Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at British Home, The during CMS and state inspections, most recent first.
A facility failed to follow ordered diets, provide ordered nutritional supplements with meals, and document meal intake for three residents with significant nutritional risk. One resident reported ordered items were not brought, another was observed eating only part of a meal while a required Magic Cup was missing, and staff stated meal consumption was not consistently documented in the EHR despite weight loss and malnutrition concerns.
Incorrect meal portions were served when cooks plated Italian beef sandwiches without weighing the meat or following the recipe portion size. Staff were unsure of the required amount, the recipe was not available at the time, and a test plate of beef measured only 1.9 oz instead of the expected 3 oz. The RD confirmed the sandwiches had less beef than the recipe picture and that meat should have been weighed before serving.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed expired and unlabeled food items, including dated deli meat and an unidentifiable unlabeled liquid, along with heavy grease buildup on hood filters, walls, and near the griddle. They also found a hole in the kitchen wall by the ice machine, a kitchen utility worker with facial hair not wearing a beard net, and missing sanitation QA entries for the dish machine, pot sink, sanitizer solution, red bucket, and test strips. The dining director, maintenance director, and RD confirmed the observations.
The facility failed to complete an accurate facility assessment by leaving out required resident, cultural, and staffing information. The assessment did not identify ethnic, cultural, or religious factors affecting care, did not reflect staffing needs by unit or shift, did not list agency nursing contracts or staffing agencies used, and did not include input from residents’ representatives or family members.
Inadequate ventilation above the dish machine allowed steam to rise and hit the ceiling tiles over the dishwashing area. Staff observed bowed, peeling ceiling tiles, exposed yellow foam insulation, and a disrepair area around the ventilation duct, and the Maintenance Director stated the damage was caused by steam from the dish machine and had required repeated tile repairs.
A facility failed to keep call lights within reach for multiple residents and failed to keep room dry erase boards updated with the correct date. Residents with dementia, cognitive impairment, hearing deficits, and functional limitations were observed with call lights out of reach, and staff acknowledged the issue. Several residents also had incorrect dates posted on their boards, which residents used for orientation and daily reference.
An LPN and surveyor found an opened multi-dose vial of Tuberculin stored in the medication refrigerator without a date opened. The LPN confirmed the vial was not dated, and the DON stated medications need a use-by date so staff know how long they remain effective. Facility policy required opened vials to be dated and assigned a new expiration date.
A resident’s Advance Directives care plan did not match the POLST and physician orders. The POLST stated no CPR/do not attempt resuscitation, and the physician order stated DNR for both pre-arrest and full-arrest emergency, but the care plan incorrectly stated the resident had chosen no advance directives and was full code. During interview, the ADON confirmed the mismatch after reviewing the resident’s POLST, orders, and care plan.
Failure to refer a resident for PASRR Level II after a bipolar dx was identified. The resident had a PASRR Level I completed before admission, later had bipolar disorder added to the record, and had orders and care plan documentation reflecting the dx. Medical Records acknowledged a PASRR II should have been initiated after the bipolar dx was added, and the Administrator stated the psych provider did not notify the facility so a new screening could be done.
Failure to Provide ADL Care for a Dependent Resident: A cognitively intact resident dependent on staff for toileting and personal hygiene was observed with a strong urine odor, a saturated incontinence brief, long facial hair, thick long broken toenails, and dry scaly skin on both shins. The assigned CNA stated the resident had been changed that morning, but the brief was found saturated with urine; an LPN later confirmed the facial hair and toenails needed attention and said the resident needed to be added to the podiatry list.
Failure to document and communicate resident changes in condition and hospice orders: A resident with ectropion and presbyopia had red, swollen lower eyelids with yellow crusting, but staff did not accurately document the full assessment, did not identify the change in condition, and no clear physician notification or eye treatment order was documented. Another resident on hospice with moderate cognitive impairment was observed receiving O2 at 4 L via NC, yet the hospice binder lacked standing orders and the hospice care plan, and the electronic care plan did not include O2 therapy.
A resident with multiple serious diagnoses, including PVD and CHF, developed a new posterior heel blister while heels were not offloaded and protective boots were not in use. Staff did not document the new skin impairment, did not notify the DON/ADON or MD/NP, and did not obtain wound treatment orders before applying dressings. The record also showed missing wound documentation for known heel and arm wounds and gaps in LAL mattress and heel offloading documentation.
Unlabeled Distilled Water Used for Tube Feeding Flushes: A resident with a GJ tube, dysphagia, and other significant diagnoses had an opened gallon of distilled water at the bedside that was not labeled with an open date. The resident said they were unsure what the water was for and did not drink anything. An RN and the DON both stated opened sterile water for tube feeding should be dated.
A facility failed to keep respiratory devices contained when not in use for two residents. One resident’s incentive spirometer was left uncontained on a windowsill while an RN acknowledged it was not stored in a bag, and another resident’s CPAP mask was observed uncontained behind a dresser and later on a dresser despite orders for CPAP at bedtime and a care plan that did not address containment. The facility policy for CPAP/BiPAP excluded storage/containment of respiratory equipment when not in use.
Missing Dialysis Physician Order: A resident with ESRD and moderate cognitive impairment had a dialysis access in place and reported being transported for dialysis, but the EMR did not contain a physician order for dialysis treatment and transportation during record review. The DON confirmed the order was not in the chart, and a dialysis order was later produced that specified twice-weekly HD, right chest CVC access, and ambulance transport.
A facility failed to maintain accurate controlled substance records for a resident receiving Pregabalin. During cart count, an LPN reported giving one capsule that morning but had not yet signed the controlled drug record, leaving the documented count inaccurate. The resident had multiple diagnoses including CHF, AKI, CKD, polyneuropathy, and RA, and facility policy required immediate documentation of the dose, remaining quantity, and nurse initials.
Significant IV Vancomycin Medication Error: A resident with osteomyelitis received IV Vancomycin through a PICC line at the wrong infusion rate. The order and medication label specified 125 ml/hr, but the infusion was observed running at 132 ml/hr, and the RN stated the pump kept changing to 175 ml/hr and that there was something wrong with the pump. The DON stated the ordered rate was important because of the medication timing window and lab trough timing.
Malfunctioning IV Pump Used for Vancomycin Infusion: An RN administered Vancomycin through a resident’s PICC line using an IV pump that would not hold the ordered rate and kept changing to a higher rate. The resident had osteomyelitis and was ordered Vancomycin 1G/250ml IV twice daily at 125 ml/hr, but the pump was observed infusing at 132 ml/hr. The RN stated the pump was not working properly, and the DON stated a faulty IV pump should not be used for resident care.
The facility failed to conduct timely background checks for a resident and nine employees, contrary to its policy. A resident identified as an offender had a delayed CHIRP check, and multiple employees had background checks completed after their hire dates. Staff interviews revealed oversight and miscommunication as contributing factors.
The facility's kitchen failed to maintain sanitary conditions, with food items improperly stored on the floor, an ice machine with dust buildup, and a malfunctioning dishwasher temperature gauge. Additionally, ice cream was not labeled with open dates, and a garbage container lacked a lid, all of which could lead to contamination and infection risks.
A resident with impaired mobility developed a new wound excoriation on the right buttock due to the facility's failure to assess and report a new skin condition. Despite CNAs observing the issue during incontinence care, it was not reported to the licensed nurse, leading to a delay in treatment. The condition was later identified as moisture-associated skin damage and diaper dermatitis, highlighting a lapse in following the facility's skin assessment policy.
A resident with severe cognitive impairment and mobility challenges fell from a wheelchair due to inadequate supervision. Despite being placed near the nursing station for monitoring, staff failed to assist as the resident attempted to reach her leg, causing the wheelchair to flip. The facility lacked an updated care plan addressing the resident's specific needs, and staff did not effectively implement fall risk management policies.
A facility experienced a 12% medication error rate involving three residents. An LPN administered an incorrect dosage of Calcium Carbonate to a resident with dementia. An RN failed to ensure proper inhalation technique for a resident using an Albuterol inhaler. Another LPN did not follow guidelines for insulin administration, neglecting to clean the needle hub or prime the pen for a diabetic resident.
Failure to Follow Diet Orders, Provide Supplements, and Document Meal Intake
Penalty
Summary
The facility failed to follow therapeutic diet orders, failed to ensure ordered nutritional supplements were provided during meals, and failed to monitor, assess, and document meal and nutritional intake for residents. These failures affected three residents reviewed for nutrition: one resident with dementia, weakness, COPD, palliative care, GERD, and documented malnutrition; one resident with severe protein-calorie malnutrition, moderate cognitive impairment, hospice care, poor oral intake, weight loss, and impaired mobility; and one resident with multiple serious diagnoses including dysphagia, diabetes, pressure injuries, and weight loss. One resident stated that the food brought to her did not match what she ordered and that requested items were not brought back. During lunch, she was served a meal and ate about 10% of it, drank all of her cranberry juice, and said she always asked for ice cream that was never brought. Her tray ticket had ice cream circled, and her physician orders included Magic Cup twice daily with lunch and dinner. Her care plan identified nutritional risk and directed that her prescribed diet and supplements be provided. Her weight decreased from 135 pounds to 125 pounds, and the MNA dated 1/14/26 documented a screening score of 7, indicating malnutrition. Another resident was observed being fed lunch in bed and ate only cream of spinach soup from a tray that also included baked fish, lo mein noodles, and spinach cream soup. The tray ticket noted no chicken and to provide Magic Cup with lunch, but no Magic Cup was on the tray. Her care plan also directed Magic Cup twice daily and Boost daily. The Dining Director stated the Magic Cups were kept in the freezer on each floor and that nursing staff should check the diet ticket with each meal. The DON stated nurses and CNAs should check the resident’s ticket for the correct meal and supplements, and that the nurse had to document when the supplement was given. For the third resident, the record showed weight loss, nutritional risk, and a plan to monitor oral intake of food and fluids, but the facility could not locate documentation showing nurses were recording meal consumption. The DON stated percentage of meal consumption was only occasionally documented in interdisciplinary notes and otherwise not documented anywhere else, and the Assistant DON stated CNAs did not document meal consumption. The Dietitian stated she monitored intake by reviewing nursing notes, but also stated there was no documentation of breakfast or dinner intake on some days and no documentation of meal consumption every day by nursing. The facility’s weight monitoring policy stated meal consumption information should be recorded.
Incorrect meal portions served without weighing meat
Penalty
Summary
The facility failed to ensure portion sizes were adequate, failed to ensure portion sizes were served according to the recipe, and failed to weigh food products to ensure correct serving sizes prior to serving. The deficiency affected all 35 residents who consume food from the kitchen. The facility menu for lunch included chicken noodle soup, an Italian beef sandwich, roasted potato wedges, marinated mushrooms and peppers, and a peanut butter cookie. The recipe for the Italian beef sandwich directed staff to serve a 3 oz slice of beef with a side cup of hot beef broth for dipping, and the recipe picture showed a sandwich that occupied about half of the plate. During meal plating for skilled rehab residents, cooks observed in the steam table were serving one to three slices of beef on a small roll that appeared about 4 inches long. One cook was unsure of the portion size and said the recipe was not available, while another said the portion varied by resident and that staff sometimes served less meat so residents would not get scared and not eat as much. The dietary director confirmed the recipes had not yet been printed and obtained the kitchen scale from the office. A test plate with three slices of beef was weighed and measured 1.9 oz. The dietary director stated the portion should have been around 3 oz and that the amount served was not enough beef. The registered dietician confirmed 1.9 oz was far less than required, that dietary staff should weigh meat products prior to serving, and that the sandwiches being served had less beef and a smaller roll than the recipe picture.
Kitchen Food Storage, Sanitation, and QA Monitoring Deficiencies
Penalty
Summary
The facility failed to label and store food items in accordance with professional standards, and surveyors observed multiple food safety issues in the kitchen. During the initial kitchen tour, a crushed red pepper container had a good-by date of 8/8/2025, taco seasoning was unlabeled, and a pitcher of tan, milky liquid was unidentifiable and had no label or date. The dining director confirmed these observations and stated the seasoning would need to be relabeled and the liquid should have been dated before it was dumped into the sink. Surveyors also observed expired and improperly stored food in the freezer. Plastic bags of deli-style ham had a use-by date of 4/30/2026, and a bag of deli-style turkey slices was undated and unlabeled. The dining director confirmed the ham was past date and removed it, and confirmed the turkey should have been dated and labeled so staff would know when it could be used by. In addition, the kitchen had heavy grease buildup on the hood filters, walls behind the cooking equipment, and a yellow-tinged grease puddle near the griddle area. The maintenance director confirmed the grease buildup and stated it needed to be cleaned up. The kitchen also had a six-by-six-inch hole in the wall next to the ice machine, with a second hole inside the wall, and the maintenance director confirmed the wall had not been patched after electrical work. Surveyors further observed a kitchen utility worker with visible beard/facial hair who was not wearing a facial hair restraint, and the dining director confirmed the worker should have been wearing a beard net. Finally, the facility’s sanitation quality assurance logs for the dish machine, pot sink, red bucket, sanitizer solution, and test strip results had no data collected for 5/10/2026, and the registered dietician confirmed the missing monitoring entries.
Facility Assessment Missing Required Resident, Staffing, and Contract Details
Penalty
Summary
The facility failed to complete an accurate facility assessment and failed to ensure all required elements of the assessment were reviewed and addressed. Record review showed the assessment, reviewed on 2/11/2026, did not identify the racial/ethnic make-up of resident needs beyond stating that all races/ethnicities were represented, and it left blank the sections for disability, socioeconomic status, preferred language, health literacy, and other factors related to health equity. The assessment also did not identify the cultural or ethnic needs or services residents required or the services the facility was providing, including food/nutrition services and activities. The assessment did not identify staffing needs by unit and shift, even though the facility had 2 floors/units and the upstairs unit was a locked unit requiring a keycode to leave. The Administrator stated the facility generally staffed with 1 nurse per floor and about 2 CNAs on each shift, but confirmed the assessment did not reflect staffing needs by unit or shift. The assessment also did not identify the facility’s use of agency nursing staff or the names of the staffing agencies used to supplement licensed nurses and CNAs, despite the facility using 4 staffing agencies and also relying on staff from sister facilities when agency staff were unavailable. The facility also failed to involve residents or their representatives in the development of the assessment. The signature section for resident representatives/family members was blank, and the Administrator confirmed that although a resident participated, no family members were included. The facility policy required the assessment to address ethnic, cultural, and religious factors, third-party contracts, resident and representative input, staffing needs by unit and shift, and contingency planning for staffing shortages, but the assessment did not include these required elements.
Inadequate Ventilation Above Dish Machine Caused Ceiling Damage
Penalty
Summary
The facility failed to ensure adequate ventilation of steam released above the dish machine, and the steam was observed rising from the dish machine and hitting the ceiling tiles above the dishwashing area. During observation, the ceiling above the dish machine was bowed, peeling, and had yellow foam/insulation hanging from it. The ceiling around the ventilation duct from the machine left an approximately 4-inch rectangular hole the length of the duct and was in disrepair. A kitchen utility worker confirmed that the ceiling gets warped from the steam. During a kitchen tour with the Maintenance Director, the warped ceiling above the dish machine was again observed, and the Maintenance Director affirmed that the ceiling tiles were in disrepair and that the exposed yellow foam insulation was from degradation of the ceiling tiles. The Maintenance Director stated the insulation within the tiles was fire-rated and explained that the degradation was caused by inadequate ventilation of steam from the dish machine. The Maintenance Director also recalled repeatedly having to exchange and repair ceiling tiles in that area due to the steam and stated damaged ceiling tiles can cause issues if insulation falls into the area of the clean dishes.
Call Lights Not Within Reach and Incorrect Dates on Resident Boards
Penalty
Summary
The facility failed to ensure that call lights were within reach for six residents and failed to ensure that dry erase boards displayed the correct date for several residents. During observation, R15, who had dementia and weakness and required partial/moderate assistance with rolling, was seen lying in bed with the call light dangling from the opposite side rail and out of reach. R15 attempted to locate the call light but could not do so, and the RN stated it should be within reach before moving it near the resident’s shoulder without securing it or placing it within reach. Several residents had dry erase boards in their rooms that displayed incorrect dates. R31, who had moderately impaired cognition and a care plan for cognitive loss/dementia, had a board stating the date was Friday, May 8, 2026, when the actual date was different; R31 stated the board was helpful because things get to be the same every day. R34, who was cognitively intact and hard of hearing, had a board stating Thursday, May 7, 2026, and said the staff do not always fix the date, though the resident liked the board and looked at it often. R25, who had cognitive communication deficit, muscle weakness, and hearing deficits, had a board stating May 7, 2026, and responded by looking at the board to identify the date. R33, who was cognitively intact, had a board stating Thursday, May 4, 2026, and said staff should remember to change the date every day. R43, who had moderately impaired cognition and a care plan for cognitive loss/dementia and impaired functional abilities, was observed with the call light behind the resident and hanging over the table, not within reach. R43 stated not knowing where the light was to get help from the nurses and said it was needed. A CNA stated she had not realized the call light was not put back after getting the resident back to bed and confirmed the resident could not reach it. The DON stated call lights should be within reach and available to residents, and that the dry erase boards are supposed to have the correct date as a reminder to residents and to keep them alert and oriented.
Opened Tuberculin Vial Found Undated in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. During an inspection of the 2nd floor medication storage room with an LPN, surveyors observed one multi-dose vial of Tuberculin 5T/0.1 ml stored in the inside door of the refrigerator in its original packaging box, and the vial was opened but not dated. The LPN confirmed there was no open date on the Tuberculin vial. When asked about medication labeling, the DON stated that medications need to be dated with a use-by date so staff know how long the medication is effective. The facility's Medication Storage Policy, dated 2/11/26, states medications must be stored according to manufacturer recommendations, and the Symbria Rx Services Medication Storage Policy states that when the original seal of a manufacturer's container or vial is broken, the container or vial will be dated and the nurse shall place a date-opened sticker and enter the date opened and new expiration date. The report states this issue had the potential to affect all 21 residents residing on the second floor reviewed for labeling of medications and biologicals.
Advance Directive Care Plan Did Not Match POLST and Physician Orders
Penalty
Summary
The facility failed to ensure that R15’s Advance Directives care plan matched the resident’s POLST and physician orders. R15’s POLST stated no CPR and do not attempt resuscitation, and the physician order stated resuscitate: no, with DNR orders for both pre-arrest emergency and full-arrest emergency. Despite these documents, R15’s care plan stated that the resident had chosen not to make any advance directives and was full code. The Advance Directives care plan was initiated on the same date the physician orders were received for advance directives. During interview on [DATE] at 3:19 p.m., the ADON reviewed the POLST and confirmed it stated no CPR/do not attempt resuscitation. The ADON also reviewed the physician order and confirmed it stated DNR. When asked whether the resident’s code status was on the care plan, the ADON initially stated she did not think that was something placed in the care plan, then reviewed it and acknowledged that it incorrectly stated the resident had chosen not to make any directives and was full code. The residents’ rights policy stated that advance directives should be copied to the chart, communicated to staff, and periodically reviewed as part of the comprehensive care planning process, with decisions documented in the medical record and communicated to the interdisciplinary team and staff responsible for care.
Failure to Refer Resident for PASRR Level II After Bipolar Diagnosis
Penalty
Summary
The facility failed to refer one resident with a possible serious mental disorder for Screening and Resident Review to the appropriate state-designated authority for further assessment. The resident had an admission date of 2/23/26, a diagnosis that included bipolar disorder, a BIMs score of 15 on 3/26/26 indicating cognitive intactness, and a care plan dated 3/4/26 noting risk for changes in mood due to bipolar diagnosis. The resident also had a physician order starting 2/23/26 for Trazadone 200 mg by mouth every night for bipolar disorder. The resident’s Notice of PASRR Level I Screen Outcome, dated 2/18/26, documented a Level I determination of no Level II required and no SMI/ID/RC. The Medical Records staff stated that the resident’s PASARR was completed before admission and that the bipolar diagnosis was added later, after admission, and acknowledged that a PASARR II should have been initiated after the bipolar diagnosis. The Medical Records staff later initiated a PASARR II on 5/13/26. The Administrator stated the breakdown occurred because the psych provider diagnosed the resident with bipolar disease after the initial PASARR was completed but did not notify the facility so a new screening could be done.
Failure to Provide ADL Care for a Dependent Resident
Penalty
Summary
The facility failed to provide ADL care to one dependent resident, R16, who was assessed as cognitively intact with a BIMS score of 14 and documented as dependent on staff for toileting and personal hygiene. During observation and interview, a strong urine odor was noted while R16 was being interviewed, and R16 stated the incontinence brief had been changed "yesterday" and then said staff had changed it but she forgot. R16 also stated the brief was "a little bit" wet. Long, thick hairs were observed on R16's upper lip and chin, and R16 said it was hard to get an appointment for facial hair care because there was only one beautician at the facility. The assigned CNA, V17, stated R16 was changed that morning and said incontinent residents are normally changed three to four times before the end of the shift. When V17 inspected the brief, the front appeared saturated and the wetness indicator lines were blue; the brief was then removed and found to be saturated with urine. R16's toenails were observed to be thick, long, and broken, and V17 described them as long. Thick, dry, scaly skin was also observed on both shins, and V17 applied lotion after describing the skin as "a little bit ashy and dry." The assigned LPN, V22, later inspected R16 and stated the facial hair needed to be taken care of because it was long, and confirmed the toenails were long, dry, and thick, stating R16 needed to be added to the podiatry list. The facility's ADL policy states residents unable to carry out ADLs will receive necessary services to maintain grooming, toileting, and personal and oral hygiene.
Failure to document and communicate resident changes in condition and hospice orders
Penalty
Summary
The facility failed to ensure that hospice orders and the hospice care plan were accessible to staff for a resident with hospice services. R28 had diagnoses including fibromyalgia, cervical region pain, adjustment disorder with mixed anxiety and depressed mood, osteoarthritis, a history of urinary tract infections, and severe protein-calorie malnutrition, and had a BIMS score of 11 indicating moderate cognitive impairment. On 5/11/2026, the resident was observed asleep in bed with the head of bed elevated and oxygen at 4 liters per nasal cannula, but the hospice binder did not contain hospice standing orders or a hospice care plan. The electronic care plan reviewed later also excluded oxygen therapy, and the ADON confirmed the hospice standing orders and hospice care plan were not in the binder. The facility also failed to identify and respond to a change in condition for R16. R16 had diagnoses including ectropion and presbyopia and a BIMS score of 14 indicating cognition intact. On 5/11/2026, the resident’s lower eyelids were observed to be red and notably swollen with yellow crust on the bilateral lower eyelashes, and the resident stated the eyes were inflamed. The assigned CNA stated the eye color was normal, and the assigned RN stated the resident gets red eyes a lot and reviewed the EMR without identifying any treatment or medication orders for the eyes at that time. Further review showed the resident’s progress note documented only that the resident had red eyes and was referred to the MD, without documenting the lower eyelid redness, swelling, yellow crust, itching, vital signs, physician notification, or orders received. The next day, the resident’s eyes remained red and swollen with yellow crust, and the resident reported gritty and itchy eyes and did not think the physician had seen the resident or that eye medication had been ordered. The LPN later stated the crusted eyes were indicative of an eye infection, and the Medical Director stated staff were expected to notify nurses of problems and nurses to inspect residents, with the NP or physician to be contacted depending on availability. The physician note in the record was blank and the 8:03 p.m. entry was later modified and redacted.
Failure to identify, document, and treat a new heel pressure injury
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for R25, who had a history of colon cancer with liver metastasis, CHF, PVD, falls with thoracic compression fractures, and atrial fibrillation. R25 was cognitively intact with a BIMS of 15 and required partial/moderate assistance for bed mobility and transfers. On 5/11/2026, R25 was observed lying on her back with no heel offloading in place and protective boots not on the resident, despite a low air loss mattress being present on the bed. Later that day, while the resident was being assisted to turn, surveyors observed a purple blistered area on the posterior right heel, approximately quarter-sized, and the RN described it as a blister likely a deep tissue injury located where the heel rested against the mattress. The record showed that staff did not identify or document the right heel skin impairment in the medical record at the time it was found, and there was no documented notification to the DON, ADON, or physician/nurse practitioner when the new wound was discovered. The DON and ADON both stated they had not been notified of the new right heel wound, and the wound physician confirmed he had not been notified of it before speaking with the surveyor. There were also no progress notes documenting notification to the wound physician or attending physician/nurse practitioner after the wound was found. The ADON later assessed the heel and described the right heel as a closed blister measuring about 2 cm by 2 cm. The facility also failed to obtain treatment orders for the new right heel wound and failed to document wound care for known wounds. The RN cleansed both heels and applied vaseline gauze with adhesive foam dressings, but the report states there was no order obtained for right heel wound care before the wound physician assessment. The record also showed no wound orders in place for the known left heel arterial wound and right forearm skin tear, and no order for a low air loss mattress for 5/8/2026 through 5/10/2026. The treatment record lacked documentation for ordered wound care to the right forearm and left heel, and the skin evaluation form on 5/11/2026 documented the right forearm wound and left heel wound but did not document a right heel wound. The care plan identified risk for skin breakdown and included heel protectors and offloading interventions, but there was no revision reflecting the new right heel wound.
Unlabeled Distilled Water Used for Tube Feeding Flushes
Penalty
Summary
The facility failed to ensure that an opened gallon of distilled water used for tube feeding flushes was labeled with an open date for one resident. The resident had diagnoses including artificial opening of the digestive tract, dysphagia, and osteomyelitis of the vertebra, sacral and sacrococcygeal region. The resident’s BIMs score was 14, indicating cognitive intactness, and the care plan documented potential for complications related to the use of a GJ tube due to dysphagia and recent displacement. A physician order directed enteral feeding flushes with 250 mL of sterile water every 6 hours, four times daily. During observation, an opened gallon of distilled water was seen on the resident’s bedside dresser without a date label. When asked about the water, the resident stated they were not sure what it was for and said they did not drink anything. An RN stated there should be an open date on the gallon and that it is dated to see how new it is. The DON stated sterile water for tube feeding is usually dated to determine how old it is and that dating it once opened is beneficial to prevent cross contamination.
Uncontained Respiratory Equipment
Penalty
Summary
The facility failed to ensure respiratory devices were stored or contained when not in use for two residents. R23’s incentive spirometer was observed on the windowsill and left uncontained. When asked about it, an RN stated the resident had pneumonia and that the spirometer was being used, and also acknowledged that the device was not contained at that time and that bags were needed for storage. R16 had physician orders for CPAP at bedtime, and the care plan included CPAP but did not include interventions for containment when not in use. R16’s CPAP mask was observed uncontained behind the dresser and touching the curtain, and later was seen on the dresser still uncontained. Staff members stated the mask should be in a bag when not in use, but it was not contained. The facility policy for noninvasive ventilation stated that storage/containment of respiratory equipment when not in use was excluded.
Missing Dialysis Physician Order
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with End Stage Renal Disease, dependence on renal dialysis, Type 2 diabetes mellitus, hypertension, hypothyroidism, benign prostatic hyperplasia, and malignant neoplasm of prostate. The resident’s comprehensive assessment dated 05/06/2026 documented a BIMS score of 11, indicating moderate cognitive impairment. During observation on 05/11/2026, the resident was asleep in bed with oxygen in place via concentrator at 1.5 ml/min humidified via nasal cannula, and a dialysis port was noted to the chest wall with enhanced barrier precautions related to the dialysis access. During record review on 05/11/2026, there was no physician’s order in the electronic medical record documenting the resident’s dialysis treatment and transportation. The resident later stated that staff take him to the hospital for dialysis and that he missed one treatment because he was not feeling well. The DON stated there should be an order for dialysis in the computer to ensure the resident is on schedule, receives the right dialysis at the right place for the right amount of time, and reviewed the orders but did not see one. A physician order for dialysis was then brought to the surveyor on 05/13/2026; it was dated and started 05/13/2026 and specified dialysis twice a week on Monday and Friday, right chest CVC access, ambulance transportation, and no fluid restriction.
Controlled Substance Record Not Updated After Administration
Penalty
Summary
The facility failed to maintain accurate records and document administration of controlled substances for one resident, R51, during controlled substance accounting on the medication cart for rooms (#). During surveyor inspection, the controlled substances count for R51 was found to be inaccurate: the controlled drug receipt/record disposition form listed 17 capsules of Pregabalin 100 mg, but only 16 capsules remained in the package. An LPN stated that one capsule had been given that morning but had not yet been signed for. R51 was admitted with diagnoses including acute systolic congestive heart failure, acute kidney failure, chronic kidney disease, polyneuropathy, and rheumatoid arthritis. The DON stated that after administering controlled medications, the nurse must sign the Controlled Drug/Receipt Record Disposition Form immediately for accuracy. The facility’s Controlled Substance Administration and Accountability Policy and Symbria Rx Services Pharmacy Policy both required controlled substances to be recorded immediately, including the date and time of administration, amount administered, remaining quantity, and the administering nurse’s initials.
Significant IV Vancomycin Medication Error
Penalty
Summary
The facility failed to follow policy and procedure and failed to ensure that one resident was free from a significant medication error during IV Vancomycin administration. The resident had diagnoses including osteomyelitis of the vertebra, sacral, and sacrococcygeal region, was cognitively intact with a BIMs score of 14, and had a care plan stating the infection would be resolved after completion of the antibiotic course and that the resident would take the antibiotic as prescribed. The physician ordered Vancomycin 1G/250 ml in 0.9% sodium chloride IV twice a day for osteomyelitis. On observation, the resident’s Vancomycin IV was being administered through a left PICC line at 132 ml/hr, while the medication label documented an infusion rate of 125 ml/hr over 120 minutes twice a day. The RN stated the medication was supposed to go at 125 ml/hr and that she had been trying to change the rate but it kept going to 175 ml/hr; she said she should have gotten another pump and that there was something wrong with the pump. The DON stated that administering Vancomycin at the ordered rate was necessary because of the medication’s timing window and because lab troughs are based on the timing of the last dose.
Malfunctioning IV Pump Used for Vancomycin Infusion
Penalty
Summary
Essential equipment was not maintained in safe operating condition when an IV pump that was identified as malfunctioning continued to be used for resident care. R33 had diagnoses including osteomyelitis of the vertebra, sacral, and sacrococcygeal region, and was cognitively intact with a BIMS score of 14. R33’s care plan documented the resident’s infection and the goal of completing the antibiotic course, and the physician ordered Vancomycin 1G/250ml in 0.9% sodium chloride IV twice daily for osteomyelitis. On 5/11/26, R33’s Vancomycin was observed infusing through a left PICC line at 132 ml/hr, while the medication label documented an ordered infusion rate of 125 ml/hr over 120 minutes. The RN stated she was trying to change the rate but the pump kept going to 175 ml/hr, that she should have gotten another pump, and that there was something wrong with the pump. The RN said she would get a working pump and tag the malfunctioning one so it could be checked out. The DON stated that an IV pump that is not working properly should not be used on a resident and that a new pump should be obtained from central supply.
Failure to Conduct Timely Background Checks for Residents and Employees
Penalty
Summary
The facility failed to adhere to its policy of conducting timely background checks for both residents and employees, which has the potential to affect all 36 residents residing in the facility. Specifically, the facility did not conduct a Criminal History Information Response Process (CHIRP) check for a resident identified as an offender until more than two weeks after admission. This resident, an elderly male with cognitive and visual impairments, was admitted with multiple diagnoses, including adjustment disorder with depressed mood. The delay in conducting the CHIRP check resulted in multiple hits, necessitating further fingerprinting, which was not completed within the required timeframe. Additionally, the facility failed to perform timely background checks for nine out of ten employees reviewed. These employees, including CNAs, a receptionist, a scheduler, and RNs, had their background checks completed after their hire dates, contrary to the facility's policy. The checks included the Illinois Department of Public Health Health Care Worker Registry, Illinois Sex Offender background checks, and other necessary verifications. The facility's policy mandates that these checks be completed before employment to ensure the safety of residents, but this was not adhered to, as evidenced by the late completion of these checks. Interviews with facility staff, including the Director of Admissions, Human Resource Support, and the Medical Director, revealed a lack of clarity and communication regarding the responsibility and timing of these checks. The staff acknowledged the lapses and attributed them to oversight and miscommunication, particularly when key personnel were unavailable. The facility's policy clearly outlines the need for pre-employment and pre-admission background checks to prevent abuse, neglect, and exploitation, but these procedures were not followed, compromising resident safety.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the preparation and serving of food to 37 residents. During an inspection, a surveyor observed boxes of cucumbers, broccoli, and tomatoes placed directly on the floor, contrary to facility policy. Additionally, the ice machine had dust and hard water marks, and the ice cream freezer contained half-full gallons of ice cream without open or best buy dates. A garbage container without a lid was also noted, which could lead to contamination. The facility's dishwasher final rinse temperature gauge was not functioning, and the staff could not confirm if the final rinse temperature met the required 180 degrees Fahrenheit. This malfunction could result in improper dishwashing, increasing the risk of infection. The Director of Dining Services acknowledged these issues, and the facility's policies on sanitation and infection prevention were not adhered to, as evidenced by the lack of proper labeling, dating, and storage of food items, as well as the maintenance of kitchen equipment.
Failure to Assess and Report New Skin Condition
Penalty
Summary
The facility failed to assess a new skin condition on a resident with impaired mobility and did not notify licensed staff to evaluate the skin condition. This resulted in the resident developing a new wound excoriation on the right buttock area. The resident, an elderly female with a history of tubulo-interstitial nephritis, urinary tract infection, and ESBL resistance, was noted to have no new skin issues in a skin evaluation conducted shortly before the incident. However, during incontinence care, CNAs observed a small, open red area on the resident's right lower buttock and redness and swelling in the groin areas. Despite this observation, the CNAs did not report the new skin issue to the licensed nurse, and there was no documentation of the new skin issue being reported. When the wound care nurse was informed, they assessed the resident and identified the condition as moisture-associated skin damage (MASD) on the right buttock and groin areas. The facility's policy requires immediate notification of the nurse on duty when skin concerns are observed, but this protocol was not followed. The lack of communication and documentation led to a delay in addressing the resident's skin condition, which was later diagnosed as diaper dermatitis exacerbated by MASD. The facility's policy on skin assessment emphasizes the importance of conducting a full body skin assessment upon admission, readmission, and when new skin alterations are identified, but this was not adhered to in this case.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall involving a resident, identified as R194, who was affected by severe cognitive impairment and physical limitations. R194, a female resident with a history of dementia, cerebral infarction, and a right below-the-knee amputation, was admitted to the facility with significant mobility challenges, requiring maximum assistance for transfers and a mechanical lift. Despite these needs, R194 was left unattended in a wheelchair near the nursing station, where she attempted to reach her leg, causing the wheelchair to flip forward, resulting in a fall and a parietal scalp hematoma. The incident occurred after R194 had undergone a speech evaluation and physical therapy session, during which she used her right leg prosthesis for the first time since admission. The physical therapist assistant placed her in the wheelchair by the door of her room, intending for her to be monitored by the nursing staff. However, video footage revealed that nursing staff passed by without assisting R194 as she shifted her body and slumped in the chair, ultimately leading to her fall. The nursing staff failed to adhere to the facility's policy of monitoring residents at risk of falls closely, as no effective monitoring was in place at the time of the incident. Interviews with facility staff, including the Director of Nursing and the Registered Nurse, highlighted a lack of updated care plans addressing R194's mobility, transfers, and use of a leg prosthesis. The Director of Nursing acknowledged the failure in monitoring and the absence of a comprehensive care plan tailored to R194's specific needs. The facility's policy on falls and fall risk management was not effectively implemented, as evidenced by the lack of interventions to prevent the fall and the absence of documentation on the resident's response to interventions aimed at reducing fall risks.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a 12% medication error rate. This involved three residents out of a sample of 30. One resident, a female with unspecified dementia, was prescribed 1000 mg of Calcium Carbonate to be taken orally three times a day. However, the LPN administered only 500 mg, failing to provide the correct dosage as per the physician's order. Another resident, a female with chronic obstructive pulmonary disease, was prescribed an Albuterol Sulfate HFA inhaler to be used every eight hours. The RN did not follow the proper procedure for administering the inhaler, as the resident did not hold her breath after inhaling the medication, which is necessary for effective delivery of the medication. The third resident, a female with type 2 diabetes mellitus, was to receive 10 units of Novolog Flexpen insulin three times a day. The LPN administering the insulin did not follow the manufacturer's guidelines, as she failed to clean the needle hub, prime the pen, or perform an airshot before injection. These actions are necessary to ensure the correct dosage and prevent air from being injected.
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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 Brookfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Of Lagrange Park, The | 1.8 mi | ★★★★★ | 4 | 0 |
| Plymouth Place | 1.8 mi | ★★★★★ | 3 | 0 |
| Nexus At Berwyn | 2 mi | ★★★★★ | 12 | 2 |
| Aperion Care Forest Park | 2.2 mi | ★★★★★ | 15 | 0 |
| Meadowbrook Manor - Lagrange | 2.3 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.