Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Balmoral Home during CMS and state inspections, most recent first.
A resident with DM2, PVD, and metastatic cancer had a wound/skin condition that was reported to the RN by a CNA, but the RN did not complete a proper assessment. The CNA described a bleeding sacral wound with black discoloration, while the RN stated the resident had no skin issues and was independent and ambulatory. Facility records did not show wound documentation, and the resident later required hospital treatment for sepsis, suspected necrotizing skin infection, and surgical debridement.
A resident with intact cognition and diagnoses including HTN heart disease, adult failure to thrive, anemia, and nicotine dependence was placed on money management after repeated smoking-in-room incidents. Progress notes and staff interviews showed the facility restricted access to the resident’s trust funds as a consequence for unsafe smoking behavior, even though policy stated residents have the right to manage their own financial affairs and spending money.
The facility failed to protect multiple residents from resident-to-resident physical abuse despite known histories of aggression and care plans identifying risk for violence. One cognitively intact resident with schizoaffective disorder and a documented history of aggressive behavior physically attacked a peer, including hitting and pushing the peer out of a wheelchair. Another resident with quadriplegia and schizophrenia, care planned for risk of violence, was involved in more than one physical altercation, including hitting a cognitively intact roommate in the face in a hallway. A separate resident with schizophrenia, hallucinations, delusions, and a documented progression from moderate to significant aggressive behavior struck a roommate with Alzheimer’s disease while the roommate was in bed, causing facial redness and a scratch. CNAs and an LPN reported that these aggressive residents frequently attempted to hit others, screamed, cursed, and verbally threatened residents and staff, particularly female staff. The facility’s own investigations substantiated these altercations, and its policies state residents have the right to be free from abuse, yet multiple episodes of physical assault occurred.
A cognitively intact, ambulatory resident with schizophrenia repeatedly told a social worker on admission that she did not want to be in the facility, but this was not communicated to the Social Services Director and was not reflected on the elopement risk assessment or care plan, which documented no verbalized desire to leave. Later, during a night shift, alarms from stairwell and exit doors sounded, and a CNA ultimately observed the resident at an exit door, followed her outside, then briefly left her unsupervised to retrieve a coat, hat, and phone. When the CNA returned, the resident was gone, and staff and police were unable to locate her immediately; she was later found offsite and taken to a hospital after reporting possible frostbite.
Wheelchairs Not Kept in Safe Working Condition: A resident with significant neurologic and mobility impairments reported a wheelchair that was hard to move, while an LPN and restorative aide confirmed repeated complaints and maintenance involvement. Two other cognitively intact residents with hemiplegia and other mobility needs reported broken wheelchair equipment; one seatbelt strap was tied in a knot instead of properly secured, and another wheelchair had nonworking brakes with rubber parts falling off and tape used around the brakes. A maintenance supervisor and the DON acknowledged the equipment problems.
A resident with Parkinson's disease and muscle weakness experienced worsening of a sacral pressure ulcer due to the facility's failure to consistently implement and document physician-ordered preventive measures, including regular turning, use of heel protectors, and appropriate mattress support. Clinical records and staff interviews confirmed that required interventions were not reliably performed or recorded, resulting in the ulcer progressing from stage 2 to stage 3.
A resident with multiple medical conditions, including a pressure ulcer, did not have accurate or complete treatment administration records. The resident reported missed dressing changes and lack of regular repositioning, and was observed without heel protectors. Two versions of the resident's TARs were provided on different days, with the initial version missing multiple required signatures for treatments, and the later version having these areas filled in. The DON acknowledged the discrepancies, and clinical notes showed the resident's pressure ulcer was worsening.
A cognitively impaired resident with a history of ingesting non-edible items was inadequately supervised, leading to access to potentially harmful items like baby powder and liquid soap. Despite the resident's known behaviors and medical history, staff were not consistently aware of the risks, resulting in a failure to provide a safe environment as per facility policy.
A resident with moderate cognitive impairment was found with medications left on their nightstand without an assessment or doctor's order for self-administration. The facility's policies require such assessments and orders, which were not conducted, posing a risk due to the resident's dementia and impaired judgment.
An LPN in a facility failed to sign out medications after administering them to four residents, as observed by a surveyor. The facility's policy requires immediate documentation to prevent double dosing, which was not followed. The residents, who were cognitively intact, had various diagnoses, and the oversight was confirmed through a review of their Medication Administration Records.
The facility failed to enforce its smoking and sharps disposal policies, leading to safety risks. A resident was found smoking in their bathroom, contrary to the designated smoking area policy. Additionally, several residents had razors in their rooms, which is against the facility's policy due to safety concerns. Staff acknowledged these violations, highlighting a lack of supervision and adherence to established guidelines.
The facility did not follow its policy of reconciling controlled substances at the end of each shift, affecting four residents on the first floor. During rounds, it was found that the Controlled Substance Check Form lacked signatures for a shift-to-shift count. An LPN admitted to not counting narcotics with the night nurse. The DON confirmed that nurses must count narcotics between shifts, and any failure would require an investigation.
The facility failed to maintain proper storage and security of medications, including controlled substances, in medication refrigerators on the first and third floors. The refrigerators were not at the correct temperature and had frost accumulation, indicating inadequate defrosting. Additionally, controlled drugs were not stored in a separately locked compartment, as required, and were accessible to residents and staff. Staff interviews revealed a lack of awareness and adherence to facility policies regarding medication storage.
A facility failed to refer a resident for a PASRR Level 2 screening despite the resident having diagnoses of bipolar disorder and schizophrenia. The initial PASRR Level 1 screening did not identify any serious mental illness, which was an oversight. The Assistant Administrator acknowledged the requirement for Level 2 screenings for such diagnoses, as per the facility's policy, but the facility did not update the PASRR Level 1 to reflect the resident's mental health conditions.
The facility failed to label and date oxygen equipment for two residents, contrary to its policy. One resident with multiple health issues was found with an undated nasal cannula, while another resident with intact cognition had an undated nebulizer mask. LPNs confirmed the equipment should have been dated, and the DON stated that dating is necessary to prevent infection.
An LPN in a long-term care facility administered a Divalproex Sodium DR 500 mg tablet to a resident after it fell on the floor, violating infection control protocols. The LPN admitted the mistake, acknowledging that the medication should have been discarded to prevent contamination. The facility's DON confirmed that the policy requires discarding dropped medications to maintain infection control standards.
A resident experienced discomfort due to a cold room temperature, which was reported to staff but not addressed until a surveyor's visit. The room temperature was found to be 61°F, below the facility's standard of 68°F, due to a crack in the window. The resident, who has multiple medical conditions, had been complaining about the cold since the previous week.
The facility failed to post complete Daily Nursing Staffing information, missing total nursing hours for RNs, LPNs, and CNAs, potentially affecting all 159 residents. The scheduler and administrator were unaware of the requirement to include total hours, and the posted information was incomplete for evening and night shifts.
Failure to Assess and Document a Resident’s Wound
Penalty
Summary
The facility failed to perform a proper nursing assessment of a resident’s wound/skin condition after a CNA notified the nurse of the wound. The resident had diagnoses including peripheral vascular disease, type 2 diabetes mellitus, malignant neoplasm of overlapping sites of the bladder, hypertensive heart disease without heart attack, and hyperlipemia. The resident’s MDS documented a BIMS score of 14, indicating intact cognition. Hospital records later documented that the resident presented with sepsis, most likely related to a skin infection, with suspected necrotizing infection of the scrotum and inner thighs, complicated by acute kidney injury and A-fib with RVR, and that the resident was debrided in the OR by general surgery and urology. A former CNA stated that on the evening of February 13, the resident’s brother asked him to check on the resident because the resident was not talking much and was not acting like himself. The CNA stated the resident was soiled and, while providing care, he observed an untreated wound to the sacral area that was bleeding, with surrounding discoloration described as black. He stated he told the RN about the bleeding wounds, but the RN did not assess the resident’s wounds. He further stated the RN told him not to mention blood in front of the family, checked vital signs, and called an ambulance. He also stated he rechecked the wounds and continued to see bleeding from the bottom. The RN stated the resident was alert and oriented, independent, ambulatory, and had no skin issues or discoloration in the bottom. Another CNA stated the resident always refused skin assessments and that refusals were documented on shower sheets and reported to the nurse. The physician stated the resident had redness and discoloration in the sacral region on admission, but no skin breakdown was noted, and later the redness worsened after a hospital return. The facility’s records reviewed by surveyors did not contain wound records for the resident, and the wound nurse stated she was never aware of a sacral wound and the resident was not on the wound care list she received.
Resident Funds Restricted as Punishment for Smoking Non-Compliance
Penalty
Summary
The facility failed to protect a resident’s right to manage personal financial affairs by placing the resident on a money management program as a consequence for smoking in the room. The resident, R4, had diagnoses including hypertensive heart disease without heart failure, adult failure to thrive, pain in the right hip, anemia, neuralgia and neuritis, retention of urine, nicotine dependence, and cigarette non-compliance. The MDS documented a BIMS score of 15, indicating intact cognition. R4’s care plan and progress notes documented repeated incidents of smoking inside the room. After smoking materials were confiscated, the resident was placed on money/cigar management, and the restriction was extended after additional incidents. The progress notes stated that money management was initiated or extended as a consequence of the resident smoking in the room, and that the resident was closely monitored and directed to designated smoking areas. Staff interviews confirmed that the facility used money management as a response to smoking non-compliance. The administrator stated that residents who smoke in their rooms may be educated and counseled, and that repeated offenses may result in money management so the resident may not be able to take cash out from the trust fund. The DON stated that R4’s funds were restricted for a period of time after repeated smoking incidents. The social services director described money management as a tool used to control access to funds and cigarettes, and the business office manager confirmed that the facility was managing R4’s trust fund while the resident was in the facility. The facility policy stated residents have the right to manage their own financial affairs and handle their spending money, while also describing money management as an intervention for hazardous smoking behavior.
Failure to Protect Residents From Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from abuse and physical assault, specifically resident-to-resident abuse. One resident with right heart failure, schizoaffective disorder, hypertension, and type 2 diabetes, and with intact cognition (BIMS 14), had a documented history of aggressive and maladaptive behavior, including conflicts and verbal or physical aggression toward staff and loud, intimidating behavior toward a roommate. Progress notes state that this resident physically attacked a peer unprovoked, and was observed hitting and pushing another resident out of his wheelchair. The facility’s internal investigation later substantiated that this resident was physically aggressive toward the peer. Another resident involved in multiple incidents had quadriplegia, schizophrenia, traumatic brain injury, and moderately impaired cognition (BIMS 11). This resident’s care plan identified a risk for violence related to schizophrenia, with goals that the resident would maintain safe behavior and do no harm to self or others, and that staff would closely monitor behavior. Despite this, progress notes document that this resident was involved in an altercation with a peer that became physical, and in a separate incident, another cognitively intact resident reported being hit twice in the face by this resident without provocation while sitting in the hallway. A nurse documented being called to the scene of the fight between the two roommates and another staff member stated that this resident “tries to hit people all the time,” noting that staff usually intervened but were unable to do so before both residents hit each other during the incident. Additional incidents involved a resident with schizophrenia, heart failure, insomnia, pulmonary hypertension, and moderate cognitive impairment (BIMS 11), who had documented hallucinations and delusions and a history of aggressive or agitated behavior and abuse/neglect as either recipient or perpetrator. Screening assessments showed this resident’s aggressive behavior and abuse history progressed from a moderate to a significant problem. Progress notes document that this resident hit a roommate, resulting in redness to the roommate’s face and a scratch on the nose, and that the roommate, who had Alzheimer’s disease, atrial fibrillation, diabetes, hypertension, osteoarthritis, and moderate cognitive impairment (BIMS 8), indicated that this resident had hit him in the arm and face while he was in bed. CNAs reported that the aggressive resident had a pattern of aggressive behavior toward other residents, including getting in their faces, screaming, cursing, verbally threatening them, and being particularly aggressive toward female staff. The facility’s internal investigation substantiated the altercation between these two residents. The facility’s own policies state that residents have the right to be free from abuse, neglect, and mistreatment and that the facility aims to prevent abuse by establishing a resident-sensitive and secure environment, yet multiple substantiated incidents of resident-to-resident physical abuse occurred. The administrator, who serves as the abuse coordinator, stated that regulatory requirements for abuse include immediately separating residents involved, notifying the administrator, physician, and family, and reporting to the state agency, and also stated that screaming and yelling is a form of abuse. Staff interviews confirmed that residents and staff were aware of ongoing aggressive behaviors, including frequent attempts by one resident to hit others and another resident’s repeated verbal aggression and threats toward peers and staff. Despite care plans and risk assessments identifying aggression and risk for violence, and staff awareness of ongoing aggressive behaviors, multiple residents experienced physical assaults by peers, with injuries such as redness and scratches documented, demonstrating that residents were not consistently protected from abuse as required by facility policy and resident rights.
Failure to Identify Elopement Risk and Provide Adequate Supervision Leading to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to identify and supervise a resident at risk for elopement, resulting in the resident leaving the building unsupervised. The resident was admitted from the hospital with a diagnosis of schizophrenia, was cognitively intact with a BIMS score of 15/15, ambulatory without assistive devices, and required supervision with ADLs and mobility. On the day of admission, a social worker documented that the resident repeatedly stated she did not want to be in the facility and refused a mental status exam, but was able to state the correct date. Despite this, the resident’s elopement assessment later documented that the resident did not verbalize a strong desire to leave, and the care plan stated that the resident voiced no interest in community re-entry. On the night of the elopement, nursing staff documented that the resident had been lying quietly in bed during rounds before a stairwell alarm sounded. Staff responded to the alarm, and a CNA went to the third-floor stairwell door, entered the code to silence the alarm, and did not see anyone in the stairwell. Shortly afterward, another alarm sounded from the first floor. The CNA went to the first floor and observed the resident standing near an outside exit door. The resident remained at the door for about two minutes and then pushed through the exit door. The CNA followed the resident outside and stayed approximately 5–6 feet away, observing that the resident was calm and staying in place initially. The CNA then left the resident outside to re-enter the facility to obtain his coat, hat, and phone because of the cold weather, leaving the resident unsupervised. When he returned less than two minutes later, the resident was no longer in the area. Staff searched around the building and checked exit doors but were unable to locate the resident. Police were called, and the resident was later found offsite and taken to the hospital after stating she might have frostbite and requesting to go to the hospital. The Social Services Director later stated that residents are considered at risk for elopement if they verbalize wanting to leave the facility and that, had she been informed of the resident’s statements about not wanting to be there, the elopement assessment should have reflected that and the team would have addressed it. She also stated that the social worker who documented the resident’s desire not to be in the facility did not inform her of this information.
Wheelchairs Not Kept in Safe Working Condition
Penalty
Summary
The facility failed to provide wheelchairs that were in safe and working condition for 3 residents reviewed for wheelchair concerns. R12, who had diagnoses including nontraumatic intracerebral hemorrhage, traumatic subdural hemorrhage, epileptic seizures related to external causes, chronic kidney disease, and hypertensive heart disease, was cognitively intact and required substantial to maximum assistance with most ADLs. R12 stated the wheelchair was hard to move, and an LPN reported that R12 had complained the wheelchair was hard and that maintenance had been notified and said it was fixed, although R12 continued to complain. A restorative aide also stated that R12 had complained about the wheelchair about a month earlier and that maintenance had been notified. R13, who had diagnoses including unspecified cervical spinal cord injury, hemiplegia affecting the left nondominant side, and wheelchair use for mobility, was cognitively intact and required substantial to maximum assistance with most ADLs. R13 stated the wheelchair seatbelt strap was broken, and on inspection the right strap of the seatbelt was tied in a knot to the armrest rather than properly secured. V14 stated screws should be added to firmly secure the seatbelt. R14, who had diagnoses including weakness, cerebral infarction affecting the right dominant side, hemiplegia and hemiparesis, and chronic respiratory failure with hypoxia, was cognitively intact and needed moderate assistance to supervision. R14 stated the wheelchair brakes were not working and the rubber parts of the wheels kept coming off. V14 observed blue tape tied around the brakes, stated the tape had no grip or traction and caused improper brakes, and noted the rubber around the wheels fell off as R14 entered the building.
Failure to Implement and Document Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement and document physician-ordered preventive measures for a resident with a sacral pressure ulcer, resulting in the deterioration of the wound from stage 2 to stage 3. The resident, who has Parkinson's disease and muscle weakness, reported that dressing changes were not performed daily and that staff did not consistently turn or reposition him as ordered. Observations confirmed the resident was lying on his back without heel protectors, and the Treatment Administration Records (TARs) for March and April showed multiple unsigned shifts for required turning and repositioning. Additionally, discrepancies were found in the TARs, with records being modified after the fact to indicate compliance that was not originally documented. Clinical notes from the wound nurse practitioner documented a significant increase in the size of the sacral pressure ulcer over time, and staff interviews confirmed the importance of regular turning and repositioning to prevent pressure injuries. Despite physician orders for repositioning every two hours, continuous use of heel protectors, and a low air loss mattress, these interventions were not consistently established or documented. The resident's care plan included these interventions, but failure to follow and document them led to the worsening of the pressure ulcer.
Inaccurate Treatment Administration Records for Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain accurate and complete treatment administration records (TAR) for one resident with a history of Parkinson's disease, bipolar disorder, and muscle weakness, who was admitted in 2010. During an interview, the resident reported that his dressing for a pressure ulcer had not been changed the previous day or on the day of the interview, and that staff did not regularly reposition him or use heel protectors as ordered. Observation confirmed the resident was lying on his back without heel protectors, and he stated that repositioning only occurred during dressing changes, not daily as required. Upon review of the resident's TARs for March and April, two different versions were provided by the facility on consecutive days. The initial TARs showed multiple unsigned entries for required treatments, including application of an abdominal binder, heel protectors, and repositioning every two hours. The subsequent TARs had these previously blank areas filled in and signed. The Director of Nursing acknowledged the discrepancies and the presence of unsigned days in the original TARs. Clinical notes from the nurse practitioner indicated the resident's sacral pressure ulcer was deteriorating during this period. Facility policy requires that all treatments and services performed be documented objectively, completely, and accurately in the medical record.
Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately supervise and monitor a cognitively impaired resident, identified as R2, who has known behaviors of ingesting non-edible, toxic items. On multiple occasions, R2 was observed with potentially harmful items within reach, such as baby powder and liquid soap. Despite R2's history of pica and previous incidents where she ingested non-food items like baby powder and body lotion, staff members were not consistently aware of the risks or the need for supervision. For instance, a Certified Nursing Assistant (CNA) admitted to borrowing R2's overbed table and leaving baby powder within her reach, unaware of the potential for R2 to ingest it. R2's medical history includes paranoid schizophrenia, anxiety disorder, and moderate cognitive impairment, which contribute to her behaviors. The facility's Director of Nursing acknowledged the danger of R2 consuming non-edible items and emphasized the need for supervision. However, the lack of consistent awareness and supervision among staff members led to R2 having access to these items, posing a risk to her safety. The facility's policy on resident rights emphasizes the importance of a safe environment, which was not upheld in this instance.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the safe self-administration of medications, which was identified during a survey. The resident, identified as R148, has a history of dermatitis, atrial fibrillation, congestive heart failure, and dementia, with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Observations on multiple occasions revealed that medications, specifically Zinc oxide 20% ointment and triamcinolone acetonide 0.5% ointment, were left on R148's nightstand. This was contrary to the facility's policy, which requires an assessment and a doctor's order for self-administration of medications. The Director of Nursing (DON) confirmed that no assessment for self-administration had been conducted for R148, and there was no doctor's order permitting self-administration. The facility's policy mandates that medications should not be left at the bedside without proper assessment and authorization. The Registered Nurse (RN) acknowledged that the ointments should not have been at the bedside, as there was a risk of the resident mistaking them for something else, such as toothpaste. The facility's policies and job descriptions emphasize adherence to medical provider orders and compliance with regulations, which were not followed in this instance.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure that medications were signed out when administered for four residents, affecting a sample of 57 residents. On a specific date, a surveyor observed that an LPN had completed a medication pass but had not signed out the medications for four residents. The LPN admitted to administering the medications but had not yet documented it, intending to do so later. This oversight was confirmed through a review of the Medication Administration Records (MAR) for the residents, which showed that various medications were not signed out after being administered. The facility's policy requires medications to be signed out immediately after administration to prevent potential double dosing. The Director of Nursing confirmed this policy, emphasizing the risk of medications being misconstrued as not given if not signed out promptly. The residents involved were cognitively intact, with BIMS scores of 15, and had various diagnoses, including schizoaffective disorder, Parkinson's, and major depression. The failure to document medication administration as per policy could lead to significant medication errors, although the report does not specify any adverse outcomes resulting from this incident.
Failure to Enforce Smoking and Sharps Policies
Penalty
Summary
The facility failed to ensure that a resident smoked in a designated smoking area and did not adequately prevent environmental hazards, specifically the presence of razors, for several residents. One resident was observed smoking in their bathroom, which is against the facility's smoking policy. The resident, who is cognitively intact, was found with smoking materials in their possession despite being assessed as unable to handle them safely. The facility's policy states that smoking is only allowed in designated areas, and residents requiring supervision should be monitored accordingly. Additionally, the facility did not prevent residents from having razors in their rooms, which poses a safety risk. One resident was observed holding three razors, which they stated were given by staff for personal grooming. The facility's policy prohibits residents from having razors due to safety concerns, and staff are responsible for monitoring residents who shave themselves. Another resident with moderate cognitive impairment was found with a razor on their nightstand, and staff confirmed that razors should not be in residents' rooms. The facility's policy on the disposal of sharps, including razors, requires that they be placed in approved containers after use. However, observations revealed that razors were left in residents' rooms, contrary to the policy. Staff members acknowledged that razors should not be accessible to residents due to the potential for injury. The facility's failure to adhere to its policies on smoking and sharps disposal has the potential to affect the safety of all residents on the first and second floors.
Failure to Reconcile Controlled Substances at Shift Change
Penalty
Summary
The facility failed to adhere to its policy of reconciling controlled substances at the end of each shift, which has the potential to affect all four residents receiving controlled substances on the first floor. During facility rounds, it was observed that the Controlled Substance Check Form lacked signatures for a narcotic shift-to-shift count on a specific date. An LPN admitted to not counting narcotics with the night nurse at the start of her shift. The Director of Nursing confirmed that nurses are required to count narcotic medications between incoming and outgoing nurses at the end of each shift, and any failure to do so would necessitate an investigation into discrepancies. The facility's undated policy on Controlled Substances mandates that controlled medications be counted at the end of each shift by both the nurse coming on duty and the nurse going off duty. Additionally, the policy states that procedures for monitoring controlled medications to prevent loss, diversion, or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications, including controlled substances, in two of three medication refrigerators. Observations revealed that the medication refrigerators on both the first and third floors were not maintaining the correct temperature, with readings of 42 and 48 degrees Fahrenheit, respectively. Additionally, the refrigerators were found to have frost accumulation, indicating a lack of regular defrosting. The facility's policy requires regular temperature monitoring and defrosting when necessary, but these procedures were not followed, leading to improper storage conditions for medications. Furthermore, the facility did not secure Schedule II controlled drugs in a separately locked compartment, as required. Controlled medications for two residents, who had expired, were found in unlocked refrigerators accessible to other residents and staff. The facility's policy mandates that controlled substances be stored in a locked container separate from non-controlled medications, but this was not adhered to. Interviews with staff revealed a lack of awareness and adherence to these policies, contributing to the deficiencies observed.
Failure to Conduct PASRR Level 2 Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR). The resident, identified as R126, was admitted to the facility on October 11, 2024, with diagnoses including bipolar disorder and schizophrenia. Despite these diagnoses, the initial PASRR Level 1 screening conducted on August 29, 2024, indicated that no Level II screening was required, as it did not identify any serious mental illness (SMI). This oversight was noted during an interview and record review, where it was revealed that the facility did not update the PASRR Level 1 to include the resident's mental health diagnoses, which would have triggered a Level 2 PASRR. The Assistant Administrator (V10) acknowledged that Level 2 PASRRs are necessary when a resident has a mental health diagnosis such as schizophrenia or bipolar disorder. V10 stated that the facility's policy requires PASRR screenings to ensure residents are placed in appropriate facilities and that it is mandatory to conduct these screenings. The facility's policy, dated December 2023, mandates compliance with federal and state standards for PASRR assessments, expecting the appointed agency, Maximus, to complete Level 2 screenings if a PASRR condition exists. However, the facility failed to adhere to this policy, resulting in the deficiency affecting one resident in a sample size of 57 residents.
Failure to Label and Date Oxygen Equipment
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and dating of oxygen equipment, affecting two residents. Resident 54, who has multiple diagnoses including heart failure and chronic obstructive pulmonary disease, was observed with an undated nasal cannula. The resident's care plan and physician orders specify that oxygen equipment should be changed and dated weekly or as needed. However, the nasal cannula was not dated, and a Licensed Practical Nurse (LPN) confirmed that the tubing should have been dated, as it is typically changed weekly by the night shift. Similarly, Resident 126, who has intact cognition and multiple health issues such as atrial fibrillation and chronic heart failure, was observed with an undated nebulizer mask. The resident's physician orders also require the nebulization cup and tubing to be changed weekly or as needed. An LPN acknowledged the absence of a date on the nebulizer mask and discarded it. The Director of Nursing confirmed that oxygen tubing should be dated to prevent infection from prolonged use, as per the facility's policy on oxygen administration.
Medication Administration Error and Infection Control Breach
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices when a Licensed Practical Nurse (LPN) administered medication that had fallen on the floor to a resident. During a medication pass, the LPN dropped a Divalproex Sodium DR 500 mg tablet on the floor next to the resident's wheelchair and subsequently picked it up and administered it to the resident orally. This action was observed by a surveyor, and upon questioning, the LPN acknowledged the error, stating that the medication should have been discarded and replaced with a new one to prevent infection. The Director of Nursing (DON) confirmed the facility's policy that medications dropped on the floor should be discarded due to potential contamination and infection risk. The resident involved, identified as R55, had a physician's order for the medication to be administered three times a day. The facility's infection prevention and control program emphasizes maintaining a safe and sanitary environment to prevent the transmission of infections, which was not adhered to in this instance.
Failure to Maintain Comfortable Room Temperature for Resident
Penalty
Summary
The facility failed to provide a comfortable environment for a resident, identified as R162, due to a cold room temperature. On December 1st, a surveyor observed that R162's room was cold, and the resident confirmed that he had been complaining about the cold temperature since November 27th. A Licensed Practical Nurse (LPN) also noted that the room was as cold as the weather outside and considered it an immediate need. The Maintenance Director, V5, was unaware of the issue until the surveyor's visit and found the room temperature to be 61 degrees Fahrenheit, which was below the facility's standard of at least 68 degrees Fahrenheit. The cold temperature was attributed to a crack in the window. R162 has several medical conditions, including the presence of a right artificial hip joint, type 2 diabetes mellitus, hyperlipidemia, muscle wasting and atrophy, difficulty in walking, and unilateral primary osteoarthritis of the right hip. Despite these conditions, R162's cognitive status was intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The facility's policies emphasize the importance of maintaining a safe, clean, and comfortable environment for residents, yet the failure to address the cold temperature in R162's room was inconsistent with these policies.
Failure to Post Complete Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Nursing Staffing information was posted daily and completed appropriately, which could potentially affect all 159 residents. On December 1, 2024, a surveyor requested the Daily Staffing Posting from the scheduler, who was unable to locate it in the reception area. The scheduler then provided a document from a clipboard at the first-floor nurse's station, which lacked the current number of residents and did not include the total hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) for each shift. The scheduler admitted to not being informed about the requirement to include total nursing hours in the Daily Staffing Schedule. The administrator also confirmed that they were unaware of the need to include total nursing hours in the Daily Staffing Schedule. On the following day, the Director of Nursing acknowledged that the Daily Staffing Posting should include total nursing hours for each shift and be posted daily, as per regulations. However, the posted staffing information was incomplete, missing RN, LPN, and CNA hours for the evening and night shifts. The facility's Nursing Home Staffing Policy and the State Operations Manual require accurate daily staffing information to be posted, including the number of licensed nurses and CNAs, total resident census, and total nursing hours per shift.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continental Nursing & Rehab Center | 0.4 mi | ★★★★★ | 7 | 0 |
| Aperion Care Wesley | 0.8 mi | ★★★★★ | 5 | 0 |
| Park View Rehab Center | 0.9 mi | ★★★★★ | 25 | 0 |
| Foster Health & Rehab Center | 1 mi | ★★★★★ | 2 | 0 |
| All American Vlge Nrsg & Rhb | 1.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.