Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Lakeland Rehab & Hcc during CMS and state inspections, most recent first.
A resident with schizophrenia, psychosis, recent delivery, and a court-appointed State Guardian left the facility AMA after insisting on discharge despite staff education. Nursing documented the resident’s departure and an NP was notified, but there was no documentation that the attending physician or the State Guardian was informed at the time of the departure. The guardian later stated she was told after the resident had already left and had not been notified that the resident was discharging.
A resident with schizophrenia, psychosis, postpartum medical issues, and a State Guardian was allowed to leave AMA after insisting on discharge. Staff documented that risks were explained, but the guardian was not contacted before departure, the primary MD was not called, and no meds or prescriptions were provided. The AMA form was signed by the resident and a facility witness, while the guardian later stated she was notified only after the resident had already left and had no way to locate her.
A resident with schizophrenia, psychosis, anxiety, and other medical conditions left AMA after staff explained the risks and documented the departure on an AMA form signed by the resident and an LPN witness. Staff knew the resident had a court-appointed State Guardian but did not notify or involve the guardian before the resident left; the guardian was contacted only afterward and stated she had not been informed of the discharge, did not know where the resident went, and had no way to contact the resident. The facility’s own leadership stated the guardian should have been involved and signed the AMA form.
Improper transfer of dependent resident resulted in left humerus fracture. A resident with CVA-related hemiplegia, impaired balance, and a care plan requiring a mechanical lift for transfers was moved from a reclining wheelchair to bed without following the lift plan. The resident reported that CNAs used a gait belt and manual handling instead of the mechanical lift, causing him to land on his left side and develop immediate shoulder pain. Hospital CT imaging later showed a minimally displaced mildly comminuted fracture of the surgical neck of the left humerus.
Food Storage and Labeling Deficiencies: The facility failed to properly label, date, and store food items in the kitchen, freezer, dry storage, and a nourishment room. Surveyors observed expired carrots and liquid, an unlabeled open gelatin item, broccoli with visible mold-like residue, undated beef with ice buildup, undated cereal, and multiple unlabeled or undated resident food items and thickened water. The Dietary Supervisor and DON acknowledged the items were not stored or labeled correctly and that some items should have been discarded.
The facility failed to have a qualified IP responsible for the infection prevention and control program. The Administrator said an IP nursing consultant provided guidance to the DON because the DON had not completed IP training hours. The DON stated he manages the program despite not having IP training, and the last IP nurse resigned in early May 2026. The consultant said she oversees the program and guides the DON, but she does not work in the facility full-time.
A facility failed to keep resident call lights within reach for four residents reviewed. Surveyors observed call lights on the floor, under the bed, beside the bed, and wrapped around an oxygen flow meter, while staff stated call lights should be kept within reach for safety and the ADON confirmed staff are required to ensure this. The facility policy stated call lights must be placed within resident reach at all times.
Failure to Apply Ordered Splints and Provide Restorative ROM Services: A resident who had been discharged from therapy with a recommendation for restorative ROM said she had not received therapy services for over a month, while three other residents with contractures and significant neurologic diagnoses were observed without ordered splints or hand rolls in place. One resident reported her right-hand splint had not been applied for a while and that restorative programming had not occurred for a long time; staff and therapy leadership confirmed the devices and restorative services were expected to continue as ordered.
A facility failed to label enteral feeding bags with the date and time for 4 residents receiving tube feedings. Surveyors observed multiple unlabeled bags connected to residents’ enteral feeding systems, and an LPN and the ADON stated the bags should be labeled with the date, time, and flow rate per hour per facility policy.
Improper labeling and storage of insulin were found on multiple med carts. An expired insulin vial was left on an LPN cart, and other insulin products had missing resident names, open dates, expiration dates, or initials. Another expired insulin vial remained on a cart after a resident was discharged, and two unopened insulin pens were stored without required labeling and were not refrigerated. The ADON stated expired or unlabeled medication should not be on the carts.
Failure to perform hand hygiene during meal tray pass. A CNA was observed adjusting a resident's wheelchair and then her own eyeglasses before continuing to pass meal trays without sanitizing her hands. The DON stated that touching a resident's wheelchair and staff eyeglasses contaminates the hands and that hand hygiene should be performed before meal tray pass and after touching contaminated surfaces. The facility policy states ABHS should be used immediately prior to touching a resident and after touching a resident or the resident's immediate environment.
Failure to accurately offer and document flu and pneumonia vaccines affected three residents. Records showed vaccine refusals for two residents and one resident who said she wanted the flu shot but had not received it; family members for two residents stated they had never declined vaccines and were never contacted. The residents had significant medical conditions and severe or moderate cognitive impairment, and the DON stated staff would audit vaccine status and document offers for residents and new admissions.
A resident with ESRD, hypertensive heart and kidney disease, chronic systolic HF, and type 2 DM had intact cognition, but review of active orders showed no physician code status order in place. The DON stated every resident should have a code status, and the Social Service Director stated it should be entered upon admission. Facility policy required a code status order in the physician orders in accordance with advance directives on file.
Failure to Provide Shaving and Nail Care: A resident who required partial/moderate assistance with personal hygiene was observed ungroomed with facial hair and long nails, and stated he had been asking CNAs to shave him for weeks without success. A CNA said the resident needed a shave but she did not have time, while the DON stated CNAs are responsible for shaving and nail care during care, twice weekly during showers, and upon request.
A resident with significant skin issues had a prophylactic dressing applied to the left wrist/arm without a corresponding MD order, and the dressing was later found soiled. The WOC nurse said she placed it for protection and drainage, but acknowledged there was no order for that dressing. In a separate issue, staff failed to ensure another resident’s follow-up appointments were scheduled after missed visits related to transportation problems; the resident reported ongoing oral discomfort, and the admin, SW, and appointment scheduler all acknowledged the facility was responsible for arranging transportation and rescheduling appointments.
A resident’s weight was inaccurately documented in the EHR as being in the 170s, even though staff and survey reweighs showed the resident was actually in the 130s, with one scale reading 99.2 pounds and others reading about 132 to 134 pounds. Because the incorrect weight was entered by restorative staff and not reported as a significant change, the resident’s chart showed no significant weight loss, and the DON, RD, and NP relied on the inaccurate data when reviewing the resident’s nutritional status and care.
A resident with chronic respiratory failure, trach, and ventilator dependence was placed on trach collar trials with continuous pulse oximetry and 1:1 sitter orders, but the RT left after initiating the trial and did not return to reassess the resident. Staff later found the resident unresponsive and pulseless, and an RN reported no alarms were sounding. Surveyors also observed multiple pulse oximeters on other residents with blinking displays but no audible alarm, and staff stated they did not know why the monitors were not sounding.
Unsafe food storage temperatures and missing logs were identified after a resident reported clumpy, spoiled milk served on a tray and an LPN removed the milk and notified dietary. Surveyors found refrigerated foods, including milk, deli meats, cheese, and ground beef, held above safe temps, a freezer and refrigerator with inconsistent thermometer readings, several frozen items not fully frozen, and a missing freezer temp log entry. The dietary supervisor stated cold foods should be held at 41 degrees Fahrenheit and that foods above that range can cause residents to become sick.
The deficiency involves multiple failures in safe respiratory care for residents with tracheostomies, including one resident on high-flow O2 via trach collar who was cognitively impaired and required continuous pulse oximetry but was not adequately monitored, later found with a dislodged trach and pronounced dead after staff attempts at reinsertion and CPR. An LPN caring for this resident reported no trach or respiratory training and did not know the ordered O2 settings, while HR records showed required competency evaluations for two LPNs were not completed. Surveyors observed several trach residents without complete bedside reinsertion supplies or functional pulse oximeters, and one nurse misidentified an Airvo high-flow device as a ventilator and found it turned off. Another resident with a trach had multiple missed physician-ordered trach care, inner cannula changes, and suctioning, and was later hospitalized with pneumonitis, leukocytosis, and tracheal cultures consistent with pneumonia and sepsis. The facility also failed to conduct an incident report, investigation, or required State reporting for the trach-related death, despite policies requiring reporting of accidents and deaths with potential injury.
A resident with multiple comorbidities was admitted with intact skin but quickly developed sacral MASD that was documented by nursing staff and care planned for barrier cream, yet no corresponding treatment was recorded on the TAR for an extended period. Physician orders for zinc oxide and a wound consult were not obtained until many days after MASD was first noted, and the wound APN did not assess the resident until more than two weeks after the consult order. By that time, the sacral area had progressed to a large open wound, later confirmed by culture to be infected, and the resident was ultimately hospitalized for sepsis and sacral pressure ulcer evaluation, while a family member reported not being informed of the wound’s development.
The facility failed to ensure that each resident had individual, accessible call lights, resulting in residents in three-bed rooms sharing a single call light string that was sometimes hidden behind furniture and out of reach. Several cognitively intact residents with conditions such as spinal stenosis, COPD, diabetes, chronic kidney disease, dementia, history of falls, and heart failure reported that only two call lights were available for three beds, and that less mobile residents could not readily access the call system and sometimes had to walk to the nurse’s station. Staff, including CNAs, an LPN, and a social worker, were unaware of residents’ mobility limitations and complaints about call light access, while leadership (the DON, maintenance director, and administrator) acknowledged that policy requires every resident to have their own call light within reach at all times.
Two residents experienced multiple fall incidents during Hoyer lift transfers when staff failed to follow the facility’s mechanical lift policy, including required pre‑use checks of slings for rips, tears, or abnormal wear and proper positioning close to the receiving surface. One resident with multiple comorbidities and a left BKA was transferred in cramped room conditions that forced staff to conduct Hoyer transfers in or near the hallway; the lift tilted and struck the resident’s head in one incident and, in another, a sling strap broke, causing a fall and head impact on the lift frame. Another resident was being transferred from bed to wheelchair when a Hoyer sling strap tore while he was suspended above the chair, resulting in a fall documented in a facility investigation as caused by a torn sling harness. Staff interviews also revealed that some Hoyer lifts on the unit did not work properly and that room dimensions did not accommodate safe use of the shower bed with the lift, contributing to unsafe transfer practices.
Two residents did not receive scheduled medications as ordered, and the missed doses were not properly documented. One resident’s MAR showed blank entries for scheduled doses of baclofen and pregabalin, which staff confirmed indicate the medications were not administered, despite facility expectations that missed or refused doses be documented with progress notes and notifications. Another resident’s MAR showed a missing scheduled dose of gabapentin ordered every eight hours for polyneuropathy, with no documented explanation. Staff, including an LPN and the DON, verified that blank MAR boxes represent missed doses, contrary to facility policy requiring medications to be administered per physician orders.
A resident with a tracheostomy on high-flow O2 died after the trach became dislodged, and facility documentation of the event was inaccurate, incomplete, and inconsistent. An LPN noted the resident manipulating trach oxygen tubing but did not document any intervention to prevent dislodgement. Later, an RT documented reinserting the trach, stating the resident had a pulse and labored breathing while CPR was charted as occurring, and 911 times in the notes conflicted with EMS records. Paramedics reported finding the resident pulseless and apneic, with staff attempting trach reinsertion, and noted significant facial and tongue swelling that prevented intubation. The RT gave multiple, changing accounts about swelling and trach reinsertion and admitted omitting key clinical details, while a nurse consultant stated that the LPN had not actually performed CPR despite charting that she had. These discrepancies show the facility failed to maintain accurate, complete medical records for the incident.
A resident with intact cognition and multiple chronic conditions reported that another resident had been verbally abusive for about a year, including repeated racial slurs, derogatory name-calling, false accusations, and offensive gestures at the doorway of the resident’s room. Several staff, including an RN, an LPN, and CNAs, confirmed hearing the abusive language and described the aggressor as having a history of verbally abusive behavior toward multiple residents. The resident became socially isolated, stopped attending activities, and began eating meals in the room to avoid the aggressor. Although staff notified social services and the administrator, the abuse coordinator did not initiate a new investigation or report the repeated allegations to the state agency, assumed they were related to a prior incident, and did not interview the involved residents. The abuse risk assessment and care plan were not updated to reflect the ongoing verbal abuse, and there was no documented protective action such as relocating the aggressor away from the affected resident, despite facility policies requiring immediate reporting, investigation, protection, and documentation of abuse concerns.
The facility failed to follow its abuse policy by not timely reporting an initial verbal abuse incident and by not reporting a subsequent allegation of ongoing verbal abuse between two residents. A cognitively intact resident with multiple comorbidities reported that another cognitively intact resident repeatedly used racial slurs and offensive gestures toward her over an extended period. Staff, including an RN, LPN, and Social Services, were aware of a serious verbal abuse episode that led to the aggressor’s hospital transfer, but the Administrator, serving as abuse coordinator, did not submit the required report to the state agency within the 2‑hour window and instead reported it more than 24 hours later. When a new allegation of continued verbal abuse was reported to the RN and Social Services and brought to the Administrator’s attention, the Administrator assumed it related to the prior incident, did not interview the involved residents, did not submit a new report to the state agency, and the resident was not informed of any investigation or its outcome, contrary to the facility’s Abuse Prevention Program requirements.
Two residents who were dependent on staff for toileting hygiene and bed mobility were left soiled or wet for extended periods after bowel and bladder incontinence. One cognitively intact resident with cauda equina syndrome and osteoarthritis remained in feces for about three hours despite repeated call light activation and staff passing the room without providing care, causing pain, itching, burning, and emotional distress. Another moderately cognitively impaired resident with spinal stenosis, a sacral pressure ulcer, and a gastrostomy remained wet for about two hours after an LPN turned off the call light and left, relying on a returning CNA to finally provide incontinence care. Staff reported working short with only two CNAs for approximately forty residents and noted that a primary CNA had been sent out to a medical appointment, leaving coverage gaps.
Two residents experienced prolonged periods in soiled briefs and delayed incontinence care after using call lights and verbally requesting assistance, while multiple residents and staff reported chronic understaffing of nurses and CNAs. On one unit, a resident who reported a bowel movement waited about three hours before a CNA returned with supplies and provided care, after another CNA had turned off the call light and left without assisting. Another resident who stated she was wet and had been wet a long time remained so for about two hours after an LPN turned off the call light, left to handle an admission, and only verbally relayed the need to an unidentified aide. Staff interviews and schedules showed that units, including a vent unit with many bedbound, total-assist residents, were operating with fewer nurses and CNAs than expected, and that on a prior holiday one nurse was responsible for an entire floor and another nurse covered both a vent unit and an adjacent unit when multiple nurses called off and no replacements were found. Residents consistently reported long waits for help with bowel movements and other ADLs, and staff described ongoing staffing shortages and increased workloads.
The facility failed to ensure proper respiratory care by not maintaining correct oxygen settings, not labeling and storing respiratory equipment appropriately, and providing oxygen without a physician order. One resident on continuous oxygen for COPD and chronic respiratory failure had a nebulizer mask left unlabeled and uncovered at the bedside. Another resident with chronic respiratory failure and heart disease was observed with a nasal cannula in place while the wall oxygen flow meter was turned off, and an undated, unbagged nasal cannula attached to a portable tank was present. A third resident with multiple respiratory diagnoses was found using oxygen via concentrator without any corresponding physician order or care plan. Facility leadership and policies confirmed that oxygen should be administered only with a physician order (except in emergencies), at the prescribed LPM setting, and that nasal cannulas and nebulizer equipment must be dated and stored in clean bags to prevent contamination.
A resident with a history of joint replacement and long-term anticoagulant use did not receive their scheduled blood thinner medication for four days due to delays in pharmacy delivery. Despite available procedures for obtaining missing medications, staff did not ensure the medication was administered as ordered by the physician, as confirmed by documentation and staff interviews.
Failure to update fall care plans after resident falls. Two residents with significant neurologic and mobility impairments had fall risk care plans, but the record did not show new interventions added after their falls. Staff stated that fall interventions should be documented on the care plan, and observations showed floor mats and other fall-related measures in place near the residents' beds.
A resident with a history of vascular disease and prior pulmonary embolism experienced significant leg swelling and pain, but staff failed to promptly schedule diagnostic tests, follow up on abnormal results, and notify the physician of a positive DVT finding. The physician was not informed of the resident's worsening pain or the abnormal duplex scan until several days later, delaying appropriate treatment.
A resident with unilateral leg swelling and pain underwent diagnostic testing that revealed deep venous thrombosis, but staff failed to notify both the physician and the resident's family of the abnormal results. The physician was incorrectly told the test was negative and only discovered the positive result upon personal review, contrary to facility policy requiring prompt notification of changes in condition.
A resident with complex medical needs missed multiple off-site imaging appointments due to the facility’s failure to arrange timely transportation and coordinate with dialysis schedules. Staff cited issues with the facility’s ride-hailing service, last-minute escort cancellations, and lack of communication as contributing factors, resulting in delayed diagnostic care.
A facility failed to report and investigate a sexual abuse allegation after a family member observed a male resident in a female resident's room and reported inappropriate touching. Both residents had severe dementia, and the incident was not documented or reported to authorities as required by facility policy. Staff did not follow up with the reporting family member, and the administrator did not consider the event an abuse allegation.
A resident with an indwelling urinary catheter and complex medical needs did not receive documented catheter care or timely catheter changes as ordered by the physician and required by facility policy. The resident was later hospitalized with a catheter-associated UTI, and staff confirmed that proper catheter care and drainage bag management were not performed or documented.
A resident requiring enhanced barrier precautions for multiple infection risks, including MDRO and C. auris, was placed in a room with another resident who had a history of C. auris and other resistant organisms, but not the same active infections. Staff interviews and facility policy confirmed that residents should be cohorted based on the same organism, which was not followed in this case, resulting in a failure to maintain proper infection control.
A resident with cancer missed two chemotherapy appointments due to the facility's failure to arrange proper transportation and escort services. The resident, who requires a stretcher for transport, was not provided with an escort, leading to a missed appointment. The facility's inaction caused stress and concern for the resident and their family about the progression of the cancer.
The facility failed to provide prescribed wound care and proper pressure ulcer management for several residents. One resident was hospitalized for sepsis due to worsening heel wounds, as heel protectors were not applied as ordered. Additionally, the facility did not date wound care dressings, leading to missed treatments, and set a low air mattress at an incorrect setting for another resident, increasing the risk of pressure ulcers.
A facility failed to conduct a fingerprint-based criminal history check for a CNA, V28, as required by their policy, potentially affecting residents on the 3rd floor Vent Unit. Interviews revealed that V28's work eligibility was 'Not Yet Determined' due to incomplete fingerprinting, and staff were unclear about the process. The facility's policies on abuse prevention and background checks were not followed, allowing V28 to work without verifying her eligibility.
The facility failed to timely implement dietary recommendations for five residents on feeding tubes, as the Clinical Support Nurse missed an email from the dietitian. This resulted in delays of up to 29 days in adjusting tube feeding regimens, potentially affecting residents' health. The facility lacked a specific policy for handling dietary recommendations, relying on the expectation that recommendations would be promptly transcribed and carried out.
A resident, who is cognitively intact, was taken to a dental appointment wearing only a gown, jacket, and hat, despite cold weather. The resident reported feeling embarrassed and humiliated, and the facility's policy on maintaining self-esteem and privacy was not followed. The CNA claimed the resident preferred to wear a gown, but the resident denied this, highlighting a communication failure.
A resident was not administered prescribed antibiotics, vancomycin and metronidazole, upon readmission to the facility, leading to the development of sepsis. The facility's medication records only showed administration of cefepime, and the necessary orders were not transcribed into the system. The oversight was confirmed by the DON and the Clinical Support Nurse, who missed the transcription during a quality assurance audit. The attending physician and consultant pharmacist affirmed the necessity of the antibiotics, and the facility's Administrator failed to recognize the severity of the situation.
Two residents in an LTC facility experienced significant medication errors. One resident developed sepsis after not receiving prescribed antibiotics, while another received an incorrect dosage of micafungin. The errors were not caught during quality assurance audits, indicating a failure in the facility's medication verification process.
The facility failed to ensure agency staff had the necessary competency and training, potentially affecting all 162 residents. An agency RN admitted to working shifts but could not confirm details of their work, including the transcription of critical medication orders. The facility relies on agency staff without a formal procedure for training or competency evaluation, and there was no evidence that the agency RN was aware of or reviewed available resources.
The facility's assessment failed to accurately document staffing needs, particularly for the ventilator unit, and did not identify respiratory therapists as necessary staff. The Director of Respiratory oversees the program, ensuring a staffing ratio of one therapist per 16 airways, but the facility's assessment lacked a detailed staffing breakdown, relying on a general assessment tool without a specific policy.
The facility failed to maintain an effective infection control program, with foley catheter tubing found on the floor for two residents and inadequate tracking of infections. The infection preventionist did not document infections not treated with anti-infective medications, contrary to facility policy. The Director of Nursing and a Registered Nurse Consultant acknowledged these deficiencies, noting incomplete infection control logs and lack of infection mapping.
The facility failed to provide adequate oral care to residents on the ventilator unit, as observed in a resident with secretions on their lips and teeth. Despite claims of care being provided, documentation was lacking, and staff did not follow the facility's oral care policy. The DON and Medical Director acknowledged the risk of infections due to poor oral hygiene.
The facility failed to change a resident's nebulizer tubing weekly as per policy, potentially affecting respiratory care. The resident, who is cognitively impaired and ventilator-dependent, had tubing dated over a week old. This was confirmed by an LPN, and the resident was later diagnosed with a UTI, pneumonia, and sepsis.
The facility failed to respond to call lights in a timely manner, affecting multiple residents who reported waiting up to an hour for assistance, particularly during afternoon and night shifts. Staff interviews confirmed the importance of prompt responses to prevent potential harm, yet ongoing issues were documented in meeting minutes and grievance forms.
Failure to Notify Physician and State Guardian of AMA Departure
Penalty
Summary
The facility failed to notify the resident’s attending physician and court-appointed State Guardian when the resident left the facility against medical advice after a significant psychiatric and medical decompensation. The resident had diagnoses including schizophrenia, gestational hypertension, PTSD, mood disorder due to a known physiological condition with depressive features, psychotic disorder with hallucinations, anxiety disorder, hypomagnesemia, and a history of falling. The clinical record identified a court-appointed State Guardian as the legally authorized representative for healthcare decision-making and care planning. Hospital records described the resident as requiring high-acuity psychiatric and medical stabilization after decompensation of schizophrenia and a recent delivery, with a history of self-harm, physical aggression, and lack of stable housing. The records also stated the resident had active psychosis, attempts at self-harm to terminate her pregnancy, physical aggression toward hospital staff, and a cognitive decline with a Modified Short Blessed Cognitive Test score of 16. The resident required ongoing 24-hour supervision, medication management, therapeutic monitoring, and assistance with activities of daily living. On the day the resident left, nursing documentation stated the resident remained persistent on leaving AMA despite education and encouragement, risks were explained, and the nurse practitioner was notified and gave consent for the AMA request. The resident left the unit ambulatory with personal belongings and no acute distress was noted. However, there was no documentation that the attending physician was informed of the departure to provide medical direction regarding medication management, follow-up treatment, or interventions to reduce interruption of care. There was also no evidence that the State Guardian was informed of the resident’s departure, current status, healthcare needs, or the risks associated with leaving without ongoing psychiatric and medical treatment. The State Guardian later stated she was informed after the resident had already left and that she had not been told the resident was discharging from the nursing home.
Unsafe AMA Discharge Without Guardian Involvement or Medications
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge process for a resident with serious mental illness and multiple medical conditions, including schizophrenia, gestational hypertension, post-traumatic stress syndrome, mood disorder due to known physiological condition with depressive features, psychotic disorder with hallucinations, anxiety disorder, hypomagnesemia, and a history of falling. The resident’s record identified a court-appointed State Guardian as the legally authorized representative responsible for healthcare decision-making and participation in care planning. Hospital records described the resident as requiring a high-acuity psychiatric and medical stabilization environment, with a history of self-harm, physical aggression, unstable housing, active psychosis, and a need for 24-hour supervision and medication management. The resident repeatedly stated a desire to leave against medical advice, and nursing documentation noted that risks of leaving were explained and that the resident continued to refuse treatment and requested discharge. The resident signed an AMA form, with a facility witness signature, and left the unit ambulatory with personal belongings. The LPN stated that the resident insisted on leaving, that the resident was told it was not safe to leave, and that the resident said she was going to a shelter house. The LPN also stated that the State Guardian was not called before the resident left, the primary doctor was not called, and no medications or prescriptions were provided at discharge. The State Guardian stated that the facility informed her after the resident had already left and that she was not told in advance that the resident was discharging. The guardian stated she had not met the resident, did not know where the resident went, and had no way to contact her. The Behavioral Health Director stated that if a resident has a State Guardian and wants to leave AMA, staff would explain that it is not safe to discharge, call the primary doctor and psychiatrist, and call the State Guardian. The psychiatric NP stated that the call she received did not include information about psychosis, suicidality, aggression, delirium, incapacity, guardianship, or unsafe discharge concerns, and she stated that she does not discharge residents. The Assistant Administrator stated that if a resident has a guardian, the State Guardian should sign the AMA form and that the guardian is the decision maker. The resident’s primary doctor stated that if contacted about the resident wanting to leave AMA, the answer would have been no.
Failure to Notify State Guardian of AMA Departure
Penalty
Summary
The facility failed to protect the rights of 1 resident by not notifying and involving the resident’s court-appointed State Guardian when the resident left the facility against medical advice (AMA). The resident had diagnoses including schizophrenia, gestational hypertension, post-traumatic stress syndrome, mood disorder due to known physiological condition with depressive features, psychotic disorder with hallucinations, anxiety disorder, hypomagnesemia, and a history of falling. The clinical record identified a court-appointed State Guardian as the legally authorized representative responsible for healthcare decision-making and participation in care planning. Hospital records described the resident as requiring high-acuity psychiatric and medical stabilization after decompensation of schizophrenia and a recent delivery, with a history of self-harm, physical aggression, and lack of stable housing. The resident was documented as needing 24-hour clinical supervision, medication management, therapeutic monitoring, and assistance with activities of daily living. Progress notes stated the resident remained persistent on leaving AMA, risks were explained, alternatives and the recommended plan of care were discussed, the nurse practitioner was notified, and the resident left the unit ambulatory with personal belongings. The State Guardian stated she was informed 2 days after the resident left and was not informed before the discharge. She reported that the facility contacted the in-house psychiatrist instead of her, that she had not met the resident, did not know where the resident went, and had no way of contacting the resident. The LPN stated she knew the resident had a State Guardian but did not call the guardian when the resident wanted to leave AMA. The Assistant Director of Nursing stated she called the guardian the day after the resident left using the after-hours number and left a message. The Assistant Administrator stated the AMA form should have been signed by the resident, the decision maker, and the facility representative, and that if the resident had a guardian, the State Guardian should have signed the form. The facility policy required staff to give the resident’s legal representatives an explanation concerning the risks involved in leaving the facility.
Improper Transfer of Dependent Resident Resulted in Left Humerus Fracture
Penalty
Summary
The facility failed to perform a dependent resident’s transfer from a reclining wheelchair to bed with a mechanical lift as identified in the resident’s care plan. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, chronic respiratory failure with hypoxia, liver transplant status, kidney transplant status, dependence on renal dialysis, and chronic embolism and thrombosis of deep veins in both lower extremities. The resident’s MDS documented a BIMS score of 14 and indicated the resident was dependent on staff for sit-to-lie and chair/bed-to-chair transfers. The care plan stated the resident required a mechanical lift for transfers due to impaired balance related to CVA. The resident stated that after returning from hemodialysis, two CNAs transferred him into bed without using the mechanical lift. The resident reported that one CNA grabbed the back of his incontinence brief and gown near the neck area, shoved him onto the bed, and then lifted both legs very high, causing his upper body to fall onto the bed and land on his left side, which immediately caused left shoulder pain. The resident also stated that a gait belt was not used during the transfer. The resident’s hemodialysis record showed he returned to the in-facility dialysis center and completed treatment that day. A CNA later stated that she and another CNA were transferring the resident into bed using a mechanical lift when the resident’s arm got stuck behind his body and the other CNA pulled the arm out. The RN stated the incident was reported to her and that she assessed the resident and gave pain medication. The DON stated that when a care plan requires a mechanical lift, two staff members should complete the transfer using the lift, and the OT stated that a gait belt is not considered a mechanical lift and should not be used for residents who cannot move their body or have no balance. The hospital CT report documented a minimally displaced mildly comminuted fracture of the surgical neck of the left humerus.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to label and date opened food stored in the refrigerator and freezer, failed to discard expired food, and failed to store fresh produce in an intact container. On 06/01/26 at 9:37 AM, the walk-in refrigerator contained a pan of carrots with a use-by date of 05/30/26, a container with yellow liquid with a use-by date of 05/28/26, an open container of purple gelatin substance with no open or use-by date, and a box of broccoli with green fuzzy material covering the box. The Dietary Supervisor stated that the expired foods should be discarded, that the residue on the broccoli was not safe and the broccoli should have been discarded, and that all opened items in the refrigerator should have a use-by date on them. On 06/01/26 at 9:50 AM, the walk-in freezer contained brown meat with ice on top and no label or date; the Dietary Supervisor identified it as some type of beef and stated it was not dated or stored properly and needed to be discarded. On 06/01/26 at 9:55 AM, the dry storage room contained a container of dry cereal with no use-by date, and the Dietary Supervisor stated he did not date it because it is good for 6 months. On 06/01/26 at 11:07 AM, the 2nd floor nourishment room refrigerator contained a large black bag with food not contained in a container or dated, a bag of food with no resident label dated 05/11/26, two white foam containers with no resident label or date, and a bottle of thickened water with an open date of 01/21/26 and an expiration date that was not legible. The DON stated that the nourishment room is used to store resident food and that food should be labeled and dated with name, date, and room number so residents do not consume expired food.
Qualified Infection Preventionist Not Designated
Penalty
Summary
The facility failed to have a qualified Infection Preventionist responsible for the infection prevention and control program. The Administrator stated that an Infection Preventionist nursing consultant provided guidance to the DON because the DON had not completed Infection Preventionist training hours. The DON stated that the consultant’s documentation was submitted because she completed the Infection Preventionist training course on 12/12/2020, but also acknowledged that he manages the infection prevention and control program in the facility and does not have Infection Preventionist training. He further stated that the facility’s last Infection Preventionist nurse resigned during the first week of May 2026. The consultant stated that she serves as the Infection Preventionist consultant overseeing the program and providing guidance to the DON, but she does not work in the facility full-time. The facility policy required the designation of one or more qualified Infection Preventionists responsible for the infection prevention and control program.
Call lights not kept within resident reach
Penalty
Summary
The facility failed to place resident call lights within reach according to its policy. Four of four residents reviewed for call lights—R10, R36, R155, and R169—were observed with call lights not accessible. R169’s call light was wrapped around the oxygen flow meter, and R155’s call light was on the floor and not accessible. R36 was observed with the call light on the side of the bed and not within reach, and later the same resident’s call light was observed on the floor under the bed and not accessible. R10’s call light was observed on the floor and not within the resident’s reach. The residents involved had multiple diagnoses, including chronic respiratory failure, encephalopathy, epilepsy, cerebral palsy, acute respiratory failure with hypoxia, hemiplegia, hypotension, type 2 diabetes, chronic systolic CHF, cerebral infarction, bronchitis, Lensox-Gastaut syndrome, adult failure to thrive, and metabolic encephalopathy. Staff interviews stated that call lights should be within residents’ reach for safety and that staff check to make sure they are in reach. The ADON stated staff are required to ensure all resident call lights are within reach and referenced routine monitoring and education, while the facility policy stated call lights are to be placed within resident reach at all times.
Failure to Apply Ordered Splints and Provide Restorative ROM Services
Penalty
Summary
The facility failed to ensure that splints were applied to residents with limited range of motion and contractures, and failed to provide restorative programming for one resident. R11 was observed lying in bed watching television, alert and able to make needs known, and stated she would like restorative therapy daily and had not received therapy services for over a month. Her record showed multiple chronic diagnoses, a BIMS score of 15, and a care plan that included assistance with positioning and turning in bed. Therapy staff stated R11 last received therapy services on 09/13/2025 and was discharged with a recommendation for restorative range-of-motion services to the upper extremities to maintain upper body function. R110 and R137 were both observed in bed with bilateral hand contractures, and neither resident had the ordered hand rolls or splints in place at the time of observation. R110 was nonverbal, had diagnoses including anoxic brain damage and quadriplegia, had a BIMS score of 0, and had a care plan directing staff to apply bilateral hand rolls each morning and remove them each evening. R137 was also nonverbal, had diagnoses including spastic quadriplegic cerebral palsy and neuromuscular dysfunction, had a BIMS score of 3, and had a care plan directing staff to apply splints and braces as ordered. R149, who was alert and able to communicate needs, stated staff had not applied her right-hand splint for a while and that she had not participated in restorative programming for a long time. Her record showed diagnoses including right-sided hemiplegia and cerebral infarction, a BIMS score of 14, and a care plan requiring a resting hand splint to the right upper extremity at night. On a later observation, R149 was again without the right-hand splint, and she stated the splint applied earlier was oversized and came off during her shower. The restorative consultant, restorative aide, and DON stated that restorative services and splint use were expected to continue as ordered, and that splints and hand rolls were intended to prevent worsening contractures and maintain functional positioning.
Unlabeled Enteral Feeding Bags
Penalty
Summary
The facility failed to label enteral feeding bags with the date and time the tube feeding was started, contrary to its policy requiring the bag/container to be labeled with the resident’s name, date, and time. During observations, surveyors found unlabeled tube feeding bags connected to the enteral feeding systems of 4 residents: one resident with chronic respiratory failure, encephalopathy, epilepsy, and cerebral palsy; one resident with acute respiratory failure with hypoxia, hemiplegia, hypotension, type 2 diabetes, and chronic systolic CHF; one resident with cerebral infarction, acute respiratory failure with hypoxia, type 2 diabetes, and bronchitis; and one resident with Lennox-Gastaut syndrome, adult failure to thrive, metabolic encephalopathy, and epilepsy. Surveyors observed that the feeding bag for one resident was not labeled at 11:53 AM, another resident’s bag was not labeled at 12:11 PM and again at 9:52 AM the next day, a third resident’s bag was not labeled at 9:55 AM, and a fourth resident’s bag was not labeled at 9:48 AM. An LPN stated the feeding bags should be labeled and dated to ensure the resident is getting the correct feeding and to prevent the bag from being outdated, and another LPN stated the date and time are needed to know how long the bag has been hanging. The ADON stated feeding bags are required to be labeled with the date, time, and flow per hour, and the facility policy stated open-system enteral feeding bags should be changed every 24 hours and labeled with the name, date, and time.
Improper Labeling and Storage of Insulin
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles, and expired insulin was found stored on medication carts. On observation, an expired Humalog insulin vial belonging to R155 was found on an LPN’s medication cart, and the LPN stated the insulin had expired and should no longer be given. The same cart also contained insulin aspart with no resident name, a multidose injection pen with no expiration date, and another multidose injection pen with no name, date opened, or expiration date. The ADON stated expired medication should be discarded and unlabeled or expired medication should not be on the cart. Additional insulin storage and labeling problems were identified on other medication carts. R1’s expired Humulin was found on another LPN’s cart after the resident had been discharged to the hospital, and the LPN stated it was there due to an oversight. Two insulin injection pens for R211 were found on a different medication cart with no dates and no initials on the labels, and the LPN stated they were unopened. The ADON stated the pens were not refrigerated and there was a risk of expiration because the facility did not know how long they had been outside the safe zone. The facility’s policy stated residents’ medications must be stored under proper temperature conditions, properly labeled, and outdated medication must be immediately removed and returned or disposed of according to procedure.
Failure to Perform Hand Hygiene During Meal Tray Pass
Penalty
Summary
The facility failed to perform hand hygiene during dining after touching contaminated surfaces. On 06/01/26 at 12:23 PM, a CNA was observed adjusting a resident's wheelchair and then adjusting her own eyeglasses, and then continued passing meal trays without performing hand hygiene. At 12:30 PM, the CNA stated that she should have performed hand hygiene after adjusting the resident's wheelchair and her eyeglasses. On 06/03/26 at 1:22 PM, the DON stated that hand hygiene should be done before meal tray pass and after touching contaminated surfaces, and that touching a resident's wheelchair is considered contamination. The DON also stated that if staff touch their eyeglasses, their hands are considered contaminated and the staff member should sanitize their hands before continuing to pass resident meal trays. The facility's Hand Hygiene policy dated 10/2024 states that hand hygiene is to be performed to reduce the potential spread of pathogens and that ABHS should be used immediately prior to touching a resident and after touching a resident or the resident's immediate environment.
Failure to Accurately Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to immunize and accurately document influenza and pneumonia vaccination information for three residents, R110, R137, and R152, out of five residents reviewed for immunizations. The record review showed that each of these residents had immunization reports dated 06/03/2026 documenting refusal of influenza and pneumonia vaccines, with education noted as provided by a nurse on 10/31/2025. However, the medical records did not show that the vaccines were offered again after that date, even though the records also documented that the residents or their families declined all vaccines. R152 was observed on 06/01/2026 after returning from dialysis, alert and responsive, able to make needs known, and denied pain or discomfort. R152 stated that she had requested the influenza vaccine but had not yet received it. Her record showed diagnoses including end-stage renal disease, dependence on renal dialysis, chronic respiratory failure, diabetes mellitus, anemia, hyperlipidemia, morbid obesity, legal blindness, and hypertensive heart and chronic kidney disease. Her MDS dated 03/02/2026 documented a score of 12, indicating moderate cognitive impairment. V15, the dialysis nurse/RN, stated on 06/03/2026 that R152 did consent to receive the influenza vaccine, but that facility staff would administer it and consent should be signed at the time of administration. For R110 and R137, family members stated on 06/04/2026 that they had never declined vaccinations for the residents and wanted them vaccinated to protect them from viruses in the facility. Both family members stated they were never called by anyone from the facility regarding vaccine administration. R110’s record documented diagnoses including anoxic brain damage, chronic respiratory failure, dysphagia, anemia, convulsions, essential hypertension, muscle spasms, quadriplegia, and tachycardia, with an MDS score of 3 indicating severe cognitive impairment. R137’s record documented diagnoses including spastic quadriplegic cerebral palsy, diabetes mellitus, epilepsy, anemia, cortical blindness, chronic respiratory failure, muscle wasting, scoliosis, and dysphagia, with an MDS score of 3 indicating severe cognitive impairment. The DON stated that the nursing team would audit residents who were interested in vaccines and that staff would offer and document vaccines for new admissions and for influenza season.
Missing Advance Directive and Code Status Order
Penalty
Summary
The facility failed to ensure that resident R117 had an advance directive in place. R117 had diagnoses including end stage renal disease, hypertensive heart and kidney disease, chronic systolic heart failure, and type 2 diabetes. R117’s MDS dated [DATE] showed a BIMS score of 15, indicating intact cognition. Review of R117’s active orders on 06/02/26 at 10:38 AM showed no active physician order for code status. The DON stated on 06/03/26 at 1:22 PM that every resident should have a code status and that it tells staff how to care for a resident in an emergency and how to follow the resident’s wishes. The Social Service Director stated on 06/03/26 at 1:55 PM that a resident’s code status should be entered upon admission. The facility policy titled Advance Directives, dated 11/22, states that the Social Service Director and/or designee will assess, care plan, and implement advance directives, and that the resident will have a code status order entered in physician orders in accordance with advance directives on file.
Failure to Provide Shaving and Nail Care
Penalty
Summary
The facility failed to ensure that a resident who depended on staff assistance for ADL care received shaving and nail care. R84 had diagnoses including anxiety, insomnia, muscle weakness, unsteadiness on feet, and adult failure to thrive, and a BIMS score of 11 indicating some cognitive impairment. On 06/1/26, R84 was observed in bed awake and alert, but ungroomed with facial hair, a beard, and long nails. R84 stated that nobody shaves him, that he asks all the time, and that he had not been shaved in weeks despite requesting it from CNAs. On 06/2/26, R84 was again observed in bed awake and alert, still ungroomed with facial hair and long nails, and stated he still had not been shaved and had been asking for it. A CNA stated that residents are shaved upon request and twice weekly during showers, but also stated she had last shaved R84 about a week earlier and that although she was assigned to him on 06/1/26 and 06/2/26 and saw he needed a shave, she did not have time to shave or trim his nails. The DON stated CNAs are responsible for providing shaving and nail care daily during care, twice weekly during showers, and upon request. R84's care plan called for assistance with personal hygiene as needed, and the MDS showed he required partial/moderate assistance with personal hygiene. Facility policies stated that shaving is intended to remove facial hair and improve appearance and morale, that all residents will have clean, well-trimmed nails, and that grooming includes shaving and trimming nails.
Unordered dressing and missed follow-up appointments
Penalty
Summary
The facility failed to obtain a physician’s order for a prophylactic dressing that was applied to a resident with multiple skin conditions and high risk for pressure injury. R124 had diagnoses including pressure ulcer of the left hip, dermatitis, pressure ulcer of unspecified site and stage, persistent vegetative state, and cellulitis of the left upper limb, and was cognitively impaired and nonverbal. During observation, R124 was found in bed with a dry dressing on the left arm/wrist area that was visibly soiled with brown-gray and yellowish discoloration and debris. The wound care nurse stated she had placed the dressing there as a prophylactic measure and for drainage, but acknowledged that there was no physician’s order for the dressing and that residents should have orders for treatment dressings so they can be checked, changed, and kept clean. The record review showed that the active physician orders and TAR contained an order for the right wrist, not the left wrist/arm area that had been dressed at the time of observation. The wound care nurse and DON both acknowledged that the dressing on the left wrist/arm area lacked a corresponding physician’s order. The resident’s wound care plan identified a potential for altered skin integrity related to the left hand, and the resident’s skin assessment documented a left outer wrist area measuring 0.76 cm by 0.83 cm with no depth. The facility policy required identification of skin alterations and implementation of appropriate treatment modalities, and also required that medication orders be documented in the resident’s medical record with the date and signature of the person receiving the order. The facility also failed to ensure that ordered follow-up appointments were scheduled for another resident. R17 was alert, responsive, and able to make needs known, and reported discomfort in the back of the mouth and difficulty attending appointments because transportation was not available, causing late arrivals or missed visits. R17 and staff reported that appointments had been missed or not rescheduled, including dental, cardiology, pulmonology, and primary care appointments. The social worker, administrator, and appointment scheduler each stated that the facility was responsible for arranging transportation to and from appointments, but the administrator said an email from R17 about repeatedly missing appointments had gone to spam and was not reviewed, and the appointment scheduler stated that three appointments still needed to be rescheduled. R17 stated he never said he did not want the dental appointment rescheduled and said he still needed dental evaluation.
Inaccurate Weight Documentation and Failure to Report Significant Weight Loss
Penalty
Summary
The facility failed to accurately document a resident’s weight and failed to follow its weight policy for one resident who had a significant weight loss. The resident’s record listed multiple monthly weights in the 170-pound range, but the resident told surveyors that staff had not been weighing him regularly and that the documented 170-pound weights were not accurate. The resident was cognitively intact and had diagnoses including anoxic brain damage, hypertension, cerebrovascular disease, bipolar disorder, convulsions, anxiety, depression, encephalopathy, cognitive communication deficit, cardiomegaly, and aphasia. On observation and reweighing, the resident’s weight was found to be much lower than the documented weights. Surveyors observed the resident in bed, and he stated staff did not weigh him. The resident was weighed multiple times on different mechanical lift scales, with results including 134.4 pounds, 99.2 pounds, and 132.2 pounds, while the facility’s weight summary showed 172.6 pounds on the most recent documented weight and prior weights in the 173 to 175 pound range. Staff later stated the resident’s actual weight had been in the 130s and that the 172.6-pound entry was a typo, while another staff member acknowledged the large weight loss should have been reported. The facility’s weight policy required residents to be weighed monthly and required reporting any weight loss greater than 5% within one month to nursing supervision, the physician or NP, dietary supervisor, RD, and family or responsible party. The resident’s nutrition assessment documented no significant weight change in the past 1, 3, or 6 months because the charted weights appeared stable in the 170s. Staff interviews showed the nurse, restorative aides, DON, RD, and NP were relying on the inaccurate documented weights, and the NP stated she had not been alarmed because the chart showed consistent 170-pound weights. The RD stated that if she had known the resident was in the 130s, interventions would have been put in place sooner, and the resident’s significant weight loss had not been identified until the inaccurate documentation was discovered.
Failure to Monitor Ventilator-Dependent Resident and Audible Pulse Oximetry Alarms
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who was dependent on mechanical ventilation and had orders for trach collar use during the day as tolerated, ventilator support at night or if unable to tolerate the trach collar trial, continuous pulse oximetry, and 1:1 sitter supervision. The resident’s diagnoses included chronic respiratory failure, dependence on respirator, tracheostomy, heart failure, atrial fibrillation, and essential hypertension, and the MDS documented severely impaired cognition. The resident’s respiratory progress note documented placement on 40% trach collar with oxygen saturation of 94% and no distress noted. Surveyor observations showed that pulse oximetry monitors for multiple residents were not functioning with audible alarms. One LPN observed that a resident’s pulse oximeter was connected but no oxygen saturation was displayed and the monitor was blinking with no sound; the same LPN then found another resident’s monitor had visual blinking but no alarm sounded when the probe was removed. Another LPN observed a resident’s pulse oximeter sensor on the floor with the monitor flashing and no alarm sound, and observed another resident’s monitor not showing oxygen saturation with the audio sound off. The LPN stated she did not know why the monitors were not sounding and that the alarm should sound when oxygen is low or the sensor is removed. The respiratory therapist stated that when the resident was placed on trach collar trials, the resident should have been on continuous pulse oximetry, but he left the room to continue rounds on other residents and did not return to check on the resident. He also stated that he did not communicate with nursing staff when removing the resident from the ventilator and placing the resident on trach collar trials, and that the resident did not have a sitter at the bedside at that time. An RN later found the resident unresponsive and pulseless, and stated that no alarms were sounding when the resident was found. The pulmonologist stated that the resident should have had continuous pulse oximetry while on trach collar and that it was not safe practice to have the resident off the ventilator without monitoring the oxygen saturation and audible alarm. The DON stated that the resident should have had a pulse oximeter on and that if the resident had an active 1:1 order, it should have been followed. The record also showed no care plan found for the resident’s respiratory needs.
Unsafe Food Storage Temperatures and Missing Temperature Logs
Penalty
Summary
The facility failed to ensure food was stored at safe temperatures, failed to maintain required temperature logs, and failed to discard potentially hazardous food stored above safe temperature ranges. During observation and interview, a CNA reported that a carton of milk served on a resident tray appeared clumpy, and an LPN stated the resident reported his milk had curds and lumps in it. The LPN removed the milk from the resident and told other residents to return their milk to staff. The resident stated he had been served milk that was curdy and spoiled for the first time. The dietary supervisor later verified milk temperatures at 48 degrees Fahrenheit and stated that refrigerated food should have an open date and expiration date, that cold foods should be held at 40 degrees Fahrenheit, and that foods held above 41 degrees Fahrenheit can cause residents to become sick. Surveyor observations in the dietary area found a refrigerator cooler thermometer reading 45 degrees Fahrenheit, parmesan cheese with a manufacturer date of 3/10/2026 and a handwritten date of 4/15/2026, deli ham with an expiration date of 4/11/2026, leftover turkey with an expiration date of 4/15/2026 and no use-by date, and five 10-pound packages of ground beef at 49 degrees Fahrenheit. On a later observation, the walk-in freezer internal thermometer read 34 degrees Fahrenheit while the external thermometer read 42 degrees Fahrenheit, the refrigerator measured 38 degrees Fahrenheit while the outside thermometer read 53 degrees Fahrenheit, and the freezer temperature log had no entry for 4/18/2026. Additional food items were observed not frozen, including pork sausage at 23 degrees Fahrenheit, Salisbury patties at 24.3 degrees Fahrenheit, and vegan homestyle chicken tenders at 30.9 degrees Fahrenheit. The dietary supervisor stated the ground beef had been placed in the refrigerator on 4/15/2026 for use by 4/21/2026, that staff sometimes leave the refrigerator open, and that he was not 100% sure at what temperature spoilage begins.
Failure to Provide Safe Tracheostomy Respiratory Care and Monitoring
Penalty
Summary
The deficiency involves multiple failures in providing safe and appropriate respiratory care, particularly for residents with tracheostomies, including one resident who died after a tracheostomy dislodgement. One resident with toxic encephalopathy, respiratory failure with tracheostomy collar, and hemiplegia had a physician order for high-flow O2 at 20 L/min via trach collar and continuous pulse oximetry. On the day of the incident, an LPN observed this resident with oxygen tubing connected to the trach tubing on the resident’s finger but documented no intervention to prevent dislodgement, despite the resident’s impaired cognition and care plan indicating the resident rarely or never understood redirection. Later that afternoon, a respiratory therapist found the trach tube dislodged and attempted reinsertion, while CPR was documented as starting within about a minute of that time and 911 was called shortly thereafter. Paramedic documentation states the crew arrived to find the resident unresponsive, pulseless, and apneic, with staff attempting to reinsert the trach, and noted facial and tongue swelling that prevented intubation; the resident was pronounced dead. The facility did not complete an incident report or investigation for this death and did not report it to the State agency, with the nurse consultant characterizing it as a medical case despite the facility’s own policy requiring reporting of accidents or incidents with injury or potential for injury, including deaths due to accidents. The report also identifies failures in staff competency and training related to tracheostomy and respiratory care. The LPN assigned to the deceased resident stated she did not know the resident’s oxygen requirements, was unfamiliar with ABG and FiO2 changes, and reported receiving no respiratory or trach-specific training at the facility. Human resources records for this LPN and another LPN showed that required nursing skills competency evaluations, including orientation elements such as nursing procedures and multiple specific competencies (e.g., hand hygiene, IV piggyback, PPE, policy review), were not completed; the forms were only signed and dated by the nurses without documented evaluation. The DON confirmed there were no trach care or respiratory care trainings and described onboarding evaluation as a process to identify training needs, but no trach-specific competencies were documented. Staff interviews indicated that RT coverage for trach residents had been reduced, and that nurses, rather than RTs, were responsible for some trach patients, with RTs not performing CPR. Additional deficiencies were found in assessment, monitoring, and equipment readiness for residents with tracheostomies. The facility lacked an initial assessment process specific to trach residents to determine acuity and levels of care, as acknowledged by the DON. For the deceased resident, the care plan and orders required continuous pulse oximetry and oxygen saturation monitoring, yet there was no oxygen saturation documentation on the day of death in the vital sign history, and the MAR showed only a single oxygen saturation entry for that day with no vital signs documented in clinical notes. Observations on the respiratory unit showed multiple residents with trachs lacking required bedside equipment per the facility’s “Reinsertion of Tracheostomy Tube with Accidental Extubation” policy, including missing spare trach tubes, sterile 4x4s, tape, and nonfunctional or disconnected pulse oximeters. Staff acknowledged defective or disconnected pulse oximeters and incomplete supply setups, and in one case a nurse believed an Airvo high-flow device was a ventilator and found it turned off while the resident was ordered to receive high-flow O2. The report further documents failure to follow physician orders for trach care and suctioning for another resident, who was initially admitted without infection and later developed respiratory infection and pneumonia. This resident had orders for trach care, inner cannula changes, and suctioning at specified frequencies, but the treatment administration record showed multiple missed entries for trach care, inner cannula cleaning and changing, and scheduled suctioning across several days. The infection preventionist and a physician stated that trach care, suctioning, and inner cannula changes are intended to clear mucus, maintain airway patency, limit bacterial growth, and reduce infection risk, and that missed care increases the risk of infection. This resident was subsequently sent to the hospital for difficulty breathing and infection, with hospital records noting tachycardia, tachypnea, leukocytosis, chest x-ray with superimposed pneumonitis, and tracheal cultures positive for organisms associated with pneumonia and sepsis. These documented omissions in ordered trach care and suctioning, combined with the lack of respiratory assessments and incomplete documentation, formed part of the cited deficiency. The surveyors determined that these failures constituted an immediate jeopardy beginning when the trach-dependent resident was pronounced dead after being found unresponsive, pulseless, and apneic following trach dislodgement. The facility’s own leadership acknowledged that residents at risk of trach dislodgement should not be left alone and that trach dislodgement can result in low oxygen, confusion, altered mental status, or death, yet there was no trach-specific acuity assessment, no documented respiratory assessments, and incomplete monitoring for the affected residents. The combination of inadequate monitoring, lack of staff competency evaluation and training, failure to maintain functional and complete emergency trach equipment at the bedside, failure to follow physician orders for trach care and suctioning, and failure to report and investigate the death related to trach dislodgement formed the basis of the cited respiratory care deficiency for multiple trach-dependent residents. The nursing home is disputing this citation, but the report documents that eight of eleven reviewed residents with tracheostomies were affected by one or more of these failures, including the resident who died after trach dislodgement, several residents lacking required trach reinsertion equipment or functional monitoring devices, and one resident who developed respiratory infection and pneumonia in the context of missed trach care and suctioning orders. The survey findings are based on interviews with staff and family, review of clinical records, physician orders, hospital records, death certificate, and direct observations of residents and equipment on the respiratory unit.
Failure to Provide Timely MASD Treatment and Wound Management Leading to Infected Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate preventive treatment for sacral moisture-associated skin damage (MASD) and to prevent worsening of a wound for one resident. The resident, an older adult with diagnoses including cerebral infarction, anoxic brain damage, morbid obesity, and diabetes mellitus, was admitted with intact skin and no wounds on 01/13/2026. On 01/14/2026, a wound nurse documented intact skin with MASD on the sacrum, and the care plan dated 01/27/2026 indicated the need for barrier cream to areas exposed to moisture/incontinence. However, the January 2026 treatment administration record (TAR) contained no documentation of any sacral MASD treatment. For eighteen days there were no documented physician orders or TAR entries for MASD treatment. On 01/31/2026, a registered nurse notified the physician of MASD to the sacrum and left buttock, and the physician ordered zinc oxide cream every shift with each incontinent care and a wound care consult. The wound APN did not see the resident until 02/17/2026, seventeen days after the wound consult was ordered. At the first wound APN evaluation, the sacral area had progressed from intact skin to a wound measuring 10 cm by 15 cm by 0.1 cm, and the APN documented that the sacral MASD had worsened. A culture and sensitivity was ordered to rule out localized infection and to refer to an infectious disease specialist. Dakins solution was added as a new treatment on 02/17/2026. The resident was transferred to the hospital on 02/18/2026 with an elevated temperature and an elevated white blood cell count of 18.5, and clinical notes from 02/19/2026 state the resident was admitted for sepsis and sacral region pressure ulcer evaluation. On 02/20/2026, the facility received culture and sensitivity results confirming a positive wound infection. The resident’s family member reported that the facility did not communicate the wound status and that he first learned from the hospital that the resident had a golf ball–size pressure ulcer about a month after admission. Staff interviews indicated that there should have been an earlier order for zinc oxide cream for MASD and that wound staff were expected to address skin concerns as early as possible to prevent wound issues.
Failure to Ensure Individual, Accessible Call Lights for All Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that each resident had access to an individual, functioning call light in their rooms and bathrooms/bathing areas, as required by facility policy. Multiple cognitively intact residents with significant medical conditions, including spinal stenosis, intervertebral disc degeneration, diabetes, COPD, anoxic brain damage, chronic kidney disease, dementia, history of falls, hypertension, and heart failure, reported sharing a single call light string between beds in three-bed rooms. In one room, a single yellow call light string was attached to a wall switch between two beds and was hidden behind a nightstand, requiring residents to kneel and retrieve it to use it. One resident stated they rarely used the call light because they were independent and walked to the nurse’s station, but reported that their roommate, who was less ambulatory and used a cane, could not reach the call light and would like access to it in case of an emergency. Another resident reported that only two call lights were available in their three-bed room, requiring residents in beds B and C to share a call light string, and that the residents in those beds were less mobile and needed access to the call light. Additional observations and interviews showed that residents in other three-bed rooms also shared call lights, and that at least one resident’s call light string was not within reach and the resident was unable to answer surveyor questions. Another resident reported sharing a call light with their roommate and stated that a call light would be useful because they sometimes could not get to the nurse’s station. CNAs, an LPN, and a social worker stated they were not aware that one resident had difficulty moving around the room due to multiple wheelchairs or that the resident had complained about having only one call light. The DON stated that every resident was expected to have their own call light regardless of mobility status, and the maintenance director stated they were not aware that only one yellow string was attached to the call light switch for two residents in three-bed rooms. The administrator confirmed the expectation that call lights be within reach for each resident at all times, consistent with the facility’s written policy requiring call lights to be placed within resident reach at all times.
Failure to Ensure Safe Hoyer Lift Transfers and Equipment Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe mechanical lift transfer procedures and to check lift equipment in accordance with its own policy for residents who required Hoyer lift transfers. For one resident with diabetes mellitus, foot ulcer, anxiety, depression, and a left below-knee amputation, staff used a Hoyer lift in connection with showering and transfers despite room space limitations that prevented the shower bed from fitting inside the room. The resident reported two separate incidents involving the Hoyer lift: during a Christmas transfer from shower to bed, the lift tilted forward and the handle where the sling was attached struck his head, and staff told him he was unconscious for several seconds; in a later incident, again after a shower, the sling strap attached to the lift broke while transferring him from a shower table to a Geri chair, causing him to fall to the floor and be sent to the hospital. Clinical notes documented that the lift fell and hit the resident’s forehead with a brief unresponsiveness, and that on another date the sling strap broke and the resident’s head hit the frame of the lift during transfer from the Hoyer to the bed. Staff interviews and observations further showed that the Hoyer lifts and slings were not consistently maintained or inspected as required. A registered nurse stated that some Hoyer lifts on the unit did not work properly and that their functioning was inconsistent, with one of two lifts on the floor not working at the time of inspection. Measurements taken with the maintenance director showed that the shower table dimensions exceeded the available space at the side of the resident’s bed, leaving insufficient room to maneuver the shower bed into the room, resulting in transfers being performed in or near the hallway and doorway area. A certified nursing assistant who assisted with both incidents stated that the resident, who weighed approximately 385 lbs, was transferred via Hoyer lift from the hallway near the door to the bed, and that the resident fell at the entrance of the room when the sling broke. A second resident reported being dropped when a Hoyer sling tore during a transfer from bed to wheelchair on an upper floor. The resident stated that as staff began to lower him, the lower strap tore free from the sling, causing him to land on the wheelchair and then be lowered to the floor, after which x‑rays were obtained and he was sent to the hospital and later returned to a different floor. The fall investigation for this incident documented that two CNAs were transferring the resident via Hoyer lift when the sling strap ripped and tore apart while the resident was hovering above the wheelchair, with the root cause identified as a torn sling harness. Facility policy for total mechanical lift use required staff to check the sling for rips, tears, or abnormal wear prior to use and to remove any damaged sling from circulation and notify the DON, and also required positioning as close as possible to the receiving surface; however, the repeated incidents of sling tearing and equipment malfunction during transfers showed that these procedures were not followed for the affected residents.
Missed and Undocumented Scheduled Medication Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders and documented appropriately for two residents. Review of one resident’s medication administration record (MAR) for 2/1/2026 to 2/28/2026 showed that scheduled doses of baclofen 5 mg and pregabalin 10 mg, ordered for administration on 2/25/2026 at 2:00 PM, were not documented as given. Two LPNs separately confirmed that an empty box on the electronic MAR at a scheduled date and time indicates the medication was not administered or was refused, and that when a medication is given, the system displays a check mark in the box. Both LPNs verified that the baclofen and pregabalin administration boxes for that resident on 2/25/2026 at 2:00 PM were blank, and one LPN stated that if a medication is not given or is refused, the physician and family should be notified and a progress note entered. For another resident, review of the MAR for 3/1/2026 to 3/31/2026 showed a missing 6:00 AM dose of gabapentin 300 mg on 3/16/2026, ordered as one capsule by mouth every eight hours for polyneuropathy, with an active order date of 1/6/2026. An LPN explained that an empty box on the MAR can also mean the nurse is waiting for the pharmacy to deliver a reordered medication, but no documentation was cited in the report to explain the missed dose. The DON stated that a green check mark with nurse initials appears in the electronic record when a medication is administered, and that a blank box for a scheduled medication indicates a missed dose, which should be investigated and documented in progress notes. The DON verified that the baclofen and pregabalin doses for the first resident on 2/25/2026 at 2:00 PM were missed, and facility policy dated 9/2020 requires drugs to be administered in accordance with written physician orders.
Inaccurate and Conflicting Documentation After Dislodged Tracheostomy and Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation regarding a resident who expired following a dislodged tracheostomy. The resident had toxic encephalopathy, respiratory failure with a tracheostomy collar, and hemiplegia/hemiparesis after a cerebral infarction, and had been admitted with an order for high-flow oxygen at 20 L/min via trach collar after an ICU stay and tracheotomy. On the day of the incident, an LPN documented at 3:30 PM that the resident was observed with oxygen tubing connected to the tracheostomy tubing in his finger, but no interventions were documented to prevent trach dislodgement. Later, the respiratory therapist (RT) documented that at approximately 4:45 PM he reinserted the tracheostomy, that the resident had a pulse and labored breathing, and that CPR was initiated at 4:46 PM, 911 was called at 4:47 PM, and paramedics arrived at 4:55 PM. These facility records conflicted with the paramedic report and with staff interviews. The 911 report documented dispatch at 4:47:24 PM and arrival at 5:52:37 PM, and stated that the crew found the resident unresponsive, pulseless, and apneic, with staff attempting to reinsert a dislodged trach, and that CPR was initiated by the crew upon arrival. The paramedics noted facial and tongue swelling that prevented intubation, and documented multiple rounds of epinephrine with persistent asystole/PEA until resuscitation was terminated in the field; the death certificate listed time of death as 5:31 PM. The DON stated that CPR is to be performed only when there is no pulse, consistent with facility policy and AHA guidelines, yet the RT’s note indicated the resident had a pulse and labored breathing at the same time CPR was documented as being performed. Further inconsistencies arose in staff accounts and documentation of the resident’s condition and the sequence of events. Initially, the RT stated the resident had vital signs after trach reinsertion, denied facial swelling or subcutaneous emphysema, and admitted he did not document vital signs or appearance because he forgot. Later, after being informed of paramedic findings and family-provided photos showing substantial facial and body swelling, the RT changed his statement multiple times, acknowledging swelling, difficulty reinserting the trach, and uncertainty whether the tube was fully inserted. The DON stated that the LPN was the first to know the trach was dislodged, while the RT claimed he was first to see it dislodged. A nurse consultant stated that the LPN did not actually perform CPR despite documentation indicating she had, and remarked that “it is not always true what they chart.” These conflicting notes, omissions, and changing statements demonstrate that the facility failed to accurately and completely document the incident and the resident’s status surrounding the dislodged tracheostomy and subsequent death.
Failure to Protect Resident From Ongoing Verbal Abuse and to Follow Abuse Reporting Policy
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from ongoing verbal abuse by another resident and to follow its abuse prevention and reporting policies. One resident (R1), who had intact cognition with a BIMS score of 15 and multiple medical diagnoses including spinal stenosis, type 2 diabetes, morbid obesity, and chronic pain conditions, reported that another resident (R3) had been verbally abusive for about a year. R1 stated that R3 repeatedly called R1 racial slurs including the n-word, used other derogatory names such as "stupid pedophile," "nasty," and "disgusting," and made false accusations that R1 was misusing the system, not caring for R1’s children, and pretending to be sick to obtain state funding. R1 reported that R3 would wheel to the doorway of R1’s room, sit in front of the door, scream and curse at R1, and make offensive finger gestures. R1 said these behaviors were ongoing and continuous, and that R1 had informed multiple staff members over the course of the year but felt the facility was not doing anything to stop R3’s verbal abuse. Multiple staff interviews corroborated that R3 had a history of verbally abusive behavior, including racial slurs directed at R1 and other residents. An RN (V4) stated that on one occasion in the dining room, R3 rolled up to R1 and called R1 the n-word, which V4 heard, and that V4 reported this to a supervisor. V4 also documented in R1’s progress note on 2/2/2026 that R1 verbalized concerns about another resident making false accusations and continuing to approach R1 despite R1’s discomfort, and V4 reported this to social services and the DON. An LPN (V12) reported hearing R3 call R1 the n-word at the nurse’s station and noted that R1 had become more socially isolated and now ate in the room instead of the dining room. CNAs (V16 and V9) and another resident (R6, a former roommate of R3 with impaired cognition) described R3 as verbally abusive, yelling, cursing, using racial slurs, and calling others names on a daily basis. The Social Services Director (V14) acknowledged that R3 had a history of verbal abuse as part of R3’s diagnosis, that R1 had reported being called the n-word, and that staff had reported R3 sitting in front of R1’s room in a wheelchair. The facility failed to follow its abuse policy and abuse prevention program requirements for reporting, investigating, protecting residents, and care planning. The Administrator (V1), who is the abuse coordinator, stated awareness only of an incident from 10/10/2025 involving racial comments by R3 toward R1, which was reported to the state agency the following day rather than on the day of occurrence, and could not explain the delay. V1 stated that when a nurse raised concerns again on 2/2/2026 about R3 calling R1 racially derogatory names, V1 assumed it referred to the prior incident, did not initiate a new investigation, did not interview R1 or R3 about the new allegations, and did not report the new allegation to the state agency. V14 also admitted speaking with R1 about R3’s name-calling a few weeks before the survey but did not document the conversation in R1’s progress notes. Despite R1’s repeated reports and staff awareness of R3’s ongoing behaviors, there was no documentation of a new investigation, no evidence of protective measures such as relocating R3 away from R1’s room or unit, and no update to R1’s care plan to address the risk or occurrence of verbal abuse. R1’s abuse risk assessment had not been updated since admission, and R1’s care plan contained no focus on verbal abuse or risk for abuse, even though R1 reported feeling safe only in R1’s room, avoiding common areas, no longer attending activities or dining in the dining room, and isolating to avoid contact with R3. The facility’s written policies required immediate reporting of suspected abuse to supervisors or the administrator, timely reporting to the state agency, protection of residents involved in possible abuse incidents, removal from contact of an alleged abuser during investigations, assessment of residents with behaviors that could cause conflict, and documentation and review of residents’ concerns through the grievance process. The abuse policy defined verbal abuse as disparaging or derogatory oral, written, or gestured language and mental abuse as harassment or humiliation that could cause fear or shame. Despite these requirements, the facility did not consistently report or investigate repeated allegations of verbal abuse by R3 toward R1, did not ensure R3 was removed from contact with R1 or relocated to another floor, and did not document or address R1’s expressed concerns and behavioral changes such as social withdrawal and eating in the room. R1 stated that after the October 2025 incident, no one followed up with R1 about what happened or the outcome of any investigation, and that staff responses focused on telling R1 to ignore or avoid R3 rather than implementing protective interventions in accordance with facility policy.
Failure to Timely Report and Investigate Repeated Verbal Abuse Allegations
Penalty
Summary
The facility failed to follow its abuse policy by not timely reporting allegations of verbal abuse to the state agency and by not reporting a subsequent allegation at all for two cognitively intact residents. One resident (R1), with multiple medical conditions including spinal stenosis, type 2 diabetes mellitus, morbid obesity, chronic venous insufficiency with a non‑pressure ulcer, lumbar radiculopathy, and other comorbidities, had a BIMS score of 15 indicating intact cognition. Another resident (R3), with end‑stage renal disease on dialysis, cerebral palsy, chronic kidney disease, sequelae of cerebral infarction, major depressive disorder, PTSD, ADHD, and other diagnoses, also had a BIMS score of 15. R1 reported that R3 had been verbally abusive for almost a year, including calling R1 the n‑word and other racial slurs, and stated that the facility was not preventing this behavior. On 10/10/2025, staff, including an RN (V4) and an LPN (V12), observed or were informed that R3 was verbally aggressive, yelling racial slurs at R1 and others passing R3’s room. The Social Services Director (V14) documented in R3’s progress note that R3 was being verbally abusive and making racial slurs toward another resident and completed a petition for involuntary/judicial admission citing increased agitation, aggression, and racial comments. R3 was sent to the hospital and returned the same day. The Administrator (V1), who is the facility’s abuse coordinator, acknowledged that the incident occurred on 10/10/2025 but reported it to the state agency on 10/11/2025 at 9:09 PM, more than 24 hours after the occurrence, despite the facility’s Abuse Prevention Program requiring that reports of suspected abuse be filed no later than 2 hours from suspicion. The facility’s incident report to the state agency characterized the event as R3 being verbally impolite to R1. V1 stated being unsure why the report was not submitted on the date of the incident. On 2/2/2026, R1 again reported ongoing verbal abuse by R3 to the RN (V4), including continued use of the n‑word, racial name‑calling, and offensive gestures while R3 sat in front of R1’s room. V4 documented R1’s concerns in R1’s progress note and reported them to Social Services and the Director of Nursing, and also went to the Administrator’s office to notify V1. V4 stated that V1 responded that V1 was aware of the issues and was already investigating. V14 reported that about a week before the survey (on or around 2/2/2026), a staff nurse informed V14 that R1 said R3 was verbally abusing R1 again; V14 spoke with R1 but was unsure if this was reported to V1 and had no documentation of this interaction. V1 acknowledged that a nurse spoke with V1 about R3 calling R1 racially derogatory names but assumed the nurse was referring to the prior October incident, did not speak with R1 or R3 about the new allegation, and did not report the new allegation to the state agency. R1 stated that no one followed up after the October incident, that R1 was not informed of any investigation conclusions, and that R1 did not deny the October incident occurred. Review of state reportables from 10/1/2025 to 2/10/2026 showed only the single verbal abuse report from October, confirming that the February allegation was never reported, contrary to the facility’s Abuse Prevention Program requirements for immediate reporting, documentation, and resident notification. The facility’s Abuse Prevention Program (for Illinois facilities) specifies that employees must immediately report any observed, heard about, or suspected incident to a supervisor or the Administrator, that an initial report of an accusation should be completed immediately, and that a written report must be sent to the state agency no later than 2 hours from suspicion. It also requires that the Administrator inform the resident that a report has been made and that an investigation has started, and later notify the resident of the conclusion of the investigation. In this case, the October 10 verbal abuse incident involving racial slurs was not reported to the state agency within the required 2‑hour timeframe, and the subsequent February allegation of ongoing verbal abuse was not reported at all. Additionally, R1 reported not being informed about the investigation or its conclusion and not being asked if R1 felt safe, despite the policy requiring resident notification and follow‑up. These actions and inactions by the Administrator and other staff led to the identified deficiency in timely reporting and handling of abuse allegations.
Failure to Provide Timely Incontinence and ADL Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely ADL and incontinence care to residents who were dependent on staff assistance. One resident with diagnoses including lack of coordination, cauda equina syndrome, osteoarthritis, and major depressive disorder was cognitively intact and care planned as dependent for toileting hygiene and bed mobility. On the morning in question, this resident reported having a bowel movement after breakfast and stated they had just turned on the call light. A strong fecal odor was noted in the room. Despite the call light sounding, the assigned LPN remained at the medication cart nearby and a CNA walked past the room multiple times over a 14‑minute period without entering. The resident’s assigned CNA had been sent out of the facility around 8:30 a.m. to accompany another resident to a medical appointment, and coverage was to be provided by other CNAs on the unit. At 10:00 a.m., a covering CNA entered the resident’s room only to turn off the call light and then left without providing care. When the surveyor re-entered the room at 10:15 a.m., the resident was crying and reported that the CNA had said they were busy and would return in a few minutes, which did not occur. Continuous surveillance from 9:00 a.m. to 11:50 a.m. showed that the CNA did not return. The resident reactivated the call light at 11:45 a.m., and another CNA responded at 11:50 a.m., returning with supplies and initiating incontinence care around noon, resulting in the resident remaining soiled with feces for approximately three hours while reporting itching, burning, pain, humiliation, and feeling “like a dog” lying in feces. A second resident, with medical conditions including spinal stenosis, weakness, a gastrostomy, a sacral pressure ulcer, and polyosteoarthritis, was moderately cognitively impaired and care planned as dependent for toileting hygiene and bed mobility. During the same surveillance period, this resident was heard calling out for help and reported being wet for a long time. The surveyor activated the call light, which the LPN answered by entering the room, turning off the call light, and then leaving to return to the nursing station. The LPN later stated that the resident needed to be cleaned up and that she had told one of the aides but did not recall which one, noting she was occupied with an admission. The resident remained wet until a CNA who had been out on a medical escort returned to the unit and, at the surveyor’s request, provided incontinence care, resulting in the resident being left wet for approximately two hours. Staff interviews referenced ongoing staffing issues and working short, with only two CNAs on the floor for about forty residents and the reassignment of a primary CNA to an outside appointment.
Prolonged Incontinence and Delayed ADL Care Due to Insufficient Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ ADL and incontinence care needs in a timely manner, resulting in prolonged periods in soiled briefs and unmet requests for assistance. On multiple occasions, residents and family members reported that staffing was inadequate and that residents waited a long time, sometimes hours, for incontinence care. One family member stated that on a holiday evening there was only one nurse covering approximately fifty residents on a floor after another nurse called off, and that there had been several times when the resident’s under brief was entirely wet and soiled with feces stuck to her body. This family member reported that staffing issues were ongoing and ultimately moved the resident to another facility. On one survey day, a resident on the third floor was observed with a strong fecal odor in the room shortly after activating the call light and reporting a bowel movement after breakfast. The resident stated that staffing was terrible and that he often waited a long time, sometimes hours, to be changed and cleaned up. The surveyor observed that a CNA entered the room, turned off the call light, exited without providing care, and the resident turned the call light back on. Surveillance of the room from 9:00 AM to 11:50 AM showed that incontinence care was not initiated until approximately 11:50 AM, meaning the resident remained soiled with feces for about three hours. The CNA later stated she had told the resident she would return but forgot because she was very busy with her assigned residents and that there were only two CNAs on the floor for approximately forty or more residents. Another resident was heard yelling for help, stating she was wet and had been wet for a long time. The surveyor turned on the call light, and an LPN entered, turned off the light, left the room, and returned to the nursing station. When asked later, the resident reported she was still wet and that the staff member had said she would be back. The LPN stated the resident needed to be cleaned up and that she had told one of the aides but could not recall which one, explaining she had an admission coming and needed to get report, and that staffing had been an issue for a while. The resident did not receive incontinence care until a CNA who had been off the unit escorting another resident to a medical appointment returned and was asked by the surveyor to provide care, resulting in the resident remaining wet for about two hours. Staff interviews and staffing records showed that on the day of survey the vent unit had only one nurse and two CNAs instead of the expected two nurses and three CNAs, and CNAs reported that most residents on that unit were bedbound and total assist, making it difficult to care for everyone properly when short staffed. Residents on the third floor and other units reported that there were not enough CNAs or nurses, that they had to wait a long time for assistance, and that short staffing was common, especially on weekends and holidays. The nurse scheduler described expected staffing levels for each floor and shift and confirmed that on a prior holiday three nurses had called off and replacements could not be found, resulting in only one nurse on the second floor for a 7:00 AM–7:00 PM shift and one nurse covering both the vent unit and the west unit for part of a shift. A nurse who worked that day stated she was the only nurse on the second floor, that there were normally two nurses, that she notified the former DON, and that she resigned shortly afterward due to unsafe staffing. The administrator acknowledged being notified of nurse call-offs on the holiday and stated that attempts to contact the DON, ADONs, staff nurses, and an agency did not result in additional coverage, and that staff worked short that day. The acting DON, who assumed the role after these events, stated that residents should not wait three hours for assistance, that the second floor should have two nurses, and that the vent unit and west unit each needed their own nurse to provide adequate care. Multiple staff members and residents reported ongoing staffing issues, including insufficient CNAs and nurses, increased workloads, delayed response to call lights, and delays in changing residents after bowel movements. The facility did not have a staffing policy, despite a facility assessment statement indicating that extra and relief staffing would be provided by sister facilities and corporate employees, and federal regulations require sufficient nursing staff with appropriate competencies and skill sets to meet residents’ needs on a 24-hour basis.
Failure to Ensure Proper Oxygen Orders, Settings, and Equipment Handling
Penalty
Summary
The deficiency involves failures in providing safe and appropriate respiratory care, including incorrect oxygen settings, unlabeled and improperly stored respiratory equipment, and use of oxygen without a physician order. One resident with COPD, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and pulmonary hypertension had care plan interventions directing staff to administer oxygen as ordered. The physician order allowed oxygen via nasal cannula at 1–5 L/min continuous. During observation, this resident was on 3 L/min via nasal cannula with the wall flow meter set at 3 L/min, and the nebulizer mask was found lying on a bedside table, unlabeled and not stored in a bag. Another resident with primary pulmonary hypertension, acute and chronic respiratory failure with hypoxia, and chronic systolic congestive heart failure had a care plan indicating PRN oxygen therapy related to chronic respiratory failure and interventions to administer oxygen per MD orders. This resident was observed in bed with a nasal cannula in place while the wall oxygen flow meter was turned off. An oxygen tank with a nasal cannula attached was on the wheelchair, undated and without a storage bag. The resident reported using oxygen sometimes as needed and stated the prescribed amount was 2 L, but when the surveyor checked, the flow meter was set at zero and the resident reported not feeling any oxygen until the nurse turned the flow meter to 2 L. A third resident with diagnoses including pleural effusion, chronic pulmonary edema, pneumonia, acute metabolic acidosis, and acute and chronic respiratory failure with hypoxia was admitted without any physician order for oxygen in the electronic medical record and without a care plan addressing oxygen use. Despite this, the resident’s oxygen concentrator was observed running at 1 L/min via nasal cannula, and the resident stated they had been using oxygen since admission. The acting DON/nurse consultant stated that there should be a physician order and care plan for oxygen, that oxygen should only be given without an order in an emergency, and that nasal cannulas and nebulizer masks should be stored in clean bags and dated when changed, consistent with facility policies on oxygen therapy and equipment storage and change schedules.
Failure to Administer Prescribed Anticoagulant Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of joint replacement surgery, use of an artificial hip joint, polyosteoarthritis, and long-term anticoagulant therapy did not receive their prescribed blood thinner medication, Rivaroxaban, for four days. The resident, who was cognitively intact, reported missing the medication and expressed concern about the risk of blood clots. Documentation in the Medication Administration Report confirmed that the medication was not administered on four specific days, with notes indicating the facility was waiting for pharmacy delivery. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, revealed that procedures existed for obtaining medications not immediately available, such as retrieving them from a medication dispensing machine or requesting a rush delivery. Despite these procedures, the resident's medication was not provided as ordered by the physician, and the facility's policies require medications to be administered according to physician orders. The failure to ensure timely administration of the blood thinner directly affected the resident.
Failure to Update Fall Care Plans After Resident Falls
Penalty
Summary
The facility failed to update fall-related interventions on the care plans of two residents, R8 and R9, after their falls. R8 was admitted with Parkinsonism, Huntington's disease, muscle spasms, a history of falling, obstructive sleep apnea, unspecified head injury sequela, and dysarthria/anarthria. R8's quarterly MDS showed a BIMS score of 14, impairments to both upper and lower extremities, and dependence in all ADLs except upper body dressing. R8's fall care plan dated 9/24/2025 identified mobility, coordination, and gait deficits related to Huntington's disease, but the record did not show any interventions added after R8's fall on 10/9/2025. Staff stated that R8 had fallen repeatedly since that fall. R9 was admitted with hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, abnormal gait and mobility, encephalopathy, unspecified convulsions, and chronic embolism and thrombosis of unspecified deep veins or lower extremity. R9's quarterly MDS indicated R9 was rarely understood. R9's fall care plan dated 9/24/2025 identified R9 as at risk for falls, but the record did not show any interventions within 24 hours after R9's fall on 10/5/2025. During observations, floor mats were seen on both sides of R8's bed and near R9's bed, and staff stated that fall interventions should be added to care plans after falls. The facility's Management of Falls policy required revising the plan of care to minimize fall incidents and injuries, and the Care Planning policy required the plan of care to be changed and updated as care changes.
Failure to Timely Communicate and Act on Diagnostic Results for DVT
Penalty
Summary
The facility failed to follow its own policies and procedures regarding timely diagnostic testing, follow-up on diagnostic results, and physician notification for a resident experiencing a change in condition. The resident, who had a history of obesity, cellulitis, peripheral vascular disease, and prior pulmonary embolism, presented with unilateral leg swelling, warmth, and increased pain. Despite these symptoms, there was a delay in scheduling and performing the ordered venous and arterial doppler studies, with the tests being conducted three days after the initial order. After the diagnostic tests were completed, the results of the venous duplex scan, which confirmed deep vein thrombosis (DVT), were not promptly communicated to the physician. The physician was not notified of the abnormal findings or the resident's escalating pain, which increased to a rating of 8/10. The physician only became aware of the positive DVT result during a subsequent visit, seven days after the initial symptoms were noted, and initiated appropriate anticoagulant therapy at that time. Interviews with facility staff revealed that required documentation, such as the SBAR communication form, was missing for the period in question, and there was no record of the change in condition being communicated via the facility's established communication systems. Staff acknowledged that the expected process for reporting and following up on diagnostic results was not followed, and the physician confirmed that he was not informed of the abnormal results or the resident's increased pain until several days later.
Failure to Notify Physician and Family of Abnormal Diagnostic Results
Penalty
Summary
The facility failed to follow its policy and procedures regarding notification of a change in condition for a resident who developed unilateral leg swelling, pain, and abnormal diagnostic test results. Despite the resident's symptoms and subsequent orders for venous and arterial doppler studies, the facility did not notify the resident's emergency contacts or family about the change in condition or the abnormal findings. Documentation shows that family notification was excluded at multiple points, even though the facility's policy requires notifying the responsible party of all changes in condition. Additionally, the facility failed to accurately communicate abnormal diagnostic results to the physician. The physician was incorrectly informed that the venous doppler was negative for clots, when in fact it was positive for deep venous thrombosis. The physician only became aware of the true results upon personal review of the report days later. Staff interviews confirmed that abnormal results should be reported to providers, especially when positive, but this did not occur in this case.
Failure to Arrange Timely Transportation for Medically Necessary Appointments
Penalty
Summary
The facility failed to provide appropriate transportation arrangements for a resident requiring a CT scan, resulting in multiple missed appointments and a delay in treatment. The resident, who has a complex medical history including traumatic brain injuries and end stage renal disease requiring dialysis, was dependent on the facility to coordinate transportation due to her use of a wheelchair. Documentation and staff interviews revealed that the transportation coordinator encountered issues with the facility’s ride-hailing service card, which was unavailable for a period, necessitating reliance on insurance-based transportation that required advance notice. Additionally, there were scheduling conflicts with the resident’s dialysis treatments, and a lack of available escorts further contributed to missed appointments. Staff interviews indicated that the transportation coordinator was not always aware of all scheduled appointments and did not consistently arrange transportation in advance. On one occasion, an escort canceled last minute, and the appointment was not rescheduled in a timely manner. There was also confusion and lack of communication among staff regarding the resident’s appointment times and the ability to adjust dialysis schedules to accommodate external medical appointments. The resident missed several appointments due to these coordination failures, including one where transportation was not set up and another where the dialysis schedule could not be changed. Facility records and staff statements confirmed that the resident’s appointments for necessary imaging studies were repeatedly missed or rescheduled due to transportation and scheduling issues. The facility’s own policy stated that it would assist residents in arranging transportation as needed, but this was not consistently followed. As a result, the resident experienced delays in receiving diagnostic imaging required for ongoing neurosurgical care.
Failure to Report and Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of sexual abuse involving a resident with severe cognitive impairment. A family member observed a male resident in a female resident's room and reported witnessing inappropriate touching of the female resident's inner thigh. The family member immediately notified staff at the nurse's station, but no one followed up with her for further details about her observation. The nurse who responded to the report did not observe any distress or inappropriate behavior and did not document the incident, only redirecting the male resident due to wandering. The social services director and administrator were made aware of the allegation through internal communication, not directly from the family member. Both residents involved had diagnoses of dementia and were severely cognitively impaired according to their most recent BIMS scores. The female resident was unable to recall the incident, and the male resident denied any inappropriate behavior. Despite the facility's policy requiring immediate reporting and investigation of abuse allegations, no report was made to the state agency, and the incident was not documented in the facility's reported incidents log. Interviews with staff and review of records revealed that the facility did not consider the event an abuse allegation and therefore did not initiate the required reporting or investigation procedures. The administrator stated that he did not believe anything inappropriate occurred based on his interviews and the information provided by staff. The facility's failure to report and investigate the allegation was contrary to its own abuse policy, which mandates prompt reporting and investigation of all abuse allegations, including those not witnessed by staff.
Failure to Provide Ordered Catheter Care and Timely Drainage Bag Emptying
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including anoxic brain damage, quadriplegia, chronic respiratory failure, and an indwelling urinary catheter, did not receive appropriate catheter care as ordered by the physician and outlined in the facility's protocol. The resident's physician orders specified that the catheter should be changed monthly and that daily catheter care should be provided. However, a review of the treatment administration record for a three-month period showed no documentation that catheter changes or daily catheter care were performed. The resident was observed with a urinary catheter and a drainage bag containing 1100 milliliters of urine, and staff interviews confirmed that catheter care and timely emptying of the drainage bag are necessary to prevent complications. Further, the resident was admitted to the hospital with a diagnosis of catheter-associated urinary tract infection (CAUTI) during the review period. Staff interviews revealed that failure to provide catheter care and timely emptying of the drainage bag could lead to urinary tract infections. The facility's policy requires daily catheter care and emptying of drainage bags at least once per shift, but there was no evidence that these procedures were followed for this resident, as confirmed by both record review and staff statements.
Failure to Cohort Residents with Infectious Risks According to Policy
Penalty
Summary
The facility failed to prevent the risk of communicable disease transmission by inappropriately cohorting a resident with multiple infection risks, including a multidrug-resistant organism (MDRO) and Candida auris (C. auris), in a room with another resident who did not have the same infectious agents. Observations and staff interviews confirmed that a resident requiring enhanced barrier precautions (EBP) due to tube feeding, tracheostomy, indwelling catheter, ventilator, wounds, and a history of MDRO was placed in a room with another resident who had a history of C. auris and other resistant organisms, but not the same active infections. Facility policy and CDC guidance require cohorting residents with the same organism to prevent cross-transmission, which was not followed in this instance. Staff interviews revealed that the standard practice is to cohort residents based on the specific organism and mechanism of transfer, and to avoid rooming residents with different infectious agents together. Despite this, the resident with multiple infection risks was placed in a room with another resident with a history of C. auris due to a lack of available rooms with piped-in oxygen. Both residents were on ventilators and under EBP, but the facility's actions did not align with their own infection prevention and control policy or CDC recommendations, resulting in a failure to maintain appropriate infection control practices.
Failure to Ensure Resident's Chemotherapy Appointments
Penalty
Summary
The facility failed to ensure that a resident diagnosed with cancer received two scheduled chemotherapy treatments, leading to stress and worry for the resident about the potential progression of their cancer. The resident, who is cognitively intact and has a diagnosis of malignant neoplasm of the lung, quadriplegia, and other conditions, missed the first chemotherapy appointment due to a failure in setting up transportation. The second missed appointment occurred because the resident was picked up too early and, without an escort, had to be returned to the facility. The transportation personnel indicated that the first appointment did not appear on their report due to a missing end date in the order, and the second appointment required an escort due to the resident's need for a stretcher. The resident expressed concern about the missed appointments, emphasizing the importance of consistent chemotherapy treatments every six weeks. The resident's family also voiced concerns about the facility's passive approach to rescheduling these critical appointments. The facility's policy states that it will assist residents in arranging transportation as needed, but in this case, the policy was not effectively implemented, resulting in the resident missing essential cancer treatments. The surveyor's findings highlight the facility's failure to coordinate and ensure the resident's access to necessary medical care.
Deficiencies in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to provide prescribed wound care as ordered by the physician for several residents, leading to significant deficiencies in pressure ulcer management. For instance, the facility did not date wound care dressings, which is against standard practice, and there was no policy in place to justify this omission. This lack of documentation led to missed wound care treatments for residents, as evidenced by the Treatment Administration Records (TAR) showing missing signatures for wound care on specific dates. The absence of proper documentation and adherence to physician orders resulted in the worsening of wounds and increased risk of infection. One resident, identified as R1, suffered from multiple pressure ulcers, including on the sacral region and both heels. The facility failed to apply heel protectors as ordered, and the resident was observed lying flat without any pressure-relieving devices in place. This oversight contributed to the deterioration of R1's heel wound, ultimately leading to hospitalization for sepsis. The facility's failure to follow wound care protocols and physician orders, such as offloading heels and documenting wound assessments, directly impacted the resident's health. Additionally, the facility did not set the low air mattress at the appropriate setting for another resident, R10, whose mattress was set at a weight significantly higher than the resident's actual weight. This improper setting could lead to the mattress being too firm, thereby increasing the risk of pressure ulcers. The facility's lack of adherence to proper wound care protocols and equipment settings highlights significant deficiencies in their pressure ulcer prevention and treatment practices.
Failure to Conduct Fingerprint-Based Background Check for CNA
Penalty
Summary
The facility failed to adhere to its policy of conducting a fingerprint-based criminal history records check for a Certified Nursing Assistant (CNA), identified as V28, which is a crucial step in preventing abuse at the facility. This oversight was discovered during an interview and record review, revealing that V28's work eligibility was marked as 'Not Yet Determined' due to the absence of a completed fingerprinting process. The CNA was assigned to the 3rd floor Vent Unit, which had a daily census of 33 residents, potentially affecting all residents on that floor. Interviews with various staff members, including the Business Office Manager/HR Manager (V24), the Administrator/Abuse Coordinator (V1), and the Senior Business Office Manager (V27), highlighted a lack of clarity and communication regarding the fingerprinting process. V24 admitted that V28's work eligibility was not determined because the fingerprinting had not been completed, and V1 was unaware of the 'Not Yet Determined' status. V27 confirmed that the absence of a 'FEE_APP' in the IDPH portal indicated that V28 had not been fingerprinted, and thus, her eligibility to work at the facility was uncertain. The facility's policies, including the abuse prevention program and the fingerprint-based criminal history records check, were not followed as required. The policy mandates that all new hires undergo a background check and fingerprinting to ensure they do not have a history of abuse, neglect, or other criminal activities. Despite these policies, V28 was hired and allowed to work without completing the necessary fingerprinting process, which is a critical step in safeguarding residents from potential abuse.
Delayed Implementation of Dietary Recommendations for Tube Feeding
Penalty
Summary
The facility failed to ensure that dietary recommendations for residents on feeding tubes were ordered and carried out in a timely manner for five residents. The dietitian, identified as V8, made specific recommendations for adjustments to the tube feeding regimens of these residents, which were documented in the General Notes Report. These recommendations included changes in the type of formula, infusion rates, and water flushes. However, these recommendations were not promptly converted into orders by the Clinical Support Nurse, V22, leading to delays in implementation. The Director of Nursing, V2, and the Clinical Support Nurse, V22, acknowledged the process for handling dietary recommendations. V22 was responsible for reviewing the dietitian's recommendations and writing the corresponding orders within 24 hours. However, an email containing these recommendations, sent on January 16, 2025, was missed by V22, resulting in a delay of up to 29 days for some residents before the orders were placed. This oversight affected residents with various medical conditions, including diabetes, dysphagia, and those requiring dialysis, potentially impacting their nutritional status and health. The facility did not have a specific policy for handling dietary recommendations, but the expectation was that once a recommendation was agreed upon by the physician, it should be transcribed and carried out. The delay in implementing these recommendations was acknowledged by V22 and V2, who admitted that the oversight could lead to potential weight loss and other health issues for the affected residents. The deficiency was identified during a survey, highlighting the need for timely and accurate processing of dietary recommendations to ensure quality care for residents.
Resident Not Properly Dressed for Appointment
Penalty
Summary
The facility failed to ensure that a resident, who is cognitively intact with a BIMS score of 15, was properly dressed for a dental appointment outside the facility. The resident, who has medical conditions including hemiplegia, hemiparesis, and cognitive communication deficit, reported being taken to the appointment wearing only a gown, a jacket, and a hat, despite the cold weather. The resident expressed feelings of embarrassment and humiliation, stating that the staff did not know about the appointment until the last minute, which led to the inadequate preparation. The transportation personnel reported that the resident's CNA claimed the resident did not want to get dressed and preferred to wear a gown. However, the resident refuted this, stating he would never choose to wear a gown outside the facility. The incident was further corroborated by the resident's sister, who was upset upon seeing the resident at the appointment. The facility's policy on dressing and grooming emphasizes maintaining the resident's self-esteem, privacy, and confidentiality, which was not upheld in this instance.
Failure to Administer Prescribed Antibiotics Leads to Resident's Sepsis
Penalty
Summary
The facility failed to ensure a resident, identified as R1, was free from neglect by not administering necessary antibiotics to treat R1's infections. R1 was discharged from the hospital with instructions to continue antibiotics, including vancomycin, metronidazole, and cefepime. However, the facility's medication administration records showed that R1 only received cefepime, and there was no documentation of vancomycin or metronidazole being administered. The orders for these antibiotics were not transcribed into the facility's physician orders, and the Director of Nursing confirmed the oversight. The Consultant Pharmacist and the attending physician both affirmed that the antibiotics were necessary to treat the bacteria identified in R1's cultures. The lack of administration of vancomycin and metronidazole contributed to R1 developing sepsis, as confirmed by the attending physician. The Clinical Support Nurse, responsible for quality assurance audits, admitted to missing the transcription of the antibiotic orders into R1's medical record. The facility's Administrator, who is also the abuse prevention coordinator, was unable to provide a clear definition of neglect and did not recognize sepsis as a life-threatening condition. The Agency Registered Nurse, who was responsible for transcribing the orders, could not provide a consistent explanation for the missing orders. The facility's policy affirms the right of residents to be free from neglect, which includes the failure to provide necessary medical services, as occurred in this case.
Significant Medication Errors Lead to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, which contributed to a resident developing sepsis and requiring hospitalization. The first resident, R1, was discharged from the hospital with instructions to continue antibiotics, including vancomycin, metronidazole, and cefepime. However, the facility's medication administration records showed that R1 only received cefepime, and there was no documentation of vancomycin or metronidazole being administered. The Director of Nursing confirmed that these medications were not transcribed into the facility's records, and the consultant pharmacist verified that the pharmacy was not made aware of the orders for vancomycin and metronidazole. The attending physician confirmed that the lack of these antibiotics could have contributed to R1 developing sepsis. Another resident, R3, was affected by a medication error involving the incorrect dosage of micafungin. R3's hospital discharge paperwork indicated an order for 100 mg of micafungin every 24 hours, but the facility's records showed that R3 received only 50 mg. The Director of Nursing confirmed the error and could not provide a reason for the discrepancy. The Clinical Support Nurse, responsible for quality assurance audits, admitted to missing the error during the audit process. The facility's policy on re-admissions requires that medications for residents readmitted to the facility are verified and initiated on a timely basis. However, the failure to accurately transcribe and administer the correct medications for both R1 and R3 indicates a breakdown in this process. The errors were not caught during the quality assurance audits, leading to significant medication errors that affected the residents' health outcomes.
Inadequate Training and Competency Evaluation for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff had the necessary competency, training, and skills to care for its residents, which could potentially affect all 162 residents residing in the facility. An agency registered nurse, identified as V20, admitted to working shifts at the facility but could not confirm specific dates or details of their work, including the transcription of critical medication orders for a resident readmitted on a particular date. V20 acknowledged transcribing orders and contacting a nurse practitioner but failed to document orders for metronidazole and vancomycin in the electronic health record. V20's explanation for the missing orders was inconsistent, and they could not provide further information about the incident. The Director of Nursing, V2, confirmed that the facility relies on agency staff to fill staffing needs and does not have a formal procedure for training or evaluating the competency of agency nurses before they start their shifts. V2 stated that the agency did not have training documents for V20, and the facility lacked documentation proving V20's competency in completing admissions. Although a resource binder was available for agency staff, there was no evidence that V20 was aware of or had reviewed its contents. The facility's job description for staff nurses requires knowledge of nursing practices and procedures, including admission processes, but the facility assessment tool's training and competencies tab was not provided during the survey.
Inaccurate Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. The assessment did not include specific staffing information, such as the number of staff needed per shift or unit, and did not identify respiratory therapists as necessary staff members for the facility's population. Additionally, the assessment failed to mention the ventilator unit, which houses 36 residents, and did not identify the contracts for staffing respiratory therapists. Interviews and record reviews revealed that the Director of Respiratory, a registered respiratory therapist, oversees the respiratory therapy program and stated that the facility contracts with a medical staffing agency to staff the ventilator unit. The staffing needs for the ventilator unit are determined by the Director of Respiratory, with a staffing ratio of one respiratory therapist to every 16 airways, ensuring at least two respiratory therapists are on site at all times. Despite these arrangements, the facility's administrator stated that the facility assessment is completed yearly and does not require a breakdown of staffing needs, relying instead on a facility assessment tool without a specific policy for completing the assessment.
Inadequate Infection Control and Foley Catheter Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling of foley catheter tubing and inadequate infection tracking and surveillance. Observations revealed that foley catheter tubing for two residents was found lying on the floor, which was acknowledged by a Resident Care Coordinator as a potential source of infection. The facility's policies on catheter care did not provide specific instructions on preventing catheter tubing from touching the floor, contributing to this oversight. Additionally, the facility's infection preventionist, who was responsible for tracking infections, did not adequately document or track infections that were not treated with anti-infective medications. This included failing to track pathogens, symptoms, and mapping of infections, which are essential components of an effective infection control program. The infection preventionist believed that only infections treated with anti-infective medications needed to be tracked, which was contrary to the facility's policy and best practices. The Director of Nursing and a Registered Nurse Consultant acknowledged the deficiencies in the infection control program, noting that the previous assistant director of nursing had been responsible for these tasks before leaving the facility. The Registered Nurse Consultant, who was overseeing the infection preventionist's work, confirmed that the infection control logs were incomplete and that mapping of infections had not been conducted. This lack of comprehensive infection tracking and surveillance could potentially lead to outbreaks within the facility, as noted by the Director of Nursing.
Inadequate Oral Care for Ventilator Unit Residents
Penalty
Summary
The facility failed to ensure that oral care was provided to residents on the ventilator unit in accordance with professional standards and facility policy. This deficiency was observed in the case of a resident who was dependent on staff for oral care. The resident was found with thick, beige secretions on their lips and teeth, indicating a lack of proper oral hygiene. Despite a Certified Nursing Assistant claiming to have provided oral care earlier, the Licensed Practical Nurse noted the need for immediate attention and attempted to clean the resident's mouth using a dry washcloth, which is not in line with the facility's oral care policy. Further investigation revealed that other residents on the ventilator unit also did not receive adequate oral care. Documentation showed that oral care was not consistently provided twice daily as required, and in some cases, there was no documentation to confirm that oral care was provided at all. The facility's policy for oral care of unconscious residents was not followed, as staff did not use the appropriate equipment and procedures outlined in the policy. The Director of Nursing and the Medical Director both acknowledged the importance of proper oral care to prevent infections such as pneumonia, yet the facility's practices did not align with these standards.
Failure to Change Nebulizer Tubing Timely
Penalty
Summary
The facility failed to adhere to its policy regarding the timely change of nebulizer tubing, which has the potential to affect the respiratory care of a resident. The resident, identified as R12, is cognitively impaired, unable to speak, and dependent on staff for daily activities, while also utilizing a ventilator. During an observation, it was noted that the nebulizer tubing attached to R12's tracheostomy site was dated 1/15/2025, indicating it had not been changed in accordance with the facility's policy of weekly changes. This oversight was confirmed by the Resident Care Coordinator, a Licensed Practical Nurse, who acknowledged the tubing should be changed weekly to prevent infection. Subsequently, R12 was diagnosed with a urinary tract infection, pneumonia, and sepsis, as documented in the resident's progress notes.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to adhere to its policy of ensuring that call lights are answered promptly, affecting five residents out of seven reviewed. Residents reported that their call lights often went unanswered for extended periods, sometimes up to an hour, particularly during the afternoon and night shifts. This delay in response left residents in uncomfortable and potentially harmful situations, such as sitting on soiled linens for too long. Interviews with staff, including a CNA and the Social Worker Director, confirmed that call lights should be answered promptly to prevent potential harm to residents, such as falls or medical emergencies. The Director of Nursing stated that the expectation is for staff to respond to call lights within 2 to 3 minutes to meet residents' needs. However, the facility's failure to meet this standard was documented in Resident Council Meeting Minutes and Grievance/Concern Forms, which highlighted ongoing issues with call light response times. The deficiency was further supported by the Minimum Data Set of one resident, which showed dependency on staff for toileting and transfers, emphasizing the critical need for timely assistance.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,700 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Selfhelp Home Of Chicago | 0.3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Margate Park | 0.4 mi | ★★★★★ | 25 | 0 |
| Carlton At The Lake, The | 0.5 mi | ★★★★★ | 25 | 0 |
| Admiral At The Lake, The | 0.5 mi | ★★★★★ | 10 | 0 |
| Mado Healthcare - Uptown | 0.6 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.