Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Burgess Square Healthcare Ctr during CMS and state inspections, most recent first.
Failure to monitor pressure ulcers and maintain ordered wound care: A resident’s coccyx pressure ulcer worsened from stage 2 to necrotic, unstageable tissue without timely reporting or reassessment, and another resident developed a new MDRPU from Foley tubing while an existing buttock pressure ulcer was left uncovered. Staff did not consistently report wound changes, complete weekly wound assessments, or ensure ordered dressings and skin protection were in place.
Kitchen sanitation and hair restraint practices were not maintained. Multiple dietary staff were observed preparing food or handling dishes with hair not fully covered, sanitizer in the dishwashing sink tested below the facility’s stated QUAT range, and the food prep area had dust and particles on vents and a ceiling panel, peeling paint, food buildup on a blender base, and an uncovered personal mug on the meat slicer base. The DON acknowledged the sanitation concerns and the presence of personal beverages in the kitchen.
Infection control practices were not followed during peri-care, wound care, and care for residents on EBP. Staff changed gloves between tasks without hand hygiene, used soiled gloves during wound care, and provided direct care to residents on EBP without complete PPE such as gowns and gloves. One resident had an abscess and wound care needs, another was dependent for toileting with an indwelling urinary catheter, and others required assistance with toileting and transfers.
Failure to Offer Updated COVID-19 Vaccine to Residents: The facility did not offer the updated COVID-19 vaccine to 5 residents reviewed for immunizations, and their EMRs lacked documentation that the vaccine had been received or offered. The DON stated the residents were not offered the updated vaccine because they had received or been offered the prior season's vaccine earlier in the year, despite the facility policy requiring routine offers of COVID-19 vaccinations and boosters and CDC guidance showing older adults may need more than one dose of the 2025-2026 vaccine.
Failure to maintain dignity during personal care and feeding: a resident was transported to and from the shower partially draped with her chest and back exposed, a CNA fed a resident while standing instead of sitting beside her, and another resident received catheter care and dressing assistance with inadequate privacy and body exposure when the room door was opened. The residents involved included one cognitively intact female with cancer and weakness, a 91-year-old resident with dementia, and a cognitively intact resident recovering from a femur fracture.
Unsafe resident transfers occurred when a CNA attempted to weigh a cognitively intact resident with gait belt use interrupted and the resident fell to her knees, and when a resident with severe cognitive impairment and total transfer dependence was moved with a mechanical lift while an untrained private caregiver assisted. The DON confirmed the caregiver was not authorized to help with mechanical lift transfers, and the CNA stated the gait belt was not replaced before the transfer back to the chair.
Inadequate perineal and catheter care was observed for two residents. One resident who was incontinent of bowel and bladder received brief care without cleaning the groins or frontal perineum, and another resident with an indwelling Foley catheter did not receive proper hand hygiene, clothing removal, labial separation, or cleansing around the catheter insertion site. Facility policy and the DON described clean technique, front-to-back wiping, and thorough cleansing of the perineal area.
Medication administration errors resulted in a 12% error rate, exceeding the 5% threshold. During observation, an RN gave a resident multiple inhalers back-to-back in less than a minute and crushed an ER tablet before administration. The DON stated ER or DR medications should not be crushed and inhalers should be spaced by at least one minute for the same medication and two minutes for different medications; facility policy also required medications to be given safely and as prescribed.
Failure to Offer Additional Pneumococcal Vaccines: The facility failed to ensure two residents were offered additional pneumococcal vaccination after prior PCV13 immunization. One resident had dementia, CHF, hypotension, and AFib; the other had Alzheimer’s disease, DM2, and CKD. The DON stated the facility follows CDC timing recommendations, and the facility policy required pneumococcal vaccines to be offered and re-offered to qualifying residents.
A resident with severe cognitive impairment and anticoagulant therapy received overlapping warfarin orders when staff failed to discontinue prior orders before entering new ones, resulting in duplicate doses, a critically elevated INR, Vitamin K administration, and hospitalization. A second resident also received an extra Coumadin dose after a nurse did not discontinue the previous order, and the MAR showed both the 5 mg and 6 mg doses were given the same day, with a later elevated INR noted.
A temporary agency CNA was found responsible for the theft of credit cards and cash from multiple residents in the facility. Unauthorized charges were made on the stolen cards, and one resident was contacted by the CNA for money due to personal hardships. The facility's investigation linked the thefts to the CNA, who was assigned to the affected residents' rooms during the incidents.
The facility failed to safely reposition a resident with multiple health issues, as a CNA improperly pulled the resident by the arm without assistance, against policy. Additionally, oxygen tanks were found unsecured in residents' rooms, posing a tipping hazard, despite the facility's policy requiring them to be secured.
The facility failed to safely store medications for five residents, leading to deficiencies in medication management. Medications were found loose and unlabeled on a medication cart, and unauthorized medications were stored at residents' bedsides without proper orders. The facility's policies on secure and labeled medication storage were not followed.
The facility failed to follow infection control practices for residents on transmission-based precautions, affecting five residents. Staff, including CNAs and housekeeping, did not consistently wear required PPE such as gowns and gloves during high-contact activities, despite clear signage and facility policies. This non-compliance was observed in residents with conditions like MDRO, MRSA, and those with indwelling medical devices, highlighting a significant lapse in infection prevention protocols.
The facility failed to ensure IV medications were administered by qualified staff, involving three residents receiving IV therapy. An LPN administered Ceftriaxone and Ertapenem through PICC lines, despite regulations indicating LPNs should not initiate IV medications through midline or central lines. Another LPN confirmed she would not perform such tasks, highlighting a discrepancy in practice. The facility's policy and state regulations both indicate that LPNs should not perform these tasks, pointing to a failure in adhering to professional standards of quality care.
Two residents with urinary catheters received improper care, including inadequate cleaning techniques and unsecured drainage bags. One resident's catheter tubing was obstructed, and the drainage bag was placed on the floor. Another resident's catheter and genital area were cleaned with the same washcloth. The DON confirmed the facility's catheter care policy was not followed.
A resident's PEG tube placement was not properly verified before medication administration, and the nurse failed to follow physician orders for water flushes and medication dilution, risking gastrointestinal irritation.
The facility failed to maintain proper care for two residents with PICC lines, as their dressings were not changed according to physician orders and facility policy. One resident's dressing was soiled and unchanged for days, while another's dressing was not updated for over a week. The Director of Nursing acknowledged the oversight, citing a missed change due to a hospital visit.
A resident with multiple health conditions was receiving oxygen without a physician's order, contrary to the facility's policy. Observations showed the resident receiving 3.5 to 4 liters of oxygen via nasal cannula, but the Physician Order Sheet lacked the necessary order. Staff confirmed the requirement for a physician's order for oxygen, which was not obtained.
The facility failed to accurately log and dispose of controlled medications for two residents. An LPN improperly stored medication documentation and pre-pulled medications against policy. The DON confirmed the need for proper documentation and storage.
Failure to Monitor Pressure Ulcers and Maintain Ordered Wound Care
Penalty
Summary
The facility failed to monitor and report changes in existing pressure ulcers, prevent new pressure areas, and ensure pressure ulcer treatments were in place for two residents. One resident, who had multiple sclerosis, dementia, muscle weakness, gait impairment, and dependence on staff for ADLs, had a facility-acquired coccyx pressure ulcer that was documented as stage 2 and stable with granulation tissue on a weekly skin note. Seven days later, during wound care observation, the wound bed was found to have approximately 50% slough and necrotic soft tissue, and the wound care nurses stated they had not been informed that the wound had deteriorated. The wound was cleaned and dressed, but the wound care nurse said the wound did not need physician re-evaluation or a change in treatment at that time. The same resident’s wound was later documented as having deteriorated to stage 3 with eschar/maroon tissue, and then was reassessed by the NP as unstageable with 100% slough tissue. The NP stated the wound required a treatment change to remove necrotic tissue and needed evaluation by the wound physician. The resident’s care plan identified the coccyx wound as facility-acquired and included monitoring and reporting abnormalities, assessing for progression and declination, and consulting the wound care physician. The wound care nurse stated that floor nurses were responsible for daily dressing changes and reporting wound changes, and that the wound care team depended on nursing staff to inform them of deterioration. A second resident had multiple wounds on admission, including pressure ulcers and MASD, and was dependent on staff for dressing, bathing, and toileting assistance. During observation, the resident had no dressing on a buttock pressure ulcer that still required daily treatment, and catheter tubing was pressing against the left inner thigh. The resident reported discomfort from the tubing, and the wound care nurse identified two new open linear areas on the left posterior thigh as a new facility-acquired MDRPU related to Foley tubing. The nurse also noted that the resident’s right buttock pressure ulcer should have been covered as ordered. The resident’s weekly wound assessments had not been completed for the prior two weeks, and the wound care nurse stated residents with wounds required weekly assessments to ensure they were monitored for complications and treated appropriately.
Kitchen Sanitation and Hair Restraint Deficiencies
Penalty
Summary
Food was not prepared and the kitchen was not maintained under sanitary conditions. Surveyors observed multiple dietary staff preparing or handling food with hair not completely covered by hair restraints, including a dietary aide assisting with dishwashing, a cook preparing food, another cook preparing burgers, dietary aides preparing fruit cups and juices, and a dietary aide rolling silverware. The facility’s hair covering policy stated that all staff, contractors, volunteers, visitors, and inspectors entering dietary areas must wear an appropriate hair covering that fully restrains hair. Surveyors also observed sanitation problems in the kitchen’s food preparation and ware washing areas. The sanitizer in the three-compartment sink used to clean dishes was tested at 150 ppm on more than one occasion, while the dietary manager stated the QUAT sanitizer should be between 200 and 300 ppm for proper sanitation. A cook also tested the sanitizer and found it to be between 0 and 150 ppm, and said she would change the solution. The facility’s sanitizer policy stated that QUAT sanitizer must be used at the proper concentration range specified by the manufacturer and monitored regularly. Additional observations showed the kitchen environment was not clean and sanitary. Surveyors noted peeling and bubbling paint near the vent above the main food prep table, dust and particles on vents and a ceiling panel directly above the prep area, dust hanging from the panel with air from adjacent vents blowing it, cracked and peeling paint near the steam table, food particle buildup on the base of a blender used for food preparation, and an uncovered personal mug with a hot beverage sitting on top of the meat slicer base. The dietary manager acknowledged the dust, food buildup, and peeling paint, and stated personal beverages should not be kept in the kitchen. The facility’s kitchen cleaning and food preparation policies stated that the kitchen must be maintained in a sanitary condition and that no personal belongings, drinks, or food may be kept in prep areas.
Infection Control Lapses During Peri-Care, Wound Care, and EBP Care
Penalty
Summary
The facility failed to follow infection control practices during perineal care, wound care, and care for residents on Enhanced Barrier Precautions (EBP). For one resident with an abscess to the right buttock, decreased mobility, and assistance needs for ADLs, a CNA assisted the resident to the toilet, then later provided peri-care while changing gloves multiple times without performing hand hygiene. The same resident later received wound care from a nurse who removed a soiled dressing, cleansed the wound, applied zinc cream, and covered it with a bordered foam dressing while wearing the same soiled gloves. The same CNA also assisted another resident to the bathroom and provided peri-care while changing gloves between tasks without hand hygiene. The ADON/Infection Preventionist stated staff are to perform hand hygiene and change gloves from dirty to clean tasks during incontinence care, and that staff are to wear complete PPE for residents on EBP when providing direct care such as incontinence/toileting, transfers, and wound care. For a resident on EBP with spinal stenosis, scoliosis, chronic kidney disease, and gait/mobility abnormalities, a therapy technician/CNA assisted the resident in the bathroom and transferred the resident back to a wheelchair without wearing a gown or gloves, despite an EBP sign on the doorway. For another resident who was cognitively intact, dependent for toileting, and had an indwelling urinary catheter, a staff member donned gloves without hand hygiene or a gown and performed incontinence care using the same gloves and wipes throughout cleaning of the groin and buttock areas without changing gloves or using hand sanitizer. The DON stated staff providing direct care to residents on EBP need to wear a gown, sanitize hands, and put on gloves before starting care, and the facility policy required hand hygiene before and after resident contact, after glove removal, and before and after glove use.
Failure to Offer Updated COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the updated 2025-2026 COVID-19 vaccine to 5 of 5 residents reviewed for immunizations: R13, R39, R78, R97, and R112. Their EMRs and Immunization Reports dated December 2 and December 3, 2025, did not show that each resident had received or been offered the updated vaccine, and the facility had no documentation showing the vaccine was offered to them. The residents had multiple diagnoses, including dementia, chronic diastolic heart failure, hypotension, paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, Alzheimer's Disease, type 2 diabetes mellitus, chronic kidney disease, COPD, chronic respiratory failure, seizures, hypertension, and acute upper respiratory infection. During an interview on December 2, 2025, the DON stated the facility follows CDC vaccination guidelines and said newly admitted residents are being offered the updated 2025-2026 COVID-19 vaccine. The DON also stated that R12, R39, R78, R97, and R112 had not been offered the updated vaccine because they had received or been offered the 2024-2025 vaccine in February 2025 and the COVID-19 vaccine is given yearly, so they were not due for another vaccine. The facility policy stated residents, families, and staff are to remain up to date with COVID-19 vaccinations and that the facility will offer vaccinations and boosters on a routine basis. The CDC Adult Immunization Schedule dated October 7, 2025, showed adults 65 years or older are recommended to receive two or more doses of the 2025-2026 COVID-19 vaccine and did not show waiting one year after the 2024-2025 vaccine was received.
Failure to Maintain Resident Dignity During Personal Care and Feeding
Penalty
Summary
The facility failed to ensure residents were treated with dignity by maintaining adequate draping and privacy during personal care and by assisting a resident in a dignified manner during feeding. R31, a cognitively intact female with diagnoses including malignant neoplasm of the breast, major depressive disorder, muscle weakness, and basal cell carcinoma, was observed being transported to and from the shower room in a wheelchair through the hallway with only a small folded blanket that did not fully cover her chest and back. Multiple staff and residents were present, and R31 stated she did not want her body exposed and that the CNA should have ensured she was properly draped. The facility also failed to provide dignified feeding assistance to R107, a 91-year-old resident with dementia and generalized weakness, when a CNA fed her while standing in the dining room. The facility’s dining policy stated staff should sit next to residents who require assistance with eating, and the ADON stated staff must sit beside residents to ensure feeding is done in a dignified manner. In addition, R152, a cognitively intact resident admitted after a right femur fracture and dependent on staff for toileting and substantial bathing assistance, was provided catheter care and dressing assistance in a room where the privacy curtain by the door was not extended around the bed. The resident’s gown was pulled up exposing her incontinence brief, the door was opened during care, and later her breast was exposed when the roommate’s caregiver entered; R152 stated she wished staff would give her dignity and not expose her nakedness to everyone who opened the door or walked into the room.
Unsafe Resident Transfers
Penalty
Summary
The facility failed to safely transfer residents. R105’s EMR showed multiple diagnoses including spinal stenosis, scoliosis, chronic kidney disease, and other abnormalities of gait and mobility. R105’s MDS dated September 4, 2025, documented that she was cognitively intact and required moderate assistance from staff to come from sitting to standing. Her fall care plan identified fall risk related to recent spinal fusion, decreased mobility, recent hospitalization, diuretic use, and episodes of incontinence, and included an intervention to monitor for safety with transfers and mobility. On September 29, 2025, R105 was observed kneeling on the floor facing her chair while a CNA held her by the waistband of her pants, and she did not have a gait belt in place. R105 stated the CNA had been attempting to weigh her and had moved her back and forth between her chair and the scale until her legs gave out, causing her to kneel on the floor; she also stated the CNA did not place a gait belt on her during the transfer to the scale and her foot hurt afterward. The CNA stated she removed the gait belt to weigh R105 and did not put it back on before transferring her back to the chair. The DON stated the CNA should have put the gait belt back on before completing the transfer. The facility also failed to safely transfer R5, whose EMR showed diagnoses including CHF, CAD, PVD, and a history of CABG. R5’s MDS documented severe cognitive impairment, total dependence for transfers, and the need for a mechanical lift for all transfers. On September 30, 2025, R5 was transferred from bed to a reclining wheelchair using a mechanical lift by a CNA with assistance from R5’s private caregiver, who stated she had not received training on the lift. The DON confirmed the caregiver was not authorized to assist with mechanical lift transfers and that untrained individuals are not permitted to participate in such transfers.
Inadequate Perineal and Catheter Care
Penalty
Summary
The facility failed to provide catheter and perineal care in a manner that would prevent UTI for 2 of 4 residents reviewed for perineum and catheter care. One resident, who was 79 years old with diagnoses including hemiplegia affecting the left non-dominant side, reduced mobility, and a personal history of UTI, required assistance with toileting and hygiene and was incontinent of bowel and bladder. During toileting care, a CNA removed the resident’s soiled brief and cleaned only the back perineum before placing a new brief, without cleaning the groins or frontal perineum. The facility’s perineal care policy stated that male perineal care includes washing the penis, scrotum, and inner thighs. A second resident was cognitively intact, dependent on staff for toileting, and had an indwelling urinary catheter related to recent surgery and acute urinary retention. The care plan directed staff to provide routine hygiene using clean technique of the urinary meatus during daily bathing and to cleanse the perineal area after bowel movements, wiping away from the urinary meatus. During observed catheter care, the CNA began pulling the resident’s pants up, stated she was about to do catheter care, and did not remove the pants before starting. The CNA did not wash hands or use hand sanitizer before putting on gloves, used the same wipe for the right groin, left groin, and under the stomach fold, did not spread the labia, and did not touch or clean around the catheter insertion site. The DON stated staff should wash hands or use hand sanitizer before care, remove lower-body clothing, clean from inner to outer areas, wipe front to back, spread the labia for female catheter care, and change gloves or clean hands between areas.
Medication Administration Errors Exceeded Threshold
Penalty
Summary
Medication administration errors resulted in a 12% medication error rate, exceeding the 5% threshold. Based on observation, interview, and record review, the facility failed to administer medications as ordered and in accordance with standards of care and facility policy. The deficiency involved 1 of 4 residents reviewed for medication administration, R65, in a sample of 27 residents. During observation on September 30, 2025, at 9:45 AM, V5 administered multiple medications to R65, including Fluticasone Vilanterol inhaler, Tiotropium Bromide inhaler, and Mucinex ER tablet. V5 administered the two inhalers one after another in less than a minute and crushed the Mucinex ER tablet before giving it to R65. On December 2, 2025, the DON stated that ER or DR medications should not be crushed because it affects the medication’s effect, and that inhaler medications should be separated by more than a minute to allow enough time for each dose to be absorbed in the lungs. The facility’s medication administration policy stated that medications are to be administered safely and as prescribed, that medications can only be crushed if indicated in the order, and that if the manufacturer states a medication should not be crushed, nursing staff and/or the pharmacist must notify the attending physician to identify an alternative medication and/or dosage form. The inhaler administration policy stated to allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications.
Failure to Offer Additional Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure residents were offered the pneumococcal vaccine. In a sample of 27 residents reviewed for immunizations, this applied to 2 of 5 residents reviewed for immunizations, R13 and R78. R13’s EMR showed a resident with dementia, chronic diastolic heart failure, hypotension, and paroxysmal atrial fibrillation. R13’s Immunization Report showed receipt of PCV13 on November 16, 2022, but the facility had no documentation showing that additional pneumococcal vaccines were offered. R78’s EMR showed a resident with Alzheimer’s Disease, type 2 diabetes mellitus, and chronic kidney disease. R78’s Immunization Report showed receipt of PCV13 on December 1, 2015, but the facility also had no documentation showing that additional pneumococcal vaccines were offered. The DON stated the facility follows CDC vaccination timing recommendations and said both residents should have already been offered an additional pneumococcal vaccine. The facility policy stated residents or their legal representatives are to be provided CDC information and that pneumococcal vaccinations will be offered and re-offered to qualifying residents.
Warfarin Orders Not Discontinued, Leading to Duplicate Doses and Elevated INR
Penalty
Summary
The facility failed to administer warfarin as ordered for two residents, resulting in significant medication errors. R1 had multiple diagnoses including long-term anticoagulant use, severe cognitive impairment, anemia, and recent hospitalization for sepsis-related care. The record shows R1 had an October 27, 2025 warfarin order for 1 mg on selected days, which was discontinued, but subsequent warfarin orders were entered without discontinuing prior orders. On October 28, 2025, an LPN entered a 2 mg warfarin order, and later that day another LPN entered a 4 mg warfarin order without discontinuing the 2 mg order. On October 30, 2025, another 2 mg order was entered, and the earlier 2 mg order was not discontinued until November 3, 2025. Because the overlapping orders remained active, R1 received duplicate doses of warfarin on multiple days. The MAR shows R1 received 4 mg on October 28, 6 mg on October 29, 4 mg on October 30, 31, November 1, and November 2, and INR results became progressively elevated, reaching 10.64 on November 3 and 13.10 on November 4. The facility administered phytonadione (Vitamin K) on November 3, and hospital documentation shows R1 was admitted on November 4 with a supratherapeutic INR and received another dose of phytonadione in the emergency department. Staff interviews indicated the prior warfarin order was not discontinued before new orders were entered, and the DON stated the resident received an additional 2 mg daily because of this error. R4 also experienced a warfarin medication error. R4 had diagnoses including atrial fibrillation, dementia, peripheral vascular disease, and recent orthopedic aftercare following toe amputation, and had severe cognitive impairment. The facility’s medication error report states that on October 31, 2025, R4 received an additional dose of Coumadin because the nurse obtaining the physician order failed to discontinue the previous order. The order audit shows R4 had a 5 mg warfarin order and a later 6 mg warfarin order, and the MAR shows both doses were administered on the same day for a total of 11 mg. The NP stated the prior order should have been discontinued if the physician wanted the higher dose, and noted that R4 later had an elevated INR of 5.04 related to receiving the incorrect dose.
Misappropriation of Resident Property by Temporary CNA
Penalty
Summary
The facility failed to prevent the misappropriation of resident property, as evidenced by multiple incidents involving the theft of credit cards and cash from residents. The investigation revealed that a temporary agency CNA, identified as V4, was responsible for the thefts. This CNA was assigned to the rooms of the affected residents during the time the items went missing, and unauthorized charges were made near V4's home. The facility's initial investigation identified multiple residents missing credit cards, and further investigation linked the thefts to V4. One resident, R1, discovered unauthorized charges on her credit card after being contacted by a convenience store. Upon checking her belongings, she found her credit and debit cards missing. R1's daughter reported the unauthorized use to the facility, and the administrator assisted in canceling the card and filing a police report. Similarly, R2 noticed unauthorized charges on her account and reported missing cards and cash. R4 also reported missing a credit card and cash, with unauthorized charges appearing on her account. R3, after hearing about her roommate's missing items, discovered cash missing from her drawer. Additionally, R6 was contacted by V4 via text message, where V4 requested money due to personal hardships. This contact was reported to the police by the administrator. The facility's abuse prevention policy states that residents should be free from misappropriation of property, which includes the wrongful use of a resident's belongings or money without consent. The facility's failure to prevent these incidents constitutes a deficiency in protecting residents from misappropriation of property.
Unsafe Repositioning and Unsecured Oxygen Tanks
Penalty
Summary
The facility failed to ensure safe repositioning of a resident and secure oxygen tanks, leading to potential accident hazards. A resident with multiple diagnoses, including Parkinson's disease and dementia, was improperly repositioned by a CNA who pulled the resident by the upper arm without assistance, contrary to the facility's policy requiring two staff members and a draw sheet. This action was observed by other staff members who confirmed that the correct procedure was not followed, potentially risking injury to the resident. Additionally, the facility did not secure oxygen tanks properly, posing a risk of them tipping over. Oxygen tanks were found unsecured in the rooms of residents with respiratory conditions, such as acute and chronic respiratory failure. Despite being observed on multiple occasions, the tanks remained unsecured, which was acknowledged by the facility's staff as a safety concern. The facility's policy requires that portable oxygen containers be protected from falling over, which was not adhered to in these instances.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to safely store medications for five residents, leading to deficiencies in medication management. For one resident, medications were found loose in an unlabeled cup on a medication cart, and the nurse was unsure of their identity or ownership. The Director of Nursing confirmed that medications should be prepared at the time of administration and not stored in the cart once removed from their original packaging. Another resident had unauthorized medications, including eye drops and an inhaler, stored at their bedside without proper orders. The resident admitted to using these medications, which were not prescribed or approved for bedside storage. Similarly, a third resident had a nebulizer treatment and an inhaler in their room, brought by a family member, without the facility's knowledge or proper orders. Additional residents were found with unlabeled medications, such as glucose tablets and creams, at their bedside without orders for self-administration or bedside storage. The Director of Nursing stated that no residents had orders for bedside medication storage or self-administration, and any medications brought by family should be handled by nursing staff. The facility's policies require medications to be stored securely and labeled correctly, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Use
Penalty
Summary
The facility failed to adhere to infection control practices for residents on transmission-based precautions, affecting five residents. One resident, admitted with a urinary tract infection and MDRO, was on contact isolation. Despite signage and available PPE, a CNA was observed providing care without wearing a gown, contrary to the facility's policy requiring gowns, gloves, and masks for contact precautions. Similarly, another resident with an unstageable pressure ulcer and MRSA infection was under Enhanced Barrier Precautions (EBP), yet an LPN did not wear a gown while performing IV maintenance, violating the requirement for gown and gloves during direct contact. Another resident, with diagnoses including COPD and dementia, was under EBP, but a housekeeping staff member only wore gloves while changing linens, disregarding the need for a gown. This staff member also mishandled dirty linen, placing it on the ground and against her clothing, which is against infection control protocols. Additionally, a resident with a urinary catheter was under EBP, but a CNA provided catheter care without performing hand hygiene or wearing a gown, and a housekeeping staff member also failed to wear a gown while changing bed sheets, despite clear signage. The facility's policies and signage clearly outlined the need for PPE, including gowns and gloves, during high-contact activities for residents under EBP. However, staff consistently failed to comply with these protocols, as evidenced by the observations of care provided to residents with indwelling medical devices and those at risk for infections. The Director of Nursing confirmed the expectations for PPE use, emphasizing the importance of proper hand hygiene and PPE to prevent infection transmission, yet these practices were not consistently followed by the staff.
Unqualified Staff Administering IV Medications
Penalty
Summary
The facility failed to ensure that intravenous medications were administered by qualified staff, specifically involving three residents receiving IV therapy. Resident R426 had an order for Ceftriaxone Sodium injection to be administered intravenously. On September 25, 2024, an LPN administered the medication through a PICC line, despite the Illinois Nurses Act indicating that LPNs are not permitted to initiate IV medications through midline or central lines. The Director of Nursing confirmed that LPNs were trained by RNs to administer IV medications, including antibiotics. Resident R324, with a history of an unstageable pressure ulcer and infections, was administered Ertapenem by an LPN on two occasions. The LPN described the process of administering the IV antibiotics, which included flushing the PICC line and checking for blood return. Similarly, Resident R321, who had a PICC line for surgical aftercare, received Sodium Chloride IV fluids administered by an LPN. Another LPN stated that she would not hang IVs as it was outside her scope of practice, highlighting a discrepancy in practice among staff. The facility's policy and the Illinois Nurses Act both indicate that LPNs should not perform these tasks, pointing to a failure in adhering to professional standards of quality care.
Improper Catheter Care and Hygiene Practices
Penalty
Summary
The facility failed to provide proper catheter care for two residents, leading to deficiencies in infection control and hygiene practices. One resident, with diagnoses of urinary retention and urinary tract infection, was observed not receiving catheter care after a bowel movement, and their catheter drainage bag was placed on the floor. Later, the same resident's catheter tubing was found underneath their thigh, causing obstruction, and the catheter was improperly cleaned with multiple upstrokes towards the urethra. The catheter drainage bag was left unsecured, hanging over the side of the bed. Another resident, also with urinary retention and neuromuscular dysfunction of the bladder, was observed receiving improper catheter care. The CNA used a single washcloth to clean the catheter with multiple upward and downward strokes and then used the same washcloth to clean the resident's genital area before returning to the catheter. The Director of Nursing confirmed that catheter care should be provided every shift and during incontinence care, with catheters cleaned away from the urethra and drainage bags kept off the floor and secured.
Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to properly verify the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube before administering medications to a resident, identified as R171. During the medication administration process, a registered nurse (RN) used a stethoscope to auscultate the abdomen after injecting air through the PEG tube, but did not check the gastric content to confirm the tube's placement. This method of verification was not in accordance with the facility's guidelines, which require checking the gastric content to ensure proper tube placement. Additionally, the RN did not adhere to the physician's orders regarding the administration of water flushes and medications through the PEG tube. The RN administered 60 ml of water flush before and after medication administration, and 20 ml between each medication, which deviated from the prescribed 30 ml flush before and after, and 10-15 ml between medications. Furthermore, the RN failed to dilute the liquid Potassium Chloride as required by the manufacturer's guidelines, which could lead to gastrointestinal irritation. The Director of Nursing confirmed that the nurse should have followed the physician's orders and diluted the medication appropriately.
Failure to Maintain PICC Line Care
Penalty
Summary
The facility failed to provide appropriate care for residents with PICC lines, as evidenced by observations and record reviews. One resident had a PICC line with a transparent dressing that was soiled with dry blood and lacked a date, despite physician orders for daily care and dressing changes every Friday or as needed. The dressing remained unchanged and soiled over consecutive days, indicating a failure to adhere to the prescribed care plan. Another resident's PICC line dressing was not changed for over a week, despite facility policy requiring weekly changes or sooner if the dressing is compromised. The Director of Nursing acknowledged that the dressing should have been changed and attributed the oversight to the resident's hospital visit. The facility's policy emphasizes the importance of sterile dressing changes and regular assessments to prevent catheter-related infections, which were not followed in these cases.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration for a resident who was receiving oxygen. The resident, who was admitted with multiple diagnoses including hypertensive encephalopathy, type 2 diabetes mellitus, and dementia, was observed receiving between 3.5 to 4 liters of oxygen via nasal cannula on two separate occasions. Despite this, the resident's Physician Order Sheet did not include an order for oxygen administration. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that residents receiving oxygen should have a physician's order, which was not present in this case. The facility's Oxygen Management Policy also mandates a physician order for oxygen administration, which was not adhered to in this instance.
Controlled Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure the accuracy of controlled medication counting logs and proper disposal of controlled medications for two residents. For one resident, the Controlled Substances Proof of Use sheet was improperly stored inside the controlled box rather than in the narcotic control counting log binder. The sheet lacked essential information such as the medication name, dosage, and administration instructions. Additionally, there were discrepancies in the packaging of the medication, with one package unsealed and containing a loose half tablet. For another resident, the Controlled Substance Proof of Use sheet was also stored incorrectly and did not include the ordered medication administration instructions. Furthermore, there was no active order for the medication found in the resident's records. The LPN admitted to pre-pulling controlled medications from the facility's narcotic convenience box, which is against the facility's policy. The Director of Nursing confirmed that all controlled substance documentation should be kept in the narcotic control sign-off binder and that medications should not be pre-pulled or improperly stored.
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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 Westmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of Westmont | 0.9 mi | ★★★★★ | 14 | 0 |
| Oak Trace | 1.4 mi | ★★★★★ | 6 | 0 |
| Oakwood Rehab And Nursing Center | 2.1 mi | ★★★★★ | 14 | 0 |
| Chateau Nrsg & Rehab Center | 2.5 mi | ★★★★★ | 2 | 0 |
| Eden Vista Burr Ridge | 2.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.