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 Casey Rehab And Nursing during CMS and state inspections, most recent first.
Staff failed to immediately report two separate abuse-related incidents as required by facility policy and training. In one case, a CNA delayed reporting an allegation that another CNA struck a cognitively impaired resident with a positioning cushion and used hateful language, despite having been trained to report suspected abuse immediately to a supervisor and the administrator. In another case, a CNA and an RN witnessed a verbal altercation in which one resident threatened to beat another, but did not promptly notify facility leadership or the on-call manager, and the incident only came to the attention of the administrator and DON when they later reviewed documentation in the electronic medical record.
A resident with diabetic polyneuropathy and muscle weakness experienced frequent severe pain and received more than the prescribed amount of PRN acetaminophen without required physician notification. When stronger pain relief was needed, there was an 18-hour delay in obtaining Tramadol due to prescription processing issues, resulting in prolonged discomfort despite staff efforts to provide comfort.
A resident with mild dementia and high elopement risk repeatedly attempted to leave the facility, triggering alarms and requiring staff intervention. Staff responses were limited and not always documented, and some staff lacked required dementia training and were unfamiliar with elopement prevention procedures, resulting in inadequate care and monitoring.
A resident with dementia, agitation, and impaired decision-making experienced multiple falls after the facility failed to consistently implement documented fall prevention interventions, such as non-slip strips, safety checks, and hourly toileting. Observations showed missing safety equipment and incomplete documentation, while a change in the resident's condition was not fully addressed due to a missed blood test order.
A resident with a urostomy showing signs of infection experienced a delay in starting prescribed antibiotics for a UTI because the ordered dose was not available in the backup medication system. Staff did not notify the provider about the delay, and the antibiotic was not administered until two days after it was ordered, contrary to facility policy.
A resident with a diabetic ulcer on the left heel experienced worsening of the wound due to the facility's failure to prevent cross-contamination and adhere to physician orders for wound care. The resident's dressing changes were not completed as prescribed, and incontinence care was not provided timely, leading to the dressing being saturated with drainage and urine. Observations showed improper wound care procedures, and facility policies were not followed, resulting in the need for antibiotics due to infection.
The facility failed to maintain their survey results book in an accessible manner, affecting all 51 residents. During a resident meeting, none of the residents could locate the book. It was found positioned too high for wheelchair-bound residents, without signage indicating its location, as confirmed by the Administrator and Regional Representative.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 51 residents. The Dietary Manager, in charge since February 2024, lacks necessary qualifications, having only completed a one-day ServSafe course. The Registered Dietician works one day per month and was misled about the manager's qualifications. The facility's assessment requires a full-time qualified professional, which is unmet.
A facility failed to obtain a Level 2 screening for a resident newly diagnosed with severe mental illness, including Delusional Disorder and Affective Mood Disorder, to assess the need for specialized mental health services. The resident, admitted in 2006, was observed with hyper-manic speech and lacked a documented Level 2 screening after the 2021 diagnoses. The administrator confirmed the absence of a recent screening.
A facility failed to complete a discharge summary for a resident who wished to move to another SNF. The resident, who required verbal cues and medication management due to cognitive deficits, had no supportive family or caregivers. The facility's policy mandates a discharge summary for each resident, but the medical record lacked this, along with a physician order and nurse progress notes. The administrator cited a change in facility ownership as the reason for missing documentation.
A facility failed to secure an E type oxygen cylinder, leaving it freestanding in a resident's room. The resident was approximately 10 feet away from the unsecured tank. The facility's policy requires oxygen tanks to be secured in a holder, in line with NFPA regulations. The resident had a previous episode of low blood oxygen levels, but no documented oxygen use since then.
A facility failed to properly label medications and monitor expiration dates, leading to errors in medication administration for a resident. An LPN administered expired Pantoprazole, Ibuprofen without a label, and Zinc Sulfate instead of Zinc Gluconate without questioning the discrepancy. The DON confirmed these were labeling errors, and the pharmacist noted the importance of adhering to labeling policies.
A facility failed to maintain a complete medical record for a resident due to a recent change in ownership. The resident's EMR was missing critical documentation, including physician and nurse progress notes, vital signs, and ADL charting. The administrator acknowledged the incomplete record and the lack of a policy to address such issues.
The facility failed to use proper PPE for two COVID-19 positive residents on isolation precautions. A CNA did not wear a gown or gloves while assisting a resident with eating, and an LPN did not wear an N95 mask, gloves, or gown while administering medications. Both staff members were aware of the residents' isolation status, and the DON confirmed the need for PPE to prevent the spread of infection.
A resident with severe cognitive impairment and a history of elopement left an LTC facility unnoticed due to inadequate supervision. Despite being identified as high risk for elopement, the resident's care plan was not updated with necessary interventions. The resident exited the Dementia unit and was found 0.9 miles away, having crossed multiple streets in extreme heat. Staff interviews revealed a history of elopement and failure to follow facility policies.
The facility failed to provide mandatory training on the QAPI program to all staff, affecting the quality of care for 44 residents. Interviews revealed that an RN and CNAs had not received any QAPI training, with some staff unaware of the program. The administrator admitted that QAPI meetings occur quarterly, but information is only shared by word of mouth, leading to a lack of implementation of new interventions and policy updates.
The facility did not ensure that CNAs received the required twelve hours of annual training, affecting all 44 residents. Records showed that five CNAs completed fewer than the mandatory training hours. The Lead CNA confirmed the deficiency and the absence of documentation for these CNAs.
A resident with dementia and a high fall risk experienced multiple falls due to inadequate interventions and unsafe footwear. The resident wore slip-on shoes and sandals without back straps, contributing to falls. A mechanical lift left in the hallway posed an additional hazard. Staff were aware of the resident's wandering and unsafe footwear but did not take timely action. A urine analysis ordered after a fall was delayed, indicating a lack of prompt response.
The facility failed to protect residents from physical abuse by peers, as incidents involving three residents were reported. A resident with a history of inappropriate behavior made contact with another resident's forehead, while another resident with cognitive disorders and aggressive tendencies made contact with the same resident's face. Despite the facility's abuse prevention policy, these incidents highlight a failure to prevent abuse.
The facility failed to follow physician orders for two residents, resulting in delayed care. A urinalysis for a resident was not obtained promptly after a fall, and a repeat EGD was not scheduled within the recommended timeframe for another resident. Communication and order management issues contributed to these deficiencies.
Failure to Timely Report Alleged Staff Abuse and Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to timely report multiple allegations of abuse and a resident-to-resident altercation within the required immediate, not more than 24-hour timeframe. In the first incident, a CNA (V3) reported that another CNA (V4) hit a cognitively impaired resident (R2) with a positioning cushion and stated, "I hate you." The facility’s investigation report shows the alleged event occurred on 10/27/25, but the allegation was not brought to facility leadership until 11/10/25. V3 later stated she witnessed the incident on 10/27/25 but delayed reporting it for about a week because she was a new employee and feared backlash from other staff. V3 had previously signed a Training Acknowledgement Form stating it was her responsibility to immediately report any signs of abuse, neglect, or mistreatment to her supervisor and the administrator, and to report any observed, heard about, or suspected mistreatment immediately. In the second incident, staff failed to immediately report a resident-to-resident verbal altercation in which one resident (R3) threatened to beat another resident (R4). The facility’s investigation report documents that the altercation occurred on 11/29/25 and was witnessed by a CNA (V5) and an RN (V6). The administrator (V1) and DON (V2) did not learn of the incident until they read an RN progress note in the electronic medical record on 12/1/25. V5 acknowledged witnessing the altercation, separating the residents, and reporting it only to the nurse on duty, and did not notify the administrator or the on-call manager. V2 confirmed that neither V5 nor V6 contacted her over the weekend to report the incident. V5 had also signed a Training Acknowledgement Form stating that any alleged violations involving mistreatment, neglect, or abuse must be reported immediately to a supervisor and the administrator. The facility’s abuse prevention policy states that all allegations or suspicions of abuse will be reported in the proper timeframe.
Failure to Provide Timely and Adequate Pain Management
Penalty
Summary
A resident with Type II Diabetes Mellitus, Diabetic Polyneuropathy, and muscle weakness was admitted to the facility and had physician orders for Acetaminophen 650 mg every six hours as needed for mild pain, with instructions to notify the physician if more than three doses were given in 48 hours. The resident also had an order for Tramadol 50 mg as needed for pain. Review of the Medication Administration Record showed that the resident received more than three doses of Acetaminophen in 48-hour periods on multiple occasions, but there was no documentation that the physician or advanced practice provider was notified as required. The resident consistently reported high pain levels, rating her pain at eight or higher for most doses administered during this period. On one occasion, the resident experienced unbearable pain and requested stronger pain medication. The DON attempted to contact the nurse practitioner, but did not receive a response, leading the overnight RN to contact the Medical Director, who ordered Tramadol. However, the new prescription could not be sent to the pharmacy immediately, resulting in an 18-hour delay before the resident received the medication. During this time, the resident remained tearful and uncomfortable, and staff attempted non-pharmacological interventions to provide comfort. The delay in medication administration and failure to notify the physician as required by the standing order contributed to inadequate pain management for the resident.
Failure to Provide Appropriate Dementia Services and Elopement Prevention
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate services for a resident diagnosed with mild dementia, agitation, and anxiety disorder, who was assessed as high risk for elopement. The resident repeatedly attempted to leave the facility, triggering personal alarms on multiple occasions and requiring staff intervention to prevent elopement. Despite the resident's ongoing exit-seeking behavior, staff responses were limited to escorting the resident back inside and attempting to re-educate him, which was noted as unsuccessful due to cognitive impairment. Documentation indicated that the resident's exit-seeking had increased in frequency, yet interventions remained largely unchanged and were not consistently documented. Further contributing to the deficiency, not all staff had received dementia training as required by facility policy, and some were unfamiliar with the location or use of the elopement logbook, which is essential for tracking and preventing unsafe wandering. The facility's own policy mandates a multi-faceted approach to elopement prevention, including staff education and awareness of procedures, but interviews revealed gaps in staff training and knowledge. These failures resulted in inadequate implementation of interventions and monitoring for a resident at high risk for elopement.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement and maintain fall prevention interventions for a resident with multiple risk factors, including dementia, agitation, delusional disorders, impaired decision-making, and frequent incontinence. The resident's care plan and bedside Kardex included several fall prevention measures such as visible signage, hourly toileting, non-slip strips in key areas, 15-minute safety checks, and assistance with transfers. Despite these documented interventions, observations and record reviews revealed that many of these measures were not in place or not consistently implemented. For example, non-slip strips were missing from the bathroom and recliner, the 'Call Don't Fall' sign was not visible, and non-slip material was absent from the wheelchair and recliner seats. Additionally, the resident's room was not moved closer to the nurse's station as planned, and required safety checks and hourly toileting were not documented or observed during the survey period. The resident experienced multiple falls over a three-month period, with documented incidents occurring in various locations such as in front of the recliner and in the bathroom. Progress notes indicated that the resident often attempted to move independently, including trying to use the toilet or brush teeth, which led to falls. Staff interviews confirmed that required 15-minute safety checks were not accurately documented or performed, and that interventions such as non-slip strips and materials were not consistently maintained. The resident also had a change in condition, including pitting edema and a diagnosis of hyponatremia, which was not fully addressed due to a missed blood test order that was neither completed nor followed up with the provider. Facility policy required thorough investigation of all falls, evaluation for changes in condition, provider notification, and implementation of new interventions as needed. However, the facility did not ensure that these protocols were followed, as evidenced by the lack of documentation, incomplete implementation of care plan interventions, and failure to complete ordered diagnostic tests. These lapses contributed to the resident's repeated falls and unaddressed changes in medical condition.
Delay in Initiation of Antibiotic Therapy for UTI Due to Medication Unavailability
Penalty
Summary
A resident with a urostomy experienced increased weakness, lethargy, and confusion following a fall. Nursing notes documented that the resident's urine was dark amber and cloudy, prompting notification of the nurse practitioner and orders for urinalysis and culture. Laboratory results showed significant abnormalities, including elevated leukocyte esterase, increased white blood cells, and high bacterial counts, indicating a urinary tract infection (UTI). Despite these findings, there was a delay in initiating antibiotic therapy. The nurse practitioner ordered Augmentin, but the specific dose was not available in the facility's backup medication system, and the medication was not started until two days after the order was written. Facility records and interviews revealed that staff did not notify the provider of the delay in starting the antibiotic, as required by facility policy. The backup medication system did not stock the ordered dose, and although the pharmacy was contacted, there was no documentation of provider notification regarding the unavailability of the medication. The facility's pharmacy guide instructs staff to notify the provider if a medication is not available, but this step was not documented or carried out, resulting in a delay in treatment for the resident's UTI.
Failure to Prevent Cross-Contamination and Inadequate Wound Care
Penalty
Summary
The facility failed to prevent cross-contamination during wound care for a resident with a left plantar heel open diabetic ulcer. The resident's wound care was not conducted according to physician orders, leading to the worsening of the wound. The dressing changes were not completed as prescribed, and the resident did not receive timely incontinence care, resulting in the dressing being saturated with wound drainage and urine. This lack of proper care led to the resident requiring antibiotics due to a Staphylococcus infection. The resident, who is cognitively intact, has a medical history that includes acute osteomyelitis of the left ankle, diabetes mellitus type II with foot ulcer, morbid obesity, and polyneuropathy. The resident requires maximum assistance for toileting and moderate assistance for personal hygiene. Despite these needs, the facility's records show that the dressing changes were not documented on several occasions, and the resident's wound showed signs of deterioration, including increased purulent drainage and foul odor. Observations revealed that the resident's dressing was often saturated, and staff failed to follow proper wound care procedures, such as changing gloves and performing hand hygiene. The facility's policies on wound care and skin prevention were not adhered to, as evidenced by the lack of incontinence care and monitoring of the resident's wound. The Director of Nurses and the Administrator acknowledged these failures, noting that the staff did not monitor the wound or document treatments as required, contributing to the resident's wound worsening.
Inaccessible Survey Results Book
Penalty
Summary
The facility failed to maintain their survey results book in a manner accessible to residents, potentially affecting all 51 residents residing in the facility. During a resident group meeting, none of the four residents present were able to state where the survey results book was located. The survey book was found positioned five feet six inches above the floor in a wall caddy outside the facility business office, without any signage indicating its location. This placement made it inaccessible to residents, particularly those in wheelchairs, as confirmed by the facility's Administrator and Regional Representative.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 51 residents. The Dietary Manager, V18, has been in charge since February 2024 but lacks the necessary qualifications, such as being a Certified Dietary Manager or having equivalent training. V18 only completed a one-day ServSafe course, which does not cover clinical nutrition. V18 admitted to not meeting the State of Illinois standards for a food service manager or dietary manager and lacks qualifications in clinical nutrition. The facility's Registered Dietician, V19, works only one day per month and was misled by V18 about their qualifications. The Regional Consultant, V14, reported previous success in reversing similar citations by presenting the one-day course as equivalent to the required clinically focused nutrition course. However, the facility's assessment documents the need for a full-time clinically qualified professional as the Dietary Manager, which is not currently being met. The facility's application for Medicare and Medicaid confirms the presence of 51 residents, all potentially affected by this deficiency.
Failure to Obtain Level 2 Screening for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to obtain a Level 2 screening for a resident who was newly diagnosed with severe mental illness, specifically Delusional Disorder and Affective Mood Disorder, to determine the need for specialized mental health services. This deficiency affected one resident out of two reviewed for pre-admission screening. The resident, admitted to the facility in 2006, was observed speaking in a hyper-manic pattern and unable to maintain the topic of conversation. Despite the new diagnoses made in 2021, there was no documented Level 2 screening in the resident's medical record. The facility's administrator confirmed that the only pre-admission screening available was from 2006, with no subsequent Level 2 screening recorded.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as R48, who was reviewed for discharge among a sample of 27 residents. According to the facility's policy, a discharge summary should be prepared for each resident discharged, especially when moving to a private residence or another nursing care facility. R48's electronic medical record indicates an admission date of 6/30/22 and a discharge date that is unspecified in the report. R48's care plan, initiated on 2/26/24, notes the resident's desire to be discharged despite lacking supportive family or caregivers, and highlights R48's need for verbal cues and medication management due to cognitive deficits. However, the medical record lacks a discharge summary, physician order for discharge, or nurse progress notes documenting the discharge. The facility administrator acknowledged the absence of documentation, attributing it to a change in facility ownership on 11/1/24, during which all resident information was transferred to the previous corporation.
Unsafe Storage of Oxygen Cylinder
Penalty
Summary
The facility failed to maintain safe storage of oxygen cylinders, resulting in a deficiency related to accident hazards. During an observation, an unsecured E type oxygen cylinder was found standing freely inside the doorway of a resident's room. The resident was reclining in bed approximately 10 feet away from the cylinder. Both the Administrator and the Director of Nursing confirmed that oxygen tanks should not be left unsecured on the floor. The facility's policy, dated 3/8/22, mandates that E tanks must be secured in a holder and never left unsecured, in accordance with NFPA regulations. The resident's nurse's note indicated an episode of low blood oxygen levels on 1/9/25, but there was no documented use of oxygen since that date.
Medication Labeling and Expiration Monitoring Deficiencies
Penalty
Summary
The facility failed to properly label medications and monitor expiration dates for a resident, leading to several medication administration errors. A Licensed Practical Nurse (LPN) administered Pantoprazole suspension to a resident despite a sticker indicating it should not be used after a certain date. Additionally, the LPN administered Ibuprofen suspension that lacked a medication instruction label and Zinc Sulfate instead of the prescribed Zinc Gluconate, without questioning the discrepancy. The multivitamin administered from a stock bottle also lacked an open date, which is against facility policy. The Director of Nurses (DON) confirmed that all medications should have a label and that expired medications should not be administered. The DON acknowledged that the LPN should have noticed the difference in the Zinc order and questioned the label discrepancy. The Registered Pharmacist/Pharmacy Manager stated that while there is no significant clinical difference between the Zinc formulations, the discrepancy should have been questioned. The pharmacist also noted that administering expired Pantoprazole should have been avoided, and all medications should adhere to the facility's labeling policy.
Incomplete Medical Record Due to Ownership Change
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was reviewed for closed records. The resident was admitted and later discharged to another skilled facility at their request. However, the Electronic Medical Record (EMR) for this resident was incomplete, lacking essential documentation such as Physician Orders, Nurse Progress Notes, Physician Progress Notes, Social Service Progress Notes, the resident's weight and vital signs, Activities of Daily Living (ADL) charting, and Assessments. The facility's administrator acknowledged the incomplete EMR and stated that due to a recent change in ownership, the facility could not provide additional documentation of the resident's stay. There was no paper documentation available, and the administrator confirmed that there was no policy in place to address this issue, although it was understood that complete medical records were expected.
Failure to Use PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols for residents who tested positive for COVID-19 and were on droplet and contact isolation precautions. Specifically, a Certified Nurse Aide (CNA) did not wear a gown or gloves while assisting a severely cognitively impaired resident, who was COVID-19 positive, with eating. The CNA also failed to perform hand hygiene before assisting the resident, who was seated at a table by the nurses' station. The CNA later admitted to not knowing the requirement to wear gloves when assisting a COVID-19 positive resident. Additionally, a Licensed Practical Nurse (LPN) did not wear an N95 mask, gloves, or gown while administering medications to another COVID-19 positive resident on droplet and contact isolation precautions. Despite the presence of signs indicating the need for such precautions and a bin with PPE supplies outside the resident's room, the LPN acknowledged awareness of the resident's isolation status and the necessity of wearing appropriate PPE. The Director of Nurses confirmed that staff should wear proper PPE to prevent the spread of COVID-19 and other organisms.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident with a history of elopement, resulting in the resident leaving the facility unnoticed and unattended. The resident, who has frontal lobe dementia, was able to exit the alarmed Dementia unit and elope 0.9 miles away from the facility. This incident occurred despite the resident being identified as high risk for elopement and having a care plan that required checks every 15 minutes. The resident's medical history includes dementia, major depressive disorder, altered mental status, cognitive decline, colostomy status, a history of cerebral vascular accident, and chronic ulcerative enterocolitis. The resident was admitted to the facility with a documented severe cognitive impairment and a behavior of exit-seeking, which was noted in the social service progress notes. Despite these documented risks, the resident's care plan was not updated to include necessary interventions until after the elopement incident. On the night of the elopement, the resident was left unsupervised in the main nursing home area after a CNA allowed the resident to leave the Dementia unit. The staff failed to monitor the resident as required, and the door alarms did not sound, allowing the resident to leave the facility unnoticed. The resident was later found at a family member's house, having crossed multiple streets in extreme heat and high humidity. Interviews with staff and family members revealed that the resident had a history of elopement and that the facility's policies and procedures were not adequately followed to prevent such incidents.
Failure to Train Staff on QAPI Program
Penalty
Summary
The facility failed to provide mandatory training to all staff members on the Quality Assurance and Performance Improvement (QAPI) program, which is essential for ensuring quality care for all residents. The facility's policy mandates that QAPI training should be conducted regularly and involve all employees, departments, and services. However, interviews with staff members, including a Registered Nurse (RN) and Certified Nurse Aides (CNAs), revealed that they had not received any training on the QAPI process. The RN mentioned that they believed QAPI was something managed by the facility's managers, while the CNAs were unaware of the program entirely. The facility's administrator acknowledged that the management team, including the Medical Director, holds QAPI meetings at least quarterly. However, the information from these meetings is not effectively communicated to the staff, as it is only shared by word of mouth. This lack of formal training and communication means that staff are not informed about new interventions for residents or updates to policies and processes, leading to a failure in implementing necessary changes to improve resident care.
Failure to Provide Mandatory CNA Training
Penalty
Summary
The facility failed to provide the required twelve hours of annual training for Certified Nurse Aides (CNAs), which has the potential to affect all 44 residents residing in the facility. The facility's in-service attendance records from August 2023 through August 2024 did not document that five CNAs, identified as V27, V28, V29, V30, and V31, completed the mandatory training hours. Specifically, V27 and V28 each completed six hours, V29 completed four hours, V30 completed eight hours, and V31 completed five hours of in-service training in the past twelve months. The Lead CNA, V21, confirmed that all CNA staff should receive twelve hours of training annually and acknowledged the lack of documentation for the mentioned CNAs.
Failure to Prevent Falls and Maintain Safe Environment
Penalty
Summary
The facility failed to provide appropriate fall interventions and maintain a safe environment for a resident identified as a high fall risk. The resident, who has a history of agitation due to dementia, major neurocognitive disorder, and Alzheimer's disease with behavioral disturbances, experienced multiple falls within a short period. The resident's care plan documented interventions for falls, including ensuring appropriate footwear and keeping hallways clear of clutter. However, the resident was found wearing unsafe footwear, such as slip-on shoes and sandals without back straps, which contributed to the falls. Additionally, a mechanical lift was left in the hallway, posing a hazard that the resident encountered during one of the falls. The facility's staff, including LPNs and CNAs, were aware of the resident's wandering behavior and the unsafe footwear but did not take timely action to address these issues. Interviews with staff revealed that the resident often wore gripper socks or slip-on shoes, which were not suitable for preventing falls. Furthermore, a urine analysis ordered after the resident's second fall was delayed, indicating a lack of prompt response to the resident's fall risk. The facility's fall prevention policy, intended to ensure resident safety, was not effectively implemented, leading to the resident sustaining a laceration that required sutures.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by incidents involving three residents. Resident 8, who has a history of inappropriate behavior and physical aggression, was involved in an incident where they made contact with Resident 7's forehead in the dining room. Resident 8's medical history includes unspecified dementia with psychotic disturbance and depression, and they are not cognitively intact. Despite these known behaviors, the facility did not prevent the incident from occurring. Similarly, Resident 1, diagnosed with mild neurocognitive disorder and unspecified dementia with agitation, made contact with Resident 7's face. Resident 1 has a history of entering rooms uninvited and displaying physically aggressive behaviors. Interviews with staff confirmed that Resident 1 can exhibit aggressive behaviors. The facility's abuse prevention policy emphasizes the importance of protecting residents from abuse by others, yet the incidents involving Residents 1 and 8 indicate a failure to implement effective measures to prevent such occurrences.
Failure to Follow Physician Orders for Urinalysis and EGD
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. For one resident, a urinalysis was ordered after a second fall but was not obtained until several days later. The delay occurred because the resident was unwilling to sit down, and the order was passed through multiple nurses before being executed. The Director of Nursing confirmed that the urinalysis should have been obtained promptly after the order was given. For another resident, the facility did not schedule a repeat Esophagogastroduodenoscopy (EGD) within the recommended four-week timeframe following an emergency department visit for food impaction. The resident was on an antibiotic, which complicated scheduling, but there was no documentation of an appointment being made. The staff member responsible for scheduling appointments was unaware of the need for a follow-up EGD, indicating a breakdown in communication and order management.
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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 Casey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartland Nursing & Rehab | 0.5 mi | ★★★★★ | 4 | 0 |
| Greenup Rehab And Nursing | 9.6 mi | ★★★★★ | 6 | 0 |
| Charleston Rehab And Nursing | 16.3 mi | ★★★★★ | 21 | 0 |
| Marshall Rehab & Nursing | 16.6 mi | ★★★★★ | 6 | 0 |
| The Haven Of Ridgeview | 21.6 mi | ★★★★★ | 26 | 0 |
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