Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Evergreen Park during CMS and state inspections, most recent first.
Medication administration was not completed as ordered for several residents. A resident with glaucoma and cataract surgery missed ordered eye drops because they were unavailable in the med cart, and staff did not document timely provider notification. Other residents received multiple scheduled meds late, including eye drops, BP meds, pain meds, and bowel meds, and the DON and ADON stated that late or missed doses require provider notification and documentation.
Failure to provide timely incontinence care: A resident dependent on staff for ADLs was found with a urine-soaked brief, wet linens, and brownish staining on the incontinence pad after staff had not checked and changed her every 2 hours as required by policy. The resident had COPD, morbid obesity, HTN, and moderately impaired cognition, and staff stated they were expected to provide incontinence checks and changes every 2 hours and as needed but were unable to keep up with assigned residents.
A resident dependent on staff assistance with ADLs had a nonfunctioning call device after the cord was found wrapped on the siderail. When the resident activated it, neither the wall box nor the overhead indicator light illuminated, and the ADON and Maintenance Director both confirmed the device was not working. The resident had COPD, morbid obesity, HTN, and moderately impaired cognition, and the care plan directed staff to keep the call light within reach for toileting and incontinence assistance.
Failure to Supervise High-Fall-Risk Residents: The facility did not consistently provide supervision or follow fall precautions for residents with cognitive impairment, mobility limitations, and prior falls. A resident with severe dementia was left alone in a wheelchair in a room, fell, sustained a humerus fracture and head hematoma, and later died; the record also showed delayed post-fall documentation and no timely care plan revision for the new injuries. Two other residents were left without needed assistance during toileting, and both fell when wheelchair safety and supervision measures were not maintained.
A facility failed to consistently provide bedtime snacks to residents who wanted them. Residents reported that snacks were often unavailable at night, that staff sometimes said there were none to give, and that some residents went without unless family brought food. Resident council members said there were not enough snacks for everyone, diabetic residents did not always receive snacks, and CNAs sometimes ate the snacks. EHR task records also showed multiple dates with no documentation that residents received or declined a snack, despite the facility policy requiring bedtime snacks daily.
Improper Garbage and Refuse Disposal: Surveyors observed dumpsters with scattered garbage on the ground, including PPE gloves, cans, food wrappers, soiled boxes, and other refuse. One dumpster lid was fully open and another could not fully close because of overfilled trash bags and boxes. Refuse, including dead leaves, cigarette butts, food wrappers, and drink containers, was also found in the adjacent smoking area. The Dietary Mgr and Maintenance Dir confirmed the findings, and the Admin stated the facility had no garbage/refuse/dumpster policy.
Infection control failures involved inconsistent EBP use, improper PPE use, and poor clean linen containment. A resident with dialysis-related care and a dressing had no EBP sign posted, while another resident on EBP received high-contact care from a CNA wearing gloves but no gown. A contract phlebotomy staff member doffed PPE in the hallway outside a resident’s room, and clean linen carts used for facility-wide transport had open grated shelves and torn or uncovered covers, exposing linens to contamination.
Dirty and damaged dryer lint screens were observed in the laundry room, including lint compartments with loose lint on the floor and screens fully covered with lint. One dryer had a damaged lint screen that the Laundry Manager said needed replacement because it was not capturing lint properly. The Administrator stated the facility census was 164 residents, and record review noted there was no dryer maintenance policy.
Call lights were not kept within reach for multiple residents with documented assistance needs, including residents with cognitive impairment, hemiplegia, and fall risk. Staff observed call lights on the floor, between the bed rail and mattress, dangling below the mattress, or attached to bed rails where they could not be reached from bed or wheelchair positions, and staff acknowledged several were out of reach. In addition, one resident who required 1:1 feeding assistance was observed eating alone without staff support.
Failure to provide grooming care for dependent residents: Five residents who were dependent for ADLs were observed with long, dirty fingernails, and two also had facial hair and requested shaving. Records showed ADL care plans for residents with significant neurologic and mobility impairments, while the ADON stated that nail care and shaving should be completed by CNAs during ADL care.
Medication pass errors exceeded the allowed rate when staff failed to give ordered meds within the required 1-hour window, resulting in a 22.22% error rate. An LPN and an RN prepared multiple meds for two residents well after the scheduled times, and one resident later refused one medication, which was excluded from the error count.
Medication carts, narcotics, and refrigerated meds were not properly secured or stored, and several resident meds were not labeled correctly. An LPN left a med cart unlocked and unattended, another cart’s keypad would not lock, narcotics were single locked, multiple insulin pens and a multidose med were opened and undated or missing pharmacy labels, and the med refrigerator was found at 48F with vaccines, insulin, and other refrigerated meds inside.
Personal resident refrigerators were not properly monitored, cleaned, or managed for food safety. One resident’s fridge had no temp log and visible buildup, two residents shared a fridge with undated food items, and another resident’s fridge had missed temp checks and was reading 50 degrees. Staff gave inconsistent accounts of who checked temps, who cleaned the fridges, and who dated or discarded open food items.
Failure to Develop and Provide Baseline Care Plan: A resident admitted after a fall and infected groin wound did not receive a baseline care plan or a copy/summary within the required timeframe. The resident, who had multiple diagnoses including DM2, HTN, AKI, anemia, and Fournier Gangrene, stated no care plan copy had been provided. The RN MDS coordinator confirmed there was no documentation that the baseline care plan or summary was given, and the plan did not include the resident's active therapy services.
The facility failed to keep care plans current for two residents. One resident’s chart listed DNR/DNH on the face sheet and POLST, but the care plan documented Full Code. Another resident sustained a fall with a head injury and closed supracondylar fracture of the right humerus, yet the care plan was not revised to address the new fracture, splint use, or neurological monitoring after the injury.
Pressure injury care and prevention were not followed for a resident with limited mobility, altered mental status, and a high Braden score. The resident developed a facility-acquired DTI on the right bunion while on a LAL mattress, but was observed in bed with both heels resting on the mattress and without heel boots. The wound care notes called for heel offloading and turning/repositioning every 2 hours, yet the charting showed repositioning on only 7 of 28 days, and staff were unsure how often repositioning was documented.
Failure to provide and document restorative splint and brace care: Two residents with hemiplegia, contractures, and physician-ordered restorative devices did not receive consistent splint/brace use or proper Nursing Rehab documentation. One resident’s right hand splint was observed off and left on a dresser, the right knee brace was omitted from Nursing Rehab tasks, and staff were unclear about timing and responsibility. Another resident with severe functional dependence had no left-hand splint or brace in use, and staff could not confirm the ordered devices were being provided; monthly documentation was largely marked with X’s.
A resident ordered continuous O2 was observed without the nasal cannula on, with the tubing and cannula laid over the machine and not bagged, and the resident stated staff had removed the O2 earlier and did not put it back on. In a separate event, another resident’s nebulizer mask and tubing were found on a nightstand without a date and not contained; the RN and DON stated the equipment should be dated and kept in a clear plastic bag when not in use.
Untimely post-fall charting and neurocheck documentation left a resident’s record inaccurate and not readily accessible for days after a fall. The resident, who had dementia and multiple medical conditions, fell from a wheelchair, struck the head, was sent to the ED, and later returned with a head hematoma and R humerus fracture. Survey review found several neurocheck and post-fall entries were signed late, including after the resident had died, and one day of post-fall charting was missing. The DON stated the facility standard was to chart as you go, and the HS/Falls Nurse acknowledged the last neurocheck due at 10:00 AM was not completed.
Inaccurate Daily Nurse Staffing Posting: The facility failed to accurately complete the daily nurse staffing posting. The census on the posted staffing information did not match the Administrator’s reported census, and the Staffing Coordinator/Scheduler acknowledged the census number was incorrect and that he likely did not look at it right while moving fast. The facility policy stated required postings must comply with federal regulations.
The facility failed to timely submit required initial and final reports to the State Agency for an injury of unknown origin involving a resident who sustained a displaced right hip fracture requiring emergency surgical fixation. The resident, admitted for therapy and medical management with multiple comorbidities and mobility issues, complained of hip pain, and the DON reported that the resident’s daughter expressed concern about the appearance of the hip. An agency nurse notified the unit manager, who obtained orders for an X-ray and PRN Tylenol, but the daughter requested hospital transfer rather than waiting for on-site imaging. Progress notes documented the family’s request for transfer and subsequent ER confirmation of a right hip fracture, with no documented fall or injury in the facility. An incident report categorized the event as an injury of unknown origin and indicated an investigation was initiated, but the final report was not sent to the State Agency until it was requested by a surveyor, and the Administrator acknowledged she had forgotten to send it, contrary to facility policy requiring immediate reporting and submission of a final investigation within five working days.
A resident with multiple chronic conditions and intact cognition reported that dentures documented on an earlier inventory were missing after readmission, but staff did not complete a grievance form or provide timely follow-up as required by facility policy. The resident repeatedly requested to speak with administration and Social Services without receiving a response, and although the resident was placed on a monthly dental sign-up list, the resident was never actually seen by the dental provider before discharge. Facility policies required grievances to be filed and addressed within 72 hours and mandated prompt dental referral within three days for lost dentures or documentation of measures taken to ensure the resident could still eat and drink, but these procedures were not followed for this resident.
A resident with multiple comorbidities, including ESRD, heart transplant status, depression, and type 2 DM, had a care plan requiring a safe environment with a working, reachable call light for fall prevention. While seated in his room and needing assistance back to bed, he repeatedly called out for help after pressing his call light without response. A surveyor and staff confirmed that pressing the call light produced no corridor light or audible signal for either bed in the room. The maintenance assistant later found the call light unit disconnected with a wire needing soldering, noting he had previously repaired the same unit. Staff interviews showed reliance on the call light system for residents to request help and uncertainty about how residents would obtain assistance when call lights were nonfunctional, while the maintenance log documented a prior call light request for the room without details of the repair, despite facility policy requiring daily checks of call lights and alternative means for residents to call for assistance when call lights are not functional.
A resident with a complex medical history exhibited clear signs of sepsis, including hypoxia, tachycardia, low blood pressure, and altered mental status, but staff did not follow facility sepsis protocols or promptly transfer the resident to the hospital. Despite abnormal vital signs and family requests for transfer, the resident remained in the facility for several hours before being sent to the hospital, where they were diagnosed with septic shock and pneumonia.
The facility did not maintain room temperatures within the required comfort range, resulting in multiple rooms exceeding 81 degrees Fahrenheit. Several residents, including those with respiratory and cardiac conditions, experienced discomfort due to excessive heat, and staff were aware of the issue but did not take timely or effective action. Maintenance staff confirmed that air conditioning units were not functioning properly, and portable fans were only considered after residents complained.
A deficiency occurred when the facility did not maintain acceptable ambient temperatures in two wings due to a malfunctioning cooling system. Broken fan belts on roof fans and non-functioning individual AC units led to hallway temperatures exceeding the facility's policy range, resulting in uncomfortable conditions for residents, staff, and visitors.
A resident with multiple chronic conditions and moderate cognitive impairment, who was prescribed tramadol and a fentanyl patch for pain, did not receive effective bowel management. Despite facility policy requiring monitoring and documentation of bowel movements, the resident experienced several days without a bowel movement, leading to severe fecal impaction and hospitalization. Staff interviews confirmed that the issue was not identified or communicated in a timely manner.
Two residents at high risk for pressure ulcers did not receive consistent assessment or proper use of pressure-relieving equipment. One developed a facility-acquired unstageable sacral wound without clear documentation of preventive interventions, while another experienced pain and inadequate pressure redistribution due to a deflated alternating air mattress that was not promptly addressed by staff.
The facility did not consistently assess residents for the need of bed side rails or obtain proper consent prior to their use, as required by policy. Several residents had side rails in use without current assessments or documented consent, and some were unable to use the rails independently. Staff confirmed that required assessments and consents were missing or outdated for these individuals.
Surveyors found that staff did not consistently label opened insulin with open or expiration dates and failed to remove or discard medications for discharged residents. Insulin vials and pens for several residents with diabetes were observed on medication carts without required labeling, and staff confirmed that these actions were not in line with facility policy.
Staff and contracted personnel failed to follow infection prevention and control policies by not performing required hand hygiene and not donning gowns when providing direct care to residents under enhanced barrier precautions. Multiple staff, including nurses, nurse practitioners, a wound care director, and a laboratory employee, entered rooms and performed care activities with inadequate PPE, contrary to facility policy.
The facility did not follow its electronic monitoring policy by failing to post required signage and obtain informed consent from two residents before initiating video and audio monitoring in their shared room. Both residents and a resident's POA were unaware of the monitoring, and documentation was incomplete, lacking necessary signatures and details.
A resident who was alert and able to communicate was observed in bed with the call light out of reach, unable to locate or use it to request assistance. The call light remained inaccessible during multiple observations, despite facility policy requiring call lights to be within reach for prompt staff response.
Staff failed to accurately code MDS assessments for three residents, including incorrect documentation of dialysis treatment, hospice status, and terminal prognosis. These errors were identified through record review and staff interviews, revealing discrepancies between residents' actual care needs and what was recorded in the MDS.
A resident recovering from a hip fracture was transferred by CNAs without the use of a gait belt or mechanical lift, contrary to the care plan that required two staff and a full-body mechanical lift for transfers. Staff actions did not align with the documented care plan or the resident's current needs, resulting in a deficiency related to care plan implementation.
A resident who was totally dependent on staff for ADLs did not receive incontinence care or repositioning for at least two hours. During this time, staff failed to check or change the resident's saturated brief, resulting in soiled bedding and a saturated pressure ulcer dressing, despite facility expectations for care every two hours.
A resident recovering from a hip fracture was transferred without the use of a gait belt or mechanical lift, as required by facility policy and care plan, resulting in a fall and acute femoral fracture. Staff did not follow established transfer protocols or provide adequate supervision, and documentation failed to specify necessary safety interventions.
A resident with a need for supplemental oxygen was observed with a nasal cannula in place, but the oxygen concentrator was off and not functioning properly. Staff replaced the faulty concentrator, but it was discovered that there was no current physician order for oxygen therapy, as required by facility policy. The last order had been discontinued after a hospital stay and was not renewed upon readmission.
A resident with a history of C. diff was on antibiotics, but staff failed to consistently monitor and document antibiotic use and potential side effects as required by the care plan. The facility lacked protocols and a system for antibiotic monitoring, and nurses did not complete daily assessments or documentation, despite expectations from the IP Nurse.
A resident was found in a room with persistent dry substances on the floor, walls, tube feeding machine, and bed framing, as well as soiled bed linens that were not changed after a bed bath. The resident reported discomfort due to urine-stained linens, and staff confirmed that cleaning and linen changes should have occurred according to facility policy.
A hospice resident with multiple diagnoses experienced a fall that was not documented in the electronic health record, and the family was not notified promptly. The nurse on duty, who was new to the facility, did not complete the required risk management forms or notify the family, as per the facility's protocols. The Director of Nursing confirmed the lapse in protocol adherence, which led to delayed family notification.
The facility did not follow its Abuse and Neglect Policy by failing to report an allegation of rough handling of a resident to the Administrator immediately. The Director of Nursing was informed of the allegation but did not report it to the Administrator, who was unaware of the incident and would have initiated an investigation if informed. The policy requires immediate reporting to the Administrator and to IDPH within two hours.
A resident with multiple medical conditions fell during a transfer when a CNA failed to follow the facility's protocol requiring two staff members for mechanical lift operations. The CNA attempted the transfer alone, resulting in the lift tipping over and the resident experiencing severe back pain. The facility's policy and training emphasize the need for two staff members to ensure safety during such transfers.
The facility failed to implement adequate fall prevention interventions and supervision, resulting in multiple resident falls and injuries. Residents were not properly assessed for the safe use of assistive devices, leading to incidents such as a resident with hemiplegia falling and fracturing their fibula, and another resident with dementia falling and sustaining a head injury. Additionally, a resident using a motorized wheelchair with visual impairments was not supervised, resulting in fractures. The facility's fall coordinator and director of nursing did not adequately address these issues.
A resident's finances were mismanaged by the facility, resulting in an unauthorized withdrawal of $5,504.06 from the resident's account. The resident's POA did not consent to this transaction, and discrepancies in signatures and billing records were found. The facility failed to provide itemized billing or adequate documentation, leading to a deficiency in financial management.
The facility failed to provide adequate pressure ulcer care, resulting in deficiencies for three residents. A resident developed an infected hand wound due to lack of preventive measures, while another had soiled dressings not replaced promptly. Additionally, two residents had air mattresses set incorrectly, affecting pressure redistribution. These issues highlight the facility's failure to implement an effective pressure sore prevention plan.
A resident at high risk for falls experienced three falls within 30 days due to the facility's failure to implement new fall interventions and complete incident reports. The resident, with diagnoses including dementia and hypertension, was found on the floor multiple times after attempting to go to the bathroom unassisted. Despite being identified as high risk, the care plan lacked updated interventions, and an incident report was not completed for a fall on 8/17/24. The resident was eventually hospitalized with a subacute subdural hematoma after a fall on 9/11/24.
A resident with vascular dementia and severe malnutrition was not adequately hydrated through their prescribed g-tube feeding regimen, leading to dehydration and hospitalization. Despite receiving Jevity 1.2 at 65 ml/hr and 100 ml water flushes every four hours, the resident had a free water deficit of 1.9 liters and elevated sodium levels. Facility staff noted the resident's minimal oral intake and reliance on enteral feeding, but inconsistencies in the administration of prescribed hydration were found.
A resident experienced a fall while trying to go to the bathroom, but the facility failed to notify the family and physician as required by their policy. The assigned nurse did not make the necessary notifications, and another nurse confirmed the lack of communication. The fall nurse found no documentation of notification, despite the facility's policy mandating immediate notification in such cases.
A resident with type II diabetes and hidradenitis suppurativa did not receive proper wound care as per physician orders. The resident's dressing was not secured after a shower, and no dressing was present during an interview. The wound care director confirmed the dressing should have been changed, but it was not, violating the facility's policy to follow physician orders.
Medication Administration and Notification Failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet each resident’s needs by not ensuring ordered eye drops were available for administration, not administering medications within the ordered timeframes, and not notifying the prescriber when medications were unavailable or doses were missed. These failures affected 5 of 5 residents reviewed for medication administration in the sample of 9. For one resident with a history of cataract surgery and glaucoma, the resident stated that nurses told her in May 2026 they did not have her eye drops in the med cart. The MAR documented missed doses from 05/26/2026 through 05/31/2026, and the assigned LPN and RN were identified during the missed doses. The LPN stated she did not see the medication in the med cart, reordered it in the EHR when she found it missing, and said she informed the nurse supervisor but did not document that notification or notify the provider. The RN stated she informed the unit manager and called the pharmacy, and that the NP was in the room when the resident reported the missing eye drops, but this was not documented in the chart. Progress notes for the resident showed no documentation that the provider was notified for the missed medications. For the other residents reviewed, medication audit reports showed multiple medications were administered late compared with scheduled times. One resident’s Aricept, vitamins, and ophthalmic ketotifen were given later than scheduled; another resident’s gabapentin, metformin, baclofen, and senna were administered late on multiple doses; another resident’s docusate sodium, lidocaine cream, and Tylenol were given after the scheduled times, with the next topical and Tylenol doses administered less than 12 hours apart as scheduled; and another resident’s Procardia XL was administered later than scheduled. The ADON stated the expectation was to administer medications within one hour before or after the scheduled time and to call the doctor if a medication was given late. The DON stated that if a resident missed a dose, the provider should be notified, and if medication was given late, the nurse should call the provider and document that notification.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for ADLs was checked and changed every two hours and as needed in accordance with the facility’s incontinence policy. During observation on 06/26/2026 at 10:48 a.m., a strong smell of urine was noted in the resident’s room. The resident stated the last time staff came in to check her brief was before breakfast. When the brief was checked at 10:51 a.m., it was fully soaked with urine. At 10:55 a.m., the incontinence pad and flat sheet underneath the resident were checked. The resident was turned to her left side, and the flat sheet was wet. The incontinence pad had brownish staining formed at the border between the wet and dry areas. The assistant director of nursing stated the flat sheet, incontinence pad, and gown were all wet and that there was brownish staining on the pad. The resident’s breakfast was documented as being served from 7:15 a.m. to 8:30 a.m. The resident’s record showed diagnoses including COPD, morbid obesity, and hypertension. The MDS documented a BIMS score of 11, indicating moderately impaired mental status, and coded the resident as dependent for toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. The care plan addressed bowel and bladder incontinence, skin breakdown prevention, and assistance with toileting and perineal care. A CNA stated she was assigned to the resident, checked her between 6:30 a.m. and 6:40 a.m., and was expected to check and change residents every two hours and as needed, but was unable to do so because she was busy caring for other mostly dependent residents. The DON and administrator both stated the expectation was for residents to be checked and changed every two hours and as needed.
Nonfunctioning Call Device Not Available to Resident
Penalty
Summary
The facility failed to ensure that a resident dependent on staff assistance with ADLs had a functioning call device. During observation on 06/26/2026 at 10:39 a.m., R4’s call device cord was wrapped on the right-side rail. When R4 activated the device, no light illuminated on the call device box attached to the wall or on the overhead indicator box outside the room. R4 stated she had been calling but nobody seemed to notice. At 10:47 a.m., the ADON pushed R4’s call device and there was still no light on the call device box or the overhead indicator outside the room. At 11:00 a.m., the Maintenance Director tested the device and no light was lit on the call device box. He unwound the cord from the side rail and stated it should not have been tied there because raising the head of the bed pulled the cord off the call device box. He stated the cord should have been clipped to the resident’s gown or sheet and replaced the device with a new one. R4’s record showed diagnoses including COPD, morbid obesity, and HTN, with a BIMS score of 11 indicating moderately impaired mental status. Her care plan directed staff to keep the call light within reach and assist with toileting and incontinence care as needed.
Failure to Supervise High-Fall-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and failed to ensure fall precautions were implemented for residents at risk for falls. Three residents were identified in the report as affected by these failures: one resident with severe cognitive impairment, dementia, restlessness, agitation, and a history of falls; one resident with hemiplegia/hemiparesis, dizziness, osteoporosis, diabetes, atrial fibrillation, and moderate cognitive impairment; and one resident with dementia, gait impairment, anemia, and a prior fall with facial fractures. The report states these failures were identified through observation, interview, and record review. For the resident who died after the fall, the record shows the resident had severe cognitive impairment and required assistance with hygiene and transfers. The resident’s care plan identified high fall risk and included interventions such as keeping items within reach, maintaining a safe environment, reminding the resident to ask for assistance, and using fall mats/early riser measures. On the day of the incident, a CNA provided care and transferred the resident to a wheelchair, then left the resident unsupervised in the room while continuing rounds. Staff later heard the roommate yelling for help and found the resident on the floor with a forehead hematoma. The resident reported leaning forward to reach for something before sliding out of the wheelchair. Hospital records documented a closed supracondylar fracture of the right humerus and traumatic hematoma of the forehead. The report also states the care plan was not updated after the fall to address the fracture, head injury, splint use, or neurological monitoring needs, and post-fall documentation and neurochecks were charted late, including entries signed days after the resident had died. For the other two residents, the report describes falls that occurred when supervision and fall precautions were not followed. One resident with moderate cognitive impairment and significant assistance needs for toileting hygiene and toilet transfer called for help to use the bathroom, but an activity aide brought the resident back to the room and left the resident unattended; the resident then slid off the toilet and fell when the wheelchair was not locked. Another resident with moderate cognitive impairment, gait problems, and a history of falls slipped while trying to get on the toilet after the wheelchair moved. The report states staff interviews and record review showed both residents were at high risk for falls, needed assistance with toileting and transfers, and had care plans that called for prompt toileting, supervision, and use of a call light, yet those measures were not consistently carried out during the events described.
Evening snacks not consistently provided to residents
Penalty
Summary
The facility failed to provide evening snacks to residents, including four residents reviewed for snack availability. Residents stated that snacks were often not available at night, that staff sometimes said there were no snacks to give, and that some residents had to go without unless family or friends brought food. One resident reported losing weight and said snacks in between meals were important, with the resident’s weight decreasing from 147.4 pounds on 10/1/2025 to 136.2 pounds on 4/6/2026, a 7.6% loss in six months. Another resident stated that staff said there were no snacks sometimes, including two nights before the interview, and a third resident said the facility quite often did not have evening snacks. Resident Council members stated that the facility provided snacks on a tray in the evening, but there were not enough for every resident who wanted one. They also stated that diabetic residents were supposed to get snacks, but they did not always receive them, and that CNAs sometimes ate the snacks. The Dietary Manager stated snacks were sent to the units between 6 PM and 7 PM for residents on a snack list, and that extra snacks were added after hearing residents were not getting them. The Regional Clinical Nutrition Manager stated snacks were delivered to the nurses station and passed by nursing, and that it was a resident’s right to get a snack. Review of EHR task documentation showed multiple dates with no response or no documentation that the residents took or declined a snack, and the facility policy stated bedtime snacks must be offered daily.
Improper Garbage and Refuse Disposal
Penalty
Summary
Facility failed to dispose of garbage and refuse appropriately, failed to ensure dumpster lids were covered, and failed to ensure garbage, including food and drink waste and medical waste, was properly contained. The deficiency affected all 164 residents in the facility. On 4/27/2026, surveyors observed facility dumpsters with scattered garbage on the ground, including PPE gloves, cans, food wrappers, and soiled boxes. One dumpster lid was fully open, and another could not fully close because large boxes and trash bags were filling the dumpster. Directly adjacent to the garbage area, surveyors observed piles of refuse including dead leaves, cigarette butts, food wrappers, and drink containers covering approximately 15% of the smoking area, with about 60% of the area having cigarette butts on the ground. The Dietary Manager observed the area and confirmed the findings, and stated the garbage/refuse disposal responsibility lies with housekeeping/maintenance. On a later observation, the garbage/refuse was still on the ground around the dumpsters and in the direct vicinity, and the dumpster lids were still open with the same refuse present. The Maintenance Director confirmed the observations and stated the dumpster lids should be closed and garbage should be in the dumpster. The Administrator stated the facility did not have a garbage/refuse/dumpster policy.
Infection Control Failures With EBP, PPE Use, and Clean Linen Transport
Penalty
Summary
The facility failed to follow its infection prevention and control policies by not consistently using Enhanced Barrier Precautions (EBP) and by not properly managing clean linen carts. During observation of one resident with an AV fistula for hemodialysis and a dressing on the left forearm, the resident’s door did not have an EBP sign posted. The resident’s care plan identified the resident as being on EBP and directed staff to use gown and gloves during high-contact care activities. The DON stated that if a resident has a dressing, it should be classified as EBP and an EBP sign should be posted. During observation of another resident with hemiplegia, hemiparesis, and multifocal osteomyelitis, a CNA was providing care while wearing gloves but no isolation gown, despite the resident having EBP signage posted at the door. The CNA was touching the resident’s sheets and gown while performing patient care. A LPN observed the interaction and stated staff should wear gown and gloves when performing high-contact care to prevent cross contamination and infection. The DON also stated staff are expected to don isolation gown and gloves when rendering high-contact resident care when contact is anticipated. The facility also failed to ensure appropriate PPE doffing and clean linen containment. A contract phlebotomy staff member was observed doffing PPE in the hallway outside a resident’s room and stated the doffing procedure is inside the room, but she did not see the garbage can. In addition, clean linen carts used to transport linens throughout the facility were observed with open grated bottom shelves, and facility staff confirmed the open shelving did not prevent environmental contamination of clean linens. On unit 400, a clean linen cart at point of use was observed uncovered with a torn mesh cover exposing the linens, and staff later confirmed the cart had tears and was not covered and contained.
Dirty and Damaged Dryer Lint Screens
Penalty
Summary
The facility failed to ensure dryer lint traps were clean and without damage to provide a safe environment for residents. During a tour of the laundry room with the Laundry Manager/Accounting Manager, the lint compartment for dryer #4 was observed with loose lint on the floor of the compartment and the lint screen fully covered with lint. The Laundry Manager stated there should not be that much lint and said the dryer lint compartments are cleaned every hour and staff document when the lint screens are cleaned. The lint compartment for dryer #2 was also observed with a damaged lint screen and a large amount of lint, and the Laundry Manager stated the screen needed to be replaced because it was not capturing lint properly. The lint compartment for dryer #1 had loose lint on the floor and the lint screen was fully covered with lint. The Administrator stated the facility census was 164 residents, and the record review noted there was no dryer maintenance policy.
Call Lights Left Out of Reach and Required Feeding Assistance Not Provided
Penalty
Summary
The facility failed to keep call lights within reach for multiple residents who had documented needs for assistance and, for one resident, failed to provide required feeding assistance. The general care policy stated the facility would provide care to meet residents’ physical and psychosocial needs, including ADLs, and the call light policy stated call lights should be placed within reach of residents who are able to use them at all times. During observation, interview, and record review, surveyors found call lights out of reach for five residents: one resident’s call light was on the floor, another’s was between the side rail and mattress, another’s was dangling below the mattress with the cord tied to the bed rail on the resident’s impaired side, another’s was on the side of the bed and not reachable from the resident’s wheelchair, and another’s was attached to the upper bed rail where the resident could not reach it from the wheelchair. One resident had a BIMS score of 8, required substantial to maximal assistance for rolling and was dependent for transfers, and the care plan directed staff to keep the call light within reach when in the bedroom. On observation, the resident was lying in bed with the call light on the floor and the cord tied to the side rail; staff acknowledged it was not within reach and one CNA placed it on the resident’s chest without securing it. Another resident with a BIMS score of 3 and dependence for rolling also had the call light between the side rail and mattress, and an LPN stated it should be on top of the resident. A third resident with a BIMS score of 4 and dependence for rolling had the call light dangling below the mattress, with the cord tied to the bed rail on the resident’s impaired side, and the LPN confirmed it was out of reach. Additional observations showed a resident with diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, and a BIMS score of 10 had the call light on the side of the bed while seated in a wheelchair and could not reach it; the LPN confirmed it should be within reach, but the cord was too short to place near the resident’s lap. Another resident with a BIMS score of 14 and a care plan directing staff to keep the call light within reach was observed in a wheelchair at the end of the bed, stated a need to have a bowel movement, and said the call light was attached to the left upper bed rail and could not be used from the wheelchair because of pain in both shoulders; an RN confirmed it was out of reach. The facility also failed to provide required feeding assistance to one resident who was observed eating alone despite a dietary card indicating 1:1 feeding assistance and a functional assessment showing supervision or touching assistance was needed for eating.
Failure to Provide Grooming Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that staff provided grooming care, including nail care and shaving, for residents who were dependent on staff for ADL care. Observation, interview, and record review showed that five residents reviewed for ADL care had long, dirty fingernails, and two of those residents also had facial hair and requested shaving. The deficiency involved residents who were dependent on staff for all or most ADLs and whose care plans identified ADL self-care performance deficits and impaired mobility. R16, who had a history including nontraumatic intracerebral hemorrhage, iron deficiency anemia, gastrostomy status, adult failure to thrive, heart failure, and diabetes mellitus, was assessed as dependent for all ADLs and was observed in bed with long dirty fingernails on both hands and crusty dry skin. R59, with a history including hemiplegia and hemiparesis following cerebral infarction, malnutrition, depression, heart disease, seizures, hyperlipidemia, hypertension, and dysphasia, was assessed as dependent for all ADLs and was observed with long dirty fingernails, including nails digging into the hands. R69, with a history including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage, dysphagia, hyperlipidemia, lack of coordination, and anemia, was observed with long fingernails and brownish substances on both hands and stated that he wanted them trimmed. R165, with a history including hemiplegia and hemiparesis following cerebral infarction, dysphagia, difficulty walking, hyperlipidemia, hypertension, and osteoarthritis, was observed with lots of facial hair and long fingernails with brownish substances on both hands and stated that he wanted a shave and did not remember the last time his nails were trimmed. R176, with a history including gait and mobility abnormalities, muscle wasting and atrophy, hyperlipidemia, generalized anxiety disorder, and hypotension, was observed with lots of facial hair and long dirty fingernails and stated that he wanted a shave and did not recall the last time he was shaved. The ADON stated that nails should be free of debris, clean, and at acceptable length, and that nail care and shaving should be done during ADL care by CNAs.
Medication Pass Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to follow its medication pass policy and failed to administer medications within the required time frame of 1 hour before to 1 hour after the scheduled time, resulting in a medication error rate of 22.22% with 6 medication errors out of 27 opportunities. Two of four residents in the medication administration sample, R89 and R144, were affected by late medication administration. The facility’s medication pass policy, revised 7/25/25, states that it is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. R89 had physician orders for Sevelamer Carbonate 800 mg with meals, Amlodipine Besylate 10 mg daily, Aspirin chewable 81 mg daily, Renal Capsule 1 mg daily, and Hydralazine HCL 50 mg three times daily. At 9:30 a.m., an LPN dispensed R89’s Sevelamer Carbonate, Amlodipine Besylate, Aspirin, Renal Capsule, and Hydralazine in a medication cup even though the EMAR scheduled them for 7:30 a.m. or 8:00 a.m.; the LPN stated this was the end of her med pass and she had other things to prioritize. R144 had orders for Magnesium Oxide 400 mg daily and Metoprolol Succinate ER 25 mg, 2 tablets daily. At 9:51 a.m., an RN dispensed R144’s Metoprolol Succinate ER and Magnesium Oxide in a medication cup even though the EMAR scheduled them for 7:30 a.m.; the RN stated staff try to wrap it up but it gets busy because residents are going to dialysis and everything. R144 later refused the Metoprolol, which was excluded from the medication error rate.
Medication Labeling, Storage, and Temperature Control Deficiencies
Penalty
Summary
Medication storage and labeling practices were not followed for multiple residents’ medications. On 4/28/26, the front medication cart contained R105’s Humalog pen without a bag or pharmacy sticker, and the resident’s name was handwritten in smeared marker and was barely legible. During the same survey, the back medication cart was left unlocked and unattended in the hallway by an LPN, and when the cart was later checked, the drawer could be opened without using the electronic keypad. A second medication cart was also found to have a locking keypad that was not functioning, and narcotic medication on both carts was single locked rather than double locked. The facility’s policy stated medications from the pharmacy must be labeled with the resident’s name, route, instructions, medication name, strength, and expiration date when applicable, and that Schedule 2 medications must be double locked. Additional medication storage issues were identified in the carts and medication room. R17’s Lispro and a Geri-Tussin container were opened and undated, and several insulin pens, including R1’s Lantus, R74’s Novolog, R49’s Novolog, and R136’s Lispro, were opened, unbagged, and lacked pharmacy stickers, with handwritten names on the pens. On 4/29/26, the medication refrigerator temperature was 48F, which was outside the facility’s stated required range of 38-41F. At that time, the refrigerator contained an emergency box with six insulin pens, R133’s Prevnar 20 vaccine, R133’s Abrysvo vaccine, and R25’s Trulicity. The report also noted that refrigerated medications and emergency box insulins were stored in the refrigerator while it was out of range.
Personal Resident Refrigerators Not Properly Monitored or Maintained
Penalty
Summary
The facility failed to ensure that residents’ personal refrigerators were maintained at safe temperatures for food storage, failed to properly document daily refrigerator temperature checks, failed to date open food items, and failed to keep residents’ refrigerators clean. These issues involved four residents reviewed for the safety of personal food items: R17, R50, R78, and R89. On observation, R17’s personal refrigerator did not have a temperature monitoring log, and a large amount of a brown, sticky substance was present on the bottom shelf. R17, who was cognitively intact with diagnoses including osteomyelitis of the vertebra, diabetes mellitus, and paraplegia, stated the refrigerator contained only personal food and that the facility had provided it. R17 also said housekeeping usually cleaned the refrigerator, but was unsure when it was last cleaned. A staffing coordinator acknowledged the missing temperature log and that the refrigerator was not clean. R50 and R78 shared a personal refrigerator that contained an undated Tupperware container with garlic bread and lasagna and an undated plastic sandwich bag with cheese puffs. R50, who was cognitively intact, identified the food as belonging to R78 and said both residents used the refrigerator. R78 had a BIMS score indicating moderately impaired cognition and could not be interviewed due to altered mental status. In another room, R89’s refrigerator had a temperature log with no entries from 4/23/26 through 4/27/26, and the thermometer read 50 degrees. Staff stated the refrigerator should be between 38 and 40 degrees, that housekeeping checked and cleaned resident refrigerators daily, and that the refrigerator had not been checked since 4/22/26. The nursing supervisor stated the refrigerator was too warm, had not been checked, and that the food may not have been properly stored; R89 later stated staff told them the refrigerator was taken away because it was not working right.
Failure to Develop and Provide Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident and failed to provide the resident with a copy or summary of that baseline care plan within the required timeframe. R202 was admitted following hospitalization for a fall and an infected groin wound, and the record documented diagnoses including surgical aftercare following surgery on the skin, muscle wasting and atrophy, anemia, type 2 diabetes mellitus with hyperglycemia, hypertension, acute kidney failure, and Fournier Gangrene. R202 was alert and oriented x4 and stated that no copy or summary of a baseline care plan had been provided, despite being told a care plan meeting was scheduled. The record review and staff interview showed there was no documentation that the baseline care plan or a summary was given to R202. The MDS Coordinator/RN confirmed residents are supposed to receive a copy of the baseline care plan within 48 to 72 hours of admission and that this should be documented in the clinical record, but there was no such documentation for R202. The baseline care plan in the chart also did not address R202's therapy services, even though R202 was actively receiving therapy and had physician orders for treatment. The facility policy stated baseline care plans are to be completed within 48 hours of admission and should include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable.
Care plans not updated after fall injuries and incorrect code status
Penalty
Summary
The facility failed to keep resident care plans current after changes in condition and after changes in advance directive status. For one resident, the record showed advance directives of DNR and DNH on the face sheet and on an IDPH POLST form, but the care plan documented the resident as Full Code and stated the EMR chart should identify Full Code status. The Social Service Director stated that social services was responsible for advance directives, that code status changes should be reflected in the care plan, and that staff were supposed to check weekly for changes and update accordingly. For another resident, the record showed a history of COPD, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and a displaced supracondylar fracture of the right humerus. The resident’s MDS indicated severe cognitive impairment and need for substantial to maximal assistance with personal hygiene and partial to moderate assistance with transferring. After a fall from a wheelchair, the resident was sent to the ED, where imaging diagnosed a closed supracondylar fracture of the right humerus, a fall, and a traumatic hematoma of the forehead. The resident returned to the facility with the right arm in a splint and was to follow up with primary care in 1 to 2 days. The progress notes documented the fall, transfer to the hospital, return from the ED, and later a code blue when the resident was found unresponsive and was pronounced deceased. The facility’s incident report stated the resident had an unwitnessed fall, was treated at the hospital, and that the plan of care was updated to address the resident’s needs. However, review of the care plan showed fall-risk interventions only and no revision to address the new right humerus fracture, splint use, or monitoring for neurological decline after the head injury. The House Supervisor/Falls Nurse and the DON both reviewed the record and affirmed that the care plan was not updated to include the fracture diagnosis or head trauma.
Pressure Injury Care and Repositioning Not Followed
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not followed for one resident with a low air loss mattress order and a high Braden risk score. The resident had a BIMS score of 8, was unable to be interviewed due to altered mental status, had limited mobility, and had a history of prior pressure ulcers that had resolved. The care plan identified the resident as high risk for skin breakdown and included interventions for skin checks every shift, offloading heels, and turning and repositioning at least every 2 hours and as needed. Record review showed that a new pressure injury developed on the right bunion and was documented by the wound care nurse practitioner as a deep tissue injury. The wound was first noted as new skin alteration with a size of 1 cm x 1.1 cm, then later measured larger at 1 cm x 2 cm. The wound care notes stated the resident was at moderate risk for pressure ulcer formation related to incontinence, decreased mobility, and comorbidities, and recommended floating the heels while in bed with heel boots. The resident’s order summary included a low air loss mattress and wound care to the right bunion. On 4/28/26 and again on 4/29/26, the resident was observed lying in bed with both feet and heels resting directly on the mattress, without heel boots or other heel offloading devices in place. The wound care nurse practitioner stated the heel boots were to be on at all times while the resident was in bed and affirmed that offloading heels and repositioning every 2 hours were intended to help improve and prevent worsening of the facility-acquired pressure ulcer. Record review of the turning and repositioning documentation showed that, out of 28 days, the resident was repositioned on only 7 days as recommended. The facility also stated it did not have a policy for turning and repositioning, and staff were unsure whether repositioning was charted every time or only once per shift.
Failure to Provide and Document Restorative Splint and Brace Care
Penalty
Summary
The facility failed to provide and document restorative care for two residents with significant mobility limitations and contractures. One resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right side, and physician orders for a right knee brace for contracture management and a right hand resting splint. The care plan stated the resident was on a splint and/or brace assistance program, but the Nursing Rehab documentation for April 2026 included the right hand resting splint without specified times for application and removal, and the right knee brace was not included in the Nursing Rehab tasks. On observation, the resident’s right arm and hand were contracted, the splint was found on the dresser and not in use, and staff did not apply it when they entered the room. Staff interviews showed confusion about who was responsible for applying the splint and when it should be used, and the resident’s family stated the splint and knee brace were not being put on. The resident’s April 2026 documentation survey report showed Nursing Rehab entries for the right hand resting splint with X’s throughout the month, which the ADON confirmed meant nothing had been documented for application or removal. The restorative aide stated splints were put on by restorative staff and on weekends by CNAs, but also stated there were no designated times for placement and removal. The ADON confirmed the right knee brace was not included in the Nursing Rehab tasks. The report also noted that the resident had a wound on the right forearm/antecubital area, and the restorative aide stated being unaware of the wound. A second resident, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, protein calorie malnutrition, depression, ischemic heart disease, seizures, hyperlipidemia, hypertension, and dysphasia, was assessed as dependent on staff for all ADLs and had a BIMS score of 3. The resident had physician orders for a resting hand splint to the left upper extremity at bedtime and a right arm rest comfort device. During observations, the resident was in bed with left-sided contracture, had no brace or splint on the left side, and had long, dirty fingernails digging into the hand. The resident stated he had no splint, brace, or arm rest, and multiple staff members, including a CNA, LPN/restorative nurse, and restorative aide, could not confirm that he had any such device. The April 2026 Nursing Rehab documentation for left hand resting splint application and removal was marked with X’s for the entire month except after the issue was brought to staff attention.
Failure to Follow Respiratory Orders and Handle Equipment Properly
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents. For R129, the facility failed to follow the respiratory equipment policy when a nebulizer mask and tubing were observed on the resident’s nightstand without a date and not contained. On 04/27/2026, a red and white sign on the door indicated no smoking, no open flame, and oxygen in use. The RN observed the nebulizer mask and tubing on the nightstand and stated they were not labeled with the date and were not contained; the RN stated the equipment should be dated and kept in a clear plastic bag. The DON later stated the nebulizer mask should be contained in a clear plastic bag when not in use and labeled with the date it was changed. R129 had diagnoses including COPD, respiratory failure with hypoxia, and sepsis, and had an active order for ipratropium-albuterol inhalation solution every 6 hours as needed for shortness of breath or congestion. For R101, the facility failed to follow the provider order for continuous oxygen. R101 had an order dated 4/14/2026 for oxygen at 3 liters per minute via nasal cannula continuously, and the resident’s diagnoses included end stage renal disease, peripheral vascular disease, acute pulmonary edema, acute respiratory failure with hypoxia, anemia in chronic kidney disease, and major depressive disorder. On 04/28/2026, R101 was observed not wearing oxygen, and the oxygen tubing and nasal cannula were laid over the machine and not in a bag. R101 stated staff had taken the oxygen off earlier that morning and did not put it back on. A CNA stated the tubing and cannula should be in a bag so they do not get dirty, and the House Supervisor/LPN stated R101 should be on oxygen because the order was for continuous oxygen.
Untimely Post-Fall and Neurocheck Documentation
Penalty
Summary
The facility failed to document post-fall charting and neurological checks in a timely manner, leaving R197’s medical record not readily accessible or accurate for up to 9 days after the fall. R197 was a [AGE]-year-old resident with chronic obstructive pulmonary disease, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and a displaced supracondylar fracture of the right humerus. The MDS documented severe cognitive impairment, and the resident required substantial to maximal assistance with personal hygiene and partial to moderate assistance with transferring. After R197 fell from a wheelchair while leaning forward to reach for something, the resident struck her head and was noted to have a hematoma, soft blood pressure, slight hypoxia requiring oxygen, and was on aspirin. The resident was sent to the ED and later returned with diagnoses of a closed supracondylar fracture of the right humerus and traumatic hematoma to the forehead. The record shows neurochecks and post-fall follow-up entries were completed by multiple nurses, but several were signed as complete on dates after the resident had already died, and survey review found multiple neurocheck and post-fall entries charted on or after a date 6 or more days after death. The House Supervisor/Falls Nurse stated the facility completed post-fall charting and neurological checks to monitor level of consciousness and neurological decline, and acknowledged the last neurocheck was due at 10:00 AM and was not completed by the nurse. The DON stated the facility standard is to chart as you go so nothing is missed and that untimely charting may not be accurate. Staff interviews showed the assigned LPNs and agency nurses did not recall completing the documentation late, while the record review showed day 3 post-fall charting was not completed and several entries were signed after the fact.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the required daily nurse staffing information was accurately completed. On 4/27/26, the Administrator stated the facility census was 164 residents, but the Daily Nurse Staffing information posted near the receptionist area showed a census of 177. The posted staffing form for that date documented that the correct census of residents residing in the facility was not recorded. On 4/28/26, the Administrator’s email documented the facility census as 163 residents, yet the Daily Nurse Staffing information posted near the receptionist area again showed a census of 177. The Staffing Coordinator/Scheduler stated that he was responsible for the daily staffing posting and that it was supposed to be accurate, but acknowledged the census number was not right and said, "I probably didn't look at it right. I was moving fast." The facility policy titled, Postings, stated the facility would comply with federal regulations regarding required postings.
Failure to Timely Report Injury of Unknown Origin Involving Serious Bodily Injury
Penalty
Summary
The facility failed to comply with abuse reporting requirements by not submitting an initial and final report to the State Agency within required timeframes for an injury of unknown origin involving a resident who sustained a serious bodily injury. The resident, an older adult admitted for therapy and medical management with multiple diagnoses including end stage renal disease, difficulty walking, cognitive communication deficit, adult failure to thrive, and a stage 2 sacral pressure ulcer, complained of hip pain. According to the DON, the resident’s daughter reported that the resident’s hip did not look right, and the resident went to therapy but complained of pain to an agency nurse, who notified the unit manager. The unit manager obtained orders for an X-ray and PRN Tylenol. The daughter did not want to wait for the X-ray provider and requested that the resident be sent to the hospital, and the resident was transferred per family request. Progress notes show that the family requested transfer to the hospital for a dislocated hip, and later documentation from the ER indicated the resident was admitted with a right hip fracture. An incident report dated the day after the transfer identified the event as an injury of unknown origin and documented that there had been no fall or injury at the facility since admission and that an investigation was initiated. The initial report listed the date and time staff became aware of the incident as that same morning and indicated it was sent to the State Agency at 11:00 a.m. The final report for the same incident was not sent until a later date, which coincided with the day the surveyor requested the report. When the surveyor discussed this with the Administrator, she stated that she had forgotten to send the final report, despite having completed it. This sequence of events shows the facility did not adhere to its own abuse and retaliation policy, which requires all allegations of abuse, including injuries of unknown origin, to be reported to the State Agency immediately, not exceeding two hours after receipt, with a final investigation submitted within five working days.
Failure to Process Grievance and Arrange Timely Dental Services for Missing Dentures
Penalty
Summary
The deficiency involves the facility’s failure to timely address a resident grievance regarding missing dentures and to ensure provision of dental services as outlined in facility policy. The resident, an adult with diagnoses including lipoprotein deficiency, plasma-protein metabolism disorder, glaucoma, legal blindness, right ear hearing loss, essential hypertension, low BMI, and right foot pain, was cognitively intact with a Brief Interview for Mental Status score of 14. An inventory list dated prior to hospitalization documented upper and lower dentures, while a subsequent inventory list after readmission showed no dentures. Upon readmission, the resident reported the dentures missing, but no grievance form was completed by the staff who received the concern, despite facility policy requiring grievances/concerns to be filed and followed up within 72 hours. The resident reported repeatedly asking to speak with the Administrator, being told the Administrator was on vacation, being redirected to the Assistant Administrator without follow-up, and speaking with Social Services without receiving any response regarding the missing dentures. The facility also failed to ensure timely referral and provision of dental services after the dentures were reported missing. Facility policy required that if dentures are lost or damaged, the resident must be promptly referred for dental services within three days, or the facility must document what was done to ensure the resident could still eat and drink and any extenuating circumstances for delay. Staff interviews confirmed that the Social Services staff reported the missing dentures to administration but did not complete a grievance form, and the Assistant Administrator acknowledged awareness of the concern without initiating the grievance process. The DON stated that residents who report missing dentures are to be referred to dental services, but was unsure why this resident was not seen by dental services before discharge. Although the Activity Director indicated the resident was placed on a monthly sign-up list for dental services, the resident was not actually seen by the dental provider prior to discharge, and the resident reported not seeing any dental services or being informed of any follow-up on the dentures during the stay or after discharge.
Failure to Ensure Functioning Call Light System for Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call light system for a resident’s bed, as required by the resident’s care plan and the facility’s call light policy. The resident is an adult male with end stage renal disease, heart transplant status, depression, type 2 diabetes mellitus without complications, and essential hypertension. His care plan, initiated on 12/31/2025, includes an intervention that he be provided a safe environment with a working and reachable call light as part of fall prevention. On 1/2/2026 at 12:41 p.m., the resident was observed sitting in a chair in his room, alert and able to make his needs known, repeatedly calling out for help because he needed assistance getting back to bed. The resident reported that he had been pressing his call light as instructed but was not receiving help because the call light was not working and the light did not come on. The surveyor observed the resident pressing the call light and confirmed that the corridor light above the door did not illuminate, the light on the call light panel was not on, and there was no audible sound. When informed, a restorative aide entered the room, observed the resident pressing the call light, and stated that the light should illuminate outside the door and that residents use the call light to let staff know they need help. An agency LPN attempted to re-plug the call light and determined that the call light for both bed one and bed two was not working and that maintenance would need to be called. The maintenance assistant later examined the call light and stated that when the button is pressed, the light is supposed to come on over the door, and that both call lights for bed one and two go into one unit so if one does not work, the other will not work. He reported that he had previously fixed this call light the Saturday before Christmas, that it had come off the wall, and that it must have come loose again. Upon further inspection, he found the call light was not connected and that a wire needed to be soldered back, confirming that neither call light would work. Staff interviews revealed inconsistent understanding of how residents would obtain help if a call light was not functioning, with both a CNA and an agency LPN acknowledging they would not know a resident needed help without a working call light. The DON and nurse manager described expectations for rounds and for reporting defective call lights, and the assistant administrator and maintenance assistant referenced routine checks and alternative measures such as bells or room changes, but the maintenance log for 12/30 only showed a checked box for a call light request in this resident’s room without documentation of what was fixed or the nature of the concern, despite the facility’s policy requiring that the call system be in proper working order and that nonfunctional call lights be addressed and alternative means provided.
Failure to Promptly Transfer Resident with Sepsis Symptoms
Penalty
Summary
A facility failed to follow its own guidelines for the prompt transfer of a resident exhibiting signs and symptoms of sepsis, resulting in a delay of approximately six hours before the resident was sent to the hospital. The resident, who had a complex medical history including cerebral neoplasm, seizures, spastic hemiplegia, encephalopathy, diabetes, and a history of sepsis, began showing abnormal vital signs and symptoms such as hypoxia, tachycardia, low blood pressure, and altered mental status. Multiple staff members, including a speech therapist and registered nurse, noted these changes and communicated them to the nurse practitioner, who ordered diagnostic tests and treatments but did not assess the resident's vital signs during their visit or address the abnormal findings reported by nursing staff. Despite the facility's policy requiring sepsis screening and prompt action when two or more SIRS criteria are met, no formal sepsis screening was completed, and key laboratory tests such as blood cultures, CMP, coagulation tests, and lactate were not ordered or drawn as required. The resident's family expressed concern and requested hospital transfer, citing a history of sepsis, but the transfer was not initiated until later that evening after further deterioration and abnormal lab results were noted. Documentation and interviews revealed that staff were aware of the resident's change in condition and the potential for sepsis but did not follow the facility's sepsis care guidelines, which call for immediate physician notification, IV fluids, and consideration for hospital transfer unless specific exceptions apply. The delay in recognizing and responding to the resident's sepsis symptoms resulted in the resident being hospitalized and diagnosed with septic shock and pneumonia. Interviews with staff, including the DON, nurse practitioner, and medical director, confirmed that the facility was not equipped to treat sepsis in-house and that the established protocol was not followed. The facility's failure to implement its sepsis guidelines and promptly transfer the resident for higher-level care constituted a deficiency in quality of care.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures within the comfortable range of 71 to 81 degrees Fahrenheit, as required by policy. During a facility tour, multiple rooms and hallways were observed with temperatures exceeding 81 degrees, with specific measurements ranging from 81.3 to 81.6 degrees Fahrenheit. Residents reported that their rooms were very hot, especially over the weekend, and that staff were aware of the issue but had not taken effective action to resolve it. One resident stated that she was sweating and uncomfortable, and her family had to bring a portable fan to help alleviate the heat. Another resident reported being moved to a different room only after enduring the heat for several days. Staff interviews confirmed that the building was warm and that the air conditioning system was not functioning properly, particularly in the 100-unit area where individual AC units were not working due to broken fan belts. The Maintenance Director acknowledged the issue and suggested providing portable fans for residents who continued to complain about the heat. A Certified Nurse Assistant also noted that the facility was very hot at the beginning of her shift and that staff were instructed to close windows, but could not recall who gave the directive. Medical records indicated that several affected residents had significant health conditions, including acute respiratory distress, dependence on supplemental oxygen, severe persistent asthma, heart transplant status, and immunodeficiency. Facility policies required maintaining ambient temperatures within a specified range and outlined procedures for extreme heat, including identifying high-risk residents and ensuring proper functioning of air conditioning systems. Job descriptions for maintenance and nursing staff emphasized their responsibility to ensure a safe and comfortable environment for residents.
Failure to Maintain Acceptable Ambient Temperatures Due to Inoperable Cooling System
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not ensuring that the cooling system was in proper working order, resulting in ambient temperatures exceeding the facility's policy range of 71 to 80 degrees Fahrenheit. Observations and interviews revealed that the air conditioning system in the 100-unit and 200-unit wings was not functioning adequately, with measured temperatures in the hallways reaching 81.3 and 81.5 degrees Fahrenheit. The Assistant Maintenance Director reported that the entire 100-unit area was hot due to broken fan belts on the roof fans, which led to insufficient cool air circulation. Additionally, the vents were not producing enough cool air, and individual AC units in the 100-unit wing were not working. The Administrator confirmed awareness of the temperature issue and acknowledged that the problem was reported to her. The Maintenance Director also confirmed that the temperatures were elevated and attributed the inadequate cooling to the broken fan belts. Facility policy requires maintaining ambient temperatures within the specified range and activating special procedures during extreme heat, but these measures were not effectively implemented, resulting in uncomfortable conditions for residents, staff, and the public in affected areas.
Failure to Prevent Constipation in Resident on Pain Medication
Penalty
Summary
The facility failed to provide effective bowel management for a resident who was prescribed pain medications known to cause constipation. The resident had multiple diagnoses, including dependence on supplemental oxygen, heart failure, spinal stenosis, type II diabetes, and atrial fibrillation, and was moderately cognitively impaired. Physician orders included tramadol and a fentanyl patch for pain management. Despite these medications, which increase the risk of constipation, the resident's bowel movements were not adequately monitored or managed, as evidenced by documentation showing only small bowel movements on two days and none for the following five days. Staff interviews revealed that the nurse practitioner was not made aware of any constipation concerns, and the assistant director of nursing acknowledged that the resident's hospital stay for fecal impaction was preventable. The resident was ultimately hospitalized with severe fecal impaction, confirmed by CT scan, and required disimpaction and an enema. Facility policy required documentation of bowel movements and physician notification for changes in bowel patterns, but these procedures were not effectively implemented for this resident.
Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Assessment and Equipment Use
Penalty
Summary
The facility failed to consistently and accurately assess, monitor, and implement interventions to prevent skin breakdown for two residents at high risk for pressure ulcers. One resident was admitted with intact skin and a high Braden score risk, but developed a facility-acquired unstageable sacral pressure injury within weeks. There was no documented order or clear record of when a low air loss (LAL) mattress was implemented for this resident, despite its presence at the time of survey. The wound care nurse practitioner and wound care director confirmed the development of the pressure ulcer and noted the use of wound care treatments and nutritional supplements, but the initial preventive interventions and monitoring were not adequately documented or implemented per guidelines. Another resident with a history of surgical dehiscence and a full-thickness ankle wound was observed on an alternating air mattress that was not properly inflated due to the power cord being disconnected from the socket. The mattress was set at an incorrect weight and remained deflated in the upper middle portion, causing discomfort and pain for the resident. Staff were aware of the deflation but did not promptly resolve the issue, and the mattress was not providing the required pressure redistribution as per manufacturer guidelines. These failures in monitoring and equipment management contributed to inadequate pressure ulcer prevention and care for both residents.
Failure to Assess and Obtain Consent for Bed Side Rail Use
Penalty
Summary
The facility failed to follow its own side rail policy and federal requirements regarding the assessment and consent for the use of bed side rails for four residents out of a sample of forty-nine. Observations revealed that these residents had raised upper quarter or half side rails on both sides of their beds. Interviews with staff confirmed that all beds in the facility are equipped with bilateral upper side rails and that side rail assessments are required on admission, quarterly, upon significant change, and annually. However, for the residents in question, there were missing or outdated side rail assessments and, in several cases, no documented consent for side rail use in the medical records. Specifically, one resident had only a single assessment from several years prior, and others had no consent forms or assessments available at all. Further review of the residents' medical records showed that some were totally dependent on staff for activities of daily living and unable to use side rails independently. Despite this, care plans for side rail use were initiated without the required ongoing assessments or proper consent documentation. Staff interviews confirmed that the facility's policy requires alternative devices to be tried first, assessments to be completed, and consent to be obtained and documented before side rails are used. These steps were not consistently followed, resulting in the deficiency.
Failure to Properly Label, Store, and Discard Insulin and Medications
Penalty
Summary
The facility failed to comply with its medication labeling and storage policies by not discarding medications belonging to discharged residents and by not ensuring that open and expiration dates were labeled on insulin pens and vials. During observations, multiple instances were found where insulin bottles and pens for several residents were opened but not dated, and in one case, insulin for a discharged resident remained on the medication cart instead of being discarded. Staff interviews confirmed that facility policy requires opened insulin to be dated and medications for discharged residents to be removed from the cart, but these procedures were not followed. Specifically, insulin bottles and pens for residents with Type 2 Diabetes Mellitus were found on medication carts without open or expiration dates, and in one case, insulin for a resident who had been discharged was still present and not discarded. Staff, including nurses and the assistant director of nursing, acknowledged that insulin should be dated upon opening and discarded after expiration, but these requirements were not met for several residents reviewed. The facility's own policy states that all opened medication vials should be labeled with the date opened and discarded within a specified timeframe, but this was not consistently implemented.
Failure to Follow Infection Control and PPE Protocols During Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy by not performing appropriate hand hygiene and not donning required personal protective equipment (PPE) before entering and after exiting resident rooms under enhanced barrier precautions (EBP). Multiple staff members, including nurses, nurse practitioners, and a wound care director, were observed entering EBP rooms and providing direct resident care without donning gowns as required. For example, a nurse entered a resident's room, donned only gloves, and performed gastrostomy tube care without a gown. Nurse practitioners conducted a head-to-toe skin assessment on a new admission without wearing gowns, and the wound care director initially entered a resident's room and removed a dressing without any PPE before later donning PPE for wound care. Additionally, an outside laboratory employee entered an EBP resident room to collect a blood specimen, donned only gloves, and did not perform hand hygiene or wear a gown while touching various surfaces and performing the procedure. The infection prevention nurse confirmed that staff are expected to observe signage for required PPE, don gowns for direct care, and perform hand hygiene before and after entering resident rooms. The facility's policy, revised 7/31/24, specifies that gloves and gowns are required for high-contact care activities and that hand hygiene must be performed before and after direct patient contact.
Failure to Obtain Consent and Post Signage for Electronic Monitoring
Penalty
Summary
The facility failed to follow its own electronic monitoring policy by not posting required signage at facility entry points and at the entrance to the resident's room where electronic monitoring was in use. Additionally, the facility did not obtain informed consent from the residents or their representatives before initiating video and audio monitoring in the room shared by two residents. Both residents were unaware of the presence of the electronic monitoring device, and neither had been informed or given consent for the monitoring. One resident's power of attorney was only contacted after the device was already in place and was not fully informed about the extent of the audio recording, believing it would be voice-activated rather than continuous. Documentation related to the electronic monitoring was incomplete and did not include required information such as the names of residents, dates of consent, or the presence of staff during consent discussions. There was also no evidence that the device was turned off during exams or provision of care, as required by policy. The care plan for one resident did not address the use of electronic monitoring, and the consent form lacked signatures and documentation from the roommate. These failures affected both residents in the room and did not comply with the facility's policy or regulatory requirements for resident rights and privacy.
Call Light Accessibility Not Maintained for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident was observed resting in bed with the call light hanging down to the floor and out of reach. The resident, who was alert and able to communicate, stated she did not know where her call light was and was seen feeling around for it but was unable to reach it. The call light remained out of reach during a subsequent observation. The Assistant Director of Nursing confirmed that call lights should be accessible to residents, as they are used to request assistance from nursing staff. The facility's policy requires prompt response to call lights and ensures the call system is in proper working order.
Inaccurate MDS Coding for Special Treatments and Prognosis
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessments for three residents, resulting in inaccurate documentation of their care needs and treatments. One resident, who was alert and oriented, reported not having received dialysis in over two years and had a new kidney, yet her MDS indicated she was receiving dialysis at the facility. Review of her physician orders confirmed there were no orders for dialysis treatment. Another resident, admitted with anemia, dementia, adult failure to thrive, and malnutrition, was on hospice care with documentation supporting a prognosis of less than six months. However, the MDS was coded to indicate the resident did not have a terminal prognosis, despite the presence of appropriate documentation in the medical record prior to MDS completion. A third resident's MDS was coded to reflect ongoing hospice care, even though the resident had been removed from hospice and had a payor source change. Social service notes confirmed the last hospice coverage date, and staff interviews revealed that the MDS should have been updated to reflect the change in hospice status. The failure to accurately code the MDS assessments was confirmed through record review and staff interviews, affecting the accuracy of resident assessments and care planning.
Failure to Update and Implement Resident Transfer Care Plan
Penalty
Summary
The facility failed to ensure that care plans accurately reflected a resident's current care needs for safe transfer status, specifically regarding the use of a mechanical lift. A certified nursing assistant (CNA) assisted a resident, who was recovering from a hip fracture, to stand and transfer to the toilet without applying a gait belt or using a mechanical lift, despite the resident requiring verbal and physical cueing. The CNA stated that they followed care card instructions and were aware of the resident's recent hip fracture. Another CNA reported transferring the same resident from bed to wheelchair without any equipment or gait belt, recalling the resident as a stand and pivot with one-person assist for transfers. The restorative nurse confirmed that prior to the resident's fall, the transfer status was stand and pivot with one assist, but following the hip fracture, the resident should have been transferred using a mechanical lift. The care plan, dated after the hip fracture, indicated the need for two staff and a full-body mechanical lift for transfers, but did not document the previous transfer status or the use of a gait belt. The MDS assessment identified the resident as using a walker and requiring partial to moderate staff assistance for transfers. These inconsistencies between the care plan, staff actions, and resident needs led to the deficiency.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
Staff failed to provide incontinence care and turning/repositioning at least every two hours for a resident who was totally dependent on staff for activities of daily living. During a two-hour observation period, there was a persistent malodor coming from the resident's room, and no incontinence care or repositioning was provided. A nurse entered the room to provide gastrostomy tube care but did not check for incontinence needs. At the end of the observation, the resident was found with a urine-saturated brief, a wet flat sheet with brown discoloration, and a mattress with pooled liquid under the buttocks. The resident's sacral pressure ulcer dressing was also saturated with urine. Staff interviews confirmed that the resident was unable to assist with ADLs and was fully dependent on staff. The wound care director stated that staff are expected to turn and reposition residents and provide incontinence care every two hours and as needed. The resident's medical records indicated a low BIMS score and total dependence on staff for care. Despite these needs, the required care was not provided during the observed period.
Failure to Follow Transfer Protocols and Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to follow established transfer protocols and policies for a resident who required assistance, resulting in a significant injury. Specifically, staff did not use a gait belt during a bed-to-wheelchair transfer and did not adhere to the identified mechanical lift transfer status for a resident recovering from a hip fracture. The resident, who had a recent decline in cognitive status and was identified as needing increased assistance, was transferred without the required equipment or support, leading to a fall and an acute right femoral fracture that required surgical intervention. Observations and interviews revealed that staff members were aware of the facility's policy requiring the use of gait belts for assisted transfers, and that all CNAs were issued gait belts and trained on their use. Despite this, the staff involved in the incident did not utilize a gait belt or mechanical lift as indicated in the resident's care plan and transfer status. The resident was left alone on the toilet without supervision, and during another transfer, was assisted by only one staff member without the appropriate safety equipment, contrary to the care plan and facility guidelines. Documentation review showed inconsistencies in the resident's fall risk assessments and care planning. The care plan did not specify the use of a gait belt or the required level of assistance prior to the incident, and the only fall risk evaluation available was completed on the day of the fall, identifying the resident as high risk. The facility's fall prevention program and employee handbook both require individualized assessment and the use of safety interventions, including gait belts, but these were not implemented as required for this resident.
Failure to Ensure Physician Order and Proper Functioning of Oxygen Therapy
Penalty
Summary
A resident with a history of dependence on supplemental oxygen, heart failure, and atrial fibrillation was admitted to the facility. During observation, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was turned off. When staff were notified, the Assistant Director of Nursing attempted to turn on the concentrator, which began to beep and was not functioning properly. The concentrator was then replaced with a new one. The Assistant Director of Nursing stated she had not been previously informed of any issues with the concentrator. Further review revealed that there was no current physician order for the resident's oxygen use. The last order for oxygen had been discontinued when the resident was hospitalized, and was not renewed upon readmission, despite the ongoing need for supplemental oxygen. The facility's policy requires a physician order for oxygen therapy, including specific details such as liter flow and delivery device, and mandates equipment checks and proper setup prior to administration. These requirements were not followed, resulting in the deficiency.
Failure to Monitor and Document Antibiotic Use for Resident with C. diff History
Penalty
Summary
The facility failed to develop and implement protocols and a system to monitor antibiotic use for a resident with a history of Clostridium difficile who was currently receiving antibiotics. Interviews with the Infection Prevention (IP) Nurse revealed that although the resident was removed from contact isolation due to the absence of symptoms, there was an expectation for nurses to monitor and document antibiotic assessments and any side effects. However, it was acknowledged that there was no policy in place requiring nurses to document these assessments, and documentation was not being completed as expected. Review of the resident's records showed that the only monitoring documented was related to the use of Doxycycline and Amoxicillin for underarm skin microbiota. The resident's bowel movements were noted to be loose or putty-like over several days, but there was no consistent documentation of daily antibiotic assessments or monitoring for adverse effects as outlined in the care plan. The care plan did include interventions to monitor for side effects of antibiotics every shift, but these were not being followed or documented by staff.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident was observed in a room that was not maintained in a clean and homelike condition. Over multiple days, surveyors observed dry substances on the tube feeding machine, floor, walls, bedside table, and bed framing in the resident's room. These substances, some of which appeared to be related to tube feeding, remained present despite the passage of time and daily cleaning schedules. The housekeeper supervisor acknowledged awareness of the substances and stated that such conditions should not exist, noting that nurses should address spills promptly before they dry and harden. Additionally, the resident reported receiving a bed bath but indicated that her bed linens, including the pillowcase, had not been changed. The pillowcase was observed to be stained and smelled of urine, and the bed sheets were also found to be soiled with yellow/brown stains. The resident expressed discomfort with the situation, and a registered nurse confirmed that the linens should have been changed during the bed bath. Facility policy requires daily cleaning and sanitizing of resident rooms and bathrooms, but these standards were not met in this instance.
Failure to Document Fall and Notify Family
Penalty
Summary
The facility failed to document a resident's fall in the electronic health record and did not notify the family of the incident. This deficiency affected a resident who was a hospice patient with multiple diagnoses, including senile degeneration of the brain, shortness of breath, dysphagia, and a history of falling. On the day of the incident, the resident was found on the floor next to her bed by a nurse during rounds. The nurse on duty, who was an agency nurse at the time, was informed of the fall by another nurse and assessed the resident. However, the nurse did not fill out the risk management forms, notify the family, or document the incident in the resident's medical record. The Director of Nursing confirmed that the nurse should have notified the doctor and the family within the same shift and completed the risk management documentation. The facility's policies require that an incident report be completed for each fall and that the resident's legal representative or family be notified of any significant change in the resident's condition. The failure to follow these protocols resulted in a lack of documentation and delayed family notification, as the family was informed of the fall the following day.
Failure to Report Allegation of Rough Handling
Penalty
Summary
The facility failed to adhere to its Abuse and Neglect Policy by not reporting an allegation of rough handling of a resident to the Administrator immediately. On December 3, 2024, the surveyor informed the Director of Nursing (V1) and the Assistant Director of Nursing (V2) about allegations of night shift staff rough handling a resident (R1). However, V1 did not report this incident to the Administrator (V17) as required by the policy. On December 5, 2024, V17 stated that she was unaware of the rough handling allegation received on December 3, 2024, and would have initiated an investigation immediately if informed. V1 acknowledged the failure to report the incident to V17 and stated she would inform the Administrator about the allegation immediately. The facility's policy mandates that all allegations of abuse must be reported to the Administrator immediately and to the Illinois Department of Public Health (IDPH) within two hours of receiving the allegation.
Failure to Follow Mechanical Lift Protocol Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its protocol for operating a full body mechanical lift, which requires the presence of two staff members during resident transfers. This deficiency was highlighted when a CNA attempted to transfer a resident alone, resulting in the mechanical lift tipping over and the resident falling to the floor while still attached to the sling. The incident occurred as the CNA was preparing the resident for dialysis, and the lift tipped over during the transfer process. The resident involved in the incident had multiple medical conditions, including orthopedic aftercare, heart failure, atrial fibrillation, peripheral vascular disease, chronic kidney disease, end-stage renal disease, and a displaced fracture of the left femur. Following the fall, the resident complained of severe back pain and reported hitting her head. The CNA admitted to not following the protocol of having a second person assist during the transfer, acknowledging that they had been trained to always have two people present. Interviews with other staff members, including a restorative nurse and the director of nursing, confirmed that the facility's policy mandates two staff members for mechanical lift transfers to ensure resident safety. The CNA involved had received training on this protocol, and the facility's mechanical lifts had passed inspection prior to the incident. Despite this, the CNA proceeded with the transfer alone, leading to the resident's fall and subsequent pain.
Inadequate Fall Prevention and Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to implement adequate fall prevention interventions and supervision for residents, resulting in multiple incidents of falls and injuries. Six residents were affected, with some sustaining serious injuries such as lacerations, fractures, and head injuries. The facility did not ensure that residents were properly assessed for the safe use of assistive devices, such as walkers and motorized wheelchairs, which contributed to the incidents. One resident with a history of hemiplegia and cognitive impairment was not properly assessed for the use of a walker, leading to a fall that resulted in a fibula fracture. The fall coordinator admitted that the resident's ambulation status was not evaluated, and the walker was removed only after the incident. Another resident with dementia and a history of falls attempted to go to the bathroom without assistance, resulting in a fall and head injury. The facility's fall coordinator did not adequately investigate the resident's fall history or implement effective interventions. Additionally, a resident using a motorized wheelchair, who had visual impairments, was not provided with the necessary supervision, leading to an incident where the resident ran over their own foot, resulting in fractures. The physical therapist noted the resident's visual limitations but did not communicate this to the facility staff. The facility's director of nursing acknowledged that the resident did not have a care plan for the motorized wheelchair, and the resident's visual impairment was not adequately addressed.
Financial Mismanagement of Resident's Account
Penalty
Summary
The facility failed to properly manage the finances of a resident, identified as R3, resulting in a significant financial discrepancy. R3, who had diagnoses including Cerebral Infarction, Depressive Disorder, Diabetes, Heart Disease, and Dementia, had been residing at the facility since 2016 and passed away recently. The facility collected $5,504.06 from R3's managed account without providing an itemized record of services for the amount taken. This action was taken without the consent of R3's Power of Attorney (POA), V19, who claimed that neither she nor the other POA had authorized the withdrawal. The Business Office Manager (BOM), V13, disclosed that the withdrawal was made to cover an outstanding balance, but V19 denied signing any authorization for this transaction. V19 also stated that she had not been informed of any outstanding balance when R3's account was closed. The facility's investigation revealed discrepancies in the signatures on the withdrawal documents, which did not match V19's known signature. Despite V19's request for an explanation and itemized billing, the facility failed to provide adequate documentation or a clear account of the financial transactions. Further complicating the issue, the facility's records showed inconsistencies in the amounts owed and paid, particularly concerning R3's dental and vision plans. The BOM admitted that the facility lacked a policy for handling large financial transactions and that authorization is required for any fund withdrawal. Despite these requirements, the facility did not present collection letters or itemized billing statements during the survey, and the withdrawal consent document's authenticity was questioned. The facility's failure to manage R3's finances transparently and with proper authorization led to this deficiency.
Deficiencies in Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to develop an effective pressure sore prevention plan, which resulted in multiple deficiencies in the care of residents with pressure ulcers. Resident R2, diagnosed with vascular dementia and adult failure to thrive, developed an infected pressure wound on her left hand due to contracted fingernails pressing into her palm. Despite being on restorative services for range of motion, there was no treatment or preventive measures such as splints or carrots to prevent contraction. The wound was not documented or treated by the wound nurse practitioner, and the Director of Nursing was unaware of the wound until reviewing hospital records. Resident R3, with a history of peripheral vascular disease, diabetes, and multiple pressure ulcers, was found with soiled dressings that were not replaced in a timely manner. The wound director acknowledged that the nurse on the floor should have changed the dressing when it was soiled. Additionally, R3's air mattress was improperly set at a weight much higher than the resident's actual weight, which could affect the effectiveness of pressure redistribution. The wound nurse practitioner confirmed that mattress settings should be adjusted according to the resident's weight. Resident R4 also had an air mattress set incorrectly, at a weight higher than the resident's actual weight. This resident was at high risk for skin breakdown, as indicated by a Braden scale score. The facility's failure to ensure proper mattress settings and timely wound care interventions contributed to the deficiencies observed during the survey.
Failure to Implement Fall Interventions and Complete Incident Reports
Penalty
Summary
The facility failed to adhere to its fall policy by not implementing new and effective fall interventions and not completing an incident report or fall investigation following a fall for a resident identified as high risk for falls. This deficiency affected a resident who sustained three falls within 30 days, ultimately resulting in a transfer to the hospital with a diagnosis of a subacute subdural hematoma. The resident was admitted with diagnoses including unspecified dementia, hypertension, anemia, and atrial fibrillation, and required partial moderate assistance for toilet transfers. The resident's incident report on 8/12/24 documented a fall where the resident was found on the floor after attempting to go to the bathroom without assistance, highlighting issues such as improper footwear and unsafe transfer. Despite being identified as high risk for falls, the resident's care plan did not include new interventions after subsequent falls on 8/17/24 and 9/11/24. The fall on 8/17/24 was not documented in an incident report, and no new interventions were implemented, despite the resident being found on the floor by staff. On 9/11/24, the resident fell again while attempting to get up from the toilet, resulting in a skin tear and a head injury, leading to a hospital transfer. The facility's policy required that residents be assessed for fall risk, interventions be put in place, and incident reports be completed for each fall. However, these procedures were not consistently followed, contributing to the resident's repeated falls and subsequent hospitalization.
Resident Dehydration Due to Inadequate G-Tube Hydration
Penalty
Summary
The facility failed to ensure that a resident, who was prescribed a mechanical soft diet with thin liquids and gastrostomy tube feeding, received adequate hydration to prevent dehydration. This deficiency affected a resident diagnosed with vascular dementia, metabolic encephalopathy, severe protein-calorie malnutrition, and adult failure to thrive. The resident was on a continuous enteral feed of Jevity 1.2 at 65 ml/hr, with an additional 100 ml water flush every four hours, totaling 1439 ml of water daily. Despite this regimen, the resident was found to have a free water deficit of 1.9 liters, elevated sodium levels, and fecal impaction upon hospital admission. Interviews with facility staff, including dietitians and a wound nurse practitioner, revealed that the resident was considered a dual feeder, receiving both g-tube feeding and a mechanical soft diet. However, the resident's oral intake was minimal, and all nutrition and hydration were primarily provided through the enteral feed and water flushes. The dietitian noted that the enteral feeding was calculated to meet the resident's caloric and protein needs, and additional water should have been provided if the resident had conditions like fever or wounds with exudate, which were not documented. The resident's medical records indicated inconsistencies in the administration of the prescribed enteral feeding and water flushes. Specifically, there was no documentation of the administration of 100 ml of water at 2200 hours and the Jevity feed on a particular date. The resident's nutritional assessment highlighted severe protein-calorie malnutrition and a high risk of malnutrition, with no dietary interventions implemented at the time. The resident was eventually transferred to the hospital for worsening wounds and was diagnosed with hypovolemic hypernatremia due to inadequate g-tube replenishment.
Failure to Notify Family and Physician After Resident Fall
Penalty
Summary
The facility failed to adhere to its notification policy for changes in a resident's condition, specifically following a fall incident involving one resident. The incident occurred when the resident attempted to go to the bathroom but could not find his urinal, resulting in him sitting on the floor between the bed and the wall. Despite the fall being documented in the resident's fall risk evaluation, there was no notification made to the resident's family or physician, as required by the facility's policy. Interviews with the staff involved revealed that the nurse assigned to the resident during the morning shift did not make any notifications to the family, doctor, or falls coordinator. Another nurse who assisted during the incident confirmed that she did not notify anyone and that the responsibility lay with the assigned nurse. The fall nurse also confirmed the absence of any documentation regarding the notification of the physician or family. The facility's policy mandates immediate notification to the resident, physician, and family in the event of an accident involving injury or a significant change in the resident's status, which was not followed in this case.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for wound treatment for a resident with a diagnosis of type II diabetes and hidradenitis suppurativa, who also had bilateral below-knee amputations. The resident was admitted with a high risk for skin breakdown, as indicated by a Braden scale score of nine. During an observation, it was noted that the resident's dressing for a non-pressure wound on the right underarm was not secured after a shower, and no dressing was present at the time of the interview. The wound care director confirmed that the dressing should have been changed when it was soiled or within two hours after removal, as per the physician's orders. The resident's wound care notes and physician orders specified the use of Dakin's solution for cleansing and the application of Hydrofera Blue and silver alginate for different wound sites, with daily changes required. However, during the survey, it was observed that the wound care was not performed as ordered, with the resident's right axillary and flank sites lacking proper dressing. The facility's policy mandates adherence to physician orders for treatments and care plans, which was not followed in this instance, leading to the deficiency.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,642 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Evergreen Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercy Circle | 0.7 mi | ★★★★★ | 11 | 0 |
| Warren Barr Oak Lawn | 1.8 mi | ★★★★★ | 3 | 0 |
| Aliya On 87th | 1.8 mi | ★★★★★ | 18 | 0 |
| Smith Village | 1.9 mi | ★★★★★ | 6 | 0 |
| Belhaven Nursing & Rehab Center | 2 mi | ★★★★★ | 29 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.