Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairhaven Christian Ret Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including CKD, COPD, and Alzheimer’s disease, experienced a significant weight loss over several months while the facility failed to follow its own care plan and weight policy. Although the care plan required monitoring and recording of food intake and weights, and notification of the physician and family for significant weight changes, the resident’s monthly and weekly weights were missed or delayed, and meal intakes went undocumented on many days. A physician order for weekly weights was not carried out as scheduled, and the RD was not notified when a significant weight loss was identified, learning of it only later from a weight change report. These inactions resulted in an extended period without timely nutritional assessment or intervention despite clear evidence of ongoing weight loss.
Staff failed to consistently check and document temperatures for all hot foods on unit steam tables before service and relied mainly on checking meat items, despite policies requiring proper cooking and holding temperatures. Observations showed staff on multiple units needed repeated instruction to take temperatures on all items, had difficulty using thermometers, and served or reheated foods that were below required temperatures, while temperature logs over several weeks showed incomplete documentation. In addition, a cook preparing mechanical soft and pureed foods repeatedly handled blended meat and vegetables with the same gloved hands, touching food, equipment, and pans without changing gloves or using utensils, even though the dietary supervisor stated that utensils must be used to prevent cross contamination.
A resident with severe cognitive impairment, an indwelling catheter for urinary retention, and a history of UTIs was observed multiple times with catheter tubing dragging on the floor while in a wheelchair in common areas, during transport to the bathroom and shower room, and while transferring on and off the toilet. The resident did not have a catheter secure device in place as required by the care plan, and the tubing hung freely, touched the floor, and was stepped on by the resident. Nursing and CNA staff were present and assisted with mobility and toileting while the catheter tubing remained unsecured and in contact with the floor, contrary to the facility’s urinary catheter management policy and the DON’s stated expectations.
The facility failed to ensure hot foods were served at palatable temperatures, as multiple cognitively intact residents reported that their meals, including items such as roast beef, fries, and cooked vegetables, were consistently served cold in the dining room. During an observed lunch service, three residents stated their food was cold, and Resident Council minutes documented ongoing complaints that vegetables and entire meals were cold, along with concerns about how food temperatures were being checked. The Dietary Supervisor stated that food temperatures were taken in the main kitchen and again on the steam table and acknowledged the importance of serving hot foods hot, while facility policy required provision of palatable meals and routine meal rounds to assess temperature and other meal qualities.
A resident with Alzheimer’s disease and vascular dementia who tested positive for COVID-19 was placed on contact, droplet, and airborne precautions, with appropriate isolation signage posted. Surveyors observed CNAs entering and exiting the resident’s isolation room wearing an N95 respirator over an existing surgical mask, rather than using the N95 alone as required for a proper seal. One CNA stated she left the surgical mask on because she was already wearing it, despite the resident being on COVID isolation. The DON confirmed that COVID isolation PPE should include a gown, N95, eye protection, and gloves, and that a surgical mask under an N95 prevents an adequate seal, contrary to facility policy and CDC guidance.
A resident with Alzheimer's, vascular dementia, and swallowing difficulties was served the wrong diet and left unsupervised during a meal. The resident, known for eating quickly and impulsively, choked on improperly prepared food and died despite staff intervention. The care plan did not specify the need for supervision due to impulsive eating, and staff were unaware of the recent diet change.
A resident with dementia and physical decline fell and fractured their clavicle due to inadequate supervision and failure to use a gait belt during transfer. The CNA did not anticipate the resident's weakness, exacerbated by illness, and attempted to assist without proper equipment, contrary to facility policy.
A multidose vial of Tubersol used for TB testing was found in the medication room refrigerator without a label indicating the date it was opened. The DON confirmed that the vial, which was months old, should have been disposed of after 28-30 days. The facility's policy requires nurses to label multidose vials with the opening date, expiration date, and their initials, which was not followed.
The facility failed to ensure proper PPE use and infection control in COVID-19 isolation rooms. Staff entered rooms without required N95 masks and eye protection, and some wore surgical masks under N95 masks. Additionally, CNAs did not change gloves or perform hand hygiene during resident care, risking cross-contamination.
The facility failed to provide timely assistance with activities of daily living for two residents with dementia and other conditions. One resident was left in a recliner for hours without being taken to the toilet, resulting in a saturated incontinence brief and reddened skin. Another resident, usually continent, was found with urine in her brief after being left unattended for an extended period. The facility's policy requires perineal care every two hours, which was not followed.
A resident with limited range of motion in their right hand did not have their prescribed splint applied as required. Despite instructions for daily use, the splint was observed unused, and staff were unclear about their responsibilities for its application. The resident's care plan and therapy notes indicated the necessity of the splint to maintain joint mobility.
A significant medication error occurred when an agency nurse, misinformed by an LPN, administered another resident's medications to a resident with a history of heart failure and diabetes. The error led to a dangerous drop in the resident's blood pressure, requiring emergency intervention and hospitalization. The facility failed to ensure proper resident identification before medication administration.
A resident with Alzheimer's and moderate cognitive impairment was forced to get out of bed by CNAs despite expressing a desire to stay in bed due to back pain. The resident's care plan emphasized the need for choice and independence, which was not respected. The CNAs admitted to not honoring the resident's rights, and both an LPN and the DON confirmed the failure to respect the resident's care choices.
A resident with Alzheimer's, low back pain, and osteoarthritis expressed pain to CNAs, but it was not reported to the nurse, delaying pain management by 11 hours. The facility's policy requires reporting resident concerns, which was not followed, leading to a deficiency in pain management.
A resident with a high fall risk and multiple health issues sustained a clavicle fracture due to improper use of a stand lift during a transfer. Despite being unable to bear weight or assist, staff used a stand lift instead of a full mechanical lift, leading to the injury.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to identify and respond to a significant weight loss for one resident, as well as failure to consistently document meal intakes. The resident had diagnoses including chronic kidney disease stage 3, urinary tract infection, chronic obstructive pulmonary disease, and Alzheimer’s disease. The resident’s care plan stated that health problems could impact nutritional status and directed staff to monitor and record food intakes, monitor and record weight, and notify the physician and family of significant weight changes. Despite this, the facility assessment indicated no weight loss, and the resident reported having lost weight since moving into the facility and being unsure about receiving nutritional supplements. Weight records showed that the resident weighed 124.4 lbs on 11/12/25 and 114.2 lbs on 02/11/26, an 8.2% loss within three months. A dietician note from 1/12/26 documented a notable downward trend in weight since admission, with a significant 5.5% loss from October to November, and stated that weight had stabilized but remained down overall, with a goal of weight and appetite stability and the current plan of care remaining in place. On 1/20/26, the physician ordered weekly weights for four weeks to monitor the downward trend, but no weights were documented for 1/21 or 1/28, and the next recorded weight was not obtained until 2/4/26, 14 days after the order. The dietician later confirmed that the resident did not have a weight obtained the prior month despite being due for at least monthly weights. Staff interviews and documentation revealed additional failures in monitoring and communication. The LPN stated that CNAs obtain weights and provide them to nurses, who then pass them to nursing administration for entry, and that significant weight changes should trigger reweighs and notification of the physician and dietician. The DON stated that if a resident is unavailable for a scheduled weight, a one-time order should be entered for the next shift or day, and that significant weight changes should be communicated to the physician and power of attorney, with documentation in progress notes. However, the DON confirmed that no weights were written down for the resident on 1/20 or 1/28. The registered dietician reported she was not notified of the significant weight change identified on 2/4, only discovering it later through a weight change report, and stated that the resident should have had at least monthly weights. Additionally, the resident’s meal intake logs for January and February showed that meal intakes were not documented on 29 of 57 days, contrary to the care plan and the facility’s weight policy, which required documentation of all weights and specific actions for significant weight changes.
Failure to Monitor Food Temperatures and Use Proper Utensils During Food Preparation
Penalty
Summary
The deficiency involves failure to consistently check and document food temperatures for all menu items before service and failure to follow proper food handling practices, affecting all 69 residents in the facility. The Dietary Manager stated that food was prepared in the main kitchen, placed in hot boxes, and transported to unit kitchenettes, where temperatures were to be taken from the steam table prior to service. During observation, a cook transported lunch to the second-floor kitchenette, placed all items on the steam table, and only checked temperatures of the regular and pureed meats, stating that other items were checked in the main kitchen. When the same cook delivered food to the third-floor kitchenette, she initially had no thermometer and, once one was obtained, again checked only the meats. The Dietary Manager then instructed that all foods needed to have temperatures checked, and a return visit to the second-floor kitchenette showed that staff there also required repeated direction to check all items and had difficulty using a thermometer. A pureed vegetable item was found at 101°F and had to be reheated multiple times while the manager verbally guided the process. Staff gave inconsistent statements about required holding temperatures, while the Dietary Manager stated all food needed to be at 140°F before serving. Review of Food Temperature Monitor Sheets showed that only limited items (hot cereal, regular egg, regular meat, and pureed meat) were routinely checked, and multiple meals over several weeks lacked documented temperatures prior to service, despite policies stating that improper cooking, cooling, reheating, and holding temperatures are major causes of foodborne illness and that hot foods must be held at 135°F and checked frequently. A second deficiency was observed in food handling and utensil use during preparation of mechanical soft and pureed foods. A cook preparing these textures placed meat in a blender, pulsed it, and then repeatedly scooped out and handled the meat and subsequent portions with the same gloved hand, including breaking apart additional meat, spraying the pan, and handling the blender lid without changing gloves or using utensils. After being handed a spatula by the Dietary Supervisor, the cook continued to mix and portion meat and vegetables, then wiped off the spoon with the same gloved hands that had been used to arrange pans. The Dietary Supervisor stated that utensils must be used to move food from one place to another to prevent cross contamination.
Failure to Maintain Proper Indwelling Catheter Management and Tubing Positioning
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper management of an indwelling urinary catheter, including securing the catheter and keeping the tubing off the floor. During observation, a resident with an indwelling catheter was seated in a wheelchair in the dining room with the drainage bag under the wheelchair in a privacy bag and the catheter tubing looped under the chair, touching the floor. After lunch, the resident self-propelled from the dining room to the nurses’ station and then to a common area, with the catheter tubing continuing to drag on the floor throughout these movements. A registered nurse interacted with the resident at the nurses’ station, and later a CNA prepared the resident for a shower and pushed the wheelchair toward the resident’s room, while the catheter tubing continued to drag on the floor. In the bathroom, the CNA assisted the resident to transfer from the wheelchair to the toilet. The resident did not have a catheter secure device in place, and the catheter tubing was hanging freely. After toileting, the resident was assisted back to the wheelchair, and the tubing again touched the floor as the resident propelled to the sink to wash his hands and then out of the bathroom. The resident stepped on the catheter tubing with both feet as he exited, and the tubing went under his foot and continued to drag on the floor as the CNA pushed him to the shower room. Record review showed the resident had an indwelling catheter related to urinary retention, severe cognitive impairment, a history of UTIs, and other diagnoses including Alzheimer’s disease and benign prostatic hypertrophy. The care plan included an intervention to use a catheter strap (secure device), and the DON stated that catheter tubing and drainage bags should not touch the floor and that residents with indwelling catheters should have a secure device in place, consistent with the facility’s urinary catheter management policy.
Failure to Serve Hot Foods at Palatable Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure hot food was served at palatable temperatures for three cognitively intact residents who dined in the main dining room. One resident reported that hot food was being served cold and that by the time her meal reached her in the dining room, it was cold; she stated this concern had been raised during Resident Council meetings. During a lunch observation, this resident was served roast beef on a bun with au jus, fries, and cooked carrots and immediately stated her food was cold and that she was tired of food coming out cold. Another resident at the same meal reported that her fries and carrots were cold, and a third resident later stated her food was served cold. Resident Council Meeting minutes documented ongoing dietary concerns about food temperature. In one meeting, residents requested more efficient ordering so food would not be cold and suggested staff serve 4–6 tables at a time so everyone’s food would be hot and served simultaneously. In a later meeting, residents stated that vegetables were always cold and that a specific dinner meal had been cold; they also questioned whether food temperatures were being taken on the surface or deep in the pan. The Dietary Supervisor explained that food is prepared in the main kitchen, temperatures are checked before it leaves the kitchen, then food is placed on a steam table in the health center and temperatures are checked again, and acknowledged the importance of serving hot foods hot for quality and enjoyment. The facility’s Resident Meal Service policy states residents will be provided with nourishing, palatable, attractive meals and that the food service manager will routinely perform meal rounds to assess temperature, flavor, and other meal characteristics, but residents’ reports and surveyor observations showed hot foods were not consistently served at palatable temperatures.
Improper N95 Respirator Use During COVID-19 Isolation Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of personal protective equipment (PPE) for a resident on COVID-19 isolation. The resident had diagnoses including Alzheimer’s disease, diarrhea, rash, and vascular dementia, and nursing progress notes documented a positive COVID-19 test with placement on contact, droplet, and airborne precautions. A sign on the resident’s door reflected these precautions. Despite this, on multiple observations staff did not use N95 respirators as intended. One CNA was observed donning a gown, gloves, shoe covers, and an N95 mask over an existing surgical mask before entering the COVID-positive resident’s room. On another occasion, a different CNA was observed exiting the same resident’s room wearing a surgical mask underneath an N95 respirator. This CNA stated that she kept the surgical mask on under the N95 because she already had it on and did not think it made sense to remove it to apply the N95, acknowledging the resident was on isolation for COVID. The DON later stated that appropriate PPE for COVID isolation should include a gown, N95 mask, goggles or face shield, and gloves, and clarified that a surgical mask should not be worn underneath an N95 because it prevents a proper seal and puts staff at risk for contracting COVID. Facility policy described masks and face coverings as intended to limit the risk of exposing coworkers or residents to undetected illnesses, including COVID-19, and CDC guidance cited by surveyors emphasized that an N95 must form a seal to the face and that gaps can occur if it is not put on correctly.
Failure to Supervise Resident and Provide Correct Diet Results in Fatal Choking Incident
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident with significant medical conditions, including Alzheimer's disease, vascular dementia, and a history of swallowing difficulties, was properly supervised during mealtime and received the correct diet. The resident had recently experienced difficulty swallowing stringy meat, which led to a downgrade of her diet to mechanical soft. Despite this change, the resident was served a regular meal of pulled pork instead of the required mechanical soft diet. Dietary staff were unaware of the diet change and provided the wrong food consistency, resulting in the resident receiving larger pieces of meat than appropriate for her condition. During the meal, a CNA was initially present to supervise the resident but left the table to attend to another resident, leaving the resident unsupervised with food within reach. The resident, known for eating quickly and impulsively, grabbed food and began to eat rapidly. This led to choking, and despite immediate intervention by staff, including the Heimlich maneuver and suctioning, the resident became unresponsive and subsequently died. Staff interviews confirmed that the resident had a history of eating too fast and required supervision during meals to prevent such incidents. The resident's care plan indicated a need for supervision during meals but did not specify the reasons, such as impulsivity or rapid eating, nor did it detail the specific risks associated with her eating behavior. Staff, including the DON and LPN responsible for care planning, acknowledged that the care plan lacked critical information about the resident's eating habits and the necessity for close monitoring. The facility's policies required food to be prepared according to dietary orders and identified eating too quickly as a behavioral risk factor for choking, but these protocols were not followed in this instance.
Removal Plan
- Instruct nursing staff that plates need to be cleared from the table when a resident that requires supervision or assistance is done eating and no longer has direct staff supervision.
- Update care plans for residents needing supervision or assistance with meals to indicate the reason they need assistance.
- Update the white board as diets are changed by the dietary supervisor or designee. Retrain dietary staff to the new system. Require dietary staff to initial on their schedule indicating that they reviewed the diet cards and the white board at the beginning of their shift.
- Implement diet card color system on all tables showing each resident's diet. Train dietary staff to the new system.
- Verify residents to ensure the correct resident is in their preferred seating arrangement. If the resident is unable to verbally verify name or location, wheelchair or other staff will verify their name. Train dietary staff to the new system.
- Develop Resident Feeding Assistance Policy.
- Monitor compliance through the QA process: audit a minimum of ten current residents to ensure that they are receiving the appropriate level of assistance with meals, and audit a minimum of ten current residents to ensure care plan is updated to reflect dietary assistance needs.
- In-service staff on safety and supervision in the dining room and the removal of plates when the resident that needs assistance has finished eating.
Failure to Ensure Safe Transfer and Ambulation
Penalty
Summary
The facility failed to ensure a resident was transferred and ambulated safely, resulting in a fall and a right clavicle fracture. The resident, who had diagnoses including dementia, right clavicle fracture, and kyphosis, was at risk for falling due to age, muscle weakness, and physical decline. The care plan indicated the resident required contact guard assistance with transfers and ambulation using a walker and staff assistance. On the day of the incident, the resident was on isolation for cold symptoms and was not walking well, but this information was not communicated to the Certified Nursing Assistant (CNA) responsible for the resident's care. The CNA attempted to transfer the resident from a recliner to a wheelchair using the resident's walker, but the resident fell unexpectedly. The CNA admitted to not using a gait belt and trying to grab the resident's arms to prevent a hard fall, which was against the facility's policy. The Director of Nursing and other staff confirmed that a gait belt should have been used, especially since the resident was ill and weaker than usual. The incident report and interviews with staff highlighted the resident's unsteady gait due to illness as the probable cause of the fall.
Failure to Label and Date Multidose Vial
Penalty
Summary
The facility failed to ensure that a multidose vial of Tubersol, used for TB testing, was labeled and dated when opened. During an inspection of the 2nd floor medication room, a surveyor and the Director of Nursing (DON) discovered the vial in the refrigerator without an opening date, despite the preprinted date on the vial being several months old. The DON acknowledged that the vial should have been disposed of after 28-30 days and confirmed that it was used for all residents, including new admissions and those requiring annual TB testing, as well as staff. The facility's policy mandates that nurses label multidose vials with the opening date, expiration date, and their initials, which was not adhered to in this instance.
Infection Control and PPE Deficiencies in COVID-19 Isolation Rooms
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and adherence to infection control protocols in COVID-19 isolation rooms. Staff members, including a housekeeper and certified nursing assistants (CNAs), entered isolation rooms without the required N95 masks and eye protection, despite clear signage indicating the need for such PPE. In one instance, a housekeeper entered a COVID-19 isolation room wearing only a surgical mask, gown, and gloves, contrary to the facility's policy requiring an N95 mask and eye protection. Additionally, a CNA was observed wearing a surgical mask under an N95 mask, which is against the facility's guidelines. Another CNA was found in a COVID-19 positive room without any PPE, having removed it before exiting the room. The facility also failed to ensure proper glove use and hand hygiene during resident care, leading to potential cross-contamination. In one case, a CNA did not change gloves or perform hand hygiene after handling soiled incontinence briefs and before touching clean items while providing peri care to a resident. Similarly, another CNA did not change gloves or perform hand hygiene when transitioning from handling soiled items to clean items during toileting assistance for a resident. These actions were in violation of the facility's policy on the proper use of gloves, which mandates changing gloves and performing hand hygiene after contact with bodily fluids.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, R54 and R27, who were reviewed for ADL care. R54, who has diagnoses including dementia and anxiety disorder, was observed sitting in a recliner for several hours without being assisted to the toilet, despite showing signs of restlessness and attempting to stand. When finally transferred to the toilet, R54's incontinence brief was found to be saturated with dark urine, and her buttocks were reddened, indicating a lack of timely incontinence care. Similarly, R27, who has diagnoses including Parkinson's disease and dementia, was observed in a recliner for an extended period without receiving peri care. Although R27 was usually continent, her incontinence brief was found to contain urine when she was eventually transferred to the toilet. The facility's policy requires perineal care to be performed at least every two hours, but this was not adhered to, as confirmed by the Director of Nursing. These observations highlight a deficiency in providing necessary ADL assistance to residents who are dependent on staff for toileting and incontinence care.
Failure to Apply Splint for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a splint was placed on a resident with limited range of motion in their right hand. The resident, identified as R51, was observed multiple times without the splint, despite a sign above their bed indicating that the splint should be worn in the mornings, initially for 1-2 hours and progressing to all-day wear. The splint was noted to be sitting in a chair next to the resident's bed, and the resident was unable to open their right hand, which was in a closed fist. Interviews with staff revealed confusion about who was responsible for placing the splint. A CNA familiar with the resident was unsure if the resident used a splint, while another CNA stated that restorative staff were responsible. However, the Restorative CNA indicated that the resident was not on any restorative programs. The Rehabilitation Director confirmed that occupational therapy was seeing the resident twice a week and that the floor CNAs or restorative staff were responsible for placing the splint on days when occupational therapy did not see the resident. The resident's care plan and progress notes indicated the need for daily splinting to maintain joint mobility.
Significant Medication Error Due to Misidentification
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was mistakenly given another resident's medications. The error occurred when an agency nurse, unfamiliar with the residents, administered medications intended for one resident to another. The nurse was misinformed about the identity of the resident by an LPN, leading to the administration of high blood pressure medications to a resident who did not have orders for them. This resident, who had a history of congestive heart failure, diabetes, and other conditions, experienced a significant drop in blood pressure as a result of the error. The resident's blood pressure dropped to dangerously low levels, prompting the nurse practitioner to order frequent monitoring and administration of midodrine to counteract the hypotension. Despite these efforts, the resident's condition did not stabilize, and she was sent to the emergency room for further evaluation. The incident highlights a failure in the facility's medication administration process, as staff did not verify the resident's identity using available resources such as photographs on their computers before administering medications.
Failure to Honor Resident's Care Choices
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding their care, specifically for a resident with Alzheimer's disease, low back pain, and osteoarthritis. The resident, who has moderate cognitive impairment, expressed a desire to remain in bed due to back pain and repeatedly asked the staff to leave her alone. Despite this, two Certified Nursing Assistants (CNAs) continued to get her dressed and took her out of her room against her wishes. The resident's care plan emphasized the importance of providing her with options and respecting her independence, yet this was not adhered to by the staff. The CNAs involved acknowledged that they did not honor the resident's rights, with one stating that they were accustomed to the resident's refusals and continued with care regardless. A Licensed Practical Nurse (LPN) and the Director of Nursing (DON) both confirmed that the resident's rights were not respected, emphasizing that care should be provided on the resident's terms and that refusals should be reported to a nurse for further handling. The Illinois Long-Term Care Ombudsman Program's guidelines were cited, highlighting the resident's right to dignity, respect, and participation in their own care decisions.
Failure to Report and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately assess, report, and treat a resident's pain, leading to a deficiency in pain management. The resident, who has diagnoses including Alzheimer's disease, low back pain, pain in the left knee, and osteoarthritis, was reported to have moderate cognitive impairment. On a specific day, the resident expressed back pain to two CNAs during morning care, but the pain was not reported to the nurse. One CNA did not report the pain because they believed it was a common complaint from the resident and assumed it was not genuine, while the other CNA had previously been told by a nurse that the resident's pain was normal and not to be concerned. As a result, the resident did not receive any pain medication or assessment until later in the evening, approximately 11 hours after initially reporting pain. The facility's policy requires CNAs to report any resident concerns to the nurse and the Director of Nursing, but this protocol was not followed. The Director of Nursing acknowledged that the resident's pain reports were only discovered during an abuse investigation, and no follow-up was conducted because the pain was not reported. The facility's policy on pain assessment emphasizes the importance of assessing and managing pain to enhance residents' quality of life, which was not adhered to in this case.
Improper Transfer Procedure Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a clavicle fracture during a stand lift transfer. The incident occurred when the resident became weak and had to be lowered to the floor by CNAs during a transfer from the toilet to a wheelchair. Later, the resident became unresponsive on the toilet, and staff attempted to use a stand lift for the transfer, despite the resident being unable to bear weight or assist with the transfer. This inappropriate use of the stand lift led to the resident's clavicle fracture. The resident's medical history included dementia, hypertension, and a high risk for falls, as indicated by a Fall Risk form score of 17. On the day of the incident, the resident was lethargic and unresponsive at times, with vital signs indicating potential health issues. Despite these conditions, staff used a stand lift, which is only appropriate for residents who can bear some weight and assist with the transfer. The resident's inability to bear weight and the staff's decision to proceed with the stand lift transfer directly contributed to the injury. Interviews with staff revealed that the proper procedure would have been to use a full mechanical lift, especially given the resident's condition. The facility's policy on safe handling and limited lift/movement clearly states that a full mechanical lift should be used for non-weight-bearing residents or those unable to assist with transfers. The failure to follow this policy and the improper use of the stand lift resulted in the resident's clavicle fracture and subsequent hospitalization.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alpine Fireside Health Center | 0.2 mi | ★★★★★ | 12 | 0 |
| The Citadel At Saint Anne Place | 1.7 mi | ★★★★★ | 8 | 0 |
| East Bank Center, Llc | 2.1 mi | ★★★★★ | 1 | 0 |
| Rock River Health Care | 2.2 mi | ★★★★★ | 14 | 1 |
| Pa Peterson At The Citadel | 2.5 mi | ★★★★★ | 4 | 0 |
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