Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchwood Plaza during CMS and state inspections, most recent first.
Food storage and sanitation processes were not followed in the kitchen. Food items were found without proper labels or dates, expired items remained on hand, and required temp logs for refrigerators, freezers, and the dishwasher were not being kept. During puree prep, the 3-compartment sink was not filled properly, dishes were not fully immersed in sanitizer for the required time, and the blender bowl was reused before fully drying.
A resident with dementia and severe cognitive impairment was observed drowsing during lunch when a CNA woke the resident, asked if help was wanted, and then stood over the resident while feeding. The CNA said she could not sit because she had to check on other residents. The DON stated staff should sit facing the resident during feeding because standing can be intimidating and may appear as though staff are trying to force the resident to eat.
Failure to Post Lighthouse Sign for Resident Unable to Use Call Light: A resident with moderate cognitive impairment and a care plan stating she could not use a call light did not have the required lighthouse sign posted outside her room. Surveyors observed that the resident did not recognize the call light, confused it with the overhead lamp string, and said she shouted out for help because staff took a long time to assist her. An LPN stated the call light should be visible and within reach, and the DON stated cognitively impaired residents should have a lighthouse sign posted and should not be shouting out for help.
Advance Directive and Care Plan Not Consistent With DNR Status: A resident with moderate cognitive impairment and multiple diagnoses, including breast cancer, CVA, PTSD, hypertensive heart disease, and asthma, had an active DNR order and stated she wanted her DNR wishes honored. However, the care plan listed her as full code, and the advance directives care plan also reflected full code despite the DNR form and physician order showing no CPR.
A nurse left a computer on a hallway medication cart with a resident's MAR visible to anyone passing by while she stood away talking with a family member. The resident had type 2 DM, CKD, osteoarthritis, and moderate cognitive impairment. The DON stated resident information should be kept out of others' view and computers locked when staff step away.
Late MDS Submission: The facility failed to submit MDS assessments within the required timeframe for three residents. The DON confirmed the assessments were completed and transmitted late, and the facility policy states it follows the RAI manual, which requires MDS completion no later than 14 days from the ARD.
A resident with severe cognitive impairment had an expired PASRR short-term approval without specialized services, and the facility missed the recommended PASRR determination date. Staff stated the PASRR process is important for proper treatment, but the facility does not have a PASRR policy and procedure and follows Maximus guidelines.
A resident’s person-centered care plan did not include interventions for a documented hearing impairment. The resident was observed to be very hard of hearing and unable to hear, and the SW stated the issue should be care planned with interventions. Review of the care plan showed no documentation addressing the resident’s hearing needs.
Failure to provide shaving assistance: A resident with Parkinson's disease and a care plan for total staff assist with personal hygiene was observed with facial hair on the chin on multiple occasions. The resident stated staff had not asked to shave her and that she felt bad about her appearance, while a CNA said shaving female residents was done only if they wanted it and that she had not yet gotten to the resident because she was busy. The DON stated the resident needed help with shaving and could not do it herself.
A resident ordered for contact isolation for ESBL on a left foot wound was observed without the required isolation signage on the door, and a CNA provided care and assisted with lunch without gown or gloves. In a separate event, a CNA performing incontinence care for another resident used the same gloves after handling a soiled sheet and then applied barrier cream to the resident’s perineal area, with the CNA later acknowledging the infection control issue.
Resident Room Square Footage Deficiency: The facility failed to provide the required square footage in multiple resident bedrooms, affecting 26 residents across 19 rooms. The Associate Administrator stated the facility had a room waiver for rooms measuring less than the required space, and email correspondence and the waiver document confirmed CMS granted an annual waiver for the listed rooms.
Staff at the facility failed to maintain residents' dignity by feeding them while standing, contrary to policy. Observations showed CNAs and the DON standing over residents in wheelchairs during meals, affecting four residents with varying cognitive and physical impairments. The facility's policy requires staff to sit while feeding to ensure respect and dignity.
The facility failed to implement adequate fall prevention measures for residents at risk, leading to repeated falls for three residents and potential risk for another. Residents were observed without proper footwear, such as non-skid socks, despite care plans indicating their necessity. The facility's policy requires such measures, but they were not consistently applied, contributing to the deficiency.
The facility failed to ensure call light devices were within reach for two residents, leading to a deficiency. One resident with Alzheimer's and other conditions had a call light cord on the floor, while another with multiple diagnoses had the call light behind the bed. Staff confirmed the devices should be accessible, aligning with the facility's policy.
The facility failed to coordinate PASARR assessments and refer residents for Level II reviews upon significant changes in mental status, affecting three residents and potentially impacting 34 others. A resident's bipolar disorder was not reflected in the PASARR form, and another resident with a new diagnosis of schizoaffective disorder did not receive a Level II screening. The receptionist responsible for PASARR screenings was not informed of new diagnoses, leading to a lack of necessary assessments.
A facility failed to include a resident's psychiatric diagnoses in the PASARR screening, affecting the accuracy of the pre-admission process. The resident had documented diagnoses of schizoaffective disorder and schizophrenia, which were omitted by the non-clinical staff responsible for the PASARR. This led to an incorrect initial determination that no Level II screening was needed, later corrected to require further evaluation.
The facility failed to provide timely oral care and personal hygiene shaving for two dependent residents. One resident had significant facial hair and was not offered shaving assistance, despite requiring substantial help due to cognitive impairment. Another resident had visible dental plaque, indicating a lack of oral care, and reported not receiving assistance for a long time. These deficiencies reflect lapses in adhering to facility policies on grooming and hygiene.
The facility failed to implement pressure ulcer prevention interventions for three residents with dementia who were at risk for pressure ulcers. Observations revealed that these residents were seated in wheelchairs without pressure-relieving cushions, contrary to their care plans and the facility's policy. An LPN acknowledged the issue, noting that cushions were sometimes sent to the laundry, but did not ensure their immediate use.
A resident with severe malnutrition and quadriplegia did not receive the correct amount of Enteral g-tube feeding due to the feeding machine being turned off. The LPN on duty was unaware of the machine's status, resulting in the resident receiving only 100 ml instead of the expected 280 ml over four hours. The facility's policy requires adherence to physician orders for tube feeding to ensure proper nutrition and hydration.
The facility failed to label and change respiratory equipment for two residents receiving oxygen therapy. A resident with COPD had a nasal cannula that was not dated, and the oxygen tubing and humidifier bottle were not changed weekly as required. Another resident with multiple diagnoses also had a nasal cannula that was not dated, and the humidification bottle was overdue for a change. These lapses were identified during a survey, affecting the quality of care.
Staff at the facility failed to perform proper hand hygiene during resident feeding, potentially spreading infections. CNAs were observed not sanitizing hands between feeding different residents and after touching personal body parts. Residents with cognitive impairments and requiring assistance with eating were affected. The DON acknowledged the importance of hand hygiene, but facility policies were not followed.
The facility did not meet the required 80 square feet per resident in multiple resident bedrooms for 19 rooms, affecting 29 residents. Despite having an annual waiver from the State Department of Public Health, the facility confirmed that some rooms are below the required square footage, although all necessary furnishings and equipment are provided.
The facility failed to secure medication and treatment carts, posing a potential hazard to 40 residents. A medication cart was left unattended and unlocked in the hallway, contrary to facility policy requiring carts to be locked when not in use or out of sight. Similarly, a treatment cart was found unattended and unlocked with resident medications. The DON confirmed the policy mandates all medication storage areas be locked unless in use and under direct observation.
The facility failed to properly store and label food, with dented cans mixed with undented ones, unlabeled beef patties, and expired pastrami. The ice machine was also found dirty, lacking cleaning records. These issues could affect all 145 residents consuming meals from the facility's kitchen.
Food Storage, Temperature Monitoring, and Sanitizing Process Deficiencies
Penalty
Summary
The facility failed to follow its food storage and sanitation policies by not ensuring that food items in the kitchen were properly labeled and dated, by allowing expired food items to remain in the kitchen, by not recording required temperatures for refrigerators, freezers, and the dishwasher, and by not following manufacturer instructions for use of the three-compartment sink. During a kitchen tour, a pan of gelatin in the refrigerator had a prep date of 1/27/26 and a use-by date of 2/2/26, a bucket of corn flake crumbs had no prep date or opened date and only a use-by date of 12/30, a bucket containing rice was labeled breadcrumbs with a prep date of 1/19/26 and a use-by date of 1/23/26, and a pan covered with aluminum foil had meatballs/hamburgers marked 1/30/26 with no indication whether that was the date placed in the refrigerator or the discard date. A 55-pound bag of Pizzeria Wheat Flour was labeled 013125 and V18 stated it was supposed to be picked up by the distributor. When asked for temperature logs for the refrigerators, freezers, and dishwasher, logs were not provided and V18 stated they had not been started yet. During puree preparation, the wash and sanitizer compartments of the three-compartment sink were not adequately filled with water, dishes could not be completely immersed, and V18 was continually instructing staff on how to use the sink. The blender bowl was not allowed to completely dry before the next dish was blended, and V19 washed the blender bowl without allowing it to remain immersed in the sanitizer for the appropriate time before setting it to dry. V18 stated that expired foods should not be in the kitchen, that opened foods should be dated, that food labels should be accurate, that refrigerator and freezer temperatures should be logged, that dishwasher temperatures should be monitored and recorded, and that items should remain in the sanitizer compartment for at least one minute and air dry.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain dignity for one resident reviewed for dining services. The resident had diagnoses including unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other diseases of the pharynx. The MDS dated 12/16/2025 documented a BIMS score of 4/15, indicating severe cognitive disability, and the self-care section documented the resident required supervision and touching assistance. The care plan noted the resident may be at risk for weight loss related to mild cognitive impairment resulting in mental status changes, confusion, and disorientation. On 02/04/2026 at 12:21 PM, the resident was observed eating lunch and dosing on and off. A CNA entered the resident's room, woke the resident, asked if assistance with eating was wanted, and after the resident nodded yes, stood over the resident and fed the resident. The CNA stated she is supposed to sit down while assisting residents with meals but could not because she had to check on other residents. The DON stated that when staff assist a resident with feeding, the staff should sit facing the resident and should not stand because standing can be intimidating and can appear as though staff are trying to force the resident to eat. The DON further stated the resident needs encouragement to eat, and sitting while assisting creates a harmonious, comfortable, and non-intimidating environment.
Failure to Post Lighthouse Sign for Resident Unable to Use Call Light
Penalty
Summary
The facility failed to follow its policy for a resident who was unable to use a call light by not posting the lighthouse sign outside the room for R32. R32’s MDS dated January 6, 2026, showed a Brief Interview Score of 10 and indicated moderate cognitive impairment. The care plan dated October 13, 2025, documented that R32 was not able to use a call light and that purposeful rounding would be observed, with the lighthouse posted outside the room with the bed number. During observations on February 4 and February 6, 2026, surveyors did not observe the lighthouse sign inside or outside R32’s room. R32 was observed sitting in her chair, well groomed, calm, and free of pain, but alert only to person and confused about place and time. R32 stated staff did not come to help her when she needed them and said she shouted out for help because staff took a long time to assist her. When asked about the call light, R32 pointed to the string attached to the overhead bed lamp and later stated she was not aware that the red string on top of her bed was a call light. An LPN stated that when a resident is confused, the call light should be attached to the person and always visible, within reach, and working, and the DON stated residents who are cognitively impaired should have a lighthouse sign posted and should not be shouting out for help.
Advance Directive and Care Plan Not Consistent With DNR Status
Penalty
Summary
The facility failed to ensure that one resident’s advance directive and code status were consistent with the comprehensive care plan. The resident’s MDS showed moderate cognitive impairment, and the EMR documented diagnoses including malignant neoplasm of unspecified site of unspecified female breast, chronic iron deficiency anemia secondary to blood loss, other cerebral infarction, PTSD, hypertensive heart disease without heart failure, and moderate persistent asthma with status asthmaticus. The physician order sheet showed an active DNR order, and the resident stated that her code status was DNR because she had lived for seventy-six years and wanted the facility to honor that wish. The social worker stated she oversaw advance directives care planning and confirmed the resident had a DNR order on file upon admission, and that the initial and comprehensive care plan should reflect the actual DNR status to prevent conflict of care. However, review of the resident’s care plan showed she was care planned as full code. The resident’s DNR form documented “No CPR: Do not attempt resuscitation,” while the advance directives care plan listed the resident as currently full code with a full code intervention. The DON/Care Plan Coordinator stated it was her expectation that the care plan be completed accurately and that the resident’s DNR status should be care-planned as DNR, not full code.
Resident Medical Record Left Visible on Hallway Medication Cart
Penalty
Summary
The facility failed to maintain confidentiality of medical records for one resident with type 2 diabetes mellitus with hypoglycemia without coma, chronic kidney disease, and unspecified osteoarthritis, who also had moderate cognitive impairment with a BIMS score of 10/15. On 02/04/2026 at 12:25 PM, a nurse's computer was observed on the medication cart in the middle of the hallway with the resident's Medication Administration Record visible to anyone passing by. The nurse was away from the computer and standing near the dining room talking to a resident family member, and stated she was about 12 feet away from the computer and should have locked the screen before stepping away to protect the resident's private information under HIPAA. The DON later stated that computer screens with resident information should be faced away from others and locked when staff step away to protect resident medical records from unauthorized viewing.
Late MDS Submission
Penalty
Summary
The facility failed to follow the Resident Assessment Instrument (RAI) manual to ensure timely submission of MDS assessments for three residents, R5, R38, and R131, out of eight residents reviewed in a sample of twenty-seven. R5's annual MDS assessment, R38's quarterly MDS assessment, and R131's quarterly MDS assessment were each submitted on 01/31/26 and exceeded the 14-day submission requirement from the ARD. During interview on 02/06/26 at 2:28 PM, the DON stated she was responsible for completing MDS assessments, explained that the ARD is when the assessment is due, and confirmed that the assessments for R5, R38, and R131 were submitted late. The facility policy stated that it follows the protocol in the RAI manual, and the RAI Version 3.0 Manual states that the MDS completion date must be no later than 14 days from the ARD.
Missed PASRR Determination for Resident With Severe Cognitive Impairment
Penalty
Summary
The facility failed to obtain a PASRR screening for Mental Disorders or Intellectual Disabilities for 1 of 7 residents reviewed for resident assessment, affecting R12. R12’s MDS dated 12/24/2025 showed a BIMS score of 5, indicating severe cognitive impairment. During record review on 02/05/2026, the PASRR documentation showed a short-term approval without specialized services with a determination date of 04/05/2025 and an end date of 08/03/2025. On 02/06/2026, the Associate Administrator stated a new PASRR Determination report had been run that morning and that R12 did not require specialized services, with results expected to be available on 02/09/2026. The Office Manager stated it was important to follow up with the PASRR determination for the resident to receive proper treatment, and the DON stated the recommended date of 08/03/2025 for R12’s PASRR determination was missed. The facility also stated it does not have a PASRR policy and procedure and follows the Maximus guidelines.
Care Plan Missing Hearing Impairment Interventions
Penalty
Summary
A person-centered care plan was not developed to reflect R84’s current condition, goals, and services, because the care plan did not include interventions for the resident’s hearing impairment. R84’s face sheet listed diagnoses including history of falling, anxiety disorder, and unspecified dementia. During observation on 02/04/2026, R84 was sitting in a specialized chair with a call light button and a red string attached to the right upper arm and part of the gown, and was noted to be very hard of hearing and not able to hear. R84 told the surveyor, “I didn’t hear that, I try to read their lips.” On 02/06/26, the Social Worker stated that R84 has a hard time hearing, can understand when spoken to closely to the ears, and that hearing problems should be care planned with interventions. Review of R84’s care plan with the Social Worker showed no documentation regarding the resident’s hearing impairment.
Failure to Provide Shaving Assistance
Penalty
Summary
The facility failed to ensure that one resident who depended on staff assistance for ADL care received shaving. R3, a [AGE]-year-old resident admitted with diagnoses including Parkinson's Disease without dyskinesia, tremor, and need for assistance with personal care, had a self-care deficit care plan stating that personal hygiene required total staff assist with personal hygiene and oral care. During observation, R3 was noted with facial hair on the chin and stated that staff assist with showers but had not removed the facial hair. R3 also stated she was not sure if staff were rushing. On a later observation, R3 was still not shaved and still had facial hair on the chin. R3 stated that no staff had come to ask if she wanted to be shaved and said she felt bad about her facial hair because people were going to think she was a male. A CNA stated that staff shave female residents only if they want to, that shaving can be done anytime and not only on shower days, and that she had not yet shaved R3 because she was busy. The DON stated that R3 needed help with shaving, could not shave herself, and that it was not okay for the resident to feel bad about her facial hair because it could hurt her dignity.
Failure to Follow Isolation Precautions and Clean Technique During Incontinence Care
Penalty
Summary
The facility failed to ensure staff followed contact isolation precautions for a resident with physician-ordered contact isolation for Proteus bacteremia MDRO and ESBL on a left foot wound. The resident’s face sheet listed diagnoses including sepsis, cystitis with hematuria, a history of urinary tract infections, type 2 diabetes mellitus with unspecified complications, pneumonia, and other bladder disorders. The MDS documented a BIMS score of 10/15, indicating moderate cognitive impairment. Although enhanced barrier precaution signage was observed on the door, there was no contact isolation sign posted. During observation, a CNA assisted the resident with repositioning and lunch while not wearing a gown or gloves. The CNA stated she was not aware the resident was on contact isolation. An RN stated the resident should have contact isolation signage on the door and that staff were supposed to gown and glove before entering and leaving the room. The RN supervisor/infection preventionist also stated there should be contact isolation signage outside the room, that the resident was on contact isolation because of ESBL on the left foot wound, and that staff must wear PPE and perform hand hygiene before entering the room. The facility also failed to maintain clean technique during incontinence care for another resident. That resident’s face sheet listed diagnoses including urinary tract infection, multiple sclerosis, hydronephrosis with renal and ureteral calculous obstruction, and reduced mobility. The resident’s MDS documented a BIMS score of 11/15, indicating moderate cognitive intactness. During care, a CNA removed a soiled brief, cleaned the resident, handled a soiled flat sheet, and then used the same gloves to apply barrier cream to the resident’s perineal area. The CNA also touched the same soaked and soiled flat sheet again while applying a new brief and continued care with the same gloves. The CNA later stated she should not have touched the soiled sheet and then applied barrier cream to the resident’s perineal area due to infection control. The DON stated CNAs are not supposed to use the same gloves that touched the soiled sheet to apply barrier cream and that proper infection control should be followed during incontinence care.
Resident Room Square Footage Deficiency
Penalty
Summary
The facility failed to provide the required square footage of 80 square feet per resident in multiple resident bedrooms for 19 rooms out of 86 rooms in the facility, affecting 26 residents in the sample of 137 residents. During interviews and record review, the Associate Administrator stated the facility had a room waiver for resident rooms that measured less than 80 square feet per resident in multiple resident rooms and less than 100 square feet for single resident rooms, and provided a list of rooms included on the waiver. Email correspondence documented that the facility had an annual waiver for resident bedrooms that did not measure 80 square feet per resident in multiple resident bedrooms. The waiver document stated that CMS granted a waiver of the federal requirement for resident rooms to afford 80 square feet per bed in multi-patient rooms for rooms 111, 113, 114, 115, 116, 118, 121, 122, 210, 211, 212, 214, 215, 217, 311, 313, 315, 317, and 325, subject to annual review.
Failure to Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that staff were feeding residents from a seated position during dining service, which affected four residents. Observations revealed that staff members, including CNAs and the Director of Nursing, were feeding residents while standing, contrary to the facility's policy that requires staff to be seated to maintain the residents' dignity. This practice was observed during lunch service, where staff were seen standing over residents in wheelchairs while feeding them, which is considered authoritative and not respectful of the residents' rights to dignity. The residents involved had various medical conditions that required assistance with eating. For instance, one resident had severe cognitive impairment and required partial to moderate assistance with meals, while another had moderate cognitive impairment and required extensive assistance. Another resident was cognitively intact but dependent on staff for feeding, and the last resident had severe cognitive impairment and required substantial assistance. Despite these needs, staff did not adhere to the policy of sitting while feeding, which is intended to promote dignity and respect. The facility's policy on feeding clearly states that staff should sit beside the resident to feed them, ensuring a respectful and dignified interaction. The Director of Nursing acknowledged the importance of this practice and admitted to standing while feeding a resident, which was against the facility's guidelines. The failure to follow this policy was observed and documented, highlighting a deficiency in maintaining the residents' rights to dignity and respect during meal times.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate fall prevention interventions for residents at risk for falls, resulting in repeated falls for three residents and potential risk for another. Resident R23 was observed sitting at the edge of the bed without proper footwear, despite having a history of falls and being at risk for falls due to poor safety awareness and mild cognitive impairment. The care plan for R23 indicated the need for proper footwear, yet the resident was found without non-skid socks, which are necessary to prevent falls. Resident R43, who also had a history of repeated falls, was observed in a wheelchair without proper footwear. The care plan for R43, who has mild cognitive impairment and difficulty walking, also required well-maintained footwear to prevent falls. Despite this, the resident was not wearing non-skid socks, which are part of the facility's fall prevention policy. Resident R58, with severe cognitive impairment and a history of falls, was observed walking with a walker without the necessary fall prevention measures in place. The facility's policy requires non-skid socks or shoes for residents at risk of falls, but this was not consistently implemented. Additionally, Resident R34, who is at high risk for falls due to cognitive and functional impairments, was observed without non-skid socks, contrary to the care plan's requirements. The facility's failure to ensure that residents at risk for falls were wearing appropriate footwear and receiving adequate supervision contributed to the repeated falls and potential risk for further incidents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident R103, diagnosed with Alzheimer's Disease, Type 2 Diabetes Mellitus, Hypertension, Abnormalities of Gait and Mobility, and Muscle Weakness, was observed with a call light cord hanging from the wall on the floor, out of reach. R103's care plan emphasized the importance of using the call light for assistance, yet the device was not accessible. Similarly, Resident R301, with diagnoses including Metabolic Encephalopathy, Pyothorax, Sepsis, Retention of Urine, and Hypertension, was found with the call light hanging behind the bed, also out of reach. R301 expressed unawareness of the call light's location and a need for instruction on its use. Interviews with facility staff, including a Registered Nurse (V26) and a Certified Nursing Assistant (V9), confirmed that the call light cords should be within reach of the residents. The Director of Nursing (V2) also stated that the call light device should be clipped to the resident and accessible. The facility's call lights policy, revised in January 2019, mandates that residents capable of using the call light should have it accessible within reach. The observations and staff interviews indicate a failure to adhere to this policy, resulting in the deficiency noted by the surveyors.
Failure to Coordinate PASARR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program and did not refer residents for Level II reviews upon significant changes in mental status. This deficiency affected three residents and potentially impacted an additional 34 residents with mental disorders or intellectual/developmental disabilities. Specifically, one resident was admitted with multiple mental health diagnoses, including bipolar disorder, which was not reflected in the PASARR form. Another resident had a new diagnosis of schizoaffective disorder, but no PASARR Level II screening was conducted following this significant change. The report highlights that the facility's receptionist, responsible for completing PASARR screenings, was not informed of new diagnoses by the nursing staff, leading to a lack of necessary Level II screenings. This oversight was evident in the cases of residents with serious mental health conditions, such as schizoaffective disorder and bipolar disorder, who did not receive the required assessments. The failure to update PASARR screenings upon significant changes in residents' mental health status indicates a breakdown in communication and procedural adherence within the facility.
Failure to Include Psychiatric Diagnoses in PASARR Screening
Penalty
Summary
The facility failed to ensure that a resident's psychiatric diagnoses were accurately included in the pre-admission screening, specifically the PASARR (Pre-Admission Screening and Resident Review) process. This deficiency affected one resident, identified as R109, who had documented diagnoses of schizoaffective disorder and schizophrenia. Despite these diagnoses being present in the resident's medical records and active medication orders, they were not included in the PASARR Level I screening. As a result, the initial determination incorrectly indicated that no Level II screening was required, which could have impacted the assessment of the resident's needs. The error occurred because the receptionist/office manager, who was responsible for completing the PASARR, did not include the necessary psychiatric diagnoses. The associate administrator acknowledged that the receptionist/office manager, being non-clinical, should have been guided by the nursing and social service departments regarding the resident's diagnoses and medications. This oversight was later corrected when a subsequent PASARR Level I screen identified the need for a Level II evaluation, citing the resident's mental health disabilities, including schizophrenia and schizoaffective disorder.
Deficiencies in Personal Hygiene and Oral Care
Penalty
Summary
The facility failed to provide timely oral care and personal hygiene shaving care for two dependent residents. One resident was observed with significant facial hair, including a mustache and chin hair, which she expressed a preference to have removed. Despite requiring substantial assistance with personal hygiene due to moderate cognitive impairment and other health conditions, the resident reported not being offered shaving assistance by the CNAs. The facility's policy and the Director of Nursing confirmed that shaving is part of the daily grooming routine for all residents, including females, and should be documented if refused. Another resident was observed with a creamy brown substance on her teeth, indicating a lack of oral care. When questioned, the resident stated that it had been a long time since staff assisted with mouth care. The CNA present acknowledged not having provided mouth care to the resident but indicated an intention to do so later. The resident's care plan noted a self-care deficit requiring assistance with ADLs, and the facility's policy mandates daily oral hygiene. These deficiencies highlight a failure in the facility's adherence to its policies regarding personal hygiene and oral care, impacting the residents' dignity and quality of life. The facility's policies and job descriptions emphasize the importance of maintaining residents' grooming and hygiene, yet the observations and resident interviews indicate lapses in the execution of these duties.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions as outlined in the care plans for three residents with dementia who are at risk for pressure ulcers. On March 31, 2025, three residents were observed sitting in wheelchairs without any pressure-relieving devices, such as cushions, during activities in the dining room. This observation was made twice, first at 11:08 AM and again at 12:15 PM. A Licensed Practical Nurse (LPN) acknowledged the absence of cushions and mentioned that sometimes staff send the cushions to the laundry, promising to ensure the residents receive the necessary cushions. The records for the three residents indicated that they were at risk for pressure ulcers, as documented in their respective care plans and Minimum Data Set (MDS) assessments. Each care plan specified the use of pressure-relieving cushions when the residents were seated in chairs. The facility's policy on pressure ulcer prevention also emphasized the importance of using pressure-relieving devices for at-risk residents. Despite these documented interventions, the facility did not adhere to the care plans, resulting in the deficiency noted by the surveyors.
Failure to Administer Correct Enteral Feeding Amount
Penalty
Summary
The facility failed to ensure that a resident receiving Enteral g-tube feeding was administered the correct amount of feeding as per the physician's orders. On March 31, 2025, a resident was observed with their Enteral g-tube feeding machine turned off and not connected, despite the feeding bottle being dated for that day. The Licensed Practical Nurse (LPN) on duty was unaware of who turned off the machine or for how long it had been off. The resident, who is alert and talkative, was supposed to receive continuous feeding at a rate of 70 ml/hr for 20 hours, but only 100 ml had been infused over a four-hour period, instead of the expected 280 ml. The resident involved has multiple diagnoses, including severe protein-calorie malnutrition and quadriplegia, and relies entirely on tube feeding for nutrition. The Director of Nursing (DON) confirmed that the feeding should have been running according to the physician's orders and that the resident should have received the full amount of feeding to meet their caloric needs. The facility's policy and job descriptions emphasize the importance of maintaining proper nutrition and hydration through tube feeding, yet the deficiency occurred due to a lapse in following these procedures.
Failure to Label and Change Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of respiratory equipment for two residents receiving oxygen therapy. Resident R11 was observed using a nasal cannula that was not labeled with the date it was changed, and the oxygen tubing and humidifier bottle were not changed weekly as required. The Director of Nursing confirmed that the facility's policy mandates labeling the humidifier bottle with the date of change and replacing the nasal cannula weekly to prevent infection. R11, who has a diagnosis of shortness of breath and chronic obstructive pulmonary disease, was receiving oxygen therapy at 2-3 liters per minute, and the facility's policy requires changing the equipment every Wednesday night shift. Similarly, Resident R79, diagnosed with metabolic encephalopathy, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia, was found with a nasal cannula that was not dated, and the humidification bottle was last dated over a week prior. The Registered Nurse confirmed that the oxygen tubing and humidification bottle should be changed weekly on the night shift and dated accordingly. These lapses in following the facility's oxygen therapy policy were identified during the survey, affecting the quality of care provided to the residents.
Inadequate Hand Hygiene During Resident Feeding
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident dining services, which could potentially lead to the spread of infectious microorganisms. Observations revealed that a Certified Nursing Assistant (CNA), identified as V13, did not perform hand hygiene after touching a resident's meal tray and before feeding another resident. Similarly, another CNA, V11, was observed not sanitizing hands between feeding different residents and after touching personal body parts, such as the face and ears, while feeding a resident. The report highlights specific instances involving residents R28, R43, and R77, who were affected by these lapses in infection control. R43, with a diagnosis of severe protein-calorie malnutrition and moderate cognitive impairment, required partial assistance with eating. R77, with severe cognitive impairment and a dependency on staff for feeding, was also at risk. R28, with severe cognitive impairment and requiring substantial assistance with eating, was observed being fed by V11, who did not perform hand hygiene at various points during the feeding process. The Director of Nursing (DON), identified as V2, acknowledged the importance of hand hygiene in preventing infection transmission and stated that staff are expected to perform hand hygiene before and after resident contact, especially when feeding residents. The facility's policies on infection control and hand hygiene were not adhered to, as evidenced by the observations of CNAs not washing or sanitizing their hands between resident interactions and after touching potentially contaminated surfaces or their own body parts.
Facility Fails to Meet Room Size Requirements Despite Waiver
Penalty
Summary
The facility failed to provide the required square footage of 80 square feet per resident in multiple resident bedrooms for 19 rooms out of 86 in the facility. This deficiency affected 29 residents in the total sample of 75 residents. During the entrance conference, the Administrative Consultant mentioned that the facility has an annual waiver for room sizes, which is renewed every year. The Associate Administrator confirmed that some rooms have less than the required square footage for each resident, but stated that all required furnishings and equipment are provided. The facility has an annual waiver from the State Department of Public Health, allowing them to bypass the federal requirement for room size under 42 CFR 483.90. This waiver is granted for specific rooms and is subject to annual review. The facility's policy on Resident Room Waivers indicates compliance with both IDPH and CMS federal requirements for these waivers. The waiver covers the rooms identified in the report, which do not meet the 80 square feet per bed requirement in multi-patient rooms.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that medication and treatment carts were secured, leading to a potential accident hazard for all 40 residents on the 1st floor. On December 24, at 10:30 AM, a medication cart was observed unattended and unlocked in the hallway without a nurse present. The LPN responsible for the cart admitted to leaving it to pick up something, acknowledging that the facility policy requires the cart to be locked when not in use or out of the nurse's sight. Additionally, at 10:40 AM, a treatment cart was found unattended and unlocked with resident treatment medications inside. The DON confirmed that the facility policy mandates that all medication storage areas, including carts, must be locked unless in use and under direct observation by the medication nurse. The facility's policy, revised in November 2011, clearly states these security requirements.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, which could potentially affect all 145 residents consuming meals from the facility's kitchen. During an inspection, dented cans of banana pudding and diced peaches were found co-mingled with undented cans in the dry storage room, contrary to the facility's policy that requires dented cans to be stored separately. Additionally, a white bucket labeled breadcrumbs lacked an open date and a use-by date. In the walk-in freezer, beef patties were found without open or use-by dates and were not in their original manufacturer's container. A tray of sliced pastrami was noted to be 13 days over the seven-day storage limit, and other food items in the refrigerator, such as pureed chicken and baked salmon, were also found to be past their allowed storage time without proper labeling. The ice machine in the kitchen was observed to be in an unsanitary condition, with blackish and brownish particles inside and whitish splashes on the outside. The Dietary Manager admitted that the machine should be cleaned monthly but could not provide a cleaning log or confirm the last cleaning date. The facility's policies on food labeling and ice machine cleaning were not followed, as evidenced by the lack of proper labeling and cleaning records. The Dietary Manager acknowledged the confusion caused by new labeling practices and the need for staff education to prevent foodborne illnesses.
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What surveyors actually found near you
We read the 1,689 citations issued within 25 miles in the last 12 months — including the 23 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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fargo Health Care Center | 0.1 mi | ★★★★★ | 5 | 0 |
| Waterford Care Center, The | 0.1 mi | ★★★★★ | 13 | 0 |
| Lakefront Nursing & Rehab Ctr | 0.1 mi | ★★★★★ | 0 | 0 |
| Chalet Living & Rehab | 0.2 mi | ★★★★★ | 18 | 1 |
| Clark Manor | 0.4 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.