Above 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 Astoria Place Living & Rehab during CMS and state inspections, most recent first.
Two residents at high risk for skin breakdown developed or experienced worsening unstageable pressure ulcers after staff failed to consistently implement and document pressure injury prevention and treatment measures. One resident with multiple comorbidities and impaired mobility progressed from incontinence-associated dermatitis to a large unstageable sacral ulcer, with delayed care plan updates, late initiation of a pressure-reducing mattress, and incomplete skin assessment documentation. Another resident admitted with a deep tissue injury and a very low Braden score later had sacral and mid-back wounds progress to unstageable status with malodor and slough, while staff claimed the resident refused a low air loss mattress but did not document any refusal or ensure orders were in place. Infection prevention staff and the ID NP were not informed of worsening wounds despite culture results showing MRSA and E. coli, and existing facility policies on Braden assessment, skin care, pressure redistribution mattresses, and Enhanced Barrier Precautions were not followed or properly documented.
A wound care dressing change for a resident was performed without proper infection control practices when the Wound Care Coordinator handled the treatment cart, surgical drape, personal items, and gauze with bare hands and delayed hand hygiene until after preparing several wound care supplies. The Infection Preventionist later described that facility expectations and policy require hand hygiene before and after contact with the treatment cart and wound care supplies, and the written infection control policy specifies that staff must perform hand hygiene before and after direct patient contact and after each situation requiring hand cleansing.
A resident with multiple psychiatric diagnoses alleged that a male CNA engaged in inappropriate sexual touching and attempted to kiss her during personal care. Several staff members became aware of the allegation at different times but did not immediately report it to the administrator or law enforcement as required by facility policy. The delay in reporting and failure to notify authorities constituted a breach of the facility's abuse prohibition policy.
A resident with multiple chronic conditions did not have required documentation for several scheduled medications in the MAR. Nursing staff failed to record administration or use appropriate codes for missed doses, as confirmed by the DON and ADON. Facility policy and RN job descriptions require accurate and timely documentation of medication administration.
A resident with multiple serious conditions did not receive scheduled pain medication as ordered due to delays in medication reordering, lack of timely communication with hospice, and failure to utilize available emergency medication stock. Staff provided PRN Morphine instead of the scheduled HYDROmorphone, and documentation errors occurred, resulting in the resident experiencing increased pain and agitation.
Multiple residents experienced inadequate pain management due to missed pain assessments, failure to obtain or follow physician orders, and delays in administering pain medication. One resident with severe arthritis and cervical radiculopathy reported ongoing, unrelieved pain and lack of regular assessment, while another with dementia and a bruised, swollen foot did not receive pain medication as prescribed, with staff failing to use language services to assess pain. A third resident had missing pain assessments and unavailable prescribed medication, and overall, staff training on pain management was insufficient.
The facility failed to ensure that medications were available, transcribed, and administered as ordered for four residents, including issues with unavailable pain patches, missing insulin doses, undocumented eye drop administration, and confusion over narcotic dosage forms. These deficiencies were confirmed through record review and staff and resident interviews.
A resident with a history of falls, poor trunk control, and high fall risk was left sitting upright and unattended in a geri-chair while two CNAs prepared for a transfer. One CNA left to get the mechanical lift, and the other was across the bed, leaving the resident unsupervised. The resident leaned forward, fell, and sustained a head laceration requiring hospitalization and stitches. Staff interviews and records confirmed that proper supervision and support were not maintained during the transfer process.
The facility failed to properly date, label, and discard prepared foods stored in the walk-in cooler, potentially affecting 154 residents receiving an oral diet. During a kitchen tour, unlabeled trays of prepared foods and improperly labeled items like grated parmesan cheese and pie crust were found. The Dietary Manager confirmed that all prepared foods should be labeled and dated, as per the facility's policy, which was not followed.
The facility failed to follow care plans for residents requiring oxygen therapy, resulting in deficiencies such as unlabeled nasal cannulas, improper storage of oxygen tubing, lack of required signage, and incorrect oxygen flow rates. The Director of Nursing confirmed these issues, which were contrary to the facility's policies and physician orders.
The facility failed to properly label, store, and dispose of medications for six residents, including not dating opened inhalers and nasal sprays, not refrigerating unopened eye drop solutions, and not discarding expired medications. The DON confirmed that medications should be labeled and dated once opened to ensure proper disposal and effectiveness.
A facility failed to follow its infection control policy, leading to deficiencies in PPE use and linen handling. CNAs did not wear required PPE when entering a resident's room on Contact Isolation for ESBL, and soiled linen was improperly handled without hand hygiene. Incorrect signage and lack of a specific linen handling policy contributed to these issues, potentially affecting all residents on the floor.
A resident's urinary catheter bag was left uncovered and visible from the hallway, violating the facility's privacy and dignity policy. The DON acknowledged that catheter bags should be covered to prevent dignity issues. The resident required the catheter due to a neurogenic bladder, and the facility's policy mandates covering urine bags, which was not followed.
A facility failed to set a low air loss mattress correctly for a resident with a stage 4 pressure ulcer. The resident, at high risk for pressure ulcers, had a mattress set to 210 lbs instead of the correct 180 lbs. The wound care team confirmed the importance of setting the mattress to the resident's weight to aid in wound healing, as per facility policy.
A resident with cognitive impairment and high fall risk was found on the floor with their head on a wheelchair leg rest. The LPN documented the incident as a behavior slide instead of a fall, contrary to the facility's policy. The DON later acknowledged the incident should have been treated as a fall, highlighting the need for staff training on differentiating between falls and behavior slides.
A resident with multiple diagnoses, including hyperthyroidism, was found with medication left at the bedside, contrary to facility policy. The RN identified the pill as possibly a thyroid medication, and the DON confirmed that medications should not be left unless there is an order and assessment for self-administration, which was absent. The resident's cognition was moderately impaired, highlighting the deficiency in medication administration procedures.
A resident with severe cognitive impairment was physically and verbally abused by their roommate in an LTC facility. The incident, involving a skin tear and derogatory language, was witnessed by a CNA and another resident. Despite staff intervention and reporting to health authorities, the facility failed to prevent the abuse, highlighting a deficiency in resident protection.
Failure to Prevent and Manage Pressure Ulcers and Document Skin Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care, prevent new ulcers, and adequately document skin monitoring for multiple residents, resulting in new unstageable pressure ulcers. One resident (R1) had multiple comorbidities including diabetes, anemia, hypertension, hyperlipidemia, schizoaffective disorder, bilateral hearing loss, and impaired mobility. R1 initially had incontinence-associated dermatitis (IAD) to the left buttock documented on 12/9/25, with treatment ordered but no mention of an air mattress intervention on the skin alteration evaluation. By 12/16/25, R1 had developed a new unstageable pressure ulcer from the sacrum to buttock, documented by the wound NP and in subsequent wound assessments as largely covered with slough. The care plan for risk of pressure ulcer development, including the need for assistance with repositioning and transfers and the use of pressure-reducing devices, was not updated until 12/31/25, approximately 24 days after the sacral pressure ulcer was first documented. There were discrepancies between the MDS documentation and wound assessment dates regarding when the wound was first observed, and the air mattress was not ordered until 12/16, one week after identification of a skin impairment. R1’s skin monitoring documentation was incomplete and lacked detail. The Shower/Bathing & Skin Monitoring records between 12/1/25 and 12/17/25 showed multiple entries marked “yes” for bathing but did not describe skin condition, and the facility was unable to provide documentation of skin integrity observation details when requested by surveyors. On 12/16/25, records showed that R1 received a shower or bath, but there was no documentation by CNAs, nurses, or the wound care nurse of alterations in skin integrity that day, despite the presence of a new unstageable sacral pressure ulcer documented in wound care records. Staff interviews indicated that CNAs reported performing daily skin assessments and documenting skin impairments in the electronic record, but the surveyors verified that the follow-up question report for skin assessment and showers did not document R1’s skin integrity. The DON and Wound Care Coordinator acknowledged that air mattresses are used for residents with wounds or at risk for skin breakdown and that refusals of care should be care planned, but there was no documentation of refusal related to pressure-relieving surfaces for R1. A second resident (R3) was admitted with an intact deep tissue injury (DTI) to the sacrum and intact skin to the mid-back, with a Braden score of 8 indicating high risk for skin breakdown and intact cognition. Early wound assessments documented a sacral DTI present on admission and a new mid-back DTI with intact epithelium and evidence of deeper tissue injury. By 01/06/26, wound assessments showed that both the sacral and mid-back wounds had progressed to unstageable pressure injuries with malodorous odor post-cleansing, increased size, and 100% slough at the mid-back site. Progress notes identified R3 as high risk for pressure sore development and ordered a low air loss mattress and offloading/repositioning interventions; however, the Wound Care Coordinator stated that although she believed there was a standing order for air mattresses and claimed R3 refused an air mattress, she had no documentation of such refusal and did not place an order. The wound care nurse similarly stated that R3 refused the low air loss mattress but admitted she did not document the refusal. Review of progress notes and care plans showed only one entry of R3 refusing wound care and no documentation of refusal of an air mattress or other care, despite staff statements that refusals should be documented and care planned. The facility also failed to consistently implement and document infection prevention measures related to worsening wounds. R3’s wounds later cultured MRSA and E. coli, and staff interviews indicated that the wounds showed signs of infection and had an odor. The Infection Preventionist stated that residents with wounds should be placed on Enhanced Barrier Precautions (EBP), which are to be care planned, and that she was never informed that R3’s wounds were worsening or showing signs of infection. She indicated that, had she been informed, she would have contacted the Infectious Disease NP to consider empiric antibiotics. The Infectious Disease NP confirmed she had not been notified of R3’s worsening wounds after 11/19/25. Surveyors also found that the facility did not have specific policies titled “Pressure Wound Care” and “Pressure Wound Prevention,” and that existing skin care and Braden Scale policies, which required prompt identification, documentation, use of pressure redistribution mattresses, and implementation of interventions per Braden score, were not followed for R1 and R3. These combined failures in prevention, timely intervention, documentation, and communication led to the development and worsening of unstageable pressure ulcers in both residents. The facility’s documentation systems and staff practices did not align with their written policies on skin care, Braden risk assessment, and use of pressure redistribution surfaces. For R1, there was a delay in ordering an air mattress and updating the care plan despite documented high risk and the presence of skin impairment, as well as missing or nonspecific documentation of skin assessments around the time the unstageable sacral ulcer developed. For R3, despite high risk status, admission with a DTI, and subsequent progression to unstageable wounds, there was no documented order or consistent implementation of a low air loss mattress at the time staff claimed it was offered and refused, and no documented refusals of this intervention. Additionally, staff acknowledged that they did not routinely review care plans, even though they relied on them to know resident interventions. These actions and omissions collectively constitute the deficiency in failing to provide appropriate pressure ulcer care, prevent new ulcers, and document skin monitoring as required.
Failure to Perform Proper Hand Hygiene During Wound Care Procedure
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during a wound care dressing change for one resident reviewed for wound care. During an observation of a wound care procedure, the Wound Care Coordinator prepared wound care supplies without performing hand washing or hand sanitizing, while opening and touching the treatment cart drawers. The Wound Care Coordinator opened a surgical drape and touched it with bare hands, touched her glasses, and then used the same hand to type on her laptop while reading the wound care order. She then opened another drawer and removed a stack of gauze with bare hands before using hand sanitizer and removing additional supplies from the cart. In an interview conducted shortly after the observation, the Wound Care Coordinator acknowledged that she should practice handwashing and infection control practices before, between, and after wound care, and verified that she used hand sanitizer only after opening the surgical drape and preparing other wound care supplies. The Infection Preventionist stated that for a clean wound care procedure, the nurse should wash hands, gather equipment, wash hands again, don PPE, and then complete the wound care, and further explained that the outside of the wound care treatment cart is considered dirty and that hand hygiene should be performed after touching the outside of the cart and before handling wound care dressing supplies. The facility’s infection control policy requires hand hygiene before and after direct patient contact and after each situation that necessitates hand hygiene, using alcohol-based hand rubs or hand washing for 20 seconds.
Failure to Immediately Report Alleged Sexual Abuse and Notify Law Enforcement
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not immediately reporting an allegation of staff-to-resident sexual abuse to the abuse coordinator and by failing to notify local law enforcement of a suspected crime. A resident with a history of mood disorder, schizoaffective disorder, bipolar disorder, major depressive disorder, and generalized anxiety disorder was admitted for therapy following knee surgery. On the evening of admission, the resident alleged that a male CNA performed inappropriate and non-consensual touching during personal care, including touching her genital area and breast, and attempting to kiss her. The resident reported these actions to a nurse the following morning and also communicated the incident to her social worker via text messages. Multiple staff members became aware of the resident's allegations at different times, but failed to follow the facility's abuse policy requiring immediate reporting to the administrator and law enforcement. The night shift nurse, morning nurse, and wound care nurse each received information about the alleged abuse, but did not promptly report it as required. Some staff expressed disbelief in the resident's account due to her psychiatric history, and others admitted not knowing the reporting requirements or failing to act due to the time of day or personal judgment. The administrator was eventually informed by the wound care nurse, but this was not immediate, and the facility did not report the incident to police, citing the resident's refusal, despite policy requiring such reporting. The facility's abuse policy, consistent with federal guidelines and the Social Security Act, mandates immediate reporting of all allegations or suspicions of abuse to the administrator and law enforcement, especially in cases of sexual abuse. The policy specifically defines sexual abuse to include unwanted touching of the breast or perineal area and requires notification of law enforcement within a specified timeframe. The failure to adhere to these procedures resulted in a delay in both internal and external reporting of the alleged abuse, contrary to established protocols.
Failure to Document Medication Administration in MAR
Penalty
Summary
The facility failed to ensure that a resident's medications were properly documented as administered according to physician orders. During a review of medication administration records (MARs) for one resident with multiple diagnoses, including Dementia, Asthma, Bipolar Disorder, Chronic Diastolic Heart Failure, and Major Depressive Disorder, surveyors found missing entries of nurses' signatures, initials, or codes for several scheduled medications. Specifically, on a certain date and time, there were no documented entries for the administration of Levothyroxine Sodium, Pantoprazole Sodium, and Advair Diskus, all of which were ordered to be given in the morning. The absence of documentation was confirmed by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who stated that nurses are responsible for administering medications and documenting their administration in the electronic MAR. Codes are available for situations such as resident refusal or absence, but blank spaces indicate that the medication was not administered. Facility policy requires that after medication is administered, the MAR must be signed to confirm administration. The Registered Nurse job description also mandates completion of medical records documenting care provided, in accordance with nursing policies and confidentiality standards. The failure to document medication administration as required was observed during the survey and confirmed through staff interviews and policy review.
Failure to Provide Scheduled Pain Medication Due to Medication Availability and Communication Lapses
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including multiple sclerosis, palliative care needs, colon cancer, and a cervical vertebra fracture, did not receive pain management in accordance with their comprehensive care plan and physician orders. The resident was prescribed scheduled HYDROmorphone HCl (Dilaudid) and PRN Morphine Sulfate for pain and difficulty breathing. The care plan required administration of medications as ordered and monitoring for effectiveness and side effects. However, there were instances where the scheduled Dilaudid was not available, and the resident missed doses, which led to increased pain and agitation as reported by the resident. Staff interviews revealed that nurses did not consistently reorder pain medications in a timely manner, waiting until supplies were low before notifying hospice or the pharmacy. On one occasion, the resident was not given the scheduled Dilaudid because it was not available, and the nurse did not check the emergency medication box for an alternative supply, despite it being stocked with Dilaudid. Instead, the resident was offered PRN Morphine, which he accepted, but this was not in accordance with the scheduled pain management plan. Documentation errors also occurred, with a nurse mistakenly recording administration of Dilaudid when it was not given. The facility's own policies required assessment and management of pain in all situations where pain was possible, and residents' rights included the provision of safe and appropriate care. Despite these policies, the resident experienced lapses in pain management due to medication availability issues, lack of timely communication with hospice, and failure to utilize available emergency medication stock. These actions and inactions resulted in the resident not receiving pain management as planned and ordered.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for multiple residents, as evidenced by a lack of pain assessments, failure to obtain and follow physician orders, and delays in administering pain medication. One resident with a history of cervical radiculopathy and rheumatoid arthritis reported experiencing severe, unrelieved pain and stated that staff did not assess her pain regularly or provide her with prescribed pain medication, despite her repeated requests. The resident's care plan indicated a need for pain monitoring and medication administration, but there were no pain medications listed in her physician orders, and staff did not document or assess her pain as required. Another resident with dementia and palliative care needs was observed in apparent pain, with physical signs such as grimacing and guarding a bruised, swollen foot. Despite having orders for pain assessments and medications, staff failed to document pain assessments on multiple shifts and did not administer pain medication as prescribed. Communication barriers were not adequately addressed, and staff did not use available language services to assess the resident's pain level. Pain medication was not given according to the prescribed pain scale, and there were significant delays in administration. A third resident with a history of hip dislocation and sciatica also experienced lapses in pain management, with missing pain assessments on several days and a prescribed lidocaine patch marked as unavailable. Facility records and staff interviews confirmed that residents often waited a long time for pain medication, and staff training on pain management was insufficient, as evidenced by limited participation in in-service sessions. Facility policies required regular pain assessments and prompt administration of pain medication, but these were not consistently followed.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper medication administration and documentation for four residents, resulting in multiple deficiencies. For one resident with a history of hip dislocation and pain, the prescribed 4% Lidocaine patch was not available on a documented date, and the Medication Administration Record (MAR) was marked as unavailable. Staff interviews confirmed that the facility sometimes had to purchase patches from a drug store due to supply issues, but the patch was not always on hand. Another resident with diabetes did not consistently receive prescribed Glargine insulin, as evidenced by a blank entry on the MAR and the resident's report of inconsistent administration and poor blood sugar control. A third resident, with diagnoses including cataracts and neuropathy, did not have a prescribed Lidocaine patch transcribed onto the MAR, and administration of prescribed Latanoprost eye drops was not documented on the MAR. The resident reported not receiving the eye drops and being told by staff that the medication was not available. For a fourth resident with dementia and palliative care needs, there was confusion regarding the form and dosage of Hydromorphone, with staff unsure whether the medication should be administered as a tablet or liquid, and the physician order specifying a tablet but the dosage written in milliliters. Facility policy requires that all medications and treatments be administered and documented as ordered, but these requirements were not met in these cases.
Failure to Provide Adequate Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident with a history of falls, poor trunk control, and high risk for injury during a transfer from a geri-chair to bed. Two CNAs were preparing to transfer the resident, who was dependent on staff for transfers and required a reclining wheelchair for proper positioning. One CNA left to retrieve the mechanical lift while the other stood on the opposite side of the bed, leaving the resident sitting upright and unattended in the chair. The resident, who was not reclined and had poor trunk support, leaned forward and fell from the chair, resulting in a laceration to the forehead that required hospitalization and stitches. Interviews with staff confirmed that the resident was left without close supervision during the transfer process, despite care plan instructions and facility policy requiring two staff to assist and maintain support for residents with poor trunk control. The incident report and hospital summary documented the fall and resulting injury. Staff acknowledged that being within arm's reach and maintaining physical support was necessary for this resident's safety, and that the resident's chair was not reclined at the time of the fall, increasing the risk of leaning forward and falling.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure that prepared foods stored in the walk-in cooler were properly dated, labeled, and discarded by the use-by date. During an initial kitchen tour, a surveyor observed a food cart with trays of prepared foods such as ham sandwiches, vanilla pudding, chocolate pudding, cups of fruits, and pitchers of lemonade, none of which were labeled with preparation dates. Additionally, a plastic cover on the food cart lacked a label. An opened bag of grated parmesan cheese was found with a label indicating a prepared date of 11/9/24 and a use-by date of 11/16/24, but no manufacturer's expiration date was noted. A tray of pie crust inside a clear bag was also found without a label. The Dietary Manager stated that all prepared foods should be labeled and dated, and they are considered good for seven days after opening, after which they should be discarded. The facility's Receiving policy requires all food items to be appropriately labeled and dated either through manufacturer packaging or staff notation. The facility's roster indicated 156 residents, with two residents who are NPO (Nothing by Mouth), potentially affecting 154 residents receiving an oral diet.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to the care plans for several residents requiring oxygen therapy, leading to deficiencies in the administration and management of oxygen. For instance, a resident with chronic respiratory failure was observed receiving oxygen via a nasal cannula that was not labeled, and the resident could not recall when it was last changed, contrary to the facility's policy requiring weekly changes and labeling. The Director of Nursing confirmed that the nasal cannula should be changed weekly or as needed and labeled accordingly. Another resident was observed with oxygen tubing improperly stored, hanging on an oxygen tank, which contradicts the facility's policy that requires oxygen tubing to be stored properly to prevent contamination. Additionally, a resident receiving oxygen therapy did not have the required oxygen signage posted by the room entrance, which is necessary to alert staff and visitors of oxygen use. The Director of Nursing acknowledged that signage should be posted as a warning. Furthermore, discrepancies were noted in the oxygen flow rates administered to two residents. One resident's oxygen was set at 4 liters per minute, while the physician's order specified 2-3 liters per minute. Similarly, another resident's oxygen was set at 4 liters per minute, contrary to the physician's order of 2-3 liters per minute. The Director of Nursing stated that nurses are responsible for ensuring that oxygen settings align with physician orders, which was not followed in these cases.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly manage the labeling, storage, and disposal of medications for six residents across three medication carts. Specifically, the facility did not date opened multi-dose respiratory inhalers and nasal sprays, did not store unopened multi-dose eye drop solutions correctly, and did not discard expired multi-dose medications. During an inspection, it was found that a resident's Latanoprost ophthalmic solution was not refrigerated as required, and another resident's opened Latanoprost solution was not discarded after the recommended six weeks. Additionally, several inhalers and nasal sprays were found without open dates, making it difficult to determine their expiration. The Director of Nursing confirmed that medications should be labeled and dated once opened to ensure proper disposal and maintain their effectiveness. The facility's policy mandates compliance with federal regulations regarding medication storage, labeling, and disposal, including following pharmacy recommendations for discarding medications after opening. The failure to adhere to these guidelines could potentially affect the potency and safety of the medications administered to residents.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy, resulting in multiple deficiencies. Certified Nursing Assistants (CNAs) V12 and V13 did not don the appropriate personal protective equipment (PPE) when entering a resident's room who was on Contact Isolation precautions due to an ESBL infection in a wound. Despite the requirement to wear gowns and gloves, both CNAs only performed hand hygiene when entering the room to deliver a meal tray, which was contrary to the facility's policy and the Centers for Disease Control (CDC) guidelines. Additionally, there was a failure in the proper handling of soiled linen. CNA V12 was observed carrying soiled linen with bare hands down the hallway, which had visible stains, and did not place it in a plastic bag immediately after removal from the bed. V12 admitted to not washing hands after handling the soiled linen and before entering the clean supply room, acknowledging the lapse in following infection control procedures. This action was against the facility's expectations for handling soiled linen to prevent cross-contamination. The facility's Infection Preventionist Nurse, V4, confirmed that the incorrect signage was posted outside the resident's room, which contributed to the misunderstanding of the required precautions. The Director of Nursing, V2, stated that there was no specific policy for handling linen, which further highlights the gaps in the facility's infection control practices. These deficiencies have the potential to affect all residents on the residential floor, as they increase the risk of spreading infections.
Failure to Ensure Privacy and Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide privacy and promote dignity for a resident using a urinary catheter. During an observation, the resident's urinary catheter bag was found hanging on the side of the bed, half-filled with urine and visible from the hallway, without a protective cover. The resident explained that the catheter was necessary due to a wound. The Director of Nursing confirmed that the catheter bag should not face the door and should be covered to maintain privacy, as per the facility's policy. The physician's orders indicated the use of an indwelling catheter for a neurogenic bladder, ordered on a previous date. The facility's policy on privacy and dignity mandates that urine bags be covered with privacy bags, which was not adhered to in this instance.
Incorrect Low Air Loss Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress device was set to the correct weight setting for a resident with a stage 4 pressure ulcer. The resident, who was admitted with multiple sclerosis and a high risk of developing pressure ulcers, had a physician's order for a low air loss mattress. The resident's care plan included checking the mattress's functionality every shift and as needed. Despite this, the mattress was observed to be set incorrectly at 210 lbs, while the resident's recorded weight was 180 lbs. The wound care coordinator and treatment nurse confirmed that the mattress should be set according to the resident's current weight to effectively offload pressure and promote wound healing. The facility's policy on specialized mattresses emphasizes the importance of using these devices to control moisture, heat, and friction for residents with severe pressure sores. The incorrect setting of the mattress could compromise its intended function, potentially affecting the resident's wound healing process.
Failure to Distinguish Between Behavior Slide and Fall
Penalty
Summary
The facility failed to properly distinguish between a behavior slide and a fall for a resident, R119, who was at high risk for falls due to cognitive deficits, poor balance, and limited mobility. R119's clinical record indicated a history of cerebral infarction with hemiplegia, coronary angioplasty, and other medical conditions, along with moderate cognitive impairment. The care plan noted R119's behavior of sliding onto the floor when experiencing abdominal discomfort, but this behavior was not consistently documented or treated according to the facility's fall occurrence policy. During an observation, a surveyor found R119 on the floor with his head resting on a wheelchair's leg rest. The Licensed Practical Nurse (LPN), V8, did not witness the incident but assumed it was a behavior slide rather than a fall, as instructed by the Director of Nursing (DON). The incident was documented as a behavior slide without a neurological assessment or proper documentation of the head's position on the wheelchair leg. The facility's policy required that any fall, witnessed or not, should be documented and treated as a fall, with an incident report and appropriate assessments. The Restorative Director and the DON acknowledged that R119 was a high fall risk and that the behavior slide should have been treated as a fall if the resident was found off the floor mat. The facility's inability to provide a 24-hour sitter for R119, who required constant supervision, was also noted. The DON admitted that the incident should have been documented as a fall, and the staff needed further training to differentiate between a fall and a behavior slide. The original behavior care plan was missing, and the updated care plan was only entered after the surveyor's request.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, identified as R113, by leaving medication at the bedside. R113 was admitted with multiple diagnoses, including hemiplegia, hypertension, and hyperthyroidism, and was observed sitting on the side of the bed with a white round pill inside a medication cup on the bedside table. The resident was unaware of what the medication was, and the Registered Nurse (RN) identified it as potentially being a thyroid medication from the previous shift. The RN acknowledged that medication should not be left at the bedside unless there is an order and assessment for self-administration, which was not present in R113's records. The Director of Nursing (DON) confirmed that nurses are expected to administer medications as ordered and ensure residents take them before leaving the room. The facility's policies on medication pass and storage emphasize adherence to federal and state regulations and securing medications in a locked storage area. However, R113's physician order summary did not include permission for self-administration, and no assessment for self-administration was found in the electronic health record. Additionally, the Minimum Data Set (MDS) indicated that R113's cognition was moderately impaired, further underscoring the inappropriateness of leaving medication at the bedside.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident, identified as R1, from abuse by their roommate, R2. R1, who was admitted under hospice care, has severe cognitive impairment and requires substantial assistance with activities of daily living. An incident occurred where R2, who also has severe cognitive impairment and a history of aggressive behavior, physically and verbally assaulted R1. R2 grabbed R1's arm, causing a skin tear, and verbally abused R1 over a disagreement about the television. The incident was witnessed by a Certified Nursing Assistant (CNA) and another resident, R3, who reported seeing R2 shaking R1 by the arm and yelling derogatory terms. The CNA intervened and separated the two residents, but the altercation had already resulted in a skin tear on R1's arm. The wound was assessed by a wound care nurse, who confirmed the presence of a skin tear with minimal bleeding. The facility's staff, including the Assistant Director of Nursing and the Nursing Supervisor, were involved in managing the situation. They documented the incident and took steps to ensure R1's safety by removing R2 from the room. The facility's administrator, who is also the Abuse Coordinator, acknowledged the incident as abuse and reported it to the Illinois Department of Health. Despite these actions, the initial failure to prevent the abuse constitutes a deficiency in the facility's obligation to protect residents from harm.
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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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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincolnwood Place | 0.6 mi | ★★★★★ | 2 | 0 |
| Warren Park Health & Living Ctr | 1.1 mi | ★★★★★ | 12 | 0 |
| Buckingham Pavilion | 1.2 mi | ★★★★★ | 6 | 0 |
| Ryze At The Ridge | 1.2 mi | ★★★★★ | 1 | 0 |
| Westwood Vlge Nrsg And Rhb Ctr | 1.2 mi | ★★★★★ | 3 | 0 |
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