Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elevate Care Windsor Park during CMS and state inspections, most recent first.
A facility failed to keep the interval between dinner and breakfast within 14 hours and did not provide a substantial bedtime snack for all residents. Dinner was served as early as 4:40 PM and breakfast as late as 8:20 AM, while snack trays were limited, intended mainly for residents with diabetes, and not distributed room by room. A resident with bilateral BKA and another resident with DM2 both stated they were not offered a snack every night, and the RD said a sandwich would be a substantial snack, while applesauce, pudding, or fruit would not.
Respiratory Care Deficiencies: A facility failed to ensure correct oxygen flow rates, physician orders, oxygen signage, care planning, labeling/dating of oxygen tubing, and proper storage of nebulizer masks for several residents. One resident was observed on 4 L oxygen despite an order for 2 L, another had oxygen in use with no signage posted and no documented oxygen order, and other residents had unlabeled tubing or nebulizer equipment left out of proper storage. The DON and nursing staff acknowledged the missing orders, signage, and storage issues during observation and record review.
Medication labeling and storage were deficient across multiple med carts. An LPN and RN were observed with expired meds, inhalers and other meds missing resident names or open dates, and a controlled substance record that did not clearly match the morphine bottles. The DON stated that meds should have open dates, expiration/discard dates, and proper identifiers, and the facility policy required expired or improperly labeled meds to be separated and handled according to storage rules.
Food items were not consistently labeled, dated, rotated, or sanitized according to policy and posted directions. An opened sour cream container was past its use-by date, ricotta cheese had an expired best-by date, older pudding cans were stored behind newer cans instead of using FIFO, and kitchen equipment used for pureed food prep was only briefly dipped in quat sanitizer rather than being submerged for the required time.
Infection control failures occurred when an LPN used reusable BP equipment on multiple residents without cleaning and disinfecting it between uses and failed to perform hand hygiene before and after resident contact and medication preparation. During wound care for a resident with a Stage IV sacral pressure ulcer, staff wore gloves but not gowns, EBP signage was not posted, PPE was not accessible, and no EBP care plan was found. The DON stated residents with open wounds or Stage IV pressure ulcers should be on EBP and that proper PPE and signage were required.
Call lights were not kept within reach for two residents with care plans directing staff to ensure access to the call light. One resident with hemiplegia and other significant diagnoses stated he could not reach the call light, which was found on the floor on the other side of the bed; a CNA later placed it by his side. Another resident with DM2, OA, a fall history, and moderate cognitive impairment said he did not know where the call light was, and it was found on the floor under the bed until a CNA clipped it to the sheet. The DON stated the call light should always be within physical reach.
The facility failed to document physician orders for code status for two residents reviewed for advance directives. An SS coordinator stated the code status should be in the POS to ensure residents’ wishes are documented and honored, and an LPN stated DNR or Full Code should be documented on admission to prevent wrong intervention during an emergency. The DON stated nurses are expected to document code status in the POS upon admission, with a corresponding care plan completed by social work.
Failure to document clinical contraindication for psychotropic GDR. Three residents receiving psychotropic meds had MDSs showing no GDR attempt and no physician documentation that GDR was clinically contraindicated. Psychiatry notes for residents with dementia, schizophrenia, bipolar disorder, and other behavioral/psych diagnoses did not recommend GDR or explain why dose reduction could not be attempted; one later late-entry note documented GDR contraindicated after earlier notes had already been reviewed.
Failure to refer a resident with newly identified psychosis for PASRR Level II review. A resident was admitted after an initial PASRR Level I screen found no SMI/IDD/RC, but later records added a psychosis diagnosis and showed psychiatric/mood disorder findings, psychotropic meds, and a behavior-related psychotropic care plan. The SS consultant stated the resident should have been resubmitted for a PASRR I/II re-screen when the SMI diagnosis was added, per facility PASRR policy.
A resident with delusional disorder and psychotic disorder was admitted with a PASRR Level I screen that indicated no SMI/ID/RC and no Level II was required. The SS consultant stated the diagnosis should have been included on the initial PASRR and that the resident needed a PASRR Level II screen, while facility policy required individualized PASRR screening and completion of Level II before admission for residents with mental disorder or ID.
Failure to provide nail care during grooming: A cognitively intact resident with hemiplegia, a contracted hand, and other significant diagnoses was observed with very long fingernails overgrowing the fingertips. The resident stated no one had offered to cut the nails and wanted them cut, and later said no staff had come to provide the care. An LPN, CNA, and DON all acknowledged that nail care is part of routine grooming and should be provided as needed, and the facility policy requires nail condition to be checked during bathing.
Failure to Assist Resident Out of Bed: A resident with a stroke history, hemiparesis, a pathological femur fracture, and dependence for bed-to-chair transfers remained in bed despite requesting to get up in a wheelchair. The resident stated there was no get-up schedule, a CNA said the resident could get up and would be assisted, but the resident was still in bed hours later while staff gave conflicting responses. The DON stated the resident was alert, oriented, had no contraindication to getting up, and should have been assisted into a high-back wheelchair.
Controlled substance counting and documentation were not completed correctly for morphine in a medication cart. An LPN found discrepancies between the narcotic sheet and the bottle amounts, including a sheet with no resident name, while the DON noted confusion from multiple open morphine bottles, including one from a different pharmacy, and an unclear match between the medication labels and the narcotic records.
A resident with multiple comorbidities and intact cognition was not kept up-to-date on the pneumonia vaccine series. The record showed only PPSV23, and the DON confirmed no other pneumonia vaccine was documented. The resident said he wanted the vaccine if not current, but there was no documentation that the facility rescreened or offered the additional dose needed to complete the series.
Uncovered Dumpsters Allowed Pest Access: Two outside dumpsters used by kitchen and housekeeping staff were observed without lids, and the FSD and Housekeeping Supervisor stated the missing lids allowed rodents to get into the garbage. Staff described using a "tap test" before placing trash in the dumpsters, especially at night, and the facility policy stated dumpster lids should be closed when disposing of trash.
The facility failed to maintain adequate nurse and CNA staffing on multiple floors and shifts, resulting in delayed medication administration and delayed response to resident care needs. On several day and evening shifts, only one nurse or fewer nurses than scheduled were present at the start of the shift, causing 9:00 AM and 5:00 PM medications to be given outside the expected time windows. A resident with multiple comorbidities and intact cognition reported frequently receiving medications, including Gabapentin for leg pain, several hours late and described significant pain when doses were delayed. On high-census shifts, CNAs were assigned to care for 19–25 residents each, including many requiring total care and mechanical lifts, leading staff to prioritize basic rounds, incontinence care, call lights, and feeding while other tasks such as grooming, getting residents out of bed, and timely changes were not consistently completed. Staff, including the DON and an advanced practice nurse, acknowledged that these staffing levels were insufficient and that the facility lacked a formal staffing policy.
Nursing staff, including an RN and multiple LPNs, repeatedly failed to administer medications within the accepted one-hour before/after window of physician-ordered times for eight residents with conditions such as COPD, heart failure, diabetes, PVD, seizures, dementia, and chronic pain. Staff reported being the only nurse on a unit, covering extra assignments, arriving late, and being unable to complete 9:00 AM med passes on time. MARs and audit reports showed frequent late administration and some omitted doses of pain medications (e.g., Gabapentin, Lidocaine patch), psychotropics, anticonvulsants (e.g., Divalproex, Levetiracetam), antihypertensives (e.g., Metoprolol, Carvedilol), antidiabetics (e.g., Metformin, insulin), antibiotics (Bactrim), and respiratory meds (Advair, Albuterol, Symbicort). Cognitively intact residents reported not receiving medications as scheduled and experiencing significant pain, while the DON and NP confirmed that such late administration violates the facility’s policy and physician orders.
Two residents experienced repeated medication errors when nurses failed to administer multiple ordered medications within the facility’s required time window and, in some cases, did not administer them at all. One resident with diabetes, peripheral vascular disease, and respiratory issues repeatedly received late doses of Gabapentin, Advair, and Albuterol, and reported severe leg pain when Gabapentin was delayed. Another resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a scheduled lidocaine pain patch and had missing doses of Jardiance and Gabapentin during a late morning med pass, while still receiving other oral medications and an inhaler. Nursing staff and the DON acknowledged that medications are expected to be given within one hour before or after the ordered time and that late or omitted doses are not in accordance with physician orders, despite a facility policy requiring safe, timely administration and adherence to the five rights of medication administration.
A resident with hemiplegia and other comorbidities, who required a full-body mechanical lift for transfers and had intact cognition, was transferred from a shower bed to a mechanical lift in a hallway rather than in the room. A CNA used a sling that had been left under the resident from a prior shift and did not identify that its straps were worn before initiating the transfer. While the resident was suspended in the air near the bedroom doorway, the sling’s foot straps broke, causing the resident to fall to the floor, resulting in leg swelling, pain, and fear of subsequent transfers. An LPN who assisted confirmed the sling strap broke during the transfer, and facility leadership and the restorative nurse acknowledged that staff are trained and expected to inspect slings for wear and remove damaged equipment from use, consistent with facility policy and the lift manufacturer’s instructions.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with a history of repeated falls and cognitive impairment experienced an unwitnessed fall while pushing a wheelchair, resulting in transfer to the hospital. The fall was not reported to the DON or restorative nurse by the agency LPN involved, and as a result, no investigation or care plan update occurred. Staff responsible for the falls program were unaware of all the resident's falls, contrary to facility policy requiring post-fall investigations and care plan interventions.
A resident with significant immobility and incontinence was admitted with an unstageable sacral pressure ulcer and was identified as high risk for further skin breakdown. Despite physician orders for daily wound care and the use of a moisture barrier cream every shift, observations and record reviews showed that wound dressings were not changed as ordered and the moisture barrier was not consistently applied or documented. The wound increased in size and became infected, with cultures confirming the presence of multiple organisms.
A resident with a complex medical history, including a CRE-positive sacral wound, did not have contact isolation precautions implemented as required. Staff, including an LPN and a CNA, entered the room and provided care wearing only gloves and not gowns, and there was no signage or PPE supplies at the room entrance. Facility staff were aware of the wound culture results but did not ensure timely implementation of precautions, contrary to facility policy.
Two residents with histories of aggression engaged in a physical and verbal altercation during an unsupervised smoking break, resulting in one resident being struck and another having milk thrown at them. Staff were not present outside to supervise, and the incident was only addressed after it occurred, contrary to facility policy prohibiting abuse and neglect.
A facility failed to administer prescribed anticonvulsant medication, Dilantin, to two residents with seizure disorders, resulting in sub-therapeutic levels and missed doses. One resident experienced seizures after missing a dose, while another had their medication misplaced and not administered as ordered. The staff did not access the emergency medication supply, and the facility's policy for medication administration was not followed.
The facility failed to provide restorative services to four residents, including one with multiple sclerosis and another with rheumatoid arthritis, leading to emotional distress and unmet care needs. Despite assessments indicating the need for restorative care, residents did not receive consistent services due to a lack of scheduling and documentation.
A facility failed to provide proper oxygen therapy to residents, including one with misplaced nasal cannula leading to low oxygen saturation, another with undated oxygen tubing, and a third receiving incorrect oxygen concentration. These issues reflect non-compliance with physician orders and facility policies.
A resident was found to be receiving unnecessary psychotropic medications without documented gradual dose reductions or non-pharmacological interventions. The resident exhibited sedation and lethargy, with no documented behaviors justifying the medication use. The facility's psychiatric provider and pharmacy consultant acknowledged the inappropriate use of QUEtiapine for dementia-related behaviors, but the medication was not discontinued despite recommendations.
The facility failed to label food items in the refrigerator and freezer with storage and use-by dates, as observed during a survey. Four boxes of wild berry magic cup desserts and a package of cheese slices were found without proper labeling. The Director of Food Service confirmed that all kitchen staff are responsible for labeling food items to monitor their storage duration and prevent health risks to residents.
The facility failed to maintain proper coverage of outside trash dumpsters, as observed by a surveyor. Two dumpsters had missing parts of their lids, which are necessary to prevent trash from escaping and to deter animals. The Dietary Aide was unaware of who was responsible for maintenance, while the Director of Food Service indicated it was the housekeeping department's responsibility. The Director of Environmental Services acknowledged the issue and had previously informed the disposal service. The facility's policy requires dumpsters to be covered and the area to be litter-free.
The facility failed to maintain infection control by improperly storing a clean linen cart in the restroom of residents on Enhanced Barrier Precautions and not securely tying soiled linen bags before chute conveyance. Observations showed the cart was uncovered, and bags burst open in the laundry area, risking contamination. Staff confirmed these actions were against policy, highlighting the need for proper linen handling to prevent infection spread.
The facility failed to conduct care plan conferences, preventing residents and their families from participating in care plan development. This affected four residents with varying cognitive impairments, who were not invited to meetings or involved in their care plans. Documentation showed missing interdisciplinary team members and non-compliance with the facility's policy requiring quarterly reviews.
A facility failed to assist a resident with grooming, as observed when the resident had long fingernails with brown matter underneath. The resident, who has dementia and moderate cognitive impairment, expressed a desire for trimmed nails but did not receive the necessary assistance, contrary to the facility's policy on activities of daily living.
The facility failed to ensure Low Air Loss Mattresses were set correctly for several residents, affecting pressure ulcer prevention. Observations revealed discrepancies between residents' weights and mattress settings, despite guidelines requiring settings to match patient weights. This deficiency impacted residents with pressure ulcers and those at risk for skin integrity issues.
The facility failed to monitor personal refrigerator temperatures in residents' rooms, leading to expired food items and unsafe temperature levels. Staff interviews confirmed that maintenance and housekeeping were responsible for daily checks, but logs were outdated or missing, and temperatures were not within the safe range. This posed a risk of foodborne illness for cognitively intact residents.
The facility failed to maintain functional call lights, affecting four residents, including one who was visually impaired. Residents reported non-responsive call lights, requiring them to yell for assistance or pull cords from walls, posing safety risks. The Maintenance Director was unaware of the issues until informed by staff and surveyors, and the system was found to be old and malfunctioning.
A facility failed to obtain informed consent for a resident prescribed QUEtiapine Fumarate for dementia with behavioral disturbance. The consent form, dated months after the medication order, incorrectly listed the dosage and lacked necessary details. Staff interviews confirmed the requirement for informed consent before administering psychotropic medications, highlighting a lapse in adherence to facility policy.
The facility failed to store a bottle of lorazepam according to the manufacturer's instructions, affecting a resident. The lorazepam, which should have been refrigerated, was found in the medication cart's narcotics drawer. The LPN acknowledged the storage error upon observing the sticker indicating refrigeration was required. The facility's policy mandates that medications needing refrigeration be stored at specific temperatures, with controlled substances in a lock box within a refrigerator.
A resident with a history of falls and abnormal medication levels fell in the dining room, resulting in a hip fracture. The facility failed to implement its fall prevention policy, as staff did not provide adequate supervision or assistive devices. Despite being aware of the resident's high fall risk due to abnormal phenytoin and valproic acid levels, the staff did not monitor the resident closely, leading to the fall and subsequent injury.
The facility failed to maintain clean and functional shower rooms, affecting 195 residents. Observations showed broken tiles, missing fixtures, and cluttered spaces, despite staff claims of regular cleaning and maintenance. Interviews revealed a disconnect between policy and practice, with maintenance issues not promptly addressed.
The facility failed to provide adequate clean bed linen for its 197 residents due to a shortage of new linens and a malfunctioning washing machine. Observations showed empty linen carts and rooms across multiple floors, and staff interviews confirmed the lack of linens. The Administrator noted that a large order of sheets had not arrived, and the facility struggled to maintain linen stock. Facility policies on linen handling and equipment maintenance were not effectively followed.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, leading to a deficiency. The resident was not placed on EBP upon admission, and there was no EBP signage or PPE available outside the room. The occupational therapist and other staff were unaware of the wound, and the infection preventionist confirmed the absence of EBP measures. The Director of Nursing acknowledged the lapse in policy adherence, as the resident's condition was not included in the EBP list, and no EBP care plan was in place.
A resident with a stage 3 pressure ulcer was found lying on a low air loss mattress set at 280 lbs, higher than their actual weight of 182.2 lbs. This incorrect setting was confirmed by staff and contradicted the facility's policy, which requires mattress settings to match the resident's weight to prevent further skin damage.
The facility failed to maintain a properly functioning nurse call system, affecting four residents who required substantial assistance. Despite activating their call lights, the signals were not visible outside their rooms or at the nurses' station, leading to delays in receiving help. The maintenance director identified that the system needed updating, as the lights would not illuminate if the bathroom call light was accidentally bumped.
A facility failed to investigate and report an alleged incident of mental abuse involving a resident and a staff member. The resident reported feeling demeaned and that staff were ganging up against her after an interaction with a CNA. The facility administrator did not investigate further or report the incident to the IDPH, believing it was not reportable since the resident cursed at the staff first. This action violated the facility's abuse prevention procedures.
Meal Timing and Bedtime Snack Deficiency
Penalty
Summary
The facility failed to ensure that no more than 14 hours elapsed between the evening meal and breakfast the following day, and it did not provide a substantial bedtime snack available to all residents. The posted meal schedule showed dinner served as early as 4:40 PM and breakfast as late as 8:20 AM on different units, creating a 15-hour interval between meals. The Food Service Director stated that each floor received a tray of evening snacks after dinner, but the trays were intended primarily for residents with diabetes and were not enough for every resident to receive a snack. The kitchen closed at 8:30 PM, and after that time staff could not access the kitchen for additional food. Observation and interviews showed the snack trays contained items such as peanut butter and jelly sandwiches, meat sandwiches, graham crackers, fruit, applesauce, and pudding, but the trays were not distributed to all residents room by room. The Registered Dietitian stated that if meals are served outside the 14-hour window, all residents must have access to a substantial snack, and that a sandwich would qualify while applesauce, pudding, or fruit would not. A CNA stated she asked residents if they wanted a snack, but there were not enough snacks for everyone and residents on pureed diets were only offered pudding or applesauce. One resident with bilateral below-knee amputations and intact cognition stated he was not offered a snack every night and had to go to the nursing station himself, where snacks were often gone. Another resident with type 2 diabetes and intact cognition stated he was not offered a snack every night and believed he should receive something after dinner because of his diabetes and nighttime hunger.
Respiratory Care Deficiencies
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents by not ensuring oxygen was administered at the correct flow rate, not obtaining or documenting physician orders for oxygen use in some cases, not posting oxygen-in-use signage, not developing comprehensive care plans for oxygen therapy, not labeling and dating oxygen nasal cannulas, and not properly storing nebulizer tubing masks when not in use. These failures affected five residents reviewed for respiratory care in a sample of 35. R173, who had diagnoses including type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebrovascular disease, dysphagia, hypertension, hyperlipidemia, benign prostatic hyperplasia, and GERD, was observed sitting up in a geri chair, alert and responsive, with oxygen via nasal cannula at 4 L/min. No oxygen-in-use signage was posted outside the room. The RN stated R173 was using oxygen continuously, that signage should be posted for safety, and that there was no signage outside the room. The RN also reviewed the EHR and stated there was no order for oxygen use. The DON stated there should be an oxygen order, signage by the room entrance, and a care plan for oxygen use. The EHR review found no physician order and no care plan for oxygen use. R89, who had diagnoses including COPD, sleep apnea, hypertensive heart disease with heart failure, dependence on supplemental oxygen, and abnormal finding of lung field, was observed on 2 liters of oxygen via nasal cannula, and the oxygen tubing was not labeled and dated. R89’s care plan referenced oxygen therapy as ordered and changing oxygen tubing and humidifier per policy, and the physician order documented oxygen at 2 LPM continuously via nasal cannula/mask. R105, who had diagnoses including dementia, anemia, malnutrition, and pressure ulcers, was observed lying in bed on a low air loss mattress with oxygen at 2 liters via nasal cannula. R105’s care plan referenced oxygen therapy as ordered, but no documented order for oxygen use at 2 liters was found. The physician orders included checking and ensuring proper placement of ear cushion on oxygen tubing and replacing it as needed. R207, who had a BIMS score indicating intact cognition and diagnoses including COPD and malignant neoplasm of the esophagus, had an active order for ipratropium-albuterol via nebulizer every 12 hours for SOB or wheezing. The resident stated he had received a nebulizer treatment that morning, but the nebulizer tubing mask was observed on the nightstand rather than stored in a bag when not in use. The RN stated the mask should have been stored in a bag to prevent infection and said she would discard and replace it. The DON stated the nebulizer tubing mask should be stored inside a bag when not in use to prevent respiratory infection. R41, who had diagnoses including hypertensive heart and CKD with heart failure, chronic pulmonary embolism, chronic diastolic heart failure, and atherosclerotic heart disease, was observed asleep in a wheelchair with oxygen at 4 liters via nasal cannula even though the physician order was for 2 liters. Nursing staff verified the incorrect setting, acknowledged the order was for 2 liters, and corrected the oxygen setting after the discrepancy was identified.
Medication Labeling, Dating, and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were properly labeled, dated when opened, and discarded when expired during review of 4 of 4 medication carts. On one cart, a Budesonide-Formoterol inhaler was found in a zip lock bag with only a handwritten date and no resident name or label. On another cart, an aspirin bottle was observed with an expiration date of 08/25. On a third cart, multiple inhalers and an antacid were observed with no open date or with an expired date, including Budesonide-Formoterol, Proventil HFA, Anoro Ellipta, and Geri max antacid/antigas. On the first-floor cart, Humalog, Epoetin Alfa, and Ketorolac ophthalmic solution were observed with no open date, and Sodium Chloride Hypertonicity ophthalmic ointment had no name or label and only a handwritten date. Controlled substance storage and accountability were also inconsistent on the third-floor medication cart. A Controlled Substances Proof of Use sheet for Morphine Sulfate documented 15 ml received but had no name listed, while the bottle in the narcotic drawer was associated with R75. Another Morphine Sulfate proof of use sheet documented 30 ml received for R75, and the nurse stated the sheet showed 29.5 ml while 30 ml was in the bottle. The nurse also stated she had counted the medication that morning. The DON later stated that medications should have an open date, expiration, and discard date, that expired medications were not effective, that inhalers were an infection control issue when not dated, and that medications without proper identifiers could create medication errors. The policy titled Medication Storage stated that expired medications or those retained longer than recommended should be stored separately until destroyed or returned, that opened medications should have the date opened recorded when they have a shortened expiration date, that medications with missing or incomplete labels should be destroyed and reordered, and that each resident's medications should be stored in the container in which they were originally received. The observations showed medications in carts and drawers that were expired, missing resident identifiers, missing open dates, or not stored in their original containers, along with controlled substance documentation that did not clearly match the medication bottles.
Food Labeling, FIFO Storage, and Sanitizing Procedure Deficiencies
Penalty
Summary
The facility failed to ensure food items were properly labeled and dated, food was rotated using First In, First Out (FIFO) guidelines, and kitchen equipment was sanitized according to manufacturer directions. During observation of the walk-in refrigerator, an opened 5-pound container of sour cream was found labeled with a delivery date of 02/24/26, an opened date of 03/02/26, and a use-by date of 03/09/26. An unopened case of whole milk ricotta cheese, consisting of four 5-pound containers, was labeled with a delivery date of 02/03/26 and a manufacturer best-if-used-by date of 03/26/26. The Food Service Director stated the sour cream should have been discarded by 03/08/26 and acknowledged the ricotta cheese best-by date had expired the prior week. In the dry storage room, 7-pound cans of chocolate pudding labeled 03/07/26 were observed in front of other 7-pound cans labeled 01/20/26. The Food Service Director stated the older-dated cans should have been placed in front so they would be used first, consistent with FIFO storage practices. Facility policy documents stated stored products are to be labeled with appropriate dates and rotated using FIFO, and that items exceeding the manufacturer's expiration or use-by date should be discarded. During pureed food preparation, the Food Service Director and a Cook each took a dirty blender container, blade, and lid to the three-compartment sink, washed and rinsed the items, and quickly dipped each piece into the sanitizing solution for about 2 seconds per item. The Pot Washer stated each item needed to be submerged in the sanitizing solution for at least 30 seconds and then air dried fully before use. Posted diagrams above the sink and facility policy stated items should be submerged in sanitizer for at least one minute or per the manufacturer's directions, and the facility was using a commercial quat-based sanitizing solution.
Infection Control Failures During Wound Care, Equipment Use, and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for a resident with a Stage IV sacral pressure ulcer. The resident was admitted with multiple diagnoses including spinal stenosis with neurogenic claudication, peripheral vascular disease, type 2 diabetes mellitus, heart failure, atrial fibrillation, anemia, neurogenic bowel and bladder, and a Stage IV pressure ulcer present on admission. During wound care observation, the wound care director and a CNA were seen wearing gloves but not gowns while treating the resident’s sacral wound. The wound was cleansed with normal saline, hydrofera blue was applied, and a dry dressing was placed, but proper PPE was not worn during the procedure. The resident’s room did not have Enhanced Barrier Precautions signage posted, and PPE supplies were not accessible for staff use. The DON stated that residents with open wounds or Stage IV pressure ulcers should be on EBP, that signage should be posted, PPE should be accessible, and proper PPE such as gown, mask, and gloves should be worn during wound care treatment. The resident’s physician order sheet included daily wound care to the sacrum, but review of the care plan found no care plan for Enhanced Barrier Precautions. The facility also failed to clean and disinfect reusable equipment and perform hand hygiene during medication administration and resident care. A nurse used a blood pressure machine and pulse oximeter on multiple residents, including residents with EBP signage on their doors, without cleaning and disinfecting the equipment between uses. The nurse also failed to perform hand hygiene before and after resident contact and before preparing medications. The nurse later stated that the blood pressure machine should be wiped down between residents and that hand hygiene should be used between residents to reduce infection and contamination.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents reviewed for reasonable accommodation of needs. One resident had diagnoses including pneumonitis due to inhalation of food and vomit, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, hypertension, nontraumatic subdural hemorrhage, chronic embolism and thrombosis of the left lower extremity, conversion disorder with seizures or convulsions, dysphagia, and adult failure to thrive. The resident’s MDS showed intact cognition and need for assistance with multiple activities of daily living. The care plan identified fall risk and directed that the call light be within reach. During observation, the resident was sitting in a wheelchair at the bedside and stated he could not reach the call light, which was found on the floor on the other side of the bed. A CNA later picked up the call light and placed it by the resident’s side, and the DON stated the call light should always be within physical reach. A second resident had diagnoses including type 2 diabetes mellitus with unspecified diabetic retinopathy, primary generalized osteoarthritis, history of falling, and peripheral vascular disease. The resident’s MDS BIMS score was 09, indicating moderate impairment, and the care plan directed staff to keep needed items in reach and ensure the call light was within reach. During observation, the resident was lying in bed and stated he would use the call light if he knew where it was, but it was observed on the floor under the left side of the bed out of reach. A CNA later entered the room, picked up the call light, and clipped it to the resident’s sheet, stating it had been under the bed and should have been attached to the bed. The DON stated the call light should be within physical reach and checked during rounding.
Missing Physician Orders for Resident Code Status
Penalty
Summary
The facility failed to obtain a physician order for code status for two residents, R10 and R12, out of eight residents reviewed for advance directives in a sample of thirty-five. R10’s MDS dated [DATE] noted moderate cognitive impairment, and her EMR showed admission to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus without complications, dementia, obstructive and reflux uropathy, myocardial infarction, and chronic kidney disease. R12’s MDS dated [DATE] noted she was cognitively intact, and her EMR showed admission to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus with neuropathy, heart failure, end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease, cervicalgia, and adult failure to thrive.
Failure to Document Clinical Contraindication for Psychotropic GDR
Penalty
Summary
The facility failed to provide a clinical contraindication for gradual dose reduction (GDR) for three residents receiving psychotropic medications. The report states that R3 had diagnoses including dementia with moderate mood disturbance, schizophrenia, bipolar disorder, and brief psychotic disorder, and was receiving Depakote, haloperidol, lithium carbonate, melatonin, and trazodone. R3’s MDS indicated antipsychotic use on a routine basis, that a GDR had not been attempted, and that the physician had not documented GDR as clinically contraindicated. Psychiatry/mental health progress notes reviewed for R3 did not include a recommendation for GDR or a description of a clinical contraindication, and the notes also reflected Depakote 500 mg daily even though the active order was Depakote 500 mg twice daily. R11 had diagnoses including vascular dementia with other behavioral disturbance, unspecified psychosis due to a substance or known physiological condition, and cognitive communication deficit. R11’s MDS likewise indicated routine antipsychotic use, no attempted GDR, and no physician documentation that GDR was clinically contraindicated. The resident had an active order for quetiapine fumarate 50 mg every 12 hours after a hospitalization, and prior to hospitalization had been receiving quetiapine 50 mg twice daily for dementia with behavioral disturbance with psychotic features. Psychiatry/mental health progress notes reviewed for R11 did not recommend a GDR for quetiapine or describe a clinical contraindication to attempting one. R70 had diagnoses including major depressive disorder, paranoid schizophrenia, and other psychoactive substance abuse with psychoactive substance induced persisting dementia. R70’s MDS indicated routine antipsychotic use, and the resident had an active order for trazodone 50 mg at bedtime. Psychiatry/mental health progress notes reviewed for R70 did not recommend a GDR for trazodone or describe a clinical contraindication to attempting one. A later late-entry note documented that GDR was contraindicated and that the medication and dosage were needed for stabilization, but this was time stamped after the earlier notes reviewed. The DON stated GDR should be considered every six months, that the prescribing provider is responsible for documenting why it is contraindicated, and that the psych NP’s notes generally stated residents were stable and to continue medications without specifically addressing GDR.
Failure to Refer Resident With Newly Identified Psychosis for PASRR Level II Review
Penalty
Summary
The facility failed to refer one resident, R11, for a Level II PASRR evaluation after the resident was later identified with a mental disorder. R11’s initial PASRR Level I screen dated 10/31/22 indicated no Level II was required and documented no serious mental illness, intellectual/developmental disability, or related condition. R11 was admitted on 11/04/22, and the admission record later added a diagnosis of unspecified psychosis on 03/06/25. Subsequent records showed R11’s MDS later identified a psychiatric/mood disorder with a specific diagnosis of psychotic disorder, and the order summary dated 04/02/26 listed Citalopram, Quetiapine Fumarate, and Divalproex Sodium. The care plan also included psychotropic medication use for behavior management dated 09/13/23. During interview on 04/01/26, the Assistant Social Service Consultant stated that if a resident is initially admitted without an SMI diagnosis but later has one added, the facility should resubmit for a PASRR Level I/II re-screen. The consultant stated this was the Social Service Department’s responsibility and that R11, whose psychosis diagnosis was added after admission, should have been referred for a PASRR Level I/II re-screen. The facility policy titled Pre-admission Screening and Resident Review stated that residents with newly evident or possible serious mental disorder, intellectual disability, or related condition are to be referred for a Level II review upon a significant change in status assessment to the state PASRR representative.
Failure to Refer Resident With Delusional Disorder for PASRR Level II Screening
Penalty
Summary
The facility failed to refer a resident with known mental illness to the appropriate state-designated authority for a PASRR Level II screening and determination. R35 was admitted with diagnoses including Delusional Disorders, and the order summary included Seroquel 50 mg twice daily for delusional disorder. The resident’s MDS also documented an active psychiatric/mood disorder, including psychotic disorder. However, the resident’s PASRR Level I screen dated 11/30/22 indicated no Level II was required and stated no SMI/ID/RC. During interview, the Assistant Social Service Consultant stated PASRR is used to determine whether residents are appropriately placed in a SNF and that residents with SMI such as psychosis or delusional disorder require referral for a PASRR Level II screen unless an exemption applies. The consultant stated the resident’s Level I screen was completed before admission but did not include the delusional disorder diagnosis, even though the resident was admitted with that diagnosis, and stated the resident needed a PASRR Level II screening completed. The facility policy stated that all potential admissions are to be screened on an individualized basis and that the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed.
Failure to Provide Nail Care During Grooming
Penalty
Summary
The facility failed to ensure nail care was provided for one resident who required supervision in grooming. The resident had an active diagnosis of hemiplegia and hemiparesis affecting the right dominant side, contracture of the right hand, acquired absence of the left leg below the knee, acquired absence of other right toes, chronic kidney disease, and type 2 diabetes mellitus with diabetic nephropathy. The resident’s MDS noted that he was cognitively intact and required partial/moderate assistance with personal hygiene. During observation, the resident was seen in his wheelchair in his room with his right hand contracted and very long fingernails that overgrew the tips of his fingers. He stated that no one had ever offered to cut his long nails, but he wanted them cut. On a later observation, his fingernails were still very long, and he again stated that no staff had come to cut them. An LPN observed the nails and stated they were surely long, that the CNA should provide nail care during daily grooming and as needed, and that she would inform the CNA to cut them. A CNA stated that fingernail clipping is part of grooming and should be done daily and as needed, and the DON stated CNAs should provide nail clipping during showers twice a week and as needed. The facility’s nail care policy states that nail condition should be observed during each bathing, including cleanliness, length, uneven edges, and hypertrophied nails.
Failure to Assist Resident Out of Bed
Penalty
Summary
The facility failed to assist a resident out of bed for 1 of 35 residents reviewed for ADLs. The resident had diagnoses including a pathological fracture of the right femur, prostate cancer with bone metastasis, adult failure to thrive, hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, absolute glaucoma in the right eye, and a history of falls. The resident’s MDS documented cognitive intactness, functional limitations of one upper extremity, and dependence on staff for transfer from bed to chair. The care plan identified deficits in bed mobility and ADLs related to generalized weakness, impaired balance, limited mobility, and musculoskeletal impairment, and documented that the resident was dependent on staff for bed-to-chair transfers and used a wheelchair for locomotion. During observation and interview, the resident was found lying in bed and stated wanting to get up because it had been a long time since sitting in the wheelchair. The resident said there was no schedule for getting out of bed and later used the call light to request assistance. A CNA responded and said the resident could get up that day and would be assisted, but the resident remained in bed for hours afterward. The resident stated that CNAs had come into the room a couple of times saying they were going to get the resident up but did not do so. A nurse stated the resident did not have a get-up schedule, and the CNA later stated the resident could get up when the resident wanted to. The DON stated the resident was alert, oriented, able to make needs known, and had no contraindications to getting up into a high-back wheelchair, and that staff should have assisted the resident out of bed.
Controlled Substance Count and Documentation Errors
Penalty
Summary
The facility failed to ensure controlled substances were counted and documented correctly in one of four medication carts reviewed during the medication storage and labeling observation. On 04/01/26 at 12:28 PM, the third-floor medication cart 2 was reviewed with an LPN, and a Controlled Substances Proof of Use sheet dated 03/19 showed 15 ml received for Morphine Sulfate 100 mg per 5 ml with no name documented on the sheet. A box with R75's name was observed in the narcotic drawer, and the LPN stated the sheet showed 15 ml but there was about 13 ml in the bottle. Another Controlled Substances Proof of Use sheet documented 30 ml received for R75, Morphine Sulfate 20 mg/ml, with directions for 0.25 ml (5 mg) by mouth or under the tongue every 2 hours as needed for shortness of breath, and the LPN stated the sheet showed 29.5 ml and there was 30 ml in the bottle. On 04/02/26 at 10:00 AM, the DON stated narcotic accountability involved pulling R75's morphine bottles and sheet, instructing nurses to label the bottles and number them if there was more than one bottle so the correct bottle matched the correct strength. The DON stated there was no name on the narcotic sheet, so it was unclear what was supposed to be given to R75, and noted that the nurses had ordered multiple bottles of morphine, including one bottle from a different pharmacy. The DON also stated that whatever was on the medication label should be transferred to the narcotic sheet, and placed four narcotic sheets, one with no name, one unopened, and three open morphine bottles on her desk while expressing the narcotic count error and confusion caused by having multiple open bottles of the same medication.
Failure to Keep Resident Up-to-Date on Pneumonia Vaccination
Penalty
Summary
The facility failed to ensure that resident R78 was up-to-date with the pneumonia vaccine series for 1 of 5 residents reviewed for immunizations. R78’s admission record documented multiple comorbidities including malignant neoplasm of the prostate, secondary malignant neoplasm of bone, atrial fibrillation, high blood pressure with heart failure, adult failure to thrive, stroke, diabetes, and high cholesterol. The 2/27/2026 MDS and care plan documented that R78 was cognitively intact. The resident’s immunization record showed receipt of Pneumovax 23 (PPSV23) on 10/25/2024, with no other pneumonia vaccine documented. On 4/01/2026, the DON stated the facility used pneumonia immunization trackers in the EMR and was supposed to run reports to identify residents due for vaccines. The CDC PneumoRecs VaxAdvisor guidance reviewed in the report stated that adults older than 50 who previously received PPSV23 and no prior PCV13 should receive one dose of PCV15, PCV20, or PCV21 at least 1 year after the last PPSV23 dose. The resident stated he wanted to receive the pneumonia vaccine if not up to date. The DON later reviewed the immunization records and stated that no other pneumonia vaccine was documented and that the resident was due for an additional pneumonia vaccine, but there was no documentation that the facility rescreened or offered the additional dose to complete the series.
Uncovered Dumpsters Allowed Pest Access
Penalty
Summary
The facility failed to ensure the outside dumpsters were covered with lids. During an initial tour of the kitchen and outside dumpster area, two large dumpsters were observed outside and both were missing lids. The Food Service Director stated these were the dumpsters used by kitchen and housekeeping staff for garbage and said she did not know why the lids were missing. She also stated that without lids, rodents could easily crawl inside and get to the garbage. On a later observation and interview, the Housekeeping Supervisor stated there were currently no lids on the dumpsters to keep garbage inside or prevent rodents from getting inside. He stated the facility did not want rodents feeding on the garbage because that would attract them toward the building. He also described a "tap test" used by staff before placing garbage in the dumpsters and stated this was mostly a problem at night. The Administrator stated he would be ordering new dumpsters because both should have had lids. The facility policy stated the dietary department should maintain the dumpster area for cleanliness and prevention of rodents and ensure dumpster lids are closed when disposing of trash.
Inadequate Nurse and CNA Staffing Leading to Delayed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff to ensure resident needs were met in a timely manner and medications were administered as ordered. On multiple occasions, nurse and CNA staffing on various floors and shifts fell below the facility’s usual staffing framework, resulting in delayed medication administration and delayed response to resident care needs. On one day shift, an LPN assigned to the first floor arrived around 10:14 AM to cover a 7-3 shift, causing some 9:00 AM medications on her assignment to be given after 10:00 AM. A registered nurse working that same day reported being the only nurse on the first floor at the start of the shift after another nurse called off, and stated that residents on the second set of rooms did not receive their 9:00 AM medications within the 8:00-10:00 AM window because of short staffing. A resident with diagnoses including chronic upper respiratory disease, congenital tracheal malformation, type 2 diabetes mellitus, morbid obesity, peripheral vascular disease, seizure disorder, schizophrenia, bipolar disorder, and anxiety reported often not receiving medications as scheduled, sometimes three hours late, and described one day when no medications were received until early afternoon. This resident, who receives Gabapentin for bilateral lower leg pain and has an intact cognition per MDS, stated that on a Saturday when the unit was short staffed and there was an emergency with another resident, his Gabapentin was not given on time and his pain level was eight out of ten. The RN confirmed that this resident’s standing 9:00 AM Gabapentin dose was administered around 11:15 AM and documented in the eMAR, outside the stated 8:00-10:00 AM window for 9:00 AM medications. The facility also failed to maintain adequate CNA staffing on several shifts. On one 7-3 shift with a census of 81 residents, only four CNAs worked on the second floor instead of the usual six, resulting in one CNA caring for approximately 19-20 residents, about half of whom required total care and three required a mechanical lift. That CNA reported prioritizing initial rounds, incontinence care, answering call lights, feeding residents, and passing out ice water, and stated that charting, nail care, shaving, and getting some residents who required a mechanical lift dressed or out of bed might not have been completed. Another resident with multiple comorbidities including partial traumatic amputation of the left lower leg, chronic venous hypertension with inflammation of both lower extremities, complex regional pain syndrome, dietary folate deficiency anemia, long-term insulin use, type 2 diabetes mellitus, long-term anticoagulant use, and chronic kidney disease, and who requires assistance with toileting, bathing, and transfers, reported that on a Saturday day shift there were only four CNAs working and that she had to wait a longer time for staff to respond to her call light and to be changed because staff were very busy. Additional staffing shortfalls occurred on other units and shifts. On one 3-11 shift on the third floor, only two nurses worked instead of the expected three, and an LPN reported that although all residents eventually received their 5:00 PM medications, some were administered outside the 4:00-6:00 PM timeframe due to the reduced staffing and the higher acuity of the dementia unit. On a separate 11-7 shift on the third floor, three CNAs worked instead of the usual four, with one CNA caring for 24-25 residents on the dementia unit and reporting that residents who wander and are at risk for falls could not all be watched and that residents had to wait longer to be changed if wet or soiled. On another morning, an LPN assigned to approximately 24 residents on the second floor arrived at 9:35 AM for a shift where 9:00 AM medications were to be given between 8:00-10:00 AM; by 10:01 AM she still had not completed the medication pass for all assigned rooms and acknowledged she would not be able to finish before 10:00 AM. The Director of Nursing and an advanced practice nurse both stated that inadequate staffing can delay medication passes, nursing assessments, accuchecks, and timely ADL care, and that CNA-to-resident ratios such as 1:20 and nurse shortages on heavier units like the locked dementia floor are problematic. The administrator reported that the facility does not have a staffing policy.
Widespread Failure to Administer Medications According to Physician-Ordered Times
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for timely medication administration for eight residents, resulting in repeated late or omitted doses. Nursing staff, including LPNs and RNs, reported being the only nurse on a unit, covering additional assignments, arriving late for shifts, and being unable to complete 9:00 AM medication passes within the accepted 8:00–10:00 AM window. One LPN stated that some 9:00 AM medications were given after 10:00 AM and acknowledged that late medications could mean residents’ pain or blood pressure were not well controlled. Another LPN reported arriving at 9:30 AM with no medications yet passed for her assignment and stated she would not be able to complete all 9:00 AM medications within the one-hour before/after window. Multiple residents experienced late administration of scheduled medications across several days, as documented in the MARs and medication audit reports. One resident with intact cognition and diagnoses including PVD, seizures, schizophrenia, COPD-related conditions, and diabetes reported often not receiving medications as scheduled, sometimes three hours late, and described a day when all medications were delayed until early afternoon. This resident’s records showed repeated late administration of Gabapentin for neuropathic pain, Advair and Albuterol for tracheal stenosis and shortness of breath, with doses scheduled for morning, afternoon, and evening frequently given several hours after the ordered times. Another cognitively intact resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a prescribed 6:00 AM Lidocaine patch and reported shoulder pain rated 8/10; the patch was not observed in place. The same resident’s 9:00 AM medications, including Bactrim DS for UTI, Hydroxychloroquine, Metformin, Symbicort, and Gabapentin, were administered after 11:00 AM, and some medications such as Empagliflozin and Gabapentin were not available and therefore not given. Additional residents with intact or impaired cognition and multiple chronic conditions also had late medication administration documented. One resident receiving psychotropic medications (Risperidone and Benztropine) and a bowel regimen had doses scheduled for 9:00 AM and 6:00 PM given several hours late on multiple days. Another resident with diabetes, hypertension, CKD, and anemia had Metoprolol, Metformin, Ferrous Sulfate, and Humalog insulin repeatedly administered beyond the ordered times, including insulin given well after the scheduled pre-meal time. A resident with neuropathic pain had Gabapentin doses scheduled three times daily administered late on several dates. Residents with seizure disorders and cardiovascular conditions had anticonvulsants (Divalproex, Levetiracetam), antihypertensives (Carvedilol), muscle relaxants (Baclofen), and other medications administered outside the one-hour before/after window, including one evening Levetiracetam dose given in the early morning of the following day. The DON and NP both stated that nurses are expected to follow the five rights of medication administration, that medications should be given within one hour before or after the ordered time, and that administration beyond this window is considered late and not following the physician’s order, consistent with the facility’s medication administration policy. The facility’s own policy on administration procedures for all medications, dated 10/25/14, requires medications to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Interviews with the DON and NP confirmed that medications given more than one hour outside the ordered time are considered late and not in accordance with physician orders. Despite this, the documented MARs and audit reports for all eight residents show a pattern of late administration and, in some cases, omitted doses due to unavailability of medications, affecting pain medications, psychotropics, anticonvulsants, antihypertensives, antidiabetics, antibiotics, and respiratory medications. These actions and inactions by nursing staff, combined with staffing and scheduling issues described by the nurses, led directly to the failure to provide pharmaceutical services in accordance with physician orders for the affected residents.
Failure to Ensure Timely and Complete Medication Administration for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically repeated late and omitted medication administrations for two residents with intact cognition and multiple chronic conditions. One resident reported frequently receiving medications up to three hours after scheduled times and described a day when all medications were delayed until early afternoon. This resident, admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, peripheral vascular disease, and other conditions, stated he receives Gabapentin for bilateral lower leg pain and reported experiencing pain at a level of eight out of ten when his Gabapentin was delayed. A registered nurse confirmed that on one day she was the only nurse on the unit due to another nurse calling off, and that she administered this resident’s 9:00 AM Gabapentin dose at approximately 11:15 AM, outside the facility’s stated 8:00–10:00 AM window for 9:00 AM medications. Record review for this resident’s physician orders, MARs, and medication audit reports showed multiple instances of late administration of respiratory and pain medications. On several dates, Advair inhaler doses ordered for 9:00 AM and 6:00 PM were given hours late, including a 6:00 PM dose administered at 10:50 PM. Albuterol tablets ordered three times daily were repeatedly given several hours after the ordered times, such as a 9:00 AM dose given at 12:06 PM and a 1:00 PM dose given at 4:19 PM. Gabapentin 600 mg ordered three times daily for neuropathy was also administered late on multiple occasions, including a 9:00 AM dose given at 12:13 PM, a 1:00 PM dose given at 4:19 PM, and doses ordered for 11:00 AM and 4:00 PM given in the mid-afternoon and late evening. The nurse practitioner stated that medications not given within one hour before or after the ordered time are considered late and not following the doctor’s order, and that pain medications not given as ordered could result in residents being uncomfortable and having mobility affected. A second resident, admitted with diagnoses including COPD, sleep apnea, hypertensive heart disease with heart failure, heart failure, type 2 diabetes mellitus, and rheumatoid arthritis, also experienced medication administration issues. During observation, an LPN who had arrived late for her shift stated that none of the medications on her set had been passed yet and acknowledged she would not be able to complete all 9:00 AM medications within the 8:00–10:00 AM window. During a medication pass, the LPN prepared and administered multiple oral medications and an inhaler to this resident but stated that Empagliflozin (Jardiance) and Gabapentin were not available and therefore were not given. The resident, alert and oriented, reported not receiving her ordered 6:00 AM lidocaine pain patch to the left shoulder and rated her shoulder pain as eight out of ten; observation confirmed there was no pain patch in place. Review of this resident’s MAR and physician orders showed scheduled medications including a daily lidocaine patch at 6:00 AM, Bactrim DS twice daily for UTI, Hydroxychloroquine, Metformin, Symbicort inhaler twice daily, and Gabapentin three times daily for pain. The DON and nursing staff stated that medications are expected to be given within one hour before or after the ordered time, that late administration beyond this window is considered not following the doctor’s order, and that pain, hypertensive, diabetic, and antibiotic medications must be given timely as ordered. The facility’s policy on administration procedures for all medications, dated 10/25/14, states that medications are to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Despite this policy, the documented late administrations, missed doses due to unavailability, and failure to apply an ordered pain patch demonstrate that the facility did not consistently follow ordered times and the five rights of medication administration for these residents. Staff interviews, resident statements, and medication records collectively show that the facility did not ensure residents were free from significant medication errors related to timing and omission of ordered medications.
Failure to Inspect Mechanical Lift Sling Leads to Resident Fall During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer using a mechanical lift and to follow its fall prevention and transfer policies for one resident. The resident had medical diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, essential hypertension, type 2 diabetes mellitus, obesity, and peripheral vascular disease, and required a full-body mechanical lift for transfers. The resident’s cognition was intact, with a BIMS score of 15. On the day of the incident, the resident was transferred from a shower bed to a mechanical lift in the hallway outside the resident’s room, rather than in the room, after receiving a shower. According to progress notes and staff interviews, a CNA placed the resident in the mechanical lift and began the transfer toward the resident’s bed. The CNA reported that the resident had been on a sling that was already under the resident from an earlier shift and that she did not realize the sling was defective. The CNA stated she did not notice the worn-out strap before attempting the transfer. While the resident was suspended in the air on the mechanical lift near the doorway to the resident’s room, the foot straps of the mechanical lift sling broke, causing the resident to fall to the floor on her buttocks and one leg. A nurse who came to assist reported that the resident was already on the lift when she arrived, that the sling strap broke during the transfer, and that she did not know whether the CNA had assessed the sling for wear and tear before use. The resident reported that the CNA told her the room was too congested and that the transfer to the lift would be done in the hallway. The resident stated that after being lifted, the CNA said something did not feel right and sought help, at which point an LPN came to assist, and then the sling strap broke and the resident fell. The resident described falling on one leg and her buttock, experiencing swelling in her left leg and ongoing pain after the fall, and feeling frightened whenever staff transfer her. The restorative nurse stated that staff are trained to inspect mechanical lift slings for wear and tear and that the sling should have been inspected prior to placing it under the resident and before the transfer. The DON stated that a quick inspection of the mechanical lift sling could have prevented the fall and confirmed that the mechanical lift is for transfers and not for transporting residents, and that moving the resident from the hallway to the bed in this manner would be considered transporting. The facility’s policies and the lift manufacturer’s manual require inspection of slings for damage and removal of malfunctioning equipment from service, which was not done in this case, resulting in the resident’s fall from the mechanical lift.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Investigate Resident Fall and Update Care Plan
Penalty
Summary
The facility failed to investigate a fall experienced by a resident with a history of repeated falls and spinal stenosis, who also had some cognitive impairment as indicated by a BIMS score below 10. The resident was able to answer surveyor questions appropriately during the survey. According to progress notes, the resident fell in the hallway while pushing a wheelchair, and the fall was unwitnessed. The resident was transferred to the hospital per physician's request, with no observable injuries except for redness on areas impacted by the fall. The resident reported having had four falls at the facility, with the most recent occurring in the bathroom with staff present but unable to prevent the fall. The resident recalled a fall in June but could not remember exact dates. Interviews with facility staff revealed that the restorative nurse and DON, who oversee the falls program, were only aware of two falls, not the third fall documented in the progress notes. The restorative nurse stated that fall investigations are conducted and care plans updated with interventions after each fall, but was unaware of the third fall until reviewing the notes during the survey. The DON confirmed that the agency LPN who documented the fall did not notify either the DON or the restorative nurse about the incident, and described the LPN as substandard and no longer permitted to work at the facility. Facility policy requires fall risk assessments and investigations after each fall, with interventions to be added to the care plan, but this process was not followed for the resident's fall on the specified date.
Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
A resident with a history of hemiplegia, aphasia, dysphagia, acute respiratory failure, and an unstageable sacral pressure ulcer was admitted to the facility and identified as high risk for pressure wounds, with a Braden Score of 12. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The care plan included the use of a moisture barrier cream with zinc after each incontinent episode and daily wound treatments as ordered by the physician. Despite these orders, observations and record reviews revealed that wound care and dressing changes were not performed as prescribed. On observation, the resident's wound dressing was found to be dated four days prior, despite a daily dressing change order. The wound was noted to have increased in size and showed signs of infection, with cultures later confirming the presence of Proteus mirabilis and CRE. The Treatment Administration Record (TAR) showed multiple dates where the application of the moisture barrier cream was not documented as completed, indicating missed treatments. Interviews with nursing staff, the wound care director, the nurse practitioner, and the wound physician confirmed that wound care and dressing changes were not consistently performed or documented as required. Staff acknowledged that failure to provide and document these treatments could lead to wound deterioration and infection, which was observed in this case as the resident's wound worsened and became infected.
Failure to Implement Contact Precautions and Provide PPE for Resident with CRE-Positive Wound
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident with multiple complex medical conditions, including a sacral pressure ulcer that tested positive for CRE (Carbapenem-resistant Enterobacteriaceae) and other organisms. Despite the resident's wound culture result indicating the need for contact isolation precautions, there was no order for transmission-based precautions or contact isolation in the physician order sheet, and enhanced barrier precautions were only noted for wounds and G-tube care. Observations revealed that the resident's room lacked required signage for transmission-based precautions, and there was no isolation setup or PPE supplies accessible at the room entrance. Staff members, including an LPN and a CNA, were observed entering the resident's room wearing only gloves and not donning gowns as required for contact precautions. The CNA provided direct care, including changing an incontinence brief and repositioning the resident, without proper PPE. Interviews with facility staff, including the infection preventionist and the director of nursing, confirmed awareness of the wound culture results and the necessity for contact isolation precautions, but these measures were not implemented in a timely manner. The infection preventionist acknowledged that the resident should have been transferred to a single room and that proper signage and PPE should have been in place immediately upon receipt of the culture results. The facility's own infection precaution guidelines require the use of transmission-based precautions, including contact precautions for residents with infections that can be transmitted by direct or indirect contact. The guidelines also specify the need for signage and PPE availability at the room entrance. The failure to follow these protocols resulted in staff providing care to the resident without proper PPE and without clear communication of the required precautions, creating the potential for cross-contamination among other residents assigned to the same staff.
Failure to Prevent Resident-to-Resident Abuse During Unsupervised Smoking Break
Penalty
Summary
Two residents were involved in a physical and verbal altercation during a smoking break on the facility's patio. Both residents have documented histories of aggression and combative behavior, as indicated in their care plans and abuse risk reviews. During the incident, one resident hit the other in the face, and the other retaliated by throwing an open milk carton, resulting in milk being spilled. Both residents exchanged insults and physical contact, with no staff present outside at the time to supervise the interaction. The altercation was only addressed after it had occurred, when a psychosocial aide/social service assistant intervened. The incident was not reported to the police, and one of the residents was sent to the hospital for evaluation. Both residents have intact cognition, as shown by their BIMS scores, and have diagnoses including schizophrenia, major depressive disorder, chronic obstructive pulmonary disease, and end stage renal disease. The facility's policy affirms residents' rights to be free from abuse and neglect, but the lack of staff supervision during the smoking break allowed the altercation to occur without immediate intervention.
Failure to Administer Anticonvulsant Medication
Penalty
Summary
The facility failed to provide prescribed anticonvulsant medication, Dilantin, to a resident diagnosed with a seizure disorder, resulting in sub-therapeutic levels and missed doses. Resident R444, who is cognitively intact, reported missing a dose on the night of 3/1/25 due to the facility running out of the medication, which led to two seizures the following morning. The emergency medication supply had doses available, but the staff did not access it, and the nurse on duty did not have access to the emergency medication dispenser. Additionally, another resident, R15, who also has a seizure disorder, did not receive their prescribed Phenytoin suspension as the medication was not located in the cart. The medication was found on the resident's dresser, and the nurse confirmed it was prescribed for R15. The resident's Phenytoin levels were consistently low, and the medication was not administered as ordered, leading to sub-therapeutic levels. The facility's policy requires medications to be administered as prescribed and to contact the pharmacy or use the emergency kit if a medication is unavailable. However, the staff failed to follow these procedures, resulting in missed doses and low therapeutic levels for both residents, increasing the risk of seizures.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide necessary restorative services to four residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Resident R445, who is cognitively intact and diagnosed with multiple sclerosis and other conditions, expressed emotional distress due to the lack of therapy or restorative services since her admission two weeks prior. Despite being assessed for restorative services, R445 was not added to the restorative list, and there was no schedule in place to ensure she received the necessary care. Resident R59, with diagnoses including rheumatoid arthritis and contractures, reported not receiving passive range of motion exercises for about a week. The restorative aide, V29, mentioned that R59 seemed to be in pain during exercises, but R59 clarified that she never refused exercises due to pain. The lack of consistent restorative services was further highlighted by the absence of a structured schedule and documentation of services provided. Resident R88, who requires assistance for range of motion exercises, and R85, who was recently discharged from therapy to restorative care, also experienced lapses in receiving restorative services. R85, in particular, noted that restorative staff did not accommodate his dialysis schedule, resulting in missed exercises. The facility's policy mandates individualized restorative programs with documented interventions, but the lack of documentation and adherence to care plans contributed to the deficiency.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide continuous supplementary oxygen to a resident, resulting in an oxygen saturation level of 89%. The resident, who has chronic obstructive pulmonary disease and other serious health conditions, was found with a nasal cannula hanging from their ear instead of being properly placed in the nostrils. This incident occurred despite the resident's care plan requiring continuous oxygen at 3 liters per minute. The resident expressed difficulty in breathing and had attempted to call for help, indicating that the nasal cannula had been misplaced for some time. Another resident was found with oxygen tubing that was not dated, contrary to the facility's policy which requires labeling of respiratory equipment with the date of use. The resident's physician order required continuous oxygen at 4 liters per minute, and the facility's policy mandates weekly changes of oxygen tubing to prevent infection. However, the Director of Nursing admitted that the tubing was not dated due to a lack of space for writing the date, although the water canister was dated. Additionally, a third resident was receiving oxygen at a higher concentration than prescribed. The resident's physician order specified oxygen at 2 liters per minute, but the oxygen concentrator was set to deliver 4 liters per minute. The Director of Nursing was unsure of the correct setting and the resident confirmed that they did not adjust the oxygen themselves. This discrepancy highlights a failure to adhere to physician orders and facility policies regarding oxygen delivery.
Failure to Implement Gradual Dose Reductions for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R58, was free from unnecessary psychotropic medication use and did not complete gradual dose reductions (GDR) as required. This failure resulted in harm to R58, who exhibited symptoms of sedation. Observations noted that R58 was difficult to arouse, appeared lethargic, and had unclear speech. The resident's care plan did not document any non-pharmacological interventions attempted prior to the administration of psychotropic medications, and there was no evidence of targeted behaviors that would justify the use of such medications. R58 was prescribed QUEtiapine Fumarate for dementia with behavioral disturbance and Sertraline for hypersexuality. However, the facility's records did not document any abnormal or targeted behaviors from October 2025 to March 2025. The facility's psychiatric provider, V34, acknowledged that QUEtiapine is not approved for dementia-related psychosis and that the medication can have sedative effects. Despite this, the provider continued the prescription, citing a lack of alternative treatments for dementia-related aggression. The facility's pharmacy consultant, V31, confirmed that the use of QUEtiapine for dementia with behaviors and hypersexuality was inappropriate and had recommended discontinuation of the medications, which was denied by the provider. The facility's policy on psychotropic medication and GDR was not followed, as evidenced by the lack of documented attempts to reduce the medication dosage. The failure to adhere to these protocols resulted in R58 experiencing sedation and being at increased risk of adverse effects from the medication.
Failure to Label Food Items in Storage
Penalty
Summary
The facility failed to ensure that food items stored in the refrigerator and freezer were labeled with the date they were placed into storage and a use-by date. During an observation of Walk-in Freezer #1, four boxes of wild berry magic cup desserts were found without any labeling indicating when they were stored or their use-by date. Similarly, in the walk-in refrigerator, a package of yellow pasteurized process American cheese slices was observed without any date labeling. These labeling omissions were noted during a survey conducted in the presence of the Director of Food Service. The Director of Food Service acknowledged that all kitchen staff are responsible for labeling food items with the date of storage and a use-by date, as per the facility's expectations. The purpose of this practice is to monitor the storage duration of food items and ensure they are consumed or discarded in a timely manner to prevent potential health risks to residents. The facility's policy on food storage, although lacking a letterhead, mandates that all food items be labeled with the name of the food and the date by which it should be sold, consumed, or discarded. The Director of Food Service's job description includes supervising the receiving and storage of food, highlighting the importance of adherence to these labeling practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the outside trash dumpsters were properly covered, as observed by a surveyor on March 4, 2025. The facility has two green-colored outside trash dumpsters, each with a black plastic lid divided into three parts. It was noted that the first part of the black plastic lid was missing on both dumpsters. The Dietary Aide, V38, confirmed that the lids are necessary to prevent trash from flying out and to deter animals from accessing the dumpsters. However, V38 was unaware of who was responsible for maintaining the dumpsters. The Director of Food Service, V4, indicated that the housekeeping department was responsible, while the Director of Environmental Services, V18, acknowledged the missing lids and stated that they had informed the disposal service about the issue some time ago. The facility's policy requires outdoor trash receptacles to be covered and the surrounding area to be free of litter.
Infection Control Deficiencies in Linen Handling
Penalty
Summary
The facility failed to maintain proper infection control practices by storing a clean linen cart inside the restroom of residents on Enhanced Barrier Precautions (EBP). Observations revealed that the cart, containing washcloths, fitted sheets, and adult diapers, was uncovered and placed inside the restroom of two residents, one of whom was cognitively intact and the other moderately impaired. The facility's policy dictates that clean linen carts should be kept in hallways and covered to prevent contamination, as entering a resident's room or restroom renders the linens contaminated. Staff interviews confirmed that the presence of the cart in the restroom was against policy and posed a risk of contamination. Additionally, the facility failed to ensure that soiled linen bags were securely tied before being conveyed via a chute to the laundry department. During an interview and observation, it was noted that a bag of soiled linen burst open upon landing in the laundry area, spilling its contents onto the floor. Further inspection revealed that some bags were not tied, and a towel was found outside of a bag. The Director of Nursing acknowledged the issue and indicated a need for staff reeducation on securely tying bags to prevent contamination during transport. The facility's Linen Handling Principles emphasize the importance of securely tying soiled linen bags to prevent the spread of microorganisms. The failure to adhere to these guidelines resulted in potential contamination risks, as the air in the laundry area could become contaminated, affecting all residents who receive linens from the facility. The report highlights the need for proper handling and containment of both clean and soiled linens to maintain infection control standards.
Failure to Conduct Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences, which resulted in residents and their families not being able to exercise their right to participate in the development and implementation of their care plans. This deficiency affected four residents, each with varying levels of cognitive impairment. For instance, one resident with mild cognitive impairment expressed a desire to discharge from the facility but was unaware of any discharge plan within their care plan. This resident, along with others, denied being asked to participate in the development of their care plans or being invited to care plan conferences. The facility's documentation revealed that care plan meetings were not held as required, and key interdisciplinary team members were absent from the meetings that did occur. The facility's policy mandates that residents and/or their representatives be invited to review the care plan with the interdisciplinary team at least quarterly, but this was not adhered to. The facility's failure to follow its comprehensive care planning policy was acknowledged by the Director of Nursing, who admitted that care plan conferences were not being completed according to policy, and no documentation of corrective action was provided.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide necessary assistance with grooming for a resident, identified as R46, who was unable to perform this activity of daily living independently. On March 3, 2025, it was observed that R46 had long fingernails with brown matter underneath them. R46 expressed a preference for shorter nails and a desire to have them trimmed. Despite this, the facility did not provide the required assistance, which is a failure to adhere to the resident's care plan and the facility's policy on activities of daily living. R46 was admitted to the facility with multiple diagnoses, including dementia, which contributed to a self-care performance deficit. The resident's Minimum Data Set indicated moderate cognitive impairment, necessitating supervision or assistance with most activities of daily living. The facility's policy aims to promote residents' independence and includes grooming as a key component. However, the facility did not fulfill this policy requirement for R46, leading to the observed deficiency.
Improper Low Air Loss Mattress Settings for Residents
Penalty
Summary
The facility failed to ensure that the Low Air Loss Mattresses (LALM) for pressure ulcer prevention were set at the correct weight settings for several residents. This deficiency was identified through observation, interviews, and record reviews, affecting five residents out of nine reviewed for pressure ulcer prevention and treatment. The facility had a list of 33 residents on LALM, with weights recorded on March 3, 2025. However, discrepancies were found between the recorded weights and the mattress settings for multiple residents. One resident, admitted with multiple pressure ulcers and severe cognitive impairment, was observed with a mattress setting significantly lower than their recorded weight. Despite the care plan specifying the need for appropriate mattress settings, the setting was not adjusted correctly. Another resident, with a history of dementia and other health issues, had a mattress setting at zero while not in bed, contrary to the requirement for settings to match or be below the resident's weight. Similarly, other residents had mattress settings that did not align with their documented weights, indicating a systemic issue in maintaining proper mattress settings. The facility's guidelines and in-service training emphasized the importance of setting air mattresses to the patient's weight and not altering the settings. However, observations revealed that these guidelines were not consistently followed, leading to improper mattress settings that could compromise pressure ulcer prevention. The failure to adhere to these guidelines and ensure correct mattress settings for residents at risk of skin integrity issues represents a significant deficiency in care provision.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerator temperatures in residents' rooms, which is crucial to prevent foodborne illnesses. Observations revealed that temperature logs were either missing or outdated for several residents, and expired food items were found in the refrigerators. For instance, in one resident's room, the temperature log was absent, and expired food items were discovered. Another resident's refrigerator had a temperature log from a previous year, and expired milk was found inside. The facility's procedure requires daily temperature checks and logging, but these were not consistently performed. Interviews with staff, including an LPN and the Assistant Director of Nursing, confirmed that the maintenance and housekeeping departments were responsible for monitoring refrigerator temperatures. However, the logs were not up-to-date, and temperatures were not within the safe range of 38F to 41F, with one refrigerator registering at 60F. The residents involved were cognitively intact, as indicated by their BIMS scores, but the lack of proper temperature monitoring posed a risk of foodborne illness. The facility's guidelines stipulate that outdated food should be discarded, and any temperature deviations should be reported immediately, but these protocols were not followed, leading to the deficiency.
Non-Functional Call Lights Affect Resident Safety
Penalty
Summary
The facility failed to ensure that residents' call lights were functional and in good working order, affecting four residents. During observations, interviews, and record reviews, it was found that several residents, including one who was visually impaired, experienced non-functional call lights. One resident reported that no staff responded to his call light for several days, requiring him to yell for assistance. Another resident had to pull the call light cord out of the wall to get it to work, which was acknowledged by a Licensed Practical Nurse (LPN) as a potential safety risk. The facility's policy requires that call lights be available and accessible to residents at all times, and defects should be promptly reported to maintenance. The Maintenance Director was unaware of the call light issues until informed by staff and surveyors. The facility did not maintain a maintenance logbook at the nursing station, and staff were expected to call maintenance directly. The Maintenance Director later confirmed that the call light system was old and malfunctioning, requiring repairs. The facility's policy emphasizes the importance of responding to residents' requests in a timely manner, but the lack of a functional call light system hindered this process, leaving residents without a reliable means to request assistance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication for a resident, identified as R58, who was prescribed QUEtiapine Fumarate (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbance. The physician's order for this medication began on 9/17/2023, but the informed consent form, dated 1/11/2024, incorrectly documented the dosage as 25 mg and lacked details on diagnosis, benefits, targeted behaviors, and alternatives. This discrepancy was noted during a survey, and no other consent forms were provided for review. Interviews with facility staff, including the Nursing Supervisor (V20) and the Director of Nursing (V3), confirmed that informed consent is required before administering psychotropic medications. V20 acknowledged the inconsistency in the dosage listed on the consent form and was unaware of why the consent was not obtained timely, as the order was initiated before their tenure. V3 emphasized the importance of obtaining informed consent to ensure residents are aware of the risks and benefits of their medications. The facility's policy on psychotropic medication also mandates obtaining informed consent prior to administration.
Improper Storage of Lorazepam
Penalty
Summary
The facility failed to store a bottle of lorazepam in accordance with the manufacturer's instructions, affecting one resident in a sample of 65. The resident had a physician's order for Lorazepam 2mg/mL concentrate, which was discontinued on December 20, 2024. On March 4, 2025, a Licensed Practical Nurse (LPN) was observed withdrawing the resident's bottle of lorazepam from the medication cart's narcotics drawer. The bottle had a sticker indicating it should be stored in the refrigerator, which the LPN acknowledged. The manufacturer's instructions specify that lorazepam oral concentrate should be protected from light and stored at temperatures between 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit). The facility's policy on medication storage, dated May 1, 2018, also requires medications needing refrigeration to be stored at these temperatures, with controlled substances stored within a lock box in the refrigerator or a locked refrigerator near the nurses' station or in a locked medication room.
Failure to Implement Fall Prevention Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement its fall prevention policy, resulting in a resident, identified as R1, experiencing a fall that led to a closed fracture of the neck of the left femur. R1's clinical record indicated a history of falling, epilepsy, dementia, and other medical conditions, and R1 was assessed as a high fall risk. Despite this, the facility did not provide adequate supervision or assistive devices, and R1 fell while attempting to stand in the dining room, leading to hospitalization and surgical repair of the fracture. The report highlights that R1's phenytoin levels were supratherapeutic, and valproic acid levels were low, contributing to gait instability and the fall. The nursing staff was aware of R1's abnormal medication levels, which increased the risk of falls, yet failed to monitor R1 closely or provide necessary interventions. Interviews with staff and family members revealed that R1's medication levels had been problematic before, and the staff was aware of the need for close monitoring when levels were abnormal. The facility's fall prevention program was not effectively implemented, as evidenced by the lack of supervision and failure to communicate R1's high fall risk to all staff members. The report indicates that the nursing staff did not follow established safety regulations, and there was a lack of leadership in directing nursing assistants to monitor R1 closely. This oversight led to R1's fall and subsequent injury, highlighting deficiencies in the facility's fall prevention measures.
Deficient Shower Room Conditions in LTC Facility
Penalty
Summary
The facility failed to provide a home-like environment and maintain clean and sanitary shower rooms, potentially affecting 195 residents. Observations revealed multiple issues in the shower rooms across different floors, including wet and used towels on the floor, broken floor tiles, missing shower fixtures, and cluttered spaces with equipment obstructing pathways. These conditions were observed despite staff claims that shower rooms are cleaned daily and after each use. Interviews with various staff members, including LPNs, CNAs, and the Director of Environmental Services, indicated that there is a system in place for reporting and addressing maintenance issues. However, the maintenance director acknowledged that repairs depend on the availability of parts and that monthly equipment rounds do not include checking shower rooms. Despite signs indicating some showers were temporarily out of service, staff stated that all shower rooms were still in use, and residents continued to use them despite the broken and cluttered conditions. The facility's policies and job descriptions for the Director of Environmental Services and Maintenance Director emphasize maintaining a clean, safe, and comfortable environment. However, the observations and interviews suggest a disconnect between policy and practice, as the shower rooms remained in disrepair and unclean. The facility's assessment tool highlights the importance of maintaining physical resources and equipment to ensure resident safety and comfort, yet the observed conditions indicate a failure to meet these standards.
Inadequate Linen Supply Due to Equipment Malfunction and Stock Shortage
Penalty
Summary
The facility failed to ensure the availability of adequate clean bed linen for its 197 residents due to an inadequate supply of new bed linens and a malfunctioning laundry machine. Observations on multiple floors revealed that clean linen carts and linen rooms were devoid of sheets. The basement supply storage room also lacked new bed linens, and one of the three washing machines in the laundry room was not functioning, contributing to the shortage of clean linens. Interviews with staff, including CNAs, the Housekeeping Manager, and the Laundry Aide, confirmed the absence of linens on the floors and the lack of new stock. The Administrator acknowledged the issue, stating that a large order of sheets had not yet been delivered and that the facility had been experiencing difficulties maintaining an adequate stock of linens. The facility's policy on Preventative Maintenance Laundry and Linen Handling Principles was not effectively implemented, as evidenced by the failure to maintain adequate linen supplies and ensure timely repairs of laundry equipment.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to implement their Enhanced Barrier Precaution (EBP) policy and procedures by not placing a resident with a pressure wound on EBP, which is intended to prevent the potential spread of multidrug-resistant organisms. This deficiency was identified during a survey when a resident, who had a stage 3 pressure ulcer on the sacral region, was not placed on EBP upon admission. The resident was readmitted to the facility, and despite having a documented wound, there was no EBP sign or personal protective equipment (PPE) available outside the resident's room. The occupational therapist, who interacted with the resident, was unaware of the wound and did not observe any EBP signage or PPE bin, indicating a lapse in communication and procedure adherence. The wound care nurse and infection preventionist confirmed the absence of EBP measures, acknowledging that the resident should have been placed on EBP due to the presence of a wound. The infection preventionist noted that the process involves checking new admissions for EBP requirements, but this was not done in a timely manner for the resident in question. The Director of Nursing confirmed that the facility's policy requires residents with wounds to be on EBP, with appropriate signage and PPE readily available. However, the resident's condition was not included in the EBP list, and there was no EBP care plan in place for the resident. This oversight resulted in a delay in implementing necessary precautions, as the enhanced barrier precaution was ordered three days after the resident's admission.
Improper Low Air Loss Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately for a resident with a pressure ulcer. During an observation, it was noted that the mattress was set at 280 lbs, which was higher than the resident's actual weight of approximately 182.2 lbs. This discrepancy was confirmed by a Certified Nursing Assistant and an Agency RN, who both verified the incorrect setting. The Wound Care Nurse explained that the mattress setting should be adjusted to the resident's weight to prevent further skin damage, and a higher setting could make the mattress firmer, increasing pressure on the resident's skin. The resident in question had a documented diagnosis of a stage 3 pressure ulcer in the sacral region and was assessed as having a moderately impaired mental status. The facility's pressure injury prevention policy emphasized the importance of setting the low air loss mattress to the appropriate weight to prevent skin breakdown. Despite this policy, the resident's mattress was not set correctly, potentially compromising the effectiveness of the pressure-relieving device intended to aid in the resident's care.
Deficiency in Nurse Call System Functionality
Penalty
Summary
The facility failed to ensure that the nurse call system was properly functioning for four residents, leading to a deficiency in the availability of a working call system in each resident's bathroom and bathing area. During the investigation, it was observed that the call lights for these residents were not illuminating outside their rooms or at the nurses' station, despite being activated. This issue was noted for residents who required substantial assistance with daily activities, including toileting, dressing, and transferring. For instance, one resident was found sitting in bed crying out for help, and although the call light was activated, it was not visible outside the room or at the nurses' station. The maintenance director later identified that the call light system required updating, as the lights outside the bedrooms and at the nurses' station would not illuminate if the bathroom call light had been accidentally bumped. This malfunction resulted in residents being unable to effectively communicate their need for assistance, as evidenced by multiple residents expressing their need for help and medication without receiving timely responses. The facility's policy mandates that call lights be answered promptly and any defects reported to maintenance, but this was not adhered to, contributing to the deficiency.
Failure to Investigate and Report Alleged Mental Abuse
Penalty
Summary
The facility failed to investigate and report an alleged incident of mental abuse involving a resident (R1) and a staff member (V8). R1, who has intact cognitive function as indicated by a BIMS score of 15/15, reported feeling demeaned and that staff were ganging up against her after an interaction with V8. R1 requested assistance from V8 to clean her back, but V8 responded in a manner that R1 perceived as mean and dismissive. R1 felt demeaned and cursed at V8. The facility administrator (V7) acknowledged the incident but did not investigate further or report it to the Illinois Department of Public Health (IDPH), as she believed the incident was not reportable since R1 cursed at the staff first. The facility's policy on abuse prevention requires all incidents to be documented and investigated, with a final investigation report submitted within five working days. However, V7 did not follow this policy, as she did not conduct a thorough investigation or report the incident to the appropriate authorities. Instead, the incident was only logged in the concerns log. Additionally, V7 attempted to address R1's distress by involving a family member in a call, but this did not resolve the issue, and R1 remained upset. The facility's failure to investigate and report the alleged mental abuse is a clear violation of their own abuse prevention procedures.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,780 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Shore Rehabilitation | 0.6 mi | ★★★★★ | 11 | 0 |
| Landmark Of Hyde Park Rehabilitation And Nursing C | 2.4 mi | ★★★★★ | 14 | 0 |
| Montgomery Place | 2.6 mi | ★★★★★ | 20 | 0 |
| Pavilion Of South Shore | 2.6 mi | ★★★★★ | 1 | 0 |
| Wentworth Rehab & Hcc | 3.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.