Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Lakeshore during CMS and state inspections, most recent first.
Failure to follow planned menu portions and diet extensions led to under-portioned meals for multiple residents. During tray line observation, a dietary aide served fish that weighed less than the ordered 3 oz portion, pudding was portioned with a smaller scoop than required, and ham portions also fell short of the recipe amount. Residents and staff reported the servings were too small, and the RD stated the kitchen should follow the menu spreadsheets and standardized recipes to ensure adequate calories and protein.
Ongoing pest control failures were documented after residents and staff reported mice, roaches, and possible bed bugs in multiple rooms and common areas. A resident described mice droppings in dresser drawers, on clothing, and in room corners, while staff observed the droppings and confirmed ongoing mouse complaints. Other residents reported mice running around at night, mice living under dressers and in clothes, and one resident reported bugs, red bite marks, and black dots on sheets. Surveyors also observed a hole in a resident’s wall where mice were entering and exiting, and the admin and maintenance director acknowledged ongoing pest problems.
Unsanitary Resident Rooms and Pest Infestation: Surveyors observed sticky floors, paper debris, cluttered surfaces, and overflowing trash throughout the facility. Multiple residents reported mice, roaches, and bugs in their rooms, with visible droppings in drawers, on clothing, and in room corners, plus dirty bathrooms and stained toilets. The ADM and maintenance staff acknowledged ongoing pest issues and inconsistent housekeeping, while one resident also had a hole in the wall where mice were entering.
Failure to Provide Timely ADL Care: Staff did not provide timely toileting hygiene, incontinence care, and personal care for multiple residents. One resident with stroke-related weakness and cognitive impairment reported repeated overnight failures to be changed and delayed nail care, while another dependent resident was found very wet with a soaked bed and soiled brief after reportedly waiting hours for incontinence care. The deficiency also involved two additional residents reviewed for ADL care.
Food Items Left Undated in Storage Areas: Surveyors observed multiple food items in the refrigerator, freezer, and dry storage without required open, use by, or expiration dates, including ice cream, pickles, salads, and cereal. The Dietary Supervisor stated dated labeling is used to prevent serving expired food, and an aide said she prepared and wrapped the salads that morning, but the tray of salads still had no dates.
Narcotic accountability sheets were not completed per protocol on two floors. An RN signed multiple controlled substance count boxes during double shifts and stated she counted by herself and entered her initials in all boxes, while another sheet lacked an off-shift signature. The DON stated the policy required a second person to validate the count, and the facility’s narcotic procedures required counting controlled substances with a partner.
Pureed Meal Not Prepared to Correct Consistency: A cook prepared the pureed chicken entree for residents on pureed diets, but the food was not blended to a smooth consistency. The chicken remained gritty with visible pieces, yet it was transferred to a container and placed in the warmer as ready for service. The DON later confirmed the texture was not smooth, and the facility policy required pureed foods to be the consistency of applesauce or smooth mashed potatoes.
Failure to follow infection control practices included a CNA delivering meal trays to four residents without using hand sanitizer between tray passes or after touching hallway surfaces, a CNA wearing PPE in the hallway and while moving between rooms for a resident with lice, and staff not following Droplet Precautions for a resident with COVID-19. The resident on Droplet Precautions had severe cognitive impairment and records directing strict isolation with droplet and contact precautions, but the PPE bin was found inside the room instead of outside the doorway.
A facility failed to keep privacy curtains in place and failed to ensure one curtain fully covered a resident’s space. Residents shared rooms without curtains separating their living areas, one resident’s curtain was too short during incontinence care, and another resident had no curtain while staff provided personal care in bed. The DON, RN, LPN, CNA, and Housekeeping Director confirmed the missing or inadequate curtains, and the Administrator stated the facility had no privacy policy.
A resident with hemiplegia, impaired mobility, incontinence, and moderate cognitive impairment, who was care planned as totally dependent for toileting hygiene and to be checked and changed every 2–3 hours and PRN, was not changed for an extended period. Documentation showed only one toileting hygiene entry during the night and none for the day shift, the resident reported not being changed since the prior evening, and observation confirmed a urine-filled brief late the following morning. An LPN acknowledged the brief had not been changed that shift, a CNA stated residents are supposed to be checked at least every two hours, and the DON stated residents should be changed at least twice per shift and more often as needed, demonstrating a failure to follow the resident’s care plan and facility incontinence policy.
A resident who was cognitively intact and needed substantial to maximal assistance was observed during incontinence care with the privacy curtain too short to fully cover the bed, leaving the resident exposed. The resident said staff often could not close the curtain all the way and that it bothered the resident not to have privacy. In another incident, a resident with moderate cognitive impairment was seen wearing a hospital wristband in the hallway that displayed name, DOB, sex, age, and MRN, and an LPN stated the information was visible to anyone and violated privacy.
Respiratory equipment was not properly labeled, dated, or contained for a resident receiving oxygen via trach collar. An LPN observed an almost empty humidifier bottle that was not dated, a trach collar that was not dated, and suction tubing hanging from a suction machine and touching the nightstand. The resident pointed to the equipment and shook his head no, and staff later stated the bottle should have been replaced and the tubing should have been dated and contained.
Missed Daily Monitoring of Resident Refrigerator Temperatures: The facility failed to monitor personal refrigerator temperature logs for three residents. Two residents had multiple missing temperature checks in February, and one resident also had a missing check in March. The Housekeeper said staff are supposed to check resident refrigerators daily for cleanliness, safe temperature, and spoiled food, and the DON stated housekeeping should check the refrigerators daily to keep temperatures at a safe level.
A resident with schizophrenia, anxiety, gait abnormalities, and a history of exit-seeking repeatedly eloped after staff failed to consistently identify and manage elopement risk. Despite an initial assessment labeling the resident as an elopement risk and an order for a wander guard, subsequent assessments incorrectly documented no elopement risk, exit-seeking episodes were not always followed by reassessment or care plan updates, and nursing staff documented that the wander guard was not in place over multiple days without correcting or reporting it. On one occasion, an LPN medicated the resident with Haldol after an attempted elopement but did not escalate the behavior; the resident later left the building and returned from the hospital with open areas on both feet. After a period on a locked unit without elopements, the resident was moved to an unsecured unit where residents knew the elevator code, had no wander guard in place, and was allowed by an LPN to leave the floor unsupervised to use vending machines. A receptionist, unaware the individual was a resident or an elopement risk, buzzed him out the front door, and the resident was later found at a hospital with a head injury and oral trauma. Staff interviews confirmed widespread lack of awareness of which residents were elopement risks, inconsistent use and monitoring of wander guards, and unrestricted resident access to elevator codes and the front exit.
Multiple residents were exposed to and bitten by bedbugs, leading to room relocations and discomfort. Staff interviews revealed confusion about pest control responsibilities, and observations showed untreated, cluttered rooms with bedbug activity confirmed by pest control reports. The facility's lack of clear communication and delayed treatment resulted in prolonged exposure for residents.
A resident with a history of aggressive behavior and severe mental illness entered a lounge area in an agitated state and made forceful contact with another resident, causing a fall and resulting in a fractured orbital wall. Despite care plans addressing both residents' risks, the facility failed to prevent the incident, and staff confirmed the aggressive contact led to the injury.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple risk factors developed a large, unstageable pressure ulcer after staff failed to complete accurate skin assessments, maintain physician-ordered wound dressings, and document or implement appropriate interventions. Nursing documentation was inconsistent, and direct observation confirmed the wound was left uncovered, contrary to orders and facility policy.
A resident with severe cognitive impairment and a history of falls was not consistently supervised or provided with required fall prevention interventions, such as non-skid footwear and accessible call lights. Despite being identified as a fall risk, the resident experienced multiple falls, including one resulting in a head laceration requiring sutures. Staff interviews and documentation revealed lapses in supervision, inconsistent implementation of care plan interventions, and inaccurate fall risk assessments.
A resident with a history of falls, dementia, and impaired mobility was not accurately assessed for fall risk, despite documented needs for supervision and assistance. The fall risk assessment incorrectly indicated no risk, even though the resident required help with walking and had experienced a recent fall resulting in injury. Staff interviews and facility records confirmed the assessment was not completed properly, leading to a lack of appropriate fall prevention interventions.
A resident with a history of falls, dementia, and impaired cognition was not consistently provided with required fall prevention interventions, such as non-skid footwear and adequate supervision, as outlined in the care plan. Multiple falls occurred, and staff interviews revealed lapses in monitoring and inconsistent application of care plan measures, including the resident being found barefoot and unable to access or use the call light.
A resident with severe cognitive impairment and a history of falls was not assessed by PT in a timely manner after a fall, despite recommendations and orders from the IDT and nursing staff. The PT evaluation occurred several days after the incident, during which the resident continued to display mobility and safety concerns. Facility staff acknowledged the delay and that it did not meet policy expectations.
A resident with failure to thrive and dysphagia did not receive the prescribed pureed diet with required supplements, instead being served a mechanical soft meal without whole milk, ice cream, or pudding. Staff confirmed the meal ticket and tray did not match the physician's orders, and facility policy requiring compliance with diet orders was not followed.
The facility did not conduct a thorough investigation or determine the root cause of an altercation between two residents, resulting in conflicting accounts about whether the incident was accidental or intentional. One resident, who was cognitively intact, reported being repeatedly punched and injured, while staff and documentation provided inconsistent descriptions. The facility's final report concluded the event was accidental without fully reconciling these differences or following abuse prevention policy requirements.
Two residents were involved in a physical altercation in a common area, resulting in one resident sustaining a large bruise, a bump on the head, and pain after being struck multiple times by another agitated resident with a psychiatric history. Staff and medical records confirmed the incident, and the facility's abuse prevention policy was not followed.
The facility did not update or revise care plans for two residents after significant events, including an abuse incident and changes in community access needs. One resident's care plan was not updated to address abuse risk after an altercation, and both residents had expired or outdated care plan goals for community access and abuse/neglect. Staff confirmed that care plans were not revised as required following these events.
A resident with severe morbid obesity and osteoarthritis fell out of bed and sustained a right femur fracture due to the facility's failure to maintain safety precautions. The resident required maximum assistance with bed mobility and was totally dependent on staff for ADL care. A CNA observed the resident sleeping near the edge of the bed but did not reposition them or check for incontinence. Later, the resident fell, claiming the CNA pushed them, which the CNA denied. The facility's failure to follow the care plan and provide adequate supervision contributed to the fall.
The facility failed to provide bedtime snacks to residents who wanted to eat outside of scheduled meal times, affecting all 235 residents on oral diets. Observations showed that snacks were scarce, with one resident keeping pizza in bed to eat when hungry. The Food Service Director confirmed snacks were mainly for those on a specific list, and documentation showed a 14.5-hour gap between dinner and breakfast, exceeding policy limits.
The facility failed to ensure proper medication management and storage, affecting multiple residents. Loose pills were found in medication carts, and several medications lacked open and expiration dates or were expired. The medication refrigerator was improperly maintained, with temperatures exceeding the recommended range, and there was confusion about temperature log documentation. These deficiencies indicate a failure to adhere to the facility's medication storage policy.
The facility failed to manage personal refrigerators for residents, resulting in expired food and inadequate temperature monitoring. Two residents with medical conditions had expired milk in their refrigerators, which lacked thermometers and temperature logs. Housekeeping staff did not maintain cleanliness or perform required checks, and there was confusion about responsibility for monitoring. This non-compliance with facility policy potentially affected all residents with personal refrigerators.
A facility failed to ensure staff wore appropriate PPE while providing care to a resident with Enhanced Barrier Precautions (EBP). A CNA was observed providing perineal care without PPE, and the Infection Preventionist was unaware of the resident's need for EBP. This oversight could affect all residents on the second floor.
The facility failed to cover the catheter drainage bags of two residents, compromising their dignity. One resident was observed in bed with an uncovered catheter bag, while another was in a wheelchair with a similar issue. Both residents have cognitive impairments and specific medical conditions. Staff acknowledged the importance of privacy bags for dignity, but the facility did not adhere to this practice.
The facility failed to ensure call lights were within reach for two residents, one with Cerebral Palsy and another with Cerebral Infarction. Despite care plans encouraging the use of call devices, the call lights were inaccessible, violating the facility's policy. Staff confirmed the deficiency, acknowledging the need for accessible call systems.
The facility failed to obtain and document Advanced Directives for two residents, one with cognitive impairments and another cognitively intact, upon their admission. Despite having medical conditions requiring clear directives, their records lacked physician orders for code status, which should have been documented by the admitting nurse. This oversight was identified during a survey, highlighting a lapse in following the facility's policy on Advanced Directives.
A resident was found with old food and a meal tray in her bed, which she consumed intermittently due to a lack of snacks. The CNA assigned to her placed the meal tray on the bed due to a shortage of staff and the absence of a bedside table. The LPN and Housekeeping Director acknowledged the unsanitary conditions and the need for proper food removal and availability of bedside tables.
A facility failed to complete a new PASARR for a resident with multiple mental health diagnoses upon admission. The resident, who was receiving medication for Bipolar Disorder, did not have a Level 1 or Level 2 PASARR in the facility's system. The oversight occurred because the resident was admitted before the facility started using the Maximus system for monitoring PASARR screenings.
A resident, who is cognitively intact and dependent on staff for showers due to multiple health conditions, did not receive her scheduled showers for over a month. Despite having a care plan for showers twice a week, documentation showed only one shower was given in January, with inadequate bed baths provided instead. The facility's ADON confirmed the expectation for scheduled showers, but the lack of documentation for missed showers indicates non-compliance with the care plan.
A resident at high risk for pressure ulcers was found lying on a low air loss mattress with multiple linens, contrary to guidelines. Staff confirmed the resident should have had only a flat sheet and a mattress pad or incontinence brief. This improper setup compromised the mattress's effectiveness in preventing and treating pressure ulcers.
The facility failed to supervise two residents at risk for falls in the dining room, despite their high fall risk scores and cognitive impairments. Staff present did not provide continuous supervision, and there was no formal policy on supervision, only an expectation of frequent monitoring. This lack of supervision violated the residents' rights to safety.
A resident with asthma and heart disease did not have their nebulizer mask changed weekly as required by facility policy. The mask, dated from June, was observed in use, and staff interviews confirmed the oversight. The facility's guidelines emphasize weekly changes to prevent infection, but this was not followed.
A facility failed to maintain accurate narcotic counts and documentation, affecting a resident receiving Tramadol. During a medication cart review, it was found that the shift change controlled substance inventory count sheet was missing, and there was a discrepancy in the narcotic count. An LPN admitted to administering a Tramadol tablet without signing the Controlled Drug Administration Record. The DON confirmed that facility policy requires accurate documentation and reporting of discrepancies.
A resident with a history of falls and multiple diagnoses, including Parkinson's and dementia, fell while attempting to pick up an item from the floor, resulting in cervical fractures. The resident's care plan included interventions like a sticky pad for the wheelchair and reminders to lock the wheelchair, but it was unclear if the wheelchair was locked at the time of the fall. Staff noted the resident's non-compliance with safety instructions, contributing to the incident.
The facility failed to maintain a pest-free environment, with roaches reported in several residents' rooms, affecting three residents directly and potentially impacting all 242 residents. Despite multiple complaints and documented infestations in various facility areas, the issue persisted, indicating a failure to adhere to the facility's pest control policy.
The facility failed to prevent residents from smoking indoors, posing a fire hazard. Two residents with mental health issues and nicotine dependence were observed smoking inside, despite policies requiring outdoor smoking and supervision. The facility's measures, such as searching visitor bags and testing residents, were insufficient to stop indoor smoking.
The facility did not conduct care plan meetings for three cognitively intact residents, as required. Clinical records lacked documentation of such meetings, and residents confirmed they were not informed or involved in care planning. Staff interviews revealed confusion and lack of coordination in scheduling and documenting these meetings, contrary to facility policy.
The facility failed to provide comprehensive bladder function assessments and care planning for residents with indwelling urinary catheters, and did not address a resident's urinalysis results, leading to untreated dysuria and burning upon urination for several weeks.
The facility failed to provide mail services to residents on Saturdays, affecting all 213 residents. Mail delivered on weekends is not sorted and distributed until Monday, and residents reported that their mail is sometimes opened when they receive it.
The facility failed to ensure adequate staffing, affecting all 213 residents. Frequent call-offs, especially on weekends, made it challenging for staff to complete their jobs. The facility was short-staffed on multiple occasions between October and December 2023. Additionally, maintenance issues were delayed until weekdays, leading to resident complaints.
The facility failed to properly label and date food items, store scoops correctly, follow manufacturer's guidelines for food storage, and sanitize cooking equipment as required. These deficiencies were observed during a kitchen tour and confirmed by the cook and food service director, potentially affecting all 209 residents.
The facility failed to ensure that dumpster lids were covered to prevent pests, insects, and rodents. During an observation, it was noted that two out of four dumpster lids were fully opened. Both the Former Food Service Manager and Housekeeping Director acknowledged that the lids should be shut to prevent rodents and garbage from flying outside. Despite these instructions, a surveyor observed two dumpster lids wide open later in the day. The facility's kitchen policy mandates that outdoor trash receptacles be kept covered and the surrounding area kept free of litter.
Failure to Follow Menu Portion Sizes
Penalty
Summary
The facility failed to follow planned menus and diet extensions for lunch meal service, including the prescribed portion sizes for baked fish, baked ham, and pudding. The report states that the kitchen policies required standardized recipes, portion control, and menus to be planned in advance and followed as written, and the diet spreadsheets specified 3-ounce portions of fish and ham, along with designated scoop sizes for pudding based on diet order. The deficiency affected the facility’s food service operations for residents receiving meals prepared in the kitchen. During observation of the lunch tray line, the cook stated the baked fish portion should be 3 ounces for regular and mechanical soft diets and that pudding portions should be served using a #8 scoop for most diets and a #16 scoop for diabetic diets. However, the dietary aide was observed placing one small piece of fish on resident trays, and when the piece was weighed it measured 1.5 ounces. The largest piece selected from the cooked fish pan weighed 2 ounces. The food service manager stated the portion should have been 3 ounces and explained that the fish was purchased as a 3-ounce fillet but lost volume during cooking, noting that larger raw portions would have been needed to yield the required serving size. Residents and staff reported that the portions were too small. One resident stated the fish portion was too small and the pudding looked like only one spoonful. Other residents stated they would have liked bigger portions and that the kitchen was not giving enough food. On the next day, the ham portions were also observed to be short of the required amount: four half-slices weighed 2.2 ounces, five half-slices weighed 2.5 ounces, and six half-slices weighed 3.1 ounces. The dietary staff stated they had not been told to weigh the sliced meat to determine the correct portion, and one dietary aide stated he used a smaller scoop for pudding because he did not want to run out of food. The registered dietitian stated the kitchen should follow the menus and diet spreadsheets so residents receive adequate calories and protein, and that no one can determine ounces by eyeballing food.
Pest Control Failure With Ongoing Mice, Roaches, and Possible Bed Bugs
Penalty
Summary
The facility failed to provide effective pest control for multiple residents, with survey findings documenting ongoing mice, roach, and possible bed bug activity in resident rooms and common areas. Pest control invoices showed repeated treatments on the third, second, and fourth floors, as well as in laundry rooms, pantry, kitchen, locker room, basement, dining rooms, nursing stations, and several fourth-floor rooms. Rodent traps were also placed on multiple nursing floors and the basement, yet resident and staff reports continued to describe active pest problems. During observation and interview, a resident stated that mice had been in the room since December 2025 and that roaches were still present. The resident described mice droppings in dresser drawers, on clothing, and in personal items, and reported that garbage cans were not emptied daily, floors were not swept and mopped daily, and food waste remained in the room. Surveyors observed black pellets consistent with mice droppings in the dresser drawer, on clothing, in room corners, and along the baseboards. Staff members, including LPN, housekeeping, and maintenance personnel, confirmed the presence of mice droppings and acknowledged ongoing mouse complaints in the facility. Additional residents reported mice running around their rooms, mice living under dressers and in clothes, and glue traps that were not working. One resident reported bugs in the room for about a month, red bite marks, and black dots on sheets, while the administrator stated the facility did not have bed bugs but would call the exterminator to check the room. Surveyors also observed a hole in a resident’s wall at the head of the bed, and the resident reported that mice came in and out of the hole and that the issue had been ongoing for months. The administrator and maintenance director acknowledged ongoing mouse and roach problems and stated that staff and residents had reported sightings of mice.
Unsanitary Resident Rooms and Pest Infestation
Penalty
Summary
The facility failed to maintain a clean, comfortable, home-like environment for nine residents in a sample of 23. During survey observations, the hallways had sticky substances on the floors, small shreds of paper were visible on the floors, and residents’ garbage cans were full of clutter and food containers. Bedside tables and window sills were also observed with clutter and food containers, and multiple resident rooms had visible stains, spills, and spots on the floors. Resident interviews and direct observations identified widespread pest and sanitation concerns in several rooms. One resident reported mice and roaches in the room since December 2025, stated that mouse droppings were found in dresser drawers and on personal items, and said garbage was not emptied daily and floors were not swept or mopped daily. Surveyors observed black pellets in the dresser drawers, on clothing, books, papers, and in room corners, along with full garbage cans and food trash stacked around the cans. Another resident reported mice living in the wall and showed a hole at the head of the bed; the administrator observed the hole and stated it was the first time knowing about it. Additional residents reported mice, roaches, or bugs in their rooms, and surveyors observed dirty bathrooms, full garbage cans, glue traps in rooms, and mice droppings near baseboards and corners. One resident stated the toilet was gross and full of stains and dirty, and surveyors observed yellow and brown stains on the toilet and floor. Another resident reported bugs, red bite marks, and black dots on sheets, and the administrator stated the facility had bed bugs. The administrator and maintenance staff acknowledged ongoing mice and roach problems, and staff stated housekeeping should empty garbage twice daily, but observations and resident statements showed rooms and bathrooms were not consistently cleaned.
Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
The facility failed to provide ADL care in a timely manner for 4 of 7 residents reviewed for ADL care. R1 had a history of stroke with left-sided paralysis and weakness, moderate cognitive impairment, and dependence on staff for toileting hygiene, lower body dressing, personal hygiene, and rolling. R1 was also incontinent of urine and frequently incontinent of bowel, with care plan interventions to check and change every 2-3 hours and keep skin clean and dry. During interview, R1 stated overnight CNAs failed to change the incontinence product on multiple nights, including 4/27/2026 and 4/28/2026, and described other recent nights when staff did not change R1 during the entire 8-hour shift. Staff interviews confirmed prior complaints that R1 had not been changed overnight, and surveyors observed R1’s fingernails long with dark brown sediment under some nails, with R1 stating staff had said they would cut them later but did not return to do so. R13 was cognitively intact but dependent on staff for toileting and personal hygiene, with urinary incontinence and frequent bowel incontinence. A CNA reported finding R13 very wet, with a very soiled brief, a soaked bed, and dark stains on the linen, stating it appeared R13 had not been cleaned all night. R13 stated night CNAs did not change the incontinence product right away, that R13 often had to wait hours for attention, and that most nights the incontinence product was changed only once during the shift, leaving R13 soaked in bed until around 5:00 AM. The report also identified two additional residents, R10 and R11, as part of the group of 4 residents for whom timely ADL care was not provided.
Food Items Left Undated in Storage Areas
Penalty
Summary
Food items in the facility were observed without required open, use by, or expiration dates. On 3/2/2026 at 9:34 am, surveyors observed a large ice cream bucket dated 10/20/2025 in the freezer, pickles in the refrigerator with a received date of 1/29/26 but no open or expiration date, nine salads on a plastic plate covered in clear plastic wrap in the refrigerator by the ice machine without use by or expiration dates, and six bowls of cereal on a tray in the dry storage room without open or use by/expiration dates. The refrigerator temperature was 36 degrees Fahrenheit, the freezer thermometer was 0 degrees, and the refrigerator temperature tracking log showed the last recorded temperature as 36 degrees. On 3/2/2026 at 9:36 am, the Dietary Supervisor stated foods are labeled with open and expiration dates to ensure the kitchen is not serving expired foods and to support first in, first out use based on the closest expiration date. A Dietary Aide was observed walking in and out of the refrigerators and freezer with a black marker and stated she was labeling lemonade prepared that morning; she also stated she prepared the salads that morning, wrapped them in plastic, and placed them in the refrigerator. The Dietary Supervisor and Dietary Aide verified that the tray containing 9 salads had no use by or expiration dates. The facility policy stated that all food not in original containers should be labeled, dated, and stored in NSF approved containers and that food should be labeled and dated to monitor food safety.
Narcotic Count Sheets Not Completed Per Protocol
Penalty
Summary
The facility failed to ensure narcotic accountability sheets were completed according to facility protocol on two floors reviewed for medication storage and labeling. On the 2nd floor, a Shift Change Controlled Substance Inventory Count Sheet in the narcotic drawer showed the same RN initials entered in four consecutive signature boxes across 3/1 and 3/2, and V34 stated those entries reflected a double shift. V34 explained that the nurse signed all four boxes when working a double shift, and V35 confirmed that she had signed the sheet in four consecutive boxes because she counted by herself and took responsibility for the whole 16-hour shift. On the 1st floor, another Shift Change Controlled Substance Inventory Count Sheet in the narcotic drawer showed that a nurse did not initial the off-shift signature box for 3/2 day shift. V35 confirmed she was the nurse who signed the narcotic sheets on the 2nd floor and stated she normally worked that floor. The DON stated the facility policy required a second person to validate the controlled substance count even during a double shift, and that nurses should not count by themselves. The facility’s narcotic sheet and policy both stated controlled substances were to be counted with a partner and that the oncoming nurse must verify the count with the nurse coming off shift.
Pureed Meal Not Prepared to Correct Consistency
Penalty
Summary
The facility failed to ensure the main entree for a pureed meal was prepared in the correct consistency for nine residents who received pureed diets. On 3/2/26, the Dietary Supervisor provided a list of residents receiving pureed meals, which included R50, R90, R116, R150, R196, R200, R219, R274, and R276. The facility menu documented the main entree for the pureed meal as Pureed Breaded Chicken. On 3/3/26, the Cook began preparing the pureed chicken by placing 15 breaded chicken cutlets into a food processor with chicken broth. The Cook stopped when the processor made a sharp noise and added more broth. Four minutes later, the Cook stopped the processor and completed a taste test and consistency check, but the chicken was not smooth, with visible pieces of chicken, a gritty texture, and a dry taste. The Cook then transferred the chicken to a container and placed it in the oven, stating it was ready for service. The Dietary Supervisor later tasted the chicken and confirmed the texture was not smooth, and stated that once a food item is placed in the warmer it is ready to be served. The facility policy titled Pureed Food Preparation states pureed foods will be the consistency of applesauce or smooth, mashed potatoes.
Failure to Follow Hand Hygiene, PPE Doffing, and Droplet Precautions
Penalty
Summary
The facility failed to ensure hand hygiene was performed during meal tray delivery for four residents on the 4th floor. On 3/2/2026 at 12:27 pm, a CNA was observed removing trays from the meal cart and delivering them to R256, R179, R152, and R214 without using hand sanitizer between tray deliveries or after touching hallway doors and other surfaces. The CNA stated she washed her hands before passing trays and used hand sanitizer only because she was taking the tray to the resident and not anyone else, while another CNA stated hand sanitizer should be used between each tray delivery to prevent the spread of germs. The facility also failed to ensure proper doffing of PPE for one resident on the 2nd floor. On 3/4/26 at 9:55 am, a CNA was observed in a white jumpsuit and gloves in the hallway outside R223's room, then walking into a shower room and back into R223's room while still wearing the same PPE, and exiting the room still in the same PPE. The CNA stated she was not supposed to wear PPE in the hallway and should have taken it off. An LPN later stated the gown needed to be removed in the room and not worn in the hallway, and the DON stated PPE should be taken off before leaving the room so nothing is taken out and contaminates others. The facility further failed to follow Droplet Precautions for R274 on the 3rd floor. R274 had diagnoses including cerebral infarction, asthma, type 2 diabetes mellitus, COVID-19, and pneumonia, with severe cognitive impairment noted on the BIMS. The resident's records documented Droplet Precautions for COVID and a care plan directing strict isolation with droplet and contact precautions. On 3/2/2026, the room had a Droplet Precaution sign, but the PPE bin was inside the room rather than in the hallway outside the room. An LPN stated PPE should be donned outside the room before entry, and the DON stated the PPE bin should be outside the room and PPE should be donned prior to entering the resident's room.
Missing and Inadequate Privacy Curtains During Resident Care
Penalty
Summary
The facility failed to ensure privacy curtains were in place and failed to ensure a privacy curtain fully covered a resident’s space for six residents: R132, R172, R183, R231, R255, and R260. R255, who had diagnoses including atherosclerotic heart disease with angina, hyperlipidemia, hypertension, malignant neoplasm of the rectosigmoid junction, and gastrointestinal hemorrhage, had a BIMS score of 12 indicating moderate cognitive impairment. On observation, R255 was seen coming out of the bathroom and sitting on his bed in a room with three beds, and no privacy curtain was hanging to cover his bed. R255 stated he did not notice the curtain was missing. Staff stated housekeeping was responsible for hanging the curtains and that the purpose of the curtain was to provide privacy and dignity during care. During room observations, R183 was receiving incontinence care and the privacy curtain was not long enough to encompass the resident’s private space, which the CNA confirmed. R172 and R231 shared a room with no privacy curtain separating their living spaces, and R231 stated a curtain was needed for one-on-one time and that people from the hallway could see in when the door was open. R132 and R260 also shared a room with no privacy curtain in place; R132 stated staff had to provide personal care in R260’s bed and that sometimes he had to leave the room or not look, while an LPN stated R260 required incontinence care in bed and could not do anything on his own. Staff and the DON confirmed the absence of privacy curtains, and the Housekeeping Director stated the curtains had been taken down to wash, there were no replacement curtains, and the residents had been without curtains for the prior three days. The Administrator stated the facility did not have a privacy policy and relied on the resident rights packet for privacy information.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living, specifically toileting hygiene and incontinence care, for one resident. The resident had diagnoses including hemiplegia and hemiparesis, muscle disorders, hypertension, history of falling, and vitamin D deficiency, and had a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment. The resident’s MDS Section GG documented that toileting hygiene required a code of 01 (dependent), meaning staff must perform all of the effort. The resident’s care plan, initiated for bladder and bowel incontinence related to impaired mobility, directed staff to check and change the resident every 2–3 hours and as needed. Facility policy on incontinence care required incontinent residents to be checked periodically in accordance with assessed incontinent episodes or every two hours and to receive perineal and genital care after each episode. Record review showed a toileting hygiene task documented at 12:14 a.m. on a specific date, with no toileting hygiene time recorded for the 7:00 a.m.–3:00 p.m. shift that same day. Late in the morning, the resident reported not having been changed since 8:30 p.m. the previous evening. Observation shortly thereafter revealed the resident’s incontinence brief contained a dark yellow liquid substance in both the front and back. An LPN confirmed that the brief did not appear to have been changed during the current shift and appeared filled with urine. A CNA stated that residents are checked every two hours or more frequently for incontinence care, that the resident was not in her assignment, but that the resident should have been changed at least once that shift and more often if necessary. The DON stated residents should be changed at least twice a shift, at the beginning and end of the shift, and more frequently if necessary. These observations and interviews showed that the resident was not checked and changed in accordance with the care plan, facility policy, and stated practice.
Failure to Maintain Privacy During Care and Protect Confidential Information
Penalty
Summary
The facility failed to provide a dignified experience during incontinence care for a resident who was cognitively intact and required substantial to maximal assistance with toileting hygiene, lower body dressing, personal hygiene, and mobility. During observed care, a CNA was providing incontinence care while the privacy curtain did not fully encompass the resident’s private space, leaving the resident’s backside visually exposed. The CNA attempted to pull the curtain around the bed but stated the curtain was too short and did not go around the bed. The resident stated that staff try to close the curtain, but it does not go all the way around, that it bothers the resident not to have privacy for the body, and that when the curtain cannot be closed all the way, the door is closed instead. The Housekeeping Director stated the facility did not have backup or replacement curtains, and the Administrator stated the facility did not have a privacy policy, relying instead on the resident rights packet given on admission. The facility also failed to ensure a resident’s confidential information was not displayed when a hospital wristband remained on the resident after return from the hospital. The resident had moderate cognitive impairment and was observed walking in the hallway with a white hospital wristband on the wrist. The wristband displayed the resident’s name, date of birth, gender, age, and medical record number. The resident stated no one had asked whether the wristband should be removed. An LPN observed the wristband and stated that if all of that information could be seen by staff, anybody could see it, and in the LPN’s professional opinion it was a violation of the resident’s privacy. The DON stated that when a resident returns from the hospital, the hospital wristband should be removed to protect privacy and that the nurse is responsible for removing it.
Respiratory Equipment Not Labeled, Dated, or Properly Contained
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for R59. R59 had diagnoses including paraplegia, tracheotomy, cerebral infarction, iron deficiency, hypoglycemia, anemia, and venous thrombosis and embolism, and was cognitively intact with a BIMS score of 13. The physician order sheet documented that trach tubing was to be changed and labeled weekly on Sunday nights, and the care plan directed suctioning as needed and use of humidified oxygen or a humidifier for airway clearance. On 3/2/26 at 10:50 a.m., R59 was observed in bed receiving oxygen through a trach collar at 5 liters. The resident pointed to the trach collar and humidifier bottle and shook his head no. The humidifier bottle was almost empty and not dated, the trach collar was not dated, and a suction machine on the nightstand had suction tubing hanging down and touching the side of the nightstand, not contained and not dated. An LPN stated the humidifier bottle and trach tubing should have been dated when hung, the humidifier bottle should have been replaced, and the suction tubing should not be hanging and should be contained and labeled with a date because of infection control. The next day, the humidifier bottle was still noted to be empty, and another LPN stated it should have been replaced the prior night. The DON later stated oxygen tubing is changed weekly on Sundays and should be dated when changed, and suction and oxygen tubing should be contained and dated if not in use because it can get dirty and to prevent microorganisms.
Missed Daily Monitoring of Resident Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that residents' personal refrigerator temperature logs were monitored for three residents, including R59, R167, and R197. R59's diagnoses included paraplegia, tracheotomy, cerebral infarction, iron deficiency, hypoglycemia, anemia, and venous thrombosis and embolism. R167's diagnoses included COPD, glaucoma, benign prostatic hyperplasia, gastritis, and arthritis. R197's diagnoses included fracture of the shaft of the left femur, chronic kidney disease, quadriplegia, disorders of muscle, multiple sclerosis, hyperlipidemia, hypertensive heart disease, and obstructive reflux uropathy. On review, R59, R167, and R197's personal refrigerator temperature log sheets had multiple days of missing temperature checks in February 2026, and R197 also had a missing temperature check on 3/3/26. On 3/4/26, the Housekeeper stated housekeeping is supposed to check resident refrigerators daily to ensure they are clean, the temperature is in a safe range, and there are no old or spoiled foods. The Housekeeper Director stated the housekeeping department checks resident personal refrigerators daily to make sure there are no spoiled foods, and the DON stated the resident refrigerator should be checked daily by housekeeping to ensure the temperature is at a safe level.
Repeated Elopements Due to Failed Elopement Risk Management and Wander Guard Oversight
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and elopement prevention for a cognitively intact resident with schizophrenia, depression, anxiety, gait abnormalities, obesity, and hypertension, who had a documented history of exit-seeking and elopement risk. As early as 4/23/25, nursing notes documented that the resident attempted to leave the building and had to be redirected. On 6/21/25, the resident left through the front lobby door and was redirected back, prompting an elopement risk assessment that identified the resident as at risk and led to an elopement care plan and an order for an electronic monitoring device (wander guard) on 6/25/25. Despite this, subsequent elopement risk assessments dated 6/23/25 and 9/25/25, completed by a social worker, incorrectly documented that the resident was not at risk for elopement, which the social worker later acknowledged as clinical errors. Exit-seeking behavior on 9/28/25 was documented, but no new elopement assessment or care plan update was completed, and the resident remained on an unsecured floor where residents could freely access the elevator without a code. On 10/12/25, the resident eloped again. Earlier that day, the resident attempted to leave through the front door but was stopped and given Haldol 5 mg by the LPN, who did not report the exit-seeking behavior because the resident had not yet left the facility. Later, the resident could not be located, and a code pink was called; the resident ultimately presented to a hospital stating he had left the nursing facility because he was hearing voices. Hospital documentation indicated the facility nurse reported that the resident had tried to elope earlier and had been medicated. When the resident returned to the facility that evening, open areas were noted on the soles of both feet. Although there was a physician order from 6/25/25 through 10/31/25 to check the electronic monitoring device placement and functionality every shift, the LPN documented "N" (no device in place) for multiple days in October and admitted that the device was not on the resident, that this was not reported to administration or a supervisor, and that the absence of the device was not corrected even after the 10/12/25 elopement. On 2/6/26, the resident eloped a third time, this time from a different unit. The resident had previously been on a secure locked unit (3 North) from 10/15/25 to 1/8/26 without elopements, but after a hospital stay was readmitted on 1/16/26 to an unsecured unit (3 South) where residents knew the elevator code. On the morning of 2/6/26, the LPN on 3 South saw the resident at the elevator stating he was going to the first-floor vending machine, and allowed him to leave the floor unsupervised, not knowing he was an elopement risk and unaware of any wander guard order or device. The resident, who knew the elevator code, reached the first floor, where the receptionist—who did not know the resident was an elopement risk and did not recognize him as a resident—buzzed him out the front door, believing he was staff. The receptionist later stated that the front door wander guard alarm did not sound and that the resident did not have an electronic monitoring device in place. The resident was later found at the hospital after having run, tripped, and fallen, sustaining a closed head injury, chipped and missing teeth, and a lower lip laceration requiring sutures. Throughout these events, staff on multiple units and at the front desk did not consistently know which residents were elopement risks, elopement assessments were inaccurately completed, the care plan was not consistently updated after exit-seeking or elopement events, and the physician order for the electronic monitoring device was discontinued without documented rationale, contributing to the resident’s repeated elopements and injuries. The Immediate Jeopardy was determined to have begun on 10/12/25, when the resident eloped and returned with bilateral foot injuries, and continued through the subsequent elopement on 2/6/26, during which the resident sustained a head injury and oral trauma. The facility’s own interviews and records showed that staff failed to consistently implement and monitor the ordered electronic monitoring device, failed to reassess and accurately document elopement risk after each incident or exit-seeking behavior, and allowed the resident to access unsecured exits and elevator codes despite a known history of elopement. The administrator acknowledged that the resident’s first documented elopement on 6/21/25 was not reported to the state agency and that no incident report or police notification occurred because there was no injury. The DON later confirmed that if a wander guard order exists and the device is not in place, nursing staff are responsible for immediately obtaining and applying a device and notifying leadership, which did not occur in this case. These combined failures in assessment, care planning, communication, and monitoring led to repeated unsupervised departures of the resident from the facility and associated injuries.
Removal Plan
- Reassess all residents for elopement risk and monitor elopement risk assessments to ensure residents are reassessed when there is a change in status.
- Review all resident care plans and revise as needed; review care plans with each change to the elopement assessment.
- Review and update the elopement binder at the front desk and on the units to ensure all residents at risk for elopement with wander guard are listed, including new admissions and re-admissions; review and update the binder with changes in resident status to ensure accuracy.
- Retrain all staff on elopement procedures, including Code Pink procedure, signs of elopement, the elopement policy, and how to identify residents at risk for elopement; retrain staff returning from leave prior to returning to work.
- Conduct Code Pink drills on all shifts to monitor staff response and identify opportunities for additional training; continue Code Pink drills.
- Conduct an ad hoc QAPI meeting with the Medical Director to discuss elopement events and facility follow up.
- Review the elopement policy with the IDT team.
- Update the elevator key code and install a new keypad; instruct staff to know the elevator key code and not disclose it to residents; change the elevator code routinely and remind staff not to disclose the code to residents.
- Audit residents who utilize wander guard and ensure each has a corresponding order to check the device each shift on the MAR and a reminder in the EMR; implement a functionality log to monitor device function and monitor for compliance.
Failure to Maintain Bedbug-Free Environment
Penalty
Summary
The facility failed to maintain an environment free of bedbugs, as evidenced by multiple residents being exposed to and bitten by bedbugs in their rooms. Several residents reported being relocated due to bedbug infestations, with some stating that the problem had persisted for weeks. Observations revealed rooms with 'Do Not Enter' tape on the doors, significant clutter, and plastic bags, making it difficult to treat the affected areas. Interviews with staff indicated confusion regarding responsibility for pest control, with the Maintenance Director, Housekeeping Director, and Assistant Administrator each providing inconsistent information about the bedbug situation and treatment efforts. The pest control company’s service report confirmed the presence of both live and dead bedbugs in several rooms, including those recently vacated by affected residents. Record review showed that residents were moved from infested rooms on various dates, and pest control documentation listed multiple rooms as having bedbug activity. The facility’s pest control policy assigns responsibility to the Environmental Services Director and requires prompt reporting and regular pest control measures. However, interviews and observations indicated a lack of clear communication and coordination among staff, resulting in delays in addressing the infestation and leaving residents exposed to bedbugs for extended periods. The affected rooms were not promptly treated due to clutter and personal belongings, further contributing to the ongoing issue.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent and protect a resident from physical abuse, resulting in a significant injury. One resident, who was cognitively intact and required supervision or assistance for mobility, was identified as being at risk for abuse and had a care plan in place to ensure safe care. Another resident, with a history of severe mental illness, psychotic disorder, and aggressive behaviors, had documented episodes of verbal and physical aggression, including multiple hospitalizations for aggressive behavior and acute psychosis. Despite these known risks, the aggressive resident was able to enter a lounge area where the other resident was present. On the day of the incident, staff accounts and interviews revealed that the aggressive resident entered the lounge in an agitated state and made forceful physical contact with the other resident, who was in the process of standing up from a chair. This contact caused the resident to fall to the floor, resulting in visible injuries including swelling, abrasions, and ultimately a diagnosis of a closed fracture of the orbital wall. Multiple staff members, including a housekeeper and the Social Service Director, witnessed or responded to the incident, confirming that the aggressive resident's actions directly led to the injury. The facility's own incident report categorized the event as resident abuse. The injured resident was subsequently transferred to the hospital, where further evaluation confirmed significant facial injuries. The facility's documentation and staff interviews indicated that the aggressive resident had a known history of unpredictable and aggressive behaviors, and that there were care plans in place addressing these risks. However, the measures in place were insufficient to prevent the incident, and the facility was unable to provide video evidence due to non-functioning cameras. The failure to adequately supervise and separate residents with known aggressive tendencies from vulnerable residents led to the occurrence of physical abuse and injury.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a significant pressure ulcer in a resident, failed to ensure wound dressings were maintained as ordered, and did not complete accurate or timely skin assessments. The resident, who had diagnoses including failure to thrive, dysphagia, and major depressive disorder, was initially documented as having intact skin. However, within a week, an unstageable pressure ulcer measuring 25x10 cm developed on the resident's sacrum. Despite the presence of risk factors such as hypertension, anemia, poor appetite, bowel and urinary incontinence, and malnutrition, not all risk factors or potential interventions were documented or addressed in the facility's investigation report. Nursing documentation was inconsistent and incomplete, with a weekly skin assessment incorrectly stating the resident's skin was intact even after the pressure ulcer had developed. No further weekly skin observations were recorded after this incorrect entry. Staff interviews revealed uncertainty about when the wound was discovered and acknowledged that the required weekly skin assessments and documentation were not completed as expected. The wound care nurse and DON confirmed that the skin assessment documentation was inaccurate and that the wound should have been described and monitored. Direct observation showed that the resident's wound was not covered with a dressing as ordered by the physician, and staff confirmed that a dressing should have been present. The wound care nurse and other staff stated that if a dressing is missing, it should be reported and reapplied, but this did not occur. The facility's own pressure ulcer policy outlines regular skin inspections, timely repositioning, and the use of pressure-reducing devices, but these measures were not consistently implemented or documented for this resident.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident prevention for a resident with a known history of falls, severe cognitive impairment, and multiple diagnoses including dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident was assessed as a fall risk and had a care plan that included interventions such as ensuring the use of non-skid footwear, frequent rounding, and supervision during mobility and transfers. Despite these documented interventions, the resident experienced multiple falls, including an unwitnessed fall that resulted in a laceration to the left eyebrow requiring sutures and hospitalization. Direct observations and interviews revealed that the resident was often found without non-skid footwear, and staff acknowledged that the resident frequently removed the socks intended to prevent falls. The resident's call light was not consistently accessible or understood by the resident, who was severely cognitively impaired and unable to reliably request assistance. Staff interviews indicated that supervision was not constant, with staff present at the nurse's station only 'most of the time,' and monitoring was often limited to visual checks from a distance. The resident's care plan interventions, such as supervision and use of non-skid footwear, were not consistently implemented or maintained. Documentation and staff statements also indicated that fall risk assessments were not always completed accurately, and there was a lack of individualized or enhanced supervision for this high-risk, impulsive resident. The facility's fall prevention policy required ongoing assessment and implementation of safety interventions, but these measures were not effectively carried out for this resident, resulting in a preventable injury. The deficiency was further supported by the facility's own policies and staff acknowledgments that interventions were not always in place or effective.
Failure to Accurately Complete Fall Risk Assessment
Penalty
Summary
The facility failed to accurately complete fall risk assessments for a resident with multiple diagnoses, including repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident's care plans, revised on several occasions, documented a history of falls, impaired safety awareness, wandering, and the need for supervision and assistance with mobility and activities of daily living. Despite these documented risks and functional deficits, the resident's Fall Risk Assessment dated 2/12/25 indicated that the resident was 'Not at Risk for Falls,' and described the resident as chair bound with gait and balance marked as not applicable. The Minimum Data Set (MDS) for the resident showed a BIMS score of 00, indicating severely impaired cognition, and documented that the resident required partial/moderate assistance to walk 10 feet. The resident experienced an unwitnessed fall on 4/7/25, resulting in an injury that required hospital evaluation and sutures. Observations on 4/20/25 found the resident attempting to stand without footwear and unable to identify the call light, further demonstrating cognitive and functional impairments. Interviews with facility staff, including the ADON, MDS Coordinator, and DON, confirmed that the fall risk assessment was not completed accurately and emphasized the importance of proper assessment for implementing appropriate interventions. Facility policies required fall risk assessments to be performed at admission, quarterly, after significant changes, and after any fall incident, with interventions tailored to identified risks. The failure to accurately assess the resident's fall risk led to a lack of appropriate interventions, as documented in the facility's policies and staff interviews. The deficiency was identified through record review, staff interviews, and direct observation of the resident's condition and environment.
Failure to Implement Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive care plan for a resident with a history of repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident was assessed as being at risk for falls and included in the elopement prevention program, with care plan interventions specifying the use of non-skid footwear, frequent rounding to ensure the resident was wearing nonskid socks, supervision during mobility and transfers, and assistance with walking. Despite these documented interventions, the resident experienced multiple falls, both witnessed and unwitnessed, and was observed barefoot with non-skid socks found under the bed rather than being worn. Staff interviews revealed inconsistent implementation of the care plan interventions. Several staff members acknowledged that the resident was a fall risk and should always have non-skid socks on, but also noted that the resident often removed the socks or refused to wear shoes. There was also inconsistency in staff awareness and monitoring, with some staff stating that the resident was checked every 15 minutes or that the room was positioned for better observation, while others admitted that supervision was not constant. The resident's call light was not accessible or understood by the resident, further limiting the ability to request assistance. Facility policies required the development and consistent implementation of individualized care plans and fall prevention measures, including proper footwear and supervision. However, the care plan interventions were not reliably carried out, as evidenced by the resident's repeated falls, lack of non-skid footwear at the time of observation, and staff statements indicating lapses in supervision and intervention. The failure to consistently implement the care plan directly affected the resident's safety and well-being.
Delay in Physical Therapy Assessment Following Fall
Penalty
Summary
A resident with a history of repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder was not assessed by Physical Therapy (PT) in a timely manner following a fall. The resident's care plan identified significant risks for falls and wandering, and documented the need for supervision and assistance with mobility and transfers. Despite these risks and multiple falls, including an unwitnessed fall resulting in injury, there was a delay in PT evaluation after the most recent incident. Following a fall on 4/7/25, the Interdisciplinary Team (IDT) recommended a PT evaluation for an assistive device on 4/8/25, and a formal order for PT evaluation and treatment was placed on 4/11/25. However, the PT assessment did not occur until 4/17/25, which was 10 days after the fall, 9 days after the IDT recommendation, and 6 days after the order was placed. During this period, the resident continued to display impaired cognition and mobility, as observed by the surveyor, including being barefoot and unable to use the call light appropriately. Interviews with facility staff, including the PT Director and DON, confirmed that PT should have been notified and completed the evaluation as soon as possible. Both acknowledged that the delay was not in accordance with facility expectations or policy, and that timely notification and assessment are necessary. Facility policies require prompt assessment and intervention following falls, and the delay in PT evaluation was not consistent with these standards.
Failure to Provide Diet as Ordered by Physician and Dietician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including failure to thrive, dysphagia, and major depressive disorder did not receive a diet in accordance with physician orders and dietician recommendations. The resident, who was cognitively intact, had an active physician order for a general diet with pureed texture, thin liquids, super cereal at breakfast, whole milk with meals, ice cream at lunch and dinner, and pudding with meals. However, during a meal observation, the resident was served a mechanical soft diet with chicken, mashed potatoes, fruit, and lemonade, and did not receive the required whole milk, ice cream, or pudding. The dietary slip accompanying the tray listed a regular diet with mechanical soft texture and did not reflect the current physician-ordered diet or supplements. Interviews with facility staff, including a CNA, LPN, Dietary Manager, Registered Dietician, and DON, confirmed that the meal ticket and tray did not match the resident's current dietary orders. The Dietary Manager and DON acknowledged that the tray should have included the specified supplements and that the facility should be following the active physician orders. The facility's policy requires compliance with physician diet orders and coordination between nursing and dietary staff, but this process was not followed, resulting in the resident not receiving the prescribed diet.
Failure to Thoroughly Investigate Resident Altercation and Determine Root Cause
Penalty
Summary
The facility failed to conduct a thorough investigation and determine the root cause of an altercation between two residents, resulting in a deficiency related to abuse prevention and response. The incident involved one resident who was agitated in a common area and another resident who was exiting the elevator. During the encounter, the agitated resident made contact with the other resident's forehead, causing the latter to fall and sustain injuries, including redness and a bruise on the forehead. The injured resident reported being repeatedly punched in the head and expressed that the incident was not accidental, while staff and documentation provided conflicting accounts, with some suggesting the event was accidental. The facility's investigation was insufficient, as it did not reconcile the differing accounts from the residents and staff, nor did it adequately address the injured resident's statements that the altercation was intentional and involved multiple blows. The facility's administrator concluded the incident was accidental without substantiating this determination through a comprehensive review of all available evidence, including interviews and medical records. The facility's abuse prevention policy requires a thorough investigation of any alleged abuse, including interviews with all involved parties and review of pertinent documentation, which was not fully executed in this case. Additionally, the facility's documentation and staff interviews revealed inconsistencies regarding the nature and severity of the incident. The injured resident was alert and oriented, with an intact cognitive status, and clearly described the event as intentional. Despite this, the facility's final report characterized the incident as an accident, which was incongruent with the findings and the resident's account. The failure to conduct a complete and objective investigation had the potential to affect all residents in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, who was alert and oriented with a BIMS score indicating intact cognition, reported being struck multiple times in the head by another resident who was agitated and had a history of schizophrenia, anxiety disorder, and altered mental status. The incident occurred in a common area near the elevator, where the agitated resident made contact with the other resident's forehead, causing him to fall and sustain a large bruise on the forehead, a bump on the back of the head, and pain rated at 2 out of 10. Witnesses confirmed the injured resident was found on the floor and appeared hurt, while the aggressor was described as frequently agitated and difficult to redirect. Staff interviews and medical record reviews confirmed the sequence of events, with the injured resident stating he was repeatedly punched in the head and that the aggressor appeared to be holding a silver object, which he thought might be a knife. The aggressor's behavior was described as delusional and agitated, and he was not redirectable following the incident. The facility's abuse prevention policy states that residents have the right to be free from abuse, defined as the willful infliction of injury or pain, which was not upheld in this case.
Failure to Revise Care Plans After Abuse Incident and Community Access Changes
Penalty
Summary
The facility failed to revise and update comprehensive care plans for two residents following significant events related to abuse and community access. For one resident, after an altercation with another resident that resulted in a large bruise on the forehead and a report of being repeatedly punched, the care plan was not updated to address the risk for abuse or to reflect the incident. The Director of Nursing confirmed that the care plan did not include any information about abuse, despite the resident having an intact cognitive status as determined by a BIMS score of 13. Additionally, the same resident's care plan for supervised community access had an expired goal target date and was not updated in a timely manner, as acknowledged by the Social Service Director. For another resident, the care plan included expired goal target dates for both community access and abuse/neglect, with the resident expressing concerns about being on restriction and disputing the medical justification for it. The Social Service Director confirmed that the care plan did not reflect the current need for supervised community access and that the target dates were not current. The facility's policy requires care plans to be reviewed and revised after each assessment and with any significant change, but this was not followed for these residents.
Failure to Maintain Safety Precautions Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure ongoing precautions were put into place and consistently maintained, resulting in a resident, R2, falling out of bed and sustaining a right femur fracture. R2, a 67-year-old resident with severe morbid obesity, bilateral primary osteoarthritis of the knee, and other medical conditions, was cognitively intact but required maximum assistance with bed mobility and was totally dependent on staff for ADL incontinence care and personal hygiene assistance. Despite these needs, the facility did not adequately follow R2's care plan, which included ensuring R2 was centered in bed while sleeping and checking and changing R2 three times per shift for incontinence. On the day of the incident, a Certified Nurse Assistant (CNA), V5, observed R2 sleeping in a twisted position near the edge of the bed but did not reposition R2 to the center of the bed or check for incontinence to avoid waking R2. Later, V5 found R2's leg hanging out of the bed and, before assistance could be provided, R2 fell to the floor. R2 reported that V5 pushed her over while trying to remove linen, despite R2's protest that she was at the edge of the bed. However, V5 denied pushing R2 and stated that R2 was already hanging off the bed when she arrived. The facility's failure to adhere to R2's care plan and provide adequate supervision and assistance contributed to the fall. The Assistant Director of Nursing and other staff acknowledged that if V5 had repositioned R2 and provided incontinence care as per the care plan, the fall might have been preventable. The incident was reported to the Illinois Department of Public Health, and an investigation was conducted, but the abuse allegation was not substantiated.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide bedtime snacks to residents who wished to eat outside of scheduled meal service times, potentially affecting all 235 residents receiving oral diets. Observations and interviews revealed that residents were not receiving adequate snacks, with one resident keeping a slice of pizza in her bed to eat when hungry between meals. Another resident reported that snacks were scarce and had to be fought for, with only a small tray of snacks being sent up, requiring residents to be on a specific snack list to receive them. The meals provided were described as insufficient, particularly breakfast, and were often late, exacerbating hunger among residents, especially those on psychiatric medication. The Food Service Director confirmed that snacks were primarily prepared for residents on a snack list, which included diabetics and those who had requested snacks, with only a few extra snacks sent for others. The facility's documentation showed a 14.5-hour gap between dinner and breakfast, exceeding the policy limit of 14 hours unless a substantial evening snack is provided. The facility's policy also required that a bedtime snack be offered to all residents, which was not being adhered to, as evidenced by the limited number of residents on the snack list compared to the total number of residents with oral diets.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage, affecting multiple residents across different floors. On the third floor, a medication cart was found with loose pills of various colors and shapes, which the LPN could not identify. Additionally, several medications, including insulin vials and inhalers, lacked open and expiration dates, and some were expired. The LPN acknowledged that expired medications should be discarded and that multi-dose vials and inhalers should be labeled with open and expiration dates. The third-floor medication refrigerator was found to be improperly maintained, with temperatures recorded at 53 and 48 degrees Fahrenheit, exceeding the recommended range of 36 to 46 degrees Fahrenheit. The LPN was unable to provide a temperature log for February 2025, and there was confusion about the origin of the log that was later presented. This lack of proper temperature control and documentation could compromise the efficacy of medications requiring refrigeration. On the first and second floors, similar issues were observed with loose pills in medication carts and medications lacking proper labeling. Expired medications were found, and a medication for a discharged resident was not removed from the cart. The facility's policy on medication storage, which requires proper labeling and temperature control, was not adhered to, leading to these deficiencies.
Deficiency in Personal Refrigerator Management
Penalty
Summary
The facility failed to ensure proper management of personal refrigerators for residents, leading to expired food items and inadequate temperature monitoring. Specifically, two residents, aged with various medical conditions including Type 2 diabetes and hypertension, were found to have expired milk in their personal refrigerators. These refrigerators lacked thermometers and temperature logs, and there were visible signs of uncleanliness, such as brown frozen or liquid substances at the bottom. The Housekeeping Director, who was responsible for maintaining these refrigerators, was absent for a week, and the housekeeping staff did not fulfill their duties of cleaning, temperature logging, and ensuring the presence of thermometers. Additionally, other residents' refrigerators were found without thermometers and temperature logs, and there was a lack of clarity among staff regarding who was responsible for monitoring these appliances. One resident's refrigerator had a temperature log that was not updated daily, with several missing entries. Despite the facility's policy requiring daily temperature checks and cleanliness maintenance by the housekeeping department, these procedures were not followed, potentially affecting all residents with personal refrigerators.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) while providing high contact care to a resident with Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) was seen providing perineal care to a resident with a chronic wound without wearing the required gown and gloves. The CNA justified the lack of PPE by stating that they were not near the wound area. This oversight has the potential to affect all 69 residents on the second floor. The Director of Nursing (DON) and the Infection Preventionist (IP) were not fully aware of the requirements for EBP, particularly for residents with chronic wounds. The IP admitted that the resident was not on the list for EBP, did not have orders in their chart for EBP, and was not care planned for EBP. The facility's document on EBP indicates that residents with chronic wounds should be on EBP to reduce the risk of transmitting multidrug-resistant organisms. The IP acknowledged the oversight and stated that a system was being worked out to ensure proper alerts for such cases.
Failure to Cover Catheter Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that the indwelling catheter drainage bags for two residents were covered with privacy bags, compromising their dignity. Resident R101 was observed in bed with an uncovered catheter drainage bag hanging on the lower part of the bed, facing the entrance of the doorway. R101 has a diagnosis of obstructive and reflux uropathy and unspecified hydronephrosis, with a BIMS score indicating some cognitive impairments. The care plan for R101 specified that the catheter bag should be positioned below the bladder and away from the entrance room door, but this was not adhered to. Similarly, Resident R56 was observed sitting in a wheelchair with an uncovered catheter drainage bag. R56 has a diagnosis of displacement of an indwelling ureteral stent, sequela, and also has cognitive impairments as indicated by a BIMS score. A CNA acknowledged the absence of a privacy bag and mentioned that R56 had just returned from the hospital. Both the CNA and an LPN recognized the importance of using privacy bags for maintaining resident dignity. The Director of Nursing confirmed that the drainage bags should be covered to maintain dignity and prevent infection.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 13, who has multiple diagnoses including Cerebral Palsy and Mild Intellectual Disabilities, was observed with a call light device wrapped around the side rail and not within reach. Despite having a hand splint on her left hand, the intervention in her care plan encouraged her to use a bell to call for assistance. A Licensed Practical Nurse confirmed that Resident 13 could not reach or use the call light, indicating a failure to provide an accessible call device. Similarly, Resident 41, who has diagnoses including Cerebral Infarction and Hemiplegia, was found with the call light on the floor behind the bed, out of reach. Although Resident 41's care plan also encouraged the use of a bell for assistance, the call light was not accessible. A Certified Nursing Assistant and the Director of Nursing both acknowledged that the call light should be within reach of the resident. The facility's call light policy mandates that the call light system be available and easily accessible to residents at all times, which was not adhered to in these cases.
Failure to Document Advanced Directives for Residents
Penalty
Summary
The facility failed to obtain a doctor's order for Advanced Directives for two residents, R133 and R56, which was identified during a survey. R133, who is cognitively intact with a BIMS score of 14, has a medical history of chronic obstructive pulmonary disease, diabetes, end-stage renal disease, and hypertensive heart disease. Despite these conditions, R133's Order Summary Report and Admission Record Form lacked a physician order for an Advanced Directive, leaving the section blank. Interviews with LPNs revealed that the Advanced Directive order should have been obtained and entered into the computer upon admission, but this was not done for R133. Similarly, R56, who has some cognitive impairments with a BIMS score of 9, was admitted with a diagnosis including displacement of an indwelling ureteral stent. R56's physician order sheet initially did not include a code status, which was only added upon request. The Director of Nursing explained that the code status should be reviewed and documented upon admission to prevent inappropriate actions during emergencies. The facility's policy requires a written physician's order for Advanced Directives, but this was not followed for R56, as the code status was not documented in the physician's orders upon the resident's return to the facility.
Resident's Bed Found with Old Food Due to Staffing Shortage
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident, identified as R589, who was found with old food, condiments, and a meal tray in her bed. R589, who is cognitively intact with a BIMS score of 14, reported having a slice of pizza in her bed since the previous Friday, which she consumed intermittently due to a lack of snacks between meals. This situation was observed during a survey, and the resident expressed that she forgot to dispose of the pizza. The Certified Nurse Assistant (CNA) assigned to R589 admitted to placing the meal tray on the resident's bed due to the absence of a bedside table and a shortage of staff, as the unit was short one CNA at the time. The Licensed Practical Nurse (LPN) acknowledged that food should not be in the resident's bed due to unsanitary conditions. The Housekeeping Director confirmed that each resident should have a bedside table and that old food should be removed by either CNA or housekeeping staff. The facility's job description for CNAs and the housekeeping cleaning schedule emphasize the importance of maintaining a clean and sanitary environment.
Failure to Complete PASARR for New Admission
Penalty
Summary
The facility failed to complete a new pre-admission screening and resident review (PASARR) for a resident upon admission. This deficiency affected one resident who had multiple diagnoses, including Hemiplegia, Dementia with Behavioral Disturbance, Major Depressive Disorder, Bipolar Disorder, and Mood Disorder with Manic Features. The resident was receiving Quetiapine Fumarate for Bipolar Disorder, and their Brief Interview of Mental Status score was 10. Despite these conditions, there was no Level 1 or Level 2 PASARR found in the facility's Point Click Care software for the resident. The deficiency was identified when the surveyor requested the PASARR documentation, and the facility staff, including the Administrator and Assistant Administrator, confirmed the absence of the required screening. The Assistant Administrator mentioned that the resident was not in the Maximus system, which is used to monitor and update PASARR screenings. The Admission Director explained that new residents should come with a Level 1 PASARR screening from the hospital or have one completed immediately upon admission. However, the resident in question was admitted before the facility began using the Maximus system, leading to the oversight.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident, identified as R74, received her scheduled showers. R74, who is cognitively intact with a BIMS score of 13, has multiple diagnoses including contracture of muscle, cerebral infarction, and hemiplegia, which render her dependent on staff for showers, baths, and transfers. According to her care plan, she has a functional ability self-care and mobility deficit due to the effects of cerebral infarction. Despite having a bathing order for showers on Sundays and Wednesdays, R74 reported not having received a shower for over a month prior to January 26, 2025, and expressed dissatisfaction with the bed baths provided, stating they were inadequate. The facility's documentation survey report for the period of January 1 to January 29, 2025, corroborates R74's account, showing only one shower on January 26, 2025, and weekly bed baths on four occasions. There is no documentation of showers on the scheduled dates of January 5, 12, and 19, 2025. The Assistant Director of Nursing confirmed that each resident should be showered or bathed on their scheduled days and that any refusal should be documented. However, the lack of documentation for the missed showers indicates that the activity did not occur, highlighting a failure in adhering to the resident's care plan and facility policy regarding personal hygiene assistance.
Improper Use of Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure proper use of a low air loss mattress for a resident identified as R13, who was at high risk for pressure ulcers. R13, who has multiple diagnoses including Cerebral Palsy, Type 2 Diabetes Mellitus, and mild intellectual disabilities, was observed lying on a low air loss mattress with an incontinence brief, mattress pad, and a flat sheet underneath. This setup was contrary to the manufacturer's guidelines and the facility's policy, which state that only a thin cotton sheet should be used over the mattress to prevent skin breakdown and promote healing. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident should have had only a flat sheet and a mattress pad or incontinence brief under them. The improper layering of linens on the low air loss mattress compromised its effectiveness in preventing and treating pressure ulcers, as outlined in the manufacturer's guide and the facility's pressure ulcer prevention policy. This deficiency was identified during a survey and affected one resident in a sample size of 84.
Failure to Supervise Fall-Risk Residents in Dining Room
Penalty
Summary
The facility failed to ensure adequate supervision for residents at risk for falls in the dining room, affecting two residents, R82 and R88. R82 has a history of hypertension, schizophrenia, schizoaffective disorder, and type 2 diabetes mellitus, with a severely impaired mental status and a high fall risk score of 15. R88 has dementia with behavioral disturbances and epilepsy, with moderately impaired cognitive skills and a fall risk score of 10. On a specific date, both residents were left unsupervised in the dining room, despite being identified as at risk for falls. Staff members, including the Wound Care Coordinator and the Administrator in Training, were present but did not provide continuous supervision. The Director of Nursing and the Restorative Nurse confirmed that residents at risk for falls should be supervised to prevent accidents. However, there was no formal policy on supervision, only an expectation of frequent monitoring and keeping fall-risk residents within sight. The facility's Fall Prevention Program emphasizes the need for safety interventions for residents identified at risk, but these measures were not adequately implemented in this instance. The lack of supervision in the dining room contravened the residents' rights to safety as guaranteed by state and federal laws.
Failure to Change Nebulizer Mask as per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing of oxygen equipment, specifically a nebulizer mask, for a resident with asthma and hypertensive heart disease with heart failure. The resident, who has cognitive impairments as indicated by a BIMS score of 6, was observed with a nebulizer mask that had not been changed since June 17, despite the facility's policy requiring weekly changes. This oversight was confirmed through interviews with a CNA and an LPN, both of whom indicated that the responsibility for changing the nebulizer mask lies with the night shift nurse. The Director of Nursing (DON) reiterated that the nebulizer mask should be changed weekly and as needed to maintain hygiene and prevent infections. The facility's documented guidelines emphasize the importance of changing disposable respiratory supplies to minimize infection risk. However, the failure to change the nebulizer mask as per the facility's policy was observed, indicating a lapse in infection control practices and adherence to established procedures.
Failure to Maintain Accurate Narcotic Count and Documentation
Penalty
Summary
The facility failed to ensure proper narcotic count procedures were followed, affecting one resident who was receiving controlled drug administration. During a medication cart review, it was observed that the shift change controlled substance inventory count sheet was missing from the narcotic binder. Additionally, there was a discrepancy in the narcotic count for the resident's Tramadol 50 mg tablets, with the Controlled Drug Administration record showing 21 tablets while only 20 tablets were present in the medication bingo card. The Licensed Practical Nurse (LPN) admitted to administering a Tramadol tablet to the resident without signing the Controlled Drug Administration Record. The Director of Nursing (DON) confirmed that the facility's policy requires nurses to document the narcotic count and sign off on the controlled drug administration sheet at the time of administration. The policy also mandates that any discrepancies in the narcotic count be reported to the Nursing Director for reconciliation. The facility's policy, revised in 2017, emphasizes the importance of counting controlled substances with a partner and verifying the accuracy of log sheets at the beginning and end of each shift. The LPN's failure to adhere to these procedures resulted in an inaccurate narcotic count and lack of proper documentation.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to implement adequate fall interventions for a resident, resulting in serious injury. The resident, a male with multiple diagnoses including Parkinson's disease, dementia, and a history of falls, was at high risk for falls. Despite being alert and able to verbalize needs, the resident was forgetful and impulsive, requiring persistent redirection for safety. On the day of the incident, the resident attempted to pick up an item from the floor while seated in his wheelchair, lost balance, and fell forward, sustaining cervical fractures. The resident's care plan included interventions such as using a sticky pad to prevent sliding from the wheelchair and re-educating the resident to lock the wheelchair when stationary. However, the report indicates that it was unclear whether the wheelchair was locked at the time of the fall, which could have contributed to the injuries. The resident was found on the floor with a laceration on the forehead and complained of significant pain, leading to hospitalization for cervical spine fractures. Interviews with staff revealed that the resident was known to be non-compliant with safety instructions and often attempted to perform tasks independently despite being unable to walk unaided. The facility's fall prevention program required assessing individual needs and implementing appropriate interventions, but the documentation did not confirm if all necessary measures, such as ensuring the wheelchair was locked, were in place at the time of the fall.
Pest Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of roaches in residents' rooms, affecting three residents directly and potentially impacting all 242 residents in the facility. Resident R3, who is cognitively intact, reported a significant roach problem in their room, exacerbated by a roommate who hoards food and dishes. Despite multiple complaints to housekeeping, the issue persisted. Similarly, R4, with moderate cognitive impairment, and R5, who is cognitively intact, also reported ongoing issues with roaches in their rooms. Observations confirmed the presence of live and dead roaches in these areas. The facility's Service Inspection Reports documented recurring roach infestations in various parts of the facility, including resident rooms, the kitchen, and common areas, over several months. The reports highlighted the need for thorough cleaning after pest control treatments to prevent re-infestation. The facility's pest control policy mandates maintaining conditions that prevent pest harborage, yet the repeated sightings and resident complaints indicate a failure to adhere to this policy effectively.
Inadequate Smoking Supervision in Facility
Penalty
Summary
The facility failed to implement adequate safety precautions to address the risk of residents smoking inside their rooms and other areas, which poses a significant fire hazard. Two residents, identified as R3 and R5, were observed engaging in smoking activities within the facility, despite the established smoking policy that restricts smoking to designated outdoor areas. R3, who has a history of smoking in prohibited areas, was observed smoking in the fourth-floor lounge and her bathroom. The facility's records, including R3's care plan and social services notes, document her inappropriate smoking behavior, yet effective measures to prevent such actions were not evident. R5, another resident with a history of mental health issues and nicotine dependence, was also found to be involved in smoking inside the facility. R5 was observed with a cigarette in the elevator and admitted to planning to smoke it later in his room. Despite the facility's policy and smoking assessment indicating that R5 requires supervision while smoking, there was no evidence of adequate supervision or intervention to prevent R5 from smoking indoors. The facility's social services director acknowledged the ongoing issue of residents smoking inside and the challenges in completely eliminating this behavior. The facility's administrator confirmed reports of residents smoking in their rooms and acknowledged the associated health and fire hazards, especially considering the presence of residents on oxygen. Although the facility has implemented some measures, such as searching visitor bags and testing residents suspected of drug use, these actions have not been sufficient to prevent residents from smoking inside the building. The facility's smoking safety policy outlines designated smoking areas and the need for smoking assessments, but the lack of enforcement and supervision has contributed to the continued occurrence of indoor smoking by residents.
Failure to Conduct Resident Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents participated in care planning conferences, as required, for three residents who were cognitively intact. The clinical records for these residents lacked documentation of any care plan meetings since their admission. Interviews with the residents confirmed that they had not been informed of or participated in any care plan meetings. One resident expressed frustration about not having a care plan meeting scheduled despite being close to discharge. Interviews with facility staff, including the Social Service Director, Director of Nursing, and MDS Coordinators, revealed a lack of clarity and coordination in scheduling and documenting care plan meetings. The staff members were unsure of the scheduling process and had not attended any care plan meetings for the residents in question. The facility's policy requires that a comprehensive care plan be developed and reviewed with the resident or their representative at least quarterly, but this was not adhered to in these cases.
Failure to Provide Comprehensive Bladder Function Assessment and Care Planning
Penalty
Summary
The facility failed to provide appropriate and sufficient services to ensure comprehensive bladder function assessment and care planning for residents with indwelling urinary catheters. Specifically, the facility did not complete a comprehensive bladder function assessment or develop a comprehensive care plan for two residents with indwelling urinary catheters. Additionally, the facility failed to address a resident's urinalysis results, leading to untreated dysuria and burning upon urination for several weeks. One resident, who had recently completed a course of antibiotics, reported burning upon urination. A urinalysis was ordered and collected, revealing significant abnormalities, but the results were not communicated to the provider in a timely manner. The resident continued to experience symptoms without appropriate follow-up care. The facility's process for notifying providers of laboratory results was not followed, and there was no documentation of provider notification in the electronic health record. Another resident, who was admitted with multiple diagnoses including urinary retention, was found to have an indwelling urinary catheter without a completed bladder function assessment or a care plan addressing the catheter use. The resident expressed distress and agitation about the catheter, indicating a lack of appropriate assessment and care planning. The facility's policies for bowel and bladder assessment and comprehensive care planning were not adhered to, resulting in inadequate care for residents with indwelling urinary catheters.
Failure to Provide Mail Services on Saturdays
Penalty
Summary
The facility failed to provide mail services to residents on Saturdays, affecting all 213 residents. During a resident council group meeting, multiple residents reported that mail is not delivered to them on Saturdays. The mail delivery process involves the business office first checking the mail, then passing it to the receptionist, who then gives it to the Activity department for final delivery to residents. However, since the business office does not work on weekends, mail delivered on Saturdays is not sorted and distributed until Monday. Additionally, residents reported that their mail is sometimes opened when they receive it. The Activity Director confirmed that Activity Aide staff members are expected to deliver mail every day, including Saturdays. The receptionist corroborated that mail is delivered on weekends but is not dispersed until the business office sorts it. The Business Office Manager stated that she is the only one who checks the mail first and opens mail from specific agencies like the Department of Human Services and the Social Security office, which is then uploaded into the resident's electronic medical record. This protocol results in delays and potential privacy violations, as residents' mail is sometimes opened without their permission.
Inadequate Staffing and Delayed Maintenance
Penalty
Summary
The facility failed to ensure adequate staffing to provide care for the residents, affecting all 213 residents. Interviews with staff revealed that there were frequent call-offs, especially on weekends, making it challenging to complete their jobs and take care of the residents. The Human Resource Director/Nursing Staff Scheduler confirmed that the facility was short-staffed on multiple occasions between October 1, 2023, and December 31, 2023. The facility does not use agency staff and has been relying on contracted nurses since January 2024 to improve staffing levels. The Director of Nursing and the Administrator acknowledged the staffing issues, noting that there has been an improvement since January 2024. However, during the period from October to December 2023, the facility was short-staffed on several dates, affecting both CNAs and nurses across different shifts and floors. Additionally, maintenance issues were reported, with repairs being delayed until weekdays due to the absence of maintenance staff on weekends. This led to resident complaints about delayed repairs for issues like a leaking toilet and a broken television antenna.
Improper Food Handling and Sanitization Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items, proper storage of scoops, adherence to manufacturer's guidelines for food storage, and correct sanitization of cooking equipment. During an initial kitchen tour, several food items in the walk-in cooler and kitchen prep cooler were found unlabeled and undated, including gelatin mixed with fruit, liquid eggs, meat sandwiches, shredded mozzarella cheese, vanilla pudding, sliced American cheese, fruit cocktail, fresh tomato, grape jelly, and pancake/waffle syrup. Additionally, an ice machine scoop was found laying directly on top of the ice, and a clear plastic scoop was left uncovered on top of a thickener container. The soy sauce was stored at room temperature despite the manufacturer's guideline to refrigerate after opening. These observations were confirmed by the cook and the food service director, who acknowledged the lapses in proper food handling and storage practices. The facility also failed to properly sanitize cooking equipment according to the manufacturer's directions. An industrial blender used to prepare pureed ham was not fully sanitized; the lid was dipped in sanitizing solution for less than 5 seconds, and the blender container was not placed in the sanitizing solution at all. The equipment was returned to the preparation area while still wet, and the cook proceeded to use it to prepare food. The food service director and a former food service manager confirmed that the sanitizing solution requires a contact time of 60 seconds to be effective, and the facility's policy mandates that items be air-dried completely before being put away. The facility's policies on labeling and dating foods, using a three-compartment sink, and storing utensils were not followed, leading to potential risks of cross-contamination and foodborne illness. The facility's provided policies and the manufacturer's guidelines for the sanitizing solution were not adhered to, as confirmed by the food service director and the former food service manager. These deficiencies have the potential to affect all 209 residents receiving food prepared in the facility's kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster lids were covered to prevent the harborage and feeding of pests, insects, and rodents. During an observation of the outside garbage dumpsters with the Former Food Service Manager, it was noted that two out of the four dumpster lids were fully opened. The Former Food Service Manager acknowledged that the lids should be fully shut to prevent rodents from getting inside and to prevent garbage from flying outside the dumpster. The Housekeeping Director also confirmed that the dumpster lids should always be kept shut to keep away animals and pests. Despite these instructions, a surveyor observed two of the four dumpster lids wide open later in the day. The facility's kitchen policy on garbage and rubbish disposal, dated 2020, mandates that outdoor trash receptacles be kept covered and the surrounding area kept free of litter.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,379 citations issued within 25 miles in the last 12 months — including the 25 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) |
|---|---|---|---|---|
| Chalet Living & Rehab | 0.2 mi | ★★★★★ | 18 | 1 |
| Atrium Health Care Center | 0.2 mi | ★★★★★ | 6 | 0 |
| Waterford Care Center, The | 0.3 mi | ★★★★★ | 12 | 0 |
| Fargo Health Care Center | 0.4 mi | ★★★★★ | 4 | 0 |
| Birchwood Plaza | 0.4 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.