Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franciscan Village during CMS and state inspections, most recent first.
A resident with morbid obesity, dementia, osteoarthritis, and dependence for all transfers and bed mobility was care planned to require substantial assistance for rolling and two staff when using a mechanical lift. Despite this, a CNA changed the resident’s linens and repositioned the resident in bed alone, pulling sheets from under the resident’s legs and using the mechanical lift without a second staff member. A skin tear and bruising developed on the right lower leg and around the knee, followed by increasing bruising, blistering, and pain with movement. An x-ray later showed an acute displaced proximal right femur fracture with osteopenia. The DON, ADON, NP, and physician all confirmed that facility policy and safe practice required two staff for mechanical lift use and that the resident’s size and inability to assist made solo bed mobility unsafe.
Multiple residents dependent on staff for transfers, including those with stroke, dementia, and mobility deficits, were not provided with required assistance or proper use of assistive devices during transfers. In one case, a nurse attempted a solo transfer of a resident needing two-person assistance, resulting in a fall and hip fracture. Other residents were transferred without gait belts or proper positioning, and required safety interventions such as non-skid wheelchair pads were not used, despite documented high fall risk and prior incidents.
Surveyors identified multiple unsanitary practices affecting all residents receiving facility-prepared meals, including use of a food processor with visible food residue to prepare mechanical soft foods, dirty and possibly rusted shelving storing pots, pans, and food-service supplies, and a deep fryer and surrounding cooking areas with accumulated food debris and spills that were not promptly cleaned. Ceiling tiles above food prep areas were covered with blackish substance and dust, and cases of juice were stored directly on the cooler floor rather than elevated. Dishes for one floor were washed in an alternate dish room where a high-temp dish machine failed to reach required rinse temperatures, test strips and a digital temperature monitor were unavailable, and temperature logs were completed only for one meal per day, contrary to facility policy requiring proper cleaning, storage, and dish machine monitoring.
Surveyors found that controlled substances were not maintained in fully sealed original packaging, as required by facility policy and DEA-related handling standards. During medication room and cart observations on multiple floors with nursing staff present, several unit-dose packages of Lorazepam, Triazolam, Hydrocodone/APAP, Tramadol, and Oxycodone were discovered with broken blisters or capsules that had been taped over instead of remaining intact. The DON confirmed that staff are expected to keep all controlled medications in their original, completely sealed packaging to ensure full accountability of each tablet or capsule, consistent with the facility’s written policies on medication storage and controlled substance management.
Surveyors found that staff did not provide fortified foods as indicated on meal tickets for six residents with documented nutritional risk, weight loss history, or inconsistent intake. The RD entered fortified food recommendations into the kitchen system so they appeared on meal tickets, and care plans for these residents included interventions to provide fortified foods. During observed meal services, residents whose tickets called for fortified pudding or a magic cup did not receive these items, despite the dining services leadership stating that fortified pudding was to be prepared and plated by servers whenever listed on the meal ticket.
Staff failed to follow the facility’s menu and portion control guidelines when serving the main entrée to residents on mechanical soft diets. On an observed meal service, a server used a #12 (3 oz) scoop instead of the menu-specified #8 (4 oz) scoop to portion ground chopped beef steak with gravy for four residents receiving dental soft diets. The facility’s color-coded scoop chart showed that the #8 scoop equaled 4 oz, and the registered dietitian confirmed that the scoop size indicated on the menu is used to ensure residents receive the planned calories and nutrition.
Surveyors found that multiple residents on mechanical soft (dental soft) diets were served foods inconsistent with their diet orders and facility policy. During an observed meal, several residents who had selected soft, chopped green beans on their meal tickets were instead served corn, and another resident on a mechanical soft diet received chopped fruit containing raw pineapple chunks. The RD later confirmed that mechanical soft diets should include only chopped canned fruits and soft, cooked vegetables, and dining services leadership acknowledged that pineapple chunks and the substituted vegetables were not appropriate for this diet level.
Two residents did not receive needed ADL assistance with feeding and incontinence care as outlined in their care plans and physician orders. One cognitively intact resident with Parkinson’s disease and dysphagia, ordered for 1:1 feeding due to self-care deficits and inadequate oral intake, was repeatedly given meal trays in the dining room and in bed without staff feeding assistance or encouragement, resulting in only partial meal consumption and spilled beverages, while dietary staff relied on nursing to communicate 1:1 feed orders that did not appear on diet tickets. Another resident with dementia and bowel incontinence was observed in bed with a strong bowel odor and flies present after several hours without personal care, despite a care plan requiring checks every two hours; a CNA described checking such residents every 2.5–3 hours, whereas the DON stated residents should be checked every two hours and as needed. Grievance logs and resident council reports documented multiple concerns about ADLs, and facility policies required provision of appropriate ADL and incontinence services for residents unable to perform these tasks independently.
A resident with dementia and a recent left femur fracture, admitted for post-surgical care and rehab, experienced significant pain during incontinence care and when movement was attempted. Despite active orders for scheduled and PRN acetaminophen and hydrocodone-acetaminophen, staff did not adequately assess or pre-medicate for anticipated pain before providing care. A CNA reported the resident screamed and yelled when touched and that the nurse initially stated she did not know if pain medications were ordered, while the nurse later indicated she was waiting until care was completed to administer analgesics. The resident declined repositioning for eating due to pain, and the DON and facility policies indicated that residents in significant pain should be assessed, medicated prior to care when possible, and care delayed or re-approached if they cannot tolerate it, which did not occur in this situation.
Surveyors observed a nurse crush and administer an ER Metoprolol tablet to a resident, contrary to the facility’s medication crushing guidelines, and fail to administer an ordered dose of Polyethylene Glycol 3350 (Miralax) listed on the MAR. During interview, the nurse stated that the medications given were the only morning medications for the resident, despite the active order for Miralax. Across 28 medication opportunities, these two errors produced a 7.14% medication error rate, exceeding the 5% standard.
Staff failed to follow standard infection control practices for hand hygiene and glove use during ADL care. In multiple instances, CNAs provided toileting and incontinence care, including peri care after voiding and bowel movements, and applied barrier cream and clean briefs while continuing to wear the same gloves throughout the care. In another case, a CNA assisted a resident with a catheter and dirty-soled shoes, touching the catheter bag, clothing, shoes, and surrounding surfaces while moving between dirty and clean tasks without changing gloves. The facility’s policy required hand hygiene after contact with body fluids, intact skin, and nearby objects, and required changing gloves when moving from contaminated to clean body sites.
A resident experienced a 12.47% weight loss over 90 days due to the facility's failure to obtain monthly weights and recognize significant weight loss. The resident expressed dissatisfaction with the facility's food, and despite orders for monthly weights and a mechanical soft diet, weights were inconsistently documented. Communication issues and staff changes contributed to the oversight, with the facility's policy on weight management not being followed.
The facility failed to manage food storage and expiration, affecting all 98 residents. Expired food items were found in dry storage, and the freezer contained unlabeled cheese. Ice buildup was observed around the walk-in freezer, with maintenance issues unaddressed despite a work order. The facility's policy on food storage and expiration was not followed.
The facility failed to provide adequate assistance with ADLs for residents dependent on staff for personal hygiene and grooming. Observations revealed residents with long, unkempt fingernails and female residents with facial hair, despite their care plans indicating a need for substantial assistance. Staff interviews confirmed the expectation for grooming assistance, yet the facility did not adhere to its policy of maintaining residents' personal hygiene.
The facility failed to maintain proper infection control practices, including hand hygiene and PPE use, during care activities for several residents. A CNA did not clean hands between tasks during meal service, and a wound care nurse and CNA did not follow hand hygiene protocols during wound care. Additionally, Enhanced Barrier Precautions were not implemented for residents requiring them, as staff failed to wear gowns during high-contact care activities.
The facility failed to ensure call lights were within reach for three residents, each with significant medical conditions and cognitive impairments. Observations revealed that call lights were either out of reach or improperly placed, preventing residents from calling for help. Staff interviews confirmed that call lights should always be accessible, aligning with the facility's policy. However, this was not consistently practiced, posing a risk to resident safety.
The facility failed to invite two residents to their care plan meetings, as required by policy. Both residents reported not attending or being invited to such meetings since their admission. The facility's records lacked documentation of invitations or attendance, and the administrator acknowledged the requirement for resident involvement but could not provide evidence of compliance.
The facility failed to provide adequate activities for two residents, as required by their care plans. One resident reported not receiving in-room activities or pop-in visits, while another expressed a desire for computer games, which were not provided. Documentation showed minimal activity entries, and staff confirmed that activities were not consistently offered to residents in their rooms, contrary to facility policy.
The facility failed to provide restorative nursing programs for residents with limited range of motion, affecting three residents. One resident with limited arm mobility and inwardly turned feet did not receive recommended exercises post-therapy. Another resident in a wheelchair reported inconsistent exercise assistance, despite having multiple diagnoses and functional limitations. A third resident with a dislocated shoulder expressed a need for exercises to prevent further decline. The Director of Nursing confirmed the absence of a restorative nurse and programs, contrary to facility policy.
A facility failed to implement fall prevention measures for a high-risk resident, as fall mats were not properly placed and the bed was not in the lowest position. Despite the resident's care plan indicating the need for bilateral floor mats, observations showed inconsistent application of these safety measures. Interviews with staff confirmed the standard practice, but it was not followed for this resident.
Failure to Provide Two-Person Assistance With Mechanical Lift During Bed Mobility Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance and supervision during bed mobility for a dependent resident, contrary to the resident’s care plan and the facility’s mechanical lift policy. The resident had multiple diagnoses including chronic kidney disease, morbid obesity, right hip osteoarthritis, dementia, and a prior right fibula fracture, and was documented as having moderate cognitive impairment. The MDS and care plan showed the resident was dependent for transfers, required substantial/maximal assistance for rolling in bed, and required two staff with a mechanical lift for transfers and repositioning. The DON and ADON both stated the resident required two staff members for bed mobility and that staff are to use two people when operating the mechanical lift, including for bed mobility. On an evening shift, a CNA reported that while changing the resident and bed linens alone, she caused a skin tear on the resident’s right shin below the knee when she pulled the sheets out from under the resident’s legs. The CNA stated she was standing on the right side of the bed, the resident was lying away from her, and she pulled the sheets from under the resident’s legs, after which she observed a skin tear and bruising. The CNA further stated she used the mechanical lift by herself to reposition the resident in bed and that she routinely used the mechanical lift alone to reposition residents who could not assist with repositioning, believing this was acceptable based on practices at other facilities. She confirmed she did not have anyone help her with this resident’s bed mobility and repositioning. Following the skin tear, nursing staff and the NP observed progressive bruising and pain associated with the resident’s right leg. The RN who initially treated the skin tear noted bruising by the skin tear and under the right knee. Over the next days, staff and the NP observed increasing bruising and a blister behind the right knee, with the NP later describing the bruising as significantly more extensive than expected for a skin tear. The resident, who had chronic lower leg and right knee pain and was a poor historian, intermittently grimaced, groaned, or screamed out in pain during turning, but often denied pain once repositioned. An x-ray ordered due to the bruising and pain revealed an acute proximal right femur fracture with displacement and osteopenia. The physician and NP indicated the fracture was not likely idiopathic, and the physician stated the fracture could have been caused by the resident being moved in bed by one staff member, noting the resident’s obesity, inability to assist with care, advanced osteoarthritis, and possible bone fragility. The facility’s mechanical lift policy required at least two nursing assistants for safe use of the lift, including for repositioning, but the CNA repositioned the resident alone with the lift and during linen changes.
Failure to Ensure Safe Transfers and Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure safe transfer mobility and adequate supervision for residents dependent on staff for transfer assistance, resulting in multiple incidents. One resident with a history of stroke, left-sided weakness, and cognitive impairment was dependent on staff for all transfers. Despite care plan instructions requiring two-person assistance, a registered nurse attempted to transfer the resident alone, during which the resident lost balance and fell from the wheelchair, hitting her head and sustaining a left femoral neck fracture. Family members present at the time reported that the nurse did not respond to their warnings about the resident's inability to move her left leg, and the transfer was performed without proper positioning or assistance, leading to the fall. Another resident with dementia, generalized muscle weakness, and a history of repeated falls was assisted by a CNA during toileting without the use of a gait belt, despite care plan interventions specifying two-person assistance and gait belt use for transfers. This resident was identified as high risk for falls and had a recent history of multiple fall incidents, as well as a visible wound on her forehead from a previous fall. A third resident with vascular dementia and a history of fractures was transferred from a reclining wheelchair to bed using a mechanical lift by two CNAs. During the transfer, the resident was not properly positioned in the sling, with lower extremities unsupported, causing the resident to scream in pain as the sling slid. Additionally, another resident with spinal stenosis and dementia, also at high risk for falls, was transferred from bed to wheelchair using a gait belt but without a non-skid wheelchair pad as required by the care plan. The resident appeared afraid and hesitant during the transfer, and the facility's fall log indicated a history of multiple falls for this resident.
Unsanitary Food Preparation, Storage, and Dishwashing Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain sanitary conditions in the kitchen and dishwashing areas for all 97 residents who receive food prepared there. During an initial kitchen tour, surveyors observed a food processor lid with orange-colored debris on the inside; the cook reported this processor is used to prepare mechanically soft foods. Shelving under a prep area that stored foil, plastic wrap, pan liners, and sandwich bags had food particles, dust, and grime. The deep fryer contained oil with blackened substances and food remnants, and there were food debris and spills on the sides of the oven near the fryer and extensive food spills and debris under the stoves. The cook stated the fryer was last used several days earlier and is cleaned twice weekly, with the next cleaning not yet due. In the dish room, shelving on a free-standing rack holding inverted pots and pans had a brownish substance that appeared to be rust. In the walk-in cooler, surveyors observed cases of orange and apple juice stored directly on the floor under shelving; the executive chef explained these juices had been moved there temporarily from the walk-in freezer due to a fan motor issue. Later the same day, a cook was seen preparing mechanical soft chicken in the same food processor previously noted to have orange-colored residue on the lid. When questioned, the cook removed the rubber lining and stated the substance appeared to be remnants of pureed carrots and that the lid was old and needed replacement. Ceiling tiles above the pureed meal prep area and other meal prep counters had extensive blackish substance and dust bunnies. The director of dining services acknowledged seeing rust on the shelving and stated that the food processor should have been cleaned and sanitized before being used to prepare the mechanical soft chicken. On a subsequent visit, the deep fryer and surrounding areas still had food debris and spills, and the ceiling tiles above food prep areas continued to have extensive blackish substance and dust bunnies. The executive chef reported that dishes for the first floor were being washed in the assisted living dish room because the main dish room was under construction. When the dish machine was started, the wash gauge read 140°F and the rinse gauge 160°F, although the chef stated it was a high-temperature machine and the rinse should normally be 180°F. When asked about test strips to verify sanitation, the chef was unable to locate them and indicated they typically used a digital monitor that was not present. The assisted living dishwasher stated the digital monitor had not been available for two months, that he only completed dish machine logs for the dinner meal, and that no one else logged temperatures for other meals. The posted dish machine temperature log showed rinse temperatures between 155–175°F for most entries in July and August and was completed for only one meal per day. Facility policies required food contact surfaces to be cleaned and sanitized after every use, foods to be stored at least six inches off the floor, and high-temperature dish machines to reach minimum wash and rinse temperatures and be monitored and documented at each meal, which was not followed in these observations.
Improper Storage and Packaging of Controlled Substances
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of controlled substances when multiple medication packages were found broken and taped over rather than remaining fully sealed in their original packaging. During medication room and cart observations conducted on all three floors, surveyors, accompanied by nursing staff, observed that specific unit-dose packages of controlled medications for seven residents were compromised. These included Lorazepam 0.5 mg tablets for one resident at tablet number 18, another at tablet number 27, and a third at tablet number 16; Triazolam 0.25 mg tablets at tablet numbers 1 and 5 for another resident; Hydrocodone/APAP 5-325 mg at tablet number 20 for another resident; Tramadol 50 mg at tablet number 12 for another resident; and Oxycodone HCL 5 mg at capsule number 29 for another resident. In each instance, the packaging was described as broken and then taped over. The DON stated that staff are required to ensure controlled substances remain in their original packaging and are completely sealed to maintain complete accountability of each tablet or capsule. The facility’s March 2021 medication storage policy requires medications and biologicals to be stored safely, securely, and properly, following manufacturer or supplier recommendations. The controlled substance storage policy further specifies that medications classified by the DEA as controlled substances are subject to special handling, storage, disposal, and recordkeeping in accordance with federal, state, and other applicable laws and regulations. The observed practice of storing controlled substances in broken, taped-over packaging was inconsistent with these stated requirements.
Failure to Provide Ordered Fortified Foods to Residents at Nutritional Risk
Penalty
Summary
The facility failed to provide ordered fortified foods to six residents who had recommendations and care plan interventions for fortified foods to address nutritional risk, weight loss, or inconsistent intake. During meal service observations on the 2nd floor dining room, residents identified as R18 and R95 had meal tickets indicating "fortified pudding" but did not receive it, and R78’s meal ticket indicated "magic cup" but she did not receive it. During meal service observations on the 3rd floor dining room, residents identified as R35, R45, and R64 had meal tickets indicating "fortified pudding" but did not receive it. The Registered Dietitian (V17) stated that when she recommends fortified foods, she enters these recommendations into the kitchen platform so they appear on the facility meal tickets, and that fortified foods do not appear on the Physician Order Sheet but should be provided if they appear on the meal ticket. The Assistant Dining Service Director (V6) stated that the facility no longer has magic cup, that residents are to receive fortified pudding instead, and that servers are supposed to plate fortified pudding in bowls and place them on the tray with the rest of the meal. Despite this, the fortified items indicated on the meal tickets were not served to the identified residents. Care plans for all six residents documented nutritional concerns and included interventions to provide fortified foods: R18 and R95 were noted to be at increased nutritional risk or at risk for unintentional weight loss related to advanced age, impaired cognition, and variable intake; R35, R45, and R64 had histories of inadequate intake and weight loss; and R78 had inadequate intake related to early satiety with observed 50% meal consumption. The Registered Dietitian confirmed that she recommended fortified pudding or magic cup for these residents due to either past significant weight loss or inconsistent intake, and that if fortified foods appear on the meal ticket, the resident should receive them.
Failure to Follow Menu-Directed Portion Sizes for Mechanical Soft Diets
Penalty
Summary
The facility failed to follow its planned menu spreadsheets and portion guidelines for residents on mechanical soft (dental soft) diets, resulting in incorrect entrée portions being served. The diet menu spreadsheet for a Tuesday (week 2) specified that residents were to receive a 4 oz portion of bacon wrapped beef, and for those on dental soft diets, the spreadsheet directed use of a #8 gray scoop of ground chopped beef steak with gravy, which the facility’s color-coded scoop chart identified as equivalent to 4 oz. During an observed meal service in the kitchen steam table area, the server (V16) instead used a #12 green scoop, equivalent to 3 oz, to serve the ground chopped beef steak to four residents on dental soft diets (R73, R96, R117, and R119), contrary to the menu spreadsheet instructions. The registered dietitian (V17) later confirmed that the scoop size shown on the menu should have been used to ensure residents received the correct portions to meet their planned caloric and nutritional needs, and the diet roster printed shortly before the observation verified that these residents were ordered dental soft (mechanical soft) diets. The deficiency centers on the discrepancy between the facility’s written menu and portion control system and the actual practice observed during meal service, specifically the use of a smaller scoop than prescribed for the main entrée for residents requiring mechanical soft diets.
Failure to Follow Mechanical Soft Diet Guidelines During Meal Service
Penalty
Summary
The facility failed to follow prescribed mechanical soft (dental soft) diet guidance for multiple residents during meal service. During an observed meal on the 2nd floor, several residents with diet orders for dental soft/mechanical soft received whole corn as a vegetable, despite their meal tickets indicating soft and chopped green beans as the selected vegetable option. Another resident on a mechanical soft diet received a 4 oz cup of chopped fruit that included chunks of raw pineapple. The facility’s dietitian later stated that residents on mechanical soft diets are allowed only chopped canned fruits and soft, cooked vegetables, and the Assistant Director of Dining Services confirmed that if green beans were circled, those residents should have received green beans and that pineapple chunks are not served on mechanical soft diets. The facility’s written policy on Mechanical Altered Diets specifies that vegetables must be cooked soft, moist, and fork-tender with no large chunks or pieces, and that only soft, peeled fresh fruits such as peaches, nectarines, melon without seeds, and sliced banana are allowed, indicating that the foods served did not conform to the established mechanical soft diet guidelines. These observations, interviews, and record reviews showed that all reviewed residents on mechanical soft diets did not consistently receive food prepared in a form designed to meet their individual diet orders and the facility’s own mechanical soft diet policy.
Failure to Provide Required ADL Assistance With Feeding and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), including dining and incontinence care, to residents who were unable to perform these tasks independently. One resident with Parkinson’s disease, dysphagia, and documented self-care and functional mobility deficits had a physician order indicating staff should now feed him and a care plan noting inadequate oral intake with an intervention to provide dining assistance as necessary. Despite this, staff repeatedly delivered meal trays without providing feeding assistance or encouragement. On multiple observed occasions in the dining room, the resident ate only portions of the meal and then stated he was done, with no staff assistance or prompting. During a breakfast observation, a CNA left the resident in bed with dry cereal, juice, and milk and did not assist, later stating the resident did not need help, even though the resident consumed only a small portion and spilled most of the juice. The registered dietician stated there was an order for 1:1 feeding and that the resident should be fed in the dining room, while dietary leadership explained that 1:1 feed orders do not automatically appear on diet tickets and rely on nursing to notify dietary and CNAs. Another resident with dementia, a leg fracture, neuropathy, and hip pain had a care plan documenting bowel incontinence with an intervention to check the resident every two hours. Surveyors observed this resident lying in bed in a gown with a strong bowel odor and multiple cups of red-colored beverages on a bedside table initially positioned a few feet away and later over the bed, with flies flying around her. A CNA reported that the last personal care and change for this resident had been provided several hours earlier in the morning. The same CNA later stated that for residents who do not use the call light, she typically checks them for incontinence care at the beginning of the shift, around breakfast and lunch, and every 2.5 to 3 hours, while the DON stated residents should be checked every two hours and as needed. Facility grievance logs and resident council reports over several months documented multiple concerns regarding ADLs. Facility policies on ADLs and incontinence care state that residents unable to carry out ADLs independently will receive appropriate services to maintain good nutrition, personal hygiene, and incontinence care based on individual needs and service plans.
Failure to Assess and Manage Pain During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and manage pain for a resident with a recent left femur fracture and dementia who experienced significant pain during routine care. The resident was admitted with a diagnosis of left femur fracture and post-surgical care, with documentation that she felt pain when turning and complained of left hip pain with movement. Physician orders included monitoring pain level and location each shift and multiple PRN and scheduled analgesic orders, including acetaminophen and hydrocodone-acetaminophen for moderate to severe pain. The care plan documented that the resident was on pain medication therapy related to pain, with an intervention to administer analgesics as ordered. On the observed date, a CNA reported that the resident screamed and yelled when touched, and surveyors observed the resident screaming and yelling in pain and calling for help during incontinence care. The resident’s meal tray remained untouched because she declined to have her bed raised due to pain and preferred not to be moved. The CNA stated she had asked the nurse about pain medication, and the nurse initially told her she did not know if the resident had any medication orders. The nurse later stated she was waiting for the CNA to finish incontinence care before administering pain medication, despite the resident’s active pain medication orders. The DON stated that when a resident exhibits significant pain during incontinence care, the nurse should assess the pain, medicate prior to care if possible, and, if the resident cannot tolerate care, wait and re-approach after pain is addressed. The facility’s policies on ADLs and pain management require recognizing and evaluating pain, anticipating pain with activities such as repositioning, and pre-medicating when possible, which was not done in this case.
Crushing of ER Medication and Omission of Ordered Laxative Result in Elevated Med Error Rate
Penalty
Summary
The deficiency involves failure to follow physician orders and facility policy during medication administration, resulting in a medication error rate above 5 percent. During a medication pass observation, a nurse (V4) administered Metoprolol Succinate ER 50 mg to a resident (R100) by crushing the extended-release tablet before giving it. Facility Medication Crushing Guidelines revised January 2018 state that time-release tablets, which are designed to release medication over 8 to 24 hours, should not be crushed. The facility’s Medication Administration Policy dated June 1, 2023, requires that medications be administered in accordance with written prescriber orders and established procedures. In the same observation and subsequent medication reconciliation, surveyors identified that R100 had a physician’s order for Polyethylene Glycol 3350 (Miralax) 17 grams powder for oral solution on the Medication Administration Record (MAR), but this medication was not administered by V4 during the morning medication pass. When interviewed later that morning, V4 stated that the medications observed being given were the only morning medications the resident had, despite the active Miralax order. Overall, there were 28 medication opportunities with 2 errors, resulting in a 7.14% medication error rate, exceeding the 5 percent threshold.
Failure to Follow Hand Hygiene and Glove-Change Practices During ADL Care
Penalty
Summary
The deficiency involves failure to follow the facility’s infection prevention and control policy regarding hand hygiene and glove use during ADL care. A CNA assisted one resident with toileting and peri care after voiding, then applied a new incontinence brief and pulled up the resident’s pants while continuing to wear the same soiled gloves. Another CNA provided incontinence care to a resident who had a bowel movement, removed the soiled brief, cleansed the perineal area, applied barrier cream, and placed a new incontinence brief without changing gloves during the entire process. In a separate incident, a CNA assisted a resident with dressing while the resident had an indwelling catheter and wore shoes used for wheelchair propulsion. During this care, the CNA touched the catheter bag, the resident’s clothing, the resident’s shoes with dirty soles, and other surrounding surfaces, moving repeatedly between dirty and clean tasks without changing gloves. The DON later stated that staff are required to perform hand hygiene and change gloves when moving from dirty to clean tasks during ADL care. The facility’s written Standard Precautions policy requires hand hygiene after contact with blood, body fluids, excretions, intact skin, and inanimate objects in the resident’s vicinity, and requires changing gloves when moving from a contaminated body site to a clean body site.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to obtain monthly weights and recognize significant weight loss for a resident, resulting in a 12.47% weight loss over 90 days. The resident, who was admitted with a weight of 152 pounds, reported dissatisfaction with the facility's food, describing it as bland and unappealing. Despite a physician's order for monthly weights and a mechanical soft diet, the resident's weight was not consistently documented, and no supplements were provided. The resident's weight was last accurately recorded on 5/9/24 at 143.6 pounds. Subsequent weights were either struck out or not documented, with no accepted weight recorded until 8/7/24, when the resident weighed 125.7 pounds. The Clinical Nutrition Manager/Dietician had requested reweights multiple times via email, but these requests were not acted upon, and the resident's significant weight loss went unrecognized. The Director of Nursing acknowledged the oversight, citing communication issues and staff changes as contributing factors. The facility's policy required monthly weights and reweights for significant changes, but these procedures were not followed, leading to the resident's weight loss going unnoticed. The resident's care plan included monitoring weight and honoring food preferences, but these interventions were not effectively implemented.
Deficiencies in Food Storage and Expiration Management
Penalty
Summary
The facility failed to manage food storage and expiration effectively, impacting all 98 residents who consume food from the kitchen. During an inspection, expired food items were found in the dry storage area, including peanuts, pistachios, almonds, and a dessert sauce. The dietary manager acknowledged that it is everyone's responsibility, especially the stock person, to check and discard expired food items. Additionally, the freezer contained opened provolone cheese without a date or label, which the dietary manager admitted should have been labeled and discarded. Further observations revealed significant ice buildup around the walk-in freezer door, floor, and on food packages, including meat rolls and white fish. The chef, a contracted worker, stated that maintenance had been notified weeks ago about the condensation issues, but no action had been taken despite a work order being placed. The facility's Food and Supply Storage policy requires covering, labeling, and dating unused portions, as well as discarding food past its expiration date, which was not adhered to in this instance.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for residents who were dependent on staff for personal hygiene and grooming. This deficiency was observed in 10 out of 10 residents reviewed for ADLs in a sample of 34. Residents were found with long, unkempt fingernails, some with a dark substance underneath, and female residents with facial hair, which they expressed a desire to have removed. Despite the residents' needs and preferences being documented in their care plans, the staff did not provide the necessary assistance. For instance, one resident was observed with long chin hairs and expressed a desire for them to be removed, but the staff did not assist. Another resident had long, dirty fingernails with a dark substance underneath, and despite expressing a desire for nail care, the staff did not provide the necessary assistance. The facility's policy stated that residents unable to perform ADLs independently should receive the necessary services to maintain grooming and personal hygiene, yet this was not adhered to. Interviews with staff, including CNAs and the Director of Nursing, confirmed that residents should not have long or dirty fingernails and that female residents should not have facial hair for dignity reasons. The staff acknowledged their responsibility to provide grooming and personal hygiene assistance, yet the observations and resident statements indicated a failure to meet these expectations. The facility's policy also emphasized the importance of providing care in accordance with the residents' care plans, which was not followed in these instances.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols during incontinence care, wound care, and meal service, affecting six residents. A CNA was observed delivering meals to residents without wearing gloves and failed to clean her hands between tasks, such as adjusting personal items and cutting food. This lack of hand hygiene was consistent across multiple interactions with residents, including handling personal items and food without cleaning hands or changing gloves. During wound care for a resident, a wound care nurse and a CNA did not follow proper infection control procedures. The CNA did not wear a gown while assisting with wound care, and the nurse failed to clean her hands after removing gloves and before applying new ones. Additionally, the nurse left the room without removing her gown and gloves, and the CNA touched various surfaces with dirty gloves. These actions were contrary to the facility's hand hygiene policy, which mandates hand cleaning between resident contacts and after handling contaminated objects. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them. A wound care nurse did not wear a gown while providing care to residents on EBP, despite the facility's policy requiring PPE during high-contact care activities. This oversight was acknowledged by the staff involved, who admitted to not following the necessary precautions. The facility's policies clearly outlined the need for PPE during wound care, yet these guidelines were not followed, leading to potential cross-contamination and infection risks.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, which is a critical aspect of accommodating their needs and preferences. This deficiency was observed in three residents, each with significant medical conditions and cognitive impairments. For instance, one resident with type 2 diabetes, dementia, and other serious health issues was left without access to a call light after receiving incontinence care. Another resident, who had congestive heart failure and moderate cognitive impairment, was found with their call light underneath the blankets, out of reach. A third resident, who was cognitively intact but required substantial assistance for daily activities, had their call light hanging off the side of the bed, making it inaccessible. Interviews with staff, including CNAs and the Director of Nursing, confirmed that call lights should always be within easy reach of residents, whether they are in bed or in a chair. The facility's policy also mandates that call lights be accessible to residents at all times. Despite this, the observations on the specified date revealed that the staff did not consistently adhere to this policy, resulting in residents being unable to call for help when needed. This oversight in ensuring the availability of call lights poses a significant risk to resident safety, particularly for those with mobility and cognitive challenges.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite two residents, R45 and R68, to their care plan meetings, which is a requirement for ensuring resident involvement in their own care. R45 reported that she had not attended or been invited to a care plan meeting since her admission to the facility. Similarly, R68 and her son, V8, confirmed that neither had been invited to or attended any care plan meetings since R68's admission. The facility's records lacked documentation of any invitations or attendance for these residents and their representatives. The facility's policy mandates that residents and their representatives be involved in developing and revising care plans, with documentation required if their participation is deemed impractical. However, during the survey conducted from August 6 to August 8, 2024, no such documentation was found for R45 and R68. The facility administrator acknowledged the requirement for resident and representative involvement and documentation but could not provide evidence of compliance for these two residents.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the preferences and needs of two residents, as required by their comprehensive assessments and care plans. Resident R45 reported that she was not offered any activities while in her room, despite her care plan indicating a preference for in-room activities and pop-in visits. Documentation showed only three activity entries over a month, and the Life Enrichment Director confirmed that staff are expected to offer and document daily activities, which was not done in this case. Similarly, Resident R68 expressed dissatisfaction with the lack of activities provided, specifically mentioning a desire to play computer games. Her care plan also indicated a preference for in-room activities and pop-in visits, yet documentation showed only four entries over a month. Staff interviews revealed that activities were not consistently offered to residents who stayed in their rooms, contradicting the facility's policy to support residents' activity choices. The facility's administrator acknowledged that activity staff should check on all residents daily to maintain their quality of life.
Failure to Provide Restorative Nursing Programs for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide restorative nursing programs to residents identified with limited range of motion, affecting three residents in the sample. Resident R53, who was observed in bed with limited range of motion in both arms and inwardly turned feet, reported not receiving exercises from the facility. The Director of Rehab confirmed that R53 was discharged from occupational therapy with recommendations for an active range of motion restorative nursing program, but no such program was implemented. R53's medical history included multiple diagnoses such as polyosteoarthritis and muscle weakness, and the MDS indicated functional limitations in both upper and lower extremities. Resident R8, observed in a wheelchair and unable to raise her right arm, also reported inconsistent assistance with exercises. Her medical history included conditions like diabetes and congestive heart failure, and the MDS showed moderate cognitive impairment and functional limitations in both upper and lower extremities. Despite these needs, R8 did not have physician orders or care plans for restorative nursing programs. Resident R55, with a dislocated left shoulder and multiple diagnoses including Parkinson's Disease and muscle weakness, expressed a desire for exercises to prevent further decline. The Director of Nursing acknowledged the absence of a restorative nurse and stated that restorative programs were not being carried out, despite recommendations from therapy. The facility's policy emphasized the importance of restorative services, but these were not being provided, leading to potential declines in residents' conditions.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall mats were properly placed for a resident identified as being at high risk for falls. Observations over several days revealed that the resident's fall mats were either folded against the wall or only placed on one side of the bed, and the bed was not consistently in the lowest position. Interviews with multiple CNAs and an LPN confirmed that the standard practice for residents at high risk of falls includes having fall mats on both sides of the bed, the bed in the lowest position, and frequent monitoring. However, these measures were not consistently implemented for the resident in question. The resident, who was admitted with conditions such as aphasia, atherosclerosis, a fracture of the right femur, hypertension, cognitive communication deficit, muscle weakness, and anemia, was noted to be cognitively intact. The resident's care plan, which included interventions like bilateral floor mats due to a high risk of falls, was not followed as observed. The facility's Fall Prevention and Management policy outlines the development of a comprehensive fall prevention care plan, but the facility was unable to provide a specific Fall Intervention policy when requested.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,549 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lemont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lemont Nursing & Rehab Center | 1.1 mi | ★★★★★ | 27 | 0 |
| Aliya Of Palos Park | 3.2 mi | ★★★★★ | 6 | 0 |
| Victorian Village Hlth & Well | 4.3 mi | ★★★★★ | 1 | 0 |
| Meadowbrook Manor | 5.7 mi | ★★★★★ | 9 | 0 |
| Chateau Nrsg & Rehab Center | 6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.