Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Northbrook Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with intact cognition, ADL self-care deficits, and dependence on staff for ambulation and transfers did not receive the ordered restorative ROM program recommended by therapy. Although therapy issued recommendations for active ROM exercises to the lower extremities and nursing notes indicated that restorative referrals were received and that the resident was "continuing" a restorative program, there was no documentation that the specific exercises were carried out. Staff interviews revealed that therapy referrals to restorative were not effectively communicated, the restorative aide reported never receiving a PT referral and confirmed the resident did not receive restorative services, and nursing leadership acknowledged a lapse in administering the restorative program over an extended period, contrary to the facility’s restorative nursing policy.
The facility failed to respond promptly to resident call lights, as reported by multiple cognitively intact residents. One resident stated that call light responses often exceeded fifteen minutes and that she also used her call light for a roommate unable to call independently. Another resident, who required two-person assistance for transfers and toileting, reported daily delays in call light response on any shift, sometimes up to an hour, leading to incontinence. A third resident on O2 via nasal cannula reported call light response times over thirty minutes and up to an hour, and described staff turning off the call light and leaving without providing assistance or returning, despite his need for help with ambulation when unsteady. Resident Council notes documented ongoing concerns about long call light response times, and leadership acknowledged that such concerns were being tracked through council reports.
Two residents received medications intended for others after staff failed to properly identify them, with one receiving another's insulin and requiring ER observation, and another receiving a full set of morning medications meant for a different resident, leading to abnormal blood pressure readings. Both incidents involved staff relying on verbal or visual cues rather than following identification protocols.
A resident with intact cognition, limited mobility, and dependence on a full-body Hoyer-style lift slid backward in the sling during a transfer and was lowered to the floor. The care plan required a full-body mechanical lift with 2 staff, but did not specify sling size or style, and staff interviews showed sling selection had been based on visual judgment rather than a clear guide. Later review and staff statements indicated the sling used was too large for the resident, and the incident documentation initially focused on poor positioning rather than the wrong sling size.
A resident with cognitive and mobility impairments was not assisted respectfully or promptly by an RN when requesting help to find a bathroom, resulting in the resident being left unattended and partially exposed while attempting self-transfer. Additionally, confidential health information was left visible and unattended on a laptop in two hallways, contrary to facility policy and staff expectations regarding privacy.
Multiple residents with significant care needs experienced prolonged waits for staff assistance, with call lights often unanswered for extended periods. This led to incontinence accidents and falls, as staff—including CNAs, RNs, and the DON—were observed not responding to call lights in a timely manner. Staff interviews confirmed that inadequate staffing contributed to these delays, and facility policy requiring prompt response was not consistently followed.
The facility failed to ensure a clean, safe, and comfortable environment by not adequately cleaning and repairing toilets, leaving beds unmade, and failing to replace or repair damaged window screens and loose electrical outlets. Multiple residents experienced persistent odors, unclean bathrooms, and unresolved maintenance issues, with staff confirming delays and inconsistencies in cleaning and repairs.
Improper Hair Restraints During Food Prep and Meal Service: Dietary staff were observed preparing and serving food with hair nets and caps that did not fully cover their hair, including exposed bangs, sides, buns, and hair in the back. Staff served from the steam table, pushed it through the hall, leaned over open food compartments, and assisted residents while their hair remained exposed. The FSM stated all dietary staff had to wear hairnets but believed a ball cap alone was enough, and the Administrator said she had told her that a ball cap did not require a hair net.
Staff failed to maintain resident dignity and respect by not keeping a resident's wheelchair clean despite repeated concerns, using inappropriate language about a resident in public, and posting signs in a resident's room about toileting without consulting the resident. These actions affected residents with severe cognitive impairment and mobility issues, and did not align with facility policies on dignity and individualized care.
A resident readmitted after severe medical conditions did not receive required physical assessments or consistent documentation of vital signs over several days. Despite ongoing health issues and facility policy mandating assessments and vitals every shift, staff failed to document these, and leadership confirmed the absence of records in the electronic health record.
Three residents were affected by the facility's failure to use foot pedals during wheelchair transport and to maintain mobility equipment in safe working order. One resident was pushed in a wheelchair without foot pedals, causing her feet to touch the ground, while another was transported without pedals due to their inconvenience at the dining table. A third resident fell when his walker, which was in poor condition with missing screws, collapsed during a transfer. Staff interviews confirmed recurring issues with missing foot pedals and inadequate equipment checks.
Failure to submit MDS assessments within the required time frame. A resident had a quarterly MDS and an annual MDS that were both marked complete, not accepted, and flagged as do not submit even though they should have been submitted. The MDS coordinator stated the facility does not have an MDS policy and follows the RAI.
A resident with ESRD and Lupus did not receive ordered Ambien before two planned AV fistula procedures even though the surgeon’s pre-op orders allowed the dose, and the MAR showed the medication was held without a hold order from the surgeon. The resident also did not receive ordered weekly Belimumab injections after the nephrologist restarted the medication, with staff failing to obtain the specialty drug and delaying contact with the nephrology office. Staff interviews showed confusion about the orders and incorrect EMR documentation.
Failure to support a resident’s activity preferences: A resident with anxiety, depression, weakness, and intact cognition stated she wanted to go outside for fresh air, but the activity record showed only indoor activities and lacked documentation that outdoor activities were offered. The AD said she had just started and planned to take residents outside twice weekly, while the DON said residents were able to go outside in the mornings.
A resident with bladder incontinence and multiple chronic conditions reported dysuria, lower abdominal pressure, urinary frequency, and concern for a kidney infection, but the chart lacked ongoing assessment and timely follow-up after the initial nursing note. A provider sent a UA with C&S order through secure messaging, yet the order was not entered into the EMR until days later, and staff interviews showed uncertainty about why the order was not processed promptly despite expectations for same-day follow-through and shift-to-shift review of messages.
An LPN failed to follow a resident’s G-tube orders and care plan by not checking tube placement or residual gastric content before starting an enteral feeding and by flushing with only 30 mL instead of the ordered 90 mL. The resident had stroke-related dysphagia, severe cognitive impairment, and was NPO with nutrition, medication, and hydration through the G-tube. Facility policy required verification of enteral tube placement before administering fluids or medications.
A resident with dementia and severe cognitive impairment signed an ADR agreement and admission paperwork without a dated signature, without a legal representative’s signature, and without the facility’s authorized agent signing. The resident later stated she did not remember signing the paperwork and did not understand she had given up the right to court litigation, while staff acknowledged the resident’s family was not present and the facility lacked policies for assessing capacity to sign agreements or when a POA/DPOA should be enacted.
Failure to Follow EBP and Soiled Linen Infection Control Practices: Staff did not consistently follow EBP for residents with a G-tube, wounds, and a catheter. An LPN and RN performed G-tube care and medication administration for a resident with severe cognitive impairment without wearing gowns, and an RN completed wound care for another resident with Stage 2 and Stage 3 pressure ulcers without a gown. A CNA emptied a catheter bag and later stated a gown and mask should have been used. The Housekeeping/Laundry Supervisor reported gowns were not worn when handling soiled linens, and the Administrator stated the facility had no policy for soiled linen handling.
The facility failed to maintain a clean and homelike environment, with multiple resident rooms having window curtains falling down or missing, and exterior windows covered in dust and grime. A resident expressed dissatisfaction with the dirty windows, and the Housekeeping Supervisor cited staff shortages and acknowledged the issues, noting that exterior windows were last cleaned in the fall.
A resident with severe cognitive impairment was physically abused by a CNA, who struck the resident on the back of the head. The incident was witnessed by a CMA and reported to the charge nurse immediately. The facility's policy mandates investigation and reporting of abuse, but the incident was not addressed promptly, resulting in a deficiency.
The facility failed to maintain a sanitary environment during dining and wound care, leading to potential infection risks. A CNA did not sanitize hands between assisting residents with meals, and food trays were transported uncovered through a COVID-positive hallway. Additionally, a nurse did not perform hand hygiene between glove changes during wound care. These actions violated the facility's infection control program, which emphasizes handwashing before and after resident contact.
The facility failed to maintain the dignity of two residents. One resident was brought to the dining room without pants, covered only by a blanket, and the issue was not promptly addressed. Another resident, requiring extensive assistance, was left exposed during personal care, and staff did not offer hand hygiene after the resident scratched herself. The DON acknowledged the care did not meet expectations, highlighting a lapse in maintaining resident dignity.
A resident with no cognitive impairment was excluded from decision-making regarding their dietary needs, despite expressing dissatisfaction with a ground meat diet and requesting a reevaluation. The facility relied on a Durable Power of Healthcare document to direct decisions to the family, assuming the resident was unable to make decisions, which was not the case. Delays in a speech evaluation were due to insurance and co-pay issues.
A facility failed to update a resident's Care Plan to include monitoring for an antidepressant prescribed months earlier. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed Remeron, but the Care Plan lacked focus, goals, or interventions related to the medication. The oversight was acknowledged by the ADON, MDS coordinator, and DON, who realized the medication was not added to the TAR for monitoring until months later.
A resident with ESRD on dialysis did not receive meals according to their prescribed renal diet, which required double protein servings and avoidance of high sodium foods. The resident reported receiving inappropriate meals, such as sauerkraut and sausage gravy, and smaller portions of eggs than ordered. The dietician confirmed these discrepancies, acknowledging the failure to provide the correct menu alternatives.
A facility failed to conduct required pre and post dialysis assessments for a resident with ESRD, despite the care plan indicating the need for such assessments. The resident, who was cognitively intact, could not recall any pattern of assessments, and a review confirmed their absence in records. The DON acknowledged the lack of these assessments.
A facility failed to notify the LTC Ombudsman of a resident's transfer to the hospital, as required by federal regulation. The resident was hospitalized for several days, and the deficiency was identified during a clinical record review and staff interview. The Administrator confirmed the lack of notification and acknowledged the expectation to notify the Ombudsman, although the facility did not have a specific policy in place.
A facility failed to notify a resident and their representative of the bed hold policy during two hospitalizations. The resident was discharged and reentered the facility twice, but there was no documentation of notification regarding the bed hold policy. The Administrator acknowledged the oversight, stating that a bed hold should be completed and explained to the resident or their representative. The facility's policy requires informing the resident or legal representative of the bed hold policy upon admission and prior to, or as soon as possible, after transfer or temporary discharge.
A resident with a history of polio and falls was transferred without the required assistance of two staff members, resulting in a fall from a mechanical lift. The incident was not immediately assessed by a nurse, and the facility lacked proper documentation and notification. The resident experienced increased pain, and staff interviews revealed inconsistencies in reporting the incident.
A facility failed to complete a quarterly MDS assessment on time for a resident with moderate cognitive impairment and multiple diagnoses, including acute respiratory failure and congestive heart failure. The assessment was overdue by 9 days, and the DON was unaware of the delay. The facility lacked a written policy for resident assessments and care planning.
A resident received Glimepiride for 77 days without a diabetes diagnosis or physician's order due to a nurse's error in entering another resident's order into the EHR. The error went unnoticed by multiple staff, including nurses, CMAs, the DON, and pharmacy consultants, leading to the resident's hospitalization for hypoglycemia. Staff interviews revealed a lack of procedures for verifying medication orders against diagnoses.
The facility failed to provide consistent restorative care for three residents, leading to a decline in mobility and range of motion. A resident with hemiplegia lacked a documented plan for range of motion activities, and their family expressed concerns about care practices. Another resident with cognitive impairment was unaware of any restorative program, and a third resident reported not being offered range of motion services. The facility lacked a restorative plan, policy, or procedure to maintain residents' functioning.
A resident with moderate cognitive impairment and no history of diabetes was incorrectly administered Glimepiride, leading to hypoglycemia. The error was not identified during three provider visits in June, despite medication reviews. The facility lacked a written policy for medication errors, and the issue was only addressed after the resident was hospitalized.
A resident with moderate cognitive impairment and no diabetes diagnosis received 77 doses of Glimepiride due to a failure in the pharmacy consultant's medication review process. The error was discovered after the resident was hospitalized for hypoglycemia, and the facility lacked a policy for addressing medication errors.
A resident with severe cognitive impairment and requiring extensive assistance for transfers fell and injured her wrist due to inadequate supervision and failure to use a gait belt as per the care plan. The CNA assisting the resident was new and unaware of the resident's needs, leading to the incident.
The facility failed to provide the required two baths weekly for four out of five residents reviewed, with some residents receiving no baths for an entire month. The issue was partly due to an increase in the facility's census and the recent addition of a designated bath aide.
The facility failed to provide appropriate assessments and interventions for residents with impaired skin and changes in condition. One resident with heart disease and Alzheimer's did not receive weekly skin assessments for over two months. Another resident with cancer and renal insufficiency had soiled dressings and extensive edema without follow-up orders or assessments. Two other residents with pressure injuries did not receive weekly assessments as required by the facility's policy.
The facility failed to follow the care plan for a resident with cognitive impairments and a history of pressure ulcers. The resident was left seated in a wheelchair for an extended period without repositioning or incontinence care, contrary to the care plan's directives. Staff interviews confirmed the lack of adherence to the care plan and facility policies for skin care and pressure ulcer prevention.
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. One resident did not receive prescribed antifungal creams, another had inconsistent application of Triad paste for a pressure ulcer, and a third did not receive Silvadene ointment as ordered. These failures resulted in inadequate treatment and documentation of the residents' conditions.
Failure to Implement Ordered Restorative ROM Program
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services as recommended by the therapy department to maintain or improve a resident’s range of motion and mobility. The resident had intact cognition, required partial to moderate assistance with dressing and hygiene, and was dependent on staff for ambulation and transfers. The MDS assessment indicated that the resident did not receive therapy or restorative services during the seven days prior to the assessment, despite having care plan interventions directing staff to encourage participation in exercise and physical activity for strengthening and improved mobility. The clinical record showed multiple physician orders for PT and OT evaluations and treatment over several months, and a therapy recommendation dated 12/19/2025 for restorative staff to administer active ROM exercises to the resident’s bilateral lower extremities one to five times per week. Nursing progress notes documented that therapy recommendations for a restorative exercise program were received on 12/4/2025 and again on 12/23/2025, with copies reportedly provided to the rehab aide for scheduling. Notes from a CNA/restorative aide on 12/6/2025 and 12/26/2025 stated that the resident continued with a restorative program and that there were no concerns, but there was no documentation that the specific recommended ROM exercises were actually implemented or performed. Interviews revealed discrepancies and gaps in carrying out the restorative program. The DON reported that the resident had a foot pedal machine in her room that she used when she allowed staff to get her up, and that therapy typically wrote restorative programs that the facility followed, but acknowledged that the facility failed to administer the resident’s therapy from mid-December through February. The occupational therapy aide stated that after therapy services ended in early December and January, therapy made a referral to restorative for a home program and later recommended lower extremity exercises when the resident admitted not using the pedal machine. The restorative aide reported having no referral from PT for this resident and confirmed the resident did not receive restorative services, while the LPN overseeing therapy acknowledged reviewing the restorative recommendation and her prior note but confirmed that the restorative aide denied receiving a copy. This sequence of events demonstrates that the interdisciplinary team did not ensure the restorative program was implemented as recommended, contrary to the facility’s Restorative Nursing Program Policy.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to consistently respond to resident call lights in a timely manner, despite the requirement to provide sufficient nursing staff each day and have a licensed nurse in charge on each shift. Record review showed that three residents with intact cognitive status reported prolonged call light response times. One resident, seated in the dining room with a walker nearby, stated that call light responses often took more than fifteen minutes and that she also activated the call light for her roommate, who was unable to call for assistance independently. Another resident, who required the assistance of two staff members for transfers and toileting, reported that staff failed to answer his call light in a timely manner at least once a day on any shift, and that he had personally timed responses taking up to an hour, which resulted in episodes of incontinence. A third resident, observed in a recliner with oxygen via nasal cannula and a walker nearby, reported that staff were slow to respond to his call light, with response times sometimes exceeding thirty minutes and up to an hour based on his own timing. He also reported that staff at times entered his room in response to the call light, turned the light off, left without providing the requested assistance, and did not return. This resident required staff assistance to ambulate when feeling unsteady. Resident Council meeting notes documented that call lights taking too long had been raised as an ongoing concern under Old Business. During an interview, the DON and Administrator acknowledged that when Resident Council reports identify call light concerns, the facility addresses them through audits and staff education and reviews the concern at subsequent Resident Council meetings.
Medication Administration Errors Due to Resident Misidentification
Penalty
Summary
The facility failed to administer medications as ordered for two residents, resulting in each receiving another resident's medications. In the first incident, a resident with diagnoses including acute kidney failure, Type 2 diabetes, and schizophrenia, and who was cognitively intact, was given another resident's insulin doses. The error occurred when an agency LPN, while administering morning insulins, relied on a CNA's identification of the resident, which was based on a visual cue (a red blanket) rather than proper identification protocols. The resident responded affirmatively to the wrong name when called, and the LPN administered both long-acting and short-acting insulin intended for another resident. The error was discovered when the LPN noticed a different name tag on the resident's door. The resident was subsequently sent to the emergency room for observation due to the risk of hypoglycemia, though she was asymptomatic at the time of transfer. In the second incident, another resident with a history of hypertension, septicemia, aphasia, and stroke, and with moderately impaired cognition, was administered a full set of morning medications intended for a different resident. The error was made by an Oral Medication Technician (OMT) who was unfamiliar with both residents, as they were new to the facility and had similar names. The OMT administered the medications after the resident answered affirmatively to the wrong name. The error was realized when the OMT saw the correct name outside the door after leaving the room. The resident received medications including antihypertensives and diuretics, and subsequent blood pressure monitoring showed several low diastolic readings, though no immediate side effects were observed by staff. Both incidents involved failures to properly identify residents before medication administration, despite facility policy requiring the use of two identifiers and positive identification before giving medications. In both cases, staff relied on verbal confirmation or visual cues rather than following established procedures for resident identification. These failures resulted in residents receiving medications not intended for them, necessitating additional monitoring and medical intervention.
Incorrect Sling Size Used During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure staff used the correct full body mechanical lift sling size for a resident who required a Hoyer-style lift with two staff assistance for transfers. Resident #3 had intact cognition with a BIMS score of 15/15, used a wheelchair, had bilateral upper and lower extremity functional impairments, and was dependent on staff for transfers. The resident also had diagnoses including arthritis, narcolepsy with cataplexy, and chronic gout, and the care plan directed use of a full body mechanical lift with two staff assistance, but did not specify sling size or style. During a transfer attempt, the resident slid backward in the sling and was lowered to the floor with the mechanical lift. The nursing note documented that no injuries were noted and the resident denied pain or discomfort. The incident report stated the resident slid down in the sling while CNAs were preparing the transfer, and the resident said, "I slid down." The incident/interdisciplinary note later identified the root cause as poor positioning in the sling, but did not identify that the resident had been placed in the wrong size sling. The investigation and interviews showed conflicting explanations about the cause of the event and how sling selection was handled. Staff later stated the sling used was too large for the resident, and one staff member explained the blue trimmed sling was way too big for her. Staff interviews also revealed that, before the incident, aides were selecting slings by visually estimating whether they looked right, without a clear guide in place. The facility’s communication materials and care plan lacked clear direction on sling size for the resident at the time of the incident, and the manufacturer manuals provided by the facility stated that the correct sized sling must be used and that slings are designed for specific lift manufacturers.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to respond respectfully and promptly to a resident's request for assistance with toileting, and did not protect residents' right to privacy regarding electronic health information. A resident with intact cognition, a history of Alzheimer's disease, stroke, cancer, and recent falls, who required staff assistance for toileting, asked a registered nurse for help locating the bathroom. The nurse informed the resident that the bathroom was in her room, questioned her presence in the hallway, and then sought assistance from another staff member who was not employed at the facility. The nurse stated she could not help due to being occupied with treatments and walked away, leaving the resident unattended. Shortly after, the resident was observed alone in her room, attempting to transfer from her wheelchair to the bed with her pants and incontinence underwear partially pulled up, exposing her upper buttocks, and the bathroom door open. Additionally, the facility did not safeguard residents' confidential health information. On two separate occasions, a treatment cart with a laptop displaying a resident's picture and confidential health information was left unattended and unlocked in residential hallways. Staff, including registered nurses, left the computer screens visible and unattended while out of sight, despite the facility's policy and staff interviews confirming the expectation to lock computer screens when not in use to protect privacy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights, resulting in unmet care needs for seven out of nine residents reviewed. Multiple observations and interviews revealed that call lights were not answered within the facility's expected timeframe of 10-15 minutes, with some residents waiting up to an hour. Staff, including CNAs, RNs, and the DON, were observed walking past active call lights without responding, and residents reported frequent delays in receiving assistance, particularly for toileting and mobility needs. Several residents with significant physical and cognitive impairments, such as hemiplegia, hemiparesis, muscle weakness, and severe cognitive impairment, were affected by these delays. Residents described waiting extended periods for help with toileting, resulting in incontinence accidents and, in some cases, falls when attempting to manage their needs independently. Documentation confirmed that some residents experienced repeated falls and accidents directly related to delayed staff response to call lights. Staff interviews corroborated the residents' accounts, with CNAs and RNs acknowledging that all staff were responsible for answering call lights but citing insufficient staffing levels as a barrier to timely responses. The facility's policy required prompt attention to call lights and for staff to remain with residents if unable to immediately meet their needs, but this was not consistently followed. The deficiency was substantiated through direct observation, resident and staff interviews, and review of facility policies and care plans.
Failure to Maintain Sanitary and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Toilets in several resident rooms were not adequately cleaned, with persistent urine odors, wet floors, and visible fecal matter remaining for days. In one case, a resident's wheelchair and cushion were not cleaned regularly, resulting in a strong urine odor that was noticed by family members. Housekeeping staff reported that bathrooms were scheduled for cleaning only on certain days, and there was confusion about who was responsible for reporting and addressing maintenance issues, such as a running and overflowing toilet that was not reported to maintenance or administration. Beds in some rooms were found unmade or only partially made, with bare mattresses or missing blankets and bedspreads. Additionally, window screens were found to be broken or missing for extended periods, with residents reporting that screens had been damaged by housekeeping staff and not replaced for months. Housekeeping and maintenance staff confirmed ongoing issues with cleaning schedules and the replacement of window screens, and documentation showed that some windows had not been cleaned or screens replaced for several months. Electrical safety was also compromised, as one resident reported loose wall outlets that had not been repaired despite being reported to the Maintenance Director months prior. Observations confirmed that plugs for essential medical equipment, such as a CPAP machine, were hanging loosely from the outlets. Staff interviews revealed that there was only one housekeeper on certain weekends, leading to delays in cleaning, and that complaints from residents about cleanliness were known but not always addressed promptly. Facility policies required daily cleaning of toilets, but this was not consistently followed.
Improper Hair Restraints During Food Preparation and Service
Penalty
Summary
Dietary staff failed to properly wear hair restraints while preparing and serving food during multiple observations. During lunch service, staff were observed serving food from the steam table outside the kitchen door while wearing hair nets or caps that did not fully cover their hair. One staff member had a hair net that left the sides of her hair and 2-3 inches of bangs exposed, and the Food Service Manager wore a ball cap with her bun and 1-2 inches of hair below the bun not covered by a hair net. The Dietary Manager was later observed wearing a ball cap with her hair in a bun and no hair net, and another staff member pushed the steam table down the hall with the back 2 inches of hair exposed. That staff member and the Food Service Manager were also observed leaning over open steam table compartments and serving food while their hair remained exposed. During the puree process and dining room service, additional staff were observed with hair not fully contained by hair restraints. One staff member had 4-5 inches of hair exposed in the back and about 3 inches exposed on the side, while another had bangs exposed in the kitchen. Later, the Food Service Manager stated all dietary staff had to wear hairnets but said she had been told a ball cap meant a hair net was not needed. The Administrator stated she, the Dietician, and other staff participated in the Food Service Manager's training and that it was still a work in progress. She also stated she had told the Food Service Manager she did not have to wear a hairnet if she wore a ball cap, although she expected the team to wear hairnets any time they were in the kitchen and when providing meal service.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Facility staff failed to treat residents with dignity and respect in several instances. For one resident with severe cognitive impairment and limited mobility, staff did not maintain the cleanliness of his wheelchair as required by his care plan. The wheelchair and its cushion were observed to have a strong urine odor, visible crumbs, and stains, and family members had repeatedly expressed concerns about the lack of cleaning. Staff interviews confirmed that the cleaning schedule was not being followed, and documentation showed the wheelchair had not been cleaned that week. In another case, a CNA used an expletive to describe a resident's behavior in a public area near other residents and staff. The resident in question had severe cognitive impairment and exhibited physical behavioral symptoms. The facility's policy required staff to treat residents with respect and dignity, but the CNA's public comment violated this expectation. Both the DON and the Administrator acknowledged that such remarks were inappropriate and not in line with facility standards. A third resident, also with severe cognitive impairment and a history of falls, had signs posted in his room and on his walker instructing him to use the call light and ask for help before getting up. These signs were placed without consulting the resident, who found them insulting and irritating. The resident reported that he had used the call light before his falls but staff did not respond promptly, leading him to attempt to use the bathroom independently. Progress notes did not document any discussion with the resident or his representative regarding the addition of these interventions.
Failure to Complete Required Assessments and Vital Signs Documentation After Resident Readmission
Penalty
Summary
The facility failed to complete required physical assessments and document vital signs for a resident who was readmitted following serious medical conditions, including cholecystitis, sepsis, and septic shock. Upon readmission, the clinical record did not include a physical assessment or vital signs on multiple consecutive days. While some pre- and post-dialysis assessments included partial vital signs, there were several days with missing documentation of both vital signs and physical assessments. Additionally, after the resident experienced bleeding from a leg wound and was sent to the emergency department, there was no documentation of an assessment or vital signs upon the resident's return. Progress notes indicated ongoing issues, such as copious drainage from leg wounds, poor circulation, and difficulty obtaining oxygen saturation readings, yet there was still a lack of documented assessments and vital signs. Interviews with the DON and ADON confirmed the absence of required documentation and assessments in the electronic health record. The facility's policy required staff to perform and document a full assessment and vital signs every shift, with no exceptions, especially when a change in condition was observed. Despite this, the required assessments and documentation were not completed for the resident.
Failure to Ensure Safe Wheelchair Transport and Equipment Maintenance
Penalty
Summary
The facility failed to ensure the use of foot pedals during wheelchair transport and did not maintain mobility equipment in good working order, resulting in deficiencies for three residents. One resident with moderately impaired cognition and dependent on staff for wheelchair propulsion was observed being pushed in her wheelchair without foot pedals, causing her feet to lightly touch the ground. Another resident, who had functional limitations in both lower extremities and was at risk for falls, was also transported in a wheelchair without foot pedals. The resident reported that the pedals were often left in his room because they got in the way at the dining table, and there was no bag on the wheelchair to store them. Staff interviews confirmed that missing foot pedals was a recurring issue, and there was no facility policy regarding their use. A third resident, with a history of falls and recent fractures, experienced a fall when his walker collapsed during a transfer from chair to bed. Documentation revealed that the walker was in poor condition with missing screws, and staff confirmed that the equipment was not safe for use. The resident had been permitted by therapy to transfer independently, and the incident was reported to the ADON. The facility's process for monitoring and maintaining equipment safety was not effectively implemented, as evidenced by the use of a defective walker.
Failure to Submit MDS Assessments Within Required Time Frame
Penalty
Summary
The facility failed to submit the Minimum Data Set (MDS) within the required time frame for 1 of 1 resident reviewed for timely submission. Clinical record review for Resident #92 showed a quarterly MDS dated [DATE] and an annual MDS dated [DATE]; both assessments were marked complete, not accepted. During an interview on 08/13/2025 at 10:31 AM, the MDS coordinator stated the quarterly assessment dated 6/20/25 was flagged as do not submit, but it should have been submitted. She further explained that it was later discovered the quarterly assessment should have been an annual assessment and that the annual assessment was completed, but it too was flagged as do not submit and should have been submitted. During a later interview on 8/13/25 at 4:45 PM, the MDS coordinator stated the facility does not have an MDS policy and follows the RAI.
Medication orders not followed for Ambien and Belimumab
Penalty
Summary
The facility failed to ensure medications were obtained and administered according to physician orders and professional standards of practice for a resident with end stage renal disease, systemic Lupus, and mild cognitive impairment. The resident reported that her nightly Zolpidem (Ambien) was withheld on two separate occasions before scheduled AV fistula procedures even though the surgeon’s pre-operative orders allowed her to receive the medication the night before surgery. The MAR showed the doses were held, and an ARNP later confirmed the resident should have received the 5/7/25 dose based on the surgery orders. Staff documented that the resident was told the medication was on hold because of the procedure, even though the resident stated the procedure had been cancelled and she had shown staff the pre-operative orders. The record also showed that the resident’s weekly Belimumab injections for Lupus were not administered after the medication was reordered by the nephrologist. The MAR reflected the medication was added with a start date, but there was no documentation explaining why the injections were not given. The DON acknowledged the resident was supposed to receive the injections and stated the facility had difficulty obtaining the medication through the contracted pharmacy because it was a specialty medication. The facility did not contact the nephrologist’s office until 23 days after the order date, and the nephrologist’s nurse reported the office had not been contacted earlier and was unaware the medication needed to be sent to a specialty pharmacy until the facility called. Staff interviews showed confusion and incorrect handling of the medication orders. One RN stated she entered a hold order for Ambien based on the pre-operative instructions but used the wrong provider name in the EMR because of limited provider options. Another staff member reported the resident complained about not receiving Ambien and said she would clarify the order with the physician. The facility policy required staff to administer medications per physician orders and professional standards of practice, but the resident’s Ambien was held without a hold order from the surgeon and the Belimumab injections were not obtained or administered as ordered.
Failure to Support Resident Choice for Outdoor Activities
Penalty
Summary
The facility failed to provide an ongoing program to support Resident #81 in her choice of activities based on her comprehensive assessment, care plan, and preferences. Resident #81’s admission MDS dated 4/23/25 listed diagnoses of anxiety, depression, and weakness, and showed a BIMS score of 14 out of 15, indicating intact cognition. The MDS and a 4/23/25 Resident Preferences Evaluation both stated it was very important to the resident to go outside when the weather was good to get fresh air. During the review period from 5/1/25 through 7/31/25, the activity participation calendars and notes provided documented participation in several indoor activities, including music, ladies tea, pet therapy, bingo, pretty nails, happy hour, Mother’s Day party, card games, exercises, and ice cream. However, the records lacked documentation that staff offered the resident outdoor activities during that period, and June 2025 activity documentation was not provided. On 8/12/25, the resident stated she was not able to go outside and wished to do so. The Activities Director stated she had just started at the facility and planned to take residents outside twice per week, while the DON stated residents were able to go outside in the mornings.
Delayed Follow-Up for Possible UTI Symptoms
Penalty
Summary
The facility failed to ensure timely assessment and follow-up for a resident who reported symptoms of a possible urinary tract infection. Resident #17 had diagnoses including atrial fibrillation, heart failure, and chronic kidney disease, and the care plan directed staff to monitor and document signs and symptoms of UTI such as pain, burning, blood-tinged urine, cloudiness, urinary frequency, foul-smelling urine, fever, chills, altered mental status, and changes in behavior or eating patterns. The resident also had bladder incontinence and a BIMS score of 14 out of 15. The resident reported to staff that she thought she had a kidney infection and described pain and burning with urination, lower abdominal pressure, and urinary frequency. A nurse documented messaging the ARNP about dysuria and abdominal distention, and acetaminophen was later given for discomfort, but the clinical record lacked further assessment, documentation, or orders related to the complaint. The resident later reported that she continued to have burning with urination, lower abdominal pressure, lower back ache, urinary frequency, and feeling unbalanced, and stated that nursing staff had not followed up or reassessed her after she first reported the symptoms. Staff interviews showed that the provider sent an order for a UA with C&S through the secure messaging system, but the order was not entered into the EMR until two days later. The RN who processed the order was unsure why it took so long, and the DON and ADON did not know why it was not entered right away. The ADON stated nurses were expected to review secure messages before leaving shift and to follow up within 24 hours if no provider response was received, while the provider stated she expected the order to be carried out the same day and would expect notification if it was not completed within 24 hours. The facility protocol for change in condition included hot charting with vital signs and focused assessment every shift, and the policy for practitioner orders required timely verification of orders.
Failure to Follow G-Tube Placement, Residual, and Flush Orders
Penalty
Summary
Nursing staff failed to follow facility policy and physician orders for a resident with a gastric feeding tube. The resident had a history of cerebral infarction (stroke), dysphagia, severe cognitive impairment, and was ordered NPO with nutrition, medication, and hydration through a G-tube. The care plan directed staff to check tube placement and gastric contents/residual volume, and the physician order required enteral feeding three times daily with Osmolite 1.5, flushing the G-tube with 90 mL before and after feeding, and delaying feeding if residual was 250 mL. During observation, an LPN prepared and administered the tube feeding by pouring two cartons of Osmolite into an IV bag, priming the tubing, and connecting it to the resident’s G-tube after flushing the tube with only 30 mL of tap water. The LPN did not check for tube placement or residual gastric content before starting the feeding. In interview, the LPN stated she checked G-tube placement once a day with a stethoscope. The next day, an RN was observed checking G-tube placement by injecting air and listening with a stethoscope before giving medication, and stated she checked placement every time she accessed the G-tube. Facility policy required verification of enteral tube placement before administering fluids or medications.
Resident Signed Arbitration Agreement Without Demonstrated Understanding
Penalty
Summary
The facility failed to ensure a resident understood the Alternative Dispute Resolution agreement before signing it. Resident #104 had a documented history of dementia with major neurocognitive disorder, and the PASRR screening noted difficulty recognizing familiar people or objects along with significant short-term and long-term memory impairment. The resident’s BIMS score was 7, indicating severe cognitive impairment, and the resident later told surveyors she was unsure of the day, did not know where she was, did not remember signing paperwork on admission, and did not understand that she had given up the right to litigation in a court proceeding. The admission packet included an Alternative Dispute Resolution attachment that showed the resident’s signature but lacked a date, and it did not contain signatures from a legal representative or the facility’s authorized agent. The admission agreement also lacked an effective date and was signed only by the resident. The resident’s son was listed as the responsible party and emergency contact, but staff reported he and the resident’s daughter were not present when the admission agreement and attachments were signed. The LPN/admissions and marketing coordinator stated she was responsible for explaining the paperwork and acknowledged she witnessed the resident sign the agreements but forgot to sign as the facility’s authorized agent. The administrator also acknowledged the facility lacked policies for determining whether a resident could understand and sign agreements and for determining when a POA or DPOA needed to be enacted.
Failure to Follow EBP and Soiled Linen Infection Control Practices
Penalty
Summary
The facility failed to ensure staff followed infection prevention policies, including enhanced barrier precautions (EBP), for residents with feeding tubes, wounds, and a catheter. Resident #4 had diagnoses of cerebral infarction and dysphagia, severe cognitive impairment, and an order for NPO status with feeding, medication, and hydration through a G-tube. The care plan identified EBP with gown and glove use for high-contact activities, including G-tube care, and the facility policy stated EBP was required for residents with wounds and indwelling medical devices such as feeding tubes. During observation, staff entered Resident #4’s room and performed tube feeding and medication administration without wearing a gown, despite the posted EBP sign and care plan instructions. One LPN donned gloves, handled the feeding setup, accessed the G-tube, and started the feeding without a gown. Another RN crushed and prepared Baclofen for G-tube administration, checked tube placement, and administered the medication without wearing a gown while accessing the G-tube. For Resident #58, who had heart failure, severe cognitive impairment, a Stage 3 sacral pressure ulcer, and two Stage 2 sacral ulcers, the care plan included advanced barrier precautions due to the wound requiring a dressing, but no EBP sign was posted outside the room. When wound care was performed for Resident #58, the RN cleaned the wounds, mixed wound products, applied treatment, and dressed the wounds while using gloves and hand hygiene but without a gown. During catheter care for Resident #6, a CNA emptied the drainage bag while wearing gloves and later stated she should have worn a gown and mask for EBP compliance. In addition, the Housekeeping/Laundry Supervisor stated gowns were not worn when handling soiled linens and that only gloves were used, while the Administrator stated the facility had no policy for handling soiled linens and believed gowns were unnecessary if linens did not contact clothing.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations and interviews conducted during the survey. On Hall A, 5 out of 9 resident rooms had window curtains that were falling down and not attached to the curtain rods. Similarly, on Hall C, 3 out of 7 rooms had the same issue, while Hall D had 6 out of 11 rooms with curtains falling down, and 2 rooms without any curtains or rods, using a white sheet as a makeshift covering. Room D-12 lacked any window covering entirely. Additionally, the exterior windows in multiple halls were found to be dirty, with dust and grime covering them, affecting 9 out of 9 rooms on Hall A, 4 out of 7 on Hall C, 10 out of 11 on Hall D, and 17 out of 21 on Hall CR. Interviews with residents and staff highlighted the impact of these deficiencies. A resident expressed dissatisfaction with the dirty windows, preferring to keep the curtains closed to avoid looking at them. The Housekeeping Supervisor acknowledged the issues, citing a shortage of housekeeping staff and noting that the exterior windows were last cleaned in the fall, despite a policy directing daily cleaning of windows. The supervisor also mentioned that the problem with curtains falling off rods had persisted for some time, and efforts were underway to install curtain rods in Hall D to address the issue.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving physical abuse. The resident, who has a history of traumatic brain injury and non-Alzheimer's dementia, requires extensive assistance for daily activities and has severe cognitive impairment, as indicated by a BIMS score of 5 out of 15. On January 15, 2025, a Certified Nursing Assistant (CNA) struck the resident on the back of the head with enough force to cause the resident's chin to move forward towards his chest. This incident was witnessed by a Certified Medication Aide (CMA), who reported the abuse to the charge nurse immediately after it occurred. The Assistant Director of Nursing confirmed that the incident was reported to her on the same day, and the CNA involved was given an opportunity to explain the situation but chose not to provide any explanation. The facility's policy on resident rights clearly states that residents have the right to be free from abuse and neglect, and any suspected violations must be investigated and reported within five working days. Despite this policy, the incident of abuse was not addressed in a timely manner, leading to a deficiency in the facility's obligation to protect the resident's rights.
Infection Control Deficiencies in Dining and Wound Care
Penalty
Summary
The facility failed to maintain a sanitary environment during dining and wound care, leading to potential transmission of infections. During a dining observation, a CNA assisted multiple residents with their meals without sanitizing hands between interactions. The CNA touched various surfaces, including tables, chairs, and residents' utensils, without performing hand hygiene, despite acknowledging the importance of sanitizing hands after touching dirty surfaces and between assisting residents. In another instance, food trays were transported uncovered through a hallway where residents were COVID-positive. A CNA carried trays without covers, exposing the food to potential contamination. The Certified Dietary Manager confirmed that food should be covered during transport, but acknowledged a shortage of covers due to an increased number of room trays required during a COVID outbreak. Additionally, during wound care for a resident, a nurse failed to perform hand hygiene between glove changes while treating open areas on the resident's legs and toes. The nurse acknowledged the oversight in hand hygiene, which is critical for infection control. The facility's infection control program emphasizes the importance of handwashing before and after resident contact and handling soiled items, but these practices were not consistently followed during the observed care.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity for two residents, leading to deficiencies in care. For one resident, who had diagnoses including dementia, anxiety, and depression, the facility did not maintain dignity by allowing the resident to be brought into the main dining room without pants, covered only by a blanket. This incident was reported by the resident's family to the facility's social worker, but the grievance form was misplaced and only found later, indicating a lapse in addressing the issue promptly. Another resident, with moderately impaired cognition and requiring extensive assistance for activities of daily living, experienced a lack of dignity during personal care. During an observation, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) failed to adequately prepare for the resident's care, resulting in the resident being left exposed and uncomfortable. The staff did not cover the resident with a sheet while searching for clean clothing, and the resident was not offered the opportunity to wash or sanitize her hands after scratching her buttocks during the care process. The facility's Director of Nursing (DON) acknowledged that the care provided did not meet expectations, noting that staff should have been better prepared and should have maintained the resident's dignity by covering her and offering hand hygiene. The facility's policy on personal degradation emphasizes the importance of maintaining personal dignity, which was not upheld in these instances.
Resident Excluded from Dietary Decision-Making
Penalty
Summary
The facility failed to include a resident in decision-making regarding their care, specifically concerning dietary choices and the need for a swallowing evaluation. The resident, who has end-stage renal disease, anxiety, and depression, was assessed with no cognitive impairment. Despite expressing dissatisfaction with the ground meat diet and requesting a reevaluation, the resident was not included in care plan meetings or decision-making processes. The facility relied on a Durable Power of Healthcare document, which only grants decision-making power to a family member when the resident is unable to make decisions, to justify excluding the resident from these decisions. Interviews with the resident, staff, and family members revealed that the resident had been consuming foods not allowed without issues and was frustrated with the limited dietary options. The speech therapist noted that the order for ground meat was given at the hospital before admission and had not been reevaluated. The Director of Rehabilitation confirmed that a new order for a speech evaluation was made but was delayed due to insurance and co-pay issues. The facility's administrator acknowledged that decisions were directed to the family, assuming the power of attorney was in effect, without confirming the resident's ability to make decisions.
Failure to Update Care Plan for Antidepressant Monitoring
Penalty
Summary
The facility failed to fully review and revise the comprehensive Care Plan for a resident with severe cognitive impairment and multiple diagnoses, including medically complex conditions, cancer, non-Alzheimer's dementia, anxiety disorder, and depression. The resident was prescribed an antidepressant medication, Remeron, in April 2024, but the Care Plan did not include a focus area, goal, or interventions/tasks related to depression or the antidepressant medication. This oversight was identified during a review of the electronic health record, which revealed that the antidepressant was not included in the treatment administration record (TAR) for monitoring. During an interview, the Assistant Director of Nursing, MDS coordinator, and Director of Nursing acknowledged that the antidepressant had not been added to the TAR for monitoring until August 2024, several months after it was prescribed. The MDS coordinator admitted that the antidepressant should have been included in the Care Plan with a focus area, goal, and interventions/tasks to monitor for adverse signs and symptoms. The facility's Care Plan Team policy requires that Care Plans reflect the resident's medical, nursing, and psychosocial assessment, with measurable outcomes and timetables, which was not adhered to in this case.
Failure to Follow Therapeutic Diet for Resident with ESRD
Penalty
Summary
The facility failed to adhere to the prescribed therapeutic diet for a resident diagnosed with End Stage Renal Disease (ESRD) who was on dialysis. The resident, who had no cognitive impairment, was supposed to receive a special renal diet with double protein servings, including double eggs at breakfast. However, during an observation, the resident reported receiving meals that did not align with the dietary orders, such as being served sauerkraut, which is high in sodium and not suitable for a renal diet. The resident also mentioned that the portion sizes, particularly of eggs, were smaller than required. Interviews with the resident and the dietician confirmed the discrepancies in meal service. The dietician acknowledged that the resident should not have been served sauerkraut and that the alternative menu option for the renal diet, roast beef, was not provided. Additionally, the resident was served sausage gravy, which was not part of the renal diet. The facility's diet policy, which was undated, specified that the renal diet should limit high potassium, sodium, and phosphorus foods, and recommended extra protein for dialysis residents, which was not consistently followed in this case.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were completed for a resident with end-stage renal disease (ESRD) who required dialysis services. The resident, who had a perfect score on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment, was scheduled for hemodialysis three times a week. Despite the care plan indicating the need for immediate intervention should complications arise, the resident could not recall any pattern of assessments related to dialysis appointments. A clinical record review confirmed the absence of these required assessments in the resident's records. The Director of Nursing acknowledged the lack of specific assessments for pre and post dialysis, despite being aware of their necessity.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman regarding the transfer of a resident to the hospital, as required by federal regulation. This deficiency was identified during a clinical record review and staff interview, which revealed that the facility did not document the notification of the LTC Ombudsman when Resident #5 was discharged to the hospital. The resident was hospitalized from May 4, 2024, until reentering the facility on May 7, 2024. During an interview, the Administrator confirmed that the LTC Ombudsman was not notified of the transfer and acknowledged the expectation to notify the Ombudsman in such cases. However, the facility lacked a specific policy for notifying the Ombudsman, relying instead on following regulations.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident and their representative of the bed hold policy, including reserve bed payment, during two separate hospitalizations. The resident was discharged from the facility and hospitalized on two occasions, with anticipated returns, but there was no documentation of notification to the resident or their representative regarding the facility's bed hold policy. The facility's computer software program showed the resident's discharge and reentry dates, but the clinical record lacked evidence of written or verbal notification. During an interview, the Administrator acknowledged that a bed hold was not completed for the resident's hospitalizations and stated that it is expected for a bed hold to be completed and explained to the resident or their representative. The facility's bed hold policy requires informing the resident or legal representative of the policy upon admission and prior to, or as soon as possible, after transfer or temporary discharge.
Failure to Follow Care Plan for Resident Transfers
Penalty
Summary
The facility failed to adhere to a resident's Care Plan for transfers, resulting in an incident where a resident was not provided with the required assistance during a transfer in the shower room. The resident, who had a history of polio, repeated falls, and a vertebral fracture, required a mechanical lift with the assistance of two staff members for transfers. However, during the transfer, only one staff member was present, leading to the resident sliding out of the mechanical lift sling. This incident was not immediately reported or assessed by a nurse, and the resident was moved without a proper assessment. The resident, who had intact cognition, reported increased pain in her back and right foot following the incident. The facility's documentation lacked an incident report, a full resident assessment, and timely notifications to the family and provider. The resident's daughter later requested x-rays, which showed no fractures, but the resident continued to experience pain. Interviews with staff revealed inconsistencies in the reporting of the incident, with one CNA admitting to transferring the resident alone and not notifying a nurse immediately. The facility's investigation highlighted that the CNA involved did not follow the Care Plan, which required two staff members for transfers. The CNA admitted to feeling pressured to move the resident quickly and did not wait for a nurse to assess the resident after the fall. The facility lacked specific policies related to resident transfers and assessments, contributing to the deficiency in care provided to the resident.
Failure to Timely Complete Quarterly Assessment
Penalty
Summary
The facility failed to complete a quarterly assessment in a timely manner for one resident. The Minimum Data Set (MDS) for this resident, who had moderate cognitive impairment and diagnoses including acute respiratory failure with hypoxia, sepsis, and congestive heart failure, was overdue by 9 days. The resident required assistance with mobility and transfers. The electronic health record indicated that the quarterly assessment was due on 7/26/24 and should have been completed by 8/9/24, but it was not completed until 8/18/24. The Director of Nursing was unaware of the late MDS and acknowledged the need to investigate the issue. Additionally, the facility did not have a written policy regarding resident assessments and care planning, as confirmed by an email from the Administrator.
Significant Medication Error Due to Misentry in EHR
Penalty
Summary
The facility failed to prevent a significant medication error involving Resident #2, who received Glimepiride 2 mg for 77 days without a diagnosis of diabetes or a physician's order. The error originated when a nurse on duty mistakenly entered another resident's order into Resident #2's electronic health record (EHR). Over the course of 77 days, 11 nurses and Certified Medication Aides (CMAs), the Director of Nursing (DON), the provider during at least three visits, and the pharmacy consultant during at least three Drug Regimen Reviews failed to identify the error. This oversight resulted in Immediate Jeopardy to the resident's health and safety. Resident #2, who had a BIMS score indicating moderate cognitive impairment, was hospitalized with low blood sugar due to the medication error. The resident, who did not have a diagnosis of diabetes, expressed fear and mistrust towards the facility staff, stating that she was not informed about the medication and would have objected if she had been. The resident was found on the floor exhibiting seizure-like activity and was later diagnosed with hypoglycemia at the hospital, where it was confirmed that Glimepiride should not have been prescribed. Interviews with staff revealed a lack of awareness and procedures for double-checking medication orders against diagnoses. Staff members, including CMAs and nurses, did not routinely verify medications against resident diagnoses, and there was no formal policy for medication errors, only an unwritten procedure. The DON confirmed that most medications were administered by CMAs, and the responsibility for comparing orders to diagnoses was shared among the DON, nurses, pharmacy consultants, and providers.
Removal Plan
- Put a new process in place for new orders to be double checked by a 2nd nurse.
- Ensure newly prescribed medications are reviewed by the pharmacy consultant for appropriateness for that resident.
- Contact providers to discuss emphasis of thorough review of Physician Order Sheets.
- Implement medication order audits.
- Audit new processes to ensure expectations are followed.
- Add medication reconciliation to QAPI agenda.
Failure to Provide Consistent Restorative Care
Penalty
Summary
The facility failed to provide consistent restorative care to prevent decline in mobility and range of motion for three residents. Resident #1, who had a history of hemiplegia following a stroke, weakness, and arthritis, required assistance with mobility and transfers. The care plan for Resident #1 lacked documentation of a plan for regular range of motion activities or a walking program. Despite the resident's family expressing concerns about the use of a mechanical lift, there was no documentation of range of motion treatment or services to maintain or improve mobility. Interviews revealed that restorative work was not consistently implemented, and staff were not adequately involved in restorative mobility or range of motion activities. Resident #2, with moderate cognitive impairment and diagnoses including coronary artery disease and congestive heart failure, also lacked a documented plan for regular range of motion activities or a mobility program. The resident was not aware of any restorative or range of motion program and reported not receiving assistance with such activities. Observations confirmed that the resident was not offered these services, indicating a gap in the facility's care planning and execution. Resident #3, who had intact cognition and required assistance with activities of daily living, similarly lacked a documented plan for range of motion activities. The resident reported not being offered range of motion services, despite observing such activities being performed with a roommate. The facility was unable to provide a restorative plan, calendar, training, policy, or procedure for maintaining residents' highest level of functioning, highlighting a systemic issue in the facility's approach to restorative care.
Medication Order Error and Lack of Review
Penalty
Summary
The facility failed to ensure that the resident's doctor reviewed medications and associated diagnoses during required visits, leading to a medication order error for one resident. The resident, who had moderate cognitive impairment and diagnoses of acute respiratory failure, sepsis, and congestive heart failure, was incorrectly administered Glimepiride for diabetes, a condition they did not have. This error went unnoticed during three visits in June 2024, where the provider did not identify the medication order error despite conducting a medication review. The resident received 77 doses of Glimepiride from April to July 2024, which was not ordered in the progress notes. The error was discovered when the resident was admitted to the hospital with hypoglycemia, a condition caused by low blood sugar, which was linked to the unnecessary administration of Glimepiride. The hospital noted that the medication should not have been prescribed as the resident had no history of diabetes. The Director of Nursing confirmed that the facility lacked a written policy for medication errors and had not addressed a new plan for error prevention until after the incident.
Failure to Identify Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that the pharmacy consultant adequately reviewed the medication regimen for a resident, leading to the administration of an unnecessary drug. The resident, who had moderate cognitive impairment and diagnoses including acute respiratory failure, sepsis, and congestive heart failure, was given 77 doses of Glimepiride, a diabetic medication, despite not having a diagnosis of diabetes. This error was not identified during three separate monthly drug regimen reviews conducted by the pharmacy consultant. The Medication Administration Record (MAR) showed the administration of Glimepiride without corresponding orders in the progress notes. The pharmacy notes from May, June, and July failed to address the Glimepiride, and no pharmacy recommendations were made. The error was discovered only after the resident was hospitalized for hypoglycemia, prompting an investigation by the facility. However, the investigation document did not include interventions involving the pharmacy consultant, and the Director of Nursing confirmed the absence of a written policy or procedure for medication errors.
Failure to Supervise Resident Leading to Fall and Injury
Penalty
Summary
The facility failed to supervise Resident #4 adequately, leading to a fall with injury. Resident #4 had severely impaired cognitive abilities and required extensive assistance for transfers and ambulation. Despite the care plan directing staff to use a walker and provide assistance with all transfers and ambulation, the resident fell while being ambulated by a CNA without a gait belt, resulting in a fracture of the left wrist. The incident occurred in the main dining room, and the resident complained of left wrist pain immediately after the fall. The care plan had been updated to include the use of a gait belt for all transfers and ambulation, but this intervention was not followed at the time of the incident. Staff interviews revealed that the CNA assisting Resident #4 on the day of the fall was new and did not have a cheat sheet or adequate knowledge of the resident's needs. The CNA reported using a walker and holding the resident's hand, but not a gait belt, which was against the facility's policy. The facility's policy required the use of gait belts for all residents needing assistance with transfers and ambulation. The lack of proper supervision and adherence to the care plan and facility policy directly contributed to the resident's fall and subsequent injury. The facility's investigation and staff interviews indicated that there was a communication breakdown and a lack of proper training for new staff. The former DON had implemented corrective actions, including educating staff on the use of gait belts and posting reminders at nurse's stations. However, these measures were not in place or effectively communicated at the time of the incident, leading to the deficiency in care and supervision for Resident #4.
Failure to Provide Required Baths to Residents
Penalty
Summary
The facility failed to provide the required two baths weekly for four out of five residents reviewed. Resident #3, who had severe cognitive impairment and required assistance with transfers, received only two baths during the entire month of December 2023. Resident #4, also with severe cognitive impairment and requiring assistance, received only one bath in February 2024 and four baths in March 2024. Resident #5, diagnosed with diabetes and dementia, received no baths in both February and March 2024. Resident #6, with long and short-term memory impairment, received no baths in March 2024. The facility's records and staff interviews revealed that the issue was partly due to an increase in the facility's census, which led to the addition of a designated bath aide only recently. Prior to this, the aides were responsible for administering showers, often leaving them without breaks. The facility had issued a memo on April 8, 2024, directing nurses and aides to ensure daily shower sheets were filled out and signed, including noting resident refusals. However, this directive was not effectively implemented, leading to the deficiency in providing the required baths to the residents.
Failure to Provide Appropriate Skin Assessments and Interventions
Penalty
Summary
The facility failed to provide appropriate assessments and interventions for residents with impaired skin and changes in condition. Resident #1, who had heart disease, Covid-related weakness, and Alzheimer's, was at risk for skin breakdown due to bladder incontinence. Despite an initial care plan and admission assessment noting skin impairments, no weekly skin assessments were conducted until the week of 4/8/24, leaving the resident without proper monitoring and care for over two months. Resident #8, with cancer, renal insufficiency, and chronic obstructive pulmonary disease, experienced a fall resulting in a closed fracture of the right ulna. Upon return from the hospital, the resident had soiled dressings and extensive edema, but no follow-up orders or assessments were conducted until prompted by the surveyors. The facility staff failed to obtain necessary wound care orders and did not perform timely assessments, leading to inadequate care for the resident's injuries. Resident #6, with dementia and depressive disorder, had a stage III pressure ulcer that was not assessed weekly as required by the facility's policy. Similarly, Resident #9, with congestive heart failure and diabetes, had a stage II pressure injury that was not assessed weekly. Both residents' care plans and physician orders directed specific treatments and assessments, but the facility staff failed to comply with these directives, resulting in insufficient monitoring and treatment of their pressure injuries.
Failure to Follow Care Plan for Resident with Pressure Ulcer Risk
Penalty
Summary
The facility failed to follow the care plan for a resident with impaired cognitive abilities, dementia, and depressive disorder. The resident, who was dependent on staff for transfers and had a history of pressure ulcers, was observed seated in a wheelchair near the nurse's station for an extended period without being repositioned or provided incontinence care. Despite the care plan's directive to assist the resident in shifting weight every 15 minutes and repositioning every two hours, the resident remained in the same position from 8:40 A.M. to 11:12 A.M. without any intervention from the staff. Staff interviews revealed that the resident had been assisted out of bed at 7:00 A.M. and had not received any incontinence care or repositioning since that time. When the resident was finally assisted to bed at 11:20 A.M., a scabbed-over wound on the coccyx was noted, indicating a failure to adhere to the care plan and facility policies for skin care and pressure ulcer prevention. The facility's Skin Care Assessment and Treatment policy mandates regular skin checks, documentation, and repositioning every two hours, which were not followed in this case.
Failure to Follow Physician's Orders for Three Residents
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. Resident #1, who had diagnoses including heart disease, Covid-related weakness, and Alzheimer's, required assistance with transfers, dressing, bathing, and hygiene. Despite a care plan indicating the need for antifungal creams to prevent skin breakdown, staff failed to administer the prescribed medications on multiple occasions, with no documentation of medication refusals. This oversight occurred over a 14-day period before the resident was discharged from the facility. Resident #6, who had impaired cognitive abilities and was dependent on staff for transfers, had a care plan to prevent pressure sores. Despite a physician's order to apply Triad paste three times a day, staff failed to administer the treatment consistently, missing numerous opportunities over several months. This inconsistency contributed to the development and persistence of a stage III pressure ulcer on the resident's coccyx, which showed minimal improvement over time. Resident #9, who had intact cognitive abilities and ambulated with assistance, had a care plan to address a stage II pressure ulcer on his right hip. The physician ordered a specific treatment regimen, but staff failed to administer the Silvadene ointment as prescribed on multiple occasions. The facility's policies on medication administration and skin care were not followed, leading to inadequate treatment and documentation of the resident's condition. The Interim Director of Nurses acknowledged the issue and indicated ongoing efforts to improve staff accountability and documentation.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hallmar Village | 1.5 mi | ★★★★★ | 11 | 0 |
| St Luke's Helen G Nassif Transitional Care Center | 1.6 mi | ★★★★★ | 4 | 0 |
| Hiawatha Care Center | 1.8 mi | ★★★★★ | 7 | 0 |
| Terrace Glen Village | 2.4 mi | ★★★★★ | 5 | 0 |
| Linn Manor Care Center | 3.3 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.