Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ahva Care Of Stickney during CMS and state inspections, most recent first.
A resident receiving multiple CNS-depressant pain medications, including suboxone, baclofen, pregabalin, tizanidine, tramadol, and gabapentin, became lethargic and slow to respond after wound care. An NP gave verbal orders throughout the day to hold several of these medications due to the altered mental status, but the orders were not transcribed to the POS and were not followed, as the night-shift nurse still administered suboxone and baclofen. The next morning the resident remained minimally responsive and was sent to the hospital, where they were found to have hypoxia and worsening neurological status and were diagnosed with gabapentin-induced toxicity, baclofen overdose, and toxic metabolic encephalopathy.
A resident with dementia and mobility issues sustained facial lacerations after rolling out of bed and hitting a garbage can. The facility failed to maintain a clutter-free environment and did not implement new interventions after the resident was found on the floor twice. The CNA reported environmental issues, but no action was taken. The RN did not recognize the initial fall, and the DON acknowledged the failure to follow the facility's fall policy.
The facility failed to maintain a clean and safe environment, with surveyors observing peeling paint, rusted pipes, and a large hole in the basement, as well as dark deposits and peeling walls in the first-floor shower room. The Administrator and Maintenance Director acknowledged the issues, attributing them to leakage from the second-floor bathroom, but had not tested for mold or made necessary repairs despite previous instructions.
A resident with a DNR order was resuscitated by staff despite clear documentation of their wishes. The resident, who had multiple health issues, was found unresponsive, and an LPN initiated CPR, which was continued by paramedics. This action violated the facility's policy to respect advance directives.
The facility failed to maintain current Food Protection Manager Certification for the Director of Food and Nutrition Services and did not provide a certified person-in-charge (PIC) during the dietary manager's absence. A dietary aid without the necessary certification was observed cooking meals, affecting all 44 residents.
Failure to Hold CNS-Depressant Pain Medications and Monitor Resident With Altered Mental Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and timely implement NP orders to hold multiple CNS-depressant pain medications and to initiate increased monitoring for a resident with altered mental status. The resident had multiple standing orders for CNS-depressant medications, including pregabalin, tizanidine, baclofen, suboxone, tramadol, gabapentin (PRN), and naproxen (PRN), which were being administered as prescribed. On one morning, after wound care at 8:20 AM, the resident became lethargic and was noted by the ADON to be sleeping and lethargic for the remainder of the day. The ADON reported this to the NP multiple times that afternoon and evening, describing the resident as lethargic, slow to respond, and moaning with movement instead of yelling as usual. In response to these reports, the NP gave a series of telephone/verbal orders on the same day to hold baclofen, then tizanidine, and later to hold suboxone and tramadol until the resident was more responsive. However, these orders were not transcribed onto the POS and were not implemented as directed. The MAR shows that the night-shift nurse administered suboxone at 9:00 PM and baclofen at midnight, despite the NP’s earlier orders to hold these medications due to the resident’s altered mental status. The ADON later stated she was not aware that these medications had been given and believed no oral medications had been administered since the morning dose. By the following morning, the resident remained lethargic and slow to respond even to a sternal rub, and the NP was again notified. The NP then ordered transfer to the hospital for a higher level of care. The private ambulance report documented that the resident was unresponsive to verbal stimuli and had been declining since the previous day. At the hospital, the resident presented with altered mental status, lethargy, nonverbal status, diaphoresis, dry mucous membranes, hypoxia, and later worsening hypoxia and low blood pressure, leading to intubation and ICU admission. Hospital diagnoses included gabapentin-induced toxicity, baclofen overdose, and toxic metabolic encephalopathy. Reference materials cited in the report note that combining suboxone with other CNS depressants such as baclofen, gabapentin, pregabalin, tizanidine, and tramadol can cause serious, life-threatening respiratory depression and increased sedation, and that such combinations require close monitoring.
Failure to Maintain Safe Environment Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident, identified as R4, who has a history of dementia, muscle wasting, and mobility issues. R4 was found to have rolled out of bed and sustained facial lacerations requiring sutures after hitting her head on a garbage can. The incident occurred despite the resident's care plan, which included interventions to keep the environment free of clutter and ensure the resident's safety. The report details that on the night of the incident, R4 was found on the floor mattress twice, with the second occurrence resulting in injuries. The Certified Nursing Aide (CNA) and Registered Nurse (RN) involved did not implement new interventions after the first fall, and the RN did not recognize the initial incident as a fall. The CNA had previously reported that R4 was not a good fit for the room due to environmental factors like noise and temperature, but no action was taken to address these concerns. The Director of Nursing (DON) acknowledged that the RN failed to recognize the fall and did not implement appropriate interventions. The facility's policy requires staff to evaluate and document falls and adjust interventions as necessary, but this was not followed. The Administrator did not provide further information on how the injuries occurred, and the facility's investigation did not fully address the environmental factors contributing to the incident.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment in good repair, affecting two of its three units. During an onsite complaint investigation, surveyors observed peeling paint on the walls leading to the therapy room and bathroom in the basement, as well as rusted pipes and a large hole in the wall leading to the ceiling inside the therapy room. Additionally, the shower room on the first floor had a large area with dark materials on the ceiling, peeling walls with holes, and patches of peeling paint. A CNA mentioned that the dark deposits on the bathroom ceiling might be due to leakage from the second-floor bathroom. The facility's Administrator acknowledged the issues, stating that the dark area on the ceiling was not mold but caused by leakage from the second-floor bathroom. The Administrator admitted that the ceiling had not been painted recently, despite verbal instructions from fire safety to fix it. The Maintenance Director confirmed the leakage issue and stated that the dark deposits had not been tested for mold. The facility's general maintenance policy requires maintaining the building in good repair, safe, and free of hazards, which was not adhered to in this case.
Failure to Honor DNR Order
Penalty
Summary
The facility failed to honor a resident's advance directives for Do Not Resuscitate (DNR) status. The resident, an elderly individual with multiple diagnoses including metabolic encephalopathy, dementia, and heart failure, had a DNR order signed by their guardian. Despite this, when the resident was found unresponsive, a Licensed Practical Nurse (LPN) initiated CPR and called 911, leading to paramedics continuing resuscitation efforts upon their arrival. This action was contrary to the resident's documented wishes and the facility's policy to adhere to residents' rights to formulate advance directives. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the situation, and it was noted that the resident's code status was available in the electronic medical record system. However, the staff involved did not adhere to the DNR order, resulting in the resident being transported to the hospital after CPR was performed. The facility's policy clearly states the importance of communicating a resident's code status to necessary individuals, yet this protocol was not followed in this instance, leading to the deficiency identified by the surveyors.
Failure to Maintain Food Protection Manager Certification
Penalty
Summary
The facility failed to maintain current Food Protection Manager Certification for the Director of Food and Nutrition Services and did not provide services of a person-in-charge (PIC) with the required certification. This deficiency was observed during a kitchen tour where a dietary aid was found cooking meals without the necessary certification. The dietary manager, who normally holds the certification, was on bereavement leave, and the former cook who was supposed to cover did not show up as planned. The dietary aid continued to cook meals in the absence of a certified PIC, which is against the facility's policy. Interviews with the administrator and the dietician confirmed that the dietary manager's certification had expired two months prior, and the dietary aid did not possess the required Food Protection Manager Certification. The facility was unable to provide a policy for the PIC with the required certification upon multiple requests. This situation had the potential to affect all 44 residents residing in the facility, as the meals were being prepared by unqualified personnel.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,881 citations issued within 25 miles in the last 12 months — including the 29 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stickney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion Of Bridgeview, The | 2.7 mi | ★★★★★ | 11 | 0 |
| Aperion Care Burbank | 2.8 mi | ★★★★★ | 1 | 0 |
| Archer Heights Healthcare | 2.9 mi | ★★★★★ | 5 | 0 |
| Nexus At Berwyn | 3 mi | ★★★★★ | 12 | 2 |
| Midway Neurological / Rehab Center | 3.3 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ahva Care Of Stickney.
100% money-back within 48 hours.
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.