Below 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 Bria Of River Oaks during CMS and state inspections, most recent first.
Infection control practices were not followed when isolation bins on the 1st and 2nd floors were observed without appropriate PPE, and a CNA was seen wearing gloves in the hallway and then removing them without performing hand hygiene. The DON and Infection Prevention Nurse stated staff should not wear gloves in the hallway, should perform hand hygiene before and after glove use, and that isolation bins should be stocked with appropriate PPE.
Multiple rooms were found to have temperatures above the required range, with several residents reporting discomfort due to excessive heat and malfunctioning air conditioning. Staff interviews confirmed that the issue had persisted for weeks, and temperature monitoring and response procedures were not effectively followed.
Air conditioning units on the second and third floors were not functioning properly, resulting in hallway temperatures of 84-85°F and several rooms blowing warm air. A blanket was used to soak up water from a leaking unit. The issue affected 127 residents, and the Corporate Maintenance Director was not informed of the problem until the day of the survey.
A resident with significant physical and mental health needs was physically taken to the floor and restrained by an activity aide/CNA after a dispute over smoking privileges. The resident sustained injuries and reported feeling scared and humiliated. Multiple staff, including security and nursing, failed to intervene or report the incident according to policy, resulting in a failure to protect the resident from abuse and ensure proper documentation and follow-up.
A staff member physically intervened with a resident using a crisis prevention technique that was not consistent with training, and failed to report or document the incident as required. The event was not communicated to the LPNs, DON, or administration, and no assessment or review was conducted, resulting in a lack of proper documentation and failure to follow facility policy.
A resident with a history of epilepsy, dementia, and chronic kidney disease experienced a delay in treatment for a fractured left hip due to inadequate pain assessment. Despite reporting severe pain and inability to move the left leg, the resident was not sent to the hospital until four days later, after an x-ray revealed the fracture. The facility failed to conduct a comprehensive assessment and did not follow its pain management policy, resulting in a significant delay in appropriate treatment.
A resident with a history of epilepsy, dementia, and chronic kidney disease experienced severe pain after a fall, which the facility failed to assess and manage properly. Despite complaints of pain, the facility did not conduct a comprehensive assessment, leading to a delay in diagnosing a left femur fracture. Pain management was inadequate, with inconsistent documentation and communication with healthcare providers.
A resident with chronic conditions was transferred to the hospital due to hyperglycemia and altered mental status, but the facility failed to notify the family, as required by policy. The family, who was the resident's power of attorney, was not informed until the resident was on life support. The nurse claimed to have called the family but did not document the call, leading to a deficiency finding.
A resident with bipolar disorder was injured in a physical altercation with a roommate who has a history of mental health issues. The incident began with a verbal dispute and escalated when the second resident attacked, resulting in a spinal fracture for the first resident. Staff present failed to de-escalate or separate the residents effectively, and security was not immediately available. The facility's policies for abuse prevention and behavior management were not followed.
The facility failed to maintain a clean and safe environment for residents, with issues such as soiled mattresses, unclean clothes, and inadequate window coverings. Observations revealed strong odors and unsanitary conditions in residents' rooms, with staff failing to address these issues promptly. The Maintenance Director acknowledged the use of paper blinds due to residents' destructive behavior, but replacements were not made regularly, leaving windows uncovered.
Two residents at high fall risk experienced falls due to inadequate supervision and monitoring. One resident with dementia and unsteadiness on feet suffered a fracture after falling unsupervised, while another resident with hemiplegia and dementia slid from a wheelchair, sustaining an ear laceration. The facility's fall risk evaluations were not accurately updated, and staff were unaware of the residents' fall risk status, leading to these incidents.
A resident with a history of hemiplegia and dementia sustained an ear laceration after sliding from a wheelchair. Despite hospital discharge instructions for a follow-up with a plastic surgeon, the facility failed to schedule the appointment. The wound care coordinator deemed the wound healed without documented consultation with a physician, and no contact was made with the plastic surgery office. The primary physician admitted to canceling non-life-threatening appointments, but there was no documentation supporting this decision.
The facility failed to provide adequate food portions to all residents, as evidenced by resident complaints and staff observations. Several residents with complex medical conditions reported insufficient meal sizes, and documentation from meetings and grievances highlighted ongoing requests for larger portions. Despite the facility's policy to meet residents' nutritional needs, the issue persisted, affecting all residents receiving meals.
The facility failed to provide timely emergency care for two residents, resulting in one resident's death and another's severe injury. A resident with high blood pressure and mental status changes experienced a two-hour delay in receiving emergency care, leading to a critical neurological event. Another resident with low blood sugar was not promptly treated with food or emergency services, resulting in cardiac arrest and hypoxic brain injury. Additionally, the facility did not adequately monitor blood sugar levels for two other residents, leading to severe hypoglycemia in one case.
Facility staff failed to identify and respond to emergency care needs for two residents with significant changes in physical and mental status. One resident with a history of cerebral infarction and diabetes was found vomiting and confused, leading to a delayed 911 call and eventual death from a subdural hematoma. Another resident experienced low blood sugar, received inadequate initial treatment, and later went into cardiac arrest. Additionally, the facility failed to monitor blood sugar levels for residents on diabetic medications and demonstrated improper insulin administration practices.
A resident developed a stage 3 sacrum pressure ulcer due to the facility's failure to provide adequate preventative measures and timely wound care. Despite being at risk, the resident was not given a low air loss mattress, and staff were not educated on pressure ulcer prevention. The Wound Nurse did not document or assess the wounds until prompted by a surveyor, and the Wound Physician confirmed the presence of a stage 3 ulcer and a skin tear, which were not previously identified by the facility staff.
A resident in a LTC facility was physically abused by another resident after being caught going through the aggressor's belongings. The incident resulted in a bleeding laceration on the victim's upper lip, requiring hospital evaluation. Both residents were alert and oriented, with histories of schizophrenia and other medical conditions. The facility's policy prohibits such abuse, yet the incident occurred, highlighting a failure to maintain a secure environment.
The facility failed to maintain a safe and comfortable environment, with observations revealing wall damage in 10 out of 12 resident rooms. Issues included rotted door jambs, large holes behind headboards, and damage at floor-wall junctions. The Maintenance Director acknowledged awareness of these issues and mentioned ongoing renovations.
The facility failed to prevent multiple incidents of resident-on-resident physical abuse, resulting in significant injuries. In one case, a resident with a history of violent behavior struck another resident, causing facial fractures. In another, a resident was hit while entering from the smoking patio. A third incident involved a resident being struck unprovoked in her room. The facility's policy on abuse and neglect was not effectively enforced.
The facility failed to ensure a resident with a stage 4 pressure ulcer was assessed by a Dietician upon admission. Despite a recommendation for a Dietician consult, no order was found, and the Dietician admitted to missing the resident due to being overloaded. The facility's policy requiring high-risk notes and nutrition assessments for such residents was not followed.
Infection Control: PPE Not Stocked and Hand Hygiene Not Performed After Glove Use
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to PPE availability and hand hygiene. On 5/23/26 at 10:03 AM, the 1st floor and 2nd floor isolation bins were observed without appropriate PPE in place. At 10:17 AM, V8, a CNA, was observed wearing gloves in the hallway, then removed the gloves and did not perform hand hygiene. V8 stated she was not supposed to wear gloves in the hallway and should perform hand hygiene before and after glove use, and acknowledged that she did not perform hand hygiene after glove removal. At 10:35 AM, V2, the DON, stated staff are not to wear gloves in the hallway for infection control purposes and should perform hand hygiene before and after glove use. V2 also stated PPE should be stocked in isolation bins and accessible to staff. At 10:45 AM, V9, the Infection Prevention Nurse, stated the isolation bins should be supplied with appropriate PPE and available to staff, and that staff are not to wear gloves in the hallway and should perform proper hand hygiene before and after glove use for infection control purposes. The facility policies on Hand Hygiene and Infection Control Program both state that hand hygiene is to be done before putting on gloves and after removing gloves, and that the infection control program includes training on hand hygiene, standard and transmission-based precautions, and PPE use.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable temperature levels within the required range of 71-81 degrees for multiple resident rooms. During observations conducted with the Maintenance Director, several rooms on the second and third floors were found to have temperatures ranging from 81 to 87 degrees. Residents in these rooms reported feeling hot and uncomfortable, with some stating that the air conditioning had been malfunctioning for an extended period. One resident noted that staff had placed a blanket under a leaking air conditioner and promised repairs, while others confirmed that the issue had persisted for weeks without resolution. Interviews with staff revealed that the Maintenance Director had only recently started working at the facility and was aware of ongoing air conditioning issues. The Corporate Maintenance Director stated that he was only made aware of the high temperatures on the day of the survey and that maintenance is typically performed twice a year. Facility policies require temperature monitoring and specific actions when indoor temperatures exceed 80 degrees, but the report indicates that these procedures were not effectively implemented, resulting in prolonged exposure of residents to excessive heat.
Failure to Maintain Functional Air Conditioning Results in Uncomfortable Temperatures
Penalty
Summary
The facility failed to maintain air conditioning units in good repair on the second and third floors, resulting in uncomfortably high temperatures in both hallways and several resident rooms. Observations revealed that the second-floor hallway temperature reached 84°F and the third-floor hallway reached 85°F. Multiple resident rooms on both floors had air conditioning units that were not functioning properly and were blowing warm air. In one room, a blanket was found placed under the air conditioner to soak up water dripping from the unit. These conditions affected a total of 127 residents residing on the second and third floors. Interviews with facility staff indicated that the Maintenance Director had only recently started working at the facility and was in the process of addressing some of the malfunctioning air conditioners. The Corporate Maintenance Director stated that the expected temperature range for resident rooms is 68-78°F and that maintenance is typically performed twice a year. However, the Corporate Maintenance Director was not made aware of the high temperature issue until the day of the survey. The facility's job description for the Maintenance Director includes responsibilities for maintaining equipment and promptly reporting facility damage.
Failure to Protect Resident from Physical Abuse and Inadequate Incident Reporting
Penalty
Summary
A staff member, identified as an activity aide/CNA, physically intervened with a resident who was seeking to smoke after refusing a blood draw. The staff member confronted the resident, grabbed him by both arms, took him down to the floor, and held him there. The resident, who has muscle wasting, atrophy, anxiety, and a right ankle contracture, subsequently complained of pain and was observed with an abrasion on his right elbow. He was later sent to the hospital and diagnosed with acute bilateral lower back pain, elbow pain, and thumb pain. The resident reported feeling scared and humiliated by the incident. Multiple staff members, including security and nursing staff, were present or nearby during the incident but did not intervene or respond appropriately to protect the resident or gather information for reporting. The activity aide/CNA did not follow proper Crisis Prevention Intervention (CPI) protocols, as confirmed by the social service director and activity director, and failed to report the incident to the appropriate supervisory staff. The nurse and other staff who were aware of the commotion did not document or escalate the event as required by facility policy. The facility's abuse prevention policy prohibits abuse, neglect, and mistreatment of residents and requires all incidents to be documented and reported. However, the incident was not promptly or properly reported to the administrator, DON, or other relevant authorities. The lack of immediate assessment and documentation, as well as the failure to remove the alleged perpetrator from duty, contributed to the deficiency in protecting the resident from abuse and ensuring a safe environment.
Failure to Document and Report Crisis Prevention Intervention Incident
Penalty
Summary
The facility failed to follow its behavior management policy and document an incident involving the use of crisis prevention intervention (CPI) techniques on a resident. On the morning in question, a staff member (activity aide/CNA) physically intervened with a resident by grabbing both wrists, taking the resident to the floor, and holding them in that position. This action was not reported to the nurses on duty, the acting administrator, or the director of nursing at the time. Multiple staff interviews confirmed that the incident was not communicated through proper channels, and the required documentation in the nursing notes was not completed. The resident did not receive an assessment for injuries following the incident, and the event was not reviewed as per facility policy. The facility's behavior management policy requires staff to use the least restrictive interventions, document resident behavior and symptoms, perform an assessment, and notify family or physician after such incidents. The abuse policy also mandates documentation and internal investigation of all incidents, whether or not abuse is suspected. In this case, the staff member's actions were not consistent with CPI training, and the incident was not documented or reported according to policy, resulting in a failure to safeguard resident-identifiable information and maintain accurate medical records.
Delayed Treatment for Hip Fracture Due to Inadequate Pain Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a resident with a new onset of left leg pain, resulting in a delay in treatment and hospitalization for a fractured left hip. The resident, who has a medical history of epilepsy, Todd's paralysis, dementia, and chronic kidney disease, reported falling while trying to get into a wheelchair. Despite complaints of severe pain and inability to move the left leg, the resident was not sent to the hospital until four days later, after an x-ray revealed a fracture. The resident first complained of left leg pain on February 17, but the initial assessment focused only on the knee, and an x-ray of the knee was negative. The resident continued to report pain, but the staff did not conduct a thorough assessment to determine the root cause of the pain. The resident's pain was initially attributed to osteoarthritis, and no further imaging was ordered until February 21, when a nurse practitioner ordered an x-ray of the left hip, which revealed a fracture. Throughout this period, the resident's pain was not adequately assessed or documented, and the facility's pain management policy was not followed. The resident's pain scores were not recorded every shift, and comprehensive pain assessments were not completed on February 19 or 20. The lack of a thorough assessment and timely intervention led to a significant delay in the resident receiving appropriate treatment for the hip fracture.
Failure to Assess and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately assess and manage a resident's new onset of pain, which led to a delay in identifying a serious medical condition. The resident, who had a history of epilepsy, Todd's paralysis, dementia, and chronic kidney disease, experienced a fall while attempting to transfer to a wheelchair. Despite the resident's complaints of severe pain in the left leg, the facility did not conduct a comprehensive assessment to determine the underlying cause of the pain. Initial assessments focused on the left knee, and an x-ray was ordered, which showed no fracture. However, the resident continued to experience significant pain, which was not effectively communicated to the primary care provider. The resident's pain persisted over several days, with staff failing to reassess the situation adequately or notify the primary care provider of the continued pain despite the administration of tramadol. The resident's pain was initially attributed to osteoarthritis, and the facility did not perform a thorough examination to rule out other potential causes. It was not until several days later that an x-ray of the left hip was ordered, revealing a fracture of the left femur. This delay in diagnosis resulted in the resident experiencing increased pain levels for four days before being sent to the hospital for treatment. Interviews with staff revealed a lack of consistent pain assessment and documentation, as well as a failure to follow up on the resident's pain management plan. The facility's policy on pain management was not adhered to, as pain assessments were not conducted every shift, and the resident's pain scores were not consistently documented. The failure to identify and address the resident's pain in a timely manner highlights deficiencies in the facility's pain management practices and communication with healthcare providers.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to adhere to its discharge and change in condition policies by not notifying a family member of a resident's change in condition and subsequent transfer to the hospital. The resident, an elderly individual with chronic obstructive pulmonary disease, type 2 diabetes, and left eye glaucoma, was assessed by a nurse practitioner for hyperglycemia and altered mental status. The decision was made to transfer the resident to the hospital for further evaluation due to confusion and uncontrolled hyperglycemia. Despite the facility's policy requiring notification of the resident's family in such situations, there was no documentation indicating that the family was informed of the transfer. The resident's family member, who was also the power of attorney, was not notified by the facility and only learned of the hospitalization through the hospital itself. This lack of communication resulted in the family member being unaware of the resident's condition until the resident was on life support. Interviews with facility staff revealed that the nurse responsible for the resident's care claimed to have called and left a message for the family but failed to document the call due to being busy. The facility's policies clearly state that family notification must be documented, including the name of the family member contacted, the phone number called, and the time of the call. The absence of such documentation contributed to the deficiency identified by the surveyors.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse prevention and behavior management policies during a resident-to-resident altercation, resulting in a serious injury. A male resident with a history of bipolar disorder, depression, muscle wasting, and atrophy was involved in a verbal and physical altercation with his roommate, who has a history of major depressive disorder, anxiety disorder, cocaine abuse, and suicidal ideations. The altercation began with a verbal exchange over the room's lighting and noise levels, which escalated when the second resident physically attacked the first, leading to a compression fracture of the spine for the first resident. During the incident, staff members present did not effectively intervene to prevent the escalation from verbal to physical aggression. A registered nurse and a certified nursing assistant were in the vicinity but failed to de-escalate the situation or physically separate the residents in a timely manner. The nurse attempted to redirect the aggressive resident verbally but was overpowered when the resident attacked. The certified nursing assistant, who was providing care to another resident, did not intervene physically due to concerns for personal safety and instead called for security, which delayed the response. The facility's administrator acknowledged that staff are trained in Non-Violent Crisis Prevention and Intervention (CPI) techniques and are expected to intervene in such situations. However, the staff did not follow the facility's policies for behavior management and abuse prevention, which include de-escalation, redirection, and environmental control. The administrator also noted that security was not stationed on the floor where the incident occurred, which contributed to the delay in response. The facility's investigation concluded that the aggressive behavior was not substantiated as abuse due to the resident's mental health condition, but the failure to prevent the altercation and protect the residents was evident.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and interviews. Nine residents were affected by the facility's inability to adhere to its housekeeping and maintenance policies. Observations revealed that residents' rooms were not kept clean, with heavily soiled mattresses not being replaced, unclean clothes not being removed promptly, and windows lacking proper coverings. For instance, residents reported that their window covers were torn or missing, and it took an extended period for repairs or replacements to occur. Specific incidents highlighted the severity of the issue. One resident's room was observed with a strong odor due to a large garbage bag left on the bathroom floor, a sheet around the toilet base, and a toilet filled with feces. The odor was so strong that it was intolerable. The resident's mattress was stained and smelled of urine, and their clothing was found wet and covered in gnats. Staff interviews confirmed that the resident had a history of urinating in inappropriate places, and there was a lack of timely intervention to clean and maintain the room. The facility's maintenance and housekeeping staff were aware of the issues but failed to address them promptly. The Maintenance Director acknowledged that residents in the Annex were destructive, leading to the use of paper blinds, which should be replaced regularly if damaged. Despite having an adequate supply of blinds, the facility did not ensure that windows were properly covered, leaving residents without privacy and comfort. The Administrator confirmed that staff should have addressed these issues immediately, but the deficiencies persisted, affecting the residents' quality of life.
Inadequate Supervision and Monitoring of High Fall-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for residents at high risk of falls, resulting in two incidents involving residents R1 and R2. R1, a resident with dementia, schizophrenia, and unsteadiness on feet, suffered a left arm fracture after falling in the hallway unsupervised. Despite being alert and oriented, R1 reported feeling pushed by an 'evil spirit' and was able to walk back to their room without assistance. The facility's fall risk evaluation for R1 was not updated accurately, and R1 was not listed as a high fall risk until after the incident. Staff interviews revealed a lack of awareness and communication regarding R1's fall risk status, and the fall binder used to track high fall-risk residents was not consistently updated or accessible. R2, a resident with hemiplegia, epilepsy, and vascular dementia, was on 1:1 monitoring due to their high fall risk. During a meal, R2 slid out of their wheelchair, resulting in a laceration to the right ear. The CNA assigned to monitor R2 reported that R2 made a sudden movement, causing the wheelchair to move, and the CNA attempted to lower R2 to the floor. However, R2's ear was injured during the fall. The facility's investigation noted that R2 was on 1:1 monitoring, but the CNA was responsible for multiple residents, and there was no clear documentation of the specific monitoring requirements for R2. The facility's policies on fall prevention and management were not effectively implemented, as evidenced by the lack of accurate fall risk assessments and communication among staff. The fall risk evaluations for R1 were not scored correctly, leading to a failure to identify R1 as a high fall risk. Additionally, the fall binder, which was intended to inform staff of high fall-risk residents, was not consistently updated or utilized by staff. These deficiencies in supervision and monitoring contributed to the incidents involving R1 and R2, highlighting a need for improved communication and adherence to fall prevention protocols.
Failure to Schedule Follow-Up for Ear Laceration
Penalty
Summary
The facility failed to follow hospital discharge instructions by not scheduling a follow-up appointment for a resident with an ear laceration. The resident, who has a history of hemiplegia, epilepsy, aphasia, and vascular dementia, sustained a skin tear on the right ear after sliding out of a wheelchair. The resident was sent to the hospital, where plastic surgery recommended follow-up care, including a potential skin graft evaluation. However, the facility did not schedule the necessary follow-up appointment with a plastic surgeon as instructed. Interviews and record reviews revealed that the wound care coordinator decided not to send the resident to the follow-up appointment, considering the wound healed. This decision was made without documented consultation with the physician or nurse practitioner. The wound care coordinator and the Director of Nursing acknowledged the importance of follow-up appointments and the need for proper documentation of any decisions to cancel such appointments. However, there was no documentation indicating that the facility contacted the plastic surgery office or that the primary physician was involved in the decision to cancel the appointment. The facility's failure to ensure the resident attended the follow-up appointment resulted in a lack of evaluation for potential reconstructive surgery. The primary physician admitted to canceling specialty appointments if deemed non-life-threatening, but there was no documentation supporting this decision for the resident's ear laceration. The facility's policy on skin tears and other non-pressure ulcers requires appropriate documentation, which was not completed in this case.
Inadequate Food Portions for Residents
Penalty
Summary
The facility failed to provide food portions that meet the needs and preferences of all 238 residents receiving meals. This deficiency was identified through observations, interviews, and record reviews. Several residents, including those with complex medical histories such as psychosis, bipolar disorder, dementia, schizophrenia, and chronic conditions like diabetes and kidney disease, reported that the food portions were inadequate. A Certified Nursing Assistant also noted that the portions, particularly for pureed meals, seemed insufficient. Residents expressed dissatisfaction with the portion sizes, indicating that they were not allowed to have seconds even when the initial serving was not enough. The deficiency was further supported by documentation from Food Committee and Resident Council meetings, as well as grievances filed between July and August 2024, which highlighted repeated requests for larger portions and more meat for breakfast. The facility's Food Quality and Palatability Policy, reviewed on September 13, 2024, states that food should be prepared and served to meet residents' needs, yet the evidence suggests this policy was not being effectively implemented. The failure to provide adequate food portions was a systemic issue affecting all residents receiving meals at the facility.
Failure to Provide Timely Emergency Care and Monitor Blood Sugar Levels
Penalty
Summary
The facility failed to identify and respond to emergency care needs for two residents, resulting in significant delays in treatment. One resident, a male with a history of cerebral infarction, type II diabetes, and dementia, exhibited symptoms of high blood pressure and mental status changes. Despite these symptoms, there was a two-hour delay before emergency services were called, during which the resident's condition deteriorated, leading to a critical neurological event and subsequent death. The physician was not notified in a timely manner, and the care plan for hypertension was not adequately followed. Another resident, also a male with type II diabetes, chronic kidney disease, and hypertension, experienced symptoms of low blood sugar. The nurse on duty administered sugar and glucagon but failed to provide food or escalate the situation to emergency services promptly. The resident went into cardiac arrest and was later revived by paramedics, but suffered a hypoxic brain injury and eventually passed away under hospice care. The care plan for diabetes management was not effectively implemented, contributing to the resident's decline. Additionally, the facility did not adequately monitor blood sugar levels for two other residents receiving diabetic medications. One resident was found unresponsive with severe hypoglycemia and required emergency treatment, while another had no documented blood sugar checks for two weeks. The lack of proper monitoring and documentation, as well as the absence of a diabetes management plan, further exemplifies the facility's failure to provide appropriate care for residents with diabetes.
Failure to Identify and Respond to Emergency Care Needs
Penalty
Summary
The facility staff failed to identify and respond appropriately to emergency care needs for two residents, R1 and R2, who exhibited significant changes in their physical and mental status. R1, a male resident with a history of cerebral infarction, type II diabetes, and dementia, was found vomiting and confused with abnormal vital signs, including low oxygen saturation. Despite these symptoms, there was a delay in calling 911, and R1 was eventually diagnosed with a large subdural hematoma and expired after being airlifted to a hospital. The physician was not notified of R1's condition prior to hospitalization. R2, another male resident with type II diabetes, chronic kidney disease, and hypertension, experienced symptoms of low blood sugar during a medication pass. The nurse on duty administered sugar and orange pop, but R2's blood sugar continued to drop, necessitating an emergency glucagon injection borrowed from another resident. R2 was later found unresponsive and was revived by paramedics after experiencing cardiac arrest. The physician noted that R2 should have been given food and sent to the emergency room immediately after the low blood sugar was detected. Additionally, the facility staff failed to monitor blood sugar levels for residents R5 and R6, who were on diabetic medications. R5 was found unresponsive with low blood sugar and was treated for hypoglycemia and sepsis. The facility also demonstrated a lack of competency in insulin preparation and administration, as observed with incorrect insulin dosing and improper use of insulin pens. The facility did not ensure the availability of resident-specific diabetes medications for emergencies, leading to the borrowing of medications from other residents.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of an avoidable pressure ulcer in a resident, identified as R77, who was admitted with conditions including End Stage Renal Disease, anxiety, and schizoaffective disorder. Despite being at risk for pressure ulcer development, the resident was not provided with adequate preventative measures such as a low air loss mattress. The care plan lacked comprehensive interventions to prevent skin breakdown, and the facility did not educate staff on pressure ulcer prevention and treatment. Observations revealed that the resident was lying on a regular mattress and reported pain from a wound on her back, which was not documented in the facility's records. The facility's wound care process was inadequate, as evidenced by the lack of timely identification, assessment, and treatment of the resident's wounds. The Wound Nurse, V5, failed to document or assess the wounds until prompted by the surveyor, and there were no treatment records in the Treatment Administration Record (TAR) for June and July. The Wound Physician, V35, confirmed the presence of a stage 3 sacrum pressure ulcer and a skin tear on the resident's back, which were not previously identified by the facility staff. The Director of Nursing, V2, acknowledged the expectation for nurses to notify physicians and the Power of Attorney when wounds are identified, but this protocol was not followed in R77's case.
Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. One resident, who was alert and oriented, reported hearing sounds and observed another resident going through his pants pocket. Despite being told to stop, the second resident did not comply, leading the first resident to physically assault him. This altercation resulted in the second resident sustaining a bleeding laceration on his upper lip, which required medical evaluation at a hospital. The incident was documented in the Facility Reported Incident as a case of physical abuse. The facility's policy on abuse clearly prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury on a resident that requires medical attention. Despite this policy, the incident occurred, indicating a failure to ensure a resident-sensitive and secure environment. The involved residents were both alert and oriented, with one having a history of schizophrenia, depression, and weakness, and the other having hypertension, schizophrenia, and chronic kidney disease. The facility's staff, including a social service worker and a registered nurse, acknowledged that the incident constituted physical abuse.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in 10 out of 12 observed rooms. Observations made on June 8, 2024, with the Maintenance Director revealed various forms of wall damage in multiple resident rooms. Specific issues included wall damage next to the toilet room door in one room, rotted metal door jambs, large holes behind headboards, and damage at the floor-wall junctions in several rooms. The Maintenance Director acknowledged awareness of these issues and mentioned ongoing renovations in resident rooms and common areas. The facility's policy, dated June 2015, outlines guidelines for maintaining cleanliness, hygiene, and proper repair, aiming to create a safe and comfortable environment for residents, staff, and visitors.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, resulting in multiple incidents of resident-on-resident violence. In one instance, a resident with a history of violent behavior struck another resident in the face, causing significant injuries including a displaced right maxillary sinus fracture and a displaced fracture of the right zygomatic arch. The incident occurred in the hallway, where staff witnessed a verbal disagreement escalate into physical violence. The injured resident was sent to the local hospital for further medical evaluation and treatment. In another incident, a resident was hit in the face by another resident while trying to enter the facility from the smoking patio. The aggressor, who was reportedly frustrated by the victim's slow movement, immediately apologized after realizing what had happened. Staff intervened by separating the residents and reporting the incident to the nurse. The aggressor was placed on 1:1 supervision to monitor for further behaviors. A third incident involved a resident being struck in the face by another resident who entered her room unprovoked. The aggressor was subsequently sent to a psychiatric unit for evaluation and has not returned to the facility. The victim was moved to another floor for her safety. The facility's policy on abuse and neglect emphasizes the prohibition of abuse and the establishment of a secure environment for residents, but these incidents indicate a failure to uphold these standards.
Failure to Assess Resident with Stage 4 Pressure Ulcer by Dietician
Penalty
Summary
The facility failed to ensure a resident with a stage 4 pressure ulcer was assessed by a Dietician upon admission. The resident, who had multiple diagnoses including diabetes, mild protein-calorie malnutrition, and end-stage renal disease, was admitted from the hospital. Despite a recommendation for a Dietician consult in the resident's Wound Care Telemedicine Initial Evaluation, no order for a Dietician consult was found in the resident's records. The Dietician admitted to being overloaded and missing the resident, acknowledging the importance of assessing residents with pressure ulcers due to their increased calorie and protein needs. The facility's policy requires the Dietician to complete high-risk notes and nutrition assessments for residents with wounds and those on dialysis, which was not followed in this case.
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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.
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Nursing homes near Burnham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Dolton | 1.4 mi | ★★★★★ | 4 | 0 |
| Countryside Nursing & Rehab Ctr | 1.6 mi | ★★★★★ | 2 | 0 |
| Thryve Of South Holland | 3.2 mi | ★★★★★ | 15 | 0 |
| Elevate Care South Holland | 3.6 mi | ★★★★★ | 12 | 0 |
| Prairie Oasis | 3.6 mi | ★★★★★ | 33 | 1 |
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