Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chicago Ridge Snf during CMS and state inspections, most recent first.
Failure to Protect Resident from Peer Physical Abuse: A resident with moderately impaired cognition was physically assaulted by another resident with a history of verbal and physical aggression toward peers. Staff documented an inappropriate interaction and separated the residents, but the assaulted resident later required hospital transfer for bruising to the eye and elbow and multiple rib fractures. Hospital records identified the event as an assault, while resident statements and staff interviews gave conflicting accounts of what occurred.
Kitchen Ice Machine and Vent Not Kept Clean: The ice machine in the kitchen was observed with visible dust and dirt, and the Dietary Manager stated it should be wiped daily. A ceiling air vent above the juice dispenser was also observed with heavy dust accumulation, and the Dietary Manager stated there should be no dust above where juice is served. Facility policy required routine cleaning and sanitizing of the ice chest and monthly cleaning and disinfecting of the ice machine.
Pressure ulcer prevention and wound care were not provided as ordered. Several residents at risk for skin breakdown were observed in wheelchairs without pressure-relieving cushions, despite care plans and assessments identifying them as high risk. A resident with a stage 4 coccyx PI also had wound care performed by a CNA who removed the dressing and cleansed the wound before the wound nurse applied the ordered treatment, and the resident’s low air loss mattress was observed set at an incorrect weight setting.
Controlled substance counts and documentation were incomplete for two residents and on the medication cart. An LPN had not signed out morning doses for two residents, causing the recorded narcotic counts to be higher than the actual counts, and an RN found multiple missing incoming and outgoing shift signatures on the controlled substances check form. The DON stated that two nurses are required to count narcotics on and off duty every shift and that administered controlled substances must be signed out immediately.
Medication Error Rate Exceeded Allowed Threshold: Surveyors observed five medication errors during a medication pass, resulting in a 19.23% error rate. An RN omitted ordered meds for three residents, gave one resident an unauthorized stool softener, and prepared an inaccurate Levetiracetam dose for another resident with a seizure disorder; the MARs also were not signed off at the time of review.
An opened container of blood glucose test strips in a med cart was found without the required open date on the label. The RN said the date was not on the container and was unsure how long the strips remain usable after opening, while the DON confirmed that glucometer strips must be labeled once opened and not used if expired. Manufacturer instructions in the vial directed staff to write the date on the label when first opened and use the strips within 3 months.
A resident with schizoaffective disorder and other comorbidities had Seroquel doses progressively increased without documented informed consent from the resident or his guardian and without behavior documentation or evidence of non-pharmacological interventions, despite facility policy requiring these steps. The resident reported concern about receiving higher doses than expected and stated he had not consented and was refusing the medication. Behavior monitoring sheets over several months showed no behaviors, while the guardian reported concerns about the resident’s worrying and frequent calls to police and believed the dose remained at 100 mg. The ADON, psychiatrist, psych NP, and an LPN all acknowledged either the absence of documented behaviors or the requirement for informed consent and behavior documentation, which were not met.
A resident with a contracted left hand and wrist was repeatedly observed sitting in a wheelchair with the hand clenched in a fist and no device in place to prevent further contracture, despite a care plan stating the resident would perform AROM to all extremities. The resident reported that staff had not encouraged arm or hand exercises. The restorative nurse stated they were unaware of the contracture and had not assessed the resident’s restorative needs, and the therapy manager reported that therapy had not been informed of the condition until the surveyor’s inquiry. On assessment, the resident experienced pain when attempting to open the hand, and the therapy manager indicated the resident would benefit from a resting hand splint, contrary to facility policies and the restorative nurse job description requiring timely restorative evaluation, coordination with therapy, and management of splints.
A resident with an indwelling urinary catheter was observed with the drainage bag hanging at the side of the bed and visible to people walking down the hallway, without a privacy bag. The resident had diagnoses including CKD, urinary retention, dementia, and BPH, and the care plan noted the resident was at higher risk for infection secondary to the catheter and candida auris. A CNA was notified, and the ADON later stated that a privacy bag should cover the drainage bag for the resident’s privacy.
An RN prepared an oral anticonvulsant at double the ordered volume before correcting the dose after being questioned, and another resident was found with two active meds left in a dresser drawer after staff reportedly set meds down and left them. The DON and ADON confirmed the orders and stated meds should be administered per the 5 rights, watched until taken, and not left at the bedside.
Failure to arrange transportation and follow up on missed appointments. A resident with TBI, convulsions, uropathy, gallbladder disease, and bipolar disorder missed scheduled MRI and other specialty appointments because transportation did not occur. The DON said the resident’s appointment list was given to her after the prior scheduler quit, but the record had no documentation of the missed appts, no evidence the MD was notified, and no documentation that the appts were rescheduled.
A resident with ESRD, CKD, DM2, HTN, osteomyelitis, a Stage 4 sacral pressure injury, and palliative care had moderate cognitive impairment and could not identify his hospice provider. Staff, including an LPN, CNA, DON, and ADON, could not locate hospice communication or identify the hospice agency, and the hospice binder was initially missing from the nurse’s station. The hospice nurse said she communicated verbally and expected a folder, sign-in sheet, and charting area for staff reference, but survey review found no sign-in documentation of hospice visits or written updates from hospice to facility staff.
A hospice nurse failed to follow EBP during high-contact care for a resident with a pressure injury and Foley catheter by wearing gloves but no gown, and did not perform hand hygiene before donning gloves. The facility also failed to handle soiled linen properly when loose linen was sent down the chute without being bagged, and the laundry area had cleanliness and storage issues in the clean linen space.
Daily staffing information was not posted in a highly visible area for residents and was missing required details. The posting was taped to the front desk windows in a locked foyer area that residents could not freely enter, and it did not include the total and actual hours worked for RNs, LPNs, or CNAs. The Scheduler confirmed the omissions and the Administrator stated there was no facility policy for the daily staffing posting.
Open dumpsters and trash around the disposal area were observed during kitchen rounds. The Dietary Mgr stated the oil dumpster may not have had a lid, while a cook stated a lid was available. On a later observation, a dumpster was again seen uncovered with trash on the floor nearby, and the Dietary Mgr noted that housekeeping may have left it open and that open dumpsters could attract rodents.
The facility failed to complete and document a facility-wide assessment with direct care staff involvement and did not identify staffing needs by shift or resident unit. The assessment listed total RN/LPN and CNA staffing needs, but the DON/Administrator review confirmed it did not show shift- or unit-specific staffing, and no updated assessment was provided before survey exit.
The facility did not follow its own Community Access Determination policy requiring Social Services to complete community survival skills assessments upon admission and quarterly for all residents, and when outside passes are requested. Record review showed that several residents had not received a community skills assessment for many months beyond the required frequency. During interview, Social Services staff described a practice of completing these assessments quarterly, annually, and with outside pass requests, while a separate internal document listed them as admission, significant change, and annual assessments, which conflicted with the written policy. The DON and ADON later clarified that this internal document was not a formal policy, yet the documented assessment schedule still did not match the policy requirements, resulting in missed assessments for multiple residents.
A resident reported that her personal cell phone went missing from her room and stated she informed the Social Service Director, an RN, and CNAs, but did not receive follow-up or a written response. The resident documented the report and later noted that a phone was found in a medication storage room, while staff interviews confirmed that the concern had been reported but not pursued. The grievance binder contained no written grievance about the missing phone, and a grievance form produced by the facility lacked the preparer’s name and only suggested another resident might have taken the phone. Review of belongings inventories showed the resident’s phone and other personal items were not listed, and the inventories were not signed by the resident, despite facility policies requiring complete documentation and resident signatures for belongings and written, timely handling of grievances.
The facility failed to implement its abuse prevention policy when a resident with psychosis, schizophrenia, and bipolar disorder, who had been frequently refusing ordered psychotropic medications, entered another resident’s room, became upset about spoiled milk, and physically assaulted her by hitting her head with a milk carton, pushing her onto the bed, and violently shaking her until another resident intervened and staff arrived. Multiple residents provided consistent statements that the aggressor was on top of and hitting the victim, who reported pain to her arm and behind her ear. Despite repeated medication refusals and a recent hospitalization for aggressive behavior, there was no documentation that the physician or psychiatrist was notified with each refusal, and NP notes indicated no nursing concerns. The facility’s abuse investigation did not include staff interviews and concluded there was no credible evidence of abuse, contrary to the resident witness accounts.
A resident with severe mental illness, documented poor impulse control, and a history of physically abusive behavior was not adequately supervised, despite care plans calling for daily monitoring and psychotropic medication management. The resident, who was known to be noncompliant with medications and exhibited delusions, disorganized thought processes, and auditory hallucinations, was able to enter another resident’s room, become agitated over a milk carton he believed was spoiled, and verbally and physically assault the resident by striking her with the carton, pushing her onto the bed, and violently shaking and hitting her until other residents and staff intervened.
The facility failed to prevent illicit drugs from being brought in, distributed, and used by residents, resulting in two residents testing positive for fentanyl and opiates and experiencing medical emergencies, including one requiring Narcan. Multiple residents and staff reported ongoing drug distribution within the facility, and drug paraphernalia was found in resident rooms and ceilings. The facility lacked an effective plan to identify how drugs were entering, did not consistently enforce its contraband policy, and staff were unclear about when to administer Narcan.
A resident receiving hydrocodone-acetaminophen for pain did not have consistent documentation in the MAR at the time of administration, and staff failed to consistently monitor and record the effectiveness of the pain medication. Interviews with the ADON and an LPN confirmed that facility policy for medication administration and documentation was not followed, resulting in incomplete records for controlled substance administration.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors observed that window drapes in the rooms of several residents were falling from curtain rods or tracks, with some rooms using towels to cover window openings. Maintenance staff acknowledged the issue but did not resolve it during the survey, and a resident reported making repeated requests for assistance with her curtains. The DON confirmed that rooms should be clean and homelike, and the facility's housekeeping policy requires a safe and sanitary environment, which was not met in this instance.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
One of two elevators was nonfunctional, causing delays for residents, staff, and visitors who rely on elevator access for daily activities and services. Maintenance staff reported ongoing issues with elevator breakdowns and could not specify which elevator was serviced or the cause of repeated failures. The facility's maintenance policy lacked protocols for elevator operation.
A resident with a history of substance abuse and a care plan restricting unsupervised passes was allowed to leave on a supervised community pass without proper verification of the escort's identity. The staff failed to ensure the person taking the resident matched the name on the pass request form, and the resident did not return to the facility.
Two residents with diabetes did not receive timely podiatry care or follow-up visits as ordered, resulting in long, thick, and discolored toenails. Despite requests for podiatry services and physician orders for regular follow-up, there was no documentation of recent podiatrist visits or adherence to the facility's policy for diabetic foot care.
A resident with a history of substance abuse obtained and used illicit drugs within the facility, resulting in an overdose that required Narcan administration and hospital transfer. Despite clear signs of drug use and staff and resident reports of suspicious behaviors, the facility did not investigate how the drugs entered the facility or how the resident accessed them, nor did they follow up with involved parties or document the incident as required by policy.
Two residents with histories of substance abuse did not receive required group programming or consistent behavioral health services, despite facility policies and care plans indicating these supports. One resident was excluded from substance abuse groups due to lack of admission documentation, and another did not receive regular counseling, resulting in illicit drug use and an overdose requiring hospital transfer.
A resident with chronic ischemia and vascular disease did not have physician orders to monitor her right foot for discoloration, pedal pulse, and temperature changes transcribed or implemented. Despite a nurse practitioner's verbal order and the presence of a blister, there was no documentation of monitoring or assessment in the medical record, and staff were unaware of the specific orders. This failure was contrary to facility policy requiring all physician orders to be recorded and followed.
A resident with a fractured ankle was physically assaulted by another resident in the dining room when no staff were present to monitor. Both residents had intact cognition and no care plans addressing abuse risk. Staff interviews and records confirmed that the dining room was often left unsupervised, especially during shift changes, and the assaulted resident required hospital evaluation for facial trauma.
A resident with a history of falls and cognitive impairment developed new right hip pain and became non-ambulatory. Despite therapy and nursing staff being notified, there was no timely or documented pain assessment, and PRN pain medication was not administered or recorded as required. The resident remained in pain for about 24 hours before being hospitalized for a hip fracture and surgery, with facility records and staff interviews confirming a lack of adherence to pain management policy.
A resident with a history of psychiatric disorders and intact cognition refused a scheduled long-acting injectable psychotropic medication. The LPN did not document the refusal or notify the physician, as required by the care plan and facility policy. The psychiatric nurse practitioner was unaware of the missed dose, and the DON confirmed that such refusals should be reported and documented.
A resident was verbally abused by a former Social Service Aide/Smoking Monitor during smoking time when the aide refused to provide a cigarette and used derogatory language. The incident was witnessed by another resident and reported to an LPN, who informed the Administrator and filed a police report. The resident involved was cognitively intact and had multiple diagnoses, including anxiety and depression.
The facility's pest control program failed to effectively manage a cockroach infestation, as evidenced by live cockroaches observed in resident rooms and frequent complaints from residents and staff. Despite scheduled pest control visits and actions taken in response to grievances, the issue persisted, affecting the facility's cleanliness and resident satisfaction.
A resident with a history of falls and multiple risk factors experienced repeated falls due to the facility's failure to implement care plan interventions and appropriate fall prevention measures. Despite requiring substantial staff assistance and having specific interventions outlined, the resident fell during unassisted transfers, and the facility could not provide evidence of required physical therapy evaluations.
The facility failed to promptly respond to call lights, affecting five residents, including those with significant health issues. Observations showed staff ignoring activated call lights, despite being nearby, leading to residents experiencing discomfort and potential health risks. The Director of Nursing confirmed that all staff should respond to call lights immediately, as per policy.
A resident with reduced mobility was left in a chair for 17 hours due to an uncharged mechanical lift. The family member reported the grievance, but the facility failed to document or resolve it promptly, violating their grievance policy.
A resident with a history of seizures and dementia eloped from a facility unsupervised, despite requiring supervision for community access. The resident was later found intoxicated by police, highlighting deficiencies in the facility's supervision and safety protocols. The facility lacked an authorized pass policy, and the resident exited through a basement back door without staff noticing.
On Christmas Day, insufficient staffing led to a failure in administering medications to 34 residents on the third floor of an LTC facility. Only one LPN was available, who did not cover the entire floor, resulting in missed medications for residents with various medical conditions. The DON was aware of the staffing issue but did not provide additional support, and the facility lacked a holiday staffing plan.
A facility failed to administer medications to 34 residents on the third floor during the day shift on Christmas Day due to understaffing. An LPN was responsible only for her assigned residents and did not cover the entire floor, while the DON was aware of the staffing issue but did not ensure all residents received their medications. The facility's policy requires supervision of medication administration, but the failure was not communicated to prescribers, highlighting a breakdown in communication and protocol adherence.
The facility failed to administer seizure medications to five residents on Christmas Day due to staffing shortages and communication issues. An LPN only administered medications to a portion of the residents, while the DON was aware of the staffing issue but did not ensure all residents received their medications. This resulted in missed doses for residents with conditions like dementia and seizures.
A resident with severe cognitive impairment was physically abused by his roommate, resulting in a chest contusion. The incident was not witnessed by staff, but the resident reported being punched, leading to a hospital transfer. The facility's failure to prevent this altercation highlights a deficiency in their abuse prevention program.
The facility failed to serve the planned meals to all 211 residents on two occasions. Residents were served white bread instead of garlic Texas toast for lunch and cream of wheat and scrambled eggs without cheese instead of oatmeal and scrambled eggs with cheese for breakfast. Additionally, there was a shortage of cold cereal and toast, leading to some residents not receiving their requested meals.
The facility failed to provide adequate dining supplies during a lunch meal service, affecting 75 residents. Initially, 45 residents received meals on plastic plates, but the staff ran out, serving the remaining 30 on Styrofoam plates. Additionally, 10 residents received coffee in Styrofoam cups without handles, and 25 residents were not given napkins. The dining room staff did not notify the kitchen to replenish supplies, despite sufficient stock being available.
A facility failed to initiate a timely falls care plan for a resident with a history of falling and generalized weakness. Despite the resident's ability to communicate needs, fall precautions were not implemented immediately upon admission. The resident was observed with injuries from a fall, and the call light cord was repeatedly out of reach. The restorative nurse did not investigate the fall or document necessary interventions in the care plan, which was initiated days later and backdated.
A resident with a history of falls was not accurately assessed for fall risk upon admission, and necessary fall prevention interventions were not implemented. The resident's call light was out of reach, and visible injuries indicated a fall. The Restorative Nurse did not investigate the fall or update the care plan, and the Director of Rehabilitation failed to prioritize the resident for skilled therapy. The facility's fall risk and post-fall assessment policy was not followed, resulting in a deficiency.
The facility failed to maintain a clean and homelike environment, with pervasive urine odors and unclean conditions affecting several residents. Staffing shortages and insufficient cleaning supplies contributed to the issue, as only one housekeeper was available for the third floor. Residents reported unclean rooms and soiled linens, while the facility's owner was unaware of the supply and staffing problems.
The facility did not follow its policy for serving food under sanitary conditions, affecting 66 residents on the 2nd floor. Meal trays were observed uncovered, with gnats present, despite available clean lids. CNAs reported lids were often unavailable or unnoticed, risking contamination. The DON confirmed the need for covered trays to prevent contamination and maintain temperature, as per the facility's policy.
Failure to Protect Resident from Peer Physical Abuse
Penalty
Summary
The facility failed to follow its abuse policy and failed to protect one resident from physical abuse by another resident. The incident involved a resident with dementia, lack of coordination, muscle wasting and atrophy, and a BIMS score of 12 indicating moderately impaired cognition, and another resident with anxiety, schizoaffective disorder, alcohol abuse, opioid dependence, and a BIMS score of 15 indicating intact cognition. The abused resident sustained bruising to the right eye and right elbow and multiple rib fractures that required hospitalization after the altercation. The record states that staff were told the two residents were involved in an inappropriate interaction and that both were separated and placed on 1:1. The abused resident’s progress note documented that she said she felt safe in the facility and was reminded to report incidents to staff. Later that day, she was transported to the hospital by stretcher for evaluation. Hospital records documented that she presented after a physical altercation at the nursing facility in which she was punched in the left lower rib cage and right eye, with bruising to the right eye and right elbow and multiple left rib fractures. X-ray findings showed posterior left seventh through ninth rib fractures, and the emergency department diagnosed closed fracture of multiple ribs of the left side, contusion of the face, and victim of assault. The abused resident later stated that the other resident blamed her for shortened smoking times, yelled at her, and then punched her in the face and side, with multiple punches occurring. The other resident stated that she punched the abused resident because she felt the resident kept pushing into her and walking into her. The other resident’s care plan documented a history of aggressive, inappropriate, attention-seeking, and maladaptive behavior, including verbal and physical aggression toward peers. Facility interviews also reflected conflicting accounts of the event, with some staff stating they did not see anyone hit anyone and others reporting that the other resident hit back after an altercation. The facility policy states that residents who allegedly abused another resident will be removed from contact with other residents during the investigation and that the accused resident’s condition shall be immediately evaluated, and it also requires informing local law enforcement first for suspected physical abuse involving physical injury inflicted by one resident on another.
Kitchen Ice Machine and Vent Not Kept Clean
Penalty
Summary
The facility failed to keep the kitchen ice machine and ice machine filter clean and free of dust, and failed to keep the ceiling air vent above the juice dispenser free of accumulated dust. During observation of the kitchen with the Dietary Manager, the ice machine was seen with visible accumulated dust and dirt, and the Dietary Manager stated that the ice machine is supposed to be wiped every day. On a later observation, the ceiling air vent above the juice dispenser machine was seen with a lot of accumulated dust, and the Dietary Manager stated that the juice machine is in use and there should be no dust in the vent right above where juice is served for residents. The facility census was 199, with 2 residents on NPO status, leaving 197 residents who receive food from the kitchen. Facility policy stated that the ice chest shall be cleaned and sanitized routinely by the dietary department, the ice machine will be cleaned and disinfected monthly by the dietary department, and the ice machine surfaces are to be scrubbed using a clean cloth and fresh detergent solution.
Pressure ulcer prevention and wound care were not provided as ordered
Penalty
Summary
The facility failed to provide pressure ulcer care and prevention in accordance with its policy and professional practice standards. During observation, several residents who were identified as at risk for pressure ulcers were sitting in wheelchairs without pressure-relieving cushions or devices. When staff were asked about the missing cushions, a CNA stated the residents did not have any and that restorative staff needed to provide them. A restorative nurse later stated the cushions had been ordered but had not yet been received, and also stated the residents should have cushions on their wheelchairs to prevent pressure ulcers. R6, R11, R21, R46, and R1 had records showing diagnoses and assessments identifying them as at risk for pressure ulcers or skin breakdown. Their care plans documented risk factors such as diabetes, limited mobility, malnutrition, incontinence, impaired mobility, weakness, and existing moisture-associated skin damage. Despite these documented risks, the residents were observed in wheelchairs without cushions during multiple observations, including after lunch and again two days later, with no cushions in place. The facility also failed to follow wound care practice for R16, who had a stage 4 pressure injury to the coccyx with undermining, exposed bone, and moderate serous drainage. During the wound care observation, a wound care CNA removed the soiled dressing and cleaned the wound with normal saline before the wound nurse applied the ordered treatment. The wound nurse stated the CNA was only supposed to prep the wound and that this had been the routine since she had been at the facility. In addition, R16 was observed on a low air loss mattress set to 400 lbs, while the resident’s documented weight was 135.2 lbs, and the wound nurse stated she was not sure how the mattress should be set for him.
Controlled substance counts and documentation were incomplete
Penalty
Summary
The facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift on the first floor, and failed to ensure the narcotic count was correct for two residents on the second floor. On the second floor, during observation of the controlled substances inventory with an LPN, R151’s Controlled Drug Receipt/Record/Disposition Form for Buoren/Nalox Film 8 - 2mg showed a remaining count of 4 films, but the actual count was 3 films. The LPN stated she had not signed for the medication given that morning and confirmed it should be signed immediately after administration. In the same observation, R163’s Controlled Drug Receipt/Record/Disposition Form for Lacosamide 200 mg tablets showed a remaining count of 4 tablets, but the actual count was 3 films, and the LPN again stated she had not signed out the morning doses after giving them. On the first floor, the Controlled Substances Check Form showed multiple missing signatures for incoming and outgoing nurses across several shifts, including missing AM, PM, and night shift signatures on multiple dates. During the observation, an RN stated she still needed to sign off that morning and confirmed she had completed the count with the night nurse but had not signed it. The DON stated that narcotic counts are to be performed by two nurses on and off duty every shift for safety and to explain any shortage, and the facility policy required administered narcotics to be signed out immediately, with two nurses counting and initialing narcotics at the beginning and end of each shift.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate at or below 5 percent. During observation, interview, and record review, surveyors identified five medication errors out of 26 medication opportunities, resulting in a 19.23% medication error rate and affecting four residents observed during medication pass. On 2/05/26 at 8:55am, V20 (RN) did not administer Cholecalciferol 1000 units to one resident, did not administer Procardia XL 60 mg to another resident, and did not administer Docusate 100 mg to a third resident. The MARs for these residents documented orders for those medications, and one MAR lacked an order for Docusate 100 mg that was given to a resident who requested a stool softener. For a fourth resident, V20 prepared Levetiracetam at 10 mL when the MAR ordered 5 mL by mouth twice daily for unspecified convulsions. The surveyor questioned the dose before administration, and V20 then placed the medication cup on a flat surface, confirmed 10 mL was in the cup, withdrew 5 mL, and returned the remaining 5 mL to the bottle. The MAR review showed the 8:00am doses for the omitted medications and the Levetiracetam dose were not signed out as given or refused at the time of review. The DON stated that a double dose of Levetiracetam could potentially cause a person with a seizure disorder to have a seizure or adverse reaction, and that medications should be given per physician's order and signed off immediately after administration.
Opened Blood Glucose Test Strips Were Not Labeled With Open Date
Penalty
Summary
The facility failed to ensure that an opened container of multi blood glucose test strips was labeled with the open date. During observation of medication storage on the first floor, an opened container of blood glucose test strips was found in the medication cart without an open date written on the label. The container itself had a blank space designated for the open date, but no date had been entered. The RN observing the container stated the open date was not on it and said she was unsure how long the strips remain usable after opening, noting they may expire after a certain number of days and could possibly give a wrong result if expired. The DON later stated that glucometer strips expire sooner once the bottle is opened and confirmed that the strips must be labeled after opening and should not be used if expired. Record review showed six residents on the first floor received blood glucose monitoring tests. The manufacturer’s instructions inside the container stated to write the date on the vial label when first opened and to use the test strips within 3 months of opening the vial.
Failure to Obtain Informed Consent and Document Behaviors for Psychotropic Dose Increases
Penalty
Summary
The deficiency involves the facility’s failure to follow its psychotropic medication policy by not obtaining informed consent for multiple increases in a resident’s Seroquel (quetiapine) dosage and by not documenting behaviors or non-pharmacological interventions to justify those increases. The resident, who has a history of major depressive disorder, schizoaffective disorder, morbid obesity, iron deficiency anemia, and vitamin D deficiency, reported being concerned that staff were giving him higher doses of Seroquel than the 100 mg he believed he should receive and stated he did not consent to the dosage changes and had been refusing the medication. Record review showed that his Seroquel dose was progressively increased from 100 mg at bedtime to as high as 600 mg at bedtime over several physician orders. When surveyors requested consent documentation for these increases, the facility produced a form that the resident had refused to sign, and there was no documentation that the resident’s guardian had been informed of or consented to the dosage increases, despite the facility’s policy requiring informed consent from the resident or guardian for psychotropic medications and dosage increases. Behavior monitoring records ordered for the resident showed no documented behaviors for the months reviewed, even though the resident’s guardian reported he had requested a medication review because the resident was always worrying about others and frequently calling the police, and believed the resident was on 100 mg of Seroquel without being informed of any increases. The ADON acknowledged that if a resident is not exhibiting behaviors, they probably should not be on psychotropic medications and confirmed that the behavior monitoring sheets showed no behaviors. A psychiatrist and a psychiatric nurse practitioner both stated that staff were supposed to document behaviors as ordered and that informed consent was required for psychotropic medications and dosage increases, but also indicated they based treatment decisions on their observations and staff reports. An LPN reported that the resident wanted the Seroquel decreased, but the psychiatric team refused, and she was not aware of any behaviors. The facility’s psychotropic medication policy required routine documentation of behaviors and resident response to the medication, as well as informed consent prior to prescribing psychotropic medications, which was not followed in this case.
Failure to Assess and Provide Restorative Care for Hand Contracture
Penalty
Summary
The deficiency involves the facility’s failure to assess and address a resident’s restorative needs related to a left-hand contracture. During observations on two separate days, the resident was seen in a wheelchair with the left wrist contracted and the fingers tightly flexed into a fist, without any device in place to prevent further contracture. When asked, the resident reported that staff had not come to encourage exercises for the arm and hand. The resident’s care plan indicated that the resident would engage in active range of motion (AROM) to all four extremities, but there was no evidence that this was being implemented for the contracted left hand. The restorative nurse stated that they were new, worked with the therapy department to determine needed services, and were not aware that the resident’s hand was contracted. The therapy manager also reported that no one had informed therapy of the contracture. Upon direct assessment, the therapy manager asked the resident to open the hand and stretch the wrist, which the resident attempted but reported pain. The therapy manager stated the resident would benefit from a left-hand resting splint. Facility policies and the restorative nurse job description require evaluation of newly admitted residents for restorative appropriateness, quarterly and with change of condition, coordination with therapy disciplines for rehabilitation plans of care, and supervision of rehabilitative/restorative equipment such as splints, but these processes were not carried out for this resident’s hand contracture.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident’s indwelling urinary catheter drainage bag was covered with a privacy bag to protect the resident’s privacy and dignity. R19 was admitted with diagnoses including chronic kidney disease, retention of urine, dementia, acquired absence of kidney, acute kidney failure, bladder neck obstruction, malignant neoplasm of kidney, and benign prostatic hyperplasia. Physician orders dated 11/18/25 and 11/20/25 show that R19 had an order for an indwelling urinary catheter, and the care plan dated 5/22/25 identified that the resident had an indwelling urinary catheter and was at higher risk for infection secondary to the catheter and candida auris to the left axilla. On 2/2/26 at 11:30 a.m., R19 was observed in bed with the urinary catheter drainage bag containing yellow urine hanging at the side of the bed and visible to people walking down the hallway, without a privacy bag. The same condition was observed again at 12:45 p.m. and V13, a CNA, was notified and stated she would let the nurse know. On 2/5/26 at 11:55 a.m., V3, the ADON, was notified and stated that there should be a privacy bag covering the drainage bag for the resident’s privacy. Facility records also included a dignity policy stating that residents shall be cared for in a manner that promotes dignity, respect, and individuality, and that using privacy coverings for urinary catheter bags is an example of promoting dignity and respect.
Medication Administration Errors and Medications Left at Bedside
Penalty
Summary
The facility failed to follow its medication administration policy and failed to ensure that residents remained free from significant medication errors for two residents reviewed. During observation of a medication pass, an RN prepared Levetiracetam for a resident with unspecified convulsions and a history of traumatic brain injury by pouring 10 mL into a medication cup even though the MAR ordered 5 mL by mouth twice daily. The medication cup was initially held in the air, and when questioned, the RN placed it on the medication cart, confirmed that 10 mL was present, withdrew 5 mL, and returned the remaining 5 mL to the bottle. The RN stated the cup should have been placed on a flat surface because the liquid level can appear different when held in the air. The DON stated that a double dose of Levetiracetam could potentially cause a person with a seizure disorder to have a seizure or an adverse reaction. The facility also failed to ensure that medications were not left at the bedside for another resident with multiple sclerosis and a BIMS score indicating cognitive intactness. During a room observation, the resident opened a dresser drawer and removed two medication cups containing two white round pills, stating the nurse comes in, sets the meds down, and leaves them there, and that the medications were 2 or 3 days old. The resident stated the medications lower his heart rate and blood pressure and that he sometimes feels weak after taking them. The ADON entered the room, identified the pills using the resident’s MAR and DailyMed, and confirmed they were active orders for Tizanidine 4 mg every 6 hours and Baclofen 10 mg every 6 hours. The DON stated that nurses should identify the resident, follow the five rights of medication administration, administer the medication at the ordered time, watch the resident take it, and then document it. The facility policy required medications to be administered according to physician orders and required the person administering the medication to initial the MAR after administration; if a medication was withheld, refused, or given other than at the scheduled time, the MAR was to be circled and a rationale documented. The resident rights pamphlet stated residents must be treated with dignity and respect and receive services and items included in the plan of care.
Failure to Arrange Transportation and Follow Up on Missed Appointments
Penalty
Summary
The facility failed to assist a dependent resident with transportation arrangements for scheduled radiology-related appointments, failed to notify the physician when appointments were missed, and failed to reschedule the missed appointments. The resident, who had a history of traumatic brain injury, unspecified convulsion, obstructive and reflux uropathy, gallbladder disease, bipolar disorder, and other conditions, stated that he was supposed to go for an MRI but did not because the facility did not have anyone to go with him. He also said the appointment had previously been cancelled and rescheduled and that he was frustrated about missing his appointments. The resident’s appointment list included an MRI scheduled for 2/2/2026 at 10:00 AM, a neurosurgery appointment for 2/13/2026 at 1:00 PM, and another appointment on 1/22/2026 at 4:30 PM. The DON stated that the resident had given her the list of appointments, that the staff member who had been scheduling appointments abruptly quit, and that responsibility then fell to her and the ADON. She said she thought the veteran clinic arranged its own transportation, but later acknowledged that the resident missed the January appointment due to transportation and missed the February MRI. The scheduler stated that she schedules appointments and arranges transportation, and said the resident did not go to the Monday MRI because the transportation people did not show up. Review of the record showed no documentation of the missed appointments, no documentation that the physician was notified, and no documentation that the appointments were rescheduled.
Inconsistent Hospice Communication and Missing Visit Documentation
Penalty
Summary
The facility failed to maintain consistent hospice communication for one resident receiving hospice care. The resident had diagnoses including End Stage Renal Disease, Chronic Kidney Disease, Type 2 Diabetes Mellitus, Hypertension, Osteomyelitis, a Stage 4 sacral pressure injury to the coccyx, and palliative care. The resident’s cognitive assessment documented moderate cognitive impairment, and when asked about hospice services, the resident was unable to answer. Staff members, including a wound care CNA, an LPN, the DON, and the ADON, were unable to identify the resident’s hospice agency or locate hospice communication at the nurse’s station during the surveyor’s observations and interviews. The resident’s hospice binder was not initially available, and an LPN stated there was no documentation of the resident’s hospice care at the facility at that time. The hospice nurse stated that the resident had been admitted to hospice for ESRD, that she saw him twice weekly, and that there should have been a folder, sign-in sheet, and a place to chart visits for staff reference, but she had not seen the folder. The DON stated that she and the ADON were responsible for ensuring the written hospice communication was present. Survey review found no sign-in documentation of hospice visits from the date of admission through the survey date and no written documentation of hospice communicating the resident’s condition after visits with facility staff.
Failure to Follow EBP and Linen Handling Procedures
Penalty
Summary
The facility failed to follow its infection control and hospice services policies when hospice staff did not adhere to enhanced barrier precautions during high-contact care for a resident with cerebral palsy, dementia, an unstageable pressure injury to the right buttock, type 2 diabetes mellitus, and an indwelling urinary catheter. The resident’s cognitive assessment documented severe cognitive impairment. During observation, the hospice nurse entered the room, identified herself, and turned the resident in bed after finding her soiled. The nurse put on gloves from the PPE bin without performing hand hygiene, then provided perineal care and changed the resident’s incontinent brief while the resident had a wound dressing to the right buttock and a Foley catheter in place. The hospice nurse did not wear a gown during this high-contact care even though the resident’s physician orders specified enhanced barrier precautions related to wounds and a Foley catheter, with PPE required during direct care. The facility’s enhanced barrier precautions policy stated that gown and gloves are the minimum PPE for high-contact resident activities, including changing briefs, providing hygiene, device care, and wound care. When questioned, the hospice nurse stated she only wore gloves and did not put on an isolation gown during the care. The DON stated that hospice staff should follow isolation procedures and don and doff PPE as required. The facility also failed to handle soiled linen in a manner that prevented contamination. In the soiled linen room, visibly soiled washcloths, shirts, clothing, and linen were observed falling from the open linen chute into the soiled linen bin, and the housekeeping manager confirmed that linen should have been bagged before being sent down the chute. In the laundry room, an open bag of chips was observed in the clean linen area, dirt and dust were present around the clean linen shelving area, and chemical barrels were on the floor. The housekeeping manager stated the floors should be swept and mopped daily and reported using a store-bought detergent in addition to the facility’s detergent because the facility product did not clean clothes well enough.
Daily Staffing Posting Not Visible to Residents and Missing Required Hours
Penalty
Summary
The facility failed to post nursing staffing information every day in a highly visible area and failed to include required staffing details. The facility census documented 199 residents. On observation, the daily staffing posting was taped to the windows at the front desk in the foyer area, and the door to the foyer from the first-floor resident area was locked and had to be unlocked by the receptionist. The staffing posting did not document the total number of hours worked or the actual number of hours worked for RNs, LPNs, and CNAs. The Scheduler, who was responsible for completing the posting, reviewed it and affirmed that those required hours were not included and was unsure whether they were required. The Administrator affirmed that residents could not freely enter the foyer area where the posting was located, and stated there was no facility policy for the daily staffing posting.
Open Dumpsters and Trash Around Disposal Area
Penalty
Summary
The facility failed to ensure that the outside dumpster garbage disposal was covered with a lid and failed to keep the floor around the dumpsters free of trash, creating an unsanitary environment. After the entrance conference, the Administrator presented a census of 199 residents. During kitchen observation with the Dietary Manager, the outside dumpster was observed open without lids, with bags of trash and spilled trash on the floor around the dumpster. The Dietary Manager stated that the dumpster was for oil and was not sure whether it had a lid, and a cook stated that there was a lid to cover the oil dumpster. On a later observation, one of the dumpsters was again seen without covers and with trash on the floor around it. The Dietary Manager stated that she would send a dietary aide to cover the dumpster and added that housekeeping staff may have left it open. She also stated that leaving dumpsters open could cause rodents to come around the building. The facility policy on Waste Management states that maintenance and housekeeping personnel shall ensure the dumpster area is kept clean, all trash bags are inside the dumpster, and dumpster lids are closed.
Facility Assessment Missing Direct Care Input and Shift-Based Staffing Detail
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that included direct care staff involvement and staffing needs by shift and resident unit. The assessment reviewed on 6/27/25 showed that the Administrator, DON, governing body, and Medical Director were involved, but there was no indication that direct care staff participated in developing the assessment. The facility census documented 199 residents in the building. The staffing plan in the assessment listed total staffing needs of 14-16 licensed nurses and 18-22 nurse's aides, along with other management, social services, food, and nutrition staff, but it did not identify staffing needs by shift or by unit. During interview, the Administrator affirmed that the assessment did not document direct care staff involvement and that staffing needs were not broken down by unit or shift. The Administrator also stated that the facility assessment was updated annually and as needed, and later said a more updated assessment would be provided, but no further facility assessment was produced before the survey ended.
Failure to Complete Required Community Survival Skills Assessments per Policy
Penalty
Summary
The facility failed to follow its Community Access Determination policy requiring Social Services to complete community survival skills assessments upon admission and quarterly for all residents, and additionally when residents request outside passes. During an interview, the Social Services staff member (V9) stated that these assessments are completed quarterly, annually, and when a resident requests an outside pass. However, review of the electronic medical records showed that for one resident (R10), the last documented community survival skills assessment was dated 3/31/25, and no subsequent assessments were present. V9 initially suggested that a more recent assessment might not be visible because it was not locked, but was informed that even in-progress assessments would appear in the record, confirming that no later assessment had been completed. Record review for three additional residents showed similar gaps in required assessments. R1’s last community skills assessment was dated 7/9/25, R17’s was dated 8/1/25, and R18’s was dated 9/8/25, with no evidence of quarterly assessments thereafter as required by the facility’s policy. The facility also produced a document titled “admission, quarterly, annual, and significant change assessments,” which indicated that community skills assessments are completed on admission, with significant change, and annually, a schedule that did not align with the written Community Access Determination policy. When asked if this document was a policy, the DON (V2) and ADON (V8) did not initially respond; after consulting with the Administrator (V1), V2 stated it was not a policy but a document listing assessments and their timing. The facility’s formal guidelines for community access determination, dated 2/8/23, specify that community skills assessments are to be completed by Social Services upon admission and quarterly for all residents, which was not followed for the four residents reviewed.
Failure to Follow Grievance and Belongings Policies for Missing Personal Phone
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance and belongings policies in response to a resident’s report of a missing personal cell phone. The resident reported that her phone went missing from her room during a specific time window while she was out of the room and stated she informed the Social Service Director, nurses, and CNAs. She reported that the Social Service Director wrote the information down but did not provide her a copy, and that staff told her they would find the phone and return it. The resident documented on an activity calendar the date and time she reported the missing phone to the Social Service Director and later noted that a cell phone was found in a medication storage room. She stated that the Social Service Director never followed up with her and that she was afraid to continue asking about her phone because she feared getting in trouble and not receiving help with a community pass and discharge. A pre-admission hospital record confirmed the phone number the resident reported as her personal phone number. Staff interviews and record review showed that the grievance process was not followed and belongings were not fully inventoried. An RN acknowledged that the resident had informed her months earlier about the missing phone and that she told the resident to talk to social services but did not follow up or report the concern. A CNA also stated the resident had reported the missing phone to her, yet the facility’s grievance binder contained no grievance related to the missing phone. A grievance/opportunity resolution form produced by the facility lacked the name of the person completing it and only noted that the resident had a phone since admission and that another resident may have taken it. The resident’s belongings inventories did not list the phone or several other personal items visible in the admission photo and in the resident’s room, and neither inventory sheet contained the resident’s signature. The facility’s belongings policy required all belongings to be recorded and signed for, and the grievance policy required all concerns to be documented in writing, overseen by the Social Service Director, with resolutions expected within 72 hours and maintained in a grievance binder for at least three years.
Failure to Prevent and Properly Investigate Resident-to-Resident Physical Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy to protect residents from resident-to-resident physical abuse. A resident with a history of psychosis, schizophrenia, bipolar disorder, auditory hallucinations, and prior hospitalization for aggressive behavior entered another resident’s room, became upset about what he believed was expired or spoiled milk, and began yelling. According to the assaulted resident and multiple resident witnesses, the aggressor struck the resident on the right side of the head with a milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently, continuing to hit her until another resident intervened and staff arrived. The assaulted resident reported pain in her right forearm and behind her right ear. Witness statements from two other residents consistently described the aggressor on top of and hitting the victim, and one resident physically pulled the aggressor away and stood between them. The aggressor’s medical record showed multiple psychotropic medications ordered for psychosis, schizophrenia, and bipolar disorder, but the MAR documented frequent refusals of these medications over an extended period, both before and after a recent hospitalization for aggressive behavior. There was no documentation that the attending physician or psychiatrist was notified each time these psychotropic medications were refused, and nurse practitioner notes during this period recorded “no concerns from the nursing staff.” The facility’s abuse investigation relied on written statements from residents but did not include any staff interviews regarding the event and concluded there was no credible evidence that abuse occurred, despite multiple resident accounts that the aggressor was hitting the victim. This sequence of events and omissions reflects a failure to follow the facility’s abuse prevention policy and to adequately address and monitor a resident with known psychiatric diagnoses and aggressive behavior, resulting in a resident-to-resident physical assault.
Failure to Supervise Aggressive Resident Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate supervision and monitoring for a resident with a known history of aggressive behavior, which allowed him to enter another resident’s room and assault her. The aggressive resident had multiple behavior care plans noting severe mental illness, including schizophrenia, psychosis with hallucinations, and bipolar disorder, with documented poor impulse control, lack of sound judgment, and a history of physically abusive behavior when agitated. His care plans included interventions such as administration of psychoactive medications as ordered, behavior tracking, reporting abnormalities to the physician, and daily monitoring and supervision. The medical record documented repeated noncompliance with medications, impaired comprehension, delusions, paranoid and disorganized thought processes, poor self-awareness, and auditory hallucinations, with social services counseling attempts that were not successful in improving his medication compliance. Despite these known risks and documented behaviors, the resident was able to access another resident’s room without effective supervision. The assaulted resident reported that the aggressive resident entered her room, became upset about a milk carton he believed was expired, yelled at her, struck her on the right side of the head with the milk carton, pushed her onto the bed, grabbed her upper arms, and shook her violently. Another resident reported hearing screaming and smacking sounds, then seeing the aggressive resident hitting the victim and intervening by pulling him off and standing between them. A roommate corroborated that the aggressive resident was hitting the victim, and another roommate stated she saw him on top of the victim punching her in the face before other residents and staff intervened. These events demonstrate that the facility did not provide adequate supervision and monitoring to prevent the aggressive resident from entering another resident’s room and engaging in physical and verbal assault, despite his known behavioral risks and documented need for close supervision.
Failure to Prevent and Control Illicit Drug Use and Distribution
Penalty
Summary
The facility failed to maintain an effective contraband policy to prevent illicit drugs from being brought into, distributed, and used within the facility. Multiple residents were found to have tested positive for fentanyl and opiates, with two residents experiencing significant medical emergencies as a result. One resident was observed slumping forward in a wheelchair, became cyanotic, and required Narcan administration after testing positive for opiates and fentanyl. Another resident was transported to the hospital for a change in condition and also tested positive for fentanyl and opiates metabolites. Both residents had a history of substance abuse and were cognitively intact at the time of the incidents. Interviews and record reviews revealed that the facility did not have a plan to determine how illicit drugs were entering the premises. There were reports and witness statements indicating that drugs were being brought in and distributed by both residents and possibly staff, including allegations of a female night staff member supplying drugs. The facility's investigation into staff involvement was inconclusive, and there was a lack of documentation regarding interviews and searches. Additionally, the facility's contraband policy was not effectively enforced, as evidenced by the discovery of drug paraphernalia in resident rooms and ceilings, and by multiple residents admitting to purchasing and using illicit substances within the facility. Staff interviews indicated gaps in communication and awareness regarding residents' substance use and related hospitalizations. There was also a lack of clarity among staff about when to administer Narcan, and the facility failed to present a policy or practice related to its use. The facility's response to suspicious behavior, drug screening, and supervision was inconsistent, and documentation of investigations and interventions was incomplete. These failures affected not only the residents who experienced overdoses but also had the potential to impact all residents reviewed for illicit substance or contraband issues.
Failure to Document and Monitor Effectiveness of Controlled Substance Administration
Penalty
Summary
The facility failed to follow its medication administration policy and did not consistently monitor or document the effectiveness of pain medication for a resident receiving high alert medications. Interviews with the Assistant Director of Nursing and a Licensed Practical Nurse revealed that staff were not accurately documenting the administration of hydrocodone-acetaminophen in the Medication Administration Record (MAR) at the time of administration, as required by facility policy. The MAR and controlled substance sheets for the resident showed discrepancies, with the controlled substance being signed out twice daily but not always recorded in the MAR. The LPN acknowledged that documentation was not completed every time the medication was administered and could not provide a reason for the omission. Review of the resident's physician order sheet confirmed an order for hydrocodone-acetaminophen to be given every 12 hours as needed for pain, and the resident's care plan included interventions for pain management and monitoring effectiveness. However, there was no consistent documentation in the medical record indicating that nursing staff monitored the effectiveness of the pain medication as required. The facility's policy specified that the person administering medication must initial the MAR before administration and that late entries should be documented if missed, but these procedures were not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Homelike Environment Due to Improperly Secured Window Drapes
Penalty
Summary
The facility failed to maintain a homelike environment for residents by not ensuring that window drapes in multiple resident rooms were properly secured to the curtain rods, tracks, or hooks. During a facility tour, surveyors observed that the window drapes in the rooms of ten residents were falling from their fixtures, with some rooms using towels to cover window openings created by the fallen drapes. Maintenance staff acknowledged the issue when it was brought to their attention, attributing it to housekeeping, but the problem persisted throughout the day. One resident reported having repeatedly requested assistance from social services to have her curtains washed and rehung due to their condition. The Director of Nursing confirmed that resident rooms should be clean, sanitary, and homelike, and that window drapes should not be falling. The facility's housekeeping policy requires maintaining a safe and sanitary environment, but the observed conditions did not meet these standards.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. The report does not specify the exact nature of the orders or preferences that were not followed, nor does it provide details about the resident's medical history or condition at the time of the deficiency.
Failure to Maintain Operational Elevators
Penalty
Summary
The facility failed to ensure that all elevators were operational, resulting in only one of two elevators functioning during the survey. On observation, the left elevator was not responding to the call button and displayed a static number. Maintenance staff confirmed that the elevator had been repaired the previous day but had broken down again, noting that elevator malfunctions have been an ongoing issue. The maintenance staff was unable to specify which elevator had been serviced and was unaware of the specific cause of the repeated breakdowns. Service records indicated recent work on one elevator, but documentation did not clearly identify which car was serviced. Multiple residents reported delays in elevator service due to only one elevator being operational. The facility census indicated 191 residents, and the elevators are used for transporting meals, staff, visitors, laundry, and housekeeping between floors. The Director of Nursing confirmed the reliance on elevators for daily operations. The facility's building maintenance policy did not include protocols or information specific to elevator maintenance or operation.
Failure to Verify Escort Identity for Supervised Community Pass
Penalty
Summary
The facility failed to follow its protocol for supervised community passes by not verifying the identity of the individual who signed out a resident for a community pass. Specifically, a resident with a significant history of substance abuse, multiple injuries, and a care plan indicating she was not capable of unsupervised outside pass privileges was allowed to leave the facility. The pass request form listed a specific individual as the escort, but the ID scanned and attached did not match the name on the form. Staff interviews revealed that the process for verifying the escort's identity was not followed because the receptionist, who was responsible for scanning the ID, was occupied with other duties and did not interact with the person taking the resident out. As a result, the resident left the facility on a supervised pass and did not return. The nurse on duty followed the process of scanning the ID and handing it to the receptionist, but the mismatch in identity was not caught. The facility's policy on community passes did not clearly outline the supervised pass procedure, contributing to the failure. The administrator confirmed that the police were not notified when the resident did not return, and did not consider the incident to be an elopement.
Failure to Provide Timely Podiatry Services for Diabetic Residents
Penalty
Summary
The facility failed to provide timely foot care treatment and ensure follow-up visits with a podiatrist for residents at risk for foot disorders, specifically for two residents with diabetes. One resident, who was cognitively intact, reported not having seen a foot doctor for a long time despite requesting to see one. Upon observation, this resident's toenails were found to be long, discolored, and thick. Physician orders allowed for podiatrist visits, and the last documented podiatrist visit was several months prior, with a recommendation for a follow-up in nine weeks that was not documented as completed. Another resident, also cognitively intact and with diabetes, showed the surveyor long, thick, discolored, and curling toenails, and stated not recalling the last podiatrist visit despite requesting one. Physician orders indicated the need for podiatry services, but the last documented visit was also several months prior, with a follow-up recommendation that was not documented as completed. Staff interviews revealed that residents are added to a list for podiatrist visits upon request, but there was no evidence provided that these residents received timely follow-up as ordered. The facility's policy requires regular foot assessments and podiatrist referrals for diabetics, which was not followed in these cases.
Failure to Monitor and Investigate Illicit Drug Use Resulting in Resident Overdose
Penalty
Summary
The facility failed to have a system in place for monitoring and investigating how illicit drugs entered the facility, to be alerted when illicit drugs were present, and to prevent resident use and possible drug overdose. This deficiency was identified after a resident with a known history of substance abuse obtained and used illicit drugs while in the facility, resulting in a drug overdose that required the administration of Narcan and emergent hospital transfer. Interviews and record reviews revealed that the facility did not conduct an investigation into how the drugs were brought in or how the resident accessed them, nor did they follow up with involved residents or staff regarding the incident. The resident involved had a documented history of substance abuse, including cocaine, marijuana, and alcohol, and had previously been admitted to behavioral health and substance abuse treatment centers. On the day of the incident, the resident was found unresponsive in another resident's room, and staff administered Narcan after observing symptoms consistent with opioid overdose. The resident later admitted to using heroin with another resident. Despite this, there was no documentation of an investigation into the overdose, and key staff members, including the DON and administrator, did not follow up with staff or residents to determine the source of the drugs or to assess the situation further. Other residents and staff reported knowledge or suspicion of drug use and distribution within the facility, including observations of abnormal behaviors and direct admissions of drug use. The facility's policies required reporting, recording, and investigating all accidents and unusual occurrences, including those requiring emergency services or resulting in hospitalization. However, these procedures were not followed in this case, as there was no accident report or investigation into the overdose incident, and the facility did not notify the appropriate parties or take steps to identify and address the source of the illicit drugs.
Failure to Provide Required Substance Abuse Services and Supports
Penalty
Summary
The facility failed to follow its own policies and procedures for providing services and supports for chemical dependence and substance abuse for two residents. One resident, a male with a history of schizophrenia, depression, suicidal ideation, and substance use disorder, was not offered substance abuse group programming despite expressing a history of substance abuse and a desire to participate. The resident reported that he was told he could not attend the group because his substance abuse history was not documented at admission, even though he later disclosed his history to staff. The care plan for this resident included individual counseling but did not address group participation, and attendance records confirmed he was not included in the substance abuse group sessions. Another resident, a female with diagnoses including epilepsy, psychotic disorders, bipolar disorder, and psychoactive substance abuse disorder, was not consistently provided with psychiatric, group, or behavioral health counseling and services as indicated by her history and care plan. Although her records documented a history of substance abuse and she was encouraged to participate in group sessions, documentation showed she only attended one group session and there was no evidence of one-to-one substance abuse counseling. Multiple staff interviews confirmed that discussions about her substance use were not consistently occurring during psychiatric or social work sessions, and her care plan interventions were not fully implemented. These failures resulted in the female resident using illicit substances within the facility, leading to an overdose that required emergent transfer to a local hospital. The facility's own policies required offering appropriate treatment and rehabilitative services to residents with substance abuse problems, but these were not consistently provided or documented for the residents in question. Staff interviews revealed gaps in communication, assessment, and follow-through regarding substance abuse history and the provision of necessary support services.
Failure to Transcribe and Implement Physician Orders for Foot Monitoring
Penalty
Summary
The facility failed to follow professional standards of care by not transcribing and implementing physician orders to monitor a resident's right foot for increased discoloration, assess pedal pulse, and monitor temperature changes. The resident had a history of occlusion and stenosis of the right carotid artery, essential hypertension, anemia, and chronic ischemia. After the resident complained of discoloration in her right foot, a nurse practitioner assessed the foot, noted it was cool to the touch with edema, and ordered a doppler ultrasound, which was negative for DVT. Despite the negative result, the plan was to monitor the foot for changes, but the nurse practitioner did not specify a time frame for monitoring and only gave a verbal order to an unidentified nurse. Subsequent interviews revealed that the LPN who cared for the resident after an unwitnessed fall was unaware of any orders to monitor the right foot and did not perform a head-to-toe assessment. The CNA reported the presence of a blister and that the foot was wrapped by a nurse. The medical doctor confirmed the resident's chronic ischemia and agreed with the monitoring orders. However, review of the resident's physician order sheet and progress notes showed no documentation of orders or monitoring for the right foot on the relevant dates. The facility's policy requires all physician orders to be transcribed and implemented, but this was not done in this case.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in the assaulted resident being sent to the hospital for evaluation of facial trauma. The incident occurred in the dining room, where a resident with a fractured ankle was using a chair to elevate his leg. Another resident attempted to take the chair, and when told to leave it, physically assaulted the first resident by punching him in the face. At the time of the incident, there was no staff present in the dining room to monitor the residents, despite multiple residents being present in the area. Interviews and record reviews revealed that both residents involved had intact cognition according to their BIMS scores, and neither had care plans addressing susceptibility or predisposition to abuse prior to the incident. Staff statements confirmed that the dining room was not consistently monitored, particularly during shift changes or when staff were occupied with other duties such as charting. The only CNA on duty for the unit reported alternating monitoring duties with nurses, but at the time of the altercation, no staff were present in the dining room. Documentation from the LPN, hospital, and police corroborated the occurrence of a physical altercation, with the assaulted resident sustaining swelling to the left eye and being sent to the hospital for further evaluation. The facility's abuse prevention policy emphasized the need for resident assessment and staff supervision to prevent abuse, but observations and staffing records indicated inadequate supervision in common areas, contributing to the incident.
Failure to Assess and Manage Resident's New Onset Hip Pain
Penalty
Summary
A resident with multiple medical conditions, including a history of falls, cognitive impairment, and mobility issues, experienced a new onset of right hip pain that was first documented by the therapy director. The therapy director reported the pain and a change in the resident's ambulatory status to the interdisciplinary team and nursing staff. Despite this notification, there was a lack of timely and thorough pain assessment and documentation by nursing staff. The assistant director of nursing and the family nurse practitioner both assessed the resident and ordered an x-ray, with the nurse practitioner instructing nursing staff to administer PRN pain medication as ordered. However, there was no documentation of pain medication being administered, and the medication administration record did not reflect any pain medication given during the relevant period. Nursing staff interviews revealed inconsistent accounts regarding the administration of pain medication. One LPN stated that pain medication was given but not documented, while another nurse reported not administering any pain medication because the resident did not verbally complain of pain during their shift. There was also a failure to document pain assessments or reviews in the resident's records, despite clear changes in the resident's condition and reports of significant pain. The facility's pain management policy requires assessment and documentation of pain, including onset, location, severity, and use of a pain rating scale, but these steps were not followed in this case. The resident remained in pain for approximately 24 hours before being hospitalized, where a right femoral neck fracture was confirmed and surgical intervention was performed. The lack of timely pain assessment, documentation, and administration of PRN pain medication resulted in the resident experiencing unmanaged pain prior to hospitalization. Progress notes and interviews confirm that the facility did not adhere to its own pain management and assessment policy during this incident.
Failure to Notify Physician of Resident's Refusal of Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician after a resident refused a scheduled psychotropic medication. The resident, who had diagnoses including Schizoaffective Disorder, Paranoid Schizophrenia, and Obsessive-Compulsive Disorder, was assessed as having intact cognition and a history of refusing care, including medications. The resident's care plan required staff to carry out the prescribed medication regimen and report any changes or complications to the physician. On the scheduled date, the resident refused a long-acting injectable psychiatric medication, as documented in the Medication Administration Record. However, there was no documentation in the progress notes that the physician was notified of this refusal. Staff interviews revealed that the LPN on duty was unsure if the resident received the scheduled medication and admitted to not documenting or notifying anyone about the refusal. The psychiatric nurse practitioner confirmed that they were not informed of the missed dose, which could have contributed to the resident's subsequent behavioral decline. The DON stated that nurses are expected to re-offer the medication and notify the physician if refusal persists, as well as document the refusal in the resident's chart. The absence of documentation and physician notification following the medication refusal constituted the deficiency.
Verbal Abuse Incident by Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a former Social Service Aide/Smoking Monitor, identified as V3. The incident occurred when the resident, R1, requested a cigarette from V3 during designated smoking time. V3 refused the request and responded inappropriately by calling R1 a derogatory term. This interaction was witnessed by another resident, R2, who confirmed the use of inappropriate language by V3. The incident was reported to a Licensed Practical Nurse (LPN), V2, who then informed the facility's Administrator/Abuse Coordinator, and a police report was filed to document the verbal aggression. R1, who was cognitively intact with a BIMS score of 15, was admitted to the facility with multiple diagnoses, including mental and behavioral issues, anxiety, and depression. The facility's Abuse Prevention Program policy defines abuse as including verbal abuse, which was violated in this instance. V3's personal file revealed a prior disciplinary action related to unsatisfactory work and attitude, as well as dishonest practices concerning smoking materials. This history suggests a pattern of behavior that was not adequately addressed, leading to the incident of verbal abuse against R1.
Ineffective Pest Control Program Leads to Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches within the premises. The Facility Pest Control Agreement, dated 12/1/2002, outlined a targeted pest control service for roaches with bi-monthly visits, yet observations and interviews revealed ongoing issues. On 2/22/25, live cockroaches were observed in two separate rooms, and multiple residents reported seeing cockroaches in their rooms, with one resident stating they see them every day. Housekeeping staff on both the second and third floors confirmed seeing live cockroaches daily, indicating a persistent problem. The Facility Grievance Opportunity Resolution Forms documented resident concerns about pests, with actions taken including deep cleaning and pest control treatments. Despite these measures, the problem persisted, as evidenced by the continued presence of cockroaches and frequent complaints from residents. The Activity Director noted receiving complaints about roaches a couple of times a week from various residents, and although pest control services were reportedly called and scheduled, the issue remained unresolved. The facility's administrator acknowledged the pest control visits but could not explain why the cockroaches were not being eradicated.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow care plan interventions and implement appropriate fall prevention measures for a resident with a history of falls and multiple risk factors, including cerebral vascular attack, hemiplegia, and mild cognitive deficit. The resident required substantial staff assistance for transfers and had multiple falls related to general weakness, poly-pharmacy, poor coordination, and use of medications. Despite having a care plan with specific interventions such as ensuring the call light was within reach, reminding the resident to use the call light for assistance, and conducting physical therapy evaluations, these interventions were not consistently implemented. The resident experienced three falls in their room during unassisted transfers from bed to wheelchair, with no injuries noted. Each fall report documented the need for a physical therapy evaluation, but the facility could not provide evidence of these evaluations being conducted. The Director of Nursing confirmed that the falls occurred during unassisted transfers and acknowledged that care plan interventions and proper footwear should have been followed. The facility's administrator noted that the resident was non-compliant and that fall interventions need to be resident-specific and consistently followed.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its call light policy, resulting in delayed responses to residents' needs. This deficiency was observed in five residents, including a female resident with Schizoaffective Disorder, COPD, and Stage 3 Chronic Kidney Disease, who reported waiting up to an hour for assistance during the night. As a result, she experienced discomfort from being left wet for extended periods. Another resident with Polyneuropathy and Reduced Mobility also reported similar delays, expressing concerns about potential urine burns from prolonged exposure to wet diapers. During an observation, a male resident with Chronic Pain Syndrome and other significant health issues had his call light activated for an extended period without response from nearby staff, including a Licensed Practical Nurse and a Certified Nursing Assistant. Despite being in proximity, staff members did not respond to multiple activated call lights, including those of two other residents. The Director of Nursing confirmed that all staff are expected to respond to call lights promptly, regardless of the resident's assignment, as per the facility's policy.
Failure to Document and Resolve Grievance Regarding Resident Care
Penalty
Summary
The facility failed to adhere to its grievance policy and procedures by not documenting, investigating, or resolving a concern reported by a resident's family member. The resident, a female with a history of polyneuropathy, reduced mobility, and chronic embolism and thrombosis, was left in a chair for 17 hours due to a mechanical lift not being charged. The family member reported this grievance to the facility, but it was not documented or addressed in a timely manner. Interviews with staff revealed that the Assistant Director of Nursing was unaware of the complaint, and the Psychosocial Rehabilitation Services Coordinator had reported the grievance to the Director of Nursing or Assistant Director of Nursing. However, the grievance was not documented in the facility's records until several days later, indicating a failure to follow the facility's grievance policy, which requires documentation and resolution of concerns within 72 hours.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident from eloping, despite being assessed as unable to navigate safely and independently in the community. The resident, a male with a history of seizures, unspecified psychosis, dementia, and other medical conditions, was admitted to the facility with a care plan that required supervised smoking and community access. On the day of the incident, the resident left the facility unsupervised and was later found intoxicated by local police, having been without access to his ordered medical care. The incident was reported to the facility's Social Service Director by a staff member who noticed the resident was missing. The staff conducted a headcount after a bed alarm went off, realizing the resident was not present. Despite the resident's care plan indicating he required supervision, the facility did not have an authorized pass policy in place, and the resident was able to exit through a basement back door. The facility's supervision policy was not effectively implemented, as the resident was able to leave without being noticed by staff. The facility's response to the incident was delayed, with the resident's emergency contact being notified the following day. The police were called, and a missing person report was filed. The facility's administrator acknowledged that the resident was discharged in the system as if he had left against medical advice, although no AMA form was signed. The lack of immediate action and effective supervision contributed to the resident's elopement and subsequent intoxication, highlighting deficiencies in the facility's safety and supervision protocols.
Removal Plan
- The facility will continue to provide a safe environment for the residents through written policies and procedures to prevent elopement and to use as a baseline to maintain a secure resident environment.
- The facility initiated an investigation. It has been determined that the resident exited the facility from the basements back door.
- Director of Social Services, Assistant Director of Social Services and PRSCs has re-assessed facility residents' elopement risk assessment and community survival skill assessments.
- The facility has provided an elopement binder to all facility units with pictures identifying residents at risk for elopement.
- Director of Social Services, Assistant Director of Social Services and PRSCs have re-screened and assessed all residents to determine any factors that would put them at risk for elopement.
- Director of Social Services, Assistant Director of Social Services and PRSCs will continue to meet and assess all residents upon admission, quarterly, annually, and with change in condition or behavioral observations that may put the resident at risk for elopement.
- Administrator, Director of Social Services and all staff will continue to monitor residents for potential signs of elopement.
- Staff were re-educated but not limited to the facility elopement policy and procedures.
- DON/Designee will in-service all newly hired staff at the time of hire on the facility's elopement policy.
- DON/Designee will in-service staff out on leave or on vacation upon their return to work.
- Elopement binders have been placed on all facility units including the front reception area.
- All exit doors have been rechecked to ensure all alarms are functioning properly and to check staff response time.
- The facility Assistant Administrator conducted an ad hoc QA meeting which reviewed the facility elopement policy as it relates to safeguarding current and future residents from elopement.
- Quality Assurance will audit random resident files to ensure the risk for elopement has been properly assessed and care planned.
- The Administrator/Designee will perform weekly audits on all newly admitted and readmitted residents to ensure the risk for elopement has been properly assessed and care planned.
- As part of the Quality Assurance Committee the Administration/DON will in-service all staff monthly on the elopement policy for a period of two months.
Medication Administration Failure Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to administer medications as ordered to 34 residents on the third floor. On Christmas Day, only one nurse was assigned to the day shift on the third floor, which resulted in medications not being administered to residents in rooms 301-311 and 326-334. The Licensed Practical Nurse (LPN) on duty, responsible for rooms 312-325, did not accept responsibility for the other medication cart and informed management of her inability to cover the entire floor. Despite being aware of the staffing shortage, the Director of Nursing (DON) did not provide additional support or coverage. The deficiency affected residents with various medical conditions, including dementia, psychosis, seizures, depression, hypertension, and chronic obstructive pulmonary disease. One resident reported not receiving medications on Christmas morning, and the LPN confirmed that medications were not administered to the entire floor. The DON, who was new to the position, acknowledged the staffing issue but was under the impression that the LPN would cover the entire floor. The facility lacked a holiday staffing plan, and the absence of a second nurse on the third floor was attributed to a call-off and the DON's inability to find a replacement. The facility's administrator and DON were not aware of any complaints or issues with medication administration until the survey. The administrator stated that there was no staffing policy in place and acknowledged the need for a holiday rotation plan. The deficiency was considered an isolated incident, and the DON accepted responsibility for the situation, noting that the facility typically staffs two nurses per shift on each floor, except for nights when only one nurse is assigned to the first and third floors.
Medication Administration Failure on Holiday
Penalty
Summary
The facility failed to provide medications as ordered by the prescriber to 34 residents on the third floor during the day shift on Christmas Day. This deficiency was identified through interviews and record reviews, revealing that medications were not administered to residents from the front cart on the third floor. The residents affected included those with various diagnoses such as dementia, psychosis, seizures, depression, hypertension, and chronic obstructive pulmonary disease. The Medication Administration Records (MAR) for December 2024 documented that medications were not given on the specified day shift. Interviews with residents and staff highlighted the issue of understaffing on the third floor during the holiday. A Licensed Practical Nurse (LPN) working that day stated that she was responsible only for her assigned residents on the back hall and did not administer medications to the residents on the front cart. The Director of Nursing (DON) was aware of the staffing shortage and the LPN's refusal to cover the entire floor, yet no alternative arrangements were made to ensure all residents received their medications. The DON and the LPN had differing accounts of the expectations and communications regarding medication administration on that day. The facility's policy and procedure for administering medications emphasize the responsibility of the Director of Nursing Services to supervise medication administration and ensure compliance with physician orders. However, the failure to provide medications as ordered was not communicated to the prescribers, and no corrective actions were documented in the report. The lack of medication administration on Christmas Day was not reported to the Nurse Practitioner or the Administrator, indicating a breakdown in communication and adherence to established protocols.
Failure to Administer Seizure Medications on Christmas Day
Penalty
Summary
The facility failed to administer significant medications to five residents on the day shift of December 25, 2024. This deficiency was identified through interviews and record reviews, revealing that seizure medications were not given to the residents as prescribed. The residents affected included those with conditions such as dementia, psychosis, seizures, and other chronic illnesses. The Medication Administration Records (MAR) for December 2024 documented that medications like Divalproex Sodium, Levetiracetam, Keppra, and Depakote were not administered at the scheduled times. Interviews with residents and staff highlighted the absence of a nurse on the third floor during the day shift on Christmas Day, which contributed to the missed medication doses. One resident reported not receiving their seizure medication for about four days due to an insurance issue and the facility's inability to verify the medication they brought with them. The Licensed Practical Nurse (LPN) on duty confirmed that they only administered medications to a portion of the residents on their assigned side of the floor, as they were not responsible for the entire floor and did not have the keys for the other medication cart. The Director of Nursing (DON) was aware of the staffing shortage but did not ensure that all residents received their medications. The DON stated that they were not informed of any medication delivery issues or residents missing doses. The facility's policy on medication administration emphasizes the responsibility of the DON to supervise medication administration and ensure compliance with physician orders. However, the lack of communication and coordination among staff led to the failure in administering medications as required.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by another resident, R3. R2, a male with severe cognitive impairment and multiple psychiatric diagnoses, reported being punched in the chest by his roommate, R3. This incident was not witnessed by staff, but R2 was found with a bruise on his chest by a CNA during morning care. R2 consistently reported that R3 was the assailant, although R3 denied any physical interaction with R2. R2's medical records indicate that he has severe cognitive impairment and is dependent on staff for most activities of daily living. On the day of the incident, R2 was found with discoloration on the left side of his chest, which was later diagnosed as a contusion. Despite R2's severe cognitive impairment, he was able to communicate that he was punched by his roommate, leading to his transfer to a hospital for further evaluation. The facility's response included separating the residents and notifying relevant parties, including the police. However, the initial failure to prevent the altercation and protect R2 from harm constitutes a deficiency in the facility's abuse prevention program. The facility's policy defines abuse as the willful infliction of injury, and the incident highlights a lapse in ensuring resident safety and adherence to this policy.
Failure to Follow Menu and Serve Planned Meals
Penalty
Summary
The facility failed to adhere to the planned menu, resulting in all 211 residents not receiving the specified meals on two separate occasions. On December 18, 2024, during lunch service across all nursing units, residents were served one slice of white bread instead of the planned 1/2 slice of garlic Texas toast. Similarly, on December 20, 2024, during breakfast service, residents were not served the planned oatmeal and scrambled eggs with cheese. Instead, they received cream of wheat hot cereal and scrambled eggs without cheese. Additionally, there was a shortage of cold cereal and toast, leading to some residents, such as one who requested cold cereal, leaving the dining room without eating breakfast. The dietary manager, V8, acknowledged the discrepancies in meal service, noting that additional cold cereal was available in the kitchen but was not requested by the staff. The kitchen staff, V13, confirmed the use of incorrect serving utensils and the absence of cheese in the scrambled eggs. These observations and interviews highlight the facility's failure to follow the menu and ensure residents received the meals as planned, impacting the nutritional needs of the residents.
Inadequate Dining Supplies During Meal Service
Penalty
Summary
The facility failed to provide adequate dining supplies during a lunch meal service on the third floor nursing unit, affecting all 75 residents. Observations revealed that initially, 45 residents received their meals on plastic plates, but the staff ran out of these plates, resulting in the remaining 30 residents being served on Styrofoam plates. Additionally, the staff ran out of plastic cups with handles, leading to 10 residents receiving coffee in Styrofoam cups without handles. Furthermore, 25 residents were not provided with napkins as the supply ran out. Despite the shortage, the dining room staff did not notify the kitchen to replenish the necessary items. A subsequent tour of the kitchen confirmed that there were sufficient supplies available, but they were not requested by the dining room staff.
Failure to Initiate Timely Falls Care Plan for Resident
Penalty
Summary
The facility failed to follow its care plan policy by not initiating an individualized falls care plan with interventions for a resident at moderate risk for falls. This deficiency was observed in a resident who had transferred from another long-term care facility and had a documented history of falling and generalized weakness. Despite the resident's ability to make needs known, as indicated by a perfect BIMS score, the facility did not implement fall precautions immediately upon admission. The resident was observed on multiple occasions with the call light cord out of reach, and had visible injuries consistent with a fall. The restorative nurse, responsible for investigating falls and updating care plans, did not investigate the resident's fall that occurred shortly after admission. Although the resident was educated on seeking assistance with transfers and physical therapy evaluation, these interventions were not documented in the care plan. The care plan was not initiated until several days after the fall and was backdated, indicating a lapse in timely and appropriate care planning as per the facility's policy.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to follow its fall risk and post-fall assessment policy, which resulted in a deficiency affecting a resident identified as R2. Upon admission, R2 was not accurately assessed for fall risk, and necessary fall prevention interventions were not implemented immediately. Observations revealed that R2's call light cord was consistently out of reach, and R2 had visible injuries, including discoloration and swelling on the left side of the face, indicating a fall had occurred. Despite these signs, the facility did not conduct a thorough investigation or update R2's care plan with appropriate interventions. The Restorative Nurse, V6, acknowledged responsibility for investigating falls and updating care plans but admitted to not investigating R2's fall on 12/11/24. Although V6 was informed of the interventions to be put in place post-fall, these were not documented in R2's care plan. Additionally, the Director of Rehabilitation, V7, failed to prioritize R2 for skilled therapy despite R2's history of falls and a decline in functional abilities noted in transfer paperwork. R2 was not evaluated by physical and occupational therapy, and the fall incident report was not provided to the surveyor. R2's medical records indicated a history of falls, generalized weakness, and a need for assistance with ambulation. However, the fall risk review and post-fall review inaccurately noted no history of falls within the last three months and did not account for R2's medications or predisposing conditions. The facility's policy required a fall risk assessment at admission and a post-fall assessment with immediate interventions, but these were not completed as required, leading to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by pervasive odors of urine and unclean conditions in several rooms on the third floor. Observations revealed that rooms were dirty, with garbage on the floors and brownish stains, and a strong urine smell was present in the hallway and several resident rooms. Residents reported that their rooms had not been cleaned for several days, and housekeeping staff confirmed that they were unable to clean all rooms due to staffing shortages. The housekeeping department was understaffed, with only one housekeeper assigned to the third floor, who could not clean all resident rooms. The Housekeeping Director reported that they were not receiving sufficient cleaning supplies, such as bleach, to maintain cleanliness standards. The facility's owner was unaware of the supply shortages and staffing issues, indicating a lack of communication and oversight. Several residents were affected by the facility's failure to provide clean linens and mattresses. Residents reported that their bed linens were wet and stained, and some mattresses were soiled and needed replacement. The Director of Nursing confirmed that soiled linens should be changed immediately, and mattresses should be replaced if stained. However, the facility's policies were not being followed, leading to unsanitary conditions for the residents.
Failure to Maintain Sanitary Conditions in Meal Service
Penalty
Summary
The facility failed to adhere to its policy and procedures for serving food under sanitary conditions, affecting all 66 residents receiving meals on the 2nd floor. Observations revealed that meal trays were left uncovered on skeleton carts, with gnats flying around the food. Despite the presence of clean lids on the dietary aides' food service cart, they were not utilized. A Certified Nursing Assistant (CNA) mentioned that meal tray lids were typically unavailable, which led to their non-use. Another CNA admitted to not noticing the absence of lids during meal delivery, acknowledging the risk of contamination. The Director of Nursing confirmed that food trays should be covered to prevent contamination and maintain appropriate temperatures, as per the facility's Food Handling Policy, which mandates covering food and beverages during transport from the Dietary Department to residents.
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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.
Illustrative
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Nursing homes near Chicago Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Chicago Ridge | 0.5 mi | ★★★★★ | 4 | 0 |
| Nexus At Palos | 1.1 mi | ★★★★★ | 20 | 1 |
| Aliya Of Oak Lawn | 1.7 mi | ★★★★★ | 4 | 0 |
| Aperion Care Oak Lawn | 1.7 mi | ★★★★★ | 15 | 0 |
| Landmark Of Oak Lawn Rehabilitation And Nursing Ce | 1.9 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.