Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Atrium Health Care Center during CMS and state inspections, most recent first.
Failure to protect a resident from physical abuse during a room altercation. Two cognitively intact residents with schizophrenia-related diagnoses argued over TV noise and room setup, then physically engaged, with one resident striking the other in the forehead and causing facial scratches and a bump. Staff heard yelling, found the residents fighting, and the incident was identified in the record as physical abuse and battery.
A resident with severe cognitive impairment, a history of falls, and documented need for partial/moderate assistance with mobility experienced an unwitnessed fall and periorbital contusion after apparently attempting to get out of bed unassisted and striking a bedside dresser that had been left close to the bed, despite a care plan intervention to move such items away from the bed/space and policies requiring frequent rounding and supervision.
Two residents, both cognitively intact and with complex medical histories, were involved in a physical altercation after one verbally provoked the other, leading to physical abuse witnessed by staff and other residents. The incident was confirmed by multiple statements and facility documentation, revealing a failure to protect residents from abuse as required by policy.
A resident with multiple chronic conditions and intact cognition was physically assaulted by another resident, who grabbed her around the neck without provocation. Two other residents witnessed the incident. The assaulted resident did not sustain injuries and reported feeling safe, but the event occurred despite the facility's abuse prevention policy.
Surveyors found that the facility did not consistently label or date food items, failed to store opened products according to manufacturer instructions, and did not discard expired foods as required. Additionally, kitchen staff did not follow proper sanitization procedures for equipment, immersing items in sanitizer for only a few seconds instead of the required 60 seconds and using towels to dry them instead of air drying. These failures were acknowledged by dietary staff and had the potential to affect all residents receiving food from the kitchen.
Surveyors found that medications, including antibiotics and multiple types of insulin, were not stored according to pharmacy guidelines, with some requiring refrigeration found at room temperature and others kept refrigerated after opening despite instructions to store at room temperature. Additionally, opened inhalers lacked date labels, and expired multi-dose vials were not discarded as required. Staff interviews confirmed that these practices did not align with facility policy or professional standards.
Several residents with dysphagia and other conditions requiring pureed diets were served regular gelatin that was not pureed, contrary to physician orders, facility recipes, and dietary policies. Staff confirmed that the gelatin was not pureed for these residents, despite documentation specifying the need for pureed consistency, resulting in a failure to meet individualized dietary needs.
A nurse administered medication via G-tube to a resident on Enhanced Barrier Precautions without wearing a gown, as required by facility policy, using only gloves during the procedure. The resident had multiple indwelling devices and was severely cognitively impaired. Facility policy and posted signage specified that both gloves and gown must be worn during high-contact care activities for residents on EBP, but this protocol was not followed.
Two residents experienced delays in meal service when a CNA distributed trays to multiple tables and rooms before completing service at their table, resulting in one resident waiting seven minutes and another asking about their meal. The Dietary Supervisor and facility policy both state that all residents at a table should be served at the same time to maintain dignity, but this procedure was not followed.
A resident with diabetes and other significant health conditions was found with long, jagged toenails that had not been trimmed since admission. The resident reported no one had offered toenail care, and staff were unable to locate the binder used to track podiatry needs. Facility policy required staff to identify residents needing toenail care, but the resident was not seen by the podiatrist as required.
A controlled medication, Lorazepam oral concentrate, prescribed to a resident with multiple complex medical conditions, was found stored in an unlocked refrigerator rather than in a locked box as required by facility policy. The DON confirmed that this medication should have been secured to prevent unauthorized access.
Surveyors observed that nurses failed to administer medications as ordered for three residents, resulting in a medication error rate of 12.49%. Errors included missed doses, incorrect dosages, and improper administration techniques, such as giving only one tablet of Vitamin D3 instead of two and administering multiple sprays of Fluticasone nasal spray instead of the prescribed amount. These findings were based on direct observation, record review, and staff interviews.
The facility did not follow its policy to request fingerprint-based background checks within 72 hours for two residents who had 'HIT' results on their name-based criminal history checks, both of whom were cognitively intact and had qualifying offenses. Required documentation was incomplete, and staff failed to provide evidence of timely scheduling.
A facility failed to comply with involuntary psychiatric admission requirements for a resident involved in a physical altercation. The staff did not ensure the resident received a petition or was informed of his rights, and the process was not documented in the progress notes. The facility's policy lacked specific notice requirements for such admissions, leading to procedural gaps.
A resident admitted with acute osteomyelitis did not receive medications as ordered. Cefepime and Vancomycin were administered late and not according to the prescribed schedule. The facility's medication administration policy was not followed, leading to a deficiency.
A facility failed to provide proper pressure ulcer care for a resident admitted with severe wounds. The facility did not document wound assessments or include the resident in the wound report. Physician orders lacked details, and treatment records showed missed dressing changes. The DON and Wound Care Nurse acknowledged these documentation gaps, and the facility's wound assessment policy was not followed.
Two residents with intact cognitive function engaged in a physical and verbal altercation over a loud television, resulting in a failure to protect them from abuse. The incident was witnessed by a housekeeper and reported to the nursing staff, who intervened by separating the residents and notifying the appropriate personnel. The facility's failure to prevent the altercation and protect the residents from abuse was evident, breaching the Abuse Prevention Policy.
The facility failed to protect residents from abuse in two incidents. A resident reported verbal abuse by a visitor, which was confirmed by the Social Service Director. In another incident, two residents in wheelchairs had a physical altercation, leading to one resident slapping the other. The incidents were investigated, and abuse was substantiated.
A resident alleged sexual assault by an unidentified male staff member, but the facility failed to report the incident to the State Agency within the required two-hour timeframe. The administrator, acting as the Abuse Coordinator, acknowledged the delay, which was contrary to the facility's Abuse Prevention Program and state regulations.
A facility failed to thoroughly investigate a sexual assault allegation involving a resident, as a key staff member, who was on duty during the alleged incident, was not interviewed. The investigation did not comply with the facility's Abuse Prevention Program, which requires interviewing all potential witnesses. The administrator acknowledged the oversight, resulting in a deficiency in handling the abuse allegation.
A resident with a history of falls and various medical conditions fell and sustained a head injury due to the facility's failure to update the care plan and provide necessary supervision. The resident was not listed on the fall risk list, and staff were unaware of the resident's fall risk status. The facility's policy on falls and fall prevention was not followed, contributing to the incident.
A cognitively intact female resident with schizophrenia and depressive disorder was involved in an altercation with a moderately cognitively impaired male resident with schizophrenia and agitation. The incident occurred when the female resident reported a conflict over seating space, leading to a verbal and physical altercation. The male resident's hand became entangled in the female resident's hair, causing her to fall. Despite care plans addressing their behaviors, the facility failed to prevent this resident-to-resident physical abuse.
A resident reported being physically abused by staff, but the social worker failed to inform the administrator, violating the facility's policy. The administrator, unaware of the allegations, did not initiate an investigation as required.
A resident reported being physically abused by staff, but the facility failed to follow its policy to investigate these allegations. The resident informed the social worker, who claimed to have notified the administrator, but the administrator was unaware of the allegations and had not initiated an investigation as required by the facility's policy.
Two residents in a LTC facility were injured due to the facility's failure to prevent abuse. One resident with schizophrenia was hit by another resident with a history of aggression, resulting in a swollen and bruised eye. Another resident was struck by their roommate after going through the roommate's belongings, leading to facial injuries. The facility's lack of effective monitoring and intervention for residents with known aggressive behaviors contributed to these incidents.
A resident with quadriplegia and a history of falls fell out of bed during repositioning by an LPN and a CNA, resulting in a scalp laceration. The resident was dependent on two-person assistance, but the staff failed to maintain control during the procedure. The facility did not update the resident's care plan with new fall prevention measures after previous falls, and no floor mats were in place at the time of the incident.
A resident with quadriplegia, requiring two-person assistance for care, fell from bed due to inadequate supervision, resulting in a head injury and post-concussion syndrome. The incident occurred when only one CNA was present, and the bed could not be lowered, contributing to the fall. Despite the care plan's requirements, the resident was often assisted by only one staff member, highlighting a failure to adhere to the facility's supervision policy.
The facility failed to protect residents from abuse, resulting in two incidents where residents with schizophrenia were physically harmed by other residents. One resident was hit in the mouth, causing facial trauma, and another was hit on the nose, resulting in bleeding and pain. Both incidents were substantiated through staff interviews, progress notes, and police reports.
The facility failed to properly secure and protect the money of six residents. Surveyors found unsealed envelopes with money in medication carts, contrary to the facility's protocol requiring money to be stored securely by social services or the administrator. The residents had varying levels of cognitive impairment, and there was no documentation of the money being inventoried.
A resident requested a fan from the social worker, who did not provide one or inform anyone else about the request. The resident's room felt warm, and the air conditioner was not effectively cooling the area near the resident's bed. The facility failed to uphold its commitment to providing a comfortable and homelike environment.
A resident's money was misappropriated after being sent to the hospital. The resident entrusted the money to a roommate, who handed it to a CNA. The money was placed in an unsealed envelope in a medication cart by an LPN without following proper protocol. Upon the resident's return, $200 was missing, and the facility failed to document or report the incident properly.
A resident reported missing money after returning from the hospital, but the facility failed to document, report, or investigate the incident as required by their policies. The resident had given the money to a roommate, who handed it to a CNA. The Assistant Psychiatric Rehabilitation Service Director returned only part of the money in an unsealed bag, and the abuse coordinator was unaware of the issue.
A resident with multiple diagnoses did not receive their prescribed Venlafaxine 150mg ER due to insurance issues and facility inaction. The medication was incorrectly documented as administered, and the resident refused the alternative medication. The LPN admitted to the documentation error, and the DON confirmed the medication was not stocked or promptly authorized.
Failure to Protect Resident from Physical Abuse During Room Altercation
Penalty
Summary
The facility failed to ensure that one resident was free from physical abuse when another resident struck him during an altercation in their shared room. The incident involved two cognitively intact residents with diagnoses including paranoid schizophrenia and psychosis/schizophrenia. The report states that staff heard yelling from the room and found the two residents physically engaging with each other, with only one resident sustaining injury. According to the record, the altercation began after the residents argued about television noise and the placement of a dresser between their beds. One resident reported that the other pushed the dresser toward his side, he walked toward the other resident, and the other resident struck him in the forehead. The injured resident was documented with a bump to the right forehead and superficial scratches to the face, while the other resident had no visible injury. Both residents were placed on 1:1 monitoring and sent out for evaluation. The facility’s documentation and staff interviews identified the event as physical abuse and battery. The administrator stated that if a resident hits another resident it is considered abuse. The injured resident’s behavior care plan and physician orders included monitoring for aggression, hitting, and other behavioral symptoms, and the other resident’s behavior monitoring orders also included aggression-related behaviors. The report also includes written statements from both residents describing the argument and the physical exchange that occurred.
Failure to Follow Fall-Prevention Care Plan and Maintain Safe Bedside Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and follow the resident’s fall-prevention care plan, resulting in an unwitnessed fall and injury. The resident had a history of heart disease, paranoid schizophrenia, hypertension, chronic pain, prior falls, and severe cognitive impairment with a BIMS score of 7. The MDS documented that the resident required partial/moderate assistance for sit-to-stand and walking 10 feet. The resident’s care plan identified her as at risk for falls related to psychotropic or new medications that may cause dizziness, with interventions including increased monitoring every 1–2 hours and, following a prior fall with injury, moving dressers and other items that could cause injuries out of the room or away from the resident’s bed/space. On the day of the incident, staff documented that the resident was observed comfortably in bed around 8:00 a.m., alert and oriented to self and able to answer yes/no questions, with scheduled medications administered and tolerated. Multiple staff, including a CNA and an LPN, reported seeing the resident in the morning with no swelling, redness, or discoloration to the face or eye area. The resident remained in her room, where she preferred to stay, and staff acknowledged that she sometimes attempted to get up unassisted despite requiring assistance for ambulation. The facility’s policies required nurses to round hourly and CNAs every two hours, with the frequency of safety monitoring determined by the resident’s risk factors and care plan. Around midday, when staff went to provide ADL care, they observed new swelling and discoloration of the resident’s right upper eyelid. The resident was later diagnosed in the ER with a periorbital contusion. The facility’s fall occurrence report and final reportable investigation documented that the resident had a prior history of falls and that environmental factors included furniture, specifically a bedside dresser located close to the right side of the bed. The investigation concluded that the resident likely attempted to get out of bed unassisted, lost her balance, fell, and struck her right eye on the edge of the bedside dresser. At the time of the surveyor’s observation, the bed was in the lowest position with one floor mat on the right side only, and the dresser had previously been close enough to the bed for the resident to hit her eye on it, contrary to the care plan intervention to move dressers and other items away from the resident’s bed/space.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse by another resident, resulting in a physical altercation between two cognitively intact residents. One resident entered another's room to look for a peer, and after being told the peer was not present, used derogatory language towards the resident in the room. This verbal provocation led the resident in the room to follow and physically assault the first resident in the hallway, with multiple witnesses observing the incident. Staff members, including a Certified Nursing Assistant and a Licensed Practical Nurse, confirmed seeing one resident on the floor and the other resident hitting him, with the altercation requiring staff intervention to separate the individuals involved. Both residents involved had significant medical histories, including hemiplegia, osteomyelitis, hypertensive heart disease, tumor of the bronchus and lung, Parkinson's disease, and schizophrenia. Despite their cognitive intactness as documented by BIMS scores, the altercation escalated quickly from verbal to physical abuse. The incident was witnessed by other residents and staff, and both residents provided statements confirming the sequence of events, with the aggressor admitting to physical assault in response to being called derogatory names. Facility documentation, including progress notes and resident statements, corroborated the sequence of events and the physical nature of the altercation. The facility's abuse prevention policy and residents' rights documentation affirm the right of residents to be free from abuse, yet the incident demonstrated a failure to uphold these protections. The event resulted in one resident being sent for psychiatric evaluation and the initiation of involuntary transfer proceedings for the aggressor due to endangerment of others' safety.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, heart failure, and carcinoma of the oral cavity, and who was cognitively intact as indicated by a BIMS score of 15, reported being physically assaulted by another resident. The incident involved the other resident approaching and grabbing the resident around the neck without provocation. Two other residents witnessed the event and confirmed the physical contact. The assaulted resident did not report pain or injury at the time of assessment and expressed feeling safe and wishing to remain at the facility. The Director of Nursing confirmed being informed of the altercation, which resulted in the discharge of the aggressor from the facility. Facility documentation of the incident noted no visible injuries or complaints of pain. The facility's abuse prevention policy states a commitment to protecting residents from abuse by anyone, including other residents. Despite this policy, the incident demonstrates a failure to ensure that the resident was free from abuse.
Failure to Properly Label, Store, and Sanitize Food and Equipment
Penalty
Summary
The facility failed to ensure proper food labeling, storage, and disposal practices in the kitchen, as well as correct sanitization of kitchen equipment. During a kitchen tour, the Dietary Supervisor stated that all food items should be labeled with delivery, opened, and use by dates, and that items should be discarded after seven days. However, observations revealed several unlabeled and undated food items, such as a container of boiled eggs and a prepared tuna fish salad, both lacking prepared and use by dates. Additionally, a mechanical soft cold cut salad was found stored past its use by date and had not been discarded as required. Further observations showed improper storage of food items according to manufacturer recommendations. An opened bottle of lemon juice and a container of soy sauce were stored on a spice rack at room temperature, despite manufacturer instructions to refrigerate after opening. These items were also not labeled with opened or use by dates. The Dietary Supervisor acknowledged that these items should have been refrigerated and properly labeled, in accordance with both manufacturer guidelines and facility policy. The facility also failed to follow proper sanitization procedures for kitchen equipment. The cook was observed washing, rinsing, and quickly dipping blender parts into the sanitizing solution for only 2-3 seconds, rather than the required 60 seconds, and then hand drying the items with a towel instead of air drying. The Dietary Supervisor confirmed that the manufacturer's instructions, posted above the three-compartment sink, require full immersion for 60 seconds and air drying. The cook stated he was unaware of the required sanitization time and used a towel to dry the items due to time constraints and limited equipment availability.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's medication storage and labeling practices. During inspection of a medication cart, a Penicillin G injection labeled for refrigeration was found stored at room temperature, and an opened multi-dose Ventolin HFA inhaler was found without an open date label. The LPN confirmed that inhalers should be dated upon opening to track when they should be discarded. In the medication room refrigerator, several opened insulin vials and pens, including Lantus, Fiasp, Basaglar, and Humalog, were stored in the refrigerator despite pharmacy labels indicating they should be kept at room temperature after opening and discarded 28 days after opening. Additionally, an opened multi-dose Tuberlicin PPD Mantoux injection vial was found in the refrigerator past its expiration date, and the RN acknowledged that expired medications should be discarded. The Director of Nursing confirmed that unopened insulin should be refrigerated, but once opened, it should be labeled with the open and discard dates and stored according to pharmacy recommendations. The facility's policies require medications to be stored at appropriate temperatures and outdated medications to be removed and disposed of immediately. Physician orders for the affected residents included various insulin regimens and inhaler use, all of which require proper storage and labeling to maintain medication efficacy and safety. The failure to follow these procedures led to the deficiencies identified during the survey.
Failure to Provide Pureed Food Consistency for Residents on Pureed Diets
Penalty
Summary
The facility failed to provide pureed food in the appropriate consistency for residents on pureed diets, as required by their dietary orders and facility policy. During observation of the lunch tray line, regularly prepared gelatin without canned fruit was served to four residents on pureed diets, rather than the required pureed gelatin. The gelatin served was firm and held its shape, indicating it was not pureed. Interviews with the Dietary Manager and Cook confirmed that the gelatin for pureed diets was not pureed, but simply served without fruit, contrary to the recipe and spreadsheet instructions. The Registered Dietitian emphasized the importance of following recipes and spreadsheets to ensure correct food consistency for residents with swallowing difficulties or who are at higher nutritional risk. The residents affected had diagnoses including dysphagia, cerebrovascular disease, chronic obstructive pulmonary disease, seizures, dementia, and other conditions requiring pureed diets with specific liquid consistencies. Their physician orders and meal tickets documented the need for pureed diets, and facility documentation specified that pureed fruited gelatin should be served, prepared according to a standardized recipe. Facility policies required that food be provided in a form designed to meet individual needs and that standardized recipes be followed, but these procedures were not adhered to in this instance.
Failure to Use Required PPE During G-Tube Medication Administration Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a nurse administered medication via a G-tube to a resident on Enhanced Barrier Precautions (EBP) without wearing the required gown, using only gloves during the procedure. The resident was observed lying in bed with a G-tube feeding in progress, and EBP signage was posted in the room. Facility policy and posted signage both specified that staff must wear gloves and gowns during high-contact care activities, such as G-tube medication administration, for residents on EBP. Interviews with the Director of Nursing and the Infection Preventionist confirmed that proper PPE, including both gloves and gown, is required for such procedures to prevent cross contamination. The resident involved had multiple medical conditions, including a gastrostomy, end stage renal disease, and dependence on renal dialysis, and was severely cognitively impaired. Physician orders and the care plan indicated the resident was on EBP due to the presence of indwelling medical devices and wounds. Despite these precautions, the nurse failed to follow the facility's EBP policy during medication administration, resulting in noncompliance with infection prevention and control protocols.
Failure to Serve Meals Simultaneously at Dining Tables Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance residents' dignity during meal service in the dining room. During an observation, a Certified Nurse Assistant (CNA) was seen distributing meal trays to residents at multiple tables and in resident rooms without completing service to all residents at one table before moving to another. As a result, one resident waited seven minutes to be served after the first resident at their table received a meal, and another resident at the same table inquired about their meal tray after experiencing a delay. The CNA explained that residents do not always arrive at the same time, making it difficult to align meal tray distribution, and acknowledged that the previous practice was to serve one table at a time. The Dietary Supervisor confirmed that the expectation is for all residents at a table to be served before moving to another table, and that residents typically sit at the same table. Facility policy and residents' rights documents both state that meals should be served at approximately the same time to all residents at a table to respect their dignity. The observed practice of serving residents at different times at the same table was inconsistent with these policies and procedures.
Failure to Provide Timely Podiatry Services for Toenail Care
Penalty
Summary
A deficiency was identified when a resident was observed with excessively long and jagged toenails, which had not been trimmed since their admission to the facility approximately 2.5 months prior. The resident reported that their toenails had not been cut since October 2024, and no one had offered or asked about toenail care since their arrival. The resident expressed difficulty putting on socks due to the length of their toenails. Staff interviews revealed that CNAs only cut fingernails and that toenail care is provided by an outside podiatrist who visits twice a month. However, the process for identifying residents in need of podiatry services was not effectively implemented, as the binder used to track residents requiring toenail care could not be located, and the resident's name was not on the list of those seen by the podiatrist. The Director of Nursing confirmed that toenail care is part of daily grooming and should be monitored by nursing staff during ADL care, with staff responsible for alerting nurses if toenails need attention. The resident in question had a medical history including diabetes, cerebrovascular disease, heart failure, and hemiplegia, and required supervision or assistance with personal hygiene. Despite these needs and the facility's policy requiring staff to identify residents needing toenail care, the resident had not received podiatry services, resulting in the deficiency.
Improper Storage of Controlled Medication in Unlocked Refrigerator
Penalty
Summary
Surveyors observed that a controlled medication, Lorazepam oral concentrate, prescribed to a resident with multiple diagnoses including cerebral infarction, hypothyroidism, seizure disorder, heart failure, vascular dementia, and dysphagia, was stored improperly in an unlocked refrigerator in the medication room. The facility's policy requires that controlled substances needing refrigeration be kept in a locked box attached inside the refrigerator. During the inspection, the Lorazepam was found accessible without the required additional security. The DON confirmed that Lorazepam is a controlled medication and acknowledged that it should have been stored in a locked box or locked refrigerator, as per facility policy and regulations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 12.49% error rate during observed medication administration. Surveyors observed medication passes for three residents, during which four errors occurred out of 28 opportunities. For one resident, a nurse failed to administer Risperidone and Oyster shell calcium as ordered, and did not provide the correct dose of Vitamin C, Acetaminophen, and Polyethylene glycol according to the frequency specified in the physician's orders. Another resident received only one tablet of Vitamin D3 instead of the ordered two tablets. A third resident was administered Fluticasone nasal spray with two sprays in each nostril, contrary to the physician's order for one spray in each nostril. These errors were identified through direct observation of medication administration, review of the Medication Administration Record (MAR) and Physician Order Sheet (POS), and interviews with nursing staff. The Director of Nursing confirmed that nurses are expected to follow the five rights of medication administration and acknowledged that missed or incorrectly administered medications could have effects on residents. The facility's medication administration policy requires checking all medications against the MAR and following specific instructions, which was not consistently done during the observed medication passes.
Failure to Timely Request Fingerprint-Based Background Checks After Criminal History 'HIT'
Penalty
Summary
The facility failed to follow its policy requiring a fingerprint-based background check to be requested within 72 hours after receiving a name-based criminal history background check with a 'HIT' result for two residents. Specifically, for both residents, the required fingerprinting consent forms were found to be unsigned and undated, and there was no documentation that the fingerprinting had been scheduled within the required timeframe. The staff responsible for scheduling the fingerprinting was unable to provide evidence of timely communication with the fingerprint service provider, and in one case, admitted to not sending the scheduling email at all. The administrator confirmed that the fingerprinting should have been scheduled within 72 hours according to facility policy, but this was not done. Both residents involved had 'HIT' results on their criminal history reports, with one resident having a conviction for prostitution (Class 4) and the other for burglary (Class 2). Both residents were documented as cognitively intact based on their BIMS scores. The facility's Identified Offender Policy and Procedure clearly states the requirement to request a fingerprint-based background check within 72 hours after a name-based check with qualifying offenses, but this process was not followed for the two residents reviewed.
Failure to Comply with Involuntary Psychiatric Admission Requirements
Penalty
Summary
The facility failed to ensure compliance with the requirements for involuntary psychiatric admission for a resident involved in a physical altercation. The resident, identified as the aggressor, was involved in an incident with a co-peer, leading to a decision to transfer him to a hospital for psychiatric evaluation. The Social Service Director, V7, acknowledged that a petition for involuntary admission was written, and the physician was contacted for an evaluation order. However, the petition was not signed by a nurse to confirm that the resident received a copy or was informed of his rights. Additionally, the petition was not documented in the resident's progress notes, and the facility's policy provided did not include specific notice requirements for involuntary/judicial admission. The surveyor's inquiry revealed that the staff was unclear about the process and documentation required for involuntary psychiatric admissions. V7 mentioned that the petition was typically given to the ambulance driver, with copies made for the hospital and the ambulance, but was unsure about the third copy. The facility's policy on involuntary discharge did not address the specific requirements for involuntary psychiatric admissions, indicating a gap in the facility's procedures. This lack of clarity and documentation resulted in the resident not being properly informed of his rights during the involuntary admission process.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, as evidenced by their handling of a resident's medication administration. The resident was admitted with a diagnosis of acute osteomyelitis, which was not included in the facility's records. The facility was instructed to continue the resident's hospital medications, which included Cefepime and Vancomycin, both to be administered intravenously every 8 hours. However, the facility did not adhere to these instructions. Cefepime was administered 6 hours after the prescribed start time, and Vancomycin was not administered until 12 hours after the prescribed start time, with subsequent doses not following the 8-hour schedule. The Director of Nursing confirmed that the medications were not administered as directed, with Cefepime starting 15 hours after admission and Vancomycin 21 hours after admission. The facility's medication administration policy requires medications to be administered within a 2-hour window, but this was not followed. The failure to administer medications as ordered and to include the correct diagnosis in the resident's records contributed to the deficiency identified by the surveyors.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident (R3) who was admitted with a diagnosis of acute osteomyelitis and a stage 4 pressure injury on the right hip, complicated by a deep penetrating ulcer on the left buttock. The facility did not follow its own policy procedures, as there was no documented assessment of R3's wounds upon admission, and the facility wound report did not include R3. Additionally, the Physician Order Sheets (POS) lacked specific details about wound locations and required medications or dressings, and the Treatment Administration Record (TAR) indicated that wound dressing changes were not administered on several occasions. The Director of Nursing (V2) and the Wound Care Nurse (V9) acknowledged the lack of documentation and assessment for R3's wounds. V2 confirmed that the wound vac ordered for R3 was received 23 hours after admission, but there was no documentation of its implementation. The facility's wound assessment policy requires a comprehensive assessment and documentation of wounds, including classification, location, staging, and other details, which was not adhered to in R3's case. This lack of adherence to policy and documentation resulted in a failure to ensure accurate and effective wound care for R3.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical and verbal altercation between them. Resident 1, diagnosed with schizoaffective disorder and bipolar disorder, and Resident 2, with chronic pain syndrome and a history of heroin poisoning, both have intact cognitive function as indicated by their BIMS scores. The incident occurred when Resident 2 asked Resident 1 to lower the volume of the television, leading to Resident 1 hitting Resident 2, who then retaliated. The altercation was witnessed by a housekeeper who reported the incident to the nursing staff. The staff intervened by separating the residents and notifying the appropriate personnel, including the Administrator, Director of Nursing, and social services. The police were also called, and a case of simple battery was documented. Despite the intervention, the facility's failure to prevent the altercation and protect the residents from abuse was evident. The facility's Abuse Prevention Policy defines abuse as any physical or mental injury inflicted upon a resident other than by accidental means. The policy outlines that physical abuse includes hitting and controlling behavior through corporal punishment, while verbal abuse involves the use of disparaging language. The incident between the two residents highlights a breach of this policy, as both physical and verbal abuse occurred, and the facility did not implement preventive measures to avoid such altercations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving verbal and physical abuse. In the first incident, a resident with a history of burns, panic disorder, schizophrenia, and chronic pain reported verbal abuse by her roommate's sister during a visit. The resident, who has a BIMS score of 15/15 and uses a wheelchair, reported the incident to the Social Service Director, who confirmed the verbal abuse after an investigation. The visitor was subsequently restricted from accessing the resident's floor. In the second incident, a physical altercation occurred between two residents, one with schizoaffective disorder and anxiety, and the other with spinal stenosis, dementia, and diabetes. Both residents were in wheelchairs when they bumped into each other, leading to an argument. One resident grabbed the other's sleeve, prompting the other to slap the first resident's arm. A Licensed Practical Nurse witnessed the incident, separated the residents, and reported it to the Administrator. The facility's investigation substantiated the physical abuse, and the resident who slapped the other was placed under 1:1 monitoring pending further evaluation.
Failure to Timely Report Alleged Sexual Assault
Penalty
Summary
The facility failed to report an allegation of sexual assault within the mandated timeframe, as required by their policy and state regulations. The incident involved a resident who alleged that she was sexually assaulted by an unidentified male staff member. The allegation was made on December 6, 2024, at approximately 3:30 PM, but the initial report to the State Agency was not sent until 6:15 PM, exceeding the required two-hour reporting window. The facility's policy mandates that such allegations be reported within two hours, which was not adhered to in this case. The administrator, who serves as the Abuse Coordinator, acknowledged the delay in reporting during an interview with the surveyor. The facility's Abuse Prevention Program outlines the necessity for immediate reporting of abuse allegations to the State Agency, emphasizing the importance of filing accurate and timely investigative reports. Despite these guidelines, the facility did not comply with the two-hour reporting requirement, resulting in a deficiency being noted by the surveyors.
Incomplete Investigation of Sexual Assault Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual assault involving a resident, identified as R2, who reported being assaulted by an unidentified male staff member. The incident was alleged to have occurred during the early morning hours of the third shift on September 25, 2024. The investigation process was initiated by interviewing the resident and reviewing the staffing schedules to identify potential witnesses. However, the investigation was incomplete as one staff member, V17, who was assigned to R2 during the alleged time, was not interviewed. V17 was reportedly on vacation during the investigation period and was not contacted for a witness statement upon returning to work. The facility's Abuse Prevention Program mandates that all allegations of abuse be promptly and aggressively investigated, including interviewing anyone likely to have direct knowledge of the incident. Despite this policy, the investigation was not thoroughly conducted as V17, a key staff member who worked during the alleged incident, was not interviewed. The facility's administrator acknowledged the oversight, stating that the investigation was not complete without V17's input. This failure to interview all relevant staff members resulted in a deficiency in the facility's handling of the abuse allegation.
Failure to Update Care Plan and Provide Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to update the care plan and provide necessary assistance to a resident who required supervision when ambulating, resulting in a fall. The resident, who had a history of falling and various medical conditions including type 2 diabetes and schizoaffective disorder, was found on the bathroom floor with a laceration to the head. The resident's Minimum Data Set (MDS) indicated intact cognition and a need for setup or cleanup assistance for mobility, but the care plan did not reflect the necessary supervision for ambulation. The incident occurred because the resident was not listed on the facility's fall risk list, and staff were unaware of the resident's fall risk status. The Director of Nursing (DON) admitted that the fall risk list is updated quarterly or after a fall, but was unaware of who was responsible for updating it. Additionally, the Physical Therapy Director noted that the resident had a gait/balance impairment and required staff assistance during toileting, but this information was not communicated effectively to the nursing staff. The facility's policy on falls and fall prevention was not followed, as the resident was not assisted to the toilet or supervised as required. The Restorative Coordinator was not informed of the resident's change in functional level from independent to supervision, which occurred while she was on vacation. This lack of communication and failure to update the care plan contributed to the resident's fall and subsequent injury.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident physical abuse, specifically involving an altercation between two residents, R1 and R2. R1, a cognitively intact female with a history of schizophrenia and depressive disorder, reported that R2, a moderately cognitively impaired male with schizophrenia and a history of restlessness and agitation, pushed her to the floor. The incident occurred in the early morning when R1 approached the nurse's station for her medication and later returned, reporting a conflict with R2 over seating space. Despite being advised by the LPN on duty to find another seat or return to her room, R1 engaged in a verbal altercation with R2, which escalated to physical contact. The LPN on duty witnessed the altercation, noting that R1 approached R2, leading to a situation where R2's hand became entangled in R1's hair, resulting in R1 falling to the ground. The LPN intervened by separating the residents and detangling R2's hand from R1's hair. The incident was reported to the facility administrator and the police department. Interviews with staff, including a CNA and the Social Services Director, revealed that R1 has a tendency to provoke others, and both residents have care plans addressing their behaviors. The facility's abuse prevention program affirms residents' rights to be free from abuse, yet the incident highlights a failure to protect R1 from physical abuse by R2. The facility's documentation and staff interviews indicate that both residents have histories of behavioral issues, with R2 exhibiting physically aggressive behavior towards others. Despite having care plans in place, the incident suggests a lapse in effectively managing and preventing resident-to-resident altercations, resulting in R1's fall and subsequent report of abuse.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to adhere to its policy for reporting allegations of abuse, neglect, or mistreatment. A resident, identified as R5, reported to a social worker that he had been physically abused by nurses and CNAs, including an incident where his walker was used to hit him. R5 also provided written statements detailing multiple instances of abuse by staff members across different shifts. Despite these allegations, the social worker did not report the incidents to the administrator, who is also the abuse coordinator, as required by the facility's policy. The administrator, V1, stated that she was unaware of the allegations made by R5 and would have initiated an investigation had she been informed. The facility's policy mandates that any suspicion or allegation of abuse must be reported immediately to the administrator, who is then responsible for conducting a full investigation and reporting the findings to the Department of Public Health within five working days. The failure to report these allegations resulted in a deficiency as the facility did not follow its own procedures for handling reports of abuse.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to follow its policy to investigate allegations of abuse for a resident, identified as R5, who reported being physically abused by nurses and CNAs. On the day of the survey, R5 informed the surveyor that he had been hit by staff members and had previously reported these incidents to the social worker. The social worker, V5, confirmed that R5 had provided written statements about the abuse and that she had notified the administrator and the Social Worker Director. However, the administrator, V1, who is also the abuse coordinator, stated that she was not informed of these allegations and had not initiated an investigation as required by the facility's policy. The facility's abuse policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator, who is then responsible for initiating an investigation and completing a full report within five days. Despite this policy, the administrator was unaware of R5's allegations until the surveyor's inquiry, indicating a breakdown in communication and failure to adhere to the established procedures for handling abuse allegations. This oversight resulted in a lack of timely investigation into the serious claims made by R5, compromising the facility's responsibility to ensure resident safety and compliance with regulatory standards.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents, R8 and R10, from abuse, resulting in both sustaining injuries. R10, a 50-year-old with schizophrenia and other medical conditions, was assaulted by another resident, R11, who has a documented history of aggressive behavior. On the day of the incident, R10 was seen by a family member and staff with a swollen and bruised eye after being hit by R11. Interviews with staff and residents confirmed that R11, who is deaf and non-speaking, became agitated with R10's behavior and struck him in the eye. Despite R11's known aggressive tendencies, he was not adequately monitored or separated from other residents, leading to the incident. R8, another resident, was also a victim of abuse by their roommate, R9. R8, who is cognitively intact, was hit in the face by R9, resulting in swelling and discoloration of the eye. R9, who has a history of socially inappropriate behavior and aggression, admitted to hitting R8 because R8 was going through R9's belongings. Staff interviews and records confirmed that R8 had a tendency to wander and go through other people's belongings, which triggered R9's aggressive response. The facility's investigation substantiated the incident, highlighting a failure to prevent abuse between residents. Both incidents demonstrate a lack of effective monitoring and intervention strategies for residents with known aggressive behaviors. The facility's policies on abuse prevention were not adequately enforced, as evidenced by the repeated aggressive incidents involving R11 and R9. The failure to protect residents from abuse and ensure their safety resulted in physical harm to R8 and R10, indicating a significant deficiency in the facility's care and supervision practices.
Failure to Prevent Resident Fall During Repositioning
Penalty
Summary
The facility failed to ensure safe practices during the repositioning of a resident, identified as R7, who was dependent on two-person assistance for bed mobility. R7, who had a history of falls and was considered a high fall risk, fell out of bed during a repositioning procedure conducted by a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA). The incident occurred when the LPN and CNA attempted to trade places while repositioning R7, resulting in the resident slipping out of the LPN's grip and falling to the floor, sustaining a laceration to the scalp. R7 had multiple diagnoses, including quadriplegia, chronic pain, and pressure ulcers, and was entirely dependent on staff for mobility. Despite these conditions, the facility did not update R7's care plan with new fall prevention interventions after previous falls. The care plan noted R7 as a two-person assist for bed mobility, but the staff failed to maintain control during the repositioning, leading to the fall. The incident was further complicated by the lack of fall prevention measures, such as floor mats, which were not in place at the time of the fall. Interviews with staff revealed that the LPN and CNA were aware of R7's spontaneous movements and the need for careful handling. However, during the repositioning, the LPN moved away from the bed, and the CNA was unable to prevent the fall. The Director of Nursing acknowledged that the incident could have been avoided if the staff had adhered to proper repositioning protocols. The facility's policy emphasized the importance of proactive fall prevention strategies, but these were not effectively implemented in R7's case.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide safe and adequate care for a resident who required a two-person assist for incontinence care and bed mobility. This deficiency resulted in the resident falling out of bed, hitting his head on a bedside dresser, and subsequently being diagnosed with post-concussion syndrome. The resident, who has quadriplegia and other medical conditions, was dependent on staff for daily activities and required supervision and assistance from two staff members for safety. On the day of the incident, only one certified nursing assistant (CNA) was providing care to the resident, despite the care plan indicating the need for two-person assistance. During the incontinence care, the CNA attempted to turn the resident, which led to the resident falling from the bed, as the bed was in a high position and could not be lowered due to a malfunction. The resident reported hitting his head during the fall and experienced severe headaches, leading to two hospital visits where he was diagnosed with post-concussion syndrome. Interviews with staff revealed that the resident was typically cared for by one CNA, contrary to the documented requirement for two-person assistance. The facility's supervision policy was not adhered to, as the resident's needs for adequate supervision and assistance were not met, contributing to the accident. The administrator and director of nursing were unaware of the concussion diagnosis, indicating a lack of communication and awareness of the resident's condition following the incident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure the right of residents to be free from abuse, resulting in two incidents involving physical harm. In the first incident, a male resident with schizophrenia and restlessness was hit in the mouth by another male resident with schizophrenia and aggressive behavior. The incident occurred near the nursing station during medication administration, leading to facial trauma and bleeding for the victim. The aggressor was subsequently transferred for psychological evaluation and did not return to the facility. The incident was substantiated through staff interviews, progress notes, and a police report documenting the simple battery incident. In the second incident, a female resident with schizoaffective disorder and paranoid schizophrenia was hit on the nose by a male resident with paranoid schizophrenia and aggressive behavior. The incident occurred in the early morning hours when the female resident entered the male resident's room without permission. The male resident admitted to hitting her, resulting in nosebleed and pain. Despite being offered medical evaluation, the female resident refused to be transferred to the hospital. The incident was confirmed through staff interviews, progress notes, and a police report. Both incidents highlight the facility's failure to protect residents from abuse, as evidenced by the physical altercations and resulting injuries. The facility's abuse prevention policy affirms the right of residents to be free from abuse, neglect, and mistreatment, yet these incidents demonstrate a lapse in ensuring this right. The facility's response included updating care plans and conducting risk assessments, but the initial failure to prevent the abuse remains a significant concern.
Failure to Secure Residents' Money
Penalty
Summary
The facility failed to properly secure and protect the residents' money for six out of eight residents reviewed. On multiple occasions, surveyors observed unsealed envelopes containing money inside the narcotic lock boxes in medication carts. Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) were aware of the money stored in these envelopes but did not follow the facility's protocol for safeguarding residents' money. The protocol requires that residents' money be given to social services or the administrator for secure storage in a facility safe. Instead, the money was improperly stored in medication carts, accessible only to nursing staff. The residents involved had varying levels of cognitive impairment, with some being moderately impaired and others being cognitively intact. There was no documentation to show that the money was inventoried by the facility. The facility's policy and the Ombudsman Program Residents' Rights for People in Long Term Care Facilities both emphasize the importance of safeguarding residents' property. The failure to follow these protocols resulted in a deficiency in protecting the residents' financial affairs.
Failure to Accommodate Resident's Preference for a Fan
Penalty
Summary
The facility failed to accommodate a resident's preference for a fan, which would have contributed to a comfortable and homelike setting. On 03/19/24 at 10:00 AM, the surveyor observed the resident sitting up on her bed without a fan in her room. The resident had requested a fan from the social worker the previous week, but the social worker did not provide one and failed to inform anyone else about the request. The resident's room felt warm, and although there was an air conditioner, it was located on the window side, while the resident's bed was closer to the room door. The social worker confirmed that the resident had requested a fan but admitted that she did not have one to give and did not communicate this to anyone else or update the resident. The facility's document on residents' rights emphasizes the importance of providing a comfortable and homelike environment, which was not upheld in this instance. The resident's diagnoses included depressive episodes, multiple sclerosis, paranoid schizophrenia, personality disorder, muscle spasm, and diabetes, highlighting the need for a supportive and accommodating environment.
Misappropriation of Resident's Money
Penalty
Summary
The facility failed to protect a resident's belongings, leading to the misappropriation of $200. The incident involved a resident (R2) who was sent to the hospital and entrusted her money to her roommate (R3) due to the absence of the social worker. R3 handed the money to a CNA (V6), who then informed an LPN (V4) about the money. V4 placed the money in an unsealed envelope inside the narcotic lock box in the medication cart. Upon R2's return from the hospital, only $185 was returned to her, leading to the discovery that $200 was missing. The investigation revealed that V6 did not touch or count the money but informed V4, who then placed the money in the medication cart without informing social services or following proper protocol. V4 admitted to not being familiar with the protocol for handling resident money and did not inform anyone about the money's location. V7, the Assistant Psychiatric Rehabilitation Service Director, was made aware of the missing money but could not verify the amount as it was never counted or documented. The facility's administrator (V1) was not informed about the missing money until the surveyor's interview. The facility's policies on personal property and abuse were not followed, as there was no documentation of the money being inventoried, and the incident was not reported to the state agency. The facility's failure to follow proper procedures and protocols led to the misappropriation of R2's money, violating the resident's right to be free from misappropriation of property.
Failure to Report and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to report and investigate the misappropriation of property for one resident (R2). R2 was transferred to the hospital and gave $385 in cash to her roommate (R3) for safekeeping. Upon returning from the hospital, R2 received only $185 back from the Assistant Psychiatric Rehabilitation Service Director (V7) in an unsealed brown paper bag. R2 reported the missing money to V7, who acknowledged the issue but did not document or report it to the state agency or the facility's abuse coordinator (V1). Interviews with R3 and V6 (CNA) confirmed that R3 handed the money to V6, who then informed V4 (LPN) and V7 about the missing amount. However, V4 stated that this was the first time hearing about the missing money during the surveyor's interview. The facility's records, including the Facility Reported Incident logs and grievance logs, showed no documentation of R2's missing money. The facility's policies on personal property and abuse and neglect require immediate reporting and investigation of such incidents, but these procedures were not followed. V1, the abuse coordinator, confirmed that she was unaware of the incident and that it should have been reported to her and the state agency. The lack of documentation and failure to follow the facility's policies led to the deficiency in handling the misappropriation of R2's property.
Failure to Administer and Document Medication Correctly
Penalty
Summary
The facility failed to acquire a physician-ordered medication and accurately document the administration of medication for one resident. The resident, who has a history of depressive episodes, multiple sclerosis, paranoid schizophrenia, personality disorder, muscle spasm, and diabetes, was admitted with a prescription for Venlafaxine 150mg ER. Despite the physician's order to continue this medication, the facility did not obtain it due to insurance coverage issues and failed to notify the provider immediately. The resident did not receive the medication from 03/12/2024 to 03/16/2024, although it was incorrectly documented as administered in the MAR. The resident reported not receiving Venlafaxine since admission and refused the alternative medication, Sertraline, ordered by the doctor. The LPN admitted to incorrectly documenting the administration of Venlafaxine. The Director of Nursing confirmed that the medication was not stocked in the facility's emergency medication box and that the prior authorization form was sent to the doctor, but could not recall the date. The facility's Medication Administration Policy requires checking all medications against the MAR prior to administration and signing out medications immediately after administration, which was not followed in this case.
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What surveyors actually found near you
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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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Lakeshore | 0.2 mi | ★★★★★ | 10 | 1 |
| Chalet Living & Rehab | 0.3 mi | ★★★★★ | 19 | 1 |
| Fargo Health Care Center | 0.4 mi | ★★★★★ | 21 | 0 |
| Waterford Care Center, The | 0.4 mi | ★★★★★ | 12 | 0 |
| Birchwood Plaza | 0.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.