Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Bella Terra Schaumburg during CMS and state inspections, most recent first.
A resident with brain cancer, dysphagia, and broken teeth was observed eating a mechanical soft meal while lying in bed with the HOB declined and the room curtain pulled, leaving him not visible from the hall. Staff later confirmed he ate in bed and needed to be upright during meals. In a separate finding, a second-floor medication cart was left unlocked in the hallway with no staff nearby until an LPN returned and locked it.
Bedtime snacks were not offered to 5 of 5 residents reviewed for snacks. During a resident meeting, all 5 said they do not receive or are not offered HS snacks, and one cognitively intact resident who served as Resident Council President said she could not even get an extra cookie or dessert to take back to her room. The Dietary Manager said snacks are only provided to residents on a dietitian list and that no other residents are offered snacks, despite facility policies stating HS snacks and between-meal snacks are to be made available.
A resident’s medication information was left visible on a cart-mounted computer in a hallway outside a resident room when an LPN stepped away from the cart and no staff were nearby. The DON stated the screen should have been closed and that exposing resident information was a HIPAA violation. The facility policy states residents have a right to secure and confidential personal and medical records, including electronic records.
A resident with severe cognitive impairment and total dependence for toileting and personal hygiene was found incontinent of stool during wound care, but staff did not fully clean the perineal and vaginal area on the first attempt. Visible stool remained on the resident and on the brief after care, and multiple wipes used during the encounter contained stool. The DON stated stool must be fully removed during care to prevent infection and skin breakdown.
A resident with severe cognitive impairment and total care needs had bruising and steri-strips on both shins with drainage visible under the strips, but staff did not identify, assess, or initiate treatment for the new skin condition. The wound care nurse and nursing supervisor were unaware of the issue, and there were no orders in place for the bilateral shins despite the resident being high risk for altered skin integrity.
Insulin Pen Not Disinfected Before Needle Attachment: An RN prepared and administered Humalog from an insulin pen to a resident with dementia and type II DM without disinfecting the rubber top before attaching the needle. The RN and an LPN stated alcohol was not needed, while the Nurse Manager and DON stated the pen should be disinfected for infection control. The facility policy did not address disinfecting insulin injector pens before needle attachment.
The facility failed to prevent cross contamination during incontinent care for two residents and failed to ensure required PPE was worn during IV access for another resident. A CNA used the same wipes across multiple areas during perineal care for a resident who was incontinent and dependent on staff, and during wound/incontinent care for another resident, staff tossed stool-soiled wipes onto the floor and then handled them while standing over the contaminated area. An RN also accessed a resident’s IV antibiotic without wearing the gown required under EBP, despite a posted sign indicating gown use for device care.
The facility failed to monitor and assess a resident who lost 21 lbs in 14 days without re-weighing or assessment. Another resident under hospice care did not receive physician-ordered supplements, risking further weight loss. The facility lacked a weight loss/prevention policy, contributing to these deficiencies.
The facility failed to ensure residents and their representatives understood the Health Care Arbitration Agreement (HCAA) they signed, affecting four residents. A resident and a POA signed the HCAA without clear explanations of its implications, such as waiving legal rights. Staff responsible for presenting the HCAA were not formally educated on how to explain the agreement, and the facility lacked a policy on the arbitration agreement.
The facility failed to prevent resident-to-resident abuse involving two residents, where one resident verbally and physically assaulted another by grabbing his wrist, causing skin breakage. The incident was reported to the administrator and documented by an LPN, who found the residents in a heated exchange. The facility's policy mandates an abuse-free environment, which was not maintained.
The facility failed to provide written notices of hospital transfers to two residents or their representatives. Staff communicated verbally but did not send written notices, and the facility lacked a policy for such notifications.
The facility failed to notify residents or their representatives of the bed hold policy in writing during hospital transfers. In three cases, staff gave paperwork to EMTs but did not inform families, and there was no documentation of written notices. Interviews revealed a consistent practice of not informing families, despite the facility's policy requiring written notification.
A resident was diagnosed with schizophrenia without proper assessment, as required by professional standards. The diagnosis appeared on her face sheet two years after admission, despite not being listed in her admission hospital records. Interviews with facility staff revealed a lack of clarity and testing regarding the diagnosis, with the primary care physician and psych nurse practitioner both acknowledging the absence of a full psychiatric evaluation.
The facility failed to provide adequate ADL care for three residents requiring extensive assistance. A resident was found in the same clothes for four days with a saturated diaper, despite needing substantial assistance due to chronic conditions. Two other residents were left in reclining wheelchairs for extended periods without being toileted, contrary to their care plans and facility policy requiring regular incontinence checks.
A facility failed to implement a resident's skin preventive treatment as ordered by the physician. During a bed bath, a CNA found the resident's diaper saturated with urine and the coccyx red with a small open area, noting the absence of a usual dressing. Wound care nurses later confirmed the condition as MASD, with preventive treatment orders in place to prevent skin breakdown. The resident, on hospice care and bedridden, had orders for calamine-zinc oxide lotion, duraseptine with xeroform, and xeroform oil emulsion gauze to be applied every shift.
Two residents developed significant pressure injuries due to the facility's failure to report and identify skin alterations in a timely manner. One resident developed an unstageable pressure injury on the coccyx, while another developed a stage 2 ulcer on the heel, despite having protective measures in place. Both residents required assistance with personal care and had care plans indicating potential skin integrity issues.
A resident with a high fall risk was left unattended on the toilet, leading to a deficiency in safety supervision. The resident, not alert and oriented, was heard calling for help with no staff present. An agency CNA admitted to leaving the resident alone, and both a CNA and an LPN confirmed that the resident should not be left unattended due to her fall risk. The resident's fall risk score was 15, indicating a high risk according to the facility's evaluation.
A resident with a history of UTI did not receive prescribed catheter care, including Betadine application and catheter flush, as documented in their Treatment Administration Record. The DON confirmed these interventions were necessary to prevent infection, but documentation was missing for specific dates, indicating a lapse in care.
A discrepancy was found in the inventory of controlled medications for a resident, where 22 doses of methadone were available instead of the 23 documented. A nurse incorrectly documented the administration, skipping an entry. The facility's policy requires accurate counts and immediate reporting of discrepancies, which was not followed.
A facility failed to implement pharmacy recommendations for a resident's psychotropic medications after the physician agreed to a gradual dose reduction. Despite the consultant pharmacist's recommendation and the physician's agreement, the resident's medication orders were not adjusted. The psychotropic nurse admitted that clarification on the specific dose was needed but not obtained.
A facility failed to implement a gradual dose reduction (GDR) for a resident's psychotropic medications, despite a consultant pharmacist's recommendation and physician agreement. The resident continued receiving the same dosages of sertraline and quetiapine for several months, contrary to federal regulations and the facility's policy. The psychotropic nurse admitted that the necessary dosage adjustments were not clarified or implemented in a timely manner.
A resident with multiple diagnoses, including Parkinson's disease and major depressive disorder, was found holding a medication cup with 7-10 pills and a pill on her bed, indicating improper medication administration and storage. The RN acknowledged the resident's habit of taking medications slowly and stated that staff should monitor until all medications are ingested, as per facility policy.
The facility failed to follow proper infection control practices during perineal care for two residents. CNAs did not change gloves or perform hand hygiene after cleaning soiled areas, violating the facility's policies. These actions were observed during care for a resident with a history of COVID-19 and another resident after a bowel movement.
A resident was prescribed Keflex for recurrent UTI prophylaxis without proper documentation or physician notes until several months after the medication was started. The Assistant DON confirmed the prescription, but the facility failed to provide documentation justifying the use of the antibiotic, despite having an infection surveillance checklist in place.
A resident with dementia and severe cognitive impairments sustained a laceration requiring 13 sutures during a transfer with a mechanical lift. The incident occurred when the resident kicked her leg, hitting the lift, while two CNAs were assisting. The resident's care plan required two staff for transfers due to poor safety awareness.
A resident with dementia and major depression disorder physically assaulted two other residents in the dining room. The incident, witnessed by a CNA, involved the resident slapping one resident multiple times and hitting another in the head with a fist. The facility's records confirmed the aggressive behavior, and the resident was sent to a hospital for increased aggression. The facility's policy mandates an environment free from abuse, but it failed to prevent this incident.
Unsupervised meal positioning and unlocked medication cart
Penalty
Summary
The facility failed to ensure that a resident's head of the bed was upright during meals. R9 had diagnoses including brain cancer, palliative care, heart disease, skin cancer, and protein-calorie malnutrition, and his facility assessment showed he needed supervision for eating and was on a mechanically altered diet. His dietary evaluation documented dysphagia and dental problems with broken or fractured teeth. During lunch, R9 was observed lying in bed with a mechanical soft meal on the over-bed table, his head of the bed declined, and he was trying to spoon food into his mouth while the room divider curtain was pulled and he was not visible from the hall. He remained in the same position for at least 17 minutes until another CNA entered and raised the head of the bed while he was still eating. Staff later stated he ate in bed and needed to be upright, and the DON stated his head of bed should be at least 45 degrees during meals. The facility also failed to ensure a second-floor medication cart was locked when unsupervised. On the second floor, the medication cart was observed in the hallway outside a resident room and was unlocked with no staff present nearby. The surveyor waited until an LPN stepped out of a resident room and immediately locked the cart, stating it should have been locked when she stepped away. The Assistant Administrator later stated the medication cart should be locked whenever staff step away for safety. The facility's medication storage policy stated medications will be stored safely and secured in a locked storage area.
Bedtime snacks were not offered to residents
Penalty
Summary
The facility failed to ensure bedtime snacks were offered to 5 of 5 residents reviewed for snacks in a sample of 47. During a group resident meeting, all 5 residents present stated they do not receive and are not offered bedtime snacks. One resident, who was the Resident Council President and had no cognitive impairment, said she could not even get an extra cookie or dessert to take back to her room to eat later and reported that staff told her no when she asked for something to eat later. Another cognitively intact resident responded, "That is a BIG NO," when asked about bedtime snacks. Record review showed the residents involved were admitted to the facility between 2019 and 2025 and had facility assessments indicating no cognitive impairment or were cognitively intact. The Dietary Manager stated snacks are provided only to residents identified by the dietitian, that there is a list of residents who receive snacks, and that snacks are delivered to the nursing station on each floor labeled with the resident name and room number. The Dietary Manager also stated no other residents are offered snacks and there is nothing available to send up if residents ask for it at bedtime. The facility's policies stated bedtime snacks are to be offered daily and that between-meal snacks/nourishments shall be made available three times per day unless otherwise indicated in the resident's plan of care.
Resident Medical Information Left Visible on Medication Cart
Penalty
Summary
The facility failed to keep a resident’s medical records private and confidential when, on 1/15/26 at 7:40 AM, the medication cart on the second floor was left in the hallway outside a resident room with the mounted computer screen open to R105’s medications and no staff present nearby. The surveyor waited by the cart until V16 LPN stepped out of a resident room and stated she had been called away, but that the screen should have been closed. Later, on 1/15/26 at 12:12 PM, V2 DON stated that when a nurse steps away from the cart the computer should be closed and no resident information exposed, and identified the situation as a HIPAA violation. The facility’s 12/8/25 policy for Notice of privacy practices states that the resident has a right to secure and confidential personal and medical records, including electronic records.
Incomplete Incontinence and Perineal Care
Penalty
Summary
The facility failed to ensure staff thoroughly cleaned a resident who was dependent on staff for incontinent care. The resident had diagnoses including dementia, osteoarthritis, diverticulosis of the small intestine, pressure ulcer of the sacral region, acute kidney failure, urine retention, and altered mental status. The resident’s assessment showed severe cognitive impairment and dependence on staff for all cares, and the care plan identified the resident as high risk for skin breakdown with interventions to keep skin clean and dry. The resident also had an ADL care plan showing dependence on staff for toileting and personal hygiene needs. During wound care, two nursing staff members found the resident incontinent of stool and began cleaning her while she was positioned on her side. Visible stool remained in the perineal area after the initial cleaning, and when the surveyor asked them to check the front area, additional stool was found on the vaginal and perineal area. Multiple wipes used during the care had visible stool on them, and the brief placed on the resident after care also had visible stool on it. The DON stated it is important to make sure all stool is cleaned off residents during care to prevent infection and skin breakdown. The facility policy stated perineal care is to ensure cleanliness and comfort, prevent infection and skin irritation, and observe the resident’s skin condition.
Failure to Identify and Treat New Shin Skin Condition
Penalty
Summary
The facility failed to prevent, identify, initiate treatment for, and notify the physician of a new skin condition for one resident with severe cognitive impairment who was dependent on staff for all cares. The resident was admitted with diagnoses including senile degeneration of the brain, dementia without behavioral disturbance, generalized anxiety disorder, insomnia, overactive bladder, hypokalemia, and hypertensive heart and chronic kidney disease without heart failure. Her care plan identified her as high risk for altered skin integrity and directed staff to perform skin checks every shift and report abnormalities to the nurse, but her current physician order sheet had no orders for treatment or monitoring of her bilateral shins. During observation, the resident’s shins were exposed and showed several dark bruises on each shin with steri-strips applied to areas on both shins, with drainage visible under the steri-strips. The resident’s son-in-law stated the bruises and steri-strips had been present on and off for months and that she had bruising or skin tears in various forms for months. The wound care nurse and nursing supervisor were not aware of the skin conditions, and the wound care nurse stated that when a new skin condition is reported she would assess it, notify the wound care company, enter treatment and monitoring orders, and start an investigation. The DON stated staff should report skin alterations right away, the wound care staff should be notified, and the wound should be assessed, documented, and reported to the physician and family; however, none of these actions were in place for the resident’s bilateral shin condition.
Insulin Pen Not Disinfected Before Needle Attachment
Penalty
Summary
The facility failed to ensure an insulin pen was disinfected before the needle was attached for one resident who was reviewed for insulin injections. The resident had diagnoses including dementia and type II diabetes mellitus, and the admission record showed she had severe cognitive impairment and required substantial to maximal assistance from staff, or was dependent on staff for all cares except eating. Her order summary showed an active order for Humalog KwikPen insulin to be given by sliding scale before meals and at bedtime, and her care plan identified her as at risk for fluctuating blood sugars due to diabetes mellitus. During observation on 01/14/2026, an RN checked the resident’s blood sugar, told her she would get the insulin ready, and then returned to prepare the medication. The RN removed the cap from the Humalog injector pen and attached the needle without disinfecting the rubber top of the pen before attaching the needle, then administered the insulin. When asked, the RN stated she did not need to alcohol the end of the insulin pen before attaching the needle. An LPN later stated nurses do not need to alcohol the top of insulin pens before attaching the needle, while the Nurse Manager and DON stated the rubber end of the insulin pen should be disinfected with alcohol wipes before attaching the needle for infection control. The facility policy titled Medication Pass, revised 7/2/2025, did not address disinfecting insulin injector pens prior to attaching the needle.
Infection Control Failures During Incontinent Care and IV Access
Penalty
Summary
The facility failed to provide incontinent care in a manner to prevent cross contamination for two residents. One resident was incontinent of bowel and bladder, had moderate cognitive impairment, and was dependent on staff for toileting hygiene and personal hygiene. During incontinent care, a CNA and a restorative aide removed the resident’s soiled brief, and the CNA used several wipes stacked together to clean the pubic area, right groin area, and middle vaginal area without using a different section of the wipes or folding them between swipes. The facility’s unit manager and DON stated that wet wipes should be discarded after each swipe and a clean wipe should be used when cleaning the vaginal area. Another resident had severe cognitive impairment, was dependent on staff for all care, and was receiving wound care after being incontinent of stool. During the care, an RN in training and an LPN donned PPE, but the LPN tossed three stool-soiled wipes over the bed toward the trash can and they landed on the floor. After care was completed, the RN in training picked the wipes up from the floor and placed them in the trash bag, then lifted the trash bag to tie it off while standing over the area where the wipes had landed. The facility also failed to ensure staff wore the required gown when accessing a resident’s IV antibiotic under Enhanced Barrier Precautions; the RN entered the room to administer the IV medication, brushed against the bedding, and was not wearing a gown even though the posted sign indicated a gown was required for device care or use.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and assess a resident, identified as R137, who experienced significant weight loss. Upon admission, R137 weighed 145.6 lbs, but over a period of 14 days, she lost 21 lbs without being re-weighed or assessed. Despite having a history of weight loss and a diagnosis of dementia, depression, and other conditions, the facility did not conduct weekly weights as required for new admissions. The resident's food intake was inconsistent, and she was not seen by a dietitian until 20 days after admission, despite her poor intake and significant weight loss. Additionally, the facility failed to provide physician-ordered nutritional supplements to another resident, identified as R118, who was under hospice care and had experienced a significant weight loss of 10.5% over six months. The resident was supposed to receive a magic cup at lunch and dinner as part of their dietary plan, but this was not provided on two observed occasions. The lack of adherence to the dietary plan could potentially exacerbate the resident's weight loss. The facility did not have a weight loss/prevention policy in place, which contributed to the oversight in monitoring and addressing the nutritional needs of residents R137 and R118. The absence of such a policy likely led to the failure in providing necessary interventions and monitoring to prevent further weight loss in these residents.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents and/or their representatives understood the Health Care Arbitration Agreement (HCAA) they were signing, which affected four residents in a sample of 30. Resident R251, who was cognitively intact, signed the HCAA without a clear explanation of its implications, such as waiving the right to legal assistance. Similarly, R20's Power of Attorney (POA) signed the HCAA without understanding its significance due to a lack of explanation and time to review the document. R73, with moderate cognitive impairment, also signed the HCAA without a clear understanding of its terms, and R144, who was cognitively intact, misunderstood the nature of the arbitration agreement, thinking it involved a committee rather than waiving legal rights. The staff responsible for presenting the HCAA, including the Guest Services Director and Admissions Director, were not formally educated on how to properly explain the agreement to residents. The facility lacked a policy on the arbitration agreement, and the staff had not seen the educational materials provided by the facility. The education packet highlighted factors that could render the HCAA unconscionable, such as issues with age, literacy, or the manner in which the contract was presented, emphasizing the importance of ensuring the signer understands the terms without being rushed.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident verbal and physical abuse, specifically involving two residents. On the afternoon of November 19, 2024, one resident reported that another resident cursed at him, rolled over in his wheelchair, and grabbed his left wrist with a strong grip, causing skin breakage without bleeding. An X-ray was conducted, revealing no fractures. The two residents reportedly did not get along well, which may have contributed to the altercation. The incident was reported to the facility administrator by a nurse, who was informed of the yelling and wrist-grabbing incident. A Licensed Practical Nurse (LPN) was alerted by a CNA about the yelling and found the two residents in a heated exchange, with one resident holding the other's wrist. The LPN noted difficulty in understanding the aggressor's speech, but identified words related to the TV being loud. Progress notes for both residents documented the altercation, with one resident's care plan indicating a history of unclear speech and the other being alert and oriented. The facility's Abuse and Neglect Policy, revised in July 2024, mandates an environment free from abuse, which was not upheld in this instance.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify residents or their representatives in writing of transfers to the hospital, as required. This deficiency was identified in two cases. In the first case, a resident was transported to the emergency room, and their Power of Attorney was informed of the hospital admission only after the transfer occurred, with no written notice provided. In the second case, another resident was admitted to the hospital without any documentation of written notice being given to the resident or their representative. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that while verbal communication with families occurred, written notices were not provided. The facility also lacked a policy addressing the requirement for written notification of transfers.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed hold policy in writing during transfers to the hospital or therapeutic leave. This deficiency was identified in three cases out of a sample of thirty residents. In the first case, a registered nurse (RN) caring for a resident who was transferred to the hospital in February admitted to giving the paperwork to the EMTs but could not recall notifying the family about the bed hold policy. The RN also could not find any documentation indicating that the family was informed. In the second case, a resident's progress notes indicated that the resident was transported to the emergency room, and the power of attorney was informed of the hospital admission, but there was no documentation of a written bed hold policy being provided. Similarly, in the third case, the facility was unable to provide documentation of a written notice regarding the resident's transfer to the hospital or the bed hold policy. Interviews with various nursing staff, including RNs and an LPN, revealed a consistent practice of giving bed hold policy paperwork to paramedics upon resident transfer, but not necessarily informing the family about the bed hold policy. The Director of Nursing confirmed that a hard copy of the transfer was not sent to the family, and the facility's policy, revised in July, stated that the resident or family must be informed of the bed hold duration in writing. This lack of documentation and communication with the residents' families regarding the bed hold policy constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Properly Assess Resident for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was properly assessed before being diagnosed with a serious mental illness, specifically schizophrenia, according to professional standards of practice. The resident, identified as R99, was admitted to the facility without a diagnosis of schizophrenia, as confirmed by her admission hospital records. However, two years after admission, schizophrenia was added to her face sheet as a diagnosis. Interviews with the psychotropic nurse and the primary care physician (PCP) revealed a lack of clarity on how this diagnosis was made. The psychotropic nurse, who began handling psychotropics in May of the current year, was unaware of the origin of the diagnosis. The PCP assumed the resident came with the diagnosis and admitted to not conducting any testing to confirm it. Further interviews with the psych nurse practitioner, who has been seeing the resident since February of the current year, indicated that the resident has a diagnosis of dementia, which could explain her behaviors. The nurse practitioner acknowledged that schizophrenia is a significant diagnosis that typically requires a full psychiatric evaluation and extensive testing, which had not been performed for this resident. The resident's face sheet also lists other diagnoses, including dementia, bipolar disorder, psychotic disorder with delusions, generalized anxiety disorder, delusional disorders, and major depressive disorder, none of which were confirmed to include schizophrenia upon her admission.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for residents requiring extensive assistance. Resident R59's family reported that he was not receiving timely care, including changing clothes and adult diapers. Observations confirmed that R59 was in the same clothes for four days, and his diaper was saturated with urine. His care plan indicated he required substantial assistance for dressing and toileting due to multiple chronic conditions, including cognitive impairment and mobility issues. Resident R118 was observed sitting in the same spot in a reclining wheelchair for extended periods without being toileted. His care plan required dependent assistance for toileting due to cognitive impairment and mobility limitations. Similarly, Resident R49 was left in a reclining wheelchair without being toileted, despite needing dependent assistance for toileting due to various chronic conditions. The facility's policy required rounds every two hours to check for incontinence, which was not adhered to, leading to these deficiencies.
Failure to Implement Skin Preventive Treatment as Ordered
Penalty
Summary
The facility failed to ensure that a resident's skin preventive treatment was in place according to physician orders. This deficiency was identified during an observation on November 18, 2024, when a hospice CNA was giving a bed bath to a resident whose adult diaper was saturated with urine, and the resident's coccyx was red with a small superficial open area. The CNA noted that there was usually a dressing on the coccyx, but it was absent that day. On the following day, two wound care nurses confirmed that the resident did not have any open pressure injuries on the coccyx, describing the condition as moisture-associated skin damage (MASD). The resident, who was on hospice care and bedridden, had preventive treatment orders to prevent skin breakdown or pressure injuries. The treatment administration record for November 2024 indicated orders for calamine-zinc oxide lotion, duraseptine with xeroform, and xeroform oil emulsion gauze to be applied to the coccyx/buttocks every shift for skin breakdown prevention.
Failure to Prevent and Identify Pressure Injuries
Penalty
Summary
The facility failed to report and identify a pressure injury in a timely manner for two residents, leading to the development of significant pressure injuries. Resident R137, who had diagnoses including dementia and required assistance with personal care, developed an unstageable pressure injury on her coccyx. The initial wound assessment indicated that the injury was facility-acquired and unstageable, measuring 3 cm by 5 cm. It was noted that the resident was incontinent and should have been changed every shift, which could have prevented the injury from becoming unstageable. The care plan for R137 indicated a potential for skin integrity issues, but the injury was not identified until it was already severe. Resident R118, who also required assistance with personal care and had a history of depression and COPD, developed a stage 2 pressure ulcer on his left heel. The wound assessment showed that the injury was facility-acquired and resulted from the resident's heel resting on the footrest of his wheelchair. Despite having heel protector boots, the injury occurred, indicating a failure to properly offload pressure from the heel. The care plan for R118 included the use of boots to offload heel areas, but this intervention was not effectively implemented, leading to the development of the pressure ulcer.
Failure to Supervise High Fall Risk Resident on Toilet
Penalty
Summary
The facility failed to adequately supervise a resident with a known history of falls while she was on the toilet, leading to a deficiency in safety supervision. On November 17, 2024, at 2:20 PM, the resident was heard shouting for help while sitting on the bathroom toilet, holding the grab bar, with no staff present in the room, bathroom, or hallway. An agency CNA admitted to placing the resident on the toilet and acknowledged that the resident was not alert and oriented. Another CNA confirmed that staff should not leave the resident alone on the toilet due to her fall risk, and an LPN reiterated that the resident should not be left unattended because of her fall risk. The resident's Fall Risk Evaluation, dated April 1, 2024, indicated a high fall risk score of 15, where a score of 8 and above is considered high risk according to the facility's reference range.
Failure in Catheter Care for Resident with UTI History
Penalty
Summary
The facility failed to provide appropriate catheter care interventions for a resident with a history of urinary tract infection (UTI). The resident was observed with a urinary catheter in place, and the Director of Nursing (DON) confirmed that catheter care, including catheter flush and application of Betadine, should be performed every shift to prevent infection. However, the Treatment Administration Record (TAR) for the resident showed missing documentation for catheter care, Betadine application, and catheter flush on specific dates, indicating a lapse in the prescribed care routine.
Controlled Medication Discrepancy
Penalty
Summary
The facility failed to ensure accurate documentation and inventory of controlled medications for a resident. During a medication administration observation, it was noted that there were 22 physical doses of methadone available for a resident, while the Individual Controlled Substance Record indicated there should have been 23 doses. The discrepancy occurred when a registered nurse administered a dose of methadone and incorrectly documented the entry, skipping the 23rd dose and signing out the administered dose on the next line. The facility's policy requires a physical inventory of all controlled substances by two licensed personnel at each shift change or when keys are transferred, with any discrepancies reported immediately to the Director of Nursing. However, the discrepancy in the methadone count was not immediately addressed, indicating a lapse in adherence to the facility's Controlled Substance Storage Policy.
Failure to Implement Agreed Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed after being agreed upon by the physician for a resident reviewed for psychotropic medications. The consultant pharmacist recommended a gradual dose reduction (GDR) for the resident's psychotropic medications, quetiapine and sertraline, on August 2, 2024. The physician agreed with these recommendations on September 24, 2024. However, the resident's order summary report dated November 20, 2024, showed no orders for the medications at a reduced dose. The psychotropic nurse, responsible for addressing medication recommendations, acknowledged that she or the floor nurse should have clarified the specific dose the doctor intended to prescribe after agreeing to the GDR.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the gradual dose reduction (GDR) of psychotropic medications for a resident, identified as R94, who was part of a sample of 30 residents reviewed for unnecessary psychotropic medication use. The consultant pharmacist recommended a reevaluation and consideration for GDR of R94's medications, quetiapine and sertraline, due to potential side effects such as drowsiness, increased risk of falls, and hypotension. The physician agreed with these recommendations; however, the facility did not implement the GDR in a timely manner. R94 continued to receive the same dosages of sertraline and quetiapine from September through November, despite the physician's agreement to the pharmacist's recommendations. The psychotropic nurse acknowledged that they should have clarified the physician's intended dosage adjustments and implemented them promptly. The facility's policy on psychotropic medications, revised in August, mandates adherence to federal regulations, which was not followed in this instance.
Medication Administration and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for a resident, identified as R123, who was part of a sample of 30 residents reviewed for medication storage. R123 was admitted with multiple diagnoses, including Parkinson's disease, major depressive disorder, and rheumatoid arthritis, among others. On November 18, 2024, it was observed that R123 was holding a medication cup with 7-10 pills and had a small yellow pill on her bed mattress. R123 reported that these were her morning medications, which she intended to take later with food. This indicates that the medications were not administered at the time they were prepared, as per the facility's policy. The Registered Nurse (RN), identified as V6, acknowledged that R123 often takes a long time to consume her medications, preferring to take them one at a time with food in between. V6 stated that staff should monitor the resident until all medications are ingested and that if a resident requests to take medications later, they should be taken away and re-administered at a later time. The facility's Medication Administration General Guidelines policy requires that medications be administered at the time they are prepared and that the resident is observed to ensure the dose is completely ingested. The failure to adhere to these guidelines resulted in the deficiency noted in the report.
Infection Control Lapses During Perineal Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during perineal care for two residents, R80 and R137. R80, who has a history of COVID-19, urinary tract infection, and is always incontinent of bowel and bladder, was observed receiving perineal care from CNAs V5 and V7. During the procedure, V7 did not change gloves or perform hand hygiene after wiping stool from R80's perineal area before assisting her to turn, which is against the facility's hand hygiene and perineal care policies. These policies require changing gloves and performing hand hygiene to prevent cross-contamination when moving from soiled to clean areas. Similarly, CNA V15 was observed changing R137's adult diaper after a bowel movement and failed to remove gloves or wash hands after cleaning the resident. Instead, V15 continued to adjust the resident's pillow, cover her, and lower the bed without performing hand hygiene. This action also violated the facility's hand hygiene policy, which mandates hand hygiene before and after assisting a resident with toileting and after contact with body fluids. These lapses in infection control practices were confirmed through interviews with the Infection Control Nurse and a review of the facility's policies.
Unnecessary Antibiotic Prescription for a Resident
Penalty
Summary
The facility failed to ensure that a resident was not prescribed an unnecessary antibiotic, specifically affecting one of the five residents reviewed for unnecessary medications in a sample of thirty. The resident, identified as R128, was prescribed Keflex Oral Capsule 250 MG for recurrent urinary tract infection (UTI) prophylaxis, starting on March 29, 2024. However, there were no physician notes or documentation regarding the initiation of this medication until November 20, 2024, when a progress note mentioned recurrent urinary tract issues and the use of Keflex. The Assistant Director of Nursing confirmed that the resident was on the medication for recurrent UTIs, but the facility did not provide any documentation prior to November 20, 2024, to justify the prescription. The facility's infection surveillance checklist, dated August 8, 2024, indicated the use of the McGreer Criteria Checklist for infection prevention and control, but this was not reflected in the documentation for R128.
Resident Injury During Transfer Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a significant injury. The resident, who was diagnosed with dementia, malnutrition, and peripheral venous insufficiency, had severe cognitive impairments and was dependent on staff for transfers. The care plan indicated that the resident required assistance from two staff members for transfers due to poor safety awareness and impulsiveness. During a transfer from a shower chair using a mechanical lift, the resident kicked her left leg, hitting the lift and sustaining a laceration that required 13 sutures. The incident occurred while two CNAs were assisting with the transfer; one was moving the lift, and the other was guiding the resident. The resident's medical history included a previous hematoma on the left leg, which was noted a day before the laceration incident. The hematoma was discovered during a transfer and was attributed to trivial trauma. On the day of the incident, the resident was not following directions and was known to become agitated during care. The wound care nurse confirmed the laceration and hematomas were sustained during the transfer, and the resident was subsequently sent to the emergency room for treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' right to be free from resident-to-resident physical abuse. On 3/16/24, a resident with dementia and major depression disorder, identified as R1, physically assaulted two other residents, R2 and R3, in the dining room. According to staff interviews, R1 slapped R2 in the head multiple times with an open hand and then hit R3 in the back of the head with a fist. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the contact was not accidental. R1 was subsequently sent to a local hospital for increased aggression. The facility's records, including progress notes and a Change in Condition Note, confirmed the aggressive behavior of R1. The facility's Abuse and Neglect policy, reviewed on 7/14/23, mandates an environment free from any type of abuse, including physical abuse such as hitting and slapping. Despite this policy, the facility failed to prevent the physical abuse incident involving R1, R2, and R3, thereby not ensuring a safe environment for its residents.
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What surveyors actually found near you
We read the 1,393 citations issued within 25 miles in the last 12 months — including the 26 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Schaumburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Encore Village | 1 mi | ★★★★★ | 12 | 0 |
| Abbington Vlge Nrsg & Rhb Ctr | 2.2 mi | ★★★★★ | 24 | 0 |
| Pearl Of Elk Grove, The | 2.2 mi | ★★★★★ | 7 | 0 |
| Ignite Medical Hanover Park | 3.9 mi | ★★★★★ | 2 | 0 |
| Alden Poplar Creek Rehab & Hcc | 4.1 mi | ★★★★★ | 9 | 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.