Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Estates Of Orland Park during CMS and state inspections, most recent first.
A resident with morbid severe obesity, vascular dementia, and moderate cognitive impairment fell during a mechanical lift transfer after becoming agitated and flailing while suspended. Two CNAs were assisting, but the lift tilted, the bed frame lifted, and the resident landed on the mattress and then to the floor, with complaints of head and back pain. The resident also had a prior fall incident documented when staff found her on the floor in her room.
A resident with advanced vascular dementia, impaired cognition, poor safety awareness, and a known fall risk was transferred by a CNA to a wheelchair and placed at the nurses' station without direct supervision while staff were rounding. With no one monitoring the area and no fall precautions in place, the resident self-propelled down a hallway, exited through an emergency stairwell door, and fell down a flight of stairs. The resident was later found at the bottom of the stairs with the wheelchair, and hospital evaluation revealed multiple comminuted fractures of the right femur and left humerus, along with diffuse bruising.
A cognitively impaired resident with known exit-seeking behavior eloped from the facility after leaving through the front door while wearing an electronic alert band, but staff did not hear the door alarm because it sounded only between closed double doors and was not audible at the nurse’s station. The resident’s care plan identified elopement risk and called for use of the electronic alert band, yet staff were unaware the resident had left until police returned the resident. In addition, several residents dependent on staff for transfers and identified as fall risks had care plans requiring two-person mechanical lift transfers and beds maintained in the lowest position, but a CNA was observed performing a stand-lift transfer alone due to short staffing, and two residents were found in beds elevated to waist height despite care-planned low-bed interventions.
Personal food items were found stored in the kitchen dry storage room, including plastic bags with tortillas, jalapeno, bread, and a tumbler with coffee. The Dietary Supervisor stated personal belongings and food should not be in the dry storage room, and the Chef said the items were hers and were brought to share. In addition, the Exec Chef/Dietary Supervisor and another Chef were observed in the kitchen with facial hair but without beard guards, despite policy requiring beard covers for staff with facial hair.
Dumpster lids were left open and the dumpster enclosure contained bags of trash and loose trash. The Dietary Supervisor stated the lids should be closed at all times and the surrounding area should be kept clean to reduce attraction of pests and rodents. A rear exit/entrance door was also observed with a gap between the floor and the door, and the Dietary Supervisor stated it was not properly sealed to prevent small critters from migrating into the facility.
Failure to use required PPE during high-contact care and failure to bag soiled linen before chute disposal were observed. A resident on EBP with diagnoses including dementia and a gastrostomy tube was repositioned by two CNAs who wore gloves but not gowns, despite direct physical contact during the task. In the laundry room, soiled linen was found in an open cart and in an unsecured bag with linen exposed and partially hanging out of the chute, contrary to facility infection control practice.
Laundry staff failed to clean a dryer lint screen and lint compartment thoroughly during a laundry room observation. Dryer #1 had loose lint in the compartment and the lint screen was fully covered with lint, despite facility policy requiring staff to clean lint screens and lint below the screens at the end of each shift and more often if needed.
A resident with severe cognitive impairment and dementia-related diagnoses repeatedly expectorated into a cup at a dining table while seated with other residents, with sputum landing on the table and being handled with fingers. Other residents commented on the behavior, and one resident later touched the table where the secretions remained. The DON stated residents would not appreciate the behavior, and several of the residents involved had dementia or other cognitive impairment.
Respiratory care was not managed according to policy for several residents. Surveyors observed a resident’s oxygen tubing and mask left uncontained on top of the concentrator, and another resident’s nebulizer mouthpiece was undated and stored outside a bag in a dresser. The facility’s equipment schedule stated nebulizer tubing should be stored in a bag when not in use, and an LPN confirmed the nebulizer items were not labeled or bagged.
Medication storage and labeling deficiencies were identified during cart and refrigerator checks. Multiple multidose meds, including eye drops and inhalers, were opened but undated, one resident’s hydrocortisone cream was opened, unlabeled, and uncontained, and one eye drop bottle had been opened far beyond the 28-day limit. The 2nd-floor med refrigerator was also found out of range, with staff reporting temperatures from 50F to 62F and ice buildup, while TB solution and several residents’ refrigerated meds were stored inside.
Psychotropic medication consent was not properly validated for two residents receiving psychotropic drugs. One resident with significant neurologic impairment and no cognitive intactness had Mirtazapine in use without a valid informed consent on file, and another resident with ALS, depression, and anxiety had Lorazepam and Sertraline orders with a questionable consent form that included an unverified signature and incorrect medication information. The DON confirmed no other consent was available for one resident.
A facility failed to ensure proper LALM use for three residents with pressure injuries or paraplegia. One resident with multiple stage 3, stage 4, and unstageable wounds was found on a LALM with multiple linen layers and a brief beneath the body, despite the mattress manual allowing only a thin cotton sheet. Two other residents reported mattress problems, including a missing bubble and a mattress that was not functioning as expected; staff were unsure about alarm meaning, required settings, and when static mode should be used, and the DON stated the facility did not have a policy for LALM use.
A resident with an IV midline had a transparent sterile dressing that remained dated far beyond the weekly change interval ordered by the physician, reflected in the care plan, and stated in facility policy. Staff gave inconsistent answers about how often IV dressings were changed, while the MAR documented the weekly dressing change as completed even though the dressing observed on the resident was dated much earlier.
Two residents with dementia, impaired cognition, unsteady gait, and documented fall risk were not adequately supervised or visually monitored in accordance with their assessed needs and care plans. One resident on a locked memory unit, known to be restless and to attempt unsafe ambulation, accessed a staff bathroom through a nurse’s closet and sustained an unwitnessed fall with a head laceration, then later stood from a locked wheelchair in the dining room, walked around a table without staff intervening in time, and fell, causing a femur fracture. Another resident, who staff stated required frequent monitoring and should not be left alone in her room unless asleep, was left unsupervised, ambulated without her rollator, and sustained an unwitnessed fall in her room with head, lip, and arm injuries, including a supracondylar humerus fracture and intracerebral hemorrhage. These events occurred despite facility fall policies and care plan interventions calling for close supervision, environmental safety, and monitoring for unsafe ambulation.
A resident with multiple complex medical conditions did not receive scheduled doses of Carvedilol and Lokelma as ordered, with no documentation or explanation provided in the MAR. Nursing staff and the DON confirmed that facility policy requires immediate documentation of medication administration or reasons for omission, but no such documentation was found, and staff could not recall or explain the missed doses.
A resident with significant cognitive impairment and multiple medical conditions was left unsupervised in the dining room after lunch, despite being identified as a fall risk. Staff responsible for monitoring the area were not present in the dining room and were unaware of the resident's fall risk status. The resident was later found on the floor with a hip fracture, and the care plan interventions for supervision and removal from common areas were not followed.
The facility did not ensure that the designated Infection Preventionist, who also served as the ADON, attended required QAA/QAPI meetings, as confirmed by review of meeting sign-in sheets and staff interviews. This failure was inconsistent with facility policy and job descriptions, and affected all residents in the facility.
A resident with multiple chronic conditions, who was cognitively intact, reported that a CNA became upset and shook the resident's bed while providing care to a roommate. The incident was captured on video, and the resident reported it to facility leadership. Although the staff member was identified, the allegation was not substantiated, and the CNA was reassigned. The facility's policy affirms residents' rights to be free from abuse.
A resident fell from a wheelchair, sustaining injuries and requiring hospital evaluation. The facility failed to notify the resident's family immediately after the fall and hospital transfer, only informing them after the resident's return. The DON confirmed that immediate notification is required by policy.
A resident fell out of bed and was moved back without a nurse's assessment or proper documentation. The facility lacked a specific post-fall procedure, and the incident was not recorded in the resident's clinical records, contrary to the facility's Fall Risk Assessment Policy.
A facility failed to schedule a resident's doctor appointments as ordered by the physician. The resident, with a history of major depressive disorder and chronic pain syndrome, had orders to follow up with a pain specialist, which were not fulfilled. Staff interviews confirmed the oversight, despite the facility's policy to assist in scheduling appointments.
The facility failed to maintain proper food storage and labeling practices, risking foodborne illness for 152 residents. Observations revealed unlabeled and undated food items in the walk-in cooler and freezer, dented cans in dry storage, and inadequate sanitization logs. Staff were unable to specify expiration periods, and the facility lacked policies for dating opened food items.
The facility failed to provide adequate ADL assistance and personal hygiene care for residents, as evidenced by unmet needs such as improper incontinence care, unaddressed facial hair, and dirty fingernails. Despite residents' requests and facility policies requiring the use of water for perineal care and regular grooming, staff did not consistently perform these tasks, leading to skin irritation and hygiene issues.
The facility failed to properly store medications and remove expired medications, affecting five residents. Issues included mixing oral and rectal medications, expired intravenous antibiotics, unsupervised access to nicotine gum, and unsecured zinc oxide and Nystatin powder. These deficiencies indicate a failure to adhere to medication storage policies, potentially compromising resident safety.
The facility failed to follow infection control practices during blood glucose monitoring and dining services. An LPN did not clean the glucometer between residents, and a CNA handled multiple residents' food and utensils without performing hand hygiene. These actions violated the facility's policies, risking cross-contamination and infection spread.
The facility failed to ensure call lights were within reach for three residents, including one with functional quadriplegia and another at risk for falls due to hemiplegia. Despite being able to use the call lights, they were often found on the floor or under the bed, making them inaccessible. Staff frequently left rooms without ensuring call lights were within reach, contrary to facility policy.
The facility failed to provide written bed hold notifications to residents and/or their representatives during hospital transfers, affecting three residents. The facility's policy requires such notifications and communication with the Ombudsman, but these steps were not completed, as confirmed by interviews with the Administrator and DON.
A resident with multiple diagnoses, including post-surgical amputation care and acute osteomyelitis, received intravenous antibiotics administered by LPNs instead of RNs, contrary to facility policy. The MAR showed multiple instances of LPNs administering Daptomycin and Ceftriaxone, despite the Director of Nursing stating that only RNs should handle IV medications.
A resident with a history of heart failure, COPD, and diabetes experienced worsening skin alterations due to incontinence, which were not assessed by a physician. Despite expressing discomfort and having visible skin issues, the facility staff failed to notify a doctor or document a recent evaluation. The resident's care plans lacked specific interventions for the skin condition, contrary to the facility's policy requiring weekly documentation and care plan development for skin integrity issues.
A resident was not provided with restorative services as recommended in their admission assessment. Despite being assessed for therapy, the resident did not receive any PROM, AROM, or bed mobility programs. The Restorative RN acknowledged the lack of services and mentioned the resident's alertness as a reason for not participating, but there was no documentation of refusal. The care plan and EHR lacked documentation of restorative therapies being offered or refused, contrary to facility policy.
The facility failed to ensure a safe environment for three residents, leading to potential accident hazards. A resident was found without non-skid socks despite being a fall risk, another had a cluttered room impeding safe movement, and a third had disinfectant spray cans within reach, violating chemical storage policy.
A resident with a PICC line had a soiled dressing that was not changed as required by facility policy and physician orders. Despite the presence of bloody drainage, the dressing remained unchanged from its original date, leading to a deficiency in care. Interviews with staff confirmed the dressing should have been changed weekly or as needed, but this was not adhered to.
A resident with chronic obstructive pulmonary disease and dependence on supplemental oxygen did not receive oxygen as ordered by the physician, leading to a blue tongue and shallow respirations. The oxygen compressor was found set to 0 liters instead of the prescribed 4 liters per minute. The RN assigned to the resident was unaware of who turned off the oxygen supply. Facility policy states that only RNs, LPNs, or RTs should administer oxygen.
A facility failed to maintain an accurate Record of Receipt for a controlled medication for a resident. A handwritten note in the Controlled Drug Receipt/Record/Disposition Form book lacked essential information such as the medication's name and licensed nurses' signatures. The resident had a box of Morphine Sulfate, but the narcotic count sheet was incomplete. The Director of Nursing acknowledged the error, highlighting the importance of proper documentation to prevent medication errors.
A cognitively impaired resident with a history of exit-seeking behavior eloped from a locked unit twice without staff supervision. The resident was found in a nearby parking lot on both occasions. The facility failed to implement adequate safety measures, including proper monitoring and activation of door alarms, leading to Immediate Jeopardy.
A resident with a history of falls and requiring assistance to ambulate fell and fractured her nasal bone due to the facility's failure to provide stand-by assistance. Despite the care plan indicating the need for supervision, staff were not adequately informed or did not adhere to this requirement, leading to the incident. The resident's medical history included conditions such as Alzheimer's and atrial fibrillation, and the facility's fall management policy was not effectively implemented.
Unsafe Mechanical Lift Transfer and Fall Prevention Failure
Penalty
Summary
The facility failed to prevent fall incidents and failed to provide a safe transfer using a mechanical lift for a resident with morbid severe obesity, vascular dementia, depression, anxiety, hypertension, and a BIMS score of 9/15 indicating moderate cognitive impairment. The resident had a care plan identifying her as at risk for falls due to cognitive and functional deficits, with an intervention to assess for anxiety and agitation prior to transfer. The facility’s fall management policy required assessment of hazards and risks, development of a plan of care, and implementation of resident interventions to minimize fall incidents and injuries. On 4/23/26, the resident fell while being transferred with a mechanical lift. Nursing documentation stated a nurse entered the room and found the resident lying on the floor on her left side with sling pads underneath her, complaining of back and head pain. The nurse contacted the physician, notified the DON, and the resident was sent to the hospital. The hospital record stated the resident came to the ED after falling out of the mechanical lift and reported right-sided head and back pain; EMS noted she had received Ativan before being placed in the mechanical lift. Staff interviews described the transfer as involving the resident becoming agitated, screaming, and moving during the lift transfer. Two CNAs were assisting, with one operating the lift and the other spotting the resident, but the resident was described as heavy, hard to position, and actively flailing her arms and legs while suspended. Staff reported the mechanical lift began to tilt, the bed frame was lifted, and the resident fell onto the mattress and then to the floor with the mattress. The DON and Administrator stated the resident’s movement caused the lift to tip during the transfer.
Failure to Supervise High-Risk Dementia Resident Resulting in Stairwell Fall and Fractures
Penalty
Summary
The facility failed to provide adequate supervision and fall prevention measures for a resident with advanced vascular dementia and a known history of falls, resulting in the resident exiting through an emergency stairwell door and falling down a flight of stairs. On the morning of 3/23/26, a CNA observed the resident attempting to get out of bed without assistance, recognized the resident as a fall risk, and transferred the resident to a wheelchair, then brought the resident to the nurses' station. At that time, all staff, including the nurse, were rounding on residents, leaving no one at the nurses' station to monitor the resident. The nurse reported that the resident self-propelled the wheelchair down the middle hallway, exited the unit via an emergency exit door, and that he only became aware of the situation when he heard the door alarm and went to locate its source. When staff responded to the alarm, the CNA found the resident at the bottom of the stairwell with the wheelchair, and the falls report documented the resident in a supine position with the wheelchair over the lower extremities, grimacing and guarding extremities. The hospital record from that day documented an unwitnessed fall down a flight of stairs, diffuse bruising, inability to tolerate movement of the left arm, a comminuted distal right femur fracture extending into the joint space, and a comminuted left humeral head and neck fracture with mild displacement, with surgical repair of the right femur performed. The resident’s care plans prior to the incident identified the resident as at risk for falls due to a history of falls, weakness, impaired cognition, use of assistive devices, narcotic and psychotropic medications, and advanced vascular dementia with significant cognitive decline, unpredictable behaviors, poor safety awareness, and impaired memory and decision-making. The nurse stated there were no fall precautions in place for the resident at the time of the incident, despite these identified risks and the resident’s need for constant redirection when in a wheelchair.
Failure to Prevent Elopement and Implement Fall Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and assistive devices to prevent accidents, including elopement and falls. One cognitively impaired resident with known exit-seeking behavior was allowed to elope from the facility without staff awareness, and multiple residents at risk for falls did not have care-planned fall prevention interventions consistently implemented. The elopement resident had a BIMS score of 6 indicating severe cognitive impairment, diagnoses including dementia, and a documented history of exit-seeking and wandering behaviors. The resident had an electronic alert band ordered and applied due to exit-seeking behavior, and the care plan identified the resident as at risk for elopement with an intervention to utilize an electronic alert band. Despite this, the resident was last seen in bed around 2:15–2:30 a.m. and subsequently left the building through the front door without staff knowledge. Police found the resident walking alone on a nearby street and returned the resident to the facility around 3:36 a.m., at which time staff documented that the facility had been unaware the resident had left. Staff interviews and observations revealed that the electronic alert system did not function effectively as an audible warning at the nurse’s station. A CNA reported not hearing any alarm when the resident exited, explaining that the sound of the alarm was located between a set of double doors and could not be heard when those doors were closed. The CNA confirmed that the last time she saw the resident, the resident was in bed with eyes closed and appeared to be sleeping. A former LPN stated she only became aware of the elopement when police arrived at the front desk and informed her that the resident had been found outside the facility. The administrator confirmed that the root cause of the elopement was that the electronic alert alarms could not be heard at the nurse’s station and acknowledged that when the system was initially tested, staff only checked the alarm audibility while standing between the double doors, and no one had checked whether the alarm could be heard outside those doors. The social services director confirmed that the resident’s elopement risk care plan had been initiated months earlier due to comments about wanting to leave and wandering behavior, and acknowledged that the interventions in place were not effective since the resident was able to elope. The facility also failed to implement fall prevention interventions as care-planned for several residents at risk for falls and dependent on staff for transfers. One resident with diagnoses including CHF, Type 2 DM, and dependence on enabling machines and devices had an MDS indicating dependence for sit-to-stand and toilet transfers, and a care plan requiring two staff and use of a total body (Hoyer) lift for transfers. Despite this, a CNA was observed transferring this resident from a wheelchair to a toilet using a stand lift alone, and she acknowledged that two staff should perform the transfer but stated she proceeded alone due to short staffing. The restorative nurse and PTA confirmed that if a resident is care-planned for two-person mechanical lift transfers, that plan must be followed for safety. Additional residents at risk for falls were observed with their beds at waist height despite care-planned interventions requiring beds to be maintained in the lowest appropriate position. One resident with hemiplegia and hemiparesis, dependent on staff for transfers and identified as at risk for falls, had a care plan specifying mechanical lift for transfers and ensuring the bed is in the lowest position. During observation, this resident was found lying in a bed at waist height. When questioned, the LPN confirmed the resident was a mechanical lift transfer and acknowledged that the bed was elevated to waist height and should be in the lowest position for safety. Another resident with paraplegia, dependent on staff for chair/bed transfers and at risk for falls, also had a care plan intervention to ensure the bed is in the lowest position. This resident was likewise observed in a bed at waist height, and the LPN confirmed the bed height. The DON stated that beds are to be in low position but noted that some residents prefer higher beds and do not allow staff to lower them, indicating that care-planned fall prevention interventions were not consistently maintained as required by facility policy and resident care plans.
Removal Plan
- Reassessed R75 for elopement risk after the elopement occurred and determined resident remained an elopement risk.
- Located R75 and returned resident to the facility.
- Completed a head-to-toe assessment for R75 with no signs of injury noted.
- Updated R75’s care plan to address the elopement event.
- Notified R75’s family member and Primary Care Physician/Medical Director of the elopement.
- Reviewed facility policies related to the occurrence (Elopement, Routine Resident Checks, Incidents/Accidents, Alarms, electronic alert band, Wanderers, Changes in Condition).
- Updated the Wanderguard policy to include considering alternative interventions in the event of equipment failure (e.g., room change to a more secure floor).
- Updated assessments and care plans for residents at risk for elopement.
- Placed R75 on 1:1 supervision pending move to a more secured unit.
- Moved the only other resident requiring electronic monitoring to a higher/more secured unit.
- Reassessed all residents for elopement risk.
- Implemented a process that all new admissions will have an elopement risk assessment completed per MDS schedule (within 7 days of admission, annually, and as needed).
- Reviewed and updated care plans for residents identified at risk for elopement on admission.
- Placed pictures of at-risk residents in binders at all nursing stations and the receptionist desk.
- Evaluated at-risk residents with active exit-seeking behaviors for possible room change to a more secured unit to limit access to the front entrance door.
- Evaluated at-risk residents to determine whether an electronic monitoring bracelet is appropriate.
- Conducted staff interviews to identify further potential risk.
- Conducted Code drills on all shifts to assess staff knowledge and preparedness.
- Reeducated all staff and managers on routine resident checks, exit seeking, incidents/accidents, elopement policy/procedure, and location of elopement-risk binders.
- Administered staff competency quizzes on elopement.
- Reeducated staff and managers on elopement risk and reporting behaviors/changes related to elopement risk to the appropriate discipline.
- Reeducated reception staff on monitoring front doors, resident safety, and proper Code Green procedure.
- Educated all staff on the electronic monitoring system.
- Implemented monitoring of exit doors by staff when unalarmed.
- Assigned receptionist to monitor the front entrance door.
- Required the receptionist to arm the door and required first-floor nurses to monitor the door when the receptionist is not present.
- Implemented alarm panel checks with a signed monitoring sheet by first-floor staff to ensure door alarms are activated when doors are not monitored by staff.
- Implemented weekly checks of exterior door alarms by the Maintenance Director and EVS Supervisor to ensure alarms are working and doors are secured.
- Met with R75’s daughter to discuss and implement new interventions.
- Initiated a work order to add an annunciator panel to the first-floor nurses station to amplify the alarm.
- Added elopement training to annual abuse training to ensure staff knowledge of elopement plans.
- Started QAA compliance audits using an elopement and door-check audit tool with review at monthly QAPI meetings.
- Assigned IDT members to complete audits and submit them to the Administrator for oversight of completion.
- Started review of audit results regarding elopement and door alarm working condition with the IDT with review at monthly QAPI.
- Implemented an Administrator daily audit to confirm the exterior front door alarm is activated each day by the receptionist prior to leaving.
- Added to new-hire orientation education on elopement and administration of competency quizzes.
- Established that the facility Quality Assurance Team/IDT will meet at least monthly to review elopement-risk residents, trends/patterns, and implement action steps.
- Held an emergency QA meeting with the IDT and Medical Director to discuss the elopement and approve the Removal Plan.
- Assigned ongoing monitoring of the Removal Plan to the Administrator, DON, ADON, and Social Services.
Personal Food Stored in Kitchen and Facial Hair Not Covered
Penalty
Summary
The facility failed to ensure kitchen staff did not store personal food items inside the kitchen’s dry storage room. During observation, two retail store plastic bags, a black plastic bag, and a tumbler were found in the dry storage room on a food cart. The Dietary Supervisor stated there should be no personal belongings or personal food items in the dry storage room because she would not know how the food items were prepared or the sanitation of the staff’s kitchen, and she did not want to contaminate residents’ food. The Dietary Supervisor then checked the tumbler and found coffee inside it. The Chef stated the bags and tumbler were hers and showed that one bag contained soft tortillas and jalapeno, while the black bag contained three pieces of bread. She stated she brought the food items to share with the ladies. The facility also failed to ensure kitchen staff with facial hair were wearing beard guards. During observation inside the kitchen, the Executive Chef/Dietary Supervisor had facial hair and was not wearing a beard guard, and the same was observed again the next day. He stated he should be wearing a beard guard upon entering the kitchen and that he works with food and does not want hair to get into or contaminate residents’ food. Another Chef with facial hair was also observed in the kitchen without a beard guard and stated he should have worn one all the time while in the kitchen to prevent hair from getting into residents’ food. The facility policy stated hair will be covered in kitchen operations areas and staff with facial hair will wear a beard cover.
Dumpster lids left open and enclosure area not kept clean
Penalty
Summary
The facility failed to ensure the dumpster lids were closed and failed to keep the dumpster enclosure area clean. On 03/09/2026 at 10:09am, the facility had 2 enclosed dumpsters, and two lids on one dumpster were open. There were bags of trash and loose trash within the enclosure. The Dietary Supervisor stated the dumpster lids should be closed at all times because pests and rodents are attracted to food and could get inside the facility, and stated the surrounding area of the dumpster should also be kept clean and free of trash for the same reason. On 03/09/2026 at 10:30am, the exit/entrance door behind the building was closed, but there was a gap between the floor and the door. The Dietary Supervisor stated the flush door was not properly sealed to prevent small critters from migrating to the facility. The facility policy stated outside dumpsters shall be kept closed at all times.
Failure to Use Required PPE and Secure Soiled Linen
Penalty
Summary
The facility failed to ensure that staff donned required PPE before repositioning a resident on Enhanced Barrier Precautions and failed to ensure that soiled linen was bagged before being placed in the laundry chute. The facility census dated 3/09/26 documented 175 residents. The report states these failures had the potential to affect all 175 residents residing at the facility. R15’s face sheet documented diagnoses including aphasia, psychosis, dementia, and gastrostomy. R15’s MDS dated 2/19/2026 documented severely impaired cognitive skills for daily decision making, and the resident was unable to be interviewed due to altered mental status. On 3/09/26 at 10:07am, an EBP sign was posted on R15’s bedroom door. R15 was observed lying sideways in bed with both legs hanging out of the bed. V12 and V13 entered the room wearing gloves but without the required gowns, then made direct physical contact with R15 while lifting the resident’s legs back into the bed and repositioning the resident. Later that day, during a tour of the laundry room, an open cart below the laundry chute was observed containing soiled linen with the bag unsecured and linen exposed and hanging out. A white cloth was also observed protruding through the closed chute door. When the chute door was opened, a bag of soiled linen was observed that was not securely closed, and a white sheet with two quarter-sized brownish stains was partially hanging out of the bag. The Housekeeping Supervisor stated that all dirty laundry is supposed to be bagged for infection control. The Infection Preventionist stated that EBP requires gown and glove use during high-contact resident care activities, and that repositioning a resident in bed is considered high-contact care.
Laundry Dryer Lint Screen Not Cleaned
Penalty
Summary
The facility failed to follow its policy and procedure for cleaning dryer lint screens and lint accumulation in the laundry room. During an observation of the laundry room with the Housekeeping Supervisor, dryer #1, the dryer farthest from the washing machines, was found with loose lint on the floor of the lint compartment and the lint screen fully covered with lint. The Housekeeping Supervisor acknowledged that the lint compartment needed attention and stated that staff clean the dryers daily and after each dry. Record review showed the facility policy titled, Equipment Maintenance, required laundry staff to clean all dryer lint screens and any lint below the screens at the end of each shift and more often if needed, with the Laundry Supervisor monitoring to assure screens are cleaned. The policy also stated that the Building Manager would vacuum the dryer fire box, lint compartment, blower motors, and any lint accumulation behind the dryers weekly. The facility census documented 175 residents residing in the facility, and the report stated the failure had the potential to affect all 175 residents.
Failure to Preserve Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that five residents were treated with dignity and respect. R80 had diagnoses including dementia with psychotic disturbance and frontotemporal neurocognitive disorder, with a BIMS score of 1 indicating severe cognitive impairment and inability to be interviewed due to altered mental status. R80’s care plan documented socially inappropriate behaviors, including spitting on a roommate’s bed, and noted that due to disease prognosis, R80 may not be able to make preferences known. During lunch in the dining room, R80 was observed repeatedly expectorating into a clear cup while seated at a table with R30, R117, and R145, with sputum also landing on the table surface and being handled with R80’s fingers in an attempt to place it into the cup. Other residents at the table reacted to the behavior, with R30 and R145 making comments about R80 spitting, and V14 acknowledging to R30 that R80 could not help it. After R80 left the dining room, R107 sat in the chair previously occupied by R80 and placed an arm on the table, coming into contact with R80’s respiratory secretions that remained on the table. R30, R107, R117, and R145 all had diagnoses including dementia or other chronic conditions, with BIMS scores showing severe to intact cognition. The DON stated that residents would not appreciate R80 expectorating into a cup at the table and agreed that many residents on the floor with R80 were cognitively impaired and would not appreciate it.
Respiratory equipment not dated or properly contained
Penalty
Summary
The facility failed to follow respiratory care policy procedures by not ensuring that respiratory equipment was properly contained when not in use and by not ensuring that one resident’s nebulizer tubing and mouthpiece were dated. The report states that four of 71 residents reviewed for respiratory care were affected, including residents with diagnoses such as COPD, chronic respiratory failure, Alzheimer’s disease, dementia, and dysphagia following nontraumatic intracerebral hemorrhage. For one resident with an order for oxygen by nasal cannula at 2 liters per minute as needed for shortness of breath, surveyors observed oxygen tubing and an oxygen mask not contained, with the items laying on top of the oxygen concentrator and removed from a clear plastic bag. For another resident with COPD and an order to change nebulizer tubing, mask, and mouthpiece weekly, the nebulizer mouthpiece was observed undated and uncontained in a dresser, and the LPN stated it was not labeled and not in a bag. The facility’s equipment change schedule stated nebulizer tubing shall be stored appropriately in a bag when not in use.
Medication Labeling and Refrigeration Storage Deficiencies
Penalty
Summary
The facility failed to follow medication storage and labeling procedures for multiple residents’ drugs and biologicals. During cart inspections, several multidose medications were found opened but undated, including Systane solution for one resident, Latanoprost solution for another resident, Brinzolamide ophthalmic suspension for a third resident, Brimonidine ophthalmic solution for one resident, Dorzolamide/Timolol ophthalmic solution for another resident, and Albuterol inhalers for two residents. Hydrocortisone cream for one resident was found opened, unlabeled, and uncontained in the medication cart drawer, and the RN stated it was for that resident’s arm but it was not labeled with the resident’s name or bagged. One resident’s Systane Ultra solution was opened and dated 1/14, and the nurse stated opened eye drops are good for 28 days, indicating the medication had remained in use beyond that timeframe. The medication refrigerator on the 2nd floor was found out of range during inspection, with temperatures reported at 50F, 62F, and 52F by different staff members, and ice buildup was noted in the freezer section. Stored in that refrigerator were TB solution, Zerbaxa IVPB, Procrit, B12 solution, and Vancomycin suspension for two residents. The report also states that one expired medication was not discarded. Facility policy required refrigerated medications to be stored between 36F and 46F, and the multi-dose vial policy required opened vials to be labeled with the opened date, expiration date, and staff initials, and to be discarded if opened longer than 28 days or expired per manufacturer guidance.
Psychotropic Medication Consent Not Validated
Penalty
Summary
The facility failed to follow its psychotropic medication policy by not ensuring valid consent was obtained before residents received ordered psychotropic medications. One resident, who had a history of hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, trigeminal neuralgia, muscle spasm, hypertension, and chronic pain syndrome, had a BIMS score of 00 out of 15 and was not cognitively intact. The resident had an order for Mirtazapine 15 mg at bedtime for depression, but the only consent provided was a verbal consent dated after the medication had already been in use since 2025, and no other informed consent was available. A second resident with a history including ALS, acute respiratory failure with hypoxia, depression, insomnia, dysphagia, and generalized anxiety disorder had orders for Lorazepam 1 mg every 4 hours as needed for anxiety and Sertraline 25 mg daily for depression, both in use since 2025. The consent form for this resident indicated the resident could not sign, but a signature appeared beside that statement and the nurse documented as obtaining consent stated it was not her signature and she did not know who signed it. The form also marked no to all medication classification and side effect categories. The DON stated the facility did not have any other consent for the first resident’s psychotropic medication and was trying to contact the family.
Improper LALM Use and Staff Uncertainty With Mattress Settings
Penalty
Summary
The facility failed to ensure proper low air loss mattress (LALM) use for three residents with pressure injuries or paraplegia. One resident had multiple pressure wounds, including stage 4 wounds to the sacrum extending to both hips, a stage 3 wound to the right buttock, and unstageable wounds to both heels, and was observed lying on a LALM with multiple layers beneath the body, including an incontinence brief, a flat sheet, and an additional folded sheet. The RN stated there were a sheet, diaper, and draw sheet in place, and further identified two parts of a draw sheet, resulting in three linen layers and a brief between the resident and the mattress. The mattress manual stated only a thin cotton sheet may be placed over the quilted mattress top cover. Two other residents with paraplegia and intact cognition were also observed on LALMs with problems in use and staff understanding. One resident reported the mattress was missing a bubble and had been uncomfortable for months, while the mattress alarm was sounding and the low pressure indicator was flashing orange; a CNA stated the mattress should not alarm when the resident moved. Another resident was observed on a LALM in static mode and stated the mattress had not been functioning properly, while an LPN was unsure of the exact order and whether static mode should be used while the resident was lying in bed. The DON stated the facility did not have a policy for LALM use and staff followed manufacturer guidelines, while the ADON stated only a flat sheet was allowed and described static mode as firming the mattress, but not being used continuously.
IV Dressing Change Not Performed per Order and Policy
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for one resident with an IV midline. The resident’s physician orders dated 2/18/26 required a transparent sterile dressing change weekly and as needed, and the care plan dated 2/19/26 directed staff to change the midline/PICC dressing weekly and as needed. On 3/9/26, the resident’s right upper extremity IV dressing was observed dated 2/22/26, which was 15 days old. During the observation, the RN identified the access as a midline/PICC line and stated dressings were changed weekly, while the ADON stated dressings were changed when residents first came in from the hospital, then as needed, and also after a month. The DON later stated IV dressing changes were required at least weekly and if soiled. The March 2026 MAR documented the transparent sterile dressing change as weekly every Sunday and showed it was documented as administered on 3/8/26, and the facility’s 04/2025 central venous access catheter devices dressing change policy stated dressings are changed one time per week and as needed.
Failure to Adequately Supervise High Fall-Risk Residents Resulting in Multiple Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring, including maintaining visual oversight, for residents assessed as at risk for falls, in accordance with their care plans and assessed needs. One resident with dementia, a history of falls, orthostatic hypotension, syncope, and severely impaired decision-making was housed on a locked dementia unit and identified as at risk for falls. This resident had an unsteady gait, wandered, and exhibited behaviors of trying to get up and walk unassisted. Despite being at the nurse’s station in a wheelchair prior to the first fall, the resident was later found on the floor in a staff bathroom located within a locked nurse’s closet that required a code to enter. Staff reported that the closet door was usually kept closed and coded, and a nurse stated that someone must have left the door open. The fall was unwitnessed, and the resident sustained a scalp laceration requiring staples. Subsequently, the same resident experienced another fall in the dining room. The resident’s care plan identified her as at risk for falls due to history of falls, weakness, impaired balance and mobility, impaired cognition, wandering, and hypotension, with interventions including monitoring for attempts to get out of a chair or ambulate without an assistive device and cueing the resident accordingly. Progress notes and behavior charting documented that the resident was restless, crying, yelling, attempting to ambulate unsafely without staff assistance, and that interventions such as walking her around the unit and offering activities did not fully resolve these behaviors. On the day of the dining room fall, staff brought the resident to the dining area in a wheelchair and locked the wheelchair at the table. Multiple staff were present in the dining room but reported they did not actually see the fall. Statements indicated that the resident stood up from the wheelchair, walked around the table, and fell before staff could reach her, resulting in a left femur fracture. Another resident with dementia, impaired short- and long-term memory, unsteady gait, use of a rollator, history of falls, and multiple risk factors including hypertension medications, antidepressants, seizure history, COPD, and occasional incontinence was also assessed as at risk for falls. This resident required supervision or touching assistance for sit-to-stand transfers and, according to a nurse, required monitoring every fifteen minutes and should not be left alone in her room unless asleep. The nurse reported that the resident was kept near the nursing station for monitoring and that the resident was forgetful and needed encouragement to use her rollator. On the day of the incident, the nurse last saw the resident in her room sitting on the bed or rollator seat, then later heard the resident yelling and found her on the floor by the window, with a hematoma on the top of her head, lip bleeding, and complaints of arm pain. The fall was unwitnessed, the resident’s walker was not near her, and she stated she had been going to answer a telephone that was not present in the room. Hospital records documented an unwitnessed fall with head injury, lip laceration, scalp abrasion, a right supracondylar humerus fracture, and intracerebral hemorrhage. These events occurred despite facility policies stating a commitment to proactively identify residents at risk for falls, plan preventive strategies, and assess and monitor the resident’s environment to manage potential hazards. The facility’s fall management policies stated that hazards and risks would be assessed, plans of care developed and implemented, and the environment monitored to minimize fall incidents and injuries. However, in these cases, residents with known dementia, impaired cognition, unsteady gait, and documented fall risk were able to access unsafe areas or ambulate without adequate supervision. The first resident accessed a staff-only bathroom through a coded nurse’s closet and fell without staff present, and later ambulated around a dining room table and fell while staff were in the room but without continuous visual oversight. The second resident, who staff acknowledged should not be left alone in her room unless asleep and required frequent monitoring, was left unsupervised in her room, ambulated without her rollator, and sustained an unwitnessed fall with significant injuries. These circumstances demonstrate that the facility did not consistently maintain the level of supervision and environmental control described in residents’ assessments, care plans, and facility policies for fall prevention.
Failure to Document and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident, who had multiple complex medical diagnoses including chronic kidney disease, heart failure, dementia, and other serious conditions. The resident was not cognitively intact, as indicated by a BIMS score of 6. Review of the medication administration record (MAR) for October showed that scheduled doses of Carvedilol and Sodium Zirconium Cyclosilicate (Lokelma) were not documented as given on two separate dates. The MAR had blank boxes for these medications, with no documentation indicating whether the medications were administered or the reason for omission. Interviews with nursing staff and the Director of Nursing (DON) confirmed that facility policy requires immediate documentation of medication administration or the reason for withholding a dose. Staff acknowledged that a blank box on the MAR means the medication was not given, and if a medication is held, the reason must be documented. The DON and staff could not provide a reason for the missing documentation or confirm whether the medications were actually administered. Progress notes for the relevant dates did not contain any entries explaining the omissions, and the assigned nurses either could not recall the events or admitted to possibly forgetting to document. Facility policies and job descriptions reviewed by surveyors further confirmed the requirement for accurate and timely documentation of medication administration and reasons for any missed doses. Despite these policies, there was no evidence in the resident's records to explain the missed or undocumented doses, and staff interviews did not clarify the circumstances. The deficiency was identified based on the lack of documentation and failure to follow established procedures for medication administration and record-keeping.
Failure to Provide Adequate Supervision in Dining Room Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure effective supervision and monitoring of residents in the dining room, resulting in an accident involving a resident assessed to be at risk for falls. The resident, who had multiple diagnoses including chronic hepatic failure, hepatic encephalopathy, Alzheimer's disease, dementia, and impaired mobility, was left unsupervised in the dining room after lunch. Staff interviews revealed that there was no clear protocol requiring staff to remain in the dining room for supervision, and the LPN assigned to monitor the area was seated at the nurse station, unable to maintain visual supervision of the resident. The resident was found on the floor in the dining room by another staff member, with no staff present in the room at the time of the fall. The resident was alert but in pain and was subsequently sent to the hospital, where she was diagnosed with a right femoral neck fracture. The care plan for this resident identified her as a fall risk, with interventions including supervision and removal from common areas after meals, but these interventions were not followed at the time of the incident. Staff interviews indicated a lack of communication regarding the resident's fall risk status, and the LPN monitoring the dining room was not informed of the resident's specific needs. The facility's fall management policy emphasized proactive identification and supervision of residents at risk for falls, but this policy was not effectively implemented, leading to the unwitnessed fall and injury.
Infection Preventionist Failed to Participate in QAA/QAPI Meetings
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), who also served as the Assistant Director of Nursing (ADON), participated in the Quality Assessment and Assurance (QAA) Committee meetings as required. Record review of QAA meeting sign-in sheets for several dates showed no documented attendance by the IP, despite the individual having assumed the IP role months prior. This was confirmed by the Assistant Administrator, who acknowledged the absence of the IP from these meetings and affirmed that participation is a standing requirement for the IP. Facility policy and the job description for the Infection Preventionist Nurse both specify participation in QAA meetings as a responsibility. The facility census indicated that 174 residents resided in the facility at the time of the deficiency. The lack of IP participation in QAA/QAPI programming was identified through interviews and record review, with the Assistant Administrator confirming the deficiency and its inconsistency with both facility policy and regulatory requirements.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A resident with multiple diagnoses, including encephalopathy, end stage renal disease, and chronic obstructive pulmonary disease, who was cognitively intact, reported an incident involving a certified nursing assistant (CNA) while care was being provided to his roommate. The resident stated that the CNA entered between the beds to turn off the call light, became upset when questioned, and shook the side of the resident's bed. The resident recorded the incident on video, which showed an unseen person shaking the bed for several seconds, followed by an argument between the resident and the individual. The resident reported the incident to facility leadership, and a police report was filed. A roommate confirmed being present in the room but did not witness the event, only hearing the resident yelling. The facility's initial and final reports indicated that the staff member involved was identified, but the allegation could not be substantiated, and the CNA was allowed to return to work on a different unit. The facility's abuse policy affirms residents' rights to be free from abuse, including physical actions such as those described in the incident.
Failure to Timely Notify Family After Resident Fall
Penalty
Summary
The facility failed to timely notify a resident's family after a fall that required transportation to a local hospital for evaluation. The incident involved a resident who fell from his wheelchair, resulting in a bruise to the right side of his head, an abrasion to his face, and blood on his lips/mouth area due to biting his lip during the fall. The resident was transported to the hospital for evaluation on the night of the incident. However, the resident's mother was not notified of the fall or the hospital transfer until several hours later, after the resident had already returned to the facility. The Director of Nursing confirmed that family should be notified immediately after a resident falls and if a resident is being sent to the hospital for a change in condition. The facility's policy on change of condition also mandates that the responsible party be notified of changes in a resident's condition. Despite these protocols, the Licensed Practical Nurse on duty only notified the resident's mother after the resident had returned from the hospital, failing to inform her at the time of the fall and subsequent hospital transfer.
Failure to Assess and Document Resident Fall
Penalty
Summary
The facility failed to ensure proper assessment and documentation following a fall incident involving a resident, identified as R2. On 12/18/24, R2 was observed on video falling out of bed at 10:20 AM. Two staff members, including a Wound Certified Nursing Assistant (CNA), entered the room and moved R2 back to bed without conducting a nurse assessment. The CNA involved did not recall notifying a specific nurse, and there was no documentation of the fall or any assessment in R2's clinical records for that day. The Director of Nursing (V2) stated that all falls should be documented, and a nurse should perform a full body assessment before moving the resident. However, the facility lacked a specific policy or procedure for staff to follow after a resident falls. The facility's Fall Risk Assessment Policy from 8/2020 requires a nurse to complete an Occurrence Report and initiate post-occurrence documentation, which was not adhered to in this case.
Failure to Schedule Resident's Doctor Appointments
Penalty
Summary
The facility failed to schedule a resident's doctor appointments as per the physician's orders for one of the residents reviewed for quality of care. The resident, who was admitted with diagnoses including major depressive disorder, chronic pain syndrome, history of traumatic brain injury, and injury to the peripheral nerves of the thorax, had specific orders from their physician to follow up with a pain specialist at a rehabilitation hospital. These orders were documented on 10/18/23 and again on 1/10/24, yet the facility did not schedule the required appointments. Interviews with facility staff, including the Unit Manager and the Administrator, confirmed that the appointments were not scheduled as ordered. The resident's Primary Care Physician and Nurse Practitioner for Pain Management both expressed expectations that the facility would arrange these appointments. The facility's appointment policy indicates that assistance should be provided to residents in scheduling appointments, yet this was not adhered to in this case.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices in the kitchen, which could lead to foodborne illness among the 152 residents receiving dietary services. During an inspection, it was observed that the walk-in cooler contained several food items, such as shredded cheese, liquid eggs, and various pureed foods, that were not labeled or dated. Additionally, some items were stored improperly, with raw foods placed above cooked foods. The kitchen supervisor acknowledged the importance of labeling and dating food items but was unable to specify the expiration periods for different foods. The facility lacked a policy on how to date opened food items or determine their expiration. In the dry storage area, several dented cans of food were found, including cans of sliced pears, fruit cocktail, chocolate pudding, and tomato sauce. The corporate executive and kitchen supervisor both stated that dented cans should not be used as they could pose a risk of contamination. However, the facility's policy on dented cans was not being followed, as these compromised cans were not separated or marked as unusable. The walk-in freezer also contained several items without proper labeling or dates, such as pie crusts, pastries, waffles, and chicken tenders. A non-English speaking staff member was unable to answer questions about proper food storage and labeling. Additionally, the facility's sanitization practices were inadequate, with only one log being maintained for both the three-compartment sink and the red sanitization buckets, despite the need for separate logs. The dietary aide confirmed that only one log was used, and the corporate executive noted that separate logs should be maintained to ensure proper sanitization levels.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate care for residents dependent on staff for activities of daily living (ADLs), as evidenced by multiple observations and interviews. One resident, who was cognitively intact and dependent on staff for toileting hygiene, reported that staff skipped washing her perianal area during incontinence care, leading to a diaper rash. Despite the resident's request for water to be used during cleaning, staff continued to use wipes, which the resident believed contributed to her skin irritation. The facility's policy required the use of water and soap for perineal care, but this was not followed, resulting in reddened and inflamed skin for the resident. Other residents were observed with unmet personal hygiene needs, such as facial hair and dirty fingernails. One resident had an accumulation of chin hairs, while another had a dark substance under her fingernails, both of whom required substantial assistance for personal hygiene. The Director of Nursing acknowledged that female residents should not have facial hair and that fingernails should be clean to prevent infections. However, these hygiene tasks were not consistently performed, as evidenced by the continued presence of facial hair and dirty fingernails over several days. Additional residents were found with long, dirty fingernails and facial hair, indicating a lack of regular personal hygiene care. One resident had long, jagged fingernails with a brown substance underneath, and another had a full beard despite expressing a desire to have it shaved. These observations highlight the facility's failure to adhere to its policies on nail care and shaving, which require residents to have clean, well-trimmed nails and facial hair removed to improve appearance and morale. The facility's inaction in providing necessary ADL assistance resulted in multiple residents experiencing unmet hygiene needs.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to properly store medications and remove expired medications from stock, affecting five residents. During an observation, it was noted that a resident's oral and rectal medications were stored together in the same drawer, which is against infection control protocols. Both the Assistant Director of Nursing and a Registered Nurse confirmed that rectal medications should not be stored with oral medications due to potential infection control issues. The resident had an active order for a rectal medication, which should have been stored separately in the treatment cart. Another deficiency was observed when a bag of Daptomycin, an intravenous antibiotic, was found in the medication room refrigerator with an expiration date that had already passed. The Assistant Director of Nursing acknowledged that expired medications should be sent back to the pharmacy and that the expired medication was still being administered to a resident for osteomyelitis. The facility's policy requires that medications be stored under proper conditions and that expired medications be removed. Additional issues included a resident having unsupervised access to nicotine gum, which was not securely stored, and another resident's zinc oxide medication being left on a bedside table instead of being locked in the medication cart. Furthermore, a bottle of Nystatin powder was found in a resident's room without an order for it to be stored there, and the Director of Nursing confirmed that medications should be secured unless there is a specific order allowing bedside storage. These observations indicate a failure to adhere to medication storage policies, potentially compromising resident safety.
Infection Control Lapses in Glucose Monitoring and Dining Services
Penalty
Summary
The facility failed to adhere to infection control practices during blood glucose monitoring and dining services, affecting five residents. On October 1, 2024, an LPN did not clean the glucometer after testing a resident's blood glucose level before using it on another resident. This practice was contrary to the facility's policy, which required cleaning and disinfecting the glucometer after each use to prevent cross-contamination. Interviews with other staff members, including another LPN and the Director of Nursing, confirmed that the glucometer should be cleaned between residents to prevent infection, especially since blood is involved. During a lunch service, a CNA was observed handling multiple residents' food and utensils without performing hand hygiene between tasks. The CNA touched a resident's plate and glass, refilled the glass from a communal carton of thickened water, and then proceeded to serve other residents without cleaning her hands. This action violated the facility's hand hygiene policy, which mandates handwashing after contact with potentially contaminated items and between resident interactions. The facility administrator acknowledged that the CNA should have cleaned her hands to prevent the spread of infectious organisms.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for dependent residents, affecting three residents in the sample. One resident, who was diagnosed with functional quadriplegia and cognitive communication deficit, was found with her call light on the floor, making it inaccessible. Despite being able to use the call light, she could not find it. The Director of Nursing confirmed that call lights should be within reach, as per the facility's policy. Another resident, with a care plan indicating a risk for falls due to weakness and hemiplegia, repeatedly had his call light under the bed and out of reach. Nurses entered and exited his room without ensuring the call light was accessible. A third resident, who required assistance with daily activities and was at risk for falls, was left without her call light within reach after being assisted to bed by a CNA. She reported that this was a recurring issue, forcing her to yell for help when she could not reach the call light.
Failure to Provide Bed Hold Notifications for Hospital Transfers
Penalty
Summary
The facility failed to provide written documentation of bed hold notifications to residents and/or their representatives when residents were transferred to the hospital. This deficiency was identified in three out of five residents reviewed for discharge and hospitalization. Specifically, the facility did not provide bed hold notifications for residents who were transferred to the hospital for various medical conditions, including elevated troponin levels, sepsis, and complications from a fall. The facility's policy requires that a bed hold notification be given to the resident or their representative at the time of transfer and that the Ombudsman be notified via a monthly transfer log. Interviews with the facility's Administrator and Director of Nursing revealed that the required bed hold assessments were not completed for the affected residents, and there was uncertainty as to why the nurses did not perform this task. The facility's policy, dated December 2018, mandates that the bed hold policy be documented and communicated to the resident and their representative within 24 hours of transfer. Additionally, the Ombudsman should be informed of all hospital transfers and therapeutic leaves. The failure to adhere to these procedures resulted in a deficiency in the facility's compliance with its own policies and regulatory requirements.
Unqualified Staff Administering IV Medications
Penalty
Summary
The facility failed to ensure that intravenous medications were administered by qualified staff, specifically Registered Nurses (RNs), as per their policy. A resident, identified as R165, was admitted with several diagnoses including orthopedic aftercare following surgical amputation, acute osteomyelitis, type 2 diabetes, and cellulitis. The resident had physician orders for intravenous antibiotics, Daptomycin and Ceftriaxone. However, these medications were administered by Licensed Practical Nurses (LPNs) instead of RNs, which is against the facility's policy. The Director of Nursing (DON) confirmed that only RNs should handle intravenous medications, yet multiple LPNs were documented as having administered these medications over several dates. The Medication Administration Record (MAR) for R165 showed that LPNs administered Daptomycin and Ceftriaxone on numerous occasions throughout September and October. This included instances where LPNs flushed the midline PICC and changed the cap, tasks that should have been performed by RNs. The facility's policy, dated January 2022, clearly states that administration of intravenous fluids through central venous access should be done by a licensed nurse trained in the procedure, implying RNs. This discrepancy between policy and practice led to the deficiency noted in the report.
Failure to Assess and Manage Resident's Skin Alteration
Penalty
Summary
The facility failed to have a skin alteration worsening assessed by a physician for a resident, identified as R16, who was reviewed for quality of care. On October 1, 2024, R16 reported having a diaper rash, and during incontinence care, CNAs observed reddened and inflamed skin from R16's lower back to upper thigh areas, including the perineal area and folds. Despite applying barrier cream to the perianal area, the CNAs did not apply it to the perineal area or folds. R16 expressed discomfort, describing a burning sensation. The Wound Care Coordinator, V34, noted that R16 was not being seen for wound rounds and emphasized the need for CNAs to alert the staff nurse for evaluation. V34 identified the condition as incontinence-related and suggested notifying the doctor for treatment evaluation. The LPN, V21, who had been caring for R16, admitted to not notifying a doctor about the skin alteration, despite the area not improving. V21 was unable to find any progress notes regarding the last physician evaluation of the wound. Although the doctor was aware of the rash and had ordered creams, there was no documentation of a recent physician assessment. The Wound Care Physician, V44, confirmed not being consulted for R16 and stated that MASD is usually managed by the primary care provider unless it does not improve, in which case he would be consulted. R16's medical history includes heart failure, COPD, and Type 2 diabetes mellitus, with a cognitive status noted as intact. The resident's care plans lacked specific interventions for the skin condition, despite a care plan indicating potential for skin integrity alteration. The facility's policy requires documentation of non-pressure skin alterations weekly and the development of a care plan for actual or potential skin integrity issues, which was not adhered to in R16's case.
Failure to Provide Restorative Services to Resident
Penalty
Summary
The facility failed to provide restorative services to a resident as recommended in the admission restorative nursing assessment. The resident, identified as R152, was admitted to the facility and had been there for about four months without receiving any therapy services, despite being assessed for restorative therapy. The assessment indicated that R152 had no impairment in his extremities but was completely dependent on staff for toileting hygiene and bed mobility, with goals to improve to only requiring substantial assistance. The Restorative Nursing assessment recommended Passive Range of Motion (PROM), Active Range of Motion (AROM), and Bed Mobility/Walking programs, but the resident's Minimum Data Set (MDS) showed he received no such services in the previous seven days. The Restorative Registered Nurse (V7) acknowledged that R152 was not on any restorative programs and mentioned that the resident did not want to participate regularly because he was alert. However, there was no documentation of the resident's refusal of services. The resident's care plan indicated an ADL Functional Performance Deficit with goals to improve functioning, but it did not document any restorative therapies being offered or refused. Additionally, the Electronic Health Record (EHR) task section did not show any reference to restorative therapy programs being ordered, offered, or refused. The facility's policy requires that residents be assessed and provided with individualized restorative programs, which were not documented or implemented for R152.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to provide a safe and supervised environment for three residents, leading to potential accident hazards. One resident, identified as R221, was observed in a wheelchair without non-skid socks or eyeglasses, despite being a fall risk due to conditions like metabolic encephalopathy and Parkinson's with dyskinesia. The staff acknowledged the oversight, as the resident was supposed to have non-skid footwear for safety. Another resident, R222, was found in a cluttered room with furniture and a mat improperly placed, which could impede safe movement. This resident, who has cognitive deficits and poor balance, was at risk for falls, and the care plan required a floor mat next to the bed, which was not followed. Additionally, a third resident, R142, who has moderate cognitive impairment and multiple health issues, was found with disinfectant spray cans within reach, contrary to the facility's policy on chemical storage. The policy mandates that chemicals be kept inaccessible to residents, stored in locked areas, or under constant supervision. The presence of these chemicals in the resident's bed and on the overbed table posed a safety risk, as they were not secured or monitored by staff.
Failure to Change Soiled PICC Line Dressing
Penalty
Summary
The facility failed to appropriately manage the dressing of a PICC line for a resident, identified as R165, who was admitted with multiple diagnoses including orthopedic aftercare following surgical amputation, acute osteomyelitis, type 2 diabetes, and cellulitis. The resident's physician orders required a transparent sterile dressing change weekly and as needed, with checks on the IV site every eight hours for signs of infection. However, observations on October 1st and 3rd revealed that the PICC line dressing, dated September 29th, was soiled with bloody drainage, indicating it had not been changed as required. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the dressing should be changed weekly or as needed if soiled. The facility's own IV Care Reference Guide and policy on Central Venous Access Catheter Device: Dressing Change also stipulated that dressings should be changed daily if covered with gauze and not visible. Despite these guidelines, the dressing remained unchanged, leading to a deficiency in the care provided to the resident.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide oxygen supplementation as ordered by the physician for a resident, identified as R42, who was admitted with diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen. The physician's order specified oxygen at 4 liters per minute via nasal cannula continuously. On October 1st, R42 was observed in bed with a nasal cannula connected to an oxygen compressor set to 0 liters, resulting in a blue tongue and shallow respirations. The assigned RN, V6, stated she did not turn off the oxygen supply and was unaware of who did. By October 3rd, the oxygen was set correctly at 4 liters, and R42's condition improved with a pink tongue and regular breathing. The facility's policy allows only RNs, LPNs, or RTs to administer oxygen, while CNAs may only adjust or reapply the nasal cannula or mask.
Inaccurate Record of Receipt for Controlled Medication
Penalty
Summary
The facility failed to maintain an accurate Record of Receipt for a controlled medication for a resident, identified as R324. During an observation of the medication cart, a handwritten note was found in the Controlled Drug Receipt/Record/Disposition Form book, which lacked essential information such as the medication's name, quantity on hand, quantity received, and licensed nurses' signatures. The resident had a box of Morphine Sulfate 30 mL in the locked box on the medication cart, but the narcotic count sheet was incomplete. The Director of Nursing acknowledged the absence of the appropriate narcotic count sheet and emphasized the importance of including the medication name to prevent medication errors. R324 was admitted with diagnoses including palliative care, vascular dementia, atherosclerotic heart disease, atrial fibrillation, and hypertension. The resident had an active order for Morphine Sulfate Solution 20 mg/mL to be administered as needed for moderate pain. The facility's Controlled Drug Documentation Policy requires a proof-of-use form for each controlled medication, which was not properly followed in this instance. The policy also mandates that controlled substances be counted and verified every shift by two licensed nurses, with any discrepancies reported to the Director of Nursing immediately.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement adequate safety measures for a resident at risk for wandering, resulting in the resident eloping from a locked unit and exiting the facility without supervision on two separate occasions. The resident, who was cognitively impaired with diagnoses including moderate vascular dementia and unspecified psychosis, was able to leave the facility unnoticed by staff. On the first occasion, the resident left the facility, walked past a pond and across a thoroughfare, and was found in a movie theater parking lot over an hour later. The facility was unaware of how the resident managed to exit the locked unit. The resident's history showed a pattern of exit-seeking behavior, including standing by the elevator and attempting to board it. Despite being assessed as at risk for elopement, the facility did not effectively monitor or prevent the resident from leaving the premises. On the second occasion, the resident again managed to leave the facility, walking past the receptionist and into the parking lot. The receptionist did not notice the resident leaving and failed to call a code green for resident elopement. The facility's policies and procedures for managing elopement and monitoring residents at risk were not adequately followed or enforced. The resident's care plan and risk assessments were not updated in a timely manner to reflect the resident's exit-seeking behaviors. The lack of supervision and failure to activate door alarms contributed to the resident's ability to elope from the facility, resulting in Immediate Jeopardy being declared.
Removal Plan
- Resident was reassessed for elopement risk after the elopement occurred and deemed an elopement risk. The resident elopement risk assessment was reviewed by Memory Care Director with no changes warranted.
- Resident was located and returned to the facility. A head-to-toe assessment was completed by the assigned nurses, with no signs of injury on either occurrence.
- The Resident care plan was updated pertaining to the elopement that occurred, by the Memory Care Director and further reviewed and updated by the MCD.
- The DON, Administrator, ADON, and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Exit Seeking, and Incidents/Accidents. No changes were made.
- The Memory Care Director and Social Service Director updated the assessments and care plans for elopement risk residents. The assessments were completed.
- The Administrator initiated further education that a resident exhibiting exit seeking behaviors should be placed on enhanced monitoring including 15 minute checks and 1:1 supervision until the behavior subsides or alternate measures are put into place. Staff were educated to alert the nurse of exit seeking behaviors who would then implement increased intervention.
- All residents were reassessed for elopement risk and completed.
- All new admissions will have an elopement risk assessment that will be completed within 24 hours upon admission and interim care plan will be initiated based off the assessment, and will be reassessed every three months, and as needed by MCD.
- All residents that are identified as-risk for elopement during admission had a review of their care plan and updates were made where applicable, completed and further reviewed.
- Pictures of at-risk residents were placed in a binder on all nursing stations and the receptionist desk which was completed and reviewed by MCD.
- All residents determined to be at-risk for elopement and with active exit-seeking behaviors will be evaluated for a possible room change to the secured unit to limit access to the front entrance door.
- Interviews were conducted by the Administrator with staff to determine further potential risk and completed. Additional interviews were initiated and completed to further identify any potential risk factors.
- All staff and managers are being reeducated on routine resident checks, exit seeking, incidents/accidents, elopement policy and procedure and where to locate the at risk of elopement binders. The reeducation was provided and was completed.
- All staff and managers are being reeducated on elopement risk and reporting behaviors or changes in factors related to elopement risk to appropriate discipline. This was started and completed.
- All reception staff were reeducated on monitoring the front doors and resident safety and proper procedure for code green completed.
- Exit doors will be monitored by staff when unalarmed. The receptionist will monitor the front entrance door. Door will be armed by receptionist and monitored by 1st floor nurses through the duration of that time.
- Exterior door alarms will be checked daily by the maintenance director and EVS Supervisor to ensure they are in working order and secured. Completed and checked again.
- After initial elopement resident was placed on 15 minute checks for 24 hours. During that time the facility met with daughter and discussed new interventions. A plan was established and implemented.
- 1:1 Visual monitoring was initiated by staff for the resident. Intervention will remain in place until the facility's wandering management system is installed and determined to be effective to prevent further incident.
- Elevator monitor was initiated. Elevator will remain monitored 24 hours a day until wandering management system is installed and determined to be effective to prevent further incident.
- A review of compliance using Quality Assurance Audit tool for elopement started by the Administrator. The Audits will be done daily for two weeks then twice weekly for four weeks, then monthly, and evaluated at the monthly QAPI meeting to determine compliance. Audits to be completed by members of the IDT team and turned into Administrator who will ensure audits are being completed.
- A review of results of audit regarding elopement and door alarm working condition with the facility's interdisciplinary team started. Audits will be done weekly for four weeks, then monthly, and then randomly by Administrator/designee until goal is attained. Results of these audits will be reviewed at the monthly QAPI to determine compliance.
- Administrator to Audit daily that exterior front door alarm is being activated each day by receptionist prior to leaving.
- A facility wandering management system install was initiated.
- During orientation of new hires, the facility Business Office Manager will educate newly hired staff on elopement and conduct competency quizzes.
- The facility Quality Assurance Team/ IDT including Medical Director, Administrator, Social Services, DON, ADON and facility consultant shall meet at least monthly to review elopement risk residents, trends, patterns and develop and implement action steps as necessary.
- The QA meeting is held monthly, then quarterly and as needed. An emergency QA meeting was held by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from the facility were discussed along with the Removal Plan. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator, DON, ADON, and Social Services.
Failure to Provide Stand-by Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide stand-by assistance to a resident who required assistance to ambulate, resulting in the resident falling and fracturing her nasal bone. The resident, who had a history of falls and was at risk for further incidents, was ambulating in the dining room with a rolling walker when she tripped and fell, striking her nose on the floor. Despite the resident's care plan indicating the need for supervision during ambulation, staff members were not adequately informed or did not adhere to the requirement for stand-by assistance. The resident's medical history included conditions such as hypertension, Alzheimer's disease, atrial fibrillation, type 1 diabetes mellitus, and chronic obstructive pulmonary disease. The care plan, initiated prior to the incident, highlighted the resident's risk for falls and included interventions such as monitoring changes in her ability to navigate the environment and encouraging the use of a wheelchair. However, these interventions were not effectively communicated or implemented by the staff, leading to the resident's fall and subsequent injury. Interviews with staff members revealed a lack of awareness and communication regarding the resident's need for stand-by assistance. Several staff members, including CNAs and memory care aides, were not informed of the requirement to walk alongside the resident during ambulation. The facility's policy on fall management emphasized the need to assess hazards, develop a care plan, and implement appropriate interventions, but these measures were not adequately followed, contributing to the deficiency.
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.
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What surveyors actually found near you
We read the 1,513 citations issued within 25 miles in the last 12 months — including the 15 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 Orland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Barr Orland Park | 2.2 mi | ★★★★★ | 6 | 0 |
| Smith Crossing | 2.7 mi | ★★★★★ | 1 | 0 |
| Victorian Village Hlth & Well | 4.3 mi | ★★★★★ | 1 | 0 |
| Crestwood Terrace | 5.9 mi | ★★★★★ | 3 | 0 |
| Aliya Of Palos Park | 5.9 mi | ★★★★★ | 4 | 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 October 2026) and official state health department websites.