Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Decatur Rehab & Health Care Ct during CMS and state inspections, most recent first.
The facility failed to provide residents and their representatives with adequate notice regarding involuntary transfers or discharges. The initial notification lacked essential information such as appeal rights, Ombudsman contact details, and advocacy agency information. Residents were discharged without proper documentation or communication of required details, affecting those with cognitive and mental health conditions.
The facility failed to document discharge planning for four residents subject to involuntary transfer due to closure. Despite notifying residents and assisting with placement, the facility did not adequately document the discharge planning process in the residents' medical records, violating regulatory requirements.
A resident with a right heel Stage 3 pressure ulcer did not receive adequate care in a facility. The care plan lacked documentation of the ulcer, and weekly skin assessments were not conducted. Treatments were inconsistently applied, and the resident was observed without a heel protector or proper pressure offloading. The facility's policy on pressure ulcer care was not followed, leading to the ulcer's deterioration.
The facility failed to properly label and store medications, affecting all residents. An LPN administered an unlabeled Combivent Inhaler, and the medication refrigerator was found unlocked with unsecured Lorazepam. Additionally, an opened Nystatin powder without a label and undated Azelastine HCL eye drops were found in the medication cart, violating facility policies.
The facility failed to employ a full-time Certified Dietary Manager, affecting all 39 residents. The absence of a Dietary Manager led to issues in the kitchen, such as improper temperature management and incorrect resident meal orders. The kitchen is overseen by the Administrator and Maintenance Director, who acknowledged the lack of guidance and training for new staff.
The facility failed to maintain proper food safety and sanitation practices, affecting all 39 residents. Observations revealed unlabeled and expired food items, inadequate cleaning of kitchen equipment, and insufficient temperature and sanitizer levels in the dishwasher. Despite these issues, dietary staff continued to use the dishwasher and serve expired milk. Interviews with staff highlighted a lack of structured cleaning schedules and oversight, with the Administrator acknowledging the absence of temperature logs and potential health risks.
The facility's antibiotic stewardship policy was found to be inadequate, lacking clear oversight and comprehensive tracking of infections. Multiple residents were prescribed antibiotics for UTIs without documented cultures or organisms, and the infection control logs were not properly maintained. The Regional Clinical Director was overseeing the logs due to the absence of a Director of Nursing, but the facility's program did not include necessary details for effective monitoring.
The facility failed to provide the required minimum square footage for resident bedrooms, affecting all 39 residents. Measurements showed that double occupancy rooms did not meet the 80 square feet per resident requirement, with rooms measuring only 69.19 square feet per resident. A resident expressed dissatisfaction with the cramped conditions, and the Maintenance Director confirmed that none of the rooms met regulatory size requirements.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting anticoagulant use, CPAP usage, and range of motion impairments. An LPN relied on the Assistant Director of Nursing for accurate assessments, resulting in errors. The MDS Nurse confirmed technical issues prevented proper documentation of CPAP use for one resident, while another resident's contracture was not accurately reflected in their MDS.
The facility failed to properly store and secure portable oxygen cylinders for several residents using oxygen. Three cylinders were found unsecured on the floor in the medication storage room, contrary to protocol. The Assistant DON confirmed the cylinders should be secured and stored outside.
The facility failed to administer medications correctly for four residents, resulting in a 19.23% medication error rate. An LPN administered insulin from a mislabeled vial and outside the recommended time frame relative to meals. Residents received medications without having eaten recently, and incorrect insulin dosages were given based on sliding scale orders.
The facility failed to maintain a safe and homelike environment, as evidenced by a resident's broken dresser, another's heavily stained and indented mattress, and poor condition of side rails for a resident with dementia. The Maintenance Director and Housekeeper confirmed these issues, highlighting a lack of timely repairs and replacements.
A resident with cognitive impairments and multiple medical diagnoses reported an allegation of physical abuse, which was not promptly reported to the facility's Administrator or the state agency as required by the facility's policy. The Administrator was unaware of the incident until several days later, highlighting a deficiency in the facility's abuse prevention program.
A facility failed to conduct a Level 2 PASRR for a resident after new diagnoses of unspecified psychosis and anxiety were added. The Business Office Manager, responsible for PASRR coordination, was unaware of the requirement for a Level 2 PASRR following a new mental illness diagnosis. The resident exhibited behaviors such as hallucinations and anxiety, yet no Level 2 PASRR was completed. The facility administrator confirmed the oversight.
The facility failed to develop comprehensive care plans for three residents, resulting in unaddressed medical and nursing needs. One resident's care plan omitted anticoagulant and antipsychotic use and behaviors of self-harm. Another resident's CPAP use was not documented, and a third resident's care plan lacked justification for antipsychotic medication use. The MDSC admitted to incomplete care planning due to limited familiarity with the resident.
A resident with Hemiparesis did not receive necessary restorative care for a contracted left hand, despite being cognitively intact and expressing concerns about the lack of therapy. The Director of Rehab was unaware of the issue until recently, and the Assistant Director of Nursing confirmed that staff should have been performing range of motion exercises. A CNA noted the contracture had been present for at least 1.5 years, highlighting a lapse in care.
A facility failed to obtain necessary medical orders for a resident's CPAP settings and did not maintain proper hygienic care and storage of the CPAP equipment. The resident's CPAP mask and tubing were left uncovered, and there were no documented orders for the CPAP settings. The resident was unsure of the settings and relied on nurses for cleaning. An LPN confirmed the mask should be stored properly, and the administrator acknowledged the lack of documented orders.
The facility failed to manage psychotropic medications properly for three residents, neglecting to attempt Gradual Dose Reductions (GDR), obtain informed consent, and conduct necessary assessments and behavior tracking. One resident with severe cognitive impairment was prescribed multiple psychotropic medications without consent or GDR attempts. Another resident with moderate cognitive impairment and self-harming behaviors received medications without proper documentation or psychiatric services. A third resident was admitted with psychotropic medications but lacked necessary reviews and consents, revealing gaps in the facility's adherence to its policies.
Two residents in the facility were served cold and unpalatable meals, with one resident's pureed meal left uncovered for 55 minutes and another resident's breakfast left for 45 minutes without reheating. The cognitively impaired resident expressed dissatisfaction with the cold food, while the cognitively intact resident reported that her meals are consistently served cold and staff fail to reheat them despite requests. The facility's administrator acknowledged the issue, noting that food should be served warm.
A resident with a history of swallowing difficulties was served a meal that did not meet the physician-ordered pureed diet consistency, leading to coughing and difficulty eating. The kitchen staff, who were new and in training, failed to follow the facility's recipes, resulting in food that was too thin. An LPN noted the inconsistency and expressed concern about the risk of aspiration.
Two residents were not offered necessary influenza and pneumonia vaccinations as per facility policy and CDC guidelines. One resident had no additional pneumonia vaccines documented after receiving PCV13, while another had no vaccination history or offerings documented post-admission. The facility's Infection Preventionist was uncertain about handling unknown vaccination histories.
A resident in a LTC facility was found without a personal call light, requiring him to rely on his roommate for assistance. Despite the resident's care plan indicating a need for supervision due to ADL decline and increased fall risk, the only working call light was attached to the roommate's bed. The Maintenance Director and Administrator acknowledged that residents should not share call lights.
The facility failed to employ a full-time DON, as required to meet resident needs. During a survey, it was confirmed that no DON was present or employed since mid-August, despite the facility's assessment indicating the necessity of a full-time nursing supervisor for the care of 39 residents.
A resident reported disrespectful treatment by staff, including a CNA who mishandled their injured arm and an RN who disregarded their preferences during care. The facility administrator acknowledged the lack of respect in the staff's interactions.
The facility failed to maintain a clean and sanitary environment in a resident room, affecting two residents. One resident reported persistent urine odors and an unclean floor, leading them to leave the facility against medical advice. Observations confirmed a strong ammonia-like odor and sticky, stained floors. The facility administrator acknowledged the issue and noted the resident's preference to change themselves.
A resident admitted with multiple medical conditions did not have a baseline care plan initiated, leading to staff being unaware of the required level of assistance. The resident reported inadequate help and an incident where a CNA mishandled their injured arm. The administrator confirmed the absence of a care plan, which is against the facility's policy.
A facility failed to complete an admission Fall Risk Assessment for a resident with a history of falls and injuries. The resident, who had multiple diagnoses and was not safe to return home, was admitted to gain strength and receive therapy. However, the required assessments were not documented, and therapy was complicated by financial considerations.
The facility failed to report abuse allegations timely to the administrator and SSA for five of six residents reviewed. Instances included delayed reporting of a resident's claim of kissing a housekeeper, a resident's allegation of theft by a former CNA, and a resident's sexually inappropriate behavior towards their roommate. The administrator admitted to not reporting certain incidents to the SSA, believing they had two hours to investigate, leading to further delays.
The facility failed to investigate an allegation of sexual abuse involving four residents. Despite reports of inappropriate sexual urges and comments, the facility did not document or formally investigate the incidents, as required by their Abuse Prevention Program.
The facility failed to care plan and monitor resident behaviors for four residents, including inappropriate sexual behaviors and infatuation with staff. Despite staff awareness, these behaviors were not documented in care plans or behavioral tracking records. The absence of a Care Plan Coordinator since March 2024 contributed to these deficiencies.
A resident with a broken femur experienced significant pain for ten hours due to the facility's failure to provide timely pain control and transfer to the hospital. Despite multiple complaints of pain, the resident received only one dose of Tylenol before being sent to the emergency room at the request of a family member.
A resident with Alzheimer's and severe cognitive impairment fell and fractured his left hip due to inadequate supervision. Despite being at high risk for falls and having a care plan in place, the resident attempted to transfer himself without staff assistance, resulting in a fall in the facility sunroom where staff could not hear him due to television noise.
Inadequate Notification for Resident Transfers
Penalty
Summary
The facility failed to provide adequate notice to residents and their representatives regarding involuntary transfers or discharges, as required by regulations. The written notification dated November 1, 2024, signed by the Administrator, informed residents of the facility's voluntary closure by February 1, 2025. However, this notice lacked essential information such as the right to appeal, contact information for the Ombudsman, and details for advocacy and protection agencies for residents with intellectual/developmental disabilities and mental illness. The facility's closure plan also failed to specify these details, promising only to notify residents and families of relocation and appeal rights once placements were determined. Observations and interviews revealed that the facility began transferring residents as early as November 5, 2024, without providing the required information. On November 13, 2024, the Administrator confirmed that the remaining four residents were discharged without proper documentation of their discharge planning or the required notices. Residents and their families reported receiving verbal and written notifications of the closure, but these did not include the necessary details about transfer dates, discharge locations, or contact information for advocacy and protection agencies. The facility's failure to document and communicate the required information was acknowledged by the Administrator, who admitted to a lack of guidance on what should be documented. The Administrator confirmed that no additional notices were provided beyond the initial letter sent on November 1, 2024, which did not meet regulatory requirements. This oversight affected residents with various cognitive and mental health conditions, including schizoaffective disorder, epilepsy, dementia, and developmental disorders, who were discharged without the necessary support and information.
Failure to Document Discharge Planning for Involuntary Transfers
Penalty
Summary
The facility failed to coordinate and document discharge planning for four residents (R1, R2, R3, R4) who were subject to involuntary transfer due to the facility's closure. The facility's written notification dated 11/1/24 informed residents of the closure scheduled for 2/1/25, and a closure plan was in place to ensure safe and orderly transfers. However, the facility did not adequately document the discharge planning process for these residents, as required by their own policies and procedures. R1, who is cognitively intact and has mental health diagnoses, was informed of the closure and chose to transfer to a sister facility. Despite verbal assurances from staff, there was no comprehensive documentation of discharge planning in R1's medical record, except for a single note by the Maintenance Director. R2, who has severe cognitive impairment, was informed of the closure only a day before the transfer and was unsure of the discharge plan. The facility's staff confirmed R2's transfer to a sister facility but failed to document the discharge planning process in R2's medical record. R3, who is on hospice care and has moderate cognitive impairment, was informed of the closure and chose a facility for transfer. However, there was no documentation of discharge planning in R3's medical record, aside from a note about a discussion with the Maintenance Director. R4, who is cognitively intact, was informed of the closure and chose a facility close to family for transfer. Despite assistance from staff and family involvement, there was no documentation of discharge planning in R4's medical record. The facility's failure to document discharge planning for these residents constitutes a deficiency in meeting regulatory requirements for involuntary transfers.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to adequately assess, monitor, and implement pressure-relieving interventions for a resident with a right heel Stage 3 pressure ulcer. The resident, who was admitted to the facility following a left below-the-knee amputation, did not have any documented skin impairments upon admission. However, the care plan did not include the resident's right heel pressure ulcer, and there was a lack of weekly skin assessments and documentation of the ulcer's condition. The treatment for the ulcer was inconsistently applied, with records showing missed treatments and a lack of adherence to prescribed interventions. The resident's medical record lacked documentation of skin risk assessments since admission, and there were no measurements or weekly assessment details for the right heel ulcer. Observations revealed that the resident was not consistently using a heel protector or having the right foot floated, despite the need for pressure offloading to facilitate healing. The facility's policy on pressure ulcer care was not followed, as the ulcer was not properly documented or included in the care plan, and additional interventions were not established to prevent worsening of the condition. The wound clinic nurse practitioner noted that the resident was motivated to heal and required reminders to offload pressure from the right heel. However, the facility did not provide adequate support to ensure the resident adhered to pressure relief interventions. The administrator acknowledged that the pressure ulcer was facility-acquired and had worsened during the resident's stay, indicating a failure to provide necessary care and interventions to promote healing.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which could potentially affect all 39 residents. An LPN administered a Combivent Inhaler to a resident without a pharmacy label, indicating the resident's name or instructions for use. The LPN acknowledged the absence of the label but identified the inhaler based on the resident's unique prescription. Additionally, the medication refrigerator was found unlocked, containing a bottle of Lorazepam, a controlled substance, and a pharmacy metal box with Lorazepam, which was also unsecured. The Assistant Director of Nursing confirmed that the refrigerator should be locked at all times. Further observations revealed an opened bottle of Nystatin powder in the treatment cart without a label, and the Facility Administrator could not confirm any resident had an order for it. Moreover, the medication cart contained open bottles of Azelastine HCL eye drops for two residents, which were not dated when opened. The facility's policy requires all medications to be labeled with specific information, including the date opened, and controlled substances to be stored under double-lock. These deficiencies highlight lapses in adherence to medication labeling and storage protocols.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager, which has the potential to affect all 39 residents residing in the facility. The Facility Assessment updated on 7/15/24 indicated the need for a Certified Dietary Manager to provide competent support and care for the resident population. However, during the survey conducted from 9/22/24 to 9/25/24, there was no Certified Dietary Manager onsite. Interviews with staff revealed that the absence of a Dietary Manager has led to issues in the kitchen, such as improper temperature management and incorrect resident meal orders. The facility's kitchen is currently overseen by the Administrator and the Maintenance Director, who acknowledged the lack of guidance and training for new kitchen staff and the ongoing struggles in the kitchen operations.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in its kitchen, which could potentially affect all 39 residents. During an inspection, it was observed that the facility's large reach-in freezer and refrigerator contained multiple food items without labels or expiration dates, including frozen potatoes, waffles, deli meat, and various other items. Additionally, the refrigerator contained expired lactose-free milk and improperly stored condiments. The kitchen's air vents were filled with dust and grime, and the range hood was covered in grease, indicating a lack of regular cleaning. The facility also failed to maintain temperature logs for its refrigeration units and dishwasher. The inspection revealed that the dishwasher was not operating at the required temperature, with a recorded wash cycle temperature of only 105 degrees Fahrenheit, below the minimum standard of 120 degrees Fahrenheit. The sanitizer level was also inadequate, as indicated by a litmus strip test showing less than 50 parts per million. Despite these issues, the dietary staff continued to use the dishwasher to clean dishes, which were then used to serve meals to residents. This practice was confirmed by the dietary aide, who acknowledged serving expired lactose-free milk to a resident. Interviews with facility staff, including the Maintenance Director and Administrator, highlighted a lack of structured cleaning schedules and oversight in the kitchen. The Maintenance Director admitted that the kitchen required a deep clean and that the contracted cleaning company only performed a deep clean of the range hood every five years. The Administrator acknowledged the absence of temperature logs and expressed concerns about the potential health risks of serving expired or improperly stored food. The facility's policies on kitchen sanitation and dishwashing were not being followed, contributing to the deficiencies observed during the inspection.
Inadequate Antibiotic Stewardship and Infection Tracking
Penalty
Summary
The facility failed to ensure its antibiotic stewardship policy was comprehensive, which has the potential to affect all 39 residents. The policy lacked documentation on who is responsible for implementation and oversight, what information should be tracked or monitored, the frequency of monitoring, and the infection surveillance tools used to ensure appropriate antibiotic prescription. The facility's infection control logs from May to August 2024 showed multiple instances where residents were prescribed antibiotics for urinary tract infections (UTIs) without listing the organism, despite prompts on the log. This included residents who were prescribed different antibiotics on multiple occasions without documented cultures or infectious organisms. Interviews revealed that the facility's infection control logs were overseen by the Regional Clinical Director due to the absence of a Director of Nursing. The facility claimed to ensure appropriate symptoms for antibiotic usage and that antibiotics were not ordered until cultures were obtained. However, the infection logs did not document UTI cultures and resulting organisms after May 2024, which was confirmed as part of surveillance monitoring for infection control and antibiotic stewardship. The facility's Antibiotic Stewardship Program was confirmed to be lacking in comprehensiveness, including oversight responsibilities, information review, frequency, and the use of infection assessment tools.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to provide the required minimum square footage of floor space for each resident in their bedrooms, affecting all 39 residents. Historical documentation and actual measurements revealed that the double occupancy rooms did not meet the minimum requirement of 80 square feet per resident, with rooms measuring only 69.19 square feet per resident. This deficiency was observed in multiple rooms, including those currently used as the Nursing Director's office and therapy room. During the survey, a resident expressed dissatisfaction with the cramped conditions, stating that the limited space made it difficult to store personal items and maneuver a wheelchair. The Maintenance Director confirmed that none of the rooms met the regulatory size requirements, acknowledging resident complaints but indicating a lack of feasible solutions.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to accurately complete resident assessments for four residents, leading to discrepancies in their Minimum Data Sets (MDS). One resident's MDS incorrectly documented antiplatelet use instead of anticoagulant, despite the resident receiving Xarelto, an anticoagulant, daily. The MDS Coordinator, who floats between three facilities, relies on the Assistant Director of Nursing to complete assessments, which resulted in this error. Another resident's MDS did not document the use of a CPAP machine or the resident's pulmonary disease, even though the resident uses the CPAP every night and has a diagnosis of Obstructive Sleep Apnea. The MDS Coordinator confirmed the oversight. Additionally, a third resident's MDS did not indicate the use of a CPAP machine, despite the resident having a CPAP machine in their room and a physician's order for its use. The MDS Nurse confirmed the CPAP was not coded on the MDS due to technical issues. Lastly, a resident with a diagnosis of Hemiparesis was observed with a contracted left hand, yet their MDS inaccurately documented full range of motion in the left hand. The Director of Rehab and a Certified Nursing Assistant confirmed the contracture, highlighting the inaccuracy in the resident's assessments.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to appropriately store and secure portable oxygen cylinders for five residents who were using oxygen. During an observation, three oxygen cylinders were found sitting unsecured on the floor in the medication storage room, which is against the facility's protocol. Additionally, three oxygen carts containing three oxygen cylinders each were also present in the room. The Assistant Director of Nursing confirmed that the oxygen cylinders were not secured in a cart as required and acknowledged that oxygen cylinders should not be stored in the medication storage room but rather outside. The facility's Residents On Oxygen form documented that the residents involved were using oxygen.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders and manufacturer recommendations for four residents. For Resident 13, the LPN administered insulin from a vial labeled for another resident and not within the recommended time frame relative to meals. The resident's glucose level was checked, and insulin was administered without ensuring the resident had eaten recently, as the resident had last eaten at 8:30 AM and was waiting for lunch at 12:21 PM. Resident 24 was administered Ferrous Sulfate without having eaten recently, as the resident was waiting for lunch and had last eaten at breakfast. For Resident 90, the LPN administered an incorrect dosage of insulin based on the sliding scale order and not within the recommended time frame relative to meals. Similarly, Resident 31 received insulin not within the recommended time frame relative to meals, as the resident had not eaten since breakfast and was waiting for lunch. The facility's medication administration practices resulted in a medication error rate of 19.23 percent, significantly exceeding the acceptable rate of less than 5 percent.
Deficiencies in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. One resident reported that his dresser was broken and missing the front of the top drawer, making it difficult for him to access his belongings. Despite notifying the staff a week prior, the issue remained unresolved. The Maintenance Director confirmed the dresser should be in good working repair. Another resident's mattress was found to be heavily stained and indented, with the housekeeper acknowledging the stains were permanent and expressing concern about the condition of many mattresses in the facility. Additionally, a resident with diagnoses including Unspecified Dementia and Cerebral Infarction was found to have side rails in poor condition, with foam that was ripped and tape that was shredded and frayed. The resident was observed in distress, shaking the side rail and calling for assistance. The Maintenance Supervisor confirmed the poor condition of the side rails and mentioned having replacement materials available. These observations indicate a failure to ensure equipment is in good repair and the environment is clean and free of debris, compromising the residents' right to a safe and comfortable living space.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident, identified as R4, to the Abuse Coordinator. The facility's policy mandates that all allegations of abuse must be reported immediately to the Administrator and to the Illinois Department of Public Health (IDPH) within 24 hours of forming the suspicion. However, in this case, the Administrator was not informed of the allegation, and the report to the state agency was delayed. R4, who has medical diagnoses including Psychotic and Mood Disturbance, Anxiety, Congestive Heart Failure, Bipolar Disorder, Dementia with Agitation, Schizophrenia, and Weakness, reported that someone named '[NAME]' cut her private parts. The facility did not have any resident or staff member by that name, and the staff assessed R4 with no findings but failed to report the incident to the Administrator. R4's Minimum Data Set (MDS) indicated moderate cognitive impairment and required moderate assistance with daily activities. Despite R4's complaint documented in a nurse progress note, the Administrator was unaware of the incident until several days later. The Administrator acknowledged the oversight and stated that the report to the state agency would be made immediately. The failure to report the allegation promptly as per the facility's policy constitutes a deficiency in the facility's abuse prevention program.
Failure to Conduct Level 2 PASRR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASRR) for a resident after a new diagnosis of mental illness. The resident, identified as R30, was admitted to the facility with no initial mental illness diagnosis, as documented in a PASRR Level 1 Screen Outcome dated August 16, 2022. However, subsequent diagnoses of unspecified psychosis and anxiety were added on October 10, 2023, and October 18, 2023, respectively. Despite these new diagnoses, a Level 2 PASRR was not completed. The Business Office Manager, responsible for coordinating PASRRs, was unaware that a Level 2 PASRR was required after a new diagnosis of mental illness. Additionally, a Licensed Practical Nurse noted that the resident had a history of behaviors such as hallucinations and yelling, and experienced paranoia and anxiety, yet no Level 2 PASRR was conducted. The facility administrator confirmed the oversight, acknowledging the lack of awareness regarding the requirement for a Level 2 PASRR following a new mental illness diagnosis.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and nursing needs. For one resident, the care plan did not include the use of anticoagulant and antipsychotic medications, nor did it address behaviors of self-harm and fixation on medications, despite multiple documented incidents of anxiety and verbal outbursts. The facility administrator acknowledged that these aspects should have been included in the care plan. Another resident's care plan failed to document the use of a CPAP machine, which the resident used independently every night. The resident was unsure of the machine's settings, and the care plan did not reflect the responsibility of the nursing staff to clean the CPAP equipment weekly. Additionally, a third resident's care plan lacked specific behaviors justifying the use of antipsychotic medication, appropriate diagnoses, and non-pharmacological interventions. The Minimum Data Set Coordinator admitted that the comprehensive care plan was not completed within the required timeline and was only basic due to limited familiarity with the resident.
Failure to Provide Restorative Care for Resident's Contracted Hand
Penalty
Summary
The facility failed to provide appropriate restorative care services for a resident diagnosed with Hemiparesis, as evidenced by the lack of range of motion exercises for the resident's contracted left hand. The resident, who had moderately impaired cognition initially and later was documented as cognitively intact, did not receive any therapy or restorative services for his left hand, despite having a contracture that developed over the past few months. The resident expressed concerns about the lack of therapy or exercises for his hand, which he noticed had become contracted recently. The Director of Rehab confirmed the contracture and stated that she was unaware of the issue until recently and was waiting for therapy orders to be signed. She also mentioned that the previous therapy company did not provide records, leaving uncertainty about past services. A Certified Nursing Assistant noted that the resident's hand had been contracted for at least 1.5 years and that attempts to open the hand during ADLs were unsuccessful. The Assistant Director of Nursing confirmed that staff should have been performing range of motion exercises on the resident's left hand, indicating a lapse in the facility's restorative care services.
Failure to Obtain CPAP Orders and Maintain Equipment Hygiene
Penalty
Summary
The facility failed to obtain necessary medical orders for a resident's Continuous Positive Airway Pressure (CPAP) settings and did not maintain proper hygienic care and storage of the CPAP equipment. The facility's policy requires specific orders for CPAP use, including unit type, pressure settings, and cleaning protocols. However, observations revealed that the resident's CPAP mask and tubing were left uncovered on the nightstand, and there were no documented orders for the CPAP settings or airway pressure. The resident, who uses the CPAP independently, was unsure of the settings and relied on nurses for cleaning. A Licensed Practical Nurse confirmed that the CPAP mask should be stored in a clear plastic bag when not in use, and the facility administrator acknowledged the lack of documented settings and airway pressure orders.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to its Psychotropic Medication Policy, resulting in deficiencies related to the management of psychotropic medications for three residents. The policy mandates the implementation of Gradual Dose Reductions (GDR), obtaining informed consent, and conducting thorough assessments and behavior tracking for residents on psychotropic medications. However, the facility did not attempt GDRs for the medications of residents R21, R35, and R37, nor did it document any clinical contraindications for not doing so. Additionally, the facility failed to obtain necessary consents for the psychotropic medications administered to these residents. Resident R21, who has severe cognitive impairment and a history of verbal behaviors, was prescribed multiple psychotropic medications, including Risperidone and Mirtazapine, without documented consent or attempts at GDRs. The facility's records lacked documentation of pharmacy recommendations being followed up with the physician, and the pharmacy consultation reports were incomplete. Similarly, Resident R35, with moderate cognitive impairment and a history of self-harm and fixation on medications, was administered several psychotropic medications without documented consents or assessments. The behavior tracking for R35 did not accurately reflect the resident's behaviors, and the facility failed to ensure psychiatric services were provided. Resident R37 was admitted with orders for psychotropic medications, but the facility did not complete psychotropic drug reviews upon admission, as required by their policy. The medical record for R37 lacked consents for the medications and did not provide justification for the decline of a GDR. The facility administrator admitted to not being aware of the requirement for psychotropic drug reviews on admission, highlighting a gap in the facility's adherence to its own policies and procedures.
Failure to Serve Palatable and Warm Food
Penalty
Summary
The facility failed to provide palatable and appropriately heated food to two residents, R14 and R22, as observed during the survey. R14, who is moderately cognitively impaired, was served a pureed meal that was left uncovered on the counter for 55 minutes before being served. The meal, consisting of blended pot roast, beets, and breadsticks, was described as lacking flavor and requiring mechanical chewing, with the resident expressing dissatisfaction with the cold temperature of the food. R22, who is cognitively intact and requires setup assistance for eating, reported that her meals are consistently served cold. On the day of observation, her breakfast tray was left in front of her for 45 minutes without being reheated, despite her requests. The resident expressed dissatisfaction with the cold oatmeal and noted that staff often fail to return to reheat her food. The facility's administrator acknowledged the issue, noting that food should be served warm and that staff might forget to reheat meals due to being busy.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to adhere to a physician's order to provide a pureed diet for a resident, identified as R14, who was moderately cognitively impaired and had a history of difficulty swallowing. The resident's physician order sheet documented a requirement for a carbohydrate-controlled diet of pureed texture and thin liquids. However, during meal preparation, the kitchen staff did not follow the facility's recipes for pureed foods, resulting in a meal that was not of the appropriate consistency. The pot roast and vegetables were prepared with an incorrect amount of water, leading to a pourable consistency with bits of meat, while the beets were overly watery. This inconsistency in food texture was observed during the resident's meal, where R14 struggled to eat, spilling food and coughing due to the thin consistency. The LPN attending to R14 noted the resident's difficulty with the meal and acknowledged the inconsistency in food preparation, highlighting previous issues with food being too thick. The LPN expressed concern about the potential for aspiration if the food consistency was not corrected. The facility administrator confirmed that the kitchen staff was new and undergoing training, acknowledging the risk of aspiration and pneumonia if the resident's meals were not prepared to the correct pureed consistency. The facility's policy on therapeutic and mechanically altered diets emphasized the importance of preparing and serving diets as planned, which was not adhered to in this instance.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility failed to maintain proper documentation and offer necessary vaccinations for influenza and pneumonia to two residents, R30 and R35, as per their own policy and CDC guidelines. R30's records indicate that they received the Pneumococcal Conjugate Vaccine 13 in August 2022, but there is no documentation of any additional pneumonia vaccines being offered thereafter. This oversight left R30 not up to date on pneumonia vaccinations, contrary to the facility's policy which mandates offering the pneumonia vaccine within 30 days of admission and following the Pneumonia Vaccination Timing Guidelines. R35's case highlights a lack of documentation and follow-up regarding vaccination history and offerings. Upon admission, R35's medical records did not contain any documentation of influenza or pneumonia vaccination history, and there was no evidence that these vaccinations were offered post-admission. Despite R35's expressed desire to receive these vaccinations, the facility was unable to obtain vaccination history due to a lack of information from the previous group home and the absence of family to consult. The facility's Infection Preventionist, V1, expressed uncertainty about handling situations where vaccination history is unknown, which contributed to the deficiency.
Deficiency in Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide an accessible working call light for a resident, identified as R25, who was part of a sample of 34 residents reviewed for call light accessibility. R25's care plan, last revised in May 2024, indicated a need for supervision with Activities of Daily Living (ADLs) and noted a decline in ADLs and increased fall risk by August 2024, warranting referrals for physical and occupational therapy. On September 23, 2024, R25 reported not having a personal call light in his room, requiring him to wake his roommate, R90, to request assistance at night. Observations confirmed that the only working call light was attached to R90's bed, leaving R25 without direct access. The Maintenance Director, V5, acknowledged that residents should not be without a call light, and the Administrator, V1, confirmed that residents should not share call lights.
Failure to Employ Full-Time Director of Nurses
Penalty
Summary
The facility failed to employ a Registered Nurse to serve as a full-time Director of Nurses (DON), which is a requirement to meet the needs of the residents. This deficiency was identified during a survey conducted from September 18 to September 24, 2024. During the survey, it was observed that there was no DON present or employed by the facility. The facility's administrator confirmed on September 20, 2024, that there has not been a full-time DON employed since August 15, 2024. The facility's assessment documents indicate that a full-time nursing supervisor is necessary to provide competent support and care for the 39 residents currently residing in the facility.
Resident Dignity and Respect Deficiency
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by the interactions between the resident and the staff. The resident, who was admitted after suffering a broken knee cap and arm, reported that a CNA was unaware of the extent of their injuries and pulled the resident's right arm despite being informed of the fracture. The resident described the CNA as uncaring and rude. Additionally, a progress note documented an RN instructing the resident on how to transfer to a bedpan, emphasizing adherence to doctor's orders over the resident's preferences. The RN acknowledged the resident's desire to leave the facility, which the resident later described as 'lying' during a phone call. The facility administrator reviewed the progress note and agreed that it was not respectful.
Failure to Maintain Clean and Sanitary Resident Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a resident room, affecting two residents. One resident reported that their roommate frequently urinated on the bed, causing a persistent bad odor, and the facility did not clean the floor, which was covered in urine. The resident left the facility against medical advice due to these conditions. Observations confirmed that the room was cluttered, had a strong ammonia-like odor, and the floor was sticky and stained with a yellow-brown substance. The roommate, who was cognitively intact and frequently incontinent of urine, was observed to have the same odor as the room. The facility administrator acknowledged the issue, noting the resident's preference to change themselves and the need for floor cleaning.
Failure to Initiate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to initiate a baseline care plan and resident-centered interventions for a resident who was admitted with multiple medical conditions, including chronic anemia, chronic depression, frequent falls, and fractures. The resident was admitted to the facility on August 7, 2024, and left against medical advice on August 13, 2024. During this time, there was no documentation of a baseline care plan or specific interventions tailored to the resident's needs, which is a requirement according to the facility's policy revised on November 1, 2017. The lack of a baseline care plan resulted in the staff being unaware of the level of assistance the resident required. The resident reported that the CNAs were not informed about the extent of help needed, leading to an incident where a CNA pulled the resident's right arm, which had been broken. The administrator confirmed that without a care plan, the staff would not have been aware of the necessary assistance for the resident.
Failure to Conduct Admission Fall Risk Assessment
Penalty
Summary
The facility failed to complete an admission Fall Risk Assessment for a resident with a history of falls and injuries. This deficiency was identified during a review of three residents, where one resident was affected. The facility's policy on Fall Prevention, revised on 11/10/18, mandates that fall assessments be conducted on the day of admission, quarterly, and with any change in condition. However, the admission nurse did not complete the required fall risk assessment or any other baseline assessment for the resident upon admission. The resident in question had multiple diagnoses, including chronic anemia, chronic depression, frequent falls, and a history of fractures. The resident was admitted to the facility after being discharged from a hospital, where it was determined that they were not safe to return home. The resident expressed that they expected to receive therapy at the facility, which did not occur. The facility administrator acknowledged the lack of documentation for the admission fall risk assessment and complete admission assessment, noting that the resident was admitted to gain strength and receive therapy, which was complicated by financial considerations related to therapy co-pays.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report abuse allegations timely to the administrator and the State Survey Agency (SSA) for five of six residents reviewed for abuse. The facility's Abuse Prevention Program mandates immediate reporting of any potential or alleged mistreatment, neglect, and abuse to a supervisor and the administrator, and further reporting to the SSA within specified timeframes. However, multiple instances were identified where this protocol was not followed, leading to delayed reporting and investigation of abuse allegations involving residents and staff members. One instance involved a resident who reported to a Licensed Practical Nurse (LPN) that they had kissed a housekeeper. The resident later mentioned cuddling with the housekeeper during an assessment interview, but this was not reported to the administrator until the following day. Another case involved a resident who alleged that a former Certified Nursing Assistant (CNA) had stolen $40 from them. The resident reported this to another CNA, who failed to report the allegation to the administrator until several months later. Additionally, there were reports of a resident exhibiting sexually inappropriate behavior towards their roommate and other residents, which were not documented in the facility's Abuse Log or reported to the SSA. The facility's administrator acknowledged that staff are required to report abuse allegations immediately but admitted to not reporting certain incidents to the SSA. The administrator believed they had two hours to investigate and determine if an incident needed to be reported, which led to further delays. Interviews with staff and residents revealed inconsistencies in the reporting and documentation of abuse allegations, highlighting a significant lapse in the facility's adherence to its Abuse Prevention Program and state reporting requirements.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving four residents. The facility's Abuse Prevention Program requires immediate reporting and investigation of any potential or alleged instances of mistreatment and abuse. However, the facility did not follow this protocol. One resident, who is cognitively intact, was reported to have inappropriate sexual urges towards another male resident. Despite these reports, the facility did not document any abuse allegations involving this resident in their Abuse Log for March or April 2024. Interviews with staff and residents revealed that the incidents were known but not formally investigated or documented as required by the facility's policy. The Administrator in Training (V1) admitted to being aware of the sexual urges and comments made by the resident but did not conduct a formal investigation, believing the information was based on hearsay. The administrator also misunderstood the requirement for immediate reporting and investigation, thinking there was a two-hour window to determine if an incident needed to be reported. This lack of proper investigation and documentation led to a failure in addressing the alleged sexual abuse, as required by the facility's Abuse Prevention Program.
Failure to Care Plan and Monitor Resident Behaviors
Penalty
Summary
The facility failed to care plan resident behaviors, develop behavioral interventions, and monitor behaviors for four residents. One resident with moderate cognitive impairment reported kissing a housekeeper and making inappropriate comments and actions towards staff. Despite these behaviors, the resident's care plan and behavioral tracking records did not include interventions to address these behaviors. Interviews with staff revealed that the resident was infatuated with the housekeeper and had been instructed to give the housekeeper space, but these instructions were not documented in the care plan or behavioral tracking records. Another resident, who is cognitively intact, exhibited inappropriate sexual behaviors towards other residents. This resident expressed a desire to move to a facility with more women for sexual intercourse and made inappropriate comments and actions towards a male roommate. The roommate was moved to another room due to discomfort, but the resident's care plan and behavioral tracking records did not include interventions to address these sexual behaviors. Staff interviews confirmed that the resident had made sexual comments and exhibited inappropriate behaviors, but these were not documented in the care plan. The facility has not had a Care Plan Coordinator since March 2024, and the responsibility for implementing behavior tracking forms falls on the Care Plan Coordinator and the Social Services Director. The lack of a Care Plan Coordinator has contributed to the failure to document and address resident behaviors appropriately. The Social Services Director and other staff members were often the last to be informed of resident behaviors, leading to a lack of timely and effective interventions.
Failure to Provide Timely Pain Control and Hospital Transfer
Penalty
Summary
The facility failed to provide timely pain control and transfer to the hospital for a resident with a broken femur. The resident, who had a history of Alzheimer's Disease, Dementia, and other chronic conditions, was found on the floor in the facility sunroom. Despite the resident's complaints of severe pain and inability to straighten his left leg, the staff delayed transferring him to the hospital for ten hours. During this period, the resident was given only one dose of Tylenol and continued to experience significant pain. The resident's progress notes document multiple instances where the resident was in pain and the staff's inadequate response. The resident was eventually sent to the emergency room at the request of a family member. The medical director confirmed that the pain could have been controlled and hours of pain prevented if the resident had been sent to the hospital sooner. The facility's pain policy emphasizes the importance of assessing and managing pain to enhance the quality of life, which was not adhered to in this case.
Failure to Prevent Falls in High-Risk Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent falls with injury for one resident (R1) who was at high risk for falls. R1, who had multiple diagnoses including Alzheimer's Disease, Dementia, and a history of falls, was found on the floor in the facility sunroom in front of his wheelchair. Despite being severely cognitively impaired and having a care plan that included reminders to lock wheelchair brakes and keep the call light within reach, R1 attempted to transfer himself without staff supervision, resulting in a fall that caused a fractured left hip and a subdural hematoma. Interviews with staff revealed that R1 frequently tried to stand up from his wheelchair due to his dementia and lack of safety awareness. Staff members acknowledged that R1 needed to be kept in supervised areas while up in his wheelchair, but on the night of the fall, R1 was not within view of the staff. The incident occurred in the sunroom where the television noise prevented staff from hearing R1's movements, leading to inadequate supervision and ultimately, the fall and injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Havens Senior Living | 1.9 mi | ★★★★★ | 36 | 1 |
| Loft Rehab Of Rock Springs, The | 2.7 mi | ★★★★★ | 5 | 0 |
| Loft Rehab Of Decatur | 2.8 mi | ★★★★★ | 12 | 0 |
| Imboden Creek Senior Living | 3 mi | ★★★★★ | 34 | 1 |
| Arc At Hickory Point | 5.8 mi | ★★★★★ | 24 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.