Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country Health during CMS and state inspections, most recent first.
Failure to Timely Report Abuse Allegations: The facility did not timely report an allegation of physical abuse involving a CNA and a resident, and did not timely report an allegation of verbal abuse between two residents. The DON and Administrator stated both incidents should have been reported immediately, but staff instead relied on documentation in the chart or delayed reporting to leadership and the State Agency.
Incomplete Abuse Investigations: The facility did not complete thorough investigations for allegations involving two residents who were physically fighting and another resident whose wrist was forcefully grabbed by an agency CNA. The Administrator and DON stated only limited interviews were completed, with no statements obtained from other staff or cognitively intact residents, despite the facility policy requiring interviews with all involved parties and potential witnesses.
Resident-to-resident verbal abuse occurred when a cognitively impaired resident used derogatory and insulting language toward another resident in a hallway. An LPN heard the resident yelling and cursing, including telling the other resident to move and calling the resident stupid and lazy. The DON confirmed the language constituted verbal abuse, and the abused resident had dementia, mobility dependence, and required extensive assistance.
A resident with multiple mobility-related diagnoses and moderate cognitive impairment was injured during a toilet-to-wheelchair transfer when an agency CNA did not use the required gait belt and reportedly held the resident's wrist very roughly. The resident said the transfer hurt and left a bruise on the right forearm, and the DON confirmed the CNA failed to use the gait belt and did not ensure the resident had protective sleeves on.
A resident who was severely cognitively impaired and dependent on staff for toileting and personal hygiene was left without timely incontinence care while sitting in a wheelchair for an extended period. When CNAs finally provided care, they did not change gloves or perform hand hygiene, and the resident was found incontinent of urine and bowel with foul odor and reddened areas on the buttocks and coccyx. The DON stated the facility expectation was incontinence care every 2 hours and as needed for residents unable to voice toileting needs.
Two residents with dementia and behavioral symptoms were involved in repeated altercations, including an incident where one resident sustained a skin tear to the wrist during mutual striking in a hallway. Despite a history of aggression, intrusive behaviors, and prior physical contact, the facility’s care plans contained only general behavior monitoring and psychotropic use, without individualized interventions such as increased supervision or environmental changes to prevent further resident-to-resident contact. After the injury, staff did not complete an abuse-specific or comprehensive post-incident skin/body assessment, and care plans were not revised to address the ongoing risk of altercations, while staff interviews reflected reliance on hospital transfers and normalization of aggressive behaviors rather than implementation of targeted preventive measures.
The facility failed to provide coordinated behavioral health services and individualized interventions for two residents with dementia, mood, and anxiety disorders who exhibited escalating behaviors such as agitation, hallucinations, aggression, and emotional instability. One resident’s care plan focused mainly on monitoring and psychotropic medications without a structured behavioral treatment plan, and the POA was not adequately educated about or given individualized clinical justification for psychotropic GDR. The other resident’s care plan contained only general measures like monitoring and redirection, with no evidence of psychiatric follow-up or structured behavioral programming, despite ongoing behavioral symptoms and vulnerability around aggressive peers. The facility did not have on-site behavioral health services and relied on hospital transfers when behaviors escalated, and these failures contributed to a resident-to-resident altercation causing a skin tear.
A resident with multiple comorbidities, including cancer, CHF, CAD, DM2, and neuromuscular bladder dysfunction, was admitted with an indwelling urinary catheter and several skin issues, but the facility did not obtain any MD orders for catheter placement, maintenance, or indication, and did not include catheter care in the care plan. The resident reported catheter-related pain during repositioning that CNAs did not investigate until an RN wound nurse later found an open wound under the catheter tubing. Although the resident had a mastectomy wound and moisture-associated skin damage to the buttocks and labia, and later developed a suspected in-house acquired pressure injury on the thigh, the care plan was not updated to reflect current wound status or needed skin and wound interventions.
A resident did not receive the prescribed increased dose of Hydrocodone-Acetaminophen for about a week after a medication order change. Staff continued to administer the discontinued lower dose due to not removing the old medication card, resulting in a significant medication error. The DON confirmed the error, and records showed the resident received the incorrect dose during this period.
A resident with multiple high-risk conditions and on medications increasing fall risk was found after a fall with no fall mats in place and the bed not in the lowest position. Staff confirmed that required fall prevention interventions were not implemented, leading to the resident sustaining a nasal fracture and laceration requiring sutures.
A resident with severe cognitive impairment and a left-hand amputation was observed eating in an assistive dining room without staff supervision or assistance, using regular tableware and becoming heavily covered in food on her face, clothing, wheelchair, and surrounding area. In addition, residents reported that agency CNAs were still talking on cell phones while providing care, and an RN confirmed this had recently occurred and was a dignity issue.
Resident wake-up time choice was not honored when agency staff got cognitively intact residents up according to staff schedules rather than the residents’ preferred times. During a resident group meeting, residents reported being awakened as early as 3:00 a.m., dressed, and then put back to bed despite stating they did not want to get up, and the DON confirmed residents have a right to determine their own sleep schedule.
A facility failed to keep care plans comprehensive for three residents. One resident’s plan did not address incontinence or a wheelchair-related injury, another resident’s plan did not address scheduled opioid use and constipation risk, and a third resident’s plan did not address dementia-related behaviors such as refusing care, wandering, and aggression. Staff confirmed the missing care plan elements.
A resident with severe cognitive impairment continued receiving Nuedexta despite a provider response documenting no pseudobulbar affect behaviors and no plans to resume the med. The MAR showed the drug was still given routinely for months after a pharmacy request to consider discontinuation, even though the resident was observed alert, pleasantly conversing, and without documented tearfulness, uncontrolled laughter, sedation, or involuntary movements.
Medication administration errors occurred when staff failed to follow pharmacy instructions and physician orders for two residents, resulting in a 10.39% error rate. An RN mixed multiple oral meds with applesauce and gave them to one resident without adequate water or ensuring whole swallowing, despite directions for potassium chloride and enteric-coated aspirin, and another RN crushed a sublingual cyanocobalamin tablet and administered it via G-tube instead of by mouth/under the tongue.
Failure to timely respond to a resident grievance. A resident reported that she had sent a grievance letter to the Administrator about ongoing pain and an unhealed ulcer on her left pinky toe, which prevented her from wearing a shoe. The Administrator confirmed the letter had been received weeks earlier but was not entered on the grievance log and was not followed up with Nursing to resolve the resident’s concerns about pain and transfers.
Failure to Report Injury of Unknown Origin: A resident with an acute/recent thoracic compression fracture was not reported to the DON or IDPH as an injury of unknown origin. The resident was alert and oriented, denied recent trauma or falls, and stated she was unsure what caused the fracture. The DON and Administrator later confirmed they were unaware of the acute fracture and that it should have been reported.
Failure to Investigate Acute Compression Fracture as Injury of Unknown Origin: The facility did not investigate a resident’s acute thoracic compression fracture as an injury of unknown origin. Hospital and imaging records identified a newer T10/T11 compression fracture, while the resident denied recent trauma or falls and was unsure what caused the injury. The DON confirmed the fracture was not investigated, and the Administrator stated it should have been treated as an injury of unknown origin.
Failure to update a resident’s care plan after a fall. A resident with severe cognitive impairment fell from a recliner, complained of hip pain, and was sent to the hospital for evaluation and treatment. The existing care plan listed prior falls and interventions but did not include the most recent fall, and the DON stated the care plan should be updated after each fall.
A resident with an indwelling Foley catheter, severe cognitive impairment, bowel incontinence, and dependence on staff for care received catheter care that involved cross-contamination. A CNA used plain water, reused the same area of a washcloth while cleaning different body areas and the meatus, and wiped the catheter tubing with the same washcloth area instead of using clean cloths as required; the resident showed signs of discomfort during the care.
A resident with dementia related to a TBI and significant weight loss had incomplete weight and meal intake monitoring. The chart showed missed weekly weights, repeated identical weights entered by an agency RN, and numerous unrecorded meal intakes across several months. Notes also described GI symptoms, isolation, declining status, confusion, and pocketing food, while the family reported the resident had been sick with norovirus, was receiving nutritional shakes, and continued to lose weight.
Failure to Change and Date Oxygen Equipment: A resident with OSA and respiratory-related diagnoses was observed using CPAP connected to an oxygen concentrator while the concentrator bottle was dated and the oxygen tubing was not dated. The physician order and facility policy required weekly changes of the water bottle, nasal cannula, tubing, and related oxygen equipment, and an RN confirmed the items should be changed and dated weekly. The resident stated they use CPAP when napping or going to bed and were unsure when the bottle or tubing were last changed.
Incorrect Transcription of Eliquis Orders Resulted in Significant Medication Error. A resident’s hospital discharge orders for Eliquis were transcribed incorrectly, causing both the 10 mg and 5 mg doses to be given together. The MAR showed the resident received 15 mg on the evening dose and then 15 mg BID the next day, and there was no documentation that the facility identified the error. The DON confirmed the transcription mistake, and the NP stated that 15 mg BID would be an excessive dose if continued.
Two residents with documented exit-seeking and wandering behaviors were not promptly identified in their care plans as being at risk for elopement, nor was the use of departure alert systems included until after physician orders were placed. Despite assessments and behavioral notes indicating risk, care plans were only updated after orders were obtained, contrary to facility policy requiring individualized planning based on cognitive assessments and activity logs.
A resident with a history of falls and mobility limitations was not provided with the required one staff assist during ambulation. Instead, a CNA positioned themselves in front of the resident and allowed the resident to walk independently, resulting in a fall and multiple injuries. Staff interviews confirmed that proper procedures for one staff assist with a gait belt and walker were not followed.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised in the assisted dining room, leading to a hot tea spill that caused burns and blisters. The facility failed to have nursing staff present, as required, to supervise residents needing assistance with eating.
The facility failed to prevent and treat pressure ulcers for two residents, resulting in one developing an unstageable deep tissue injury and another developing seven stage two wounds. Despite being at risk, daily skin assessments were not documented, and necessary interventions like specialty mattresses and timely treatment orders were not implemented. Observations revealed untreated wounds and inadequate care, contributing to the worsening of the residents' conditions.
A resident with dysphagia experienced a choking incident after an LPN left the room before ensuring the medication was swallowed. Another resident with a history of falls and hallucinations had multiple falls, including one resulting in a broken back, without thorough investigation or documentation. The facility failed to adhere to its medication administration and fall management policies.
The facility failed to implement a performance improvement program project over the past year, affecting all 85 residents. Despite having a policy for a systematic approach to quality improvement, no project was in place involving frontline staff or measures to monitor effectiveness. The administrator acknowledged this deficiency.
The facility failed to properly handle and launder linens exposed to scabies, risking contamination for all residents. Additionally, staff did not follow Enhanced Barrier Precautions for two residents, neglecting to wear gowns during high-contact care activities, despite facility protocols requiring such measures.
The facility failed to administer medications timely and according to physician's orders for four residents, resulting in a 32% medication error rate. Errors included late administration, failure to prime insulin pens, and lack of physician notification. The facility's policy requires notifying the physician of medication errors, but this was not documented.
The facility failed to maintain a clean and homelike environment for two residents, as a chair in their room was found with significant stains. The Housekeeping Supervisor was unaware of the issue, and the chair was removed for cleaning only after the deficiency was identified.
A resident with dementia and muscle weakness was observed with a lap cushion in a wheelchair, functioning as a restraint. The facility lacked a physician's order and consent for its use, and staff were unaware of the resident's inability to remove it. Documentation of restraint reduction attempts was also missing.
A resident with moderate cognitive impairment and hearing loss did not have a care plan addressing their hearing aid use until a specific date. The resident's hearing aids were missing, affecting communication, and staff were not consistently applying the remaining hearing aid. The DON confirmed the absence of a care plan prior to the noted date, leading to the deficiency.
A facility failed to manage and document the care of a resident with a g-tube. The resident received Osmolite 1.5 Cal at 60 ml per hour, but the facility did not check and record gastric residual volume to verify g-tube placement before administering medications. Instead, an RN used the air rush technique, contrary to facility policy. The total volume of feeding and water flushes was not recorded, and there were no orders to routinely check gastric residuals or parameters to hold feeding based on residual volumes. The facility's policies require checking tube placement and documenting these checks, which was not done.
The facility failed to label, store, and change oxygen and nebulizer tubing for three residents, leading to deficiencies in respiratory care. One resident's oxygen tubing was undated and uncovered, with no routine change documented. Another resident's nebulizer equipment was undated and uncovered, with no record of scheduled changes. A third resident's oxygen tubing was outdated, and the resident was unsure of change frequency. Facility policies requiring weekly changes and proper storage were not followed.
The facility failed to implement effective infection control measures for COVID-19, including not stocking isolation carts with N95 masks, missing isolation signage, and improper PPE disposal by staff. A resident with COVID-19 and multiple health conditions did not receive documented symptom monitoring as required. Staff were unaware of proper PPE procedures, increasing exposure risks.
A resident with severe cognitive impairment physically abused another resident in their room. The incident occurred when the aggressor, who has a history of aggressive behaviors, entered the victim's room and struck them in the chest after being asked to leave. The event was witnessed by another resident and reported by a CNA to an LPN, revealing a failure in the facility's policy to protect residents from abuse.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a staff member and one resident to the State Agency, and failed to report an allegation of verbal abuse between two residents to the Abuse Coordinator. For the first घटना, the resident reported that a CNA grabbed her wrist somewhat forcefully during care, causing a bruise on her right forearm. The DON stated the incident occurred when an agency CNA improperly transferred the resident from the toilet to the wheelchair, but the facility could not provide documentation that the allegation had been reported to the State Agency before the later initial report. The DON and Administrator both stated the incident should have been treated as an allegation of physical abuse and reported immediately. For the second incident, an LPN witnessed one resident verbally abuse another resident but did not report it directly to the Administrator, Abuse Coordinator, or DON. Instead, the LPN documented the behavior in a nurse progress note and believed management would review it. The Administrator stated the incident should have been reported immediately and that a resident does not have to use profanity to verbally abuse another resident. The facility could not provide documentation that this allegation had been reported to the State Agency before the later initial report.
Incomplete Abuse Investigations
Penalty
Summary
The facility failed to complete thorough investigations for allegations of abuse involving three residents. For two residents involved in a physical altercation, the Final Report to the State Agency documented that they were involved in a fight, but the facility investigation file did not include statements from other cognitively intact residents or from staff members other than one CNA who witnessed part of the incident. An LPN stated she did not witness the altercation, was not asked to provide a witness statement, and only documented the event in progress notes. The Administrator stated she only interviewed the CNA and did not interview any other residents or staff regarding the incident, even though she stated a full investigation should have been completed because one resident had a history of behaviors with staff and other residents. For another resident, the Initial Report to the State Agency documented that an agency CNA had somewhat forcefully grabbed the resident’s wrist. The resident stated the CNA held her wrist with a bear grip while assisting her from the toilet to her wheelchair, causing pain and a bruise that lasted for days. The DON stated he learned the resident had a bruise, spoke with the resident, but did not speak with the CNA, other staff, or cognitively intact residents. The Administrator stated the bruise should have been reported as an allegation of physical abuse, the CNA should have been removed from resident areas and suspended pending investigation, and a full investigation should have been completed with a final report to the State Agency.
Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure that one resident was free from verbal abuse by another resident. R9 had diagnoses including spinal stenosis, COPD, unsteadiness on feet, dementia, scoliosis, abnormalities of gait and mobility, muscle weakness, and abnormal posture. R9's MDS documented moderate cognitive impairment, dependence on staff for wheelchair mobility, and maximum assistance for transfers. R6 also had dementia and anxiety disorder, and R6's MDS documented moderate cognitive impairment. A nurse progress note documented that R6 was verbally aggressive toward R9 and that an LPN instructed R6 not to use inappropriate language, while R9 was moved so R6 could pass. The LPN later stated that R6 yelled and cursed at R9 in the hallway, using derogatory and insulting language such as telling R9 to move, calling R9 stupid, and saying R9 was lazy and dumb. The LPN stated R6 made similar comments to other residents. The DON confirmed that the language used by R6 toward R9 constituted verbal abuse. The facility policy stated residents have the right to be free from verbal abuse and defined verbal abuse as disparaging or derogatory language directed toward a resident or used within the resident's hearing or sight, regardless of the resident's ability to comprehend.
Unsafe Transfer Resulted in Resident Bruise
Penalty
Summary
The facility failed to provide a safe transfer for one resident, resulting in a bruise to the resident's right forearm. The resident had diagnoses including heart failure, osteoporosis, radiculopathy of the cervical region, repeated falls, muscle weakness, atrophy, difficulty walking, anxiety, unsteady gait, abnormalities of gait and mobility, abnormal posture, and a bone density disorder. The resident's MDS documented moderate cognitive impairment and need for moderate assistance with toilet transfers, along with dependence on staff for toileting personal hygiene, bathing, and dressing. The care plan directed staff to use a gait belt for one-assist transfers and to encourage the resident to wear protective sleeves for skin protection. During the incident, the resident stated an agency CNA assisted her from the toilet back to her wheelchair without using a gait belt and held her wrist with a "bear grip." The resident stated the transfer was very rough, hurt, and left a bruise for days. The DON stated the incident occurred when the agency CNA improperly transferred the resident from the toilet to the wheelchair, did not use a gait belt, and did not ensure the resident had protective sleeves on to help reduce the risk of injury to the resident's skin. The facility policy titled Safe Resident Handling Program Policy states gait belt usage is mandatory for all resident handling except for mechanical lift use, bed mobility, and medical contraindications.
Failure to Provide Timely Incontinence Care and Maintain Hand Hygiene
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not met when one resident who was severely cognitively impaired and dependent on staff for personal hygiene, toileting, and maximum assistance with transfers did not receive timely incontinence care. The resident’s EMR listed diagnoses including unsteady on feet, recurrent right shoulder dislocation, CHF, dementia, atrial fibrillation, type II diabetes mellitus, muscle wasting and atrophy, and generalized weakness. During observation, the resident sat in a wheelchair in the common area across from the nurses station for an extended period without staff assistance before being transferred to bed with a total body mechanical lift and then receiving incontinence care. When incontinence care was provided, two CNAs did not change gloves or perform hand hygiene throughout the process. The resident was incontinent of urine and bowel, had baseball-sized dark reddened areas on both ischial tuberosities and the coccyx, multiple red lines and wrinkled areas on the buttocks from sitting on the mechanical lift sling for an extended period, and had an extremely foul odor that permeated the room. One CNA stated she had provided incontinence care earlier in the morning and then assisted the resident to breakfast, but no further care had been provided since that time. The CNA also stated the resident should have been checked every two hours but she got busy and did not have time to check on the resident. The DON stated the facility expectation was to follow the standard of practice for incontinence care and that residents who cannot voice toileting needs and are incontinent of bladder and bowel should receive incontinence care every two hours and as needed.
Failure to Prevent and Assess Repeated Resident-to-Resident Altercations Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not assessing, care planning, and implementing effective interventions in response to repeated resident-to-resident altercations. One resident (R4) had diagnoses including frontotemporal neurocognitive disorder, dementia with agitation, mood disorder, and anxiety disorder, and a care plan that identified behaviors such as agitation, hallucinations, exit-seeking, and entering other residents’ rooms. Despite documented incidents in which this resident hit another resident in the dining room, raised a fork toward staff in a stabbing motion, and made verbal threats toward staff, the care plan only included general interventions such as monitoring behaviors and administering psychotropic medications and lacked specific, individualized interventions to prevent resident-to-resident altercations. The record showed ongoing intrusive and aggressive behaviors, including moving rapidly through hallways in a wheelchair and reaching toward others, without evidence of increased supervision, environmental modifications, or individualized behavioral strategies. Another resident (R6) had diagnoses including dementia, severe protein-calorie malnutrition, adult failure to thrive, anxiety disorder, major depressive disorder, repeated falls, and multiple chronic medical conditions, with a care plan identifying agitation, yelling, resistiveness to care, and potential for making false allegations. Documentation showed that R4 and R6 were involved in repeated altercations over several weeks, including an incident in which both residents were actively striking one another and R6 sustained a skin tear to the right wrist. The facility did not complete an abuse-specific assessment or a comprehensive post-incident skin/body assessment to determine the extent of injury, and there was no evidence that care plans were revised to address the risk of continued resident-to-resident altercations or that individualized interventions were implemented. Staff interviews indicated that aggressive behaviors were attributed to resident diagnoses and that the facility did not provide behavioral services, relying instead on hospital transfers when behaviors escalated, while the facility’s abuse policy required appropriate interventions to be implemented, care plans updated with changes in condition, and information communicated to direct care staff.
Failure to Provide Coordinated Behavioral Health Services and Individualized Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health services and individualized interventions for residents with diagnosed mental disorders and behavioral symptoms, specifically two residents with dementia and associated mood and anxiety disorders. One resident had a care plan that listed behaviors such as agitation, hallucinations, exit-seeking, and intrusive behaviors toward others, with interventions limited to monitoring and administering psychotropic medications. The care plan did not include an effective, individualized behavioral health treatment plan or structured behavioral health services, despite a documented pattern of escalating behaviors including hitting another resident in the dining room, aggressive behavior toward staff, verbal threats, and rapid movement through hallways while reaching toward others. During a gradual dose reduction of psychotropic medications, the resident’s POA reported not understanding why medications were being reduced and stated the facility only explained it as required by state law, with no evidence of individualized clinical justification or adequate education regarding the relationship between medication changes and behavioral symptoms. The second resident had dementia, anxiety disorder, major depressive disorder, and multiple chronic medical conditions, with documented behaviors including agitation, yelling, resistiveness to care, and emotional instability. The care plan contained only general interventions such as monitoring behaviors, identifying triggers, and redirection, and record review did not show evidence of effective behavioral health services such as psychiatric follow-up, structured behavioral intervention planning, or individualized behavioral supports. There was no evidence that this resident received behavioral health services to address risk factors related to repeated exposure to aggressive residents or to reduce vulnerability in shared environments. The facility’s Clinical Director of Operations confirmed that the facility does not provide on-site behavioral health services and relies on hospital transfers when behaviors escalate, with no evidence of ongoing behavioral health specialist involvement, behavioral programming, or structured interdisciplinary behavioral care planning. These failures contributed to a resident-to-resident physical altercation in which both residents struck one another and one resident sustained a skin tear to the wrist, constituting actual harm.
Failure to Obtain Catheter Orders and Update Care Plan for Skin Integrity
Penalty
Summary
The facility failed to provide physician-ordered direction and care planning for an indwelling urinary catheter and did not maintain an accurate, updated care plan for a resident with multiple skin integrity issues. The resident was admitted with an indwelling urinary catheter documented as patent on the admission assessment, but the electronic health record contained no physician order for catheter placement, maintenance, or indication for continued use. Nursing staff, including an RN and an LPN, confirmed that the resident had a catheter since admission but were unable to identify when it was placed and verified there were no corresponding physician orders or care plan interventions addressing catheter care or monitoring. The cognitively intact resident reported having the catheter on admission and stated that during repositioning, the plastic part of the catheter caused pain, and although this was reported to multiple CNAs, no one examined the catheter tubing until the wound nurse assessed it. The resident also had complex medical conditions, including malignant neoplasms of the colon and breast, chronic diastolic heart failure, hypertension, type 2 diabetes mellitus, coronary artery disease, acute kidney failure, neuromuscular bladder dysfunction, generalized weakness, and muscle wasting, and was receiving hospice/palliative care. On admission, the resident had a surgical wound at the right breast mastectomy site and moisture-associated skin damage to the buttocks and labia, along with other skin concerns. Although the care plan identified risk for impaired skin integrity related to diabetes and muscle wasting, it was not updated to reflect the current wound status or a suspected in-house acquired pressure injury on the left thigh. The wound nurse stated they were not informed of the left thigh wound until several days after admission, identified it as a potential in-house acquired pressure injury, and confirmed that the care plan had not been updated to include the resident’s current skin conditions or necessary wound management interventions.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive pain medication as prescribed following a change in their medication order. After a nurse practitioner increased the resident's Hydrocodone-Acetaminophen dose from 5 mg to 7.5 mg, staff continued to administer the original 5 mg dose for approximately one week. This error was due to staff not removing the discontinued 5-325 mg medication card and instead placing the new 7.5-325 mg card behind it, resulting in the continued administration of the lower dose despite the updated physician's order. The resident reported that they were informed by the DON that the incorrect dose had been given for a week. Medication administration records and controlled drug receipt records confirmed that the resident received the lower dose during this period. The facility's policy requires medications to be administered accurately according to physician orders, but this was not followed, leading to a significant medication error involving the administration of the wrong dose of pain medication.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
The facility failed to implement necessary fall prevention interventions for a resident identified as high risk for falls, resulting in a significant injury. The resident had multiple diagnoses including osteoarthritis, heart disease, lumbar disc displacement, anxiety, vertigo, repeated falls, glaucoma, type II diabetes, difficulty in walking, and psychotic disturbance with hallucinations. The resident was prescribed several medications known to increase fall risk, such as Haldol, Dilaudid, and Fentanyl. Despite being assessed as high risk for falls and having a recent history of falls, the resident was found alone in their room after a fall, with no fall mats in place and the bed not in the lowest position. The nightstand was positioned between the wall and the bed, and the resident was found partially under the bed, which was covered in blood along with the nightstand. Staff interviews confirmed that the fall prevention interventions, specifically the use of fall mats and maintaining the bed in the lowest position, were not in place at the time of the incident. The resident sustained an acute nasal fracture and a laceration requiring five sutures as a result of the fall. Observations after the incident further confirmed that the bed was not kept in the lowest position, and the Director of Nursing verified that if the bed had been lowered, the resident would not have been able to get under the bed. The lack of these interventions directly contributed to the resident's fall and subsequent injuries.
Failure to Preserve Resident Dignity During Dining and Care
Penalty
Summary
The facility failed to ensure a resident’s dignity while dining for R20. R20 had diagnoses including Alzheimer’s disease, weakness, and a left-hand amputation, and her MDS documented severe cognitive impairment with the need for supervision or touching assistance for eating and partial/moderate assistance for personal hygiene. Her care plan stated she was at risk for altered nutrition and self-fed with cueing in the assisted dining room for supervision with meals. During lunch, R20 sat in the feeding-assistance dining room in a wheelchair and fed herself with her right hand, but no staff were seated at the feeding-assistance table and she received no physical or verbal assistance. She was observed with food on her hands, cheeks, nose, clothing, and wheelchair, with food and spilled fluid on the table and floor around her, while using regular tableware and no assistive device despite her left-hand amputation. Surveyor observation showed R20’s meal area and clothing were heavily soiled with food, and she remained in that condition until staff later intervened. V4, the Restorative/MDS LPN, stated R20 was in the assistive dining room for supervision only, but acknowledged she did not appear to have received much supervision and that a plate guard or similar device would probably benefit her. V5, CNA, stated R20 does not get assistance with dining and that she pushes staff hands away, and also agreed it was a dignity issue for her to be covered in food. V4 later stated the amount of food on R20’s clothes and face was a dignity issue and that the right plate guard may make a difference while still fostering her independence. The facility also failed to ensure dignity during resident care when agency CNAs talked on cell phones while providing care. Resident Council minutes documented that residents were tired of CNAs being on their phones while providing care. During interviews, R8, R43, R58, and R74 all stated agency CNAs were still providing care in resident rooms while talking on their cell phones. V10, RN, stated she had recently had to direct some agency CNAs to stay off their phones during care and described the behavior as rude, unacceptable, and a dignity issue because staff were not talking to residents. V9, Activity Director, confirmed the Resident Council continued to report concerns about CNAs being on the phone while performing care.
Resident Wake-Up Time Choice Not Honored
Penalty
Summary
The facility failed to ensure residents’ right to choose their own wake-up time and to support resident self-determination through resident choice. Record review showed that four residents reviewed for resident rights had BIMS scores indicating no cognitive impairment: one resident scored 15/15, another 13/15, another 15/15, and another 14/15. During a resident group meeting, one resident stated that agency staff got them up at 3:00 a.m., cleaned and dressed them for the day, and then put them back to bed, even after the resident said they did not want to get up, be dressed for the day, or sleep in clothes. Other residents at the meeting reported similar concerns. One resident stated that agency staff did not know the residents and did not realize this was the residents’ home, and that they had to insist on staying in bed until at least 6:00 a.m. Two other residents stated that agency staff got them up according to the agency staff schedule rather than their desired time, and one added that although staff often said this was the residents’ home, it did not feel that way when agency staff came in to get them up. The DON confirmed that residents have a right to determine their own sleep schedule.
Incomplete Care Plans for Incontinence, Injury, Opioid Use, and Dementia Behaviors
Penalty
Summary
The facility failed to ensure care plans were comprehensive for three residents by not including all identified needs related to medications, diagnoses, behaviors, accidents/injuries, and incontinence. For one resident, the record showed cognitive intactness, bowel and bladder incontinence, dependence on staff for toileting, a right lower leg wound treated with wound care, and raw, bleeding areas to the inner buttocks with orders for MASD treatment; the resident also reported a recent injury after hitting the right leg on a bed frame while using an electric wheelchair and needing staff assistance with incontinence care. The active care plan did not include problem, goals, or interventions for the resident’s incontinence or the wheelchair-related accident/injury, and staff confirmed those items were missing from the care plan. For another resident, the September 2025 MAR showed scheduled Tramadol use, along with MiraLAX and Milk of Magnesia administration, but the active care plan did not address opioid use or the associated risk for constipation. For a third resident, the diagnosis list included Dementia with Agitation, and nursing notes documented episodes of refusing medications and meals, wandering, forgetting the location of the room, and being aggressive and angry toward staff; however, the active care plan did not include problem, goals, or interventions for dementia-related behaviors. Staff confirmed the care plan omissions, and the Social Services Director stated the behaviors were just updated on the care plan.
Failure to Discontinue Ordered Medication
Penalty
Summary
The facility failed to follow a physician order to discontinue Nuedexta for one resident, R69, who was reviewed for unnecessary medications. R69’s MDS documented a BIMS score of 3 out of 15, indicating severe cognitive impairment. The MAR for 9/1/25 through 9/30/25 showed Nuedexta 20-10 mg, 1 capsule by mouth every morning and at bedtime, and the resident also received the medication on the MARs for May, June, July, and August. The medication had originally been ordered on 11/19/2024 for pseudobulbar disease. The quarterly medication assessment documented no involuntary movements, excessive drowsiness, crying, or laughing outbursts. The pharmacy sent a request on 05/20/25 asking providers to consider discontinuing Nuedexta, noting the resident had been taking it since November 2024 and requesting reassessment for continued use. The NP response documented no pseudobulbar affect behaviors and stated there were no plans to resume Nuedexta, yet the medication continued to be administered. During the survey, R69 was observed sitting in a geriatric chair, alert and pleasantly conversing with staff, the surveyor, and other residents, without signs of excessive tearfulness, uncontrolled laughter, sedation, or involuntary movements. On 9/24/25, the NP stated the order should have been discontinued on 05/20/25 or clarified by the facility nurses, and acknowledged that Nuedexta had not been discontinued.
Medication Administration Errors With Oral and Sublingual Medications
Penalty
Summary
The facility failed to follow pharmacy instructions and physician orders during medication administration for two residents, resulting in three medication errors out of 29 opportunities and a 10.39 percent medication administration error rate. R66 had moderate cognitive impairment, a regular diet with regular-texture food and thin liquids, and a morning medication pass that included Potassium Chloride ER 20 mEq tablets and enteric-coated aspirin 81 mg. During the morning pass, an RN prepared 17 oral medications in a 30-cc cup, mixed them with applesauce until the medications were firmly compacted, and spooned four bites of the mixture into R66’s mouth. R66 chewed the medications with side and back teeth, was not given water between bites, coughed briefly after the third spoonful, and was then given the fourth spoonful without being directed to swallow the medications whole or without chewing. The RN later stated she did not think R66 chewed much and believed the potassium and aspirin likely went down whole. R78 also had moderate cognitive impairment and a gastrostomy tube. The current physician order for cyanocobalamin oral tablet disintegrating 500 mcg directed that it be given by mouth and under the tongue daily. An RN crushed and mixed that medication with four other medications and administered them through R78’s G-tube. The DON confirmed medication error reports were completed, and another RN stated she had always given the medication wrong and thought it was supposed to be crushed and given by G-tube with the other medications.
Failure to Timely Respond to Resident Grievance
Penalty
Summary
The facility failed to respond in a timely manner to a resident grievance for one of four residents reviewed for grievances. During a resident group meeting on 09/22/2025, R58 stated she had sent a grievance letter to the Administrator within the last month and had not received a response. R58 was observed sitting in a wheelchair without a shoe on her left foot and stated she had been unable to wear a shoe because of a toe ulcer she had for about a year. She also stated she had seen an outside podiatrist four to six months earlier, the corn had been removed, and her pinky toe never healed. On 09/24/2025, the Administrator provided an undated handwritten grievance letter from R58 and confirmed it had been given to her within the last several weeks. The Administrator confirmed the grievance had not been entered on the grievance log and had not been followed up with Nursing to determine a resolution to R58’s pain and inability to wear a shoe on her left foot. The letter documented pain in the left pinky toe, pain when standing on the mechanical stand lift, and that R58 did not want to be downgraded to a full mechanical lift for transfers. It also documented that on 5/8/25 R58 was seen by an outside podiatrist who diagnosed an ulcer at the site of a previously removed corn, and that the ulcer had not healed.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the administrator and the state survey agency for one resident reviewed for abuse. The facility’s Abuse Prohibition Policy dated 8/25/25 states that injuries of unknown origin are to be immediately reported to the administrator, who then notifies the Illinois Department of Public Health. R6’s hospital records from 8/5/25 documented an acute/recent T10 compression fracture with approximately 25% central vertebral body height loss, and neurosurgery noted the fracture was thought to be newer. R6 was alert and oriented and reported chronic back pain that had increased over the last few months, but denied any recent trauma other than a hematoma to the right lower leg from getting the leg caught between a dresser and bed. The facility added a diagnosis of wedge compression fracture of an unspecified thoracic vertebra on 8/14/25, but the abuse log did not document any allegations of abuse or injury of unknown origin after 7/18/25. On 9/22/25, R6 confirmed the compression fracture identified at the hospital in August 2025 and stated she was unsure what caused it and denied any recent falls or incidents that could have caused the injury. The DON confirmed the acute compression fracture was not reported to IDPH, and later stated the administrator was not aware of the fracture. The administrator confirmed being unaware of the August 2025 compression fracture and stated the acute fracture should have been considered an injury of unknown origin and reported to the administrator and IDPH.
Failure to Investigate Acute Compression Fracture as Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was reviewed for abuse. The facility’s Abuse Prohibition Policy stated that injuries of unknown origin are to be immediately reported to the administrator and investigated, but the abuse log did not document any allegations of abuse or injury of unknown origin after 7/18/25. Records showed the resident was hospitalized in August 2025 with an acute/recent T10 compression fracture, and neurosurgery documented the fracture was thought to be newer. The resident was alert and oriented and reported chronic back pain that had increased over the last few months, and denied any recent trauma other than a hematoma to the right lower leg from getting the leg caught between a dresser and bed. Additional records showed a thoracic spine x-ray later described the compression deformity as T11, previously reported as T10, with no significant change from prior imaging, and chronic compression deformity of T8 was also noted. The resident’s diagnosis log added a wedge compression fracture of an unspecified thoracic vertebra with routine healing. On interview, the resident confirmed the compression fracture identified at the hospital but was unsure what caused it and denied recent falls or incidents that could have caused the injury. The DON confirmed the acute compression fracture was not investigated, later stated the facility was not aware of the acute fracture found during the hospitalization, and the Administrator confirmed the acute fracture should have been considered an injury of unknown origin and investigated.
Failure to Update Care Plan After Fall
Penalty
Summary
The facility failed to revise A resident’s care plan to include interventions for a fall that occurred on 5/30/25 at 7:50 AM. The incident report submitted to the Illinois Department of Public Health documented that the resident was found sitting in front of a recliner chair with legs extended and head resting on the foot of the chair, and the resident stated, “I fell out of this chair right here.” The resident complained of hip pain and was sent to the local hospital for evaluation and treatment at 8:08 AM the same day. The resident’s MDS documented a BIMS score of 3, indicating severe cognitive impairment, and the resident later did not remember what happened. The care plan dated 5/20/25 listed previous falls and interventions, but it did not include the 5/30/25 fall. The DON stated that the care plan should have been updated after the most recent fall and that the care plan should be updated after each fall.
Cross-Contamination During Foley Catheter Care
Penalty
Summary
The facility failed to prevent cross-contamination during catheter care for one resident with an indwelling Foley catheter. The resident had diagnoses of infection and inflammatory reactions due to an indwelling urethral catheter and retention of urine, and the MDS documented severe cognitive impairment, bowel incontinence, and dependence on staff for toileting, hygiene, and transfers. The care plan documented the Foley catheter. During observed catheter care, a CNA wearing a personal protective gown and gloves used a basin of plain water and washcloths on the bedside table. The CNA washed the resident’s inner thighs and penis shaft, then reused the same washcloth area when cleaning different body areas and the catheter insertion site at the meatus. The CNA also cleaned the catheter tubing by wiping downward and then repeated wiping the tubing using the same area of the washcloth. The resident made noises indicating discomfort during the care. When asked, the CNA stated there was no soap in the water and acknowledged forgetting to turn the cloth to use a clean area when moving to a new area. The DON stated the expectation was to use peri-wash or soap and a clean washcloth each time one area was completed and a new area started. The facility policy required cleansing the catheter insertion site with a clean washcloth prepared with soap and water or peri-care cleanser, using a clean washcloth for each side, cleansing the tubing, rinsing with clean cloths, and drying with a clean towel.
Incomplete weight and meal intake monitoring for a resident with significant weight loss
Penalty
Summary
The facility failed to monitor and record weights and meal intakes for a resident with cognitive impairment and significant weight loss. The resident had dementia related to a traumatic brain injury, had been on comfort care, and the family reported that eating was something the resident did not remember. The resident’s record showed a one- or six-month significant weight loss that was not prescribed, with weights declining from 140 pounds in February 2025 to 107.8 pounds by early September 2025. The resident’s February through April 2025 records showed missing weekly weights and repeated documentation of the same exact weight by a contracted agency RN on multiple weeks. Weekly weights were not obtained or recorded as ordered on two February dates, all March weekly weights and one April weight were documented as 129.8 pounds, the next weekly weight was documented as the same as the prior week, and later weekly weights were again repeated as the same as the previous entry. The record also showed no other weights between February and April 2025. The DON confirmed there were no other recorded weights during that period and confirmed the repeated weights documented by the agency nurse. Meal intake documentation was also incomplete. The resident’s February, March, and April 2025 meal intake reports contained numerous unrecorded meals and many entries of 50% or less intake, and the later meal intake report for late August through September 2025 also contained unrecorded meals. Nursing notes documented gastrointestinal symptoms and isolation in March 2025, and a dietary note described the resident as declining, more confused, often leaving the dining room, and pocketing food. The resident’s family stated the resident had weight loss beginning in the spring, had been very sick with norovirus, was receiving nutritional shakes but had difficulty keeping anything down, and that the facility had kept the physician informed.
Failure to Change and Date Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident by not changing the oxygen tubing and humidifier bottle as ordered. The resident had diagnoses including obstructive sleep apnea and symptoms involving the circulatory and respiratory system, and the physician’s order required the oxygen clean filter on the concentrator, water bottle, nasal cannula, and bag on the concentrator to be changed weekly and as needed when in use. The facility’s oxygen administration policy also required nasal cannulas, tubing, and humidifiers to be changed weekly and labeled with the date. During observation, the resident’s oxygen concentrator bottle was dated 8/27/25 and the oxygen tubing was not dated, while the CPAP machine was connected to the oxygen concentrator and tubing as the resident napped in a recliner. A registered nurse confirmed the bottle was dated and the tubing was not dated, and stated the concentrator and oxygen should be changed weekly on night shift and dated when changed. The resident stated using the CPAP when napping or going to bed and was not sure when the concentrator bottle or tubing were last changed.
Incorrect Transcription of Eliquis Orders Resulted in Significant Medication Error
Penalty
Summary
The facility failed to accurately transcribe hospital discharge orders for R6, resulting in a significant medication error involving Eliquis. The hospital discharge orders dated 8/13/25 directed Eliquis 10 mg by mouth twice daily for two more days through 8/14/25, then 5 mg by mouth twice daily starting on 8/15/25 at 9:00 AM, with a handwritten notation that the orders were reviewed with the nurse practitioner and signed on 8/15/25. However, R6’s August 2025 MAR showed both the 10 mg and 5 mg orders were implemented together, and R6 received 15 mg on the evening dose on 8/13/25 and 15 mg twice daily on 8/14/25. There was no documentation that the facility identified the medication error. The DON confirmed the transcription error, and the nurse practitioner stated that 15 mg twice daily would be an excessive dose for an extended duration and would cause risk for bleeding complications if continued. The facility’s Physician’s Orders policy required medications and treatments to be given only upon written physician order and as prescribed at designated times.
Failure to Timely Update Care Plans for Elopement Risk and Departure Alert Systems
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing elopement risk and the use of a departure alert system for two residents identified as exit seeking. Both residents had documented histories of wandering and were assessed as being at risk for exit seeking/wandering, as evidenced by multiple behavioral notes and formal assessments. Despite these findings, their care plans did not reflect their elopement risk or the use of departure alert systems until a much later date, even after incidents such as one resident being found wandering near a door with the alarm sounding. Physician orders for the use of departure alert systems were not placed until after these risks and behaviors had been documented, and the care plans were only updated following the placement of these orders. Staff interviews confirmed that the care plans were not updated to include elopement risk and interventions until the physician's orders were in place, despite facility policy indicating that cognitive assessments and activity logs should inform individualized service plans. This delay resulted in a lack of timely, comprehensive care planning for residents at risk of elopement.
Failure to Provide Required Staff Assistance During Resident Ambulation
Penalty
Summary
A deficiency occurred when a resident, who was at risk for falls due to limited physical mobility, chronic pain syndrome, and osteoarthritis, was not provided with the required one staff assistance during ambulation. The resident's care plan specified the need for one staff assist with a gait belt and walker for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) assisted the resident off the toilet, cleaned the resident, and provided the walker. The CNA then positioned themselves in front of the resident, near the bathroom door, rather than at the resident's side or behind, and allowed the resident to ambulate independently. As the resident attempted to walk toward the CNA, the resident fell backwards, resulting in multiple injuries including a hematoma, bruises, and skin tears. Interviews with facility staff confirmed that the CNA did not follow the proper procedure for assisting a resident who requires one staff assist with a gait belt and walker. The CNA was not in a position to provide support or assist in lowering the resident to the floor if needed, as required by the resident's care plan and standard practice. The incident was witnessed and documented by staff, and the resident was assessed for injuries following the fall.
Lack of Supervision Leads to Resident Injury from Hot Beverage Spill
Penalty
Summary
The facility failed to adequately supervise a resident, identified as R504, after providing a hot beverage, resulting in the resident spilling hot tea on themselves. This incident led to the resident sustaining redness and six blistered areas on their bilateral upper extremities, requiring treatment for three days. The resident, who has severe cognitive impairment and requires supervision or assistance with eating, was in the assisted dining room at the time of the incident, which is designated for residents needing supervision. R504's medical history includes diagnoses such as Congestive Heart Failure, Reflux Disease, Alzheimer's Disease, Dementia, and other conditions that contribute to their need for supervision. The resident's care plan indicates they are at risk for altered nutrition and require queuing in the dining room. On the day of the incident, the resident attempted to remove the lid from their hot tea, resulting in the spill and subsequent burns. Interviews with facility staff revealed that there were no nursing staff present in the dining room at the time of the incident, which is contrary to the facility's requirement for supervision in the assisted dining room. The Director of Nursing confirmed that supervision should include at least one nursing staff member present when residents are in the dining room with food or beverages. The lack of supervision directly contributed to the resident's injury.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide targeted interventions to prevent skin breakdown and did not assess, evaluate, or document resident skin conditions regularly. This resulted in one resident developing a new, unstageable, deep tissue injury and another resident developing seven new stage two pressure wounds. The facility's Wound and Ulcer Policy required daily skin assessments for residents at moderate or high risk, but these were not documented for the affected residents. One resident, identified as R20, was found to have an unstageable deep tissue injury on her left heel, which was not previously documented or treated. Despite being at moderate risk for skin breakdown, R20's medical records did not show daily skin checks. Observations revealed that R20 was not provided with a specialty mattress, and her complaints of foot pain were not addressed. The wound nurse confirmed that the injury had likely been present for several weeks without treatment. Another resident, R58, was identified as having multiple new wounds on her buttocks and thighs, which were not documented or treated according to the facility's protocols. R58 was at high risk for skin breakdown, yet her medical records lacked daily wound assessments. Observations showed that R58 was sitting in a wet brief without dressings on her wounds, and the necessary notifications and treatment orders were not obtained. The facility's failure to implement appropriate interventions and conduct regular skin checks contributed to the development and worsening of these pressure wounds.
Inadequate Monitoring and Documentation in LTC Facility
Penalty
Summary
The facility failed to adequately monitor a resident with dysphagia after administering oral medication, leading to a choking incident. The resident, who was cognitively intact and had a history of muscle weakness and dysphagia, was given a chewable tablet for gas relief by an LPN. The LPN left the room before ensuring the resident had thoroughly chewed and swallowed the medication. Shortly after, the resident began to choke, and staff had to perform the Heimlich maneuver to clear the airway. Additionally, the facility did not thoroughly investigate and document falls for another resident who had experienced multiple falls, including one that resulted in a broken back. The resident, who required significant assistance for mobility and was occasionally incontinent, had a history of hallucinations and falls. The facility's documentation was incomplete, lacking details about the circumstances of the falls, staff interviews, and post-fall assessments. The facility's policies on medication administration and fall management were not followed, contributing to these deficiencies. The medication administration policy required staff to ensure residents took their medication properly, which was not adhered to in the case of the resident with dysphagia. Similarly, the fall management policy required comprehensive documentation and investigation of falls, which was not completed for the resident with multiple falls.
Lack of Performance Improvement Program in Facility
Penalty
Summary
The facility failed to develop, implement, measure, act on, or analyze a performance improvement program project over the past twelve months. This deficiency potentially affects all 85 residents residing in the facility. The facility's Quality Assessment Performance Improvement Policy, dated December 8, 2023, outlines a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality, involving all caregivers in problem-solving. However, the facility did not have a performance improvement project in place for the last four quarters, which included the involvement of frontline staff or measures to monitor effectiveness. The administrator acknowledged the absence of such a project and indicated that performance improvement projects would be integrated into the quality process in the future.
Infection Control and Barrier Precaution Failures
Penalty
Summary
The facility failed to properly store, handle, and launder linens potentially exposed to scabies, affecting all 85 residents. The facility's infection control policy for scabies requires contaminated items to be bagged and washed separately at high temperatures. However, the Housekeeping/Laundry Supervisor was unaware of this protocol, leading to the mixing of potentially contaminated items with other residents' laundry. This oversight occurred despite the Infection Preventionist's awareness of the potential for further infestation and infection. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for two residents. One resident, with wounds and a urinary catheter, had a care plan requiring staff to wear gowns and gloves during high-contact care. However, during observed care, staff did not wear gowns. Similarly, another resident with a gastrostomy tube required EBP, but staff only wore gloves during medication administration. The facility's protocol mandates gowns and gloves for high-contact activities, which were not followed in these instances.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications timely and according to physician's orders and manufacturer's instructions for four residents. A registered nurse was behind on the morning medication pass, resulting in late administration of medications for one resident, including Lantus insulin, Macrobid, Tylenol, and Metoprolol Tartrate. The nurse did not prime the Lantus insulin pen before administration, and there was no documentation that the physician was notified of the late administration and missed doses. Another resident received Humulin N insulin and Persantine late, and the nurse did not prime the insulin pen before administration, unaware of the requirement. The physician was not notified of the late administration. A licensed practical nurse administered Admelog insulin to a resident without food present, contrary to instructions to administer within 15 minutes prior to a meal or immediately after. Another resident received Brimonidine Tartrate eye drops late due to the nurse being behind in the medication pass. The facility's policy requires notifying the physician of medication errors and missed doses, but this was not documented in the cases reviewed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents, as required by regulations. During an observation, a light tan fabric chair in the sitting area of the residents' room was found to have dark and light brown stains covering at least half of the seat. The Housekeeping Supervisor, when interviewed, acknowledged that the chairs in residents' rooms are cleaned occasionally and mentioned that most were cleaned by an outside company a few months prior. However, she was unaware of the stained condition of the chair in question. The chair was subsequently removed for cleaning after the issue was identified. The facility's Fabric Furniture Cleaning policy outlines that furniture should be cleaned when soiled, but it appears this procedure was not followed in a timely manner for the chair in the residents' room.
Failure to Obtain Proper Authorization for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper authorization and documentation. A resident, diagnosed with unspecified dementia, muscle weakness, and other conditions, was observed with a lap cushion across his lap while in a wheelchair. The resident's care plan noted the lap cushion as a comfort device, and it was documented that the resident could place and remove it independently. However, during observations, the resident was unable to remove the lap cushion upon request, indicating it functioned as a restraint. The facility did not have a physician's order or a signed consent form for the use of the lap cushion as a restraint. The resident's medical records lacked documentation of restraint reduction attempts, and the facility's policies required informed consent and a plan for the progressive removal of restraints. Interviews with facility staff revealed a lack of awareness regarding the resident's inability to remove the lap cushion, and the necessary documentation and consent were not obtained until after the deficiency was identified.
Failure to Implement Hearing Devices and Care Plan for Resident
Penalty
Summary
The facility failed to implement hearing devices and develop a care plan for a resident with hearing loss. The resident, who has moderate cognitive impairment, was documented to have minimal difficulty hearing when using hearing aids. However, the care plan did not address the resident's hearing loss and hearing aid use until a specific date, despite the resident's admission assessment indicating the use of hearing aids for both ears. The resident's family reported that both hearing aids were missing, and although one was found, the other remained missing, impacting the resident's ability to communicate effectively. Staff interviews revealed that the resident was not wearing hearing aids during interactions, and there was confusion among staff regarding the resident's hearing aid needs. A Certified Nursing Assistant admitted to not applying the hearing aid due to fear of losing the remaining one. The Director of Nursing acknowledged that staff should have been applying the hearing aid daily and confirmed the absence of a care plan for the resident's hearing loss and devices prior to the noted date. This lack of a care plan and proper implementation of hearing devices led to the deficiency.
Failure to Properly Manage and Document G-Tube Care
Penalty
Summary
The facility failed to properly manage and document the care of a resident with a gastrostomy tube (g-tube). The resident, identified as R39, was observed receiving Osmolite 1.5 Cal at 60 ml per hour via g-tube, with water flushes set at 200 ml every four hours. However, the facility did not check and record the gastric residual volume to verify the g-tube placement before administering medications, as required by the facility's policy. Instead, a registered nurse used the air rush technique to check tube placement, which is not in line with the facility's protocol. Additionally, the total volume of feeding and water flushes administered was not recorded, and there were no orders to routinely check gastric residuals or parameters to hold feeding based on residual volumes. The resident's care plan and the facility's policies require checking tube placement and gastric contents/residual volume, and documenting these checks, which was not done. The Director of Nursing confirmed that the nurses should be checking g-tube placement by checking gastric residual volume prior to feeding and medication administration, and that water flush orders should be based on the dietitian's recommendations. The facility's policies also require recording the amount of feeding and water flushes administered, which was not adhered to in this case.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to properly label, store, and change oxygen and nebulizer tubing for three residents, leading to deficiencies in respiratory care. For one resident, the oxygen tubing was found undated and uncovered on the bed, with no physician order or documentation indicating routine changes. This resident had used oxygen on multiple days over a period of nearly a month. Another resident's nebulizer mask and tubing were also undated and uncovered, with visible splatters of a brown substance on the nebulizer machine. The medication administration record indicated that the nebulizer tubing and mask should be changed weekly, but there was no documentation of this being done as scheduled. A third resident was found using oxygen via nasal cannula with tubing dated ten days prior, and the resident was unsure of the frequency of tubing changes. The treatment administration record indicated that the tubing should be changed weekly, and it was signed as completed on a specific date. A registered nurse confirmed that the oxygen and nebulizer equipment should be labeled with dates, changed weekly, and stored in plastic bags when not in use. The facility's policies on oxygen administration and aerosol treatments also required weekly changes and proper storage, which were not adhered to in these cases.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to implement effective infection control measures to prevent the spread of COVID-19. Specifically, the facility did not stock isolation carts with N95 masks, failed to post isolation signage, and did not ensure staff discarded personal protective equipment (PPE) upon leaving COVID-19 positive resident rooms. These deficiencies were observed in the care of five residents, where staff did not change their N95 masks after leaving the room of a COVID-19 positive resident, and isolation signage was missing from the doors of rooms housing COVID-19 positive residents. Additionally, the facility's policy required symptom monitoring and vital signs to be taken every four hours for COVID-19 positive residents, but this was not documented in the medical records. One resident, who tested positive for COVID-19, had a history of congestive heart failure, emphysema, atrial fibrillation, and type two diabetes mellitus. Despite the resident's positive COVID-19 test and physician orders for contact/droplet isolation and vital sign monitoring twice daily, there was no documentation of symptom monitoring or respiratory assessments after the initial note. Staff members, including a CNA and a housekeeper, were unaware of the proper procedures for handling PPE and identifying COVID-19 positive rooms, leading to potential exposure risks for other residents and staff.
Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident (R2) from physical abuse by another resident (R1). R1, who has severe cognitive impairment due to dementia, exhibited aggressive behaviors such as yelling, screaming, and physical aggression. On the day of the incident, R1 entered R2's room in a wheelchair and, when asked to leave by R2, became angry and struck R2 in the chest multiple times. This incident was witnessed by another resident (R3) and reported by a Certified Nursing Assistant (V4) to a Licensed Practical Nurse (V3). R2, who is cognitively intact, confirmed the account of the incident, stating that R1 hit them three times in the chest after being asked to leave the room. The facility's policy on abuse and neglect clearly states that all residents have the right to be free from physical abuse, yet this incident indicates a failure to uphold that policy. The report includes interviews with staff and residents, which corroborate the occurrence of the abuse, highlighting a deficiency in the facility's ability to prevent such incidents.
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What surveyors actually found near you
We read the 100 citations issued within 25 miles in the last 12 months — including the 4 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
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Nursing homes near Gifford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accolade Paxton Senior Living | 10.7 mi | ★★★★★ | 2 | 0 |
| Accolade Hc Of Paxton On Pells | 11 mi | ★★★★★ | 6 | 0 |
| Clark-lindsey Village | 18.4 mi | ★★★★★ | 7 | 0 |
| Haven Of Champaign | 19.7 mi | ★★★★★ | 14 | 0 |
| Accolade Healthcare Of Savoy | 20.4 mi | ★★★★★ | 23 | 0 |
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