Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arc At Normal during CMS and state inspections, most recent first.
Failure to prevent resident-to-resident physical abuse occurred when two residents with dementia-related behaviors became involved in an altercation after one resident wandered into the other resident’s room and took a TV remote. One resident struck the other in the face, and the other struck back. Records showed one resident had severe cognitive impairment, wandering, and a history of potential aggression, while the other had multiple neurocognitive and psychiatric diagnoses. Staff interviews confirmed the incident was abuse and that the residents were separated after the event.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Multiple residents with dementia, depression, cognitive impairment, or identified abuse risk were involved in incidents of physical and verbal abuse, including one resident kicking another, one resident throwing water and being hit in return, a resident striking another on the buttocks during care, and a staff member slamming doors and shouting near residents. In addition, a CNA who was not a licensed cosmetologist cut a resident’s hair after finding knots during shower care, despite the resident later stating they did not want their hair cut and the guardian reporting that consent had not been given beforehand or informed of the option to use a licensed cosmetologist. Documentation showed the resident had bruising to the hands around the same time, and the resident’s contract and care plan emphasized the right to refuse services and the need for trauma-informed care and protection from abuse.
A resident with moderate cognitive impairment and multiple cardiac-related diagnoses, who required staff assistance for dressing, was repeatedly observed lying in bed wearing only an ill-fitting adult brief, partially covered by a sheet, and visible from an open doorway. The resident reported waiting many hours for help to put on pants and experiencing long waits for dressing assistance several times a week. Facility documents, including the admission packet and resident rights policy, affirmed the right to dignity, bodily privacy, and an environment that supports individuality and respect, while the DON stated that care requests should not exceed a one-hour wait and that dignity must always be considered.
A CNA, who had not been trained in resident transportation, used a personal vehicle while off duty to take a resident with hemiplegia and wheelchair dependence to the resident’s home without authorization or a physician order, and accepted $50.00 from the resident as compensation. The resident was away from the facility for several hours, yet there was no documentation in the nurse’s notes of the resident being out of the facility, and no incident report or required 72-hour documentation was completed, despite facility policies requiring trained personnel for transport and reporting of unauthorized departures.
A resident admitted with a thoracic vertebra compression fracture and ADL deficits did not have a complete baseline care plan developed and implemented. Although a focus assessment for ADL deficits was initiated, the care plan lacked documented goals and interventions for multiple focus areas. The MDS/care plan coordinator confirmed that the plan was not comprehensive, despite facility policy requiring timely review of a baseline plan of care by the IDT.
A resident with dementia, hip fracture, and multiple chronic conditions experienced escalating pain and new bruising over several days, with CNAs repeatedly observing the resident yelling in pain and noting bruising to the chest and changes such as spitting out food, stopping self-feeding, low-grade temperature, and leg contracture. LPNs were informed of the pain and bruising, and one LPN documented increased pain and began giving pain medication regularly, but did not assess the bruises or notify the physician or other appropriate personnel. The MAR showed frequent high pain scores despite ongoing pain medication, and there was no documented MD notification of the increased pain until several days later, contrary to the facility’s pain management policy requiring MD notification for changes in condition and ongoing assessment of pain control effectiveness.
Two residents with dementia and behavioral issues were involved in a physical altercation after one threw a liquid at the other, leading to a choking motion and physical contact. Staff separated the residents and reported the incident, but documentation did not show that the agitated resident was removed from the area prior to the event, despite known behavioral risks.
Two residents with significant fall risks did not have their care plans updated with new interventions after experiencing falls, despite the facility's policy requiring care plan revisions after such events. In both cases, the interdisciplinary team identified new interventions, but these were not transcribed into the care plans, and one intervention was not documented as completed.
A resident with multiple fractures and dependent on a mechanical lift experienced a fall from a wheelchair after the lift sling straps became tangled in the wheel and the seatbelt was found to be broken. The care plan did not include updated interventions to address these risks, and staff were aware of the broken seatbelt but did not notify maintenance for repair.
Several incidents occurred where residents with cognitive impairment physically assaulted other residents, including slapping, hitting with objects, and grabbing, often during routine activities or minor disputes. Staff witnessed and intervened in these altercations, and assessments were conducted to check for injuries. The facility's policy defines and requires investigation of all such willful actions, regardless of the residents' cognitive status.
The facility failed to accurately complete MDS assessments for two residents, including incorrect documentation of antipsychotic medication administration, misclassification of a fall with a fracture, and improper discharge coding for a resident who died after a hospital transfer. These errors were due to reliance on incomplete records and misunderstanding of MDS requirements.
Two residents experienced deficiencies in medical record accuracy and medication documentation. One resident received an anti-anxiety medication beyond the allowed duration due to a transcription error that was not corrected, while another resident's intravenous antibiotic administrations were not documented by the DON, leaving several days unrecorded.
Two residents experienced physical abuse from other residents, resulting in pain and injury. In both cases, residents with dementia and other behavioral disturbances were involved in altercations that led to one resident being struck on the hand and another being scratched. Staff and witness statements confirmed the incidents, and the facility did not prevent these occurrences.
A resident experienced a fall and subsequently reported new and worsening pain, increased confusion, and loss of mobility and continence. Despite these changes, nursing staff did not notify the physician for several days, delaying medical evaluation and treatment. When finally assessed, the resident was found to have a displaced right femoral neck fracture and had suffered a significant decline in cognitive and functional status.
A resident who suffered a fall and developed new onset pain did not receive any pain medication or treatment for two days, despite repeated complaints and a significant decline in cognitive status. Nursing staff did not notify the physician of the resident's increased pain and confusion until two days after the incident, resulting in delayed diagnosis of a displaced femoral neck fracture and hospital transfer.
A resident who is cognitively intact and dependent for toileting care reported being physically abused by a CNA, who forcefully pressed on the resident's sternum during care. The incident was witnessed by another CNA and reported to the administrator, but was documented as a grievance instead of being investigated as abuse. The DON confirmed that staff are not trained to restrain residents in this manner, and the administrator later acknowledged the incident should have been treated as abuse.
A resident reported being handled roughly by a CNA, resulting in pain to the sternum area. Another CNA present confirmed the use of physical restraint during care. The allegation was reported to the facility administrator by a staff member, but the administrator initially treated it as a grievance rather than an abuse allegation, delaying the required report to the State Agency until the following day.
A resident with multiple medical conditions was not given Lactulose as ordered upon admission, due to a failure in medication reconciliation and review of discharge paperwork. This omission led to a decline in mental status and subsequent hospitalization for hepatic encephalopathy, with improvement only after the medication was administered in the hospital.
A significant number of residents did not have access to necessary towels and washcloths for daily care, as confirmed by staff interviews and observations of empty linen rooms. CNAs reported frequent shortages, leading them to use paper towels or toilet paper for resident hygiene. The housekeeping supervisor acknowledged the issue, and the administrator confirmed that this practice was not acceptable.
A resident with a history of aggression physically struck another resident twice, despite care plan interventions intended to address such behaviors. Staff witnessed and separated the residents, but the aggressor was able to return and strike again. The incident was reported to police, and the administrator was unaware of the full extent of the event or the aggressor's prior history.
The facility failed to conduct quarterly fall risk assessments and implement necessary fall prevention measures for three residents, resulting in a serious fall incident for one resident who was hospitalized. The residents, all with severe cognitive impairments and histories of falls, did not receive the required interventions such as non-skid materials in wheelchairs and proper bed positioning, as outlined in their care plans.
The facility employed a dietary manager who has not completed the required training to qualify for the position, potentially affecting all 105 residents. The DM, who has been in the role since November 2024, was observed supervising staff during meal service without the necessary qualifications, as confirmed by the Regional Dietary Manager.
The facility's kitchen was found to have unsanitary conditions, including rust and grease-like debris on a metal shelf, loose caulking in the sink, and dust-like substances hanging over a food preparation table. These conditions posed a risk of cross-contamination and food-borne illness for all 105 residents. The Dietary Manager acknowledged the potential risk of contamination.
The facility failed to maintain comfortable room temperatures for several residents, with temperatures recorded as low as 63.2°F. Residents reported discomfort and required extra blankets or warm clothing. The Maintenance Director acknowledged the issue, noting the boiler system was functioning but not effectively warming rooms. Consultation with the heating company suggested using the parking garage heating system to help, but no immediate actions were taken.
The facility failed to conduct side rail assessments and obtain informed consent for three residents. One resident had a side rail installed without a recent assessment, while another had side rails despite the care plan indicating otherwise. A third resident also had side rails without recent assessments. The nursing staff confirmed the lack of assessments for all three residents.
A facility failed to properly secure a resident's indwelling catheter tubing to their wheelchair, resulting in the tubing dragging on the floor on two separate occasions. A CNA confirmed the improper positioning, which violated the facility's Catheter Care Policy designed to prevent infections by ensuring urinary drainage bags and tubing do not touch the floor.
The facility failed to administer IV medications on time for two residents with osteomyelitis, leading to significant delays in treatment. One resident received Vancomycin HCl 6 hours late, while another received Ceftriaxone Sodium 9 hours late. The DON left early and was unaware of the issues, and documentation was not completed on time.
A resident with dementia and behavioral disturbances was witnessed by an LPN inappropriately touching another resident with severe cognitive impairment in a common area. The incident resulted in psychosocial harm to the victim, who was unable to consent due to her condition. The facility's policy affirms residents' rights to be free from such abuse, indicating a failure to protect the resident.
A facility failed to update a resident's care plan and behavior monitoring after an incident of inappropriate touching of another resident. Despite the resident's history of making sexual advances, the care plan did not include interventions to address or prevent this behavior, contrary to the facility's Behavioral Health Services Program requirements.
The facility failed to protect residents from sexual abuse, as evidenced by an incident where a resident with dementia entered another resident's room and engaged in non-consensual sexual contact. The incident was reported to the Medical Director and the police, and the resident was placed under 1:1 observation.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse for two residents, R3 and R4, in a sample of 17 residents. R4’s care plans documented dementia, severe cognitive impairment, wandering behavior, and a history of potential aggressive behavior, including being combative with care and potentially kicking, hitting, pushing, grabbing, or biting others. R3’s care plan documented multiple diagnoses including dementia, psychotic disturbances, mood disturbances, anxiety, and neurocognitive disorder with Lewy bodies, while the MDS documented R3 as cognitively intact. The facility’s abuse prevention policy stated that it prohibited abuse and aimed to establish a resident-sensitive and resident-secure environment and identify occurrences and patterns of potential mistreatment. On 4/5/2026, an incident note documented an alleged physical altercation between two residents, with residents immediately separated and the POA, MD, police, and ombudsmen notified. During interviews on 5/14/2026, R3 stated that R4 wandered into R3’s room, took the TV remote, and hit R3 in the face after R3 took the remote back, and that R3 hit R4 back. An LPN stated R4 wandered to R3’s room, took the remote, and hit R3, and a CNA stated R3 yelled for R4 to get out of the room and not hit R3 in the face again. The Administrator stated that R3 and R4 hitting each other was a form of abuse and should have been prevented.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Failure to Prevent Resident Abuse and Obtain Proper Consent for Grooming
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and to honor resident rights related to personal care. Several residents with cognitive impairment, dementia, depression, and high or moderate risk for abuse were involved in incidents of physical and verbal abuse. One cognitively intact resident kicked another resident in the shin after threatening them, and another resident threw water on a peer who then hit them on the arm. In a separate incident, a resident entered a bathroom while a CNA was providing care to another resident and struck that resident on the buttocks twice. Another event involved an assistant dietary manager slamming doors near two residents while loudly asserting authority, behavior that was documented as disorderly and misconduct. These events occurred despite care plans identifying certain residents as being at high or moderate risk for abuse and the facility having an abuse prevention and reporting policy defining physical, verbal abuse, exploitation, and neglect. The facility also failed to protect a resident’s rights regarding grooming and consent. A CNA, who was not a licensed cosmetologist or barber, cut a resident’s hair after knots were found while providing shower care, and the resident later stated that their hair was cut against their wishes and that it was done poorly. The resident’s guardian reported not having given consent prior to the haircut, was unaware that a CNA rather than an LPN or beautician performed the cut, and was not informed of the option to use a licensed cosmetologist who routinely visited the facility. Documentation shows that the guardian’s consent was recorded after the incident and that the resident had existing and new bruising to the hands around the same period. The resident’s admission contract states the right to refuse services unless court ordered, and the care plan notes impaired cognitive function, high risk for abuse, trauma-informed care needs, and impaired visual function, underscoring the importance of obtaining proper consent and protecting the resident from unwanted interventions.
Failure to Maintain Resident Dignity and Timely Assistance With Dressing
Penalty
Summary
Surveyors identified a failure to maintain a resident’s dignity and quality of life when staff left a cognitively impaired resident in bed wearing only an ill-fitting adult brief, with inadequate covering, and visible from the open doorway on multiple occasions. The resident, admitted with diagnoses including non-ST elevation myocardial infarction, encounter for palliative care, weakness, acute on chronic systolic (congestive) heart failure, and hyperlipidemia, had a care plan indicating the need for assistance from one staff member for dressing and an MDS BIMS score of 8, reflecting moderate cognitive impairment. The admission packet and facility policy documented the resident’s rights to dignity, bodily privacy, respect, and an environment that supports individuality, independence, and choice. On one observed date at 1:06 PM, the resident was found lying in bed in only an ill-fitting adult brief with just one flat sheet available for covering, and the resident was visible from the open entry doorway. At that time, the resident reported having waited since 7:00 AM to have pants put on. Later that afternoon at 2:54 PM, the resident was again observed lying in bed with only a sheet half covering the body, the door open, and no clothing other than the adult brief. The resident reported experiencing long wait times for help with dressing a couple of times a week and expressed that staff did not like them. The DON stated that resident requests for care should not exceed a one-hour wait time and that dignity should always be considered, indicating that the observed delays and lack of privacy were inconsistent with facility expectations and written resident rights policies.
Unauthorized Resident Transport and Misappropriation of Funds by CNA
Penalty
Summary
Facility staff failed to protect a resident from misappropriation of money and unauthorized transport off premises by a CNA. On 12/11/25, a CNA (V6) transported a resident (R13) in the CNA’s personal car approximately 30 miles from the facility to the resident’s home so the resident could obtain clothing. The resident reported being away from the facility from 7:30 a.m. to 11:30 a.m. and stated that the CNA was off duty and had been told several times that the resident was planning to go home. The resident gave the CNA $50.00 as compensation for the trip. The facility file documented that the CNA informed the nurse only after returning to the facility. There was no physician order authorizing the resident to leave the facility, and the resident’s progress notes did not document that the resident was out of the facility at any time. The resident’s MDS dated 12/3/25 documented no cognitive impairment, but the MDS section GG dated 12/2/25 showed the resident ambulated with a wheelchair and required maximum assistance from staff for transfers. The resident’s care plan documented hemiplegia related to a stroke and an increased risk for falls. The facility’s Abuse Prevention and Reporting Policy defined exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The facility’s Transportation for Residents Policy required all personnel to be trained prior to transporting residents, and the Incidents and Accidents Policy required a report and nursing documentation, including 72-hour documentation, for residents leaving the premises without authorization. The CNA had no facility training related to transportation of residents, and no incident report or required nursing documentation was completed for this unauthorized absence.
Failure to Develop Baseline Care Plan With Goals and Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan that met all of a resident’s needs, with measurable goals and interventions, for one of three residents reviewed for quality of care. The resident was admitted on 12/24/2025 with diagnoses including a wedge compression fracture of the fourth thoracic vertebra (subsequent encounter with routine healing) and an unspecified fracture of the fourth thoracic vertebra. The resident’s care plan showed that a focus assessment for an ADL (Activity of Daily Living) deficit was initiated on the admission date, but no goals or interventions were documented for this focus area. On 02/03/2025 at 10:30 AM, the MDS/Care Plan Coordinator acknowledged that the resident’s care plan lacked goals and interventions for multiple focus areas and stated that care plans are considered comprehensive only when appropriate goals and interventions are in place. The facility’s comprehensive care plan policy dated 11/2012 states that the interdisciplinary team should attempt to schedule an initial meeting with the resident and/or representative within five days of admission to review the baseline plan of care. This deficiency centers on the absence of documented goals and interventions in the resident’s baseline care plan despite the resident’s identified ADL deficit and fracture-related diagnoses, and the facility’s own policy requiring timely review of a baseline plan of care by the interdisciplinary team.
Failure to Assess and Report Escalating Pain and Bruising
Penalty
Summary
Failure to assess and control a resident’s pain occurred when staff did not adequately evaluate or report escalating pain and new bruising for a resident with multiple complex medical conditions, including dementia, spinal stenosis, osteoarthritis, hip fracture, seizure disorder, and other chronic diagnoses. The resident’s care plan identified dementia with behavioral disturbances, ADL self-care deficits, incontinence, elopement risk, agitation, anxiety, restlessness, aggression, resistance to care, convulsions, restless leg syndrome, hip fracture, and seizure disorder. Facility investigation notes document that on multiple occasions staff and another resident heard or observed the resident yelling or hollering in pain. CNAs reported that the resident was in a lot of pain and had bruising on the left chest, and one CNA reported this to an LPN. Another LPN stated that on two consecutive days the resident was spitting out food, stopped feeding himself, had a low-grade temperature, a left leg contracture, and increased pain, but did not notify anyone of these changes. The Medication Administration Record shows that the resident began receiving pain medication regularly and had repeatedly high pain scores ranging from five to nine out of ten over several days, yet there was no documented physician notification of this increased pain prior to a later date. One LPN acknowledged being told about bruising and significant pain but did not assess the bruises, only gave pain medication, and did not notify anyone. Another LPN noted bruising but stated being unaware that it needed to be reported. The Director of Nursing later stated that bruising was first noticed several days before any notification was made and that the medical doctor should be notified of a change in pain, acknowledging that waiting several days for notification was a delay in care. The facility’s Pain Management Program policy required notifying the physician of a change in condition and assessing and reassessing pain control measures for effectiveness, but the record and interviews show that these steps were not followed for this resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse involving a resident-to-resident altercation. One resident with a history of aggressive behaviors related to dementia, agitation, and physical aggression was involved in an incident with another resident who also had cognitive impairment and behavioral issues. The aggressive resident was documented as being agitated, cussing, and swinging at staff, and was noted to have ongoing behavioral disturbances since admission. The care plan identified the resident as being at risk for abuse and aggressive behaviors, but behavior tracking did not document that the resident was removed from areas causing agitation. On the day of the incident, an LPN heard one resident threaten to throw hot chocolate on the other, followed by the actual act of throwing the liquid. In response, the other resident placed both hands in a choking motion and made contact with the resident's neck. Staff immediately separated the residents, and the resident who threw the liquid was moved to another wing. The incident was reported to the physician, power of attorney, ombudsman, and local police, and an investigation was initiated. Observations after the incident noted a bruise on the cheekbone of the resident with aggressive behaviors, but no other visible injuries. Interviews with staff and residents confirmed the altercation and the ongoing behavioral challenges of the residents involved. The facility's documentation showed that interventions were in place for managing behaviors, but there was no evidence that the resident was removed from the area that was causing agitation prior to the incident. Both residents had complex medical and behavioral diagnoses, including dementia, mood disturbances, and physical health issues, which contributed to the risk of altercations.
Failure to Revise and Implement Comprehensive Fall Care Plans
Penalty
Summary
The facility failed to implement and revise comprehensive care plans to address falls for two residents who were identified as being at risk for falls. For one resident with multiple fractures, diabetes, and muscle wasting, the care plan noted a risk for falls and included interventions such as ensuring the call light was within reach and conducting environmental rounds. However, after the resident experienced a fall while attempting to remove lift sling straps from her wheelchair, the new intervention to tuck the straps under the resident was not added to the care plan. Additionally, the intervention to educate the resident about asking for assistance with sling placement was not documented as completed. For another resident with vascular dementia, behavioral disturbances, and a history of falls, the care plan included several interventions to reduce fall risk, such as keeping supplies within reach and using a floor mat. Despite this, after the resident was observed crawling in the hallway, the root cause was identified as the resident purposefully placing himself on the floor to crawl. The interdisciplinary team determined that the resident should be care planned to crawl on the floor when desired, but this new intervention was not updated in the care plan. In both cases, the facility's fall policy required that care plans be revised with each fall and that new interventions be implemented as appropriate. The failure to update the care plans with new interventions following falls was confirmed by the facility administrator, indicating noncompliance with the facility's own policy and regulatory requirements for comprehensive care planning.
Failure to Implement Fall Prevention Interventions and Address Equipment Hazards
Penalty
Summary
The facility failed to implement resident-centered interventions to prevent falls for one resident, resulting in the resident falling from a wheelchair. The facility's fall policy requires individualized assessment and intervention, including the use of assistive devices and prompt repair or removal of malfunctioning equipment. Despite this, the resident's care plan did not include specific interventions to address the risk of falling from the wheelchair, and the intervention to tuck the lift sling straps under the resident was not transcribed to the care plan after the incident. The resident had multiple diagnoses, including fractures, diabetes with skin ulcer, and muscle wasting, and was dependent on a total body mechanical lift for transfers. The resident was cognitively intact and reported that the seatbelt on the power wheelchair was broken and could not be fastened. Staff were aware of the broken seatbelt, but maintenance was not notified, and the seatbelt was not repaired. The resident stated that the seatbelt was functional upon admission and that it was always worn when in the wheelchair. On the day of the incident, the resident was outside waiting for transportation to dialysis when the straps of the lift sling became tangled in the wheelchair's front wheel. While attempting to remove the straps, the resident slipped forward and fell from the wheelchair. The incident was reported to staff, and the resident was assessed and returned to the wheelchair. The lack of a functioning seatbelt and the absence of updated care plan interventions contributed to the fall.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
Multiple incidents of resident-to-resident physical abuse occurred within the facility, involving residents with varying degrees of cognitive impairment. In one instance, a resident with severe cognitive impairment was seated in a hallway when another resident, also severely cognitively impaired, approached and deliberately slapped her in the face. The incident was witnessed by a CNA, who reported that the resident who was struck appeared to be in pain but was unable to verbalize it due to her cognitive status. Both residents involved were unable to recall the incident during subsequent interviews. Another event involved a resident with no cognitive impairment being struck by a resident with severe cognitive impairment. The altercation occurred after the cognitively intact resident asked the other to move out of the way, resulting in the latter hitting her with a book. Witnesses confirmed the physical contact, and the resident who was struck reported minor pain but no lasting injury. The aggressor was described as often paranoid and confused, with a history of making accusatory remarks toward others. Additional incidents included a resident with severe behavioral symptoms hitting another resident on the head with a bingo card during an activity, and a resident grabbing another's wrist after a minor dispute over a dropped fork. In each case, the aggressors and victims had varying levels of cognitive impairment, and some were unable to recall the events. Facility staff observed and intervened in these altercations, and skin assessments were performed to check for injuries. The facility's policy defines abuse as any willful infliction of injury or pain, regardless of cognitive status, and requires all such incidents to be investigated and reported.
Inaccurate MDS Coding for Medications, Falls, and Discharge
Penalty
Summary
The facility failed to accurately complete and encode Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to antipsychotic medication administration, fall reporting, and discharge documentation. For one resident, the MDS Coordinator incorrectly documented that the resident had not received antipsychotic medication since admission, despite physician orders and medication administration records confirming daily administration of Quetiapine. Additionally, the same resident experienced a fall resulting in a right humerus fracture, but the MDS was coded to indicate a non-major injury, omitting the fracture. The MDS Coordinator stated that she relied on incomplete information from the electronic medical record and missed the documentation of the fracture, leading to inaccurate MDS coding. Another resident was sent to the hospital and died there after more than 24 hours, but the MDS Coordinator completed a 'Death in Facility' assessment instead of the required 'Discharge with Return Anticipated' assessment. The Coordinator referenced the CMS RAI User's Manual, which specifies that a discharge assessment is required if a resident is in the hospital for observation for more than 24 hours, regardless of admission status. The Coordinator acknowledged the error after reviewing the timeline and documentation, confirming that the incorrect MDS assessment was completed.
Failure to Maintain Accurate Medical Records and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Physician Order Sheet documented an order for Ativan (Lorazepam) to be administered every eight hours as needed for anxiety, with an incorrect duration of 14 months, exceeding the 14-day limit for PRN anti-anxiety medication. The consent form for this medication was incomplete, lacking documentation of the duration. The error in duration was repeated throughout the resident's chart, including the medication administration record (MAR), which was not revised or discontinued as required. As a result, the resident received a dose of Ativan after the order should have been discontinued. The Director of Nursing confirmed the error was due to a transcription mistake that was not identified in a timely manner. For another resident, hospital discharge orders required the continuation of intravenous Ceftriaxone following treatment for a urinary tract infection, sepsis, and a bacterial infection of the knee. The MAR did not document administration of the antibiotic on several days, with blank spaces where nurse initials should have been recorded. The Director of Nursing, who administered the medication, admitted to not documenting the administrations in the resident's record, resulting in several days of undocumented antibiotic administration.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, as evidenced by two separate incidents involving physical altercations between residents. In the first incident, a resident with a history of atherosclerotic heart disease and developmental delays reported being struck on the hand by another resident diagnosed with vascular dementia, agitation, autism, and dysphagia. The injured resident experienced pain and redness, and staff applied an ice pack to the affected area. Witness statements and a police report confirmed the altercation, with staff noting that the two residents were in close proximity and waving their arms at the time of the incident. In the second incident, a resident with severe unspecified dementia and major depressive disorder was scratched on the hand by another resident with moderate dementia, cognitive communication deficit, and dysphagia. Witness statements indicated that the resident who was scratched did not provoke the other resident. Both incidents were documented in care plans and reported to the appropriate authorities, but the facility's actions were insufficient to prevent these occurrences of physical abuse between residents.
Failure to Obtain Timely Medical Evaluation After Resident Fall
Penalty
Summary
The facility failed to obtain timely medical evaluation and treatment for a resident following a fall. After the fall, the resident began experiencing new onset pain, initially described as an ache and later as sharp pain, with increasing severity. Nursing staff observed right hip pain, abnormal gait, and increased confusion in the resident, but did not notify the physician until several days later. During this period, the resident also exhibited increased confusion and a decline in functional abilities, including new incontinence and increased dependence for activities of daily living. The physician was eventually notified, and x-rays revealed a displaced right femoral neck fracture. Prior to the fall, the resident was cognitively intact, ambulatory with a walker, and required only setup assistance for daily activities. Following the incident and delayed intervention, the resident's condition declined significantly, with severe cognitive impairment, loss of mobility, and total dependence on staff for care. The failure to promptly assess and treat the resident's post-fall symptoms resulted in a significant deterioration in her health status.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident experienced a fall while ambulating with a walker, resulting in new onset pain that was documented as achy and later as sharp pain in the right hip. Despite repeated complaints of pain and a significant change in cognitive status, no pain medication or treatment was administered from the time of the fall until the resident was sent to the emergency room two days later. Nursing notes and medication administration records confirm that the resident's pain ratings increased from zero to four out of ten following the fall, but no interventions were initiated. The resident's physician was not notified of the increased pain and confusion until two days after the fall, at which point diagnostic imaging and hospital transfer were ordered. Staff interviews revealed that the resident was alert and able to communicate pain after the fall, but continued to experience worsening pain, increased confusion, and new incontinence over the weekend. The resident was found to have a displaced fracture of the right femoral neck and was admitted to the hospital for pain management and further evaluation. The resident's cognitive status declined significantly during this period, as documented by a drop in the Brief Interview for Mental Status (BIMS) score from 12 to 1.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A cognitively intact resident, who is dependent on staff for toileting care, reported being physically abused by a Certified Nurses Aide (CNA) during a care episode. The resident described that while being changed by two CNAs, one CNA pushed down hard on her sternum, an area noted to be very bony and sensitive, which the resident perceived as abusive. This incident was corroborated by the resident's family member, who was informed by the resident about the rough handling and subsequently reported the concern to facility administration. The CNA who was later informed by the resident about the alleged abuse reported the incident to the facility administrator, but was not further involved in any investigation. The facility administrator, upon being notified of the incident, chose to document the event as a grievance rather than initiate an abuse investigation as required by policy. Another CNA present during the incident confirmed that the resident was held down with arms crossed over her chest to facilitate care, acknowledging that this was not standard practice and that alternative actions should have been taken. The Director of Nursing stated that staff are not trained to restrain residents in this manner and recognized the need for further education on abuse prevention. The failure to immediately investigate the allegation as abuse and the use of physical force during care led to the deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency in a timely manner for one resident. According to the facility's own policy, any allegation of abuse must be promptly reported to the State Agency and the resident's representative. On the date in question, a resident reported sensitivity and pain in the breastbone area, stating that a CNA had been too rough and had pushed down hard on her sternum during care. Another CNA present during the incident confirmed that the accused CNA held the resident down with her arms crossed over the resident's chest to facilitate care, rather than seeking alternative assistance or de-escalating the situation. The resident expressed feeling that the action was abusive and upsetting. A third CNA reported that the resident had informed her of the alleged abuse shortly after breakfast, and this CNA relayed the information to the facility administrator. However, the administrator initially chose to document the incident as a grievance rather than initiating an abuse investigation or reporting it to the State Agency as required. The administrator only began the abuse investigation and reported the incident to the State Agency the following day, after speaking with the resident's family. The administrator later acknowledged that the allegation should have been reported immediately upon receiving the report from the CNA.
Failure to Administer Discharge-Ordered Medication Resulting in Hospitalization
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with multiple diagnoses, including hepatic encephalopathy risk factors. Upon admission, the resident's hospital discharge orders included a prescription for Lactulose to be administered three times daily. However, the facility did not include this medication in the resident's physician orders for February, nor was it documented as administered in the Medication Administration Record. Staff failed to review both the paper and electronic discharge records as required, resulting in the omission of Lactulose from the resident's care. As a result of not receiving Lactulose, the resident experienced a significant decline in mental status, including confusion, weakness, and inability to hold up their head. The family noticed these changes and requested hospital evaluation, where the resident was found to have elevated ammonia levels and was diagnosed with hepatic encephalopathy. Hospital records confirmed that the lack of Lactulose administration at the facility led to the resident's condition, which improved only after receiving the medication in the hospital.
Failure to Provide Adequate Linen Supplies for Resident Care
Penalty
Summary
The facility failed to provide adequate linen supplies, specifically towels and washcloths, for 97 out of 103 residents reviewed. Multiple grievances from the resident council documented ongoing complaints about delays in laundry service and the lack of necessary linens for morning care. On several occasions, both linen rooms and the laundry room were observed to have insufficient or no towels and washcloths available. Certified Nurses Assistants (CNAs) confirmed that shortages occurred regularly, particularly during the second shift, and reported having to use wet paper towels or toilet paper to clean residents due to the lack of proper linens. Staff interviews further corroborated the persistent shortage, with one CNA stating that towels and washcloths were unavailable for two out of seven day shifts each week, and another indicating daily shortages on the second shift. The housekeeping supervisor acknowledged awareness of the issue and noted that additional linens were stored in the basement, but staff were unaware of their location. The administrator confirmed that the use of paper towels or toilet paper for resident care was unacceptable and that towels and washcloths should always be available.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident (R1) with a history of cognitive communication deficit, major depressive disorder, type 2 diabetes with polyneuropathy, and lack of coordination was physically struck in the face and legs by another resident (R2). R2 had a documented history of unspecified dementia, psychotic and mood disturbances, and was previously identified as having the potential for physical and verbal aggression, with interventions noted in the care plan to address these behaviors. On the day of the incident, a CNA (V3) witnessed R2 hit R1 in the face, separated the residents, and after assisting another resident, returned to see R2 strike R1 again. R1 reported not being injured during the incident. The facility's abuse prevention policy requires identification of residents at risk for abuse and implementation of care plan interventions to reduce such risks. Despite this, R2, who had a known history of aggression and a prior incident of striking another resident at a previous facility, was able to physically abuse R1 on two occasions during the same event. The administrator was unaware of the second strike and of R2's prior aggressive behavior at another facility. The incident was reported to the police, and witness statements were collected, but the report does not mention any corrective actions taken following the event.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to complete quarterly fall risk assessments and implement fall interventions for three residents, leading to significant incidents. One resident, who was cognitively impaired and had multiple diagnoses including vascular dementia and Alzheimer's disease, fell from a high bed onto a tile floor. This resident was hospitalized overnight due to a subarachnoid hemorrhage sustained from the fall. The fall occurred because the bed was not in the lowest position, and the head of the bed was elevated, which increased the risk of injury. The resident's care plan indicated a risk for falls, but the necessary precautions were not followed. Another resident, with severe cognitive impairment and a history of falls, was found without the required non-skid material on top of his wheelchair cushion, as specified in his care plan. This oversight was confirmed by a Certified Occupational Therapy Assistant and family members, who noted the facility's failure to adhere to the prescribed interventions to prevent falls from the wheelchair. A third resident, admitted with neurocognitive disorder and dementia, also lacked the necessary non-skid material in their highback wheelchair, despite a documented history of falls and a care plan intervention requiring it. This deficiency was confirmed by a Certified Nursing Assistant, indicating a pattern of neglect in implementing fall prevention measures across the facility.
Unqualified Dietary Manager Employed
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, which has the potential to affect all 105 residents residing in the facility. During an observation on February 18, 2025, the Dietary Manager (DM), identified as V7, was seen actively supervising dietary staff during breakfast meal service. V7 stated that he has been working at the facility as the dietary manager since November 2024 but has not taken the required classes to qualify for the position. This was confirmed by V14, the Regional Dietary Manager, on February 19, 2025, who acknowledged that V7 has not had the necessary training to qualify as the dietary manager.
Unsanitary Kitchen Conditions Risking Cross-Contamination
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the kitchen, which could potentially lead to cross-contamination and food-borne illness affecting all 105 residents. During a follow-up kitchen tour, it was observed that an eight-foot-long metal shelf above the three-well sink was covered with rust and brown and black grease-like debris. Below this shelf, approximately twenty hanging brackets held presumably clean kitchen serving utensils, such as spoons, tongs, and whisks, which were at risk of contamination from the soiled shelf above. Additionally, the three-well sink had loose chipped caulking dangling into the wash and sanitization wells, and two electrical outlet boxes above the sink were covered with thick grease-like buildup and crusted food-like substances. A metal food preparation table adjacent to the sink was situated under a suspended metal pipe with stringy dust-like substances hanging over it, and the ceiling above had a cluster of hanging paint strips. The Dietary Manager acknowledged the unsanitary conditions and confirmed that these areas posed a risk of contaminating food served to the residents.
Facility Fails to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for seven residents, as observed during a survey. Residents consistently reported their rooms being too cold, with temperatures recorded as low as 63.2 degrees Fahrenheit. The issue was documented in Resident Council Meeting Minutes over several months, indicating ongoing complaints about cold conditions. Residents expressed discomfort, with some needing extra blankets or warm clothing to cope with the low temperatures. The Maintenance Director acknowledged the problem, noting that the heating system, a boiler unit, was functioning correctly but still resulted in chilly rooms. The director mentioned consulting with the heating company, which suggested turning on the heating system in the parking garage to potentially warm the building's concrete floors and, consequently, the resident rooms. However, no immediate actions had been taken to address the cold temperatures at the time of the survey.
Failure to Conduct Side Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to implement side rails only after completing a side rail assessment and obtaining informed consent for three residents. For Resident 79, the facility did not conduct a recent quarterly side rail assessment, and the last assessment indicated that side rails were not necessary. Despite this, Resident 79 had a side rail installed prior to a new assessment being completed. The Director of Nurses confirmed the lack of a recent assessment and acknowledged that the side rail was in place before the assessment was conducted. Resident 10 had bilateral quarter side bedrails attached to their bed, but there were no quarterly side rail assessments since July 2024, despite the care plan indicating the use of side rails. The Assistant Director of Nursing confirmed the absence of recent assessments and noted that the previous assessment was incorrect. Similarly, Resident 88 had bilateral quarter side rails without any quarterly assessments since June 2024. The Assistant Director of Nursing confirmed the lack of assessments for Resident 88 as well.
Improper Securing of Indwelling Catheter Tubing
Penalty
Summary
The facility failed to properly secure the indwelling catheter tubing of a resident, identified as R96, to their wheelchair. This deficiency was observed on two separate occasions, with the catheter tubing dragging on the floor underneath the resident's high back wheelchair. On February 18, 2025, at 12:15 PM, and again on February 19, 2025, at 10:32 AM, the tubing was noted to be improperly positioned. A Certified Nursing Aide, identified as V25, confirmed the improper positioning of the catheter tubing on February 19, 2025, at 10:38 AM, acknowledging that it should not be dragging on the floor. The facility's Catheter Care Policy, dated October 2024, specifies that urinary drainage bags and tubing should be positioned to prevent contact with the floor, indicating a failure to adhere to established guidelines aimed at reducing infection risks.
Failure to Administer IV Medications on Time
Penalty
Summary
The facility failed to administer intravenous medications as ordered by the physician for two residents, affecting their treatment for osteomyelitis. One resident was admitted with acute osteomyelitis of the left ankle and foot, requiring intravenous Vancomycin HCl to be administered daily at 1:00 PM. However, the medication was administered 6 hours and 11 minutes late on one occasion. Another resident, admitted with osteomyelitis requiring intravenous Ceftriaxone Sodium for a sepsis-elbow infection, had their medication administered 9 hours and 36 minutes late. The facility's medication administration policy mandates that medications be administered according to the physician's order, including the right time. On the day of the incident, there were two registered nurses on duty, but the Director of Nursing left work early and was unaware of the medication administration issues. The Director of Nursing later logged into the medical chart remotely to document the administration, but it was not documented on time, and no progress note was entered to reflect the timely administration.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident, resulting in psychosocial harm. On June 18, 2024, a Licensed Practical Nurse (LPN) witnessed a resident (R1) touching another resident's (R2) breast in a common area. R1, who has a history of dementia with behavioral disturbances and a care plan noting a tendency to express sexual advances, was seen with his hand down R2's blouse. Despite being separated immediately by the LPN, R1's actions were inappropriate and non-consensual, as R2 has severe cognitive impairment and cannot consent to intimate touching. R2, diagnosed with aphasia and Alzheimer's disease, has significant cognitive impairments, including memory issues and an inability to understand or communicate effectively. The incident was reported to R2's family, who expressed that R2 would have been mortified and afraid if she had the cognitive ability to understand the situation. The facility's policy on abuse prevention clearly states that residents have the right to be free from unwanted intimate touching, highlighting the deficiency in protecting R2 from sexual abuse.
Failure to Update Care Plan for Inappropriate Behavior
Penalty
Summary
The facility failed to adequately care plan and implement behavior tracking and interventions for a resident, R1, who was involved in an incident of inappropriate touching/sexual abuse of another resident, R2. On June 18, 2024, an LPN witnessed R1 touching R2 inappropriately in a common area. Despite R1's history of making sexual advances towards staff and watching pornography, the care plan was not updated to include this new behavior of inappropriate touching of other residents. The facility's Behavioral Health Services Program requires that care plans be updated with new or worsening behaviors, but this was not done in R1's case. R1's care plan, revised on June 20, 2024, did not document the incident or include interventions to prevent future occurrences. The Behavior Monitoring and Interventions Report for June 2024 also failed to document the targeted behavior or specific interventions. Interviews with facility staff confirmed that R1's care plan and behavior monitoring did not address the inappropriate touching incident, despite the facility's policy to establish a system for identifying behaviors and implementing appropriate interventions. This oversight represents a deficiency in the facility's responsibility to provide necessary behavioral health care and services to its residents.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse, as evidenced by an incident involving two residents. One resident (R1) reported that another resident (R2) entered R1's room, placed R2's hand on R1's chest, and guided R1's hand to R2's groin. This incident was reported by R1 to the Medical Director the following day, who then informed the facility. The police were notified, and R2 was placed on 1:1 observation. R1 did not wish to press charges and wanted to forget the incident. R2, who has a diagnosis of Metabolic Encephalopathy, Parkinson's, Dementia, and Cognitive Communication Deficit, was unable to recall the incident due to their cognitive condition. The Director of Nursing (DON) confirmed the incident and stated that R2 had no prior history of sexual inappropriateness and believed R2 mistook R1 for R2's spouse. The facility's Abuse Prevention and Reporting Policy, dated October 2022, affirms the residents' right to be free from abuse, including sexual abuse, which is defined as non-consensual sexual contact of any type. Despite this policy, the facility failed to protect R1 from sexual abuse by R2. The incident highlights a deficiency in the facility's ability to prevent and address such occurrences, particularly involving residents with cognitive impairments. The facility's response included notifying the police, assessing R1 through Social Services, and placing R2 under 1:1 observation, but the initial failure to prevent the abuse remains a significant concern.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — including the 2 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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Normal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mclean County Nursing Home | 0.7 mi | ★★★★★ | 6 | 0 |
| Loft Rehab & Nursing Of Normal | 1 mi | ★★★★★ | 22 | 0 |
| Arcadia Care Bloomington | 1.6 mi | ★★★★★ | 13 | 1 |
| Goldwater Care Bloomington | 2.1 mi | ★★★★★ | 4 | 0 |
| Bloomington Rehabilitation & Hcc | 3.8 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 July 2026) and official state health department websites.