Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Abbington Vlge Nrsg & Rhb Ctr during CMS and state inspections, most recent first.
Unsafe food handling and storage practices were observed when unlabeled foods were kept in the kitchen refrigerator and freezer, personal drinks and items were stored in resident food areas, and staff handled ready-to-eat foods and clean dishes without proper hand hygiene. A Cook used bare hands on lettuce, changed gloves without washing hands, touched his hairnet while gloved, and continued food prep, while a Dietary Aide moved from soiled dishes and garbage to clean dishes without hand hygiene.
Infection Control Failures in Water Monitoring, Linen Handling, and Medication Administration. The facility did not follow its Legionella water management program because it lacked documentation for water temperature logs, hot water tank checks, ice machine inspection, and flushing after a water interruption. Staff also mishandled contaminated linen by using the same gloves for soiled and clean items and placing loose soiled linen into an overflowing chute/cart without proper bagging. During med pass, an RN contaminated a midline catheter lumen while giving IV Zosyn and an LPN administered insulin with contaminated gloves without hand hygiene or changing gloves.
Leaking roof and ceiling not repaired: Residents and staff reported repeated water intrusion in the dining room and resident rooms whenever it rained, with ceiling tiles needing replacement after each storm and black substance noted on a ceiling tile. A resident said water dripped on her head and pillow, another said water dripped in his room and buckets were used under the leak, and the ADM said the roof had needed repair for months.
Delayed ADL Assistance and Incontinence Care; Inadequate Grooming Support. Multiple residents who were dependent on staff for toileting hygiene and incontinence care reported waiting an hour or more for CNA help after using the call light, with some stating staff did not respond at all. The DON stated call lights should be answered within 2 to 5 minutes and incontinent residents should be checked at least every 2 hours, but residents described prolonged delays. Another resident who required staff help with grooming was observed with visible facial hair and long fingernails with debris beneath them, and both her husband and a CNA stated she needed shaving and nail care.
A resident with dementia, dysphagia, and significant weight loss was ordered whole milk at breakfast and dinner to add calories, along with a puree/mechanically altered diet and supplements. Staff served 2% milk instead of the ordered whole milk at breakfast on multiple occasions, despite the meal ticket showing whole milk and the RD stating the intervention was intended to support weight gain.
A resident with Alzheimer’s disease, severe cognitive impairment, malnutrition, immobility, incontinence, and existing heel pressure ulcers was identified as needing frequent repositioning and pressure injury prevention, but the care plan lacked a turning/repositioning program, heel off-loading, positioning devices, and specific nutrition strategies for poor intake. Skin check documentation was incomplete, with bruises and a rash noted without locations or follow-up, and several skin check forms left blank. Later, new sacral pressure ulcers were observed and treated by nursing staff, yet there was no subsequent assessment of these wounds by the wound NP or physician/physician extender, and the DON could not provide documentation of a repositioning schedule or plan to meet the resident’s identified needs.
The facility did not serve meals at the posted scheduled times, resulting in consistent delays of 20 to 60 minutes for all residents receiving oral diets. Multiple residents and staff confirmed the late meal service, which was attributed to reduced food service staffing and increased meal preparation demands. Resident council meeting minutes also documented ongoing concerns about late meal delivery.
Multiple residents, both cognitively intact and impaired, reported that their meals were frequently served late and cold. Resident Council Meeting minutes documented ongoing complaints about cold breakfast meals and delays in meal tray delivery by CNAs. The administrator confirmed the absence of a policy on food palatability or temperature expectations at the point of service.
Three residents with significant medical conditions who were fully dependent on staff for toileting and hygiene experienced prolonged waits for incontinence care, with some waiting over an hour or until the next shift for assistance. Staff did not consistently check or change incontinence briefs every two hours as required by facility policy, and communication lapses between shifts contributed to delays, resulting in residents remaining in soiled briefs for extended periods.
Multiple residents were found without accessible or functioning call lights, including individuals with limited mobility and cognitive impairments. Some had to yell or leave their rooms to seek help, while others had non-working call lights or shared a single device between beds. Facility policy requires call lights to be within reach and promptly repaired, but these procedures were not followed.
The facility did not consistently label or safeguard residents' clothing, leading to multiple reports of missing personal items after switching to an outside laundry service. Staff and resident interviews, as well as documentation, confirmed that laundry bags and clothing were often unlabeled, making it difficult to return items to the correct individuals and resulting in unresolved complaints.
The facility failed to maintain sanitary practices in the kitchen, affecting 57 residents. A dietary aide did not wash hands before handling clean dishes, and the hand sink lacked soap and towels. A sanitizer bucket had a low quaternary ammonia concentration, and food items in the cooler and freezer were improperly stored and labeled. Facility policies from 2017 were not adhered to.
The facility failed to follow its water management plan for Legionella, affecting all 57 residents. There was no documentation of required activities such as chlorine testing, ice machine maintenance, and water temperature checks. Additionally, the facility did not conduct Legionella testing during a prolonged closure of a resident unit, as confirmed by the DON.
The facility failed to maintain a homelike environment, as evidenced by cold rooms, water leakage, and damaged infrastructure affecting multiple residents. Despite reports from residents and visitors, issues such as drafts, peeling paint, and unsecured cords remained unresolved. The maintenance director acknowledged the need for repairs but did not provide immediate solutions.
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During a facility tour, it was observed that seven rooms were below ground level. The administrator acknowledged the noncompliance and mentioned a waiver application, but no waiver was provided, and a letter from the Illinois Department of Public Health indicated no waiver had been awarded.
A facility failed to maintain privacy for a resident during wound care. The ADON/Wound Care Nurse left the resident exposed from the waist down while retrieving additional items, contrary to the facility's policy on dignity and privacy. The resident, who was alert and oriented, later expressed that she should have been covered. The staff member acknowledged the importance of ensuring privacy during care.
A facility failed to implement a person-centered care plan for a resident with PTSD, despite the resident's history of trauma and multiple diagnoses. The social services staff was unaware of the PTSD diagnosis, and the facility lacked a policy on Trauma-Informed Care, resulting in no care plan to address the resident's needs.
The facility failed to provide adequate hygiene and grooming care for residents requiring assistance with ADLs. One resident was observed with unmet grooming needs over several days, while another expressed a desire for grooming that was not addressed. Additionally, a resident was found wearing double incontinence briefs, with the inner brief soiled, contrary to facility policy. The Assistant Director of Nursing confirmed that these practices were not in line with the facility's standards.
A resident with overgrown toenails was not seen by a podiatrist despite having signed a consent for podiatry services upon admission. The CNA reported the issue to the nurse, but the toenails remained unclipped. The resident expressed a desire for his toenails to be clipped, stating they had not been cut since admission. The resident's MDS indicated he was alert and required assistance for grooming.
Two residents did not receive their prescribed Lidocaine patches for pain management due to a shortage and miscommunication within the facility. Despite being aware of the issue, nursing staff did not notify the physician or provide alternative pain relief, resulting in high pain scores for the residents.
A facility failed to provide trauma-informed care for a resident with PTSD, as critical information about triggers and interventions was missing from the care plan. The resident had a history of sexual abuse and other traumas, but the facility's documentation was incomplete, and staff were unaware of the resident's PTSD diagnosis. The facility also lacked a policy on trauma-informed care for residents with PTSD.
The facility failed to provide proper pureed diets to two residents, serving them granular and lumpy pureed rice and turkey instead of the required smooth consistency. The cook used ground turkey due to a supply issue, and the consultant dietitian confirmed the meals were not safe to serve.
The facility failed to serve planned menu items to all 27 residents due to budget cuts, resulting in inadequate meal substitutions. Essential food items were missing, and the dietitian was not consulted for substitutions, violating facility policy. Residents expressed dissatisfaction with the meals, noting frequent shortages and substitutions that did not meet nutritional needs.
Unsafe Food Handling and Storage Practices
Penalty
Summary
Food was not prepared in a sanitary manner in the kitchen because stored foods were left unlabeled, personal beverages were kept in the refrigerator used for resident food, and personal items were placed on the food prep table next to the meat slicer. On April 20, 2026, an opened bag of corn, an opened bag of carrots, 9 boiled eggs, a bag of hamburger buns, a bag of hot dog buns, and several loaves of bread were observed in the kitchen freezer and refrigerator without labels. The Dietary Manager confirmed these items should have been labeled, and also confirmed that the personal soda, juice, and water bottles in the refrigerator did not belong to residents. During food preparation, the Cook handled a head of lettuce with bare hands, rinsed it, and put on new gloves without performing hand hygiene before placing the lettuce aside for later use. The Cook later used that lettuce to prepare hamburgers for meal service. The Cook also removed gloves, touched his forehead, lifted lids from steam table foods, sanitized the prep table, handled stacks of tray lids, and then donned new gloves without hand hygiene before handling stacks of plates used for meal service. Later, the Cook removed and donned new gloves without hand hygiene, touched his hairnet with gloved hands, and then began preparing pasta noodles. A Dietary Aide was also observed loading soiled dishes into the dish machine with gloved hands, then moving clean cups to a drying rack without removing gloves or performing hand hygiene. The aide then removed gloves, adjusted the garbage bin bag, donned new gloves, and repositioned clean dishes on the dish machine table without hand hygiene. The Dietary Manager stated that staff must wash, rinse, and sanitize hands after removing gloves and after touching unsanitary items, and that fresh food should not be handled with bare hands. The facility policies reviewed stated that prepared and packaged foods must be labeled and rotated, hands must be washed at appropriate times, bare hand contact with ready-to-eat foods is not allowed, personal food items must be stored only in designated areas, and handwashing is required after touching garbage, dirty dishes, bare body parts such as a hairnet, and between glove changes.
Infection Control Failures in Water Monitoring, Linen Handling, and Medication Administration
Penalty
Summary
The facility failed to follow its water management program for Legionella. The Maintenance Director stated that unused resident rooms were flushed a couple of times a week and all resident rooms were flushed once a month, but he did not have a log to document water temperatures and said he had asked for one but had not been provided one. He also stated that only one of the four hot water tanks had a temperature gauge, that he could not measure the temperature in the hot water tank itself, and that the facility had construction outside that broke a water line. He said he discarded the ice in the ice machine after the interruption in water. The Administrator stated she completed the facility’s Legionella water management assessment, said she was unaware of any areas at risk for Legionella growth, and said maintenance did not need a water temperature log unless there was a problem, but she could not provide documentation of monitoring the water management plan. The facility’s undated Water Management Program required a risk assessment of water system components, use of data such as water temperature logs, annual review of the program, monthly inspection of the ice machine, weekly testing of sink and shower temperatures, monthly checks of water heater temperature gauges, and flushing of faucets and toilets after any water system failure or interruption. The facility did not have documentation showing the ice machine was inspected, water temperatures were obtained, water heater temperature gauges were checked, or faucets and toilets were flushed after the interruption in the water system. The facility also failed to follow its policy for handling contaminated linen. A Housekeeping/Laundry Aide was observed wearing gloves while placing soiled clothing into the washing machine, then using the same soiled gloves to go to the dryer, remove clean bed linens, and fold them. The aide stated she only wore gloves when sorting soiled linen and did not wear a gown. Soiled linens were transported through a laundry chute into a plastic cart, and the cart was overflowing with laundry, with soiled items stuck in the chute and multiple soiled linens coming out loose and not in plastic bags. The Administrator stated soiled linen should be in a plastic bag before going into the laundry chute. The facility also failed to follow infection control measures during medication administration. A resident with multiple sclerosis, major depressive disorder, type 2 diabetes mellitus, cerebral aneurysm, and UTI had an order for IV Zosyn via midline catheter. During administration, an RN donned gloves, prepared the IV medication, and touched multiple non-sterile surfaces including the IV pole, IV tubing, the resident’s arm, and the resident’s blanket. She removed her gloves and put on a new pair without hand hygiene, then removed the cap from the midline catheter lumen and left it exposed while continuing to handle the IV bag and tubing. The exposed lumen contacted the resident’s blanket, a non-sterile surface, and no clean barrier was used to maintain an aseptic field. The RN then connected the tubing and administered the medication. The RN acknowledged hand hygiene and a clean barrier should have been used, and the nurse consultant confirmed the contamination required immediate replacement of the midline catheter and blood cultures. The facility also observed an LPN preparing and administering insulin to another resident with Alzheimer’s disease, type 2 diabetes mellitus, and CHF while wearing contaminated gloves after touching non-sterile surfaces, without changing gloves or performing hand hygiene before giving the injections.
Leaking Roof and Ceiling Not Repaired
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment by not repairing a leaking roof and ceiling in the first-floor dining room and in resident rooms. Survey observations found black substance along the ceiling tile in one resident’s room by the window, and the wall had a bubble-like appearance extending from the ceiling down to the floor. The maintenance director stated the ceiling in the dining room needed repair because the roof leaked when it rained, and he had been told since he was hired in late November 2025 that the roof needed repair. He also stated he replaced ceiling tiles every time it rained and believed the black substance on the ceiling tile appeared to be mold. Residents and staff described repeated water intrusion during rain. One resident said water came out of the ceiling every time it rained and reported seeing water dripping onto another resident from the ceiling. Another resident said water dripped on her head and pillow when it rained and that she had told maintenance, but no one had fixed it. A third resident said water dripped in his room when it rained and that the dining room ceiling leaked heavily enough that buckets were placed under the water and the TV had to be moved to keep it from getting wet. The administrator said she had known since winter that the roof needed repair and was waiting for warmer weather to fix it with tar, while also stating the water entered the dining room during rain but did not leak on residents.
Delayed ADL Assistance and Incontinence Care; Inadequate Grooming Support
Penalty
Summary
The facility failed to provide timely assistance with incontinence care and other ADLs for residents who required staff help. R29, who was cognitively intact and dependent on staff for toileting hygiene and was always incontinent of bowel and bladder, stated that CNAs were slow to answer the call light, sometimes took longer than an hour to respond, and sometimes did not come at all when she needed help transferring to the wheelchair for toileting. R30, who was cognitively intact and dependent on staff for toileting hygiene and incontinent of bladder, stated that when he pushed the call light it took CNAs a long time to answer and that it often took over an hour for staff to assist him to the bathroom. R52, who was cognitively intact and dependent on staff for toileting hygiene, stated that he had to wait an hour or more for help transferring to the toilet, that staff did not respond, and that he had timed the delay on his cell phone. The report also documented that the DON stated call lights should be answered within two to five minutes, that CNAs were expected to answer call lights in a timely manner, and that residents who were incontinent of bowel and bladder should be checked at least every two hours and provided incontinence care when wet with urine upon rounds. The facility policy on answering call lights stated that call lights should be answered as soon as possible and that residents who may not be able to use the call light should be checked frequently. These expectations were not met for the residents interviewed, who described prolonged waits for toileting assistance and incontinence care. The facility also failed to provide grooming assistance for R13. R13 had diagnoses including paranoid schizophrenia, bipolar disorder, malignant neoplasm of the left breast, anxiety disorder, unspecified intellectual disabilities, drug-induced dyskinesia, and borderline intellectual functioning. Her MDS showed she required staff assistance for hygiene, grooming, and other ADLs and had moderately impaired cognition, and her care plan stated she required maximal to total assistance for most ADLs. During observation, R13 was seen sitting in a wheelchair in the dining room with visible facial hair and long fingernails with sharp edges and a brownish-black substance beneath them; her husband stated she needed shaving and nail trimming, and a CNA present stated that R13 required staff assistance for shaving and nail care.
Failure to Follow Ordered Dietary Interventions for Weight Loss
Penalty
Summary
The facility failed to follow physician orders to provide dietary interventions for a resident with significant weight loss. R58 was admitted with multiple diagnoses including osteoarthritis, dementia, depression, and vitamin D deficiency. The MDS dated April 15, 2026 showed severe cognitive impairment, dependence on staff for eating, significant weight loss, and no physician-prescribed weight-loss program. The care plan documented a puree/mechanically altered diet with thin liquids, super cereal at breakfast, nutritional supplements, protein powder, and wound healing supplements, and noted that appetite varied from 51% to 100% with a 22.9% weight loss in six months. A progress note on March 14, 2026 documented continued significant weight loss and recommended whole milk with breakfast and dinner, and an order dated March 15, 2026 added whole milk at breakfast and dinner. However, on April 21 and April 22, 2026, R58 was served 2% milk at breakfast instead of the ordered whole milk. The breakfast meal ticket for April 21 showed whole milk and listed 2% milk as a dislike, and the RD stated that whole milk was intended to provide extra calories and that staff were expected to provide it as ordered.
Failure to Plan, Document, and Obtain Physician Assessment for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident admitted with bilateral heel pressure wounds and multiple risk factors, including Alzheimer’s disease, moderate protein-calorie malnutrition, immobility, incontinence, and severe cognitive impairment. On admission, the resident required total assistance with all ADLs and was identified through a tissue tolerance assessment as needing repositioning more often than every two hours. A skin condition assessment documented a right heel pressure ulcer and listed ongoing interventions such as a pressure relief device in the chair, turning and repositioning program, nutrition and hydration interventions, and dressing changes, and directed staff to initiate a care plan. Despite these identified needs and risk factors, the care plan initiated later in December did not include pressure ulcer prevention measures such as a turning and repositioning program, use of positioning devices (e.g., wedges or pillows), a repositioning schedule, or off-loading of the heels while in bed. The nutrition care plan did not outline strategies for feeding the resident or actions to take when the resident refused to eat, even though staff reported the resident often refused to open his mouth at meals. CNAs reported the resident was tall, thin, underweight, did not get out of bed, and required two-person assistance for repositioning due to yelling and swinging at staff, yet there was no documented repositioning schedule or plan to address these needs. Skin monitoring and wound management were also deficient. Daily shower skin check sheets on multiple dates were incomplete or lacked documentation of whether the skin was intact, and when bruises and a rash were noted, no locations or follow-up interventions were documented. On one date in late December, an RN documented new sacral pressure ulcers with reddened skin and two open circular areas on both sides of the sacrum, cleansed the wounds, and applied ointment and foam dressing. However, after these new sacral wounds were identified, there was no documentation that the wound NP or physician/physician extender assessed the sacral wounds from that date through discharge. The DON acknowledged that residents with pressure wounds or at risk should have care plans for prevention and healing and be repositioned every two hours, but was unable to provide documentation that this resident was repositioned as expected or that a plan was in place to meet the resident’s repositioning needs prior to the development of the sacral pressure ulcers.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve resident meals at the scheduled times as posted in the main dining room, affecting all 60 residents receiving oral diets. Observations showed that lunch trays began to be delivered 20 minutes after the scheduled time and were not fully served until 30 minutes past the scheduled time. Multiple residents reported that meals were consistently late, with some stating delays of 20 to 60 minutes. Staff interviews confirmed that meal service was often delayed, particularly after a reduction in food service aide staffing, which slowed down the tray delivery process. The facility's posted meal schedule and policy required meals to be served at specific times, but these times were not consistently met. Resident council meeting minutes from previous months documented ongoing concerns from residents about the timeliness of meal service, with repeated complaints that lunch was being served later and later. Staff, including a cook and food service workers, acknowledged the delays and attributed them to staffing shortages and the complexity of meal preparation. The facility census indicated that nearly all residents were affected, except for one who did not receive oral diets. The deficiency was identified through observation, resident and staff interviews, and review of facility records and policies.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide palatable food at appropriate temperatures, as evidenced by multiple cognitively intact and impaired residents reporting that their meals were often served late and the hot food was cold. Interviews with four out of five residents reviewed indicated consistent dissatisfaction with food temperature and timeliness. Resident Council Meeting minutes from two separate months documented ongoing complaints about breakfast meals being cold and delays in meal tray delivery by CNAs. Additionally, the facility administrator confirmed that there was no policy in place regarding food palatability or temperature expectations at the point of service to residents.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL), specifically incontinence care, to residents who were dependent on staff. Three residents with significant medical conditions, including multiple sclerosis, obesity, congestive heart failure, neuromuscular dysfunction of the bladder, hemiplegia, hemiparesis, and dementia, were identified as being completely dependent on staff for toileting and personal hygiene. These residents were always incontinent of bowel and bladder and required the use of mechanical lifts for transfers. Observations and interviews revealed that residents waited extended periods for incontinence care. One resident reported waiting from late morning until the next shift for toileting assistance, with staff confirming that the resident's incontinence brief was extremely soiled with urine and bowel movement by the time care was provided. Another resident stated that it took over an hour for staff to arrive to change a soiled brief, and that the same brief had been worn since early morning. A third resident reported routinely waiting about an hour for CNAs to respond to requests for incontinence care on both first and second shifts. Record reviews and staff interviews indicated that staff were expected to check and change incontinence briefs every two hours, regardless of whether residents could verbalize their needs. However, staff did not consistently offer or provide incontinence care at the required frequency, and communication lapses between shifts contributed to delays. Facility policies required residents to be kept dry, comfortable, and odor-free, with incontinence care provided every two hours or more frequently as needed, but these standards were not met for the residents reviewed.
Failure to Provide Accessible and Functioning Call Lights to Residents
Penalty
Summary
The facility failed to ensure that residents had functioning call lights within their reach, as observed in six out of nine residents reviewed for accommodation of needs. In one shared room, only one call light was present and it was positioned closer to one bed, leaving the other resident without access. One resident reported having to pull the call light closer to his bed, while his roommate had no call light and had to yell or leave the room to seek assistance. The Director of Nursing confirmed the absence of a call light for one resident and was unsure why only one was available in the room. Another resident was found asleep in her wheelchair with her call light on the floor behind her bed, out of reach, and the Assistant Director of Nursing acknowledged it should have been clipped to her wheelchair. Additional residents reported non-functioning call lights or a complete lack of access, with one resident stating her call light had not worked since admission and that she had informed multiple staff members without any follow-up. Further observations revealed that some residents' call lights were several feet away and inaccessible, despite their limited mobility and medical conditions such as multiple sclerosis, stroke-related paralysis, dementia, and Alzheimer's disease. The facility's policy requires that call lights be within easy reach of residents in bed or confined to a chair, and that defective call lights be promptly reported to maintenance. However, these procedures were not followed, resulting in multiple residents being unable to summon assistance as needed.
Failure to Safeguard and Label Resident Clothing Results in Loss of Personal Items
Penalty
Summary
The facility failed to ensure that residents' clothing items were properly labeled and safeguarded from loss, as required by their own policies and procedures. Multiple residents reported missing clothing items, with one resident stating that several pairs of pants had been missing since their laundry was first sent out, and another resident reporting that their clothes did not return from the laundry. A third resident indicated that clothing items went missing upon admission. Observations revealed that laundry bags and clothing were often not labeled, making it difficult for staff to identify ownership. Staff interviews confirmed that complaints about missing clothing had been received, and that there was no consistent process for labeling clothing or laundry bags. The facility had recently switched to an outside laundry service due to broken washing machines, which coincided with an increase in complaints and grievances about missing clothing. Documentation, including resident council concern forms, meeting reports, grievance forms, and email communication between the administrator and the laundry vendor, further substantiated ongoing issues with missing clothing and unreturned laundry bags. The facility's Personal Effects Policy required prompt investigation and resolution of missing property, but the lack of labeling and tracking contributed to the loss of residents' personal items. Staff interviews indicated that while there was an expectation for clothing and bags to be labeled, this was not consistently done, resulting in unidentifiable clothing and unresolved resident complaints.
Sanitary Practices Not Followed in Facility Kitchen
Penalty
Summary
The facility failed to adhere to sanitary practices in the kitchen, affecting 57 residents who received food prepared there. During an inspection, a dietary aide was observed washing dishes on the soiled side of the dish machine and then putting on new gloves without washing her hands before handling clean dishes. Additionally, the hand sink near the dish machine lacked soap and paper towels, and the dietary aide confirmed that housekeeping did not have any supplies available. Furthermore, a red sanitizer bucket in the kitchen was tested and found to have a quaternary ammonia concentration of 0-150 ppm, which is below the recommended range of 150-400 ppm. In the walk-in cooler, a tub of cottage cheese with a broken lid was found, exposing its contents, and the use-by date had already passed. In the walk-in freezer, opened bags of sliced strawberries and blueberries were found exposed to air. The dietary aide mentioned that these were used for a specific resident. The facility's policies from the 2017 manual were not followed, which included proper handwashing procedures, correct sanitizer concentration, and appropriate storage and labeling of food items.
Failure to Implement Water Management Plan for Legionella
Penalty
Summary
The facility failed to adhere to its water management plan for Legionella, impacting all 57 residents. The plan outlined specific measures to manage the risk of Legionella exposure, including quarterly testing of free chlorine levels, monthly maintenance of ice machines, weekly water temperature checks, and monthly monitoring of water heaters. However, the facility lacked documentation to confirm these activities were conducted. Interviews with the Administrator and Maintenance Director revealed that water temperature logs were not maintained, and there was no evidence of ice machine maintenance or free chlorine testing. Additionally, the facility did not implement control measures during the prolonged closure of a resident unit on the second floor, which was closed for several months and reopened without documented Legionella testing. The Director of Nursing confirmed the closure and reopening dates but acknowledged the absence of documentation for control measures or testing during this period. This oversight in maintaining and documenting the water management plan's activities and addressing the prolonged unit closure contributed to the deficiency.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for several residents, as evidenced by multiple deficiencies observed during the survey. One resident, R9, experienced a cold room due to a lack of window coverings and a draft from the window. Despite reporting the issue to staff, the curtain and rod remained unfixed for several days, and a towel was used unsuccessfully to block the draft. Additionally, there was peeling paint and water leakage from the ceiling, which had not been addressed despite being reported by the resident and a visitor. Another resident, R24, faced similar issues with water leakage from the ceiling, which had been ongoing since January. The resident's bed had to be moved due to water dripping onto it, yet the problem persisted in the new location. The maintenance request logs did not reflect the original dates of the requests, and the issues remained unresolved. The maintenance director acknowledged the draft in R9's room but did not provide a resolution. Further deficiencies were noted in other residents' rooms. In R43's room, a television cord was improperly secured, sagging from the ceiling, and there was crumbling drywall. In R45's room, the metal radiator was damaged, with rust and flaking. The maintenance director admitted that there was significant work needed in the building, but no immediate actions were taken to address these concerns.
Noncompliance with Room Location Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During an initial tour of the facility, it was observed that seven rooms (101, 102, 103, 104, 105, 106, and 107) were situated below ground level. The facility's Resident Roster confirmed that the affected residents were residing in these below-ground-level rooms. The facility's administrator acknowledged awareness of this noncompliance and mentioned that an application for a waiver had been submitted. However, no waiver was provided, and a letter from the Illinois Department of Public Health indicated that no waiver had been awarded for these rooms.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain resident privacy during wound care for one resident. On February 19, 2025, the Assistant Director of Nursing (ADON) and Wound Care Nurse, identified as V3, provided wound care to a resident with a pressure ulcer on her left buttock. During the dressing change, V3 left the resident's bedroom to retrieve additional items without covering the resident with a blanket or sheet, leaving her exposed from the waist down. The resident, who was alert and oriented according to her Minimum Data Sheet dated January 19, 2025, expressed on February 20, 2025, that the staff should have covered her before leaving. V3 acknowledged that staff must ensure privacy for dignity, aligning with the facility's policy that emphasizes promoting and protecting resident privacy during personal care and treatment procedures.
Failure to Implement PTSD Care Plan
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident diagnosed with PTSD. The resident, who was admitted with multiple diagnoses including PTSD, major depressive disorder, and anxiety disorder, did not have a care plan addressing her PTSD. The resident's electronic medical record and Minimum Data Set confirmed the PTSD diagnosis, and a progress note highlighted a history of sexual abuse. However, there was no care plan in place to address the resident's PTSD, identify her triggers, or provide interventions for her medical, physical, or mental needs. During an interview, the social services staff member, who had been at the facility for two weeks, was unaware of the resident's PTSD diagnosis. Upon reviewing the resident's electronic medical record, the staff member discovered the resident's history of trauma, including financial abuse, sexual assault, physical assault, and mental abuse, but found no identified triggers. The facility administrator confirmed that there was no policy on Trauma-Informed Care for residents with PTSD, indicating a lack of structured guidance for addressing such cases.
Deficiency in Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide adequate hygiene and grooming care for residents who require assistance with activities of daily living (ADL). Three residents were observed with unmet grooming needs. One resident was noted to have overgrown facial and nasal hair, jagged and discolored fingernails, and uncombed hair over several days, despite being totally dependent on staff for hygiene care. Another resident, who requires substantial assistance for grooming, expressed a desire for her facial hair to be shaved and her fingernails to be clipped, but these needs were not addressed. The Assistant Director of Nursing stated that nail care and shaving should be done during shower days and as needed, while hair care should be done daily. Additionally, a resident requiring substantial assistance for toileting hygiene was found wearing double incontinence briefs, with the inner brief soiled. The staff failed to change the soiled brief immediately, contrary to the facility's policy to keep residents clean, dry, and comfortable. The Assistant Director of Nursing confirmed that it is not the facility's practice to use double incontinence briefs due to the risk of urinary tract infections. The resident's care plan indicated the need for incontinence care as soon as incontinence was noted, which was not adhered to in this instance.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who required foot care was seen by a podiatrist. During an observation on February 19, 2025, a Certified Nursing Assistant (CNA) noticed that the resident had overgrown toenails that curled over the top of each toe. The CNA reported this issue to the nurse, but the toenails had not been clipped. The resident expressed a desire for his toenails to be clipped, stating that they had not been cut since his admission to the facility. The nurse confirmed that during admission, a head-to-toe assessment is conducted, and any issues requiring a physician's attention are referred. The resident had signed a consent for podiatry services upon admission, indicating that he should have been seen by a podiatrist. The resident's Minimum Data Set (MDS) indicated that he was alert and oriented and required substantial assistance for grooming and hygiene.
Failure to Administer Prescribed Pain Patches
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, R19 and R203, who had physician orders for Lidocaine adhesive patches to manage their chronic pain. R19, who has diagnoses including radiculopathy, hemiplegia, and osteoarthritis, reported not receiving his prescribed pain patches for a week, resulting in a pain score of 8/10. Despite being aware of the shortage, the nursing staff did not notify the physician or provide an alternative pain management solution. R19's care plan required the application of Lidocaine patches to multiple sites, but these were not administered as ordered. Similarly, R203, with conditions such as spinal stenosis and arthritis, also did not receive the prescribed Lidocaine patch for several days, leading to a pain score of 7/10. The Director of Nursing confirmed that the patches were house stock and should have been reordered by the central supply staff. However, due to a miscommunication, the patches were not available, and no alternative pain management was provided. The central supply staff was unaware of the shortage until it was reported, highlighting a breakdown in communication and inventory management within the facility.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as evidenced by the lack of identification of triggers and appropriate interventions in the resident's care plan. The resident, who had a history of sexual abuse and other traumas, was admitted with multiple mental health diagnoses, including PTSD. Despite this, the facility's documentation, such as the Admission Trauma-Informed Care Observation, was incomplete, with critical sections regarding triggers and responses left blank. Additionally, the care plan did not include specific behavior monitoring or interventions tailored to the resident's PTSD. Interviews with facility staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis and needs. The social services staff member, who had only been at the facility for two weeks, was unaware of the resident's PTSD and had not reviewed the care plan to address it. Furthermore, the facility lacked a policy on trauma-informed care for residents with PTSD, indicating systemic issues in addressing the needs of residents with trauma histories. The psychiatric care provided focused solely on medication without addressing the resident's trauma-related needs.
Failure to Provide Proper Pureed Diets
Penalty
Summary
The facility failed to provide pureed consistency diets for two residents who had orders for such diets. On February 18, 2025, during a lunch meal, the facility served pureed rice and turkey that appeared granular and lumpy to two residents requiring pureed diets. The cook, V8, mentioned that ground beef did not arrive as ordered, and ground turkey was used instead. The pureed food was observed to be granular and required chewing, which is inconsistent with the facility's policy for pureed diets that should be smooth and pudding-like. The consultant dietitian, V5, confirmed that the consistency was not appropriate for a pureed diet, indicating that the meals were not safe to serve to the residents.
Failure to Serve Planned Menu Items Due to Budget Cuts
Penalty
Summary
The facility failed to serve food items to residents as shown on the facility's planned and approved menu, affecting all 27 residents. During a tour of the kitchen, it was observed that the walk-in cooler and freezer shelves were sparse, lacking essential food items such as eggs, mayonnaise, and ketchup. Residents reported receiving meals that did not match the planned menu, with substitutions made due to budget cuts and lack of ingredients. For instance, on Father's Day, residents were supposed to receive roast beef but were instead served hot dogs without bread or condiments. The Food Service Director (FSD) admitted to making substitutions due to budget constraints, which included replacing roast beef with hot dogs and substituting oatmeal pies for lemon cheese bars. The facility also ran out of bread, ketchup, and mayonnaise, limiting alternative meal options. The dietitian was not consulted regarding these substitutions, which did not meet the same nutritive value as the planned menu items. The facility's policy requires menu changes to be of similar nutritive value and approved by a dietitian, which was not followed. Residents expressed dissatisfaction with the meals, noting frequent shortages of items like yogurt, mustard, and fresh fruit. The FSD acknowledged the inability to serve planned menu items due to budget cuts, resulting in inadequate meal substitutions. The facility's administrator confirmed that the food budget was cut in half, leading to these deficiencies. The facility's policy on menu changes was not adhered to, as changes were not indicated on the posted menu, nor were they of similar nutritive value.
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What surveyors actually found near you
We read the 1,455 citations issued within 25 miles in the last 12 months — including the 31 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roselle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra Bloomingdale | 2 mi | ★★★★★ | 1 | 0 |
| Bella Terra Schaumburg | 2.2 mi | ★★★★★ | 7 | 0 |
| Pearl Of Elk Grove, The | 2.3 mi | ★★★★★ | 7 | 0 |
| West Suburban Nursing & Rehab Center | 3 mi | ★★★★★ | 12 | 0 |
| Encore Village | 3 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.