Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Joliet during CMS and state inspections, most recent first.
Several residents with significant care needs did not receive timely or adequate staff assistance for ADLs such as toileting, incontinence care, nail and hair care, and oral hygiene. Residents were observed with soiled briefs, untrimmed nails, disheveled hair, and poor oral hygiene, and some reported not receiving grooming or oral care for extended periods despite repeated requests. Staff interviews and documentation revealed lapses in following care plans and facility policies for regular incontinence checks and daily hygiene support.
Facility staff failed to consistently assess, cleanse, and dress G-tube sites for multiple residents dependent on staff for care, resulting in observations of unclean sites, drainage, and missing dressings. Physician orders and facility policy required daily site care and monitoring, but documentation and direct care were lacking on several occasions, with staff acknowledging the omissions and the need for more frequent inspection and intervention.
A facility failed to follow PICC line orders requiring transparent dressings and every-shift site checks for infection signs. For multiple residents with PICC lines, the insertion sites were covered with gauze or a bio patch, and staff stated the sites could not be visualized or assessed for drainage, redness, irritation, or other signs of infection.
Opened ophthalmic medications were found in medication carts without required open and expiration dates, and some eye drops were expired but still stored in the cart. Residents with glaucoma or ocular hypertension had active orders for Latanoprost, Dorzolamide, erythromycin ophthalmic ointment, and Brimonidine, while staff confirmed the medications should be dated when opened and expired products removed.
Two residents experienced deficiencies in skin care management when staff failed to obtain or follow treatment orders for a skin tear and incontinence-associated dermatitis. In both cases, required documentation and assessments were missing, and treatments were not consistently administered or recorded as ordered by the physician.
Failure to assess and auscultate an AV fistula for a resident receiving hemodialysis. A cognitively intact resident with ESRD and dependence on renal dialysis had a physician order for every-shift assessment of the right upper arm AV fistula for bruit, thrill, and signs of infection, but the monitoring record contained multiple blank entries indicating the fistula was not assessed. The DON confirmed the blanks meant no assessment was done and stated nurses were expected to follow the order.
Failure to follow pharmacy instructions for IV Vancomycin infusion. A resident with sepsis, metabolic encephalopathy, pneumonia, symptomatic neurosyphilis, and CHF had Vancomycin 1.5 g ordered to infuse over 2.5 hours via PICC. The nurse removed the med from the pump and let it run to gravity because the pump was not working; the pharmacist and DON stated Vancomycin should be infused by pump at the ordered rate and not to gravity.
Two residents with dementia and malnutrition risk did not receive the full recommended dietary portions reflected on their meal tickets. One resident received a large portion of puree meat but smaller portions of sides, and another resident received double protein only instead of double portions of all items. Staff later stated the kitchen served meat only rather than the full portions indicated, while the Dietitian said double or large portions apply to all food items unless otherwise specified.
A resident suffered a large laceration to the left lower leg requiring 18 sutures during a transfer from wheelchair to bed performed by a CNA. Staff were unsure if wheelchair footrests were in place, and it was unclear whether the injury was caused by the bed or wheelchair. The facility lacked specific policies on safe transfers and fall prevention, providing only a limited gait belt policy without comprehensive guidance.
A resident did not receive enough food and fluids to maintain their health, as surveyors found that the facility did not adequately meet the individual's nutritional and hydration needs.
A resident with dementia and constipation was not properly monitored for bowel movements, leading to a fecal impaction and colon inflammation. Despite orders to monitor and notify the physician if no bowel movement occurred in three days, the facility failed to administer PRN laxatives or conduct necessary assessments. The resident was eventually hospitalized, where the condition was discovered.
A facility failed to develop an adequate discharge plan for a resident with multiple diagnoses, including COPD and congestive heart failure, who aimed to return to the community. The facility did not arrange necessary DME and home health services, leading to discharge delays. The resident's supportive living facility expressed concerns about the lack of preparation and documentation for the resident's safe return.
A resident admitted with chronic respiratory conditions was receiving continuous oxygen therapy without a physician's order. Despite the resident's documented need for oxygen, the facility failed to obtain the necessary order until it was identified during a survey. Staff interviews confirmed the oversight, which contradicted the facility's policy requiring a physician's order for oxygen administration.
A resident with multiple health conditions, including mild cognitive impairment, was sent alone to an outside imaging appointment using a ride-sharing service. The facility's ward clerk arranged the transportation based on insurance company protocols, which did not require an escort. The resident did not return in a reasonable time, leading staff to search for him. He was found unharmed in a nearby hospital ER, highlighting a lapse in communication and assessment of his need for supervision.
A resident on anticoagulant medication experienced a fall and hit their head, resulting in a significant delay in notifying the healthcare provider. The facility's policy required immediate notification, but the initial call was made two hours after the fall, and the resident was sent to the hospital over six hours later. This delay in communication and action deviated from the facility's policy.
The facility failed to assist six residents with personal hygiene and grooming, despite their care plans indicating the need for maximum or total assistance. Residents were observed with long, unclean fingernails and unshaven facial hair, and some expressed a desire for help. Staff did not adequately address these needs, indicating a systemic failure to provide necessary care.
The facility failed to provide adequate incontinence care for four residents, potentially leading to UTIs. CNAs did not follow proper cleaning procedures, such as separating labial folds and cleaning deeper into groin folds, as required by the facility's policy. The DON confirmed the necessity of thorough cleaning to prevent infections.
The facility failed to serve ground chicken to residents on mechanical soft diets, instead providing chopped chicken due to equipment unavailability. This affected four residents, including those with poor dentition and edentulous conditions, who could not consume the improperly prepared food. The facility's policy on modified texture foods was not followed, as confirmed by the dietary staff and registered dietitian.
The facility failed to follow infection control protocols during incontinence care for five residents. CNAs wore the same soiled gloves throughout various stages of care, including cleaning residents and handling clean linens, contrary to the facility's hand hygiene policy. This breach in infection prevention practices was observed despite the policy emphasizing the importance of hand hygiene in preventing infections.
A resident with dementia had conflicting code status documentation, with a POLST form indicating DNAR and a physician's order indicating full code. The facility's practice of using color-coded name tags also reflected this inconsistency, leading to confusion among staff about the appropriate action in a medical emergency.
A resident with cognitive impairment and physical disabilities was transferred using a mechanical lift by a single CNA, contrary to the facility's policy requiring two staff members for such transfers. The resident expressed dissatisfaction with the frequency of assistance provided, and the Director of Nursing confirmed the need for two-person assistance to ensure safety.
A resident with a gastrostomy tube (g-tube) was found with a soiled dressing that had not been changed for four days, contrary to physician orders for daily changes. The g-tube site exhibited redness, maceration, and a small open area, indicating neglect in care. The nurse practitioner was unaware of the skin breakdown, and the care plan's interventions for daily skin inspections and reporting changes were not followed.
A medication administration error occurred when a nurse failed to administer all prescribed medications to a resident, resulting in a 7.69% error rate, which is above the acceptable threshold. The Director of Nursing confirmed the expectation for nurses to follow the five rights of medication administration.
The facility did not transmit discharge MDS records within the required 14-day period for several residents, as confirmed by the MDS Coordinator. This failure to comply with state and federal regulations was identified during a review of MDS transmission for a sample of residents.
A resident with severe cognitive impairment and a high fall risk fell during a transfer with a mechanical lift, resulting in a head injury. The incident occurred because a CNA attempted the transfer alone, contrary to the facility's policy requiring two staff members. The resident's medical history included conditions that increased her fall risk, and the facility's policy was not followed, leading to the fall.
A facility failed to perform wound treatments and weekly skin assessments for a resident with an arterial heel ulcer, as ordered by a physician. Despite specific orders for care, the resident received only one out of four weekly skin assessments in November and missed wound care on multiple days in November and December. Interviews with staff indicated that treatments should be completed as ordered, but lack of documentation suggested they were not. The facility lacked a policy for treating non-pressure wounds.
A resident with severe cognitive impairment developed an unstageable pressure ulcer that was not properly assessed or treated in a timely manner. Despite initial documentation of skin redness, no assessment or physician's orders were obtained until a bandage was discovered, leading to a delay in care. The facility's policy for pressure injury prevention was not followed, resulting in a deficiency.
A resident with a history of urinary retention was hospitalized with urosepsis after the facility failed to perform bladder scans and catheterizations as ordered. Despite physician orders for scans every four hours and catheterization if more than 400 ml of urine was retained, the nursing staff did not consistently follow these orders, leading to significant urine retention and infection.
The facility failed to notify the POA of a resident's status changes, including fever, nausea, and burning during urination, leading to a diagnosis of urosepsis and the need for IV antibiotics. The DON was unaware of the communication lapses, which violated the facility's policy on notifying representatives of significant treatment or condition changes.
Failure to Provide Required ADL Assistance and Hygiene Care
Penalty
Summary
Multiple residents with significant medical and functional impairments did not receive required staff assistance for activities of daily living (ADLs), including toileting, incontinence care, nail care, hair care, and oral hygiene. In one instance, a newly admitted female resident with a recent hip fracture was left unattended for over five hours, resulting in her lying in bed with heavily soiled linens and incontinence briefs. Staff interviews and assignment board checks revealed that no CNA had been assigned to her, and no bedside care was provided during that period, despite her repeated calls for help. Other residents with diagnoses such as osteomyelitis, intellectual disability, chronic kidney disease, morbid obesity, and dementia were observed with long, unkempt fingernails, visible debris, and poor grooming. Family members and residents reported that oral care, hair brushing, and shaving were not performed daily as required, with some residents stating they had not received grooming or oral care for weeks or only on shower days. Observations confirmed the presence of thick dental plaque, disheveled hair, and facial hair that had not been addressed despite repeated requests from residents. Staff interviews confirmed that ADL care, including incontinence checks and grooming, was not consistently provided according to care plans and facility policy. In several cases, staff acknowledged that residents had not been checked or assisted for extended periods, and that care was only provided after deficiencies were brought to their attention. Facility policies required incontinence checks at least every two hours and daily grooming and oral care, but these procedures were not followed for multiple residents.
Failure to Provide and Document Required G-Tube Site Care
Penalty
Summary
The facility failed to assess and provide appropriate gastrostomy tube (G-tube) site care for four residents who were dependent on staff for all self-care and mobility. Observations revealed that G-tube sites were not properly cleansed or dressed as ordered by physicians. For example, one resident was found with a wet, undated gauze dressing and thick yellow-green drainage around the G-tube site, with moist, red, and rash-covered skin. Documentation showed that required site care was not performed or recorded on multiple occasions, particularly over weekends and specific dates. Another resident was observed with a large amount of yellowish-green drainage and no gauze dressing at the G-tube site, accompanied by foul odors. The nurse acknowledged that a dressing should have been present to manage drainage. Review of treatment administration records indicated missed documentation and lack of PRN orders for additional site care. The Assistant Director of Nursing confirmed that nurses are responsible for inspecting and cleaning G-tube sites every shift, regardless of the scheduled care orders, and should notify physicians of any signs of infection or skin breakdown. Additional residents were found with G-tube sites lacking dressings and with encrusted material present around the insertion area, sometimes seeping through clothing. Physician orders and care plans required daily cleansing and dressing changes, as well as monitoring for infection, but these interventions were not consistently documented or observed. Facility policy specified that G-tube stoma care must include daily cleansing and covering with dry gauze, which was not adhered to for the residents reviewed.
PICC Sites Not Visible for Required Infection Checks
Penalty
Summary
The facility failed to follow its PICC line management policy for residents with peripherally inserted central catheter lines by not ensuring that insertion sites were assessed and monitored every shift for signs and symptoms of infection. For R125, who had diagnoses including infective bursitis, metabolic encephalopathy, atrial fibrillation, and congestive heart failure, the physician ordered PICC dressing and cap changes with a transparent dressing and required the insertion site to be assessed every shift for drainage, irritation, and redness. However, when the PICC was observed, the insertion site was covered with a gauze dressing secured with a transparent dressing, and the site could not be visualized; dried blood was noted on the dressing. The wound care nurse later stated that the gauze dressing should not cover the insertion site because it prevented assessment for signs of infection. Similar findings were identified for R67, R102, and R31. R67, who had osteomyelitis of the right foot, peripheral vascular disease, abnormal gait and mobility, intellectual disability, epilepsy, and severely impaired cognition, had a PICC order requiring a transparent dressing and every-shift assessment for infection signs, but the insertion site was covered with gauze and dried blood seepage and could not be assessed. R102, with diagnoses including osteomyelitis, diabetes mellitus type II, peripheral vascular disease, chronic kidney disease, and right below-knee amputation, also had a PICC order for transparent dressing and every-shift site checks, yet the insertion site was covered with gauze and could not be assessed. R31, who had sepsis, metabolic encephalopathy, pneumonia, symptomatic neurosyphilis, and congestive heart failure, had orders to change the PICC dressing with a transparent dressing and check the site for infiltration, infection, drainage, and redness, but the entry site could not be seen because a bio patch was over it.
Improper Labeling and Storage of Ophthalmic Medications
Penalty
Summary
Drugs and biologicals were not properly labeled and expired ophthalmic medications were left in medication carts. During medication cart observations, surveyors found multiple opened eye medications for residents with glaucoma or ocular hypertension that did not have an open date and expiration date documented, including Latanoprost, Dorzolamide, and erythromycin ophthalmic products. One resident’s opened Latanoprost ophthalmic solution was also found in a cart with an expiration date that had already passed. The issue affected residents R6, R26, R31, R77, R101, R108, and R109, all of whom were reviewed for medication storage and labeling. The residents involved had active physician orders for ophthalmic medications such as Latanoprost, Dorzolamide, erythromycin ophthalmic ointment, and Brimonidine for conditions including glaucoma and ocular hypertension. Surveyors observed the medications stored in drawers or baskets in medication carts without required open and expiration dates, and in two instances found expired eye drops still present in the cart. Staff interviews confirmed that ophthalmic solutions should be dated when opened and that expired medications should be removed from the cart. The facility’s Medication Storage Labeling and Disposal Policy stated that the facility would comply with federal regulations in storage, labeling, and disposal of medications.
Failure to Obtain and Follow Treatment Orders for Skin Alterations
Penalty
Summary
The facility failed to obtain a treatment order, assess, and provide appropriate care for a resident who developed a skin tear on the left knee. The resident, who had multiple diagnoses including Alzheimer's disease and required substantial assistance with activities of daily living, sustained a skin tear during physical therapy. Although an incident report documented that the physician was notified and an order was obtained to cleanse the wound and change the dressing every three days, there was no corresponding treatment order on the physician order sheet, no documentation in the treatment administration record, and no evidence of wound assessment or care in the nurses' progress notes. The dressing on the resident's knee was found to be dirty and saturated, and staff were unaware of the wound or the need for ongoing care, indicating a lack of communication and documentation regarding the resident's condition and treatment needs. Additionally, the facility failed to follow a physician's order for another resident with moisture-associated skin dermatitis. The resident had a history of incontinence-associated dermatitis and was prescribed Zinc Oxide Ointment to be applied every shift as a preventative measure. Review of the electronic treatment administration record over several months revealed multiple instances where nurse signatures were missing, indicating that the treatment may not have been administered as ordered. Staff interviews confirmed that nurses are required to document treatments in the electronic record, and the facility's policy mandates prompt identification, documentation, and treatment of skin breakdown. Both deficiencies demonstrate failures in obtaining and following physician orders, documenting care, and ensuring that residents with skin alterations receive appropriate and timely treatment. The lack of documentation and communication among staff contributed to the deficiencies in care for residents with skin integrity issues.
Failure to Assess and Auscultate AV Fistula
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services. The facility failed to assess and auscultate the AV fistula for R6, a resident with end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, diabetes, glaucoma, heart failure, and muscle weakness. R6 was cognitively intact and reported receiving hemodialysis every Monday, Wednesday, and Friday, with an AV fistula in the right upper arm. A physician’s order dated May 2, 2025 directed staff to assess and auscultate the right upper arm AV fistula every shift for the presence of bruit and thrill and for signs and symptoms of infection. However, review of the AV fistula monitoring record from October 1, 2025, to December 22, 2025 showed 39 blank boxes, and the DON stated the blank boxes meant the AV fistula was not assessed and that nurses were expected to follow the physician’s order.
Failure to Follow IV Vancomycin Infusion Instructions
Penalty
Summary
The facility failed to follow pharmacy recommendations for infusing IV Vancomycin for a resident admitted with diagnoses including sepsis, metabolic encephalopathy, pneumonia, symptomatic neurosyphilis, and congestive heart failure. The resident had a physician order dated December 16, 2025 for Vancomycin HCI IV solution reconstituted 1.5 grams to be given intravenously in the morning for cholelithiasis for 12 days. On December 21, 2025, the resident’s IV Vancomycin was observed hanging on a pole and infusing into the PICC line without the IV pump that was on the same pole, and the tubing was not adjustable drip rate tubing. The nurse stated she had removed the medication from the pump and let it infuse to gravity because the pump was not working, and the infusion was finished. The resident’s Vancomycin was ordered as 1.5 grams in 300 milliliters to infuse over 2.5 hours, and the pharmacist stated it should be infused over 150 minutes to prevent Red Man syndrome. The pharmacist and DON stated Vancomycin should be infused through a pump at the pharmacy’s recommended rate and should not be given to gravity with the plunger wide open.
Dietary portions did not match ordered meal tickets for two residents
Penalty
Summary
The facility failed to provide recommended dietary portions to meet the nutritional needs and preferences of 2 residents, R17 and R63, who were both on regular diets with puree texture and thin liquids. R17 had diagnoses including unspecified dementia, moderate protein-calorie malnutrition, extrapyramidal and movement disorder, and GERD. Her care plan noted significant weight loss, risk for malnutrition related to weight loss, limited mobility, and dementia, and directed staff to provide foods she preferred and serve the ordered mechanically altered texture. On December 21, 2025, R17’s meal ticket showed large portions, but the plated puree meal at the steam table consisted of a large portion of pureed meat with smaller portions of pureed vegetables and mashed potatoes. She was fed at the nurses’ station and ate 100% of the meal. R63 had diagnoses including unspecified psychosis, history of TIA, cerebral infarction without residual deficits, and vascular dementia. His care plan identified risk for malnutrition related to limited mobility, need for mechanically altered texture, oral supplement use, dementia, and BMI under 21, and included directions to follow meal tickets for preferences and provide prescribed supplements and mechanically altered diet. On December 21, 2025, R63’s meal ticket indicated pureed meal with double portions, but the pre-plated meal from the kitchen contained double protein only, with one portion of mashed potatoes and pureed vegetables. R63 was fed in the dining room and ate 100%. The Dining Service Director stated that R17 received a large portion of meat only and not the sides, and that R63 received only double meat and not the sides; the Dietitian stated that double portions and large portions are of all food items unless otherwise indicated.
Resident Sustains Severe Leg Laceration During Unsafe Transfer
Penalty
Summary
A resident sustained a 10-12 centimeter laceration to the left lower leg requiring 18 sutures during a transfer from wheelchair to bed. The incident occurred when a CNA was transferring the resident, and the resident's leg was closest to the bed. During the pivot, the resident expressed pain, and the CNA observed a significant laceration with substantial bleeding. It was unclear whether the injury was caused by contact with the bed or the wheelchair. Blood was later found on the bedframe, and medical documentation confirmed a large skin tear due to trauma during the transfer. Interviews with staff revealed uncertainty regarding whether the wheelchair footrests were in place at the time of the incident. The facility did not have specific policies for resident transfers or fall prevention, providing only a gait belt policy that lacked comprehensive guidance on safe transfer techniques, resident mobility, staff body mechanics, or injury prevention. The absence of clear protocols contributed to the unsafe transfer and subsequent injury.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Monitor and Manage Constipation
Penalty
Summary
The facility failed to adequately assess, administer medications, and notify the physician for a resident who had not had a bowel movement in over three days on several occasions. This failure contributed to the resident developing a fecal impaction, pain, and inflammation in her colon. The resident, who was admitted with diagnoses including unspecified dementia, Parkinsonism, and constipation, had a care plan that required monitoring and intervention for constipation. Despite having orders to monitor bowel movements every shift and notify the physician if no bowel movement occurred in three days, the facility did not adhere to these orders. The resident's records showed significant gaps between bowel movements, with intervals of four to five days without a bowel movement in January 2025. Despite having PRN medication orders for laxatives, these were not administered, and there was no documentation of abdominal assessments or physician notifications. The resident was eventually sent to a hospital for an unrelated issue, where a CT scan revealed a fecal impaction and inflammation of the colon. Interviews with facility staff confirmed that the expected protocol was not followed, and the physician stated he was not notified of the resident's condition, which could have been managed with timely intervention.
Failure to Develop Adequate Discharge Plan for Resident
Penalty
Summary
The facility failed to develop an adequate discharge plan for a resident who had a goal to return to the community. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, generalized muscle weakness, and syncope, experienced delays in discharge due to the facility's failure to identify and address her needs. The resident was frustrated by the delays, and her daughter had initiated discussions regarding discharge planning. However, the facility did not make proper arrangements for necessary durable medical equipment (DME) and home health services, mistakenly believing the family would handle these arrangements. The Director of Nursing at the resident's supportive living facility expressed concerns about the lack of preparation for the resident's return, noting that the facility had not documented training for the resident on using her new wheelchair and oxygen equipment. The facility's social services were contacted by the family to discuss discharge planning, but the discharge date was postponed due to these unresolved issues. The facility's policy required discharge planning to begin within 24-48 hours of admission, but the resident's care plan and social service notes indicated delays in addressing her discharge needs, leading to the deficiency.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident who required continuous oxygen. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, and syncope, was observed receiving 2 liters of continuous oxygen via a nasal cannula. Despite the resident's need for continuous oxygen therapy being documented in the Minimum Data Set upon admission, there was no corresponding physician's order in the medical record until it was obtained during the survey. Interviews with facility staff revealed that the resident's need for oxygen was communicated during shift reports, but the necessary physician's order was not found in the resident's records. The Assistant Director of Nursing confirmed the absence of the order and stated that it is the facility's expectation for nurses to review and obtain all necessary admission orders, including those for oxygen therapy. The facility's policy on oxygen administration requires verification of a physician's order before proceeding, which was not adhered to in this case.
Failure to Provide Escort for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an escort for a resident with multiple health conditions, including mild cognitive impairment, for an outside imaging appointment. The resident, who was not considered at risk for elopement based on a screening score, was sent alone using a ride-sharing service. The transportation was arranged by the facility's ward clerk, who followed the insurance company's protocol for determining the type of transportation and whether an escort was needed. The resident had previously attended appointments without an escort without incident. On the day of the appointment, the resident did not return to the facility in a reasonable time, prompting staff to search for him. The facility's administrator and director of nursing acknowledged that the resident should have been accompanied due to his changing mental status, which sometimes led to confusion. The resident was eventually found sitting in the hospital emergency room next to the facility, unharmed but unsure of how he got there. The incident highlighted a lapse in communication and assessment regarding the resident's need for supervision during transportation.
Delayed Notification of Healthcare Provider After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's Physician or Nurse Practitioner following a fall where the resident hit his head. This incident involved a resident who was on anticoagulant medication, specifically Coumadin, and had a history of venous thrombosis and embolism. The fall was unwitnessed, and the resident was found on the floor with a bruise and swelling on the right side of his face. Despite the potential severity of the situation, there was a significant delay in contacting the healthcare provider, which resulted in a delay of over six hours before the resident was sent to the hospital for further assessment. The facility's policy required immediate notification of the healthcare provider in the event of an accident or incident involving a resident, especially when there is a need to alter medical treatment or transfer the resident to a hospital. However, the initial call to the Nurse Practitioner was not made until two hours after the fall, and the call back from the Nurse Practitioner with orders to send the resident to the emergency room was not received until over six hours after the fall. This delay in communication and action was a clear deviation from the facility's policy and contributed to the delay in the resident receiving necessary medical evaluation and treatment.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for six residents who required help with activities of daily living (ADLs). These residents, identified as having various cognitive and physical impairments, were observed with long, jagged fingernails with substances underneath, and some had unshaven facial hair. Despite their care plans indicating the need for maximum or total assistance with personal hygiene, the staff did not adequately address these needs. Resident 13, with vascular dementia and hemiplegia, was found with long, unclean fingernails on multiple occasions, despite expressing a desire for assistance. Similarly, Resident 91, who had severe cognitive impairment, was observed with long facial hair and unclean fingernails, and also requested help. Resident 106, non-verbal and severely impaired, had long fingernails that posed a risk of self-injury, yet no action was taken by the staff. Other residents, such as Resident 125, who had dementia and required assistance, were found with long facial hair and unclean fingernails. Resident 49, with a contracted hand, had nails pressing into her palm, yet staff failed to trim them. Resident 44, primarily Spanish-speaking and with a contracted arm, also had long fingernails pressing into her palm. Despite the presence of staff during observations, these hygiene needs were not addressed, indicating a systemic failure to provide necessary care as outlined in their care plans.
Inadequate Incontinence Care Leading to Potential UTIs
Penalty
Summary
The facility failed to provide adequate incontinence care to prevent urinary tract infections (UTIs) for four residents. During observations, a CNA was seen providing incontinence care to a resident with a history of UTIs by wiping the frontal perineum up and down, which resulted in fecal matter contaminating the area. The CNA did not clean deeper into the groins, only the outer area, before proceeding to clean the back perineum. Another resident, who was wet with urine, was cleaned by a CNA who did not separate the labia to clean the inner folds. Further observations revealed that two CNAs provided incontinence care to a resident with multiple urological diagnoses, including obstructive and reflux uropathy, without cleaning the scrotal area or deeper into the groin folds. Another resident was cleaned from front to back, but the CNAs did not separate the labia to clean the inner folds and only cleaned the surface of the groins. The Director of Nursing confirmed that staff must clean thoroughly from front to back, including separating labial folds and cleaning the entire groin area, to prevent infections. The facility's policy emphasizes the importance of proper perineal care to prevent infections and skin irritation.
Failure to Provide Properly Prepared Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food in the appropriate form for residents on mechanical soft diets, specifically by not serving ground chicken as required. During an observation of meal service, it was noted that the chicken breast intended for residents on mechanical soft diets was chopped into varying lengths instead of being ground. This discrepancy was observed in the secure unit dining room and affected four residents who were supposed to receive ground meat according to their diet tickets. The dietary aide, V8, confirmed that the chicken was pre-plated in the facility kitchen, and the dietary manager, V6, acknowledged the issue but needed to consult with the cook, V7, about the preparation method. The cook, V7, later explained that the chicken was chopped because the blender was in use by another staff member, indicating a lack of proper equipment availability or planning. The registered dietitian, V15, confirmed that a blender should be used to achieve the correct ground consistency, as chopping does not provide an even texture. The facility's policy on modified texture foods emphasizes the need for a standardized process to ensure the correct texture and nutritional value, which was not followed in this instance. The affected residents included those with poor dentition and edentulous conditions, who were unable to consume the improperly prepared chicken, highlighting the importance of adhering to dietary requirements for resident safety and nutrition.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control protocols during the provision of incontinence care, as observed in multiple instances involving five residents. Certified Nursing Assistants (CNAs) were noted to have worn the same soiled gloves throughout various stages of care, including cleaning residents, applying barrier creams, and handling clean linens and bed controls. This was observed with residents who had bowel movements or were wet with urine, indicating a breach in infection prevention practices. The facility's policy on hand hygiene, dated August 2024, emphasizes the importance of hand hygiene in preventing infections and promoting resident safety. The policy specifies that hand hygiene should be performed before moving from a soiled body site to a clean body site on the same resident, after touching a resident or their immediate environment, and after contact with blood, body fluids, or contaminated surfaces. Despite this, the CNAs did not change gloves or perform hand hygiene between tasks, as required by the facility's policy, leading to a failure in maintaining infection control standards.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure consistency between a resident's signed POLST form and the physician's order regarding the resident's treatment wishes in the event of a medical emergency. The resident, who had multiple diagnoses including dementia with behavioral disturbances, was documented as having a full code status on the face sheet and active physician's order. However, the signed POLST form indicated a Do Not Attempt Resuscitation (DNAR) status, creating a conflict between the two documents. This inconsistency was observed during a review of the resident's medical chart and confirmed by the nursing staff. The inconsistency in the resident's code status was further highlighted by the facility's practice of using color-coded name tags to indicate code status, with a green tag for full code and a white tag for DNR. The resident's room displayed a green name tag, indicating full code, despite the POLST form indicating DNAR. Both the LPN and the Assistant Director of Nursing acknowledged the conflicting information and the resulting confusion about which code status to follow in a medical emergency. The facility's policy required that advance directives and code status identifiers be consistent and updated, but this was not adhered to in this case.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that two staff members assisted during a full body mechanical lift transfer for a resident, as required by their policy. The resident, who has diagnoses including hemiplegia following a cerebral infarct, unspecified osteoarthritis, and dementia, was found to be moderately impaired in cognition and dependent on staff assistance for transfers. On multiple occasions, the resident expressed a desire to be assisted out of bed, indicating that she was often not helped to get up. On one occasion, a Certified Nursing Assistant (CNA) used a mechanical lift to transfer the resident without the assistance of a second staff member. The facility's policy, revised in December 2017, clearly states that two nursing associates are required to perform a mechanical lift transfer to ensure the safety of the resident. Despite this, the CNA admitted to transferring the resident alone, and the Director of Nursing confirmed that two staff members should be present during such transfers. This failure to adhere to the established procedure compromised the safety of the resident during the transfer process.
Failure to Provide Proper G-Tube Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a gastrostomy tube (g-tube), as ordered by the physician. The resident, who has multiple medical diagnoses including epileptic seizure, encephalopathy, and dementia, was found with a g-tube dressing that had not been changed since four days prior, despite orders for daily changes. The dressing was soiled with dry brown discharge and emitted an odor, indicating neglect in care. Upon further assessment by the nursing supervisor, the g-tube site was found to have redness, a small open area, and maceration, with an odor emanating from the site. The physician's orders required monitoring for signs of infection and maintaining cleanliness and dryness of the g-tube site every shift. However, these orders were not followed, as evidenced by the condition of the g-tube site and the lack of awareness by the nurse practitioner of the skin breakdown. The resident's care plan highlighted the risk for impaired skin integrity and included interventions such as daily skin inspections and reporting any changes, which were not adhered to, leading to the deficiency.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to the physician's orders, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the review of medication administration for one resident out of a sample of 21. On August 27, 2024, a nurse administered a series of medications to a resident, including Loratadine, Sitagliptin, Vitamin B12, Docusate Sodium, Escitalopram, Carvedilol, Amiodarone, Metformin, Magnesium, and Artificial Tears. However, the Medication Administration Record (MAR) indicated that additional medications, specifically Polyethylene Glycol and Medi-Pads for hemorrhoids, were also scheduled to be administered at that time but were omitted. The Director of Nursing confirmed that nurses are expected to administer medications as per the physician's orders and adhere to the five rights of medication administration: right patient, dose, medication, time, and route. This oversight in medication administration was observed and documented, highlighting a lapse in following established protocols.
Failure to Transmit Discharge MDS Records Timely
Penalty
Summary
The facility failed to transmit discharge Minimum Data Set (MDS) records within the required 14-day period as mandated by state and federal regulations. This deficiency was identified for five residents who were part of a sample of 21 residents reviewed for MDS transmission. On August 27, 2024, the MDS Coordinator, a Registered Nurse, confirmed that the completed discharge records for these residents were not transmitted within the stipulated timeframe. Specifically, the discharge MDS records for these residents were either transmitted late or not transmitted at all by the required deadline. The facility's policy, dated January 2024, mandates that all MDS assessments, including discharge records, be completed and transmitted to the CMS QIES ASAP system in compliance with current regulations, which was not adhered to in these cases.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to provide a safe transfer for a resident using a mechanical lift, resulting in the resident falling and sustaining a significant head injury. The resident, who had severe cognitive impairment and required maximum assistance with transfers, fell off the side of her bed during a transfer. The incident occurred when a CNA was transferring the resident alone, contrary to the facility's policy that requires two staff members for such transfers. The resident hit her head on a table and the floor, resulting in an 8cm laceration that required 15 staples. The resident's medical history included lymphedema, repeated falls, hypertension, cognitive impairment, and morbid obesity, making her a significant fall risk. Her care plan indicated a high risk for falls and required her to be within visibility of staff when up in a chair. Despite these precautions, the CNA attempted the transfer alone, which led to the resident's fall. The CNA admitted to being too far from the resident to prevent the fall due to the positioning of the lift. Interviews with other CNAs and the Director of Nursing confirmed that the facility's policy mandates two staff members for sit-to-stand transfers to ensure resident safety. The Director of Nursing acknowledged that the incident could have been avoided if the policy had been followed. The nurse practitioner also noted that the resident's cognitive impairment made her unable to follow directions, further emphasizing the need for adequate supervision during transfers.
Failure to Perform Wound Treatments and Assessments
Penalty
Summary
The facility failed to perform wound treatments and weekly skin assessments as ordered by a physician for a resident with an arterial heel ulcer. The resident had multiple diagnoses, including a non-pressure chronic ulcer of the left heel, heart failure, and atrial fibrillation. The wound was initially labeled as a pressure ulcer but was later identified as arterial after a Doppler study. Despite physician orders for weekly skin assessments and specific wound care treatments, the resident received only one out of four weekly skin assessments in November 2023. Additionally, the resident did not receive the prescribed wound care for eight days in November and seven days in December 2023. Interviews with the wound care nurse and the Director of Nursing revealed that treatments ordered by physicians should be carried out as prescribed. The wound care nurse indicated that floor nurses were responsible for completing daily wound care, and the absence of documentation suggested that treatments were not performed. The Director of Nursing acknowledged that blank areas in treatment records implied that treatments were not completed, which hindered wound healing. The facility was unable to provide a policy regarding the treatment of non-pressure wounds.
Failure to Assess and Obtain Orders for Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and obtain physician's orders for an unstageable pressure ulcer identified on a resident, referred to as R4. R4 was admitted with multiple diagnoses, including fractures and severe cognitive impairment, and initially had no pressure injuries. However, documentation from a bath and shower form indicated redness and a circle around the buttocks area, which was not assessed by a nurse or followed up with physician's orders. Later, R4 reported having a bandage on her backside, prompting a nurse to assess the area and find a pink and red wound with peeling skin, but no drainage or bleeding. A wound assessment on the same day identified the wound as an unstageable pressure ulcer, and treatment orders were pending. The Director of Nursing (V2) and the wound care physician (V9) confirmed that the wound should have been assessed and treatment orders obtained when first identified. The facility's policy requires new skin alterations to be documented and assessed, with physician notification and a change in the care plan. However, in R4's case, the wound was not properly assessed or treated until a bandage was discovered, indicating a lapse in following the facility's protocol for pressure injury prevention and management.
Failure to Perform Bladder Scans and Catheterizations as Ordered
Penalty
Summary
The facility failed to ensure a resident who was retaining urine had his bladder scanned and was catheterized as ordered. This failure resulted in the resident being hospitalized with urosepsis for eight days. The resident, who was alert and oriented, reported having bladder spasms and informed the nurses, but the bladder scans and intermittent catheterizations were not performed as ordered. The resident's medical records showed multiple instances where bladder scans indicated significant urine retention, but the necessary catheterizations were either not performed or not documented properly. This led to the resident developing a urinary tract infection and subsequently urosepsis, requiring hospitalization and IV antibiotics for a month. The resident had a history of urinary retention and had specific physician orders for bladder scans every four hours and straight catheterization if more than 400 ml of urine was retained. Despite these orders, the nursing staff failed to consistently perform the bladder scans and catheterizations. Progress notes indicated that the resident had significant residual urine volumes on multiple occasions, but there was no documentation of an indwelling urinary catheter being placed as ordered. Additionally, there were gaps in the progress notes, with no documentation for twelve days, during which the resident continued to experience symptoms of urinary retention and infection. Interviews with the nursing staff and the Director of Nursing revealed that they were aware of the orders but did not consistently follow them. The Director of Nursing acknowledged that the bladder scans and catheterizations should have been done as ordered and that the failure to do so could lead to urinary retention, infection, and sepsis. The facility's policy on catheterization and residual urine documentation was not followed, contributing to the resident's hospitalization and subsequent treatment for urosepsis.
Failure to Notify POA of Resident's Status Changes
Penalty
Summary
The facility failed to update the Power of Attorney (POA) on status changes of a resident. This deficiency was identified for one resident who was alert and oriented, and had a history of urinary retention. The resident reported experiencing fever, chills, and bladder spasms, which were not adequately addressed by the nursing staff. Despite receiving orders for a bladder scan and straight catheterization every four hours, the resident indicated that these procedures were not performed as required. Consequently, the resident was diagnosed with urosepsis and required intravenous antibiotics for a month. There was no documentation showing that the POA was notified of the new orders or the resident's condition changes on multiple occasions, including when the resident had a fever, nausea, and burning during urination, which led to further medical interventions without POA notification. The Director of Nursing (DON) acknowledged that she was unaware of the POA not being notified of the resident's status changes. The facility's policy on changes in a resident's condition or status, last approved in January 2024, mandates prompt notification of the resident's representative for any significant alterations in treatment or condition. However, this policy was not followed, resulting in a delay in care and communication breakdowns. The lack of documentation and communication with the POA was a clear violation of the facility's policy and contributed to the resident's deteriorating condition.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 652 citations issued within 25 miles in the last 12 months — including the 11 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Joliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parc Joliet | 0.3 mi | ★★★★★ | 29 | 0 |
| Pearl Of Joliet, The | 0.7 mi | ★★★★★ | 3 | 0 |
| Joliet Living & Rehab Center | 0.7 mi | ★★★★★ | 5 | 0 |
| Alden Estates Of Shorewood | 3.6 mi | ★★★★★ | 6 | 0 |
| Alden Courts Of Shorewood | 3.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.