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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Margate Park during CMS and state inspections, most recent first.
Resident Lacked Proper Representation for Decision-Making: A resident with dementia, severe cognitive impairment, and inability to speak or make needs known did not have a guardian or POA. Staff confirmed family members listed as emergency contacts were not documented decision-makers, and the Administrator, DON, and SW all acknowledged the resident needed formal representation to advocate for medical and personal needs.
A resident reported missing hoodies and other items and stated another resident repeatedly entered her room and may have taken them. Staff acknowledged allegations that the resident wandered onto other floors, entered rooms without permission, and had been reported by peers for asking for money and personal items. Records showed the resident’s belongings inventory listed five hoodies, while the resident’s complaint remained unresolved.
Failure to confirm ordered equipment before transfer: A cognitively intact resident was discharged with CPAP and medication planning documented, but the hospital bed discussed in the care plan was not confirmed as delivered. Staff gave conflicting statements about whether the bed arrived, and the record contained no documentation confirming delivery before the resident left.
The facility failed to protect residents from repeated resident‑to‑resident physical and verbal abuse and did not implement effective interventions to prevent recurrence. Two cognitively intact residents with psychiatric diagnoses engaged in multiple altercations involving racial slurs, other derogatory remarks, coffee being thrown, and hitting in common areas, while staff present did not consistently recognize, report, or investigate these events as abuse under facility policy. In a separate situation, a cognitively intact resident reported being bullied and followed by a former roommate with a documented history of manipulative and aggressive behavior, culminating in being pushed in the face in a public area, despite prior complaints and staff awareness of ongoing harassment. The facility did not complete individual abuse and aggression assessments and failed to ensure timely reporting, investigation, and protective measures, resulting in multiple unaddressed episodes of resident‑to‑resident abuse.
Two cognitively intact residents with significant psychiatric histories engaged in multiple altercations involving physical contact and derogatory, including racial, language, which staff observed or were informed about but did not consistently recognize, report, or investigate as abuse in accordance with facility policy. One resident reported being struck in the chest on two occasions by another resident after exchanges of insults and, in one case, after throwing coffee, while staff intervened only to separate them and did not promptly notify the administrator or initiate an abuse investigation. Social services and business office staff documented or acknowledged verbal and physical incidents but either failed to escalate them as abuse allegations or provided conflicting accounts about who was informed, and the administrator, serving as abuse coordinator, stated she was unaware of these resident-to-resident abuse events until questioned by surveyors, despite a written policy requiring immediate reporting and investigation of suspected abuse.
Insufficient nursing staffing was identified when residents reported ongoing short staffing, delayed response to call lights, and long waits for assistance with transfers and getting out of bed. The staffing coordinator described routine CNA and nurse coverage, but CNA time sheets did not match the facility assessment staffing levels, and PBJ data showed excessively low weekend staffing and a one-star staffing rating.
Infection control and immunization program deficiencies were identified when EBP signage was not posted for two residents, an LPN entered a contact precaution room without gown and gloves, and the facility did not follow its vaccination policy. The IP stated the facility did not screen residents for hepatitis B risk factors or immunization status unless the diagnosis was already known, did not provide shingles education, and had not offered or administered the varicella-zoster vaccine. A resident also stated wanting the shingles vaccine but not receiving it.
Incorrect low-air-loss mattress settings and failure to follow pressure injury care orders. A resident with a stage 3 pressure ulcer and severe cognitive impairment, another resident with impaired mental status and skin integrity risk, a non-verbal resident with multiple neurologic and medical diagnoses, and a dependent resident with MASD/dermatitis were all observed on low-air-loss mattresses set far above their documented weights; one mattress was also left in static mode. Staff interviews confirmed the settings were not correct and that the mattresses should have been set based on the residents’ weights and ordered use.
A resident with dysphagia, dementia, and other serious diagnoses was observed self-feeding in his room without the ordered 1:1 feeding assistance, while coughing and later lying in bed with his meal tray still present. His diet and SLP orders required puree/thin liquids by tsp, oral care, upright positioning, and close supervision, but staff stated he could feed himself. The facility also failed to keep smoking materials secured for several residents, with cigarettes and lighters found in drawers, under a pillow, on a nightstand, in a pocket, and in a resident’s hand despite smoking assessments and policy requiring staff control of smoking items.
Failure to Obtain Informed Consent and Physician Orders for Bed Rail Use: The facility failed to follow its bed rail policy for four residents by not having the required informed consent and/or physician order documented for upper bed rail use. Residents were observed in bed with rails up, including one resident with intact cognition, others with severe cognitive impairment or non-verbal status, and one resident with hemiplegia, aphasia, and dysphagia. A restorative nurse confirmed missing documentation in the EHR for three residents, and the DON stated residents should be assessed for appropriateness before bed rail use.
Medication Labeling and Storage Deficiencies: An LPN and RN found multi-dose nasal sprays and inhalers in medication carts that were either opened with no date or dated well past the opening date, and a medication refrigerator contained insulin and other injectable meds mixed with ginger ale, juice, Glucerna, and a protein supplement. The pharmacist and DON stated opened nasal sprays and inhalers should be dated and that food/drinks should be separated from meds in the refrigerator.
A resident with a DNR order and DNR form stating no CPR had a comprehensive care plan and advance directives care plan that both documented full code status. The SW confirmed the resident’s DNR code status was on file, but the care plan did not match the documented advance directive and physician order.
PASRR re-assessments were not completed for two residents whose PASRR Level II short-term approvals without specialized services expired. One resident had psychotic disorder and MDD, and the other had anxiety, psychosis, and MDD with antidepressant therapy documented. The PASRR notices stated a new Level I screen was required before the approval end date if continued stay was needed, but the facility had no documentation that the rescreens were completed or initiated.
A resident with CHF, asthma, COPD, and DM2 was on contact precautions for ESBL, and a contact isolation sign was observed on her door. Although the DON stated a person-centered care plan for contact isolation was expected and necessary, review of the resident’s comprehensive care plan showed no documentation of contact isolation.
Missing Oxygen Order and Door Signage: A resident with COPD and respiratory failure was observed receiving continuous oxygen via nasal cannula, with the concentrator set at 5 LPM, but the chart did not contain a physician order for oxygen therapy. Staff also found no oxygen-in-use or no-smoking sign posted on or outside the room door. An LPN stated the resident should have an oxygen order, and the DON confirmed that oxygen use should be identified with door signage and documented by order.
Medication administration errors exceeded the allowed rate, with 4 errors in 39 opportunities. During observation, an LPN omitted two ordered psychotropic medications for one resident, and another LPN omitted folic acid and Xarelto for a second resident because they were not available; the record also lacked documentation that the physician was notified about the missed doses. The DON stated nurses are expected to follow the 5 rights and administer medications as ordered.
Failure to Provide Ordered Diet and Supplement: A resident with significant weight loss and physician-ordered NAS, double portions, and house shakes twice daily did not receive the ordered supplement at lunch and reported receiving single portions instead of double portions. The meal ticket did not list the shake, and the FSD and RD confirmed that diet orders and supplements should be reflected on the ticket and followed by kitchen staff.
A resident with multiple comorbidities had an incomplete pneumococcal vaccine record, with no documented pneumonia vaccine for the current period despite prior PCV13 doses. The IP stated annual chart audits are done to identify vaccine eligibility, but the resident’s vaccine report had a blank pneumonia entry, and the IP did not know why it was blank or whether the resident had completed the series or been offered an additional pneumococcal vaccine.
Failure to Offer and Document COVID-19 Vaccination: A resident with multiple comorbidities stated wanting the COVID-19 vaccine, but the facility did not provide it and could not show that it had been offered. The resident’s immunization record showed a prior booster, while the IP, Administrator, and DON were unable to confirm eligibility or whether the vaccine was offered, and the facility had no documentation for the current year.
Improper Dumpster Closure and Garbage Disposal: Housekeeping failed to keep dumpster lids closed and garbage fully contained. A housekeeper and Housekeeping Director described the dumpster area behind the facility, and surveyors observed open dumpsters with trash hanging out, including a dumpster with no lid and a recycle dumpster partially closed with boxes and bags protruding. A large trash dumpster was later observed still open with trash at the top and papers on the ground nearby.
A resident with COPD, Type 2 DM, and candidiasis had Hydrocortisone cream at bedside without a prior self-administration assessment, physician order, or care plan in place. An LPN observed the cream on the bedside table, and the resident said a nurse had given it to him earlier and a CNA had applied it because he could not reach his back. The resident was cognitively intact, but the facility’s own policy required an interdisciplinary assessment, order, and care plan before self-administration.
Resident privacy was not maintained when one cognitively intact resident entered another resident's room and used her restroom without permission. The affected resident, who had a history of adult physical and sexual abuse and PTSD, became very upset and cried after the intrusion. Staff stated residents were not expected to use another resident's restroom and that the resident should have been redirected if staff had been present.
Failure to Follow Inhaler Rinse-and-Spit Order: An LPN administered a corticosteroid inhaler to a resident with COPD, DM2, and candidiasis but did not follow the physician order to rinse the mouth with water and spit after use, instead instructing the resident to drink water. The resident was cognitively intact, and the unit manager/assistant DON stated staff are expected to instruct residents to swish and spit after inhaler use because it can cause oral thrush.
A resident with severe cognitive impairment and multiple comorbidities sustained a full thickness burn on the leg while unsupervised. Staff were unaware of how the injury occurred, and the incident was not reported or investigated as required by policy. The facility failed to provide adequate supervision and did not follow procedures for reporting and investigating injuries of unknown origin.
A resident with severe cognitive impairment and multiple chronic conditions sustained a significant burn of unknown origin. Facility staff documented the injury but did not notify the resident's representative until nearly two weeks later, despite policy requiring prompt notification. The delay was confirmed by staff interviews and absence of documentation in the health record.
A resident with multiple chronic conditions and cognitive impairment sustained a severe full-thickness burn of unknown origin. Staff observed and documented the injury, but the DON was not notified, and no investigation or report to the State was initiated as required by facility policy. The incident was not reported or investigated until much later, despite clear procedures mandating immediate action for injuries of unknown origin.
A resident with multiple comorbidities and severe cognitive impairment sustained a full-thickness burn of unknown origin. Staff observed the injury and provided wound care, but no immediate investigation or State report was initiated as required by facility policy. The DON and administrator confirmed that the incident was not reported or investigated until prompted by surveyors.
The facility did not ensure that a resident was protected from abuse, punishment, or neglect by any individual, resulting in a deficiency related to resident safety and well-being.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, as evidenced by insufficient demonstration of required skills and knowledge to meet residents' individualized needs.
A resident with a known history of violent behavior physically assaulted another resident in the dining room, resulting in a facial bruise and hospital evaluation. Staff, including an LPN and CNA, were present but unable to prevent the attack. The incident was substantiated as abuse, and both residents were sent to the hospital.
The facility did not provide timely, approved x-ray services and did not have an agreement with an approved provider to obtain them, resulting in a deficiency.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with cognitive impairment, seizure history, and moderate fall risk was left unsupervised in the dining room during a busy meal period when all CNAs were occupied elsewhere. The lack of supervision led to the resident attempting to rise from a wheelchair, resulting in a fall, head laceration, and subsequent hospitalization. Facility policies required continuous supervision, but staff failed to ensure coverage in the dining area.
Two residents experienced abuse: one was physically struck by another resident during a dispute in an elevator, and another was verbally abused with derogatory language by a receptionist during a disagreement in the lobby. Both incidents were witnessed by staff, confirmed through interviews and facility documentation, and found to be substantiated cases of abuse according to facility investigations.
A resident with multiple complex medical conditions and intact cognition was subjected to verbal abuse by a staff member during a late-night altercation. Although the incident was witnessed by several staff, internal communication delays and the unavailability of key personnel led to the abuse report being submitted to the state agency well beyond the required two-hour window, in violation of facility policy and state regulations.
A resident was twice petitioned for involuntary hospital admission without adequate documentation or substantiation of the behaviors cited as justification. Staff cited medication refusal and alleged aggressive behaviors, but records lacked supporting notes and staff interviews revealed inconsistencies regarding the events described.
The facility failed to maintain accurate and consistent medical records for two residents, including discrepancies between physician orders, MAR, and controlled substance documentation for one resident, and unsupported behavioral documentation in petitions for involuntary hospital admission for another. Staff interviews confirmed that required documentation was either missing or not based on direct observation.
A resident with multiple diagnoses and a recent functional decline was not provided with individualized fall interventions after a significant change in condition. Despite being at high risk for falls and requiring substantial staff assistance, only standardized fall prevention measures were in place. The resident was able to ambulate unassisted, leading to a fall and head injury, as staff were not adequately informed of the resident's fall risk or the need for specific interventions.
A resident in an LTC facility did not receive their blood pressure medication as ordered on multiple occasions. The resident, who is non-verbal, reported that an LPN attempted to crush their medication, leading to refusal. The LPN did not notify the physician or check the resident's blood pressure, which is consistently high. The facility's policy requires physician notification for medication refusals, which was not followed.
A facility failed to maintain effective pest control, resulting in cockroach sightings in resident rooms. A resident, who is aphasic, reported seeing roaches, confirmed by staff and other residents. The Maintenance Director stated pest control visits weekly, but cockroaches are still seen. The facility's policy emphasizes cleanliness, yet the presence of pests indicates a lapse in maintaining a safe environment.
The facility did not update fall care plans for two residents after fall incidents, contrary to its Fall Prevention Program policy. One resident had multiple falls without timely care plan revisions, and another resident's care plan was updated only after a delay. Interviews confirmed that care plans should be updated after each fall, but this protocol was not followed.
A resident at moderate risk for falls fell in the washroom after waiting over 15 minutes for assistance that never arrived. Despite requiring partial to moderate assistance, the resident attempted to transfer independently, resulting in a fall. Staff interviews revealed that call lights were not answered promptly, contrary to the facility's Fall Prevention Program, which mandates timely responses and assistance for residents at risk of falling.
A resident with bilateral below-knee amputations did not receive consistent restorative therapy, as required by the facility's policy. Despite being cognitively intact and expressing a desire for therapy, the resident reported only receiving three therapy sessions over three months. Staff shortages and errors in documentation contributed to the inconsistency, placing the resident at risk of not maintaining their highest practical level of function.
A facility failed to provide enough restorative nurse aides, causing a resident to miss multiple therapy sessions over 90 days. The resident, who uses a prosthesis, reported losing strength due to inconsistent therapy. Staffing shortages led to restorative aides being pulled to assist CNAs, disrupting the restorative program. The facility's schedule confirmed the shortage, with only one aide working on certain days.
A resident with severe cognitive impairment and multiple medical conditions was found with a large bruise on her thigh, diagnosed as a hematoma, after being restrained by staff during care. Despite the resident's protests, staff continued care without documenting refusal, contrary to facility policy. The facility's policies emphasize residents' rights to be free from abuse, but staff actions were inconsistent with these guidelines.
A resident with severe cognitive impairment and high fall risk experienced multiple falls due to inadequate supervision at an LTC facility. Despite the Care Plan requiring one-on-one monitoring, staffing issues led to a lack of proper oversight, resulting in serious injuries. The facility's failure to adhere to fall prevention policies and the resident's Care Plan contributed to these incidents.
A resident with schizoaffective disorder and other conditions received psychotropic medication without documented informed consent, despite a previous refusal. The ADON claimed verbal consent was given but lacked documentation, violating the facility's policy requiring signed or witnessed verbal consent.
A resident with severe cognitive impairment was found with a bruise on her thigh, which was not reported to the state survey agency by the facility. The CNA noticed the bruise but delayed reporting it, and the DON and administrator did not consider it abuse. The resident's daughter raised concerns, leading to a hospital visit where elder abuse was diagnosed. The facility's policy mandates immediate reporting of such incidents, which was not followed.
A facility failed to investigate an allegation of injury of unknown origin involving a resident with a large bruise on her thigh, which was reported by her daughter as potential elder abuse. The DON did not see the bruise before the resident was sent to the hospital, and the Administrator attributed the bruise to the resident's behavior, neglecting to investigate as required by the facility's abuse prevention policy.
Resident Lacked Proper Representation for Decision-Making
Penalty
Summary
The facility failed to ensure that one resident with severe communication and cognitive limitations had sufficient representation to advocate for their needs. The resident was admitted on 11/18/24 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, depression, dementia, atherosclerotic heart disease, tachycardia, and bipolar disorder. A CNA stated the resident understood when spoken to and followed commands but could not respond verbally, and a surveyor’s attempt to communicate through a language line resulted in no verbal response from the resident. A psychosocial progress note documented that the resident was alert and oriented x1, had frequent confusion and forgetfulness, a communication deficit, limited comprehension, and a BIMS score of 00/15 indicating severe cognitive impairment. Interviews with facility staff showed that the resident did not have a guardian or POA. The Administrator stated the facility did not have a policy regarding guardianship or POA and acknowledged the resident was not verbal or able to make needs known and should have a POA or guardian. The DON stated the resident had family listed on the face sheet who could advocate as emergency contacts, but there was no guardian. The Social Worker stated the resident had no POA or guardian, that emergency contacts did not have authority to make decisions, and that a resident who is non-verbal and cannot make needs known requires a POA or guardian. The Administrator stated paperwork was being started for state guardianship, and staff confirmed the resident had been unable to make needs known for at least a year.
Failure to Protect Resident Property
Penalty
Summary
The facility failed to protect a resident from the wrongful use of the resident’s belongings or money, involving R9 and allegations that R5 entered R9’s room and took items without permission. R9 stated that an inventory of her belongings showed missing items, including sports team hoodies, and that the issue remained unresolved. R9 also stated she believed R5 took the items and reported that she had caught him in her room several times trying to steal from her, including one incident when he was by her closet and another when he came into her room around 4:00 a.m. while it was dark. Staff interviews reflected awareness of concerns about R5’s presence on other residents’ floors and in other residents’ rooms. An RN acknowledged concern that R5 was stealing items from residents and stated staff must tell him to leave floors he is not supposed to be on alone. A former CNA stated a tall Black male resident, believed to be R5, had entered R9’s room and that other residents had complained he was stealing money and taking things from them. The Social Worker stated there were allegations that R5 was stealing residents’ items and that R9 had complained previously, while the Administrator stated R9 had complained that R5 stole her hoodies and coffee. Record review showed R9 had intact cognition with a BIMS score of 15/15 and an inventory list documenting five hoodies, while R5 also had a BIMS score of 15/15 and a history of behaviors including entering another resident’s room without permission and requesting money and personal items from other residents. The facility’s abuse and exploitation policy stated it was the policy to protect residents’ rights by prohibiting and preventing misappropriation of resident property. The report also noted that the requested abuse policy and procedure were not included in the documents later sent by the Administrator.
Failure to Confirm Delivery of Ordered Hospital Bed Before Transfer
Penalty
Summary
The facility failed to follow its transfer and discharge policy to ensure that all special instructions and/or precautions for ongoing care were in place before a resident was transferred to another facility. R7 was cognitively intact and had a discharge planning meeting with the interdisciplinary team and the outside agency team, during which it was documented that 14 days of medication would be prepared, CPAP settings would be noted on the discharge form, and a hospital bed would be ordered by the outside agency team. R7 stated after transfer that his medications were delayed for a couple of hours but were eventually cleared up, that he was transferred with his CPAP machine, and that a hospital bed had been discussed but was never delivered, requiring him to order it himself. Facility staff gave conflicting accounts about whether the hospital bed was delivered and whether follow-up occurred. The Administrator stated the bed was ordered but did not know if it was delivered and said there was no communication with the outside agency confirming delivery. The Social Services Director stated everything was ready for R7 prior to discharge and that the bed should have been delivered, but verified the progress note did not confirm delivery. The LPN stated she did not follow up to confirm the bed was appropriately delivered and was not sure if it had been delivered. The DON stated the facility and outside company were responsible for coordinating equipment such as beds, oxygen tanks, and wheelchairs prior to discharge, and the facility record contained no documentation from 04/03/2026 through 04/22/2026 confirming that R7's bed was delivered.
Failure to Prevent and Address Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical and verbal abuse and to implement effective interventions to prevent recurrence. Two cognitively intact residents, R1 and R2, both with bipolar and other psychiatric diagnoses, were involved in multiple altercations that included racial slurs, other derogatory remarks, and physical aggression. R1 reported that on one occasion near the elevator, she called R2 derogatory names, including a racial slur, and threw coffee at him; R2 then wheeled toward her and punched her in the chest three times, resulting in a red scratch on her chest. R1 also described a prior incident near the bookkeeper’s office and dietary door where R2 told her to move, called her a derogatory name, and hit her across the chest. R2 corroborated that he had several altercations with a white female resident, including being called a racial slur, having coffee thrown in his face, and then hitting the resident when she would not move out of his way. Staff interviews and documentation show that these incidents were not consistently recognized, reported, or investigated as abuse in accordance with facility policy. The Business Office Manager (V6) recalled hearing R2 call R1 a derogatory name and hearing others in the hallway say, “Don’t hit her,” after which she entered the hallway, confirmed with R1 that R2 had hit her, instructed R2 not to hit R1 again, and directed R1 to move. V6 stated she reported the incident to the Social Service Manager (V7) and informed the Administrator (V1) the next morning. However, V7 denied being informed by V6 of any incident involving hitting and stated she only knew of verbal name‑calling reported by R1, with no physical component. The Psychiatric Rehabilitation Social Service Coordinator (V4) documented on 3/16/26 that R1 reported an incident with another resident involving name‑calling and that it had been reported to another social worker, but there was no documentation of a physical altercation or an abuse investigation. The Administrator, who is the abuse coordinator, stated she had no knowledge of staff reporting derogatory remarks, coffee being thrown, or hitting between R1 and R2. The facility’s own abuse policy defines physical abuse as including hitting and verbal abuse as including disparaging and derogatory terms, and requires immediate investigation, identification and interviewing of all involved persons, and thorough documentation when abuse is suspected or reported. Despite this, the repeated episodes of derogatory language, racial slurs, and physical contact between R1 and R2 were not treated as abuse events requiring immediate reporting and investigation. The Administrator acknowledged that hitting another resident or throwing coffee at another resident’s face are acts of physical abuse and that failure of staff to report such incidents prevents the facility from knowing how to prevent recurrence. The lack of timely recognition, reporting, and investigation of these resident‑to‑resident altercations, and the absence of effective interventions to prevent further incidents, constitute the deficiency. A separate deficiency component involves the facility’s handling of resident‑to‑resident abuse between R3 and R4. R3, who was cognitively intact, reported that R4, a former roommate, had been bullying her, following her throughout the facility, and making it uncomfortable for her to remain in their shared room, leading to a room change. Staff, including the PRSC (V5) and an LPN (V17), stated that R4 followed R3 to her new room, insisted she could go into any room she wanted, and continued to bother R3. R3 later reported that while she was in the receptionist area, R4 approached her, made threatening statements, jumped into her face, and pushed her on the left side of her face. The Administrator (V1) stated that R3 came to her office and reported that R4 had pushed her in the face in the receptionist area, and that video footage confirmed R4 pushing R3. Although the facility ultimately reported the incident between R3 and R4 to the state and sent R4 to the hospital for aggressive behavior, the report shows that the facility did not perform individual abuse and aggression assessments for R3 and R4, and the Administrator stated that such assessments were not done and that this information was only included in the care plan. R3’s care plan stated that she would remain safe and free of mistreatment, while R4’s care plan documented a pattern of manipulative behaviors, false claims, verbal aggression, and attempts to cause negative interactions between peers and staff. Despite this known behavioral history, R4 was able to continue following and bullying R3, including entering R3’s new room without authorization and ultimately making physical contact by pushing R3 in the face. The failure to prevent and protect R3 from resident‑to‑resident abuse, in the context of R4’s documented aggressive and manipulative behaviors, further demonstrates the facility’s failure to ensure residents were free from abuse. Across these events involving R1, R2, R3, and R4, the facility did not consistently implement its abuse, neglect, and exploitation policy, which requires immediate investigation of suspected abuse, identification and interviewing of all involved persons, and complete documentation. Staff did not uniformly recognize or report resident‑to‑resident physical contact and derogatory, racially charged language as abuse, and the Administrator was not promptly informed of all incidents. The absence of timely reporting, investigation, and effective interventions allowed repeated altercations between residents, including physical hitting, pushing, and the use of racial slurs and other derogatory remarks, affecting three of three residents reviewed for abuse.
Failure to Report and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that allegations of resident-to-resident abuse were reported and investigated in accordance with facility policy and regulatory requirements. Two cognitively intact residents, R1 and R2, were involved in multiple altercations that included physical contact and derogatory, racially charged language. R1 has diagnoses including unilateral primary bipolar disorder in full remission and generalized anxiety disorder, and R2 has diagnoses including violent bipolar disorder, bipolar disorder, major depressive disorder, schizophrenia, and schizoaffective disorder. Despite these behavioral and psychiatric histories, staff did not consistently recognize or report the incidents as abuse, and the facility’s abuse coordinator (the Administrator) was not made aware of the events at the time they occurred. R1 later reported to the Administrator that there had been two altercations with R2. In one incident near the elevator, R1 admitted to calling R2 derogatory names, including racial slurs, and throwing coffee at R2. R1 stated that R2 then wheeled toward her and punched her in the chest three times, causing a red scratch on her chest. R1 reported that staff, specifically the Activity Director, were present in the dining room near the elevator, intervened by standing between the residents and telling them to stop, and that R1 then left in the elevator. In a separate incident near the bookkeeper’s office and dietary door, R1 stated that R2 told her to move, called her a derogatory name, and hit her across the chest. R1 reported that the Business Office Manager came out, told R2 to stop hitting, and separated the residents. R1 stated she did not sustain injury from that punch and was not afraid of R2, but these events were not reported to the Administrator as abuse at the time. Staff interviews and record review showed additional failures to report and investigate. The Psychiatric Rehabilitation Social Service Coordinator documented that R1 reported an incident involving name-calling with another resident and that it had been reported to another social worker, but there was no indication that this was treated as an abuse allegation or reported to the Administrator. The Business Office Manager recalled hearing R2 call R1 a derogatory name and hearing others say “Don’t hit her,” then learning from R1 that R2 had hit her; she stated she reported this to the Social Service Manager and informed the Administrator the next day in morning meeting, but there is no evidence that an abuse investigation was initiated at that time. The Social Service Manager acknowledged being told of a verbal altercation initiated by R1 but denied being informed of any physical hitting and denied receiving a report from the Business Office Manager about the incident near dietary. R2 confirmed having several altercations with peers, including hitting a female resident at the elevator after coffee was thrown at him and hitting the same resident near the bookkeeper’s office when she would not move, and stated staff were present but did not address the incidents. The facility’s abuse policy requires immediate investigation and thorough documentation when suspicion or reports of abuse occur, but the Administrator, as abuse coordinator, denied knowledge of staff reporting these incidents of physical and verbal abuse until questioned by surveyors, demonstrating that the required reporting and investigative processes were not followed.
Insufficient Nursing Staffing Compared With Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its facility assessment to meet resident needs. During a resident council meeting, residents reported that staffing was insufficient, call lights were not answered promptly, and staff shortages were ongoing. One resident stated that on some nights there was no CNA assigned to the sixth floor, and another resident who required two CNAs for transfers reported waiting extended periods for assistance getting out of bed because staff were frequently unavailable due to short staffing. The staffing coordinator stated she was responsible for scheduling CNAs and nurses and described the facility's usual staffing levels as 19 CNAs and 8 nurses on mornings, 14 CNAs and 8 nurses on evenings, and 10 CNAs and 6 nurses on nights, with staffing adjusted by census across four resident floors. Review of CNA time sheets for multiple dates showed the total CNA staffing provided per shift did not align with the staffing levels identified in the facility assessment, which listed total nursing services staffing as 19 CNAs for days, 14 CNAs for evenings, and 10 CNAs for nights. The facility's PBJ staffing data for FY Quarter 4 2025 also showed excessively low weekend staffing and a one-star staffing rating.
Infection Control and Immunization Program Deficiencies
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program in several areas. Surveyors observed that Enhanced Barrier Precautions (EBP) signage was not posted for two residents, including one resident with a gastrostomy tube and another resident with a dialysis access catheter. The facility’s Infection Preventionist stated that the resident with the dialysis access catheter was on EBP and that signage should be posted by the door or room entrance to alert staff to the precautions and PPE requirements. The Director of Nursing also stated that EBP signs should be posted outside residents’ doors so staff and visitors know to perform hand hygiene and wear gloves and gowns for direct contact activities. For one resident on contact precautions for ESBL in urine, a Licensed Practical Nurse entered the resident’s room and administered medications without wearing a gown or gloves, despite signage at the room entrance stating that staff must put on gloves and a gown before room entry. The Infection Preventionist stated that staff entering rooms under contact precautions should wear proper PPE to prevent transmission of organisms and that staff should wear proper PPE when administering medication inside a resident’s room on contact precautions. The DON stated that staff are expected to wear proper PPE upon entry to a resident’s room on contact precautions and that failure to do so creates a risk of spread of infection or cross contamination. The facility also did not follow its General Immunization/Vaccination policy and Illinois vaccination requirements. The Infection Preventionist stated the facility did not screen residents for hepatitis B risk factors or whether they had been immunized against hepatitis B unless the resident admitted with the diagnosis, and the facility did not provide education regarding shingles or the varicella-zoster virus. A resident stated wanting the shingles vaccine but said the facility did not provide it. The facility’s vaccine report had no entries in the shingles column, and the Infection Preventionist stated the facility had not offered or administered the varicella-zoster vaccine. The facility’s policy stated residents, staff, and volunteers would be offered immunizations as per current federal, state, and local guidance, and the Illinois code required screening for hepatitis B risk factors and distribution of educational information on recommended vaccines, including shingles.
Incorrect low-air-loss mattress settings and failure to follow pressure injury care orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing by not following its support surface policy, not following physician orders, and not maintaining correct settings on low-air-loss mattresses for four residents. The report states that support surfaces were to be used in accordance with evidence-based practice and physician orders, and that the air mattress should be set at the resident’s weight or per manufacturer instructions. Survey observations and interviews showed that the mattresses for R3, R43, R80, and R41 were set incorrectly, including settings far above the residents’ actual weights and, for one resident, an incorrect static mode. R3 had a stage 3 pressure ulcer to the right elbow, severe cognitive impairment, dependence on staff for bed mobility, and a care plan calling for a pressure relieving/reducing mattress while in bed. Although the order required the low-air-loss mattress to be checked every shift and set at the patient’s weight or per manufacturer instructions, R3 was observed on 2/24/26 with the mattress set to 320 lbs and in static mode. The wound care tech stated R3 weighed about 132 lbs and that the bed was not supposed to be on static mode. The wound nurse later stated R3’s bed should not be on static and should be on dynamic mode. R43 had severe mental status impairment, required partial/moderate assistance with rolling, and had a care plan identifying risk for altered skin integrity related to bed mobility, fragile skin, and incontinence. The resident’s order required the low-air-loss mattress to be set to the resident’s weight or manufacturer instructions for prevention. On observation, R43’s mattress was set near 400 lbs and on firm, while the resident’s weight was documented as 185.6 lbs. The wound care tech adjusted the setting after stating it should be on 185 lbs. R80, who was non-verbal and had multiple serious diagnoses including hemiplegia, aphasia, dysphagia, and contracture, was also observed on a low-air-loss mattress set at 400 lbs despite weights documented around 181 to 186 lbs. R41, who was cognitively intact but dependent for self-care and mobility, incontinent, and had MASD and partial-thickness dermatitis to the left posterior thigh, was observed complaining that the bed was very hard and uncomfortable; the mattress was set between 360 and 400 lbs even though the resident’s weight was documented around 239 to 240 lbs. Staff interviews confirmed that the mattress setting was too high and that the setting should be based on the resident’s weight.
Failure to Provide Ordered Feeding Supervision and Secure Smoking Materials
Penalty
Summary
The facility failed to provide ordered feeding assistance and swallowing precautions for a resident with significant medical and cognitive impairments. The resident’s diagnoses included COPD, protein-calorie malnutrition, dysphagia, cachexia, adult failure to thrive, dementia, esophageal obstruction, GERD, Wernicke’s encephalopathy, and alcohol abuse. Speech therapy documentation and physician orders directed pleasure feeding only, puree and thin liquids by teaspoon, one-to-one supervision/feeding, oral care before feeding, upright positioning during meals and for 30 minutes afterward, no straws, small bites, slow rate, and stopping feeding if decreased alertness or aspiration symptoms occurred. The resident’s MDS also documented severe cognitive impairment and partial/moderate assistance with eating. During observation, the resident was seen feeding himself in his room without staff present, eating quickly and coughing intermittently. The meal ticket contained the ordered feeding precautions, but the resident was still observed self-feeding, and juice was served in a cup. Shortly afterward, the resident was observed lying in bed with the head of the bed only slightly elevated and the meal tray still in the room. A nurse stated the resident was allowed to feed himself and only needed set-up assistance, while the SLP and RD stated the resident required one-to-one feeding and should not eat alone in his room. The facility also failed to follow its smoking safety practices for multiple residents. Residents were observed with smoking materials in their possession, including cigarettes and lighters kept in drawers, under a pillow, on a nightstand, and in a pocket. One resident was observed holding four cigarette sticks, and another stated he kept his own cigarettes. Smoking assessments for several residents indicated that facility staff were to store cigarettes and lighters, and one resident was identified as not a safe smoker requiring supervision. The facility’s smoking policy stated residents may not keep smoking articles except when under direct supervision and that designated staff would store the lighting device in a secured location, but staff interviews indicated residents were not supposed to keep smoking materials and that monitors were to maintain possession of them.
Failure to Obtain Informed Consent and Physician Orders for Bed Rail Use
Penalty
Summary
The facility failed to follow its policy for bed rail use by not obtaining informed consent and a physician’s order for residents with bed rails in place. The deficiency involved four residents reviewed for accidents in a sample of 35: R32, R47, R80, and R129. The report states that bed rail use should be assessed on admission, quarterly, and as needed, and that informed consent and a physician’s order are required after alternatives have been attempted. R32 was admitted with diagnoses including hypertension, type 2 diabetes, hyperlipidemia, anemia, bipolar disorder, anxiety disorder, coronary artery disease, irritable bowel syndrome, cervicalgia, osteoarthritis, and movement disorder. His MDS dated 1/22/26 showed intact cognition. On 2/24/26 and 2/25/26, R32 was observed with a right upper bed rail up and stated that his right upper bed rail is always up. His Side Rail Evaluation dated 1/22/26 stated that side rails were not indicated at that time, and V26 stated there was no physician order for bed rail use in his EHR. R47, R80, and R129 were also observed with upper bed rails in use. R47 had severe cognitive impairment and was observed resting in bed with both upper half rails up; his Side Rail Evaluation dated 2/25/26 stated that two side half rails were indicated as an enabler, but V26 stated there was no informed consent and no physician order in his EHR. R80, who was non-verbal and had diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, aphasia, and convulsions, was observed with both upper bed rails up; V26 stated there was no informed consent and no physician order in his EHR. R129, who had severe cognitive impairment and diagnoses including epilepsy, epilepticus, hypothyroidism, schizoaffective disorder, bipolar disorder, and anxiety disorder, was observed resting in bed with both upper bed rails up and said she could not walk; V26 stated there was no physician order in her EHR, although informed consent was present. The DON stated bedrails are used as mobility bars and that residents should be assessed for appropriateness, noting concern for entrapment if bedrails are not recommended.
Medication Labeling and Refrigerator Storage Deficiencies
Penalty
Summary
The facility failed to follow its policy for labeling and storage of medications by not properly dating multi-dose inhalers and nasal sprays after opening, not properly discarding multi-dose inhalers and nasal sprays, and by storing medications in the same refrigerator with juices and other refreshments. During cart and refrigerator inspections, a multi-dose fluticasone nasal spray for one resident was found opened with no date, another resident’s fluticasone nasal spray was dated opened 8/10/25, one resident’s albuterol sulfate inhaler was dated opened 8/10/25, and another resident’s albuterol sulfate inhaler was opened with no date. These items were found in medication carts on the 5th and 6th floors. In the 5th floor medication storage room refrigerator, medications including insulin pens, insulin vials, Trulicity injection, and Prevnar injection were observed stored together with 1 can of ginger ale, cranberry juice, Glucerna, and a protein supplement. The pharmacist stated multi-dose nasal sprays and inhalers should preferably be dated once opened and that food and drinks should be kept separate from medications in different refrigerators. The DON stated nurses are expected to label medications with the date opened and use-by or expiration date, and that nasal sprays and inhalers are usually effective for 28 days once opened; she also stated the 5th floor refrigerator is used for all residents on that floor.
Advance Directive and Care Plan Not Consistent
Penalty
Summary
The facility failed to ensure that one resident’s advance directive and code status were consistent with the comprehensive care plan. R10 was documented as cognitively intact on the MDS, admitted to the facility with diagnoses including chronic viral hepatitis C, spinal stenosis, atherosclerotic heart disease, a non-pressure chronic ulcer of the left lower leg with necrosis of muscle, and type 2 diabetes mellitus with other circulatory complications. The physician order sheet showed a DNR order, and the resident’s DNR form stated, “No CPR: Do not attempt resuscitation.” During interview, the Social Worker stated she oversaw advance directives care plans and confirmed that R10 had a DNR code status order on file. Review of the comprehensive care plan with the Social Worker showed it documented the resident as full code, while the advance directives care plan also listed “Full Code” and stated the resident’s wishes would be honored. The facility’s policies stated that the comprehensive care plan and plan of care should be consistent with the resident’s documented treatment preferences and/or advance directive.
PASRR Reassessment Not Completed When Short-Term Approval Expired
Penalty
Summary
The facility failed to ensure PASRR re-assessments were completed when short-term PASRR approvals expired for two residents reviewed for PASRR compliance. One resident had an original admission date of 7/9/24 and diagnoses including Other Psychotic Disorder and Major Depressive Disorder. A Notice of PASRR Level II Outcome dated 10/26/25 showed a short-term approval without specialized services ending on 1/25/26 and stated that a new Level I screen had to be submitted no later than 10 days before the end date if continued stay was needed, but the facility did not provide documentation that staff completed or initiated a new Level I screen before the approval expired. The second resident’s record showed diagnoses including Anxiety Disorder, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, and Major Depressive Disorder. The resident’s Order Summary Report included Venlafaxine HCl for depression, and the MDS documented active psychiatric/mood disorders including anxiety, depression, and psychotic disorder. The resident’s PASRR Outcome Explanation and Notice of PASRR Level II Outcome both stated the resident had short-term approval without specialized services ending on 1/25/26 and required a new Level I screen no later than 10 days before that date if continued stay was needed. On interview, the Social Services staff member stated the resident should have been rescreened on or before 1/25/26 to determine continued appropriateness for the facility without specialized services.
Failure to Include Contact Isolation in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for one resident, R13, out of eight residents reviewed for comprehensive care planning in a total sample of thirty-five. R13’s MDS noted that she was cognitively intact, and her EMR showed she was admitted to the facility with diagnoses including chronic systolic congestive heart failure, unspecified asthma, chronic obstructive pulmonary disease, and type 2 diabetes mellitus with unspecified complications. Her active physician orders on 02/25/26 included isolation and contact precautions related to ESBL from 02/14/26 until 02/28/26. During observation on 02/25/26, a contact isolation sign was seen on R13’s door, and R13 stated she had been on contact isolation for a few days. The DON stated it was her expectation that a person-centered care plan for contact isolation be developed and implemented for R13, and that a comprehensive care plan was necessary because it is one way transmission of infection can be prevented. However, review of R13’s comprehensive care plan showed no documentation of contact isolation.
Missing Oxygen Order and Required Door Signage
Penalty
Summary
The facility failed to obtain physician orders for oxygen administration for one resident, R75, who was observed lying in bed wearing a nasal cannula with oxygen infusing. R75’s oxygen concentrator was set at five liters per minute, and the oxygen tubing and humidifier bottle were dated 02/22/26. R75’s record showed diagnoses including Acute and Chronic Respiratory Failure With Hypoxia, Acute Pulmonary Edema, Chronic Obstructive Pulmonary Disease, and Personal History of Nicotine Dependence. The resident’s MDS dated 02/03/26 indicated that he required oxygen therapy while a resident, but the Order Summary Report did not include a physician order for oxygen therapy. The facility also failed to place oxygen-in-use signage on or outside R75’s room door. During observation, no oxygen-in-use sign or no-smoking sign was posted in or outside the room. An LPN stated that R75 was receiving continuous oxygen via nasal cannula and that the oxygen infusion rate was part of the physician order, but she did not see any oxygen orders in the electronic health record and stated that R75 should have physician orders because he had been receiving oxygen for COPD. The DON stated that when a resident is on oxygen, a sign should be posted outside the door and that residents receiving oxygen should have an order specifying the rate, method of administration, and frequency; she stated it was an oversight that R75 did not have an oxygen order.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with 4 errors out of 39 opportunities for a 10.26% medication error rate. During medication administration observation, an LPN prepared and administered medications to one resident, but two ordered medications, olanzapine and risperidone, were not given. The resident’s POS and MAR showed both medications were ordered for administration at 9 AM and 9 PM, but they were omitted during the observed pass. In a separate medication administration observation, another LPN prepared and administered medications to a second resident, but folic acid and Xarelto were not given. The resident’s POS and MAR showed both medications were ordered for 9 AM administration, and the LPN stated they were not available. Review of the resident’s record found no documentation that the physician was notified about the two missed medications. The DON stated nurses are expected to follow the 5 rights, administer medications as ordered, and notify the doctor if a medication is omitted or missed, with documentation in the resident’s record.
Failure to Provide Ordered Diet and Supplement
Penalty
Summary
The facility failed to provide a resident with diet and supplement orders as prescribed by the physician. The resident stated he did not receive his health shake twice a day, and during lunch observation he was served one breaded fish patty, pasta noodles, squash, coffee, juice, and canned fruit, but no health shake. The resident also stated he usually only receives a single portion with meals even though he is supposed to receive double portions, and he stated he should have received two fish patties. The meal ticket documented NAS with doubled portions at all meals, but it did not indicate the health shake. The Food Service Director stated diet orders and special instructions are printed on meal tickets so kitchen staff know what to serve, and that if a resident has an order for large or double portions, everything on the plate is doubled unless the order is for protein only. The Registered Dietitian stated the resident had experienced significant weight loss and was receiving house supplement shakes twice daily, and confirmed the diet order was NAS regular texture, thin consistency, double portion all meals. The physician orders included NAS diet, regular texture, thin consistency, double portions at all meals, and house shake two times a day for weight loss. The resident's weight record showed a drop from 185.2 lbs to 169.6 lbs over one month, and the dietitian documented unplanned significant weight loss and recommended house supplement twice daily and continued double protein portions at mealtimes.
Incomplete Pneumococcal Immunization Tracking and Follow-Through
Penalty
Summary
The facility failed to ensure that resident R185 completed the pneumonia vaccine series. R185’s admission record documented multiple comorbidities including polyneuropathy, asthma, anemia, hypertension, hyperlipidemia, and heart disease. During interview, the Infection Preventionist stated annual chart audits are done to determine when residents last received the pneumonia vaccine and who is eligible, but the vaccine report for the last 12 months showed a blank entry for R185 in the pneumonia column, and the Infection Preventionist did not know why it was blank. R185’s immunization record showed Pneumo-PCV13 (Prevnar 13) on 3/28/2024 and a prior PCV13 on 9/27/2016, with no pneumonia vaccine recorded for 2025 or 2026. On follow-up interview, the Infection Preventionist stated they did not know whether R185 was complete with the pneumonia vaccine series and did not know if the facility had offered an additional pneumococcal vaccine to R185.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document vaccination status for one resident, R185. R185’s record documented multiple comorbidities including polyneuropathy, asthma, anemia, hypertension, hyperlipidemia, and heart disease. During interview, R185 stated wanting to receive the COVID-19 vaccine, stated the facility did not provide it, and stated the last COVID-19 vaccine was received in the fall of 2024. R185 also stated informing the Infection Preventionist that [R185] wanted the COVID-19 vaccine, but it had not been provided. The Infection Preventionist stated annual chart audits were done to identify residents eligible for COVID-19 vaccination, but a vaccine report for the last 12 months showed a blank/no entry for R185 in the COVID column, and the Infection Preventionist did not know why it was blank. R185’s immunization report documented a COVID-19 booster on 12/02/2024 with none recorded for 2025 or 2026. In follow-up interviews, the Infection Preventionist, Administrator, and DON stated they did not know whether the facility offered the vaccine to R185, and the facility did not provide documentation that the COVID-19 vaccine was offered to R185 in 2025 or 2026. The facility’s COVID-19 vaccination policy stated it was the facility’s policy to educate and offer the COVID-19 vaccine to residents and staff and maintain documentation of such.
Improper Dumpster Closure and Garbage Disposal
Penalty
Summary
The facility failed to ensure that dumpster lids were properly closed and that garbage and refuse were disposed of properly. On 11/18/25, a housekeeper stated she was responsible for cleaning the 2nd floor and had not observed rodents or rodent droppings on the unit or in room R5. The Housekeeping Director stated housekeeping was responsible for managing the dumpsters and that dumpsters should always be free from trash hanging out of them. He stated there were two large trash dumpsters, two small trash dumpsters, and three recycle dumpsters behind the facility in the parking lot, and that lids should always be closed to prevent trash from blowing, rodents and animals from getting into the trash, and the facility from feeding rodents. He also stated that if trash was hanging out of the dumpsters, it was not sanitary, and that trash from the kitchen was hanging outside of the dumpster with trash all over the ground near the dumpsters. On 11/18/25 at 3:29 pm, two dumpsters behind the facility were observed open, including one dumpster with no lid covering at all and garbage hanging out of the can, and a second recycle dumpster with a blue lid partially closed and brown boxes and clear plastic bags hanging out of the top. On 11/19/25 at 3:10 pm, a large trash dumpster was again observed open with trash filled to the top, clear bags hanging out of the dumpster, and papers on the floor next to it. The Administrator stated that housekeeping supervision was responsible for ensuring dumpsters were closed and the area around them remained clean and without debris to avoid rodents. Facility policies stated that garbage should be disposed of in refuse containers with lids, dumpsters should be kept covered when not being loaded, and the surrounding area should be kept clean so debris and insect/rodent attractions are minimized.
Failure to Assess and Order Self-Administration of Hydrocortisone Cream
Penalty
Summary
The facility failed to assess a resident’s ability to safely self-administer medication, failed to obtain a doctor’s order for self-administration, and failed to care plan self-administration before allowing it to occur. During medication administration observation, a tube of Hydrocortisone cream was seen on the resident’s bedside table, and the resident asked for another tube because the current one was almost empty. The resident stated that the night shift nurse had given him the tube a long time ago and that a CNA had applied the cream to his back because he could not reach it. An LPN stated the hydrocortisone cream should not have been at bedside because anyone could come into the room and take it. The resident had diagnoses including COPD, Type 2 DM, and candidiasis, and the MDS documented a BIMS score of 15, indicating cognitively intact status. The active medication order directed Hydrocortisone external cream 0.5% to be applied to the lower back/thigh back twice daily for itching, but there was no order for self-administration. The unit manager/assistant DON stated that a self-administration assessment should be completed first, along with a doctor’s order and care planning, and acknowledged that the assessment was completed, the order obtained, and the care plan updated after the fact. The facility policy stated that residents may only self-administer medications after the interdisciplinary team determines which medications may be safely self-administered and that the care plan must reflect self-administration and storage arrangements.
Resident Privacy Not Maintained When Another Resident Used Her Restroom
Penalty
Summary
The facility failed to maintain a resident's personal privacy when another resident entered her room and used her restroom. The affected resident stated she was lying on her bed when she heard a noise from the restroom, got up, and saw the other resident washing his hands in her bathroom. She stated she was very upset because he invaded her space and told her he did not give a F**K because he had to use the restroom. The Infection Preventionist stated she heard the resident yelling, "why are you in my room," and found the other resident in the restroom drying his hands while the resident stood outside the bathroom. She escorted him out and asked why he was in the room; he stated he needed to use the bathroom really bad. The Social Services Director also stated she heard the resident yelling "GET OUT" and saw her coming out of the room upset, crying, and saying the other resident was in her room using her restroom. The other resident admitted he thought no one was in the room and used the closest restroom because he had to pee. The resident whose privacy was affected had diagnoses including hypertensive chronic kidney disease, personal history of adult physical and sexual abuse, and post-traumatic stress syndrome. Her BIMS score was 14, indicating she was cognitively intact, and her care plan documented a personal history of adult physical and sexual abuse. The other resident also had a BIMS score of 15, indicating he was cognitively intact. Staff interviews stated residents were not expected to use another resident's restroom, that the door never locks, and that staff should have redirected the resident if present.
Failure to Follow Inhaler Rinse-and-Spit Order
Penalty
Summary
The facility failed to follow a physician order when administering Budesonide/Formoterol inhaler sprays to a resident. During observation of medication administration, an LPN placed the inhaler mouthpiece on the resident’s mouth, pressed the canister, and instructed the resident to inhale the medication orally, then told the resident to drink water afterward. When asked about the expected step after the inhaler use, the LPN stated she should have instructed the resident to swish and spit water to prevent a fungal infection. The resident stated nurses usually asked him to swish and spit after taking his liquid protein and that he did not know the purpose of swish and spit. The resident had diagnoses including COPD, Type 2 DM, and candidiasis, and his active order for Symbicort 160-4.5 mcg/act documented to inhale 2 puffs every 12 hours included the instruction to rinse mouth with water and spit back into a cup after use. The resident’s MDS documented a BIMS score of 15, indicating he was cognitively intact. The facility’s inhaler administration guidance stated that after using a corticosteroid inhaler, the resident should rinse the mouth and spit, and the unit manager/assistant DON stated nurses are expected to instruct residents to swish and spit water after taking the inhaler because it can cause oral thrush.
Failure to Provide Adequate Supervision Resulting in Resident Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision for a resident, resulting in the resident sustaining a full thickness burn on his left leg with a surface area of 136.90 cm^2. The incident was discovered when a staff member noticed the burn during a routine activity and sent the resident back to his floor. Multiple staff interviews revealed that no one knew how or when the injury occurred, and the resident, who is nonverbal and has severe cognitive impairment, was able to move independently between floors using the elevator without direct supervision. The resident's medical history included deafness, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease, and chronic systolic heart failure. Documentation showed that the resident had severely impaired cognitive skills for daily decision making and memory problems. Despite these vulnerabilities, staff were unclear about the resident's whereabouts and level of supervision at the time of the injury. The wound was described as severe and required specialized wound care. Facility leadership, including the DON and administrator, were not notified of the injury in a timely manner, and no investigation or report to the State was initiated as required by facility policy. The injury was classified as of unknown origin, which should have triggered an abuse investigation and mandatory reporting. Staff interviews confirmed that the resident was not adequately supervised, and the facility failed to follow its own policies regarding accident prevention, supervision, and incident reporting.
Failure to Timely Notify Resident Representative of Injury
Penalty
Summary
The facility failed to notify a resident's representative of an injury of unknown source in a timely manner. On the day of the incident, a staff member observed the resident with a significant burn on his leg and directed him to return upstairs. The agency RN on duty documented the injury in the progress notes but did not contact the family. Interviews with staff confirmed that there was no immediate notification to the resident's family or representative regarding the injury, and review of the electronic health record showed no documentation of family notification at the time of the incident. The resident involved had multiple complex medical diagnoses, including type 2 diabetes mellitus, chronic kidney disease, and congestive heart failure, and was noted to have severely impaired cognitive skills. The wound was later evaluated as a full-thickness burn, and the family was not notified until 13 days after the injury, when consent was needed for a surgical debridement. Facility policy requires prompt notification of a resident's representative in the event of an injury, but this was not followed, as confirmed by staff interviews and record review.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the reporting and investigation of an injury of unknown origin for one resident. On the day of the incident, a staff member observed a significant burn on the resident's leg and sent the resident upstairs, noting that the injury could not have occurred in the patio area. The agency RN who received the resident upstairs cleaned the wound, informed the incoming nurse, and stated she notified the DON before leaving. However, the DON later reported not being notified of the injury and confirmed that no investigation or report to the State was initiated at that time. The resident in question had multiple complex medical diagnoses, including type 2 diabetes, chronic kidney disease, and heart failure, and was cognitively impaired. Documentation showed that the injury was a full-thickness burn of significant size, described as severe by the wound care doctor. The injury was first documented in a progress note as a skin tear, and a subsequent wound evaluation confirmed the extent of the burn. Despite the seriousness of the injury and the facility's policy requiring immediate reporting and investigation of injuries of unknown origin, no such actions were taken until much later. Interviews with facility staff, including the new administrator and DON, revealed a lack of awareness and follow-through regarding the required reporting and investigation procedures. The administrator acknowledged that the injury was not reported or investigated as required by policy and federal regulations. Additionally, an email from the administrator indicated no reportables for injury of unknown origin in the relevant period, further confirming the failure to report this incident. The facility's own policy mandates immediate reporting of such events to the State and other authorities, which was not followed in this case.
Failure to Investigate and Report Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source sustained by a resident, as required by policy and regulation. On the day of the incident, a staff member observed a significant burn on the resident's leg when the resident came to the dining room for a scheduled activity. The staff member immediately sent the resident upstairs and noted that the injury could not have occurred in the patio area. Despite this observation, the staff member was not interviewed about the incident at the time, and no immediate investigation was initiated. A registered nurse on duty at the time recalled seeing the injury when the resident was brought upstairs and provided initial wound care. She reported the injury to the incoming nurse and the DON before leaving her shift. The wound was later evaluated by a wound care physician, who determined it to be a full-thickness burn with severe pain and significant size. Despite the seriousness of the injury and the facility's policy requiring immediate investigation and reporting of injuries of unknown origin, the DON stated she was not notified of the injury and no investigation or report to the State was made at the time. The facility's policy defines injuries of unknown source as potential abuse and mandates immediate investigation and reporting. However, the administrator and DON both confirmed that the injury was not reported or investigated as required. The resident involved had multiple complex medical conditions, including diabetes, heart failure, and chronic kidney disease, and was noted to have severely impaired cognitive skills, making thorough investigation and protection particularly important. Documentation showed that the injury was only reported to the State and investigated after the issue was raised during the survey.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. This deficiency indicates that there was an incident or observation where a resident was not safeguarded from such harm, as required by regulations. Specific details about the actions or inactions leading to the deficiency, or about the residents involved, are not provided in the report.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the optimal well-being of residents as required.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with a history of violent behavior, schizophrenia, and schizoaffective disorder physically attacked another resident in the dining room. The incident occurred when the aggressor confronted the other resident about seating, and after a brief interaction, ran towards the resident and struck them in the face, resulting in both residents falling to the floor. The assaulted resident sustained a bruise over the right eye and required hospital evaluation. Staff members, including an LPN and a CNA, were present in the dining room at the time of the incident but were unable to intervene before the assault occurred. The resident who committed the assault had a documented diagnosis of violent behavior, but staff reported they did not anticipate physical aggression towards others. The facility's abuse prevention policy was in place, but the event still occurred, resulting in physical harm to a resident. The incident was substantiated as abuse by the facility's Director of Nursing. Both residents were sent to the hospital following the event, and the aggressor was not present in the facility at the time of the report.
Failure to Provide Timely, Approved X-Ray Services
Penalty
Summary
The facility failed to provide timely, approved x-ray services or to have an agreement with an approved provider to obtain such services. This deficiency was identified based on the absence of either in-house x-ray capabilities or a documented agreement with an external, approved provider to ensure residents could receive necessary x-ray services as required.
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 Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who was at moderate risk for falls and had a history of seizures and cognitive impairment. The resident required substantial to maximal assistance with activities of daily living, was incontinent, and used a wheelchair. The care plan included interventions to anticipate and meet the resident's needs and to monitor for signs and symptoms of tremors, rigidity, dizziness, changes in consciousness, and slurred speech. Despite these documented needs and interventions, the resident was left unsupervised in the dining room during a busy lunch period. On the day of the incident, all four CNAs assigned to the floor were occupied with passing meal trays and feeding other residents in their rooms, leaving the dining room without staff supervision. The nurse supervisor was also engaged in another resident's care and not present in the dining room. The CNA assignment sheet indicated that staff were scheduled to monitor the dining room in 30-minute increments, but at the time of the fall, no staff were present to supervise the residents in the dining room. The staff responsible for monitoring the dining room did not inform anyone before leaving, resulting in a lapse in supervision. As a result, the resident attempted to get up from the wheelchair and fell, sustaining a laceration to the right temple that required sutures. The fall was unwitnessed, and the resident was found on the floor exhibiting seizure-like symptoms. The incident was reported to the state agency, and the resident was transported to the hospital for evaluation and treatment. Facility policies required supervision of residents, especially those at risk for falls and seizures, but these were not followed at the time of the incident.
Failure to Prevent Physical and Verbal Abuse of Residents
Penalty
Summary
The facility failed to protect residents from both physical and verbal abuse, as evidenced by two separate incidents involving residents and staff. In the first incident, a resident with multiple medical conditions, including chronic obstructive pulmonary disease, amputation, and chronic pain, was physically struck in the arm by another resident while in an elevator. The aggressor, who has a history of schizoaffective disorder, violent behavior, and cognitive impairment, admitted to hitting the other resident after a dispute over space in the elevator. This event was corroborated by a third resident who witnessed the altercation and confirmed that the aggressor used a closed fist to strike the victim. Facility staff and documentation confirmed the occurrence of physical abuse. In the second incident, a resident with paraplegia and multiple pressure ulcers was verbally abused by a staff member, specifically a receptionist, during a disagreement in the lobby area. The resident and the staff member exchanged words, and the staff member was reported by two nursing supervisors to have used derogatory and profane language towards the resident, including telling the resident to "shut up" followed by a curse word. Witness statements from both supervisors and facility documentation confirmed the use of abusive language by the staff member towards the resident. Both incidents were substantiated through interviews with the involved parties, witnesses, and review of facility records. The facility's own investigations concluded that abuse had occurred in both cases, with the physical abuse incident involving resident-to-resident aggression and the verbal abuse incident involving a staff member. The facility's policies prohibit such abuse and require the protection of residents from mistreatment by anyone, including staff and other residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely submit an initial abuse report to the state agency within the required two-hour window after an incident involving a resident and a staff member. The incident occurred in the early morning hours when a resident, who is cognitively intact and uses a manual wheelchair, had a verbal altercation with a receptionist. During the disagreement, the staff member directed derogatory and abusive language toward the resident, which was witnessed by multiple staff members, including two LPNs and a CNA. Witness statements confirm that the staff member told the resident to 'shut up b****,' and both parties exchanged curse words. Following the incident, staff attempted to notify the facility's administrator, who serves as the abuse coordinator, but were unable to reach them due to a religious holiday. The staff then attempted to contact the DON, who also missed the initial call. Eventually, the DON was informed of the incident close to 7:00 am, several hours after the event. The preliminary abuse report was submitted to the state agency at 8:33 am, which exceeded the two-hour reporting requirement outlined in both facility policy and state regulations. The resident involved had significant medical conditions, including paraplegia, multiple stage 4 pressure ulcers, chronic osteomyelitis, and other complex diagnoses, but was assessed as cognitively intact. The facility's own abuse prevention policy requires immediate reporting of abuse allegations to the administrator or designated personnel and mandates that such incidents be reported to the state agency within two hours. Despite these requirements, the delay in internal communication and subsequent reporting resulted in noncompliance with regulatory timelines.
Failure to Document and Substantiate Involuntary Transfer and Discharge
Penalty
Summary
The facility failed to meet regulatory requirements for the involuntary transfer and discharge of a resident, as evidenced by two separate petitions for involuntary admission to a hospital that lacked adequate supporting documentation. In the first instance, the petition cited ongoing medication refusals, non-compliance with care, and behavioral concerns such as irritability, agitation, aggression, and emotional distress. However, a review of the resident's records for that day revealed no documentation of these behaviors, aside from a note about medication refusal and the resident's response to education about high blood pressure. Both the social worker and the LPN confirmed that while the resident had a history of non-compliance, there was no documentation of behavioral concerns on the day of the transfer to support the petition. In the second instance, the petition alleged that the resident was physically aggressive, including slamming a laptop against a wall and pushing a door into a nurse. However, there were no notes in the record to support these claims, and interviews with staff revealed inconsistencies regarding the events described. The social worker who signed the petition did not witness the alleged behavior and acknowledged that no one had seen the resident throw the laptop. The nurse involved could not recall if the resident had a laptop, only that the resident used an iPad for communication. These failures resulted in the resident being twice petitioned for involuntary hospital admission without the required documentation or substantiation of the behaviors cited as justification.
Inaccurate and Inconsistent Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and consistent documentation in the medical records of two residents. For one resident with multiple complex diagnoses, there were inconsistencies between the physician's orders, medication administration records (MAR), and controlled substance documentation. Specifically, a nurse reported receiving a verbal order for laboratory blood work but did not enter it as an official order in the electronic record. Additionally, the MAR indicated that Methadone was administered on a day when the resident was out for an appointment, while the controlled substance proof of use form did not reflect administration on that date. The Director of Nursing acknowledged that documentation should have indicated the medication was not given due to the resident's absence, rather than being signed as administered in the facility. For another resident, documentation related to petitions for involuntary or judicial admission to the hospital was inconsistent with the clinical notes. The first petition described behaviors such as medication refusal, non-compliance, irritability, agitation, aggression, and manipulative behavior, but there was no supporting documentation in the resident's notes for the day the petition was filed. The Social Service Director confirmed that while the behaviors were ongoing, there was no specific documentation on the day of the petition to support the claims made. In a second petition for the same resident, the documentation stated that the resident was physically aggressive, including slamming a laptop against a wall and hitting a nurse with a door. However, there were no clinical notes to support these events, and staff interviews revealed uncertainty about whether the resident had a laptop and confirmed that no one witnessed the alleged incident. The Social Worker who completed the petition admitted that the documentation was not based on direct observation.
Failure to Individualize Fall Interventions After Resident Decline
Penalty
Summary
The facility failed to ensure individualized and appropriate fall interventions were identified and implemented for a resident at high risk for falls. The resident, who had diagnoses including chronic obstructive pulmonary disease, schizophrenia, dementia, and exhibited restlessness and agitation, was re-admitted to the facility with a significant decline in function. The resident required substantial maximal staff assistance for walking, transferring, and toileting, and had a history of falls and impaired gait. Despite these risk factors, the resident's fall care plan was not revised or individualized following a significant change assessment, and only standardized interventions were in place. On the evening of the incident, the resident was observed walking unassisted in front of the nursing station, carrying a Foley catheter, when he lost balance and fell, hitting the back of his head. Staff interviews revealed that the resident was considered bedridden and not at risk for falls by some staff, leading to a lack of fall interventions such as non-skid socks or staff assistance when ambulating. There was also confusion among staff regarding the resident's fall risk status and the need for individualized interventions, with one LPN stating they were not informed of the resident's high fall risk and that no interventions were in place because the resident was thought to be bedridden. The facility's policy required that fall risk assessments and individualized interventions be implemented and updated as needed, especially after significant changes in a resident's condition. However, the resident's care plan was not updated to reflect his increased needs and functional decline, and staff were not adequately informed or prepared to provide the necessary supervision and interventions to prevent the fall. The lack of individualized care planning and communication contributed to the resident's unassisted ambulation and subsequent fall.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's medication was administered as ordered by the physician, resulting in significant medication errors. The resident, who is non-verbal and uses a tablet to communicate, reported that they were not provided with their morning medications, including blood pressure medication, on two separate occasions. The resident expressed that they have no issues swallowing whole medications, yet a Licensed Practical Nurse (LPN) attempted to crush the medication, leading to the resident's refusal to take it. The LPN did not notify the physician of the refusal or check the resident's blood pressure, which is consistently high. The LPN admitted to not administering the blood pressure medication on one occasion because the resident requested it after the scheduled time. The LPN acknowledged that they should have contacted the physician to adjust the medication timing. The failure to administer the medication as ordered and the lack of communication with the physician could potentially increase the resident's blood pressure, posing a risk of another stroke. The resident's electronic medical record confirmed that the blood pressure medication was not administered on three specific dates, and there was no documentation of physician notification for the refusals. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both stated that it is expected for nurses to document medication refusals and notify the physician immediately. The DON confirmed that there was no specific order to crush the resident's medication and emphasized the importance of notifying the physician to prevent medical emergencies. The facility's policy on medication administration requires that the physician be notified when medications are not administered as per orders, which was not adhered to in this case.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in a resident's room. A resident, who is aphasic and uses a tablet to communicate, reported seeing roaches in their room, pointing out three dead roaches on the floor and one in a dresser drawer. This resident has a history of hemiplegia, aphasia, and major depressive disorder, among other conditions, and is cognitively intact with a BIMS score of 15. Another resident, with moderate cognitive impairment, reported seeing both live and dead cockroaches daily, although the surveyor did not find any in their bathroom. A third resident, also cognitively intact, mentioned seeing cockroaches in the bathroom, noting a hole in the wall as a possible entry point, but no roaches were observed by the surveyor in their room. The Maintenance Director confirmed responsibility for pest control, stating that pest control services visit weekly, although cockroaches are occasionally seen. The Housekeeping Supervisor and a CNA also acknowledged seeing roaches, with the Housekeeping Supervisor noting a recent sighting and reporting it to the front desk. The Director of Nursing was unsure of the exact frequency of pest control visits. The facility's pest control policy and job descriptions emphasize maintaining a clean and safe environment, yet the presence of cockroaches indicates a lapse in these responsibilities.
Failure to Update Fall Care Plans After Incidents
Penalty
Summary
The facility failed to adhere to its Fall Prevention Program policy by not revising fall care plan interventions after each fall incident for two residents. One resident experienced falls on three separate occasions, yet their care plan, initiated months prior, was not updated to reflect new interventions after these incidents. The care plan history showed that a new intervention was only added weeks later, indicating a lack of timely updates following each fall. Another resident also experienced a fall, but their care plan was not revised until ten days later. Interviews with the Restorative Director and the Director of Nursing confirmed that the facility's protocol requires care plan updates after each fall, based on a root cause analysis. The facility's policy mandates immediate changes in interventions following falls, but this was not followed, leading to the deficiency.
Failure to Follow Fall Prevention Program Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its Fall Prevention Program and a resident's comprehensive care plan, resulting in a fall incident involving a resident (R2). R2, who was assessed as being at moderate risk for falls, required partial to moderate assistance with activities of daily living, including toileting. On the day of the incident, R2 pressed the call light for assistance to go to the washroom but waited over 15 minutes without receiving help. Consequently, R2 attempted to transfer independently to the washroom, where R2 lost balance and fell while trying to stand from the wheelchair. Interviews with staff revealed that the call light was not answered promptly, and R2 was found on the bathroom floor by an LPN. The facility's policy mandates that call lights should be answered within 15 minutes and that residents at risk for falls should not be left alone during toileting. Despite R2's care plan indicating the need for staff assistance, a CNA stated that R2 often performed tasks independently and did not call for help. The incident highlights a lapse in the facility's protocol to provide necessary supervision and assistance to prevent falls.
Inconsistent Restorative Therapy for Resident with Bilateral Amputations
Penalty
Summary
The facility failed to provide consistent restorative therapy to a resident, identified as R10, who has a history of heart failure, peripheral vascular disease, and bilateral below-knee amputations. R10, who is cognitively intact, expressed a preference for speaking in Spanish and reported that he had not received consistent restorative therapy for the past three months. He mentioned that he had only received three therapy sessions, each lasting 15 minutes, during this period. R10 expressed concerns about losing strength and not being able to use his prostheses effectively due to the lack of regular therapy. Observations and interviews with facility staff revealed that the restorative therapy program was not consistently implemented for R10. A Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) confirmed that R10 was alert and oriented, capable of making his needs known, and able to perform transfers independently. However, they could not recall when R10 last participated in restorative therapy. The Restorative Nurse Assistant indicated that restorative therapy sessions were often disrupted due to staff shortages, leading to inconsistent therapy for residents like R10. The facility's documentation showed discrepancies in R10's restorative care plan and assessments. The Restorative Director acknowledged errors in R10's assessments, including incorrect documentation regarding the use of prostheses. The facility's policy required obtaining a physician's order for restorative therapy, but R10's physician order set did not include such an order. The lack of consistent restorative therapy and accurate documentation placed R10 at risk of not maintaining his highest practical level of function.
Inadequate Restorative Staffing Leads to Missed Therapy Sessions
Penalty
Summary
The facility failed to ensure adequate staffing of restorative nurse aides, resulting in a resident missing restorative therapy sessions multiple times over the past 90 days. The resident, who uses a prosthesis, expressed concerns about losing strength and not improving due to the lack of consistent therapy. The resident reported that when other CNAs call off or there is a staffing shortage, restorative aides are pulled to work on the floor, leaving the therapy room closed. This situation was confirmed by the Lead CNA/Staffing Coordinator, who stated that pulling restorative aides to the floor is a last resort when there are call-ins, as it affects the residents' range of motion. The Restorative Director and a Restorative Nurse Assistant both acknowledged that restorative aides are frequently pulled to assist with CNA duties, which disrupts the restorative program. The Restorative Director noted that when aides are pulled, residents do not receive the necessary exercise to maintain their maximum capacity. The Restorative Nurse Assistant mentioned being behind on tasks due to illness and the closure of the facility's gym. The facility's nursing schedule and restorative staff time sheets corroborated the shortage of restorative aides, with only one aide working on specific dates. The resident's Minimum Data Set indicated cognitive intactness, and records showed several undocumented days for walking and active range of motion tasks.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R4, from physical abuse by staff, resulting in harm. R4, who has a severely impaired cognitive status with a BIMS score of 3, was found to have a large bruise on her right thigh, which was diagnosed as a hematoma. The resident's medical history includes conditions such as hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and major depressive disorder. The incident was reported by R4's family member, who noticed the bruise and suspected abuse, leading to R4 being sent to the hospital for further evaluation. Interviews with staff revealed that R4 was often combative during care, requiring two staff members to manage her, with one holding her down while the other provided care. This practice was confirmed by multiple staff members, including CNAs and LPNs, who noted R4's resistance and the need to restrain her legs to prevent kicking. Despite R4's verbal protests during care, staff continued to provide care without documenting refusal, contrary to the facility's policy. The facility's policies emphasize the residents' right to be free from abuse and mistreatment, and the Director of Nursing acknowledged that holding a resident down would be considered abuse. The facility's abuse prevention policy outlines the need for a resident-sensitive environment and proper training for staff to handle difficult situations. However, the actions taken by the staff in R4's case were inconsistent with these policies, leading to the deficiency noted in the report.
Inadequate Supervision Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to follow the Care Plan and provide adequate supervision to a resident assessed as a high fall risk, resulting in multiple falls and injuries. The resident, who has a severely impaired cognitive status and requires substantial assistance for mobility, experienced falls on several occasions, including two significant incidents that required hospitalization. The resident's Care Plan indicated the need for one-on-one monitoring due to poor safety awareness and impulsive behavior, but this was not consistently implemented. Interviews with staff revealed that the resident was not receiving the required one-on-one monitoring at the time of the falls. The Director of Nursing acknowledged staffing issues as a reason for the lack of one-on-one monitoring, which was a critical intervention outlined in the resident's Care Plan. Despite the resident's high fall risk and history of falls, the facility did not ensure the necessary supervision to prevent further incidents. The facility's policies on fall prevention and comprehensive care planning emphasize the importance of assessing fall risks and implementing appropriate interventions. However, the failure to adhere to these policies and the resident's Care Plan resulted in serious injuries, including a head laceration requiring staples. The lack of adequate supervision and monitoring contributed to the resident's repeated falls, highlighting a deficiency in the facility's care practices.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication to a resident diagnosed with schizoaffective disorder bipolar, violent behavior, generalized anxiety disorder, and paranoid schizophrenia. The resident, identified as R2, had a documented refusal of psychotropic medication consent dated nearly a year prior, yet continued to receive Fluphenazine Decanoate injections over several months. Despite the resident's refusal to sign the psychotropic consent, the Assistant Director of Nursing claimed that verbal consent was given, although no documentation was provided to support this claim. The Director of Nursing acknowledged that consent should be obtained before administering psychotropic medication and affirmed the resident's right to refuse medication. The facility's policy on psychotropic medication consent requires either signed or verbal consent, with verbal consent needing to be witnessed by two staff members. However, in this case, there was no evidence of such consent being documented or witnessed, leading to the deficiency in ensuring informed consent was obtained prior to medication administration.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R4, to the state survey agency. R4, who has a severely impaired cognition with a BIMS score of 3, was found to have a bruise on her right thigh by a CNA on the morning of 11/10/24. The CNA initially forgot to report the bruise but did so later in the afternoon. Despite this, the Director of Nursing (DON) and the administrator did not report the incident to the state survey agency, as the administrator did not believe the bruise was a result of abuse. R4's daughter expressed concerns about potential abuse, leading to R4 being sent to the hospital, where elder abuse and a hematoma were diagnosed. The facility's policy requires immediate reporting of any suspicion of abuse to the administrator and the state survey agency within two hours if it involves serious bodily injury. However, the facility's preliminary incident investigation report was not completed until 11/19/24, nine days after the bruise was discovered. The facility's documentation indicated that the DON did not find the bruising concerning, despite the daughter's insistence on hospital evaluation. This inaction and delay in reporting violated the facility's abuse prevention policy and state reporting requirements.
Failure to Investigate Allegation of Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an allegation of injury of unknown origin, affecting one resident. The incident involved a resident who had a large bruise on her right thigh, which was reported by her daughter, who expressed concerns about potential elder abuse. The resident's hospital report documented a diagnosis of elder abuse and hematoma. Despite these concerns, the Director of Nursing (DON) did not investigate the bruise, as she was not present at the facility when it was reported and did not see the bruise before the resident was sent to the hospital. The Administrator also did not investigate the allegation, attributing the bruise to the resident's known behavior of thrashing during care. The facility's policy on abuse prevention requires prompt and aggressive investigation of all reports and allegations of abuse, neglect, and mistreatment. However, in this case, the policy was not followed. The DON and Administrator failed to initiate an investigation into the injury, despite the policy's stipulation that any incident involving abuse or injury of unknown origin should be investigated. The facility's failure to adhere to its own policy resulted in a lack of investigation into the resident's injury, which was classified as suspicious due to its location and the circumstances under which it was discovered.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,490 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Selfhelp Home Of Chicago | 0.2 mi | ★★★★★ | 0 | 0 |
| Admiral At The Lake, The | 0.3 mi | ★★★★★ | 10 | 0 |
| Alden Lakeland Rehab & Hcc | 0.4 mi | ★★★★★ | 17 | 2 |
| Mado Healthcare - Uptown | 0.5 mi | ★★★★★ | 1 | 0 |
| Aperion Care Wesley | 0.6 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.