Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arcadia Care Bloomington during CMS and state inspections, most recent first.
Failure to complete required weekly skin assessments for residents with wounds and high skin-risk conditions. A resident with CHF, ESRD on HD, DM with foot ulcer, and decreased mobility had a weekly skin assessment order, but the record showed only one documented skin assessment before the resident returned to the hospital with multiple wounds, including a new DTI to the left foot. Two other residents with active wounds also had very limited skin assessment documentation despite orders and facility policy requiring weekly licensed nurse assessments.
Failure to use PPE and prevent cross-contamination during resident care. An ADON/Wound Nurse/Infection Control entered a resident’s room for wound care without a gown despite EBP, and later left another resident’s room wearing used gown and gloves while moving a bedside table and wound supplies through the hall. A CNA provided incontinence and face care for a resident on EBP without a gown, discarded soiled items on the floor, carried dirty linens and gloves in the hall, and did not change gloves between dirty and clean tasks. Staff and the DON stated gown, gloves, and sometimes a mask were expected for EBP care, and the facility policy required gown and gloves for high-contact care.
Privacy and dignity failures occurred when occupied shower rooms were repeatedly entered without knocking or being secured, including an observed instance of a resident entering while another resident was being showered despite the occupied sign being displayed. Residents reported feeling fearful, embarrassed, awkward, and unsafe, and staff acknowledged the problem was routine. In addition, a resident’s indwelling urinary drainage bag was observed uncovered and resting on the floor under the wheelchair.
The facility failed to have RN coverage for at least 8 consecutive hours per day on two dates, as shown by Nursing Staff Daily Schedule Sheets and confirmed by the DON. The facility had 91 residents, and the facility assessment stated that an RN is needed every day to provide competent support and care for the resident population.
Expired medications and supplies were found in the medication room, including Oyster Shell Calcium Plus Vitamin D, Bisacodyl, Jevity tube feeding formula, normal saline flush syringes, and IV start kits. An open box of coffee pods was also observed in the IV storage cart with IV tubing and other medical supplies. The DON stated expired items are to be removed when found, and said all residents could potentially use the expired medications.
Environmental Maintenance and Cleanliness Deficiencies: Surveyors observed widespread damage and poor upkeep throughout the LTC facility, including scraped paint, water-damaged ceiling tiles, dirty and worn floors, broken tile, missing baseboards and trim, cloudy windows, and discolored handrails. Multiple resident rooms and hallways had holes in walls, scuff marks, and other damage, while the Maintenance Director stated there were no work orders for the wall holes and a resident reported that holes and cleanliness problems had been ongoing and known to management.
Pest Control Program Not Effectively Maintained: The facility failed to maintain an effective pest control program, and ants, flies, and other insects were observed in resident rooms, hallways, and the dining area. Residents reported ongoing insect issues, including bugs in rooms and insects flying around faces during meals, while a CNA and the maintenance director confirmed the problem had been present for weeks and that a pest control log was not being maintained.
A facility failed to maintain clean, comfortable resident rooms and dining spaces. Surveyors found multiple rooms with dirty floors, trash, sticky substances, broken closet doors, peeling paint, missing mattress frames, and bathrooms with used bedpans, urinals, dirty toilets, and missing trash can liners. Several residents said housekeeping rarely cleaned their rooms, and staff confirmed daily cleaning expectations were not being met. In the dining area, the floor was sticky, seating was overcrowded, staff had to stand or squeeze between tables to assist with meals, and two residents could not get past chairs and wheelchairs when trying to leave.
Failure to Coordinate Dialysis Communication: A resident with ESRD receiving hemodialysis three times weekly had orders for pre-dialysis VS and weights, and the care plan included coordination with outside providers. The DON reported that dialysis communication forms were supposed to go with the resident and return after treatment, but the record contained only two completed forms over more than 42 weeks of dialysis, and the binder at the nurses’ station had only blank forms. The DON also reported that nurse turnover and agency staff contributed to the forms not being completed.
Failure to obtain informed consent for psychotropic medications. A resident received multiple psychotropic meds as ordered, but the chart lacked consent documentation for an antipsychotic, antidepressants, a benzodiazepine, and an antianxiety medication. The POA stated no consent forms were signed or verbal consent given, and the DON confirmed the facility did not have informed consent on file.
Unsafe Reacher/Grabber Caused Resident Leg Injury: A resident with paraplegia, multiple pressure ulcers, chronic osteomyelitis, malnutrition, cellulitis, and a thoracic SCI was injured while using a reacher/grabber in bed. The resident was found bleeding heavily from the left leg, became intermittently unconscious, and was sent to the ED by ambulance; hospital records noted a left lower leg incision with six stitches. Later, the resident said the device had been used for years, and the DON confirmed part of the reacher/grabber had sharp edges.
A resident with a diagnosis of unspecified dementia with behavioral disturbances did not have a dementia-specific plan of care in the medical record. V2 confirmed the care plan was missing and stated the resident should have had one; a dementia care plan was added only after the surveyor notified the facility that none was present.
A resident on contact isolation for suspected C-Diff did not have access to an appropriate handwashing sink because the bathroom was locked, and an LPN used ABHS instead of soap and water after providing care. In a separate finding, a resident with an indwelling urinary catheter did not have EBP in place, with no sign or PPE outside the room and the catheter drainage bag observed on the floor under the wheelchair.
A resident who used a wheelchair was transported in a facility van when the driver failed to secure the wheelchair with the required anchor straps. The wheelchair tipped backward as the van accelerated, causing the resident to fall to the floor, hit her head and neck, and report severe pain. The driver did not call 911 after the resident requested EMS and instead continued to the appointment; ED and hospital records later documented back and neck pain and a T12 compression fracture.
The facility failed to employ a full-time DON to oversee nursing services. Staff told surveyors there was no DON in place, and the ADON stated the former DON had been terminated on an unknown date. The Facility Assessment documented the facility would employ one full-time DON, and the resident roster showed 88 residents in the facility.
Failure to protect two residents from resident-to-resident physical abuse occurred when one resident became upset during med pass, yelled at an LPN, and another resident intervened, leading to a physical altercation in which both residents reported hitting each other and one resident reported being struck with a wet floor sign. One resident had multiple psychiatric and brain injury diagnoses with moderate cognitive impairment, while the other had mood and bipolar disorder with intact cognition.
Failure to notify the physician of a resident’s right lower leg injury. A CNA reported bleeding from the leg, and an LPN applied a dressing, notified the wound nurse, and sent the resident to dialysis, but did not contact the physician. The record also lacked a progress note of physician notification, and staff confirmed there was no order for the dressing; the resident had multiple chronic conditions including DM, ESRD, HTN, cellulitis, osteomyelitis, and PVD.
Failure to Obtain and Follow Wound Care Orders: A resident with DM2, ESRD, PVD, and bilateral foot amputations had a right lower leg wound that was dressed without a dated or signed order in the chart. Staff confirmed there was no physician order for the dressing initially applied, the physician was not notified of the injury, and the TAR showed no wound treatment entered or completed despite a wound clinic AVS documenting new wound care orders.
Surveyors found that the facility did not consistently implement care-planned fall precautions for several residents. A resident with cognitive impairment and dementia was observed in bed without a reachable call light, despite a care plan requiring it to be within reach. Another resident with seizures and dementia, and a third resident with dementia and behavioral disturbances, were each found in bed without access to their call lights as specified in their care plans. A resident with a history of cerebral infarction and hemiplegia reported falling while transferring, and surveyors observed that required grip strips were missing from the bathroom and shower areas. CNAs reported that fall precautions are located in the medical record and that call lights should be within reach, and the DON stated she expected all fall interventions to be in place, but the facility’s fall prevention policy was not followed for these residents.
Surveyors found multiple shower rooms in disrepair, with broken tiles, cracked boards, dirty grout, rust, peeling caulk, and black mold-like substances. The Maintenance Director confirmed these issues, and several residents reported ongoing concerns about cleanliness and maintenance, noting that only temporary fixes were being made. These deficiencies affected all residents in the facility.
Multiple residents experienced significant delays in receiving their clean clothing, with laundry carts of clean items left undelivered for days and large amounts of dirty laundry accumulating. Residents and staff reported that it often took several days for clothes to be washed and returned, leading to repeated complaints about missing items that were later found in the laundry. The DON and Administrator confirmed ongoing issues with laundry timeliness and acknowledged multiple complaints from residents.
A resident with severe cognitive impairment and a history of impulsive behaviors experienced multiple falls and repeated removal of a gastrostomy tube, resulting in injuries and hospitalizations. Despite clear documentation of the need for a bed alarm and one-to-one supervision, these interventions were not consistently implemented by facility staff, and care plans lacked adequate updates after each incident.
A resident with COPD and hypertension, who was cognitively intact, was found in a room with dusty cobwebs containing insects along the windowsill and dirt particles on bed linens. The Housekeeping Supervisor confirmed the lack of adequate cleaning, and the Administrator acknowledged ongoing cleanliness issues, despite facility procedures requiring daily cleaning and inspection of resident rooms.
The facility failed to provide an adequate supply of toilet paper, as reported by several residents who had to use alternative items or rely on family for supplies. Certified Nurse's Aides confirmed the shortage. Additionally, the main shower room had missing and broken tiles, creating an unstable surface for dependent residents. These deficiencies affected all residents in the facility.
Multiple residents with chronic conditions experienced unclean living spaces, including dust, dead insects, ant infestations, and persistent urine odors. Residents and staff reported repeated shortages of toilet paper, leading some to use alternative items or rely on family for supplies. These deficiencies resulted in discomfort and feelings of neglect among residents.
Two cognitively intact residents with multiple chronic conditions reported ongoing ant infestations in their rooms, with observations of ants, dead insects, and dust on windowsills. CNAs confirmed the presence of ants in resident rooms and on residents, and the administrator was aware of the issue.
Two residents were involved in separate physical altercations, with one resident—who has severe dementia—being shoved and later slapped on the head by another resident. Staff intervened during both incidents, but not before physical abuse occurred. Documentation and interviews confirm that the aggressor was aware of their actions and had previously expressed frustration about the other resident's wandering and interference with personal belongings.
The facility did not thoroughly investigate or document two separate incidents of resident-to-resident physical abuse. In both cases, the investigation files lacked details on who reported the allegations to administration, whether other residents or witnesses were interviewed, and what immediate or long-term interventions were implemented to protect residents from further abuse. The administrator confirmed that the incomplete files represented the entire investigation.
The facility did not fully document the details of two separate resident-to-resident physical altercations and the subsequent investigations in the affected residents' medical records. Progress notes only briefly referenced the incidents and notifications made, without including specifics about the events, investigative steps, or interventions taken to protect those involved.
A resident with dementia and mobility needs was transported in a facility van without proper wheelchair restraints or seatbelt, resulting in the wheelchair flipping backwards during transit. The resident sustained a head injury and rib fracture, requiring increased pain management. Both the CNA and LPN involved reported they had not been trained on proper van safety procedures, and the DON confirmed the lack of restraint led to the incident.
The facility failed to maintain a clean dining environment for residents on the 300 hall. Observations showed a dirty adult brief in the garbage and staff items on the dining table. CNAs reported that due to a lack of housekeeping staff, the dining room was not cleaned regularly, forcing residents to eat in their rooms. The Maintenance/Housekeeping Director confirmed the staffing shortage and inadequate cleaning.
Two residents with severe cognitive impairments were involved in a physical altercation when one attempted to grab the other's hat, resulting in a punch to the head. The incident was witnessed by a CNA and reported to relevant authorities. The facility's policy emphasizes preventing abuse, but the incident highlights a failure to maintain a secure environment.
A facility failed to report an abuse allegation to the state agency after a CNA witnessed a physical altercation between two residents. The incident, where one resident attempted to grab another's hat and was subsequently punched, was reported to the previous administrator but not to the Illinois Department of Public Health as required. The deficiency was identified when the new administrator was informed and investigated the incident.
The facility failed to maintain a sanitary and comfortable environment, with issues such as missing paint, holes in walls, and unsanitary shower rooms. Residents reported cold temperatures in the dining room, leading them to eat in their rooms. The Maintenance Director was aware of these issues but had not fully addressed them, affecting multiple residents.
A cognitively impaired resident fell while exiting a shower room, and a CNA was observed laughing and not assisting the resident. The incident was captured on camera, and the DON determined it was abuse. The facility failed to report the incident as required by their abuse prevention policy.
A facility failed to report an allegation of mental abuse when a resident fell after attempting to grab a CNA. The Director of Nursing believed the incident needed further investigation, but the Administrator found no evidence of abuse and did not report it to authorities, contrary to facility policy.
Facility staff failed to wait for a nurse assessment after a resident's fall, contrary to the Fall Prevention Program policy. An LPN instructed CNAs to stay with the resident until she could assess him, but the CNAs, with another resident, attempted to stand him up despite his pain complaints. They placed him in a wheelchair and took him to his room. The DON acknowledged the inappropriate handling of the fall investigation.
A resident with severe cognitive impairment and wandering behaviors intruded on the privacy of other residents by entering their rooms uninvited. Despite staff attempts to redirect the resident, the behavior persisted, causing distress and safety concerns among other residents. Staff reported challenges in managing the resident's behavior due to insufficient staffing for constant supervision.
The facility failed to provide an ongoing program of activities for residents, as required by their policy. No activities were scheduled after 3:00 PM or on Sundays, and 19 residents' records lacked documentation of activity participation. Staff confirmed no activities were offered on the memory care unit, citing understaffing and lack of visits from the activity department. The former Activity Director did not track residents' activity attendance or interests, leading to a deficiency in meeting residents' needs.
The facility failed to prevent resident-to-resident abuse involving a severely cognitively impaired resident who exhibited aggressive behaviors. This resident was involved in altercations with two other residents, including throwing a TV remote and physically grabbing another resident's legs. Staff attempts to redirect the resident were unsuccessful, leading to continued aggressive interactions.
A facility failed to update the care plan and implement necessary supervision for a resident with aggressive behaviors, leading to multiple altercations with other residents. Despite the resident's history of severe cognitive impairment and aggression, the care plan did not include interventions for increased supervision, such as one-on-one monitoring or 15-minute checks. Staff interviews revealed that the resident was not adequately monitored, contributing to the deficiency in the facility's abuse prevention policy.
A resident was discharged from the facility without receiving the required 30-day written notice, as per the facility's policy. The discharge was based on a physician's order indicating no further need for nursing home care. The resident was taken to a homeless shelter without prior notification, causing confusion and distress. The facility failed to provide a safe and appropriate discharge, violating their own policies.
The facility failed to provide RN coverage for a 24-hour period on two separate days, potentially affecting all 84 residents. The Director of Nursing confirmed the absence of RN coverage as per the facility's Nursing Daily Schedule.
A resident with Type 1 Diabetes, Generalized Anxiety Disorder, and Morbid Obesity was verbally abused by a dietary aide during dinner. The aide dismissed the resident's request for an alternative meal and later used derogatory language towards the resident in front of others. The incident was reported immediately, and the aide resigned following the report.
A resident with muscle weakness and morbid obesity was improperly transferred without a mechanical lift, contrary to their care plan. A CNA, unfamiliar with the resident, attempted the transfer based on the resident's incorrect claim that a lift was unnecessary, resulting in the resident being lowered to the ground when their knees gave out. The CNA did not verify the transfer requirements, violating the facility's fall prevention policy.
Failure to Complete Required Weekly Skin Assessments
Penalty
Summary
The facility failed to perform weekly skin assessments for three residents reviewed for wound care management. R2 was admitted with multiple diagnoses including CHF, morbid obesity, type 2 diabetes with foot ulcer and diabetic polyneuropathy, Charcot foot, CKD stage 5, ESRD on hemodialysis, and atherosclerosis of both lower extremities with intermittent claudication. R2’s care plan identified risk for skin impairment related to decreased mobility, and the physician ordered weekly skin assessments every Wednesday night shift with notification to the doctor if a new impairment was found. The record documented a skin assessment on 5/11/26, but no additional skin assessments during the stay. R2 was later sent to the hospital from the facility with a new deep tissue injury to the left foot, and hospital records documented multiple wounds including pressure injuries and moisture associated skin damage. Staff interviews showed the DON and NP were aware of the chronic right foot wound but were unaware of the left foot wound, and staff stated weekly skin assessments should be documented in the skin assessment tab. R8’s wound reports showed active wounds to the left lower leg and right great plantar toe, but the record documented skin assessments only on 6/19/25 and 11/25/25 over the last 12 months. R15 had physician orders for weekly skin assessment every Wednesday night shift, and wound reports showed wounds to the left plantar foot, right lateral foot, and right lower leg, but the record documented skin assessments only on 9/4/25, 9/20/25, and 11/3/25 over a nine-month period. The facility policy required a skin condition assessment and Braden risk assessment at admission/readmission, weekly skin assessments for identified residents, and weekly assessment and measurement of pressure and other ulcers by a licensed nurse, with daily observation for skin breakdown by CNA staff.
Failure to Use PPE and Prevent Cross-Contamination During Resident Care
Penalty
Summary
The facility failed to utilize appropriate PPE when providing care for residents on Enhanced Barrier Precautions (EBP), failed to remove soiled PPE before exiting a resident’s room, failed to prevent cross contamination during incontinence and face care, and failed to ensure soiled linens were not placed on the floor. R8 was cognitively intact and had an order and care plan for EBP related to a suprapubic catheter, with instructions to use gown and gloves during high-contact care activities such as wound care. During wound care, the ADON/Wound Nurse/Infection Control entered R8’s room without donning a gown before entering or during the wound treatment. Staff interviewed stated that gown, gloves, and a mask should be worn for residents on EBP, and the DON stated EBP signs indicate staff should wear PPE such as a gown, gloves, and mask. R13 was cognitively intact and had an order and care plan for EBP related to a dialysis port/central line, with gown and glove use required during high-contact care. During incontinence care, a CNA provided care without wearing a gown, tossed the soiled brief onto the floor, used a dampened washcloth for perineal care and threw it on the floor, then used another washcloth to wipe the resident’s face and also threw it on the floor. The CNA removed soiled linens from the room without bagging them, walked down the hall with dirty gloves and linens in hand, and dropped the linens onto the hall floor when the dirty linen hamper was not available. The CNA stated she should have worn a gown, bagged the dirty linens before removing them, placed them in a dirty linen hamper instead of on the floor, and changed gloves between dirty and clean care. R15 was cognitively intact and had an order and care plan for EBP related to a CVC dialysis port, with gown and glove use required during high-contact care. After wound care was completed, the ADON/Wound Nurse/Infection Control left R15’s room wearing a gown and gloves and walked down the hall rolling a bedside table draped with a hand towel and used wound supplies on top of it. The staff member then placed the table in front of another resident room, continued down the hall still wearing the used PPE, removed the gown and gloves in the hallway, and returned to the medication cart. The staff member stated she should have removed PPE before leaving the room and should not have worn used PPE in the hallway. The DON stated staff should remove PPE prior to leaving the room and perform hand hygiene, and the facility policy stated gown and gloves must be worn for dressing, bathing, hygiene, changing linens, incontinence care, medical device care, and wound care.
Privacy and Dignity Failures During Showering and Urinary Bag Care
Penalty
Summary
The facility failed to maintain resident privacy and dignity during bathing and personal care by allowing shower rooms to remain accessible while occupied. A resident reported that two male residents attempted to enter the shower room while the resident was showering, and the resident stated the event caused fear and concern for personal safety. Another resident reported that residents and staff frequently entered shower rooms without knocking while showers were in progress, and a CNA observed a resident enter an occupied shower room without knocking while another resident was being showered, despite the occupancy indicator showing the room was occupied and the door remaining unlocked. Additional interviews showed this was a recurring issue in the shower rooms on the 100 and 400 halls. A CNA stated residents and staff entered occupied shower rooms all the time without knocking, and another CNA stated residents and staff routinely entered shower rooms while showers were being provided. A resident also reported that residents frequently ignored the occupied/vacant sign and entered shower rooms while occupied, including male residents waiting outside the bathroom area and then entering, which made the resident feel awkward, nervous, scared, and embarrassed. In a separate observation, a resident with an indwelling urinary drainage collection bag was seen with the bag uncovered and laying directly on the floor under the wheelchair while seated in the room and later in the dining/activity room; the DON stated urinary drainage collection bags are to be covered for all residents.
RN Coverage Not Provided for Required Daily Hours
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours per day. Facility Nursing Staff Daily Schedule Sheets documented that RN coverage was not provided for at least eight consecutive hours on 5/4/26 and 5/22/26. On 6/3/26 at 10:14 AM, the Director of Nursing confirmed that the facility did not have RN coverage on those dates. The facility’s Medicare and Medicaid application dated 5/31/26 documented a census of 91 residents, and the facility assessment stated that a Registered Nurse is needed every day to provide competent support and care for the resident population.
Expired Medications and Improper Storage in Medication Room
Penalty
Summary
Expired medications and other stored items were found in the medication storage room during observation, interview, and record review. The facility’s Medication Storage policy dated 10/2015 states that discontinued, outdate/expired, or deteriorated medications or biologicals should be destroyed or returned. On 6/2/26 at 8:04 AM, an LPN was observed in the medication storage room where three bottles of Oyster Shell Calcium Plus Vitamin D 250 mg with an expiration date of 5/26, two bottles of Bisacodyl 5 mg with an expiration date of 2/26, and five bottles of Jevity 1.2 CAL tube feeding formula with an expiration date of 5/26 were sitting on the shelf. The same observation also identified 50 prefilled 10 mL normal saline flush syringes with an expiration date of 7/25 and multiple IV start kits with an expiration date of 4/25 present in the medication room. On 6/2/26 at 8:25 AM, an open box of coffee pods was found in the IV storage cart with IV tubing and other medical supplies. The DON stated expired items are to be removed when found, and later stated all residents could potentially use the expired medications. The facility application dated 5/31/26 documented a census of 94 residents.
Environmental Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to protect residents’ right to a functional, sanitary, and comfortable environment. Survey observations on 5/31/26 identified multiple areas with scraped paint on walls and doors, ceiling tiles with water damage and discoloration, dirty and worn floors, broken tile, missing baseboards and trim, cloudy windows, dirty windowsills, and old discolored sanded wood handrails with no paint or stain. On 6/3/26, the Administrator confirmed the facility needed a lot of environmental work, both cosmetic and functional. Specific room observations showed holes in resident areas and damage throughout the building. On 5/31/26, the wall behind one resident’s bed had a hole measuring approximately 10 inches by 12 inches in line with the bed frame. The 200 hallway had black scuff marks along the bottom half of resident doors, dark black marks on the floors, and baseboards pulled away from the walls. The walls throughout the facility had paint chip marks and holes around the sprinkler system on the ceiling. One resident’s room had a hole measuring approximately 12 inches by 10 inches in the wall about one foot above mattress height, and two other residents’ room had a hole approximately 10 inches by 10 inches in the wall under the air conditioner. The Maintenance Director stated there were no work orders for holes in residents’ rooms and that the holes would be fixed if notified. A resident stated holes and cleanliness throughout the building had always been a problem and management staff knew because it had been reported.
Pest Control Program Not Effectively Maintained
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent and control insects within the building. The facility’s pest control policy stated that pest control was to be conducted on a regular and as-needed basis, staff were to promptly report pests, the facility was to be maintained to prevent harborage or feeding of insects and rodents, and a pest control log was to be maintained documenting the type of pest, location, and date observed. However, the maintenance director stated he was unaware of a pest control log, and the administrator stated he had considered using the contracted pest control company for additional spraying because ants were present in the facility. During observations and interviews, insects were found in multiple resident areas and common spaces. One resident’s room had food debris scattered throughout, with ants on the floor and flies in the room. Another resident was observed swatting flies in a shared room where flies were present. A cognitively intact resident reported ongoing crawling black bugs and flies throughout the facility, including in the resident’s room and hallways, and black flying insects were observed near a full trash receptacle in that room. Other residents reported ants and flying insects in rooms, hallways, and the dining area, including insects flying around faces during meals and ants crawling on the dining room floor. A CNA stated the ant and bug issue had been ongoing for several weeks and had been seen in several resident rooms and common areas.
Unsafe and Unclean Resident Rooms and Crowded Dining Area
Penalty
Summary
The facility failed to protect residents’ right to a safe, clean, comfortable, and homelike environment in resident living and dining spaces. Surveyors observed multiple resident rooms with dirty floors, trash and debris, sticky substances on floors, broken closet doors, peeling or scraped paint, missing base trim, damaged walls, broken furniture, and bathrooms with dirty toilets, used bedpans, urinals, incontinence briefs, and missing trash can liners. Several residents stated housekeeping rarely came into their rooms, that their rooms were not cleaned regularly, and that the condition of their rooms made them uncomfortable. Specific room observations included a room with garbage under the bed, dirt buildup along the floor edges, trash and debris outside the window, a strong urine smell in the bathroom, and used paper towels piled on the sink because there was no trash can. Another room had a bed frame with no mattress, clothes on the floor, a used urinal and bed pan with dark substance on the floor, and a bathroom with a dark substance on the toilet seat, peeling seat material, yellow stained towels, a plunger with a towel around it, and torn wall bases with peeling paint. Other rooms had clutter, food and drink on bedside tables, overflowing trash, broken closet doors, missing mattress frames, and dirty bathrooms with visible substances and damaged surfaces. Dining area observations showed the floor was sticky and difficult to walk on, and chairs were moved because the dining area could not accommodate all residents at the same time. Staff assisted residents with meals while standing over them or squeezing between tables, chairs, and wheelchairs because there was not enough room to place another chair. Two residents were unable to get past chairs and wheelchairs when trying to leave the dining area and required CNA assistance. The Administrator confirmed the facility needed a lot of environmental work and housekeeping staff needed to do a better job of cleaning, and the DON confirmed the room needed to be cleaned and noted housekeeping staffing turnover.
Failure to Coordinate Dialysis Communication
Penalty
Summary
The facility failed to communicate regularly with the dialysis center to coordinate dialysis care for one resident who required hemodialysis three times per week. The resident had diagnoses including end stage renal disease, type 2 diabetes mellitus, chronic embolism and thrombosis of deep veins of the lower extremity, cellulitis, peripheral vascular disease, and osteomyelitis. The resident’s physician orders required vital signs to be obtained before each dialysis treatment and the resident to be weighed every Monday, Wednesday, and Friday morning before dialysis. The care plan also identified the need for kidney dialysis and included an intervention to coordinate care with outside providers regarding dialysis. The facility’s Director of Nursing reported that communication forms were supposed to accompany the resident to the dialysis center and be returned after treatment with post-dialysis vital signs, weight, condition changes, and any new orders or instructions. However, the resident’s electronic record contained only two dialysis communication forms for more than 42 weeks of dialysis treatments, and the binder at the nurses’ station contained only blank forms with no completed forms for the resident. The DON stated that completed forms should have been in the binder, but due to nurse turnover and agency staff, forms were not being completed for residents receiving dialysis, and if the resident returned without a form, the nurse on shift should call the dialysis center to ensure coordination of care.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to one resident, R77. The facility’s Behavioral Health Services Program required consent for any new psychotropic medications prior to administration, but R77’s record did not contain informed consent documentation for Olanzapine 2.5 mg, Fluoxetine 30 mg, Trazodone 150 mg, Clonazepam 1 mg, or Buspirone 20 mg. Physician orders showed these medications were prescribed between 4/30/26 and 5/27/26, and the MAR documented that R77 received them as ordered in May 2026. On 6/1/26, R77’s POA stated that no consent forms had been signed or verbal consent given for the psychotropic medications, and the DON confirmed the facility did not have informed consent documentation for them.
Unsafe Reacher/Grabber Caused Resident Leg Injury
Penalty
Summary
The facility failed to ensure an accident hazard-free environment and failed to provide safe assistive devices for one resident, R7, who was reviewed for accidents. R7 had diagnoses including complete paraplegia, stage four pressure ulcers of the left and right lower back and right hip, chronic osteomyelitis, protein-calorie malnutrition, cellulitis, and an unspecified thoracic spinal cord injury. The care plan documented that R7 had a history of bumping lower extremities on objects while repositioning in bed and required interventions to maintain skin integrity and prevent injury. Nursing documentation showed that R7 was found bleeding from the left leg with a large amount of blood in the room and hallway after stating R7 had attempted to lift the left leg with a grabber/reacher and did not realize the leg had been cut. Staff applied pressure, initiated emergency measures, and called 911. R7 became intermittently unconscious and was transferred by ambulance to the ED. Hospital documentation noted an incision to the left lower leg with six stitches, and later observation found the grabber/reacher on the floor next to R7. R7 stated the device had been used for years and that the injury occurred when the reacher/grabber hit the left leg; the DON later confirmed part of the device had sharp edges.
Missing Dementia Care Plan
Penalty
Summary
The facility failed to develop a dementia-specific plan of care for one of three residents reviewed for dementia services. R2’s medical diagnoses list dated June 2026 documented unspecified dementia, unspecified severity, with other behavioral disturbances. On 6/02/2026 at 11:50 AM, V2 confirmed that R2 did not have a plan of care related to the dementia diagnosis and stated that R2 should have one. V2 also confirmed that a dementia care plan was added on 6/1/26 after the surveyor notified the facility that no dementia plan of care was present in R2’s medical record.
Infection Control Failures With Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide staff and resident access to an appropriate handwashing facility for a resident on contact isolation precautions for suspected Clostridioides difficile infection. The resident’s care plan documented an admission date of 5/15/2026 and a diagnosis of Enterocolitis due to C-Diff infection. On 6/1/2026, contact isolation signage was posted at the room entrance, a fecal odor was noted in the room, and the bathroom door was locked, preventing access to the sink for handwashing. The resident stated the bathroom had been locked by the facility and that staff had provided a bedside commode and alcohol-based hand sanitizer while on isolation precautions. During care on 6/2/2026, an LPN donned gown, gloves, and a mask before entering the room, administered Vancomycin to the resident, doffed PPE into the red disposal bin in the room, and then used alcohol-based hand sanitizer at the medication cart outside the room because there was no nearby area to wash hands with soap and water. The DON stated the resident was placed on isolation precautions on 5/30/2026 due to suspected C-Diff and that staff providing care did not have access to an appropriate handwashing facility following resident care. The facility also failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter: the catheter drainage bag was observed lying on the floor under the wheelchair, no Enhanced Barrier Precautions sign was posted outside the room, and PPE was not readily available. The resident had a physician order dated 10/16/25 for Enhanced Barrier Precautions related to the indwelling urinary catheter, and the DON stated the precautions should have been implemented.
Improper wheelchair securement during transport and failure to call EMS after resident fall
Penalty
Summary
The facility failed to follow its transportation policy when a resident who used a wheelchair was transported in the facility van. The resident had diagnoses including fusion of the thoracic spine, type 2 diabetes, sleep apnea, migraine, hypertension, major depressive disorder, anxiety, anemia, chronic postprocedural pain, muscle spasm, thrombocytosis, nicotine dependence, seasonal allergic rhinitis, weakness, and impaired mobility. The care plan documented that the resident used a wheelchair for mobility and required one to two staff members for assistance with activities of daily living, and the MDS documented the resident as cognitively intact. During transport to a physician appointment, the transport driver buckled the resident’s seatbelt but did not secure the wheelchair with the required four anchor straps. The resident stated she did not realize the wheelchair was not anchored because she was wearing the seatbelt and assumed the wheelchair had been properly secured. When the van accelerated from a traffic light, the wheelchair tipped backward and fell to the floor of the vehicle. The driver confirmed forgetting to attach the wheelchair anchoring straps and stated the resident was lying in the van floor after the vehicle accelerated. After the incident, the resident reported severe pain and requested emergency medical services, but the driver did not summon EMS and instead continued driving to the appointment. The driver pulled the resident back upright and continued transport. The resident later reported the incident to facility staff and the neurologist’s office, and EMS was then dispatched from the office. Emergency department records documented that the resident fell backwards out of the wheelchair in the transport van, complained of neck and back pain, and was tearful during the exam. Hospital records later documented a compression fracture at T12, and the neurosurgery note stated that the wheelchair was not secured and the resident fell back.
No Full-Time DON in Place
Penalty
Summary
The facility failed to employ a full-time Director of Nursing to oversee nursing services. During surveyor interviews on 4/23/26, staff members stated there was no DON at the facility at that time. On 5/4/26, the ADON stated the former DON had been terminated on an unknown date and there was currently no DON. The Administrator provided the Facility Assessment on 4/28/26, which documented that the facility would employ one full-time Director of Nurses. The Resident Roster dated 4/23/26 showed that 88 residents resided in the facility.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident for two residents reviewed for abuse. R5’s medical record documented diagnoses including anxiety disorder, substance abuse disorder, major depressive disorder, oxygen dependence, frontal lobe and executive function deficit, anoxic brain injury, and traumatic brain injury, and the MDS documented moderate cognitive impairment. R4’s medical record documented diagnoses of mood and bipolar disorder, and the MDS documented intact cognition. The abuse investigation documented that on 3/29/26 a resident-to-resident physical altercation occurred between R4 and R5 after R5 became upset and angry during medication administration, yelling and cursing at the nurse. The nurse attempted to educate R5 about physician orders and scheduled medication times, and R4 stepped in to intervene. The progress note stated the two residents then began a physical altercation, and police were notified. Interviews on 4/25/26 showed R4 stated R5 hit R4 and that both residents hit each other, with R4 stating R4 hit R5 with a wet floor sign. R5 stated R4 was being nosy, R5 hit R4, and then both residents began hitting each other, with R5 also stating R4 hit R5 with a wet floor sign. The administrator stated R5 was arrested for outstanding warrants after the altercation was reported to local police and was taken to jail overnight.
Failure to Notify Physician of Resident Injury
Penalty
Summary
The facility failed to notify the physician of a change in condition for one resident who had an injury to the right lower leg. The resident’s care plan documented multiple diagnoses, including Type 2 diabetes mellitus without complications, end stage renal disease, hypertension, chronic embolism and thrombosis of deep veins of the lower extremity, cellulitis, acquired absence of both feet, osteomyelitis, bilateral mixed conductive and sensorineural hearing loss, insomnia, and peripheral vascular disease. The care plan also documented that the resident required assistance from one to two staff members for ambulation and ADL care. On 4/20/26, a CNA reported that the resident was bleeding from the right lower leg. An LPN applied a dressing, notified the wound nurse, and sent the resident to dialysis, but did not notify the physician of the injury. When the resident was observed later, the right lower leg had a dressing that was undated, unsigned, and without a time. Staff confirmed there were no physician orders in the record to apply a dressing and no progress note documenting physician notification of the injury. The ADON confirmed the record lacked a progress note notifying the physician and stated nurses are expected to notify the physician of any change in condition, including an injury, and obtain a wound dressing order at the time of the call.
Failure to Obtain and Follow Wound Care Orders
Penalty
Summary
The facility failed to obtain and follow a physician’s order for a wound on R11’s right lower leg. R11 was admitted on 08/26/2025 and had multiple diagnoses including type 2 diabetes mellitus, end stage renal disease, hypertension, chronic embolism and thrombosis of deep veins of the lower extremity, cellulitis, acquired absence of both feet, osteomyelitis, bilateral mixed conductive and sensorineural hearing loss, insomnia, and peripheral vascular disease. R11 required assistance from one to two staff members for ambulation and ADL care. On 04/24/2026, R11 was observed in bed with an undated, unsigned dressing on the right lower leg, and R11 stated that after bleeding on an unknown date, a nurse applied a dressing but no nurse had been changing it daily as expected by the resident. Staff confirmed there was no physician order in the medical record for the wound dressing that had been applied to the right lower leg. An LPN stated the resident had been bleeding from the right lower leg on 04/20/2026, applied a dressing, notified the wound nurse, and sent R11 to dialysis, but did not notify the physician of the injury. The wound clinic visit summary from 04/23/2026 documented a new wound to the right lower leg and included a physician order for wound care to cleanse with wound cleanser, apply collagen then adaptic, cover with ABD, wrap with kerlix, and fasten with paper tape. The facility’s record review showed no progress note notifying the physician of the injury and no treatment entered or completed on the April 2026 Treatment Administration Record from 04/23/2026 through 04/28/2026.
Failure to Maintain Care-Planned Fall Precautions and Call Light Accessibility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain fall precautions and accident prevention measures as care planned for multiple residents. One resident with moderately impaired cognition, hallucinations, and alcohol-induced persisting dementia was observed lying crosswise in bed without the ability to rise and without a call light within reach, despite a care plan intervention directing staff to ensure the call light was within reach and to encourage its use. Another resident, who was rarely or never understood and had diagnoses of seizures and dementia with behavioral disturbance, was also observed lying in bed without a call light in reach, contrary to a care plan intervention requiring the call light to be kept within reach and used for assistance as needed. A third resident, also rarely or never understood and diagnosed with dementia with behavioral disturbances, was observed lying in bed with the call light located between the wall and the bed, out of reach, despite a care plan intervention to keep the call light within reach and encourage its use. A fourth resident, with intact cognition but with a history of cerebral infarction and hemiplegia/hemiparesis, reported having fallen while trying to transfer independently; surveyors observed that grip strips were not present on the bathroom floor or in the shower room, even though the resident’s care plan included interventions to apply grip strips in both areas with specific initiation dates. CNAs interviewed stated that fall precautions are found in the medical record and that residents should have call lights within reach, and the Director of Nurses stated she expected all fall interventions to be in place. The facility’s Fall Prevention Program policy required safety interventions to be implemented and consistently maintained for residents at risk, but these interventions were not in place for the residents reviewed.
Shower Rooms Found in Disrepair and Unsanitary Condition
Penalty
Summary
The facility failed to maintain the shower rooms in a safe and functional condition, as evidenced by multiple observations of disrepair and unsanitary conditions in the shower rooms on the 100, 300, and 400 halls. Surveyors observed loose and broken tiles, cracked shower boards, dirty grout with black substances, orange rust-like substances along baseboards, peeling caulk, and black or gray fuzzy substances resembling mold on caulking and walls. Additional findings included toilets filled with feces or black water, garbage on the floors, missing tiles, and shower chairs with apparent feces. These conditions were confirmed by the Maintenance Director, who acknowledged the need for deep cleaning and remodeling of all three shower rooms. Interviews with several residents revealed consistent concerns about the cleanliness and state of repair of the shower rooms, with residents describing the areas as dirty, gross, and in need of remodeling. Residents reported that issues such as mold, detached baseboards, and persistent uncleanliness had been ongoing, and that temporary fixes were being applied instead of permanent repairs. Resident Council Meeting Minutes also documented concerns about the adequacy of maintenance staffing to address the volume of needed repairs. At the time of the survey, 94 residents resided in the facility, all of whom had the potential to be affected by these deficiencies.
Delayed Laundry Services Result in Unreturned and Missing Resident Clothing
Penalty
Summary
The facility failed to provide timely laundry services, resulting in residents not receiving their personal clothing in a clean and usable condition. Observations over two consecutive days showed multiple carts of clean, laundered clothing remaining undelivered in the laundry room, while large quantities of dirty laundry accumulated. Interviews with residents and staff confirmed ongoing delays, with residents reporting that it often took two to three days or more to have their clothes washed and returned. Several residents described having to visit the laundry room themselves to retrieve needed clothing, and multiple staff members acknowledged that laundry was consistently backed up due to insufficient staffing and workload. Documentation and interviews revealed a pattern of missing clothing, with numerous Concern/Complaint Forms filed by residents regarding missing items that were later found in the laundry after several days. Resident Council Meeting Minutes over several months also documented repeated complaints about missing and delayed laundry. The Director of Nursing and the Administrator both confirmed the ongoing issue with the timeliness of laundry services and acknowledged receiving several complaints from residents about missing clothing that was eventually located in the laundry.
Failure to Implement Fall and Accident Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate accident and fall prevention interventions for a resident with significant cognitive impairment and multiple medical conditions, including cerebral infarction, encephalopathy, diabetes, chronic embolism, seizures, and substance abuse. Upon admission, the resident was noted to be oriented to person only, unable to follow directions, and had a history of impulsive behaviors such as pulling out medical equipment and attempting to get up unassisted. Hospital discharge documentation indicated the need for a bed alarm and one-to-one sitter, but these interventions were not consistently implemented in the facility. Despite being identified as at risk for falls and removal of medical equipment, the resident's care plan and progress notes lacked adequate and timely interventions to address these risks. The resident experienced multiple incidents, including pulling out a gastrostomy tube on two separate occasions, both requiring hospital visits for reinsertion, and sustaining falls, one of which resulted in a laceration above the left eyebrow that required sutures. After each incident, there was little evidence of new or enhanced interventions being put in place to prevent recurrence, and documentation did not reflect the use of a bed alarm or one-to-one supervision as recommended at discharge. Interviews with facility staff confirmed that the resident was impulsive, had poor safety awareness, and was unable to use the call light due to cognitive impairment. Staff acknowledged that the resident needed one-to-one care and a bed alarm, but these measures were not provided. The lack of appropriate supervision and failure to implement individualized safety interventions directly contributed to the resident's repeated accidents, including falls and the removal of the feeding tube.
Failure to Maintain Cleanliness in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident who was cognitively intact and had diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation and essential hypertension. During observation, dusty cobwebs containing insects were found accumulated along the windowsill next to the resident's bed, and dirt particles were present on top of the resident's bed linens while the resident was in bed watching television. The Housekeeping Supervisor confirmed the presence of cobwebs and insects and acknowledged that the room required better cleaning. The Administrator stated that resident rooms are supposed to be cleaned daily and acknowledged ongoing issues with facility cleanliness. Facility procedures require daily visual inspection and cleaning of resident rooms, including linens and window areas, but these procedures were not followed in this instance.
Inadequate Toilet Paper Supply and Unsafe Shower Conditions
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents by not providing an adequate supply of toilet paper and by failing to keep communal shower floors in a safe and sanitary condition. Multiple residents reported experiencing a shortage of toilet paper, with some having to rely on family members to bring supplies or resorting to using napkins and tissues for several days. Certified Nurse's Aides confirmed the shortage, stating that there were a couple of days when toilet paper was unavailable. The daily census indicated that 92 residents could have been affected by this deficiency. Additionally, the main shower room in one of the facility's halls was observed to have several missing, cracked, and loose ceramic tiles, resulting in an uneven and unstable surface where a shower chair is placed for dependent residents. This condition was confirmed by the facility administrator, who acknowledged awareness of the broken tiles. These deficiencies were identified through observation, resident and staff interviews, and record review.
Failure to Maintain Clean, Homelike Environment and Essential Supplies
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for three residents with chronic medical and mental health conditions. Observations revealed that the rooms of these residents had significant cleanliness issues, including dust, dead insects, and ants on windowsills, as well as baseboards in bathrooms crusted with brown or yellow matter and persistent odors of urine. Paint was observed peeling in multiple areas, and in one room, an empty bed with exposed springs and no linens was present. Residents reported frequent ant infestations, with ants crawling on walls and, in some cases, getting into food. Staff confirmed the presence of ants in resident rooms and noted that some residents, particularly those unable to brush them off, were affected by the insects. Additionally, the facility failed to maintain an adequate supply of toilet paper, resulting in residents being without toilet paper for several days. Residents reported having to rely on family members to bring toilet paper or using alternative items such as napkins and tissues. Staff and the facility administrator confirmed that there was a shortage of toilet paper, and residents were observed keeping extra rolls in their rooms due to previous shortages. These conditions contributed to residents feeling disrespected and ignored.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to provide adequate pest control, as evidenced by the presence of ants and dead insects in resident rooms. One resident, who is cognitively intact and has diagnoses including chronic neuropathy, anxiety, and major depression, was observed in her room where the windowsill was covered in dust, dead spiders, and ants. She reported that ants are present all the time, crawling on the walls and window. Another cognitively intact resident with chronic obstructive pulmonary disease, congestive heart failure, diabetes, anxiety, and depression also had windowsills covered with dust and dead insects, and reported frequent ant infestations, including ants getting into his food. Certified Nursing Assistants confirmed the presence of ants in resident rooms and noted that ants have been seen on residents, which is particularly concerning for those unable to brush them off. The facility administrator acknowledged awareness of the ant problem.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by two separate incidents involving physical altercations between two residents. One resident, who has severe dementia, metabolic encephalopathy, and major depressive disorder, was observed wandering the dementia unit and was involved in altercations with another resident. In the first incident, after the second resident complained to a CNA about the first resident urinating on the floor and being in their shared room, the second resident shoved the first resident on the shoulders, causing the first resident to stumble backward before being intercepted by the CNA. The second incident involved the same two residents, where the second resident was observed yelling at and then slapping the first resident on the head while the first resident was sitting on the edge of another resident's bed. Staff intervened during both incidents, but not before physical contact occurred. Documentation and interviews confirm that the second resident was aware of their actions and expressed frustration about the first resident's wandering and interference with personal belongings. The first resident, due to severe cognitive impairment, was unable to understand or respond appropriately to the situation. Staff statements indicate that the second resident deliberately struck the first resident and had previously threatened further physical harm. These events demonstrate a failure by the facility to prevent physical abuse between residents, despite awareness of the first resident's cognitive limitations and the second resident's escalating behavior.
Failure to Thoroughly Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of resident-to-resident physical abuse involving two residents. In the first incident, one resident requested a CNA to remove their roommate due to inappropriate behavior, which escalated into a physical altercation where the resident shoved the roommate. The investigation file did not include documentation of who reported the allegation to the administrator, whether other residents were interviewed, if additional witnesses were present, or any specific and immediate interventions implemented to protect residents from further abuse. The administrator confirmed that the investigation file was complete and contained the entire incident investigation. In the second incident, a CNA overheard residents yelling and intervened in a room where one resident was standing over another, yelling. As the CNA intervened and escorted one resident out, that resident struck the other in the head. The investigation included a statement from an LPN who received the report but did not document who reported the allegation to the administrator or any specific and immediate interventions or long-term measures to prevent further abuse. The administrator again confirmed the investigation file was complete. Both incidents lacked thorough documentation and failed to meet the facility's abuse prevention and reporting policy requirements.
Failure to Document Details of Resident-to-Resident Abuse Allegations and Investigations
Penalty
Summary
The facility failed to fully document the details of resident-to-resident physical abuse allegations and subsequent investigations in the medical records of the residents involved. In two separate incidents, altercations occurred between two residents, with one resident physically assaulting another. The facility's abuse investigation files contained some details about the events, such as the sequence of actions and statements made by those involved, but lacked documentation regarding who reported the allegations to the administrator, whether other residents were interviewed, the presence of additional witnesses, and the specific immediate or long-term interventions implemented to protect residents from further abuse. In both incidents, the progress notes for the residents involved only briefly mentioned that a staff member reported an alleged physical altercation and that the residents were separated, with notifications made to the physician, POA, Ombudsman, and police. No further details about the incidents, the residents' conditions, or the investigative process were documented in the electronic medical records. The administrator confirmed that these brief progress notes were the only entries related to the altercations in the residents' records.
Failure to Secure Resident in Van Results in Injury
Penalty
Summary
A deficiency occurred when a resident was transported in the facility van without proper use of vehicle safety restraints, as required by the facility's Motor Vehicle Safety Program. The program specifies that seat belts and shoulder harnesses must be used whenever the vehicle is in operation, and the vehicle should not move until all passengers are properly restrained. On the day of the incident, the resident, who uses a manual wheelchair and requires supervision for transfers, was loaded into the van by a Certified Nurse's Assistant (CNA) and accompanied by a Licensed Practical Nurse (LPN). Neither staff member secured the resident's wheelchair or provided a seatbelt before transport. During the drive, after stopping at a red light, the CNA accelerated the van, causing the resident's wheelchair to flip backwards. The resident fell, striking his head and experiencing immediate pain in the neck, head, and chest. The LPN and CNA assisted the resident back into the wheelchair and completed the transport back to the facility. The resident, who has diagnoses of dementia, major depression, and obesity, reported ongoing pain following the incident, which was not present prior to the fall. Subsequent medical evaluation revealed a closed head injury and a non-displaced acute fracture of the left sixth rib. The resident required increased pain management, including the addition of new medications. Both the CNA and LPN involved in the transport stated they had never received training on how to properly secure residents in wheelchairs in the facility van. The Director of Nursing confirmed that the failure to secure the resident led to the accident and resulting injuries.
Failure to Maintain Clean Dining Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the dining room for residents on the 300 hall. Observations revealed a dirty adult brief in the garbage can and staff items such as a drinking cup and backpack on the dining room table. Interviews with Certified Nursing Assistants (CNAs) indicated that residents typically eat in the small dining room, but due to insufficient housekeeping staff, the area has not been cleaned regularly, forcing residents to eat in their rooms. The Maintenance/Housekeeping Director acknowledged the staffing shortage and the inadequate cleaning of the facility. The Resident Council Minutes also documented a complaint about rooms not being mopped or swept daily, further highlighting the issue of cleanliness in the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents with severe cognitive impairments. Resident R3, diagnosed with Dementia, Major Depressive Disorder, and Alcohol Abuse, and Resident R4, diagnosed with Wernicke's Encephalopathy, Major Depressive Disorder, and Anxiety Disorder, were involved in a physical altercation. Both residents were unable to participate in mental status interviews due to their severe cognitive impairments. On the day of the incident, R4 attempted to grab R3's hat, leading R3 to punch R4 in the head. The incident was witnessed by a Certified Nursing Assistant (CNA) who was working at the time. The facility's administrator was informed and subsequently reported the incident to the Illinois Department of Public Health, as well as notifying the residents' Power of Attorneys, Medical Doctor, Police, and Ombudsman. The facility's Abuse Prevention Policy emphasizes the residents' right to be free from abuse and outlines the facility's commitment to preventing such occurrences. However, the incident indicates a failure in maintaining a resident-sensitive and secure environment as per the policy.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the State Agency for two residents involved in a physical altercation. On February 10, 2025, a Certified Nursing Assistant (CNA) witnessed an incident where one resident attempted to grab another resident's hat, leading to a physical confrontation where the resident in the wheelchair punched the other resident. The CNA reported the incident to the previous administrator, but the administrator did not report the incident to the Illinois Department of Public Health as required by the facility's Abuse Prevention Program policy. The facility's policy mandates that any allegation of abuse or incident resulting in serious bodily injury must be reported to the state agency immediately, but no later than two hours after the allegation. However, the incident was not reported until the new administrator was informed on February 21, 2025, and conducted an investigation. The failure to report the incident promptly constitutes a deficiency in the facility's compliance with state regulations regarding the reporting of abuse allegations.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, homelike, and comfortable environment in several areas, including shower rooms, resident rooms, and a dining room. In one resident's room, there was missing paint and a hole in the wall, which the resident had previously reported to an Ombudsman. The Maintenance Director acknowledged the issues and mentioned that the facility was waiting for corporate direction to address the problems. Additionally, the shower rooms on the 100 and 300 Halls had issues such as continuous water flow, blackened substances, and cracks in the tile grout, which allowed water to penetrate behind the wall. Residents expressed concerns about these conditions, and the Maintenance Director was aware of the issues but had not fully addressed them. The small dining room was notably cold, with food debris on the tables and floor. Residents who usually ate in this room had stopped doing so due to the cold temperature, which was confirmed by temperature measurements taken by the survey team. The Maintenance Director was aware of the draft issue and had attempted to address it with temporary measures, but the problem persisted. Staff and residents reported the cold conditions, and the Maintenance Director found a material obstructing the heating unit, but the temperature did not improve. In another resident's room, a padded floor mat was adhered to the floor by food debris, and the housekeeper had not been trained to clean underneath mats. The Maintenance Director became aware of the issue and had to replace damaged floor tiles after removing the mat. These deficiencies affected multiple residents and were observed by the survey team during their visit.
Failure to Protect Resident from Mental and Emotional Abuse
Penalty
Summary
The facility failed to protect a resident from mental and emotional abuse, as evidenced by an incident involving a cognitively impaired resident who experienced a fall. The resident, who had inattention, disorganized thinking, and memory problems, fell while attempting to reach a grab bar after exiting the shower room. A Certified Nursing Assistant (CNA) was observed laughing hysterically and did not attempt to stop the resident from falling or assist them afterward. This behavior was witnessed by a Licensed Practical Nurse (LPN) and captured on camera footage, which showed the CNA standing in the hallway laughing as the resident stumbled and fell. The Director of Nursing (DON) reviewed the incident and determined that the actions of the CNA constituted abuse. The incident was not reported immediately, and the facility's investigation revealed that the CNA, along with another CNA, failed to provide appropriate care and did not report the fall. The family member of the resident indicated that prior to the resident's cognitive decline, such behavior would have caused the resident to feel hurt and humiliated. The facility's policy on abuse prevention and reporting was not adhered to, as the incident was not reported to the Department of Public Health as required.
Failure to Report Alleged Mental Abuse
Penalty
Summary
The facility failed to report an allegation of mental abuse involving a resident who experienced a fall. The facility's policy requires that any allegations of abuse, including mental abuse, be reported to the Department of Public Health. The incident involved a resident who fell after attempting to grab a Certified Nursing Assistant (CNA) while exiting a shower room. The Director of Nursing reviewed witness statements and felt the incident warranted further investigation, reporting concerns to the Administrator. However, the Administrator determined there was no evidence of abuse and did not report the incident to the authorities.
Failure to Wait for Nurse Assessment After Resident Fall
Penalty
Summary
The facility staff failed to adhere to the Fall Prevention Program policy by not waiting for a licensed nurse to assess a resident after a witnessed fall. The incident involved a resident who fell while coming out of the shower room into the hallway. A Licensed Practical Nurse (LPN) instructed two Certified Nursing Assistants (CNAs) to stay with the resident until she could assess him after attending to another resident. However, the CNAs, along with another resident, attempted to stand the fallen resident up despite his complaints of pain. They eventually placed him in a wheelchair and took him to his room. When the LPN later assessed the resident, he was complaining of pain and was unable to move. The Director of Nursing acknowledged that the fall investigation was inappropriate and that the CNAs should not have moved the resident without a nurse's assessment, as it could have worsened his condition.
Resident Wandering Leads to Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy of residents in their rooms due to the wandering behaviors of a resident (R1) who is severely cognitively impaired. R1's Minimum Data Set (MDS) assessment indicates that R1 exhibits behaviors that intrude on the privacy and activities of others, and R1 wanders daily. Despite staff efforts to redirect R1, the resident continues to enter other residents' rooms, causing distress and potential safety issues. Multiple staff members and residents reported R1's intrusive behavior, with incidents of R1 entering rooms uninvited and, in one case, physically interacting with another resident (R3) in a manner that required staff intervention. The facility's records, including nursing and behavior notes, document several instances where R1's wandering led to altercations and distress among other residents. Staff members have expressed difficulty in managing R1's behavior due to insufficient staffing levels to provide constant supervision. The facility's inability to effectively manage R1's wandering behavior and ensure the privacy and safety of other residents constitutes a deficiency in maintaining resident rights to privacy and safety.
Deficiency in Resident Activity Program Implementation
Penalty
Summary
The facility failed to implement an ongoing program of activities for residents, as required by their Activities Program policy. The policy mandates that activities should be designed to appeal to residents' interests and enhance their well-being, with a minimum of four to seven organized activities scheduled daily. However, the facility's activity calendars showed no scheduled activities after 3:00 PM daily and none on Sundays. Additionally, the medical records of 19 out of 20 residents reviewed did not include documentation of activity attendance or participation levels. Observations revealed that residents were left without activities, with some wandering aimlessly or confined to their rooms. Interviews with staff, including CNAs and an LPN, confirmed that no activities were offered on the memory care unit, and the activity department did not visit the unit. Staff reported being understaffed and unable to conduct activities themselves. The former Activity Director admitted to not tracking residents' activity attendance or interests, and activities on the memory care unit were limited to two per day, with none offered during the second shift. This lack of activities and documentation indicates a significant deficiency in meeting the residents' needs for engagement and stimulation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident verbal and physical abuse involving three residents. Resident 1, who is severely cognitively impaired, exhibited aggressive behaviors, including wandering into other residents' rooms and handling their belongings. On one occasion, Resident 1 threw a TV remote at Resident 2, leading to a physical altercation where Resident 2 punched Resident 1. Despite staff attempts to redirect Resident 1, these efforts were unsuccessful, resulting in continued aggressive interactions. Additionally, Resident 1 was involved in another incident with Resident 3, where Resident 1 was found physically aggressive, grabbing and hitting Resident 3's legs. Staff intervention was required to separate the residents. The facility's failure to effectively manage Resident 1's behaviors and prevent these incidents highlights a deficiency in maintaining a safe environment for all residents, as outlined in their Abuse Prevention and Reporting policy.
Failure to Update Care Plan and Supervise Aggressive Resident
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Reporting policy by not updating the care plan and implementing necessary supervision for residents with aggressive behaviors. Specifically, the care plan for a resident with a history of aggression was not updated to include interventions for increased supervision, such as one-on-one monitoring or 15-minute checks, after incidents of resident-to-resident altercations. This oversight occurred despite the resident's documented history of severe cognitive impairment and aggressive behaviors, which posed a risk to themselves and others. The report details multiple incidents involving the aggressive resident, who was admitted with diagnoses including Wernicke's Encephalopathy, Major Depressive Disorder, and a history of aggression. The resident was involved in altercations with two other residents, one of which involved physical aggression where the resident threw a TV remote at a roommate, leading to a physical confrontation. Another incident involved the resident being physically aggressive towards another resident, requiring staff intervention to separate them. Interviews with staff revealed that the resident's care plan was not updated to reflect the need for increased supervision, and staff were not always able to monitor the resident closely due to insufficient staffing. The lack of updated care plans and adequate supervision contributed to the failure to prevent further resident-to-resident altercations, highlighting a deficiency in the facility's implementation of its abuse prevention policy.
Failure to Notify Resident of Discharge
Penalty
Summary
The facility failed to notify a resident of their discharge, violating the facility's own Notice of Transfer and Discharge Policy. This policy requires that residents be notified in writing at least 30 days before discharge, along with the reasons for discharge. In this case, a resident was discharged without receiving the required written notice. The resident was admitted to the facility on March 8, 2024, and was discharged on November 27, 2024, without prior notification. The discharge was based on a physician's order stating that the resident no longer needed nursing home care or services. On the day of discharge, the facility's social services and administrator contacted the corporate team for guidance, which led to the decision to discharge the resident. The resident was taken to a homeless shelter with their medications and belongings. The resident's family member was contacted on the day of discharge but was unable to accommodate the resident. The resident expressed confusion and distress over the sudden discharge, indicating they were not prepared for the transition. The facility did not provide a written notice of discharge, and the resident was not adequately prepared for a safe and appropriate discharge, as required by the facility's policies.
Insufficient RN Coverage on Two Days
Penalty
Summary
The facility failed to provide sufficient Registered Nursing (RN) hours on two specific days, which has the potential to affect all 84 residents in the facility. According to the facility's Nursing Daily Schedule, there was no RN coverage for a 24-hour period on two Wednesdays, specifically on 8/21/24 and 8/28/24. This was confirmed by the Director of Nursing, who acknowledged that the hours listed on the schedule were correct and that the facility indeed lacked RN coverage on those days. The Resident Midnight Census documented that 84 residents were residing in the facility at the time of the deficiency.
Verbal Abuse by Dietary Aide
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member, affecting one of the four residents reviewed for abuse. The incident occurred when a dietary aide, identified as V3, verbally abused a resident, R2, during dinner. R2, who has diagnoses including Type 1 Diabetes Mellitus, Generalized Anxiety Disorder, and Morbid Obesity, asked V3 for an alternative meal option. V3 responded dismissively and later, in the presence of other residents and a family member, directed a derogatory and abusive comment towards R2. This incident was witnessed by multiple individuals, including another resident and a family member, who confirmed the abusive language used by V3. The facility's Abuse Prevention and Reporting Policy, dated August 2023, clearly states the residents' right to be free from abuse, including verbal abuse. Despite this policy, the incident was reported to the Dietary Manager, V4, by the receptionist, V6, immediately after it occurred. V4 was not present at the time but was informed of the incident and took steps to address it by contacting V3, who subsequently resigned. The incident was also reported to the facility's administrator at the time, V15, due to its verbally abusive nature.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to transfer a resident using a mechanical lift with two-person assistance, as required by the resident's care plan. The resident, who has diagnoses including muscle weakness, gait abnormalities, and morbid obesity, attempted a self-transfer and was lowered to the ground by a CNA when their knees gave out. The CNA, who was not familiar with the resident, believed the resident's claim that they did not need a mechanical lift, despite the care plan specifying its necessity for transfers. The CNA was assisting on a different hall than usual and did not verify the resident's transfer requirements before attempting the transfer. The facility's policies require CNAs to provide care in accordance with established procedures, which include using assistive devices as necessary. The incident highlights a failure to adhere to the facility's fall prevention program, which aims to ensure resident safety through appropriate interventions and supervision.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 128 citations issued within 25 miles in the last 12 months — including the 1 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bloomington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Goldwater Care Bloomington | 1.2 mi | ★★★★★ | 3 | 0 |
| Loft Rehab & Nursing Of Normal | 1.4 mi | ★★★★★ | 22 | 0 |
| Arc At Normal | 1.6 mi | ★★★★★ | 11 | 0 |
| Mclean County Nursing Home | 2.2 mi | ★★★★★ | 0 | 0 |
| Bloomington Rehabilitation & Hcc | 2.4 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.