deviations to be documented with physician notification.
Insufficient CNA Staffing on Multiple Night Shifts
Penalty
Summary
The facility failed to provide a sufficient number of certified nurse assistants (CNAs) during four night shifts out of twenty-seven reviewed, as evidenced by staffing records and interviews. On the specified dates, the number of CNAs scheduled did not meet the minimum regulatory requirement of one CNA per twenty residents, given the facility's census of over 170 residents. Staffing records showed only seven CNAs present during these shifts, which was below the facility's own staffing plan and regulatory standards. Interviews with staff confirmed that the schedule is based on census and that shortages occasionally occur, with attempts made to fill gaps using agency staff or by having the staffing coordinator work as a CNA when needed. A resident reported delays in receiving assistance with personal care and water, citing a specific incident where it took several hours to receive water after requesting it at night. Staff interviews corroborated that while the facility generally maintains adequate staffing, there have been instances of CNA shortages. The staffing coordinator confirmed reliance on agency staff and efforts to ensure coverage, but acknowledged that there were shifts with fewer than the planned number of CNAs. These findings were supported by a review of daily schedule and punch reports for the relevant period.
Failure to Update Care Plans and Implement Post-Fall Interventions
Penalty
Summary
The facility failed to implement post-fall interventions to prevent future falls for four residents who were identified as being at risk for falls. In multiple instances, after residents experienced falls, there was no evidence that new or revised interventions were added to their care plans. For example, one resident with diagnoses including sarcopenia, atrial fibrillation, and syncope experienced two falls, but the care plan was not updated with new interventions after either event. The Director of Nursing (DON) confirmed that no new interventions were added following these incidents, despite facility policy requiring individualized care plan updates after falls. Another resident, who was severely cognitively impaired and had a history of falls, was found on the floor with a head injury. Review of her care plan and medical record revealed that no new interventions were added after her fall, and there was no documentation from a physician indicating that additional interventions were unnecessary. Similarly, a resident with moderate cognitive impairment and a history of falls suffered a fall resulting in a large bruise, but the care plan was not updated to address the incident or to add interventions to reduce future risk. The DON acknowledged that the care plan should have been updated but was not. A fourth resident, also with moderate cognitive impairment and multiple comorbidities, experienced several falls. Although the interdisciplinary team discussed adding new interventions after one of the falls, the care plan was not updated to reflect these changes. Facility policy requires that each resident have an individualized plan of care that is reviewed and modified as needed to include appropriate fall interventions. The failure to update care plans and implement new interventions after falls represents a deficiency in ensuring the environment is free from accident hazards and that adequate supervision and interventions are provided to prevent accidents.
Missed Skin Checks and Wound Care
Penalty
Summary
The facility failed to ensure skin checks were completed as ordered for multiple residents, including residents with impaired mobility, cognitive impairment, and existing pressure injuries. Resident #14 had a physician order for weekly skin assessments every Friday, but the treatment administration record did not show the skin checks were documented as completed for one of four scheduled times in October 2025 and were not documented as completed in December 2025. Staff BB stated she could not explain why the ordered skin checks were not completed, and the unit manager stated the checks should be completed as ordered and that any inability to complete them should be documented and reported to the provider. Resident #6 had orders for weekly skin checks every Thursday and skin prep to both outer ankles every shift. Review of the TARs showed the weekly skin checks were not documented as completed multiple times across September, October, November, and December 2025, and the skin prep was also missed numerous times during those months. The resident stated his tailbone hurt and that nurses did not do his skin checks, adding that only CNAs saw his buttock area when they changed him. The wound care nurse confirmed the skin checks were not completed as ordered and stated the charting system should have triggered a red notification for missed items. Resident #35 was admitted with diagnoses including Parkinson’s disease, adult failure to thrive, weakness, malnutrition, and dementia, and had a BIMS score of 3. Skin condition review showed one stage II pressure ulcer and one stage III pressure ulcer. Wound measurements for the stage III sacral ulcer showed improvement in November 2025, then a larger measurement on 12/10/2025. The TAR/MAR review showed multiple missed wound treatments and repositioning interventions, including missed sacral care, heel skin prep, turning and repositioning, forehead scab monitoring, and treatment to other wounds on the sacrum, toe, lower back, temporal area, left ankle, and sacrum. Staff interviews confirmed some wound care and dressing changes were not completed as ordered, including a facial bandage that was not changed on a scheduled day.
Insufficient staffing in assistive dining led to delayed and missed eating assistance
Penalty
Summary
The facility failed to provide sufficient staffing to meet residents’ needs for dining and ADL eating assistance in the assistive dining room. During three separate meal observations, residents who required supervision, cueing, or hands-on eating assistance were left waiting while staff were occupied with other tasks or other residents. The report specifically identified Residents #134, #50, and #168 as needing more than minimal eating support during lunch and breakfast services. On 12/8/2025, the assistive dining section had eight residents and only one CNA present. That CNA was assisting one resident at a table and did not intervene with Resident #134, who spent the meal pushing food off her plate, spilling liquid on her food and table, and picking up food with her fingers. Resident #134 was not served finger foods. The CNA remained with the tablemate and did not cue or redirect Resident #134, and no other staff were present in the room to assist. The ADON was elsewhere in the dining room passing trays and moving tray carts. On 12/9/2025, twelve residents were seated in the assistive dining section with only two CNAs present, and both were assisting Residents #50 and #168. Resident #134 waited without assistance for about eight minutes while she spilled liquid on her plate and table, grabbed food with her fingers, and reached for a tablemate’s cup until a CNA intervened. Staff also confirmed that residents needing cueing or full feeding assistance were present in the room and that there were not enough staff to assist everyone. On 12/10/2025, Resident #134’s breakfast tray was placed in her room while she remained in bed, but she was not assisted with eating until 32 minutes later because staff were occupied changing her roommate’s clothes and bed linen. The resident had diagnoses including DMII, Alzheimer’s disease, anemia, dysphagia, conversion disorder with seizures, insomnia, and depression, and her MDS showed a BIMS score of 00 and eating coded as supervision and touching assistance. The DON did not provide a specific dining staffing policy, and the ADON stated there should have been more staff in the assistive dining room to assist the residents who required eating help.
Infection Control Failures With PPE, Hand Hygiene, Soiled Linen, Bathroom Cleanliness, and Boot Sanitation
Penalty
Summary
The facility failed to implement infection prevention and control practices related to PPE use, contact precautions, hand hygiene, soiled linen handling, resident bathroom cleanliness, and sanitation of a heel protector boot. During observation of the 100 unit shower room, dirty linens were seen piled on the floor, hanging on the shower chair, and on the shower rails while a CNA wheeled a resident into the room before it had been cleaned. During lunch service on the 100 hall, staff removed trays from the cart and entered resident rooms, with one staff member setting up a tray and another moving an over-bed table and arranging food items, but neither performed hand hygiene before returning to the tray cart for the next tray. In a resident room bathroom, a toilet was observed with what appeared to be feces on the front, around the rim, and splattered on the floor. A family member stated that neither resident could use the bathroom independently and that staff had to assist them. The DON reviewed photos of the toilet and stated it was not acceptable and that a staff member should have cleaned it after taking the resident to the bathroom. In another observation, water cups in multiple resident rooms had no names or labels, and a family member reported that the resident’s over-bed table had been switched with the roommate’s on multiple occasions. Contact precaution practices were also not followed. A contact precaution sign was observed on a resident room door while a CNA was in the room wearing only gloves, moving around the resident bed and tray table, and then leaving the room without hand hygiene before entering another room. On another observation, two staff members entered the same room with no PPE while the contact precaution sign remained posted. Interviews showed staff had differing understandings of contact precautions and EBP, including when gowns and gloves were required and whether precautions applied to both residents in a shared room. For Resident #2, who had diagnoses including sequelae of cerebral infarction, hemiplegia, and dysphagia, and a BIMS score of 2 indicating severe cognitive impairment, a soiled heel protector boot was observed with dirty areas. The resident stated the boot had never been cleaned, and the wound care nurse and DON both acknowledged the boot should have been cleaned and that it appeared to have feces on it. The MAR/TAR also showed a wound care treatment order with no treatment documented on the day shift of 12/9/25.
Facility Equipment Not Kept Clean and Free of Leaks
Penalty
Summary
Essential facility equipment was not maintained in a clean and safe manner in the resident environment. Survey observations found PTAC systems in rooms 364, 266, 272, and 210 with filters caked with dust and debris, and vents in some rooms also had dust and debris. A PTAC unit in room [ROOM NUMBER] was observed with a puddle of water under the unit on 12/8/2025 and again on 12/11/2025, with photographic evidence obtained on both occasions. The facility also failed to keep the 300-unit ice machine free of bio growth. On 12/09/2025, black bio growth was observed on the interior surface of the ice machine chute where ice is dispensed, and it was wiped from the machine during the observation. The Maintenance Director stated PTAC filters are cleaned monthly and that maintenance performs monthly cleanings of the ice machines; however, the record showed the 300-unit ice machine cleaning log last documented cleaning on 11/12/2025, and the PTAC Air Filters Washed record showed the 300-unit filters were last cleaned on 11/23/2025 and the 200-unit filters on 11/21/2025.
Failure to Preserve Resident Dignity During Meals and by Leaving a Resident Without Clothing
Penalty
Summary
The facility failed to maintain and promote dignity for two residents by leaving one resident with meal trays and food or liquid spills for extended periods without assistance, and by failing to provide another resident with clothing, leaving him in a hospital gown on repeated observations. Resident #134 had diagnoses including DMII, Alzheimer's disease, anemia, dysphagia, conversion disorder with seizures, insomnia, and depression, and her MDS showed a BIMS score of 00 and eating coded as supervision and touching assistance. She was observed in the assistive dining room on multiple occasions with meals already served but without timely staff assistance, while she pushed food off her plate, spilled liquid on her table, lap, and clothing, and remained soiled for long periods during the meal service. On one observation, Resident #134 sat at a table with food and liquid spilled across the tablecloth and on herself while a CNA assisted only her tablemate. The CNA stated she did not realize the resident had spilled her drink and pushed food off the plate. On another observation, the resident was left with a breakfast tray in her room for 34 minutes before staff began assisting her, despite staff confirming she required help with eating. On a later observation, the tray was placed behind her and out of reach while she remained seated in bed until a CNA eventually moved the tray and began cueing and assisting her with the meal. Staff interviews confirmed she needed continued monitoring, cueing, and assistance with eating and should not have been left alone with her meal. Resident #13, who had diagnoses including ESRD on hemodialysis three times weekly, chronic diastolic CHF, type 2 diabetes, depressive disorder, generalized anxiety disorder, and insomnia, was repeatedly observed wearing a hospital gown with no clothing in his closet. He told staff he wanted to be transported to dialysis in clothing instead of a hospital gown and said he had repeatedly asked for clothes but had not received any. Staff interviews showed multiple disciplines were aware he had no clothing, but the issue had not been resolved or reported consistently, and the resident remained without clothing during repeated observations.
Failure to Notify Resident Representative Immediately of Significant Change in Condition
Penalty
Summary
The facility did not ensure a resident representative was contacted immediately when Resident #178 had a significant change in condition. Resident #178 was admitted with diagnoses including chronic respiratory failure, heart failure, and unspecified convulsions. According to the progress notes, at approximately 4:15 a.m. the assigned CNA informed the nurse that the resident had increased effort in breathing. The nurse documented vital signs showing BP 123/79, HR 148, oxygen saturation 68% on 8L nasal cannula, RR 24, and temperature 98.1, and noted the resident had been on a constant decline for the past month. The resident was repositioned upright, suctioning was attempted without success, and the provider’s office was called for new orders. The resident expired at approximately 6:47 a.m., and the record documented that the DON, ARNP, and resident representative were notified after death. The resident representative stated he had been at the facility the prior evening and saw the resident was breathing a little labored, but he was not contacted during the early morning decline and was only notified around 7:30 a.m. that the resident had passed away. The NHA and DON reviewed the record and confirmed there was only documentation showing the resident representative was called after the resident died. Facility staff and the facility policy stated that the resident representative should be notified immediately when there is a significant change in condition.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one with a BIMS score of 07 and cognitive impairment and the other with a BIMS score of 15 and intact cognition. Resident #20 was admitted with diagnoses including permanent atrial fibrillation, age-related osteoporosis without current pathological fracture, and cognitive communication deficit. Resident #166 was admitted with diagnoses including sarcopenia, endocrine disorder unspecified, and major depressive disorder. Both residents were observed in their rooms or hallway without distress during the survey, but interviews identified a reported incident involving a staff member yelling at them. Resident #20’s daughter reported that her mother called crying and said a CNA was screaming at her and her roommate. The daughter stated she called the facility around 8:57 p.m. and told staff on the unit what her mother and the roommate had reported, and that she did not want the aide to return to her mother’s room. Resident #20 later stated a staff member came into the room and yelled at her and her roommate, causing her to cry. Resident #166 stated she was helping Resident #20 get settled in bed when a staff member came into the room, got in her face, pointed a finger forcefully, and yelled at both residents, telling her not to touch the roommate and to go to bed or sit in her chair. Interviews with the nurse assigned that night, the DON, the unit manager, and the NHA showed the allegation was not immediately reported as abuse. The nurse said the residents did not report being yelled at, while the DON stated she only learned of a concern after staff overheard a conversation and then spoke with Resident #20, who said she was upset because a staff member was talking loudly in the hallway and that she felt safe. The DON did not interview Resident #166 at that time. The NHA stated she first learned from the daughter that the family had called the facility the prior evening to report the yelling and request that the CNA not be assigned back to the room. Facility policy required alleged abuse or mistreatment to be reported immediately, but not later than 24 hours if the event did not involve serious bodily injury.
Incomplete PASRR Screening for Residents with Mental Health and Dementia Diagnoses
Penalty
Summary
The facility did not ensure PASRR Level I screening was completed accurately for three residents with qualifying mental health and cognitive diagnoses. Resident #3 was admitted with diagnoses including dementia, depression, and bipolar disorder, but the PASRR Level I screen marked “No” for validating documentation supporting dementia or a related neurocognitive disorder. During interview, the DON reviewed the record and confirmed the resident had a dementia diagnosis and that the PASRR screen should have reflected it, acknowledging the screen was completed inaccurately. Resident #149 was admitted and readmitted with diagnoses including dementia, anxiety disorder, major depressive disorder, and bipolar disorder, but the Level I PASRR did not select dementia as a secondary diagnosis and was incomplete, with no Level II submitted for consideration after the qualifying diagnoses. Resident #88 was admitted and readmitted with diagnoses including dementia, anxiety disorder, major depressive disorder, bipolar disorder, and panic disorder, but the Level I PASRR did not include all qualifying diagnoses and was also incomplete, with no Level II submitted for consideration. The DON stated new diagnoses should have been added during the monthly GDR meeting, and the NHA stated the facility did not have a PASRR policy and followed federal regulations.
Failure to Provide Eating Assistance and Bed Mobility Support
Penalty
Summary
The facility failed to provide adequate ADL assistance with eating for a resident who had dementia/Alzheimer's disease, a BIMS score of 0/15, dysphagia, and orders for a mechanical soft diet with thickened liquids. During multiple meal observations, the resident was seen seated in the assistive dining room or in her room with meals set up, but without consistent staff supervision, cueing, or hands-on eating assistance. She was observed pushing food off her plate with her hands, spilling a pink liquid onto her food and the table, dropping food onto the table and her lap, and reaching for and taking a tablemate's utensils and drink. Staff observed at the table did not intervene consistently, and one CNA stated she was assisting the tablemate and did not realize the resident had spilled her drink and pushed food off her plate. On another observation, the resident was seated with two other residents and no staff in the immediate area, despite needing more than supervision and cueing for eating. She was observed grabbing at food with her fingers, spilling liquid onto her plate, dropping food repeatedly, and taking a tablemate's silverware and cup. A CNA briefly redirected her not to take her tablemate's items and to use her own utensils, then walked away, after which the resident again took the tablemate's cup and drank from it. Staff interviews confirmed the resident required continued monitoring, cueing, and eating assistance, and the Director of Rehabilitation stated she should not be left alone with her meal. The facility also failed to assist another resident with getting out of bed. That resident was cognitively intact, used a mechanical lift, and required two staff for transfers. She stated staff did not get her up when she wanted because they did not have enough Hoyer pads available, and she had complained and filed a grievance without resolution. A CNA stated the resident could not be gotten up when her Hoyer pad was in the laundry and no other pad was available. The unit manager stated that if a sling is sent to laundry, extra slings are kept in the shower room and that a sling being in laundry is not an excuse to keep a resident in bed.
Heart monitor removed before ordered monitoring period ended
Penalty
Summary
The facility failed to maintain a heart monitor in place according to physician orders for one resident who had diagnoses including essential hypertension, paroxysmal atrial fibrillation, and syncope and collapse. The resident was ordered on 12/4/25 to not remove the heart monitor, which was to remain in place for 14 days and be removed by Cardiorenal Vision. During an observation on 12/8/25, a round silver metal device with electrodes was seen on the bedside table in the resident’s room, and the resident was not present at that time. Review of the resident’s progress notes did not show documentation explaining why the monitor was no longer in place or that a provider had been notified. When the resident was later interviewed and observed, he was pleasantly confused and did not think he had anything on his chest; staff then checked and confirmed the heart monitor was not in place. The assigned LPN stated she had almost forgotten about the monitor and believed it had only been on for two days, but after reviewing the order she acknowledged it was supposed to remain for 14 days. The DON and RN/UM reviewed the record and confirmed the monitor had been placed on 12/4/25 and should have remained in place. The cardiology NP confirmed she had placed the monitor due to syncope episodes, said it should not have been removed for showers or any reason, and stated she had not been notified that the device was no longer on the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Palm Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Mark Village | 0.8 mi | ★★★★★ | 0 | 0 |
| Aviata At Countryside | 1.3 mi | ★★★★★ | 0 | 0 |
| Aviata At The Palms | 1.4 mi | ★★★★★ | 11 | 4 |
| Palm Garden Of Clearwater | 1.9 mi | ★★★★★ | 0 | 0 |
| Westchester Gardens Health & Rehabilitation | 2.3 mi | ★★★★★ | 1 | 0 |
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