Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenup Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to follow its policy requiring 72-hour post-fall neurological assessments for three residents who experienced unwitnessed falls and head trauma, including two residents on Eliquis. One resident had multiple falls with documented scalp hematomas and later was found to have a subdural hematoma and skull fracture, yet neuro checks were only ordered and documented for 24 hours after each event. Another resident was found on the floor after calling for help while on anticoagulation, and a third resident had unwitnessed falls with a head hematoma and subsequent floor-sitting episode, with neuro checks again limited to 24 hours. Staff, including LPNs, followed neuro assessment forms that specified only 24 hours of monitoring, while the facility’s written policy required 72 hours, and leadership acknowledged the forms had not been updated to align with the policy.
A resident with moderate cognitive impairment, dependent on staff for transfers and on a blood thinner, was found by a CNA to have a large, painful, dark purple bruise extending from the left breast to the armpit, which had not been present earlier that day and for which neither the resident nor staff could initially identify a cause. The IDT later documented a presumed cause related to two-person transfers with a gait belt and the resident’s combative behavior, and staff noted the bruising pattern could align with gait belt use or leaning over wheelchair armrests. The Administrator and DON believed they could investigate within two hours and, after concluding the bruise was likely from the gait belt, decided it was not an injury of unknown origin and did not report it to the state survey agency, despite facility policy requiring reporting of injuries of unknown source that are unexplained, unobserved, and suspicious due to their extent or location.
A resident with moderate cognitive impairment, dependent on staff for transfers and on anticoagulation therapy, was found by a CNA to have extensive dark purple bruising on the left side from breast to underarm, with the resident unable to explain the cause and showing pain on touch. The CNA and an LPN reported that the bruising had not been present earlier, there were no known falls or incidents, and neither staff nor the resident initially knew the cause, though the pattern could align with a gait belt or leaning on wheelchair armrests. The Administrator and DON later concluded the bruising was caused by a gait belt during transfer and did not treat it as an injury of unknown origin, but there was no documentation of a thorough investigation, including staff interviews or statements, as required by facility policy for injuries of unknown source.
Two residents with cognitive impairment and high fall risk experienced multiple unwitnessed falls, including events resulting in serious injuries such as rib fractures, pneumothorax, subdural hematoma, and skull fracture. The facility did not resume ordered 15‑minute checks after one resident’s hospital return, did not consistently document when residents were last checked or toileted before falls, and did not conduct complete fall investigations with staff interviews. Serious injuries identified in hospital records were not fully reported or investigated, and post‑fall interventions were either not documented, not implemented, or limited to generic measures such as signage and encouraging call light use, contrary to the facility’s own fall reduction policy.
A resident with severe dementia and behavioral disturbances repeatedly physically assaulted other cognitively impaired residents, including kicking, hitting, and slapping, despite a care plan requiring one-on-one supervision during aggression. These incidents were witnessed and documented by staff and other residents, and the facility's policy states residents must be free from abuse.
The facility did not submit required final investigation reports to the state agency after incidents where a resident physically assaulted two others, and failed to investigate another altercation involving residents with cognitive and behavioral impairments. The administrator acknowledged that while initial reports were made, final reports were not completed or submitted as required by policy.
The facility did not maintain the required RN coverage of at least eight consecutive hours per day, seven days a week. The nurse schedule for September showed no RN coverage on four specific dates, and during the survey, it was confirmed that the facility employs only two RNs, leading to some weekends without the necessary coverage. This deficiency potentially affects all 36 residents.
The facility failed to employ a qualified Director of Food and Nutrition Services, potentially affecting all 36 residents. The Dietary Manager was observed supervising dietary operations without the necessary certification or further education beyond a high school diploma. The Administrator confirmed the lack of required qualifications for the role.
The facility failed to employ dietary staff with the necessary certifications, affecting all 36 residents. An uncertified dietary manager and another staff member were observed handling food without the required Food Handlers and Food Sanitation certifications. The administrator confirmed the lack of certifications, violating Illinois Public Act requirements for food handlers in nursing homes.
The facility failed to honor dietary preferences and provide appropriate substitutes, affecting all 36 residents. A resident reported being served greasy beef and noodles with limited substitute options. Another resident received orange juice despite disliking it, and dietary staff admitted to not checking diet cards. Residents also reported a lack of condiments with meals.
The facility failed to serve breakfast on time to all 36 residents, with delays caused by the cook arriving late and the Dietary Manager being occupied with other tasks. Residents waited over an hour past the scheduled breakfast time, leading to frustration and unmet expectations.
The facility's kitchen was found to have unsanitary conditions, including grease build-up on floors, rusted and dirty food preparation areas, and improperly maintained equipment like a can opener with metal fragments. The Dietary Manager was unaware of proper cleaning procedures, and dishware was not air-dried correctly due to insufficient shelving. These issues posed potential cross-contamination and food-borne illness risks for all 36 residents.
The facility failed to establish a water management program to prevent Legionella growth, affecting 36 residents. The Maintenance Director admitted to conducting water testing for the first time in six years and identified 17 dead-end pipes. The facility lacked documentation of a risk assessment and monitoring protocols, and the Maintenance Director did not follow the Legionella Policy, including system flushing and shower head disinfection.
The facility failed to maintain kitchen equipment, affecting all residents. A gas-like odor was detected due to a malfunctioning exhaust fan, and the kitchen's food processor was inadequate for preparing pureed meals, resulting in improperly textured food. Additionally, the sanitization sink was non-functional, causing water leakage and requiring repeated dishwashing.
The facility failed to maintain a clean and comfortable environment in two resident-shared shower rooms, affecting all 36 residents. Observations revealed black mold-like substances, cracked concrete, and poor ventilation. The administrator and maintenance director indicated that previous management was aware but did not allocate funds for repairs, violating residents' rights to a clean and comfortable home-like environment.
The facility failed to maintain the dignity of residents during dining, as residents with severe cognitive impairments were left to eat at a soiled table without staff intervention. One resident, with multiple medical diagnoses, was observed with food smeared on her face and clothing, yet staff did not assist her in cleaning up during the meal.
The facility failed to maintain sanitary conditions for respiratory care equipment for two residents with chronic respiratory conditions. One resident's oxygen tubing was not changed as ordered and was found coiled on the floor, while another resident's oxygen tubing, CPAP mask, and nebulizer equipment were soiled and undated. The facility's policies for equipment maintenance were not followed, and the administrator confirmed the lack of documentation and adherence to these policies.
The facility failed to serve palatable and visually appealing meals, affecting several residents. One resident reported greasy beef and noodles, while another received soupy oatmeal. Multiple residents complained about cold and unappetizing food during a Resident Council Meeting. The facility's dining policy, which emphasizes nourishing and attractive meals, was not adhered to in these instances.
A facility failed to provide a resident with an Advance Beneficiary Notice (ABN) at the end of a Medicare Part A covered stay, affecting the resident's right to continue or decline therapy services at their own expense. The resident did not receive the necessary notification, although other residents did. The facility administrator acknowledged the oversight.
A facility failed to issue a written bed hold notice to a resident's family member following the resident's emergency hospital transfer due to chest pain, SOB, tachycardia, and low BP. The administrator confirmed the notice was not sent, violating the facility's policy requiring notice within 24 hours of discharge.
A resident with Dementia and Depression experienced a significant weight loss of 5.86% in less than a month, dropping from 239 to 225 pounds. Despite recommendations for nutritional supplements, there was no documentation of physician notification or implementation of dietary changes. The facility's protocols require notifying the physician of such weight loss, but this was not done, as confirmed by the Director of Nurses and the Administrator.
The facility failed to label and document expiration dates for medications for two residents and did not secure a convenience box after medication removal for another resident. An LPN was unable to provide expiration dates for medications, and the convenience box was left unsecured without proper documentation of red tab numbers. The DON confirmed the procedures for securing the convenience box.
A resident with dementia and anxiety was administered Lorazepam multiple times without proper documentation of follow-up assessments. The facility's policy requires detailed documentation of behavioral changes, which was not followed, leading to a deficiency.
A facility failed to maintain accurate controlled medication records for a resident receiving oxycodone. Discrepancies were found between the medication administration record and the controlled medication count sheet, with staff failing to document all doses and making calculation errors. The count sheet showed corrections and a late entry for medication administered earlier.
A resident with a history of falls and multiple medical conditions was not provided with an updated comprehensive care plan after experiencing two falls. The existing care plan was a baseline from admission and lacked specific interventions for recent falls. The DON confirmed the care plan was outdated and required updating.
A resident with a history of falls and complex medical conditions, including a right humeral shaft fracture and subarachnoid hemorrhage, experienced two falls while attempting to use the bathroom. The facility failed to update the resident's Plan of Care with necessary fall prevention interventions, such as frequent toileting, despite the resident's dependency on staff for transfers and toileting. The Director of Nursing confirmed the lack of updated interventions, contributing to the deficiency.
Failure to Complete Required 72-Hour Post-Fall Neuro Checks After Head Trauma and Anticoagulant Use
Penalty
Summary
The deficiency involves the facility’s failure to complete post-fall neurological assessments for the full 72 hours required by its own policy for three residents who experienced falls, some with head impact and anticoagulant use. One resident (R3) had multiple falls with head trauma documented: on 2/20/26, R3 was found on the floor in the day room; later that evening, R3 fell again and sustained an 8 cm by 7.5 cm hematoma to the back of the head; on 2/23/26, R3 fell backwards after standing with a blanket at her feet and developed a scalp hematoma on the right side/back of the head; on 3/13/26, R3 was found on the floor near the sink with a small hematoma on the back of the head; and on 3/16/26, R3 was found crawling on the floor with an open area to the left/back side of the head. Neurological Assessment Flow Sheets for these dates directed assessments every 15 minutes x4, then hourly x4, then every 4 hours x19 (total 24 hours), and there was no documentation that neurological assessments were continued for the full 72 hours after each fall. R3’s hospital discharge summary and head CT documented a recent fall with multiple rib fractures, a tiny right anterior pneumothorax, a subdural hematoma, and a non-displaced right occipital skull fracture. Staff LPNs reported that they completed post-fall neurological assessments for 24 hours, consistent with the forms, not the 72-hour policy. Another resident (R1) had an unwitnessed fall, was found sitting on the floor after yelling for help, and neurological assessments were initiated. R1’s medication record showed ongoing Eliquis 2.5 mg twice daily, and the Neurological Assessment Flow Sheet specified completion for 24 hours post fall, with no documentation of continuation to 72 hours. A third resident (R2), also on Eliquis 2.5 mg twice daily, had an unwitnessed fall while walking with a walker and later had a small hematoma and bruising to the back of the head documented. R2 had another event where the spouse reported the resident sat on the floor and denied head impact, and neurological checks were initiated. For both the 2/21/26 and 3/3/26 events, the Neurological Assessment Flow Sheets indicated 24-hour monitoring, with no documentation of 72-hour assessments. The Regional Administrator stated that facility policy requires 72 hours of post-fall neurological assessments, but when ownership changed in January 2026, the forms were not updated from 24-hour to 72-hour monitoring to match the policy, and the Administrator was unable to find documentation of neurological assessments beyond the 24-hour forms. The facility’s written policies specified detailed neurological assessment intervals extending through every shift x7, which were not reflected in practice or documentation.
Failure to Report Injury of Unknown Origin to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the state survey agency as required by its Elder Justice Act and Reporting Suspected Crimes Against Residents policy. A resident with moderate cognitive impairment, dependent on staff for transfers, and receiving Eliquis 2.5 mg twice daily, was found on one evening to have extensive dark purple bruising on the left side, extending from the mid-breast over the nipple to under the left armpit, measuring 7.5 cm by 27 cm. The bruising caused pain when touched, and the physician, family, and Administrator were notified. The resident was unable to explain what had happened due to cognitive impairment, and there was no documentation of any incident, fall, or trauma that would account for the injury. Staff interviews and documentation showed that the bruising had not been present earlier that same day, and neither the CNA who discovered it, the LPN, nor the resident could identify a cause at the time it was found. The facility’s interdisciplinary team later documented a presumed root cause related to two-person transfers with a gait belt and the resident’s combative behavior during transfers, and staff noted that the bruising pattern could align with a gait belt or with the resident leaning over wheelchair armrests. The Administrator and DON stated they believed they had two hours to investigate and, having concluded the bruising was caused by the gait belt, determined it was not an injury of unknown origin and therefore did not report it. This decision was inconsistent with the facility’s policy definition of an injury of unknown source, which includes injuries not observed by anyone, not explainable by the resident, and suspicious due to extent or location, and which identifies such injuries as reportable to the state survey agency.
Failure to Thoroughly Investigate Extensive Bruising Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate a significant injury of unknown origin for one resident. The resident had moderate cognitive impairment, was dependent on staff for transfers, and was receiving Eliquis, an anticoagulant. A nursing note documented that a CNA alerted the nurse to extensive dark purple bruising on the resident’s left side, extending from the mid-breast over the nipple to under the left armpit, measuring 7.5 cm by 27 cm. The resident was unable to explain what happened due to cognitive status and showed signs of pain when the area was touched. The interdisciplinary team later documented the root cause as likely related to use of a gait belt during two-person transfers with a combative resident and noted an intervention to in-service staff on proper gait belt placement. Despite this conclusion, there was no documentation of an investigation or staff interviews/statements to determine the cause of the injury. The Administrator stated that the bruising was identified as due to a gait belt within two hours and therefore was not considered an injury of unknown origin and was not reported as such. However, the CNA who discovered the bruising reported that it had not been present earlier, that there had been no falls or incidents during the shift, and that neither the nurse nor the resident knew what caused it at the time; the CNA stated the bruising could align with a gait belt or with the resident leaning over wheelchair armrests. The LPN confirmed that when the bruising was reported, they were not sure what caused it and that the resident was confused. The DON and Administrator reported that they conducted an investigation and obtained information from therapy and CNAs suggesting the gait belt caused the bruising, but the Administrator acknowledged having no documentation of the investigation, including staff interviews or statements, despite facility policy requiring maintenance of evidence of a thorough investigation and reporting of injuries of unknown source that meet specified criteria.
Failure to Thoroughly Investigate Falls and Implement Effective Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and fall interventions for residents at high risk for falls. One resident with dementia, osteoporosis, severe cognitive impairment, and a documented history of multiple recent falls was assessed as high risk for falls, with care plan interventions including 15‑minute checks and anticipating toileting needs. This resident was hospitalized after a recent fall with multiple rib fractures, a pneumothorax, a subdural hematoma, and a skull fracture. The facility’s investigative file and report to the state survey agency addressed the rib fractures and pneumothorax but did not identify, report, or investigate the subdural hematoma or skull fracture, despite hospital and CT documentation of these injuries and no prior subdural hematoma on earlier CTs. After this resident returned from the hospital, there was no documentation that the 15‑minute checks were resumed, and the CNA task for these checks was inactive. The resident experienced an unwitnessed fall in the early morning hours, with staff hearing a thud and finding the resident on the floor with urine on the floor and the incontinence brief on the floor, and a small hematoma on the back of the head. Nursing notes and fall investigation documents did not identify when the resident was last checked or toileted prior to the fall, and staff interviews later indicated the resident had last been seen sleeping around 2:00–3:00 AM. A subsequent unwitnessed fall occurred days later, when the resident was found crawling on the floor with an open area on the back/left side of the head; again, the fall investigation lacked staff interviews documenting the last check or toileting, and there was no documented post‑fall intervention or care plan update for this event. A stationary dining room chair remained in the resident’s room despite the DON stating its removal was the intervention. Another resident with moderate cognitive impairment and dependence on staff for transfers and toileting had an unwitnessed fall, being found sitting on the floor after yelling for help. The fall investigation for this resident did not include staff statements or interviews to determine when the resident was last checked on or toileted prior to the fall. For this fall, the documented post‑fall interventions were limited to “call don’t fall” signage and encouraging use of the call light. These practices did not align with the facility’s own Fall Reduction policy, which requires thorough review of falls, identification of root causes, development and revision of care‑planned interventions after each fall, and weekly review of events by the DON or designee and the Quality Assurance Committee to ensure objectives of the policy are met.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, specifically involving a resident with severe dementia and behavioral disturbances. This resident, who was documented as severely cognitively impaired and exhibiting physical and verbal aggression, was involved in multiple incidents where she physically assaulted other residents. These incidents included kicking another resident on the shin resulting in a hematoma, hitting a resident on the shoulder during a group activity, slapping another resident on the arm multiple times, and kicking a resident who was found in her bed. All of these incidents were witnessed by staff or other residents and were documented in incident reports. Despite the resident's known history of aggression and a care plan that called for one-on-one supervision during episodes of aggression, the facility did not prevent repeated physical abuse of other cognitively impaired residents. The facility's own policy states that residents have the right to be free from abuse, including resident-to-resident abuse, yet the aggressive resident was able to continue these behaviors. The administrator confirmed the pattern of physical aggression and acknowledged these incidents as examples of physical abuse.
Failure to Submit Final Abuse Investigation Reports to State Agency
Penalty
Summary
The facility failed to submit final investigation reports regarding allegations of abuse to the state surveying agency as required by its own Abuse, Prevention, and Prohibition Policy. The policy mandates that any allegation of abuse or neglect be reported to the mandated state agency and that a final report be submitted following an investigation within five business days. However, for two separate incidents where one resident physically assaulted two other residents, the administrator confirmed that while initial reports and investigations were completed, the final investigation reports were not compiled or submitted to the state agency. Additionally, another incident involving a resident kicking another was not investigated, and no final report was sent. The incidents involved residents with significant medical and cognitive impairments, including diagnoses such as dementia with behavioral disturbances, muscle weakness, and major depressive disorder. One resident's progress notes documented a change in condition following a physical altercation, yet no investigation or final report was completed for this event. These failures affected three of five residents reviewed for abuse in the sample and were confirmed through interviews and record reviews.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. This deficiency was identified through observation, interview, and record review during the facility's Annual Certification Survey. Specifically, the nurse schedule for September 2024 showed no RN coverage on four specific dates: 9/7/24, 9/8/24, 9/21/24, and 9/22/24. On 9/22/24, at the time of the surveyors' entrance at 7:55 AM, there was no RN on duty. The Director of Nurses confirmed that the facility employs only two RNs, resulting in some weekends lacking the required eight hours of consecutive RN coverage. The facility's assessment indicated that staffing would be based on residents' needs to provide competent support and care, yet this requirement was not met, potentially affecting all 36 residents residing in the facility.
Unqualified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a qualified Director of Food and Nutrition Services, which has the potential to affect all 36 residents residing in the facility. On the morning of September 23, 2024, the Dietary Manager, identified as V9, was observed actively supervising dietary operations and food preparation in the facility kitchen. During an interview, V9 admitted to not having a dietary management certification and only possessing a high school diploma with no further education. Later that day, the facility Administrator, identified as V1, confirmed that V9 had not taken any Dietary Manager classes to qualify as a Director of Food Services. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated September 22, 2024, documented that 36 residents reside in the facility.
Lack of Certified Dietary Staff in Facility
Penalty
Summary
The facility failed to employ dietary support staff with the necessary competencies to effectively carry out the functions of the food and nutrition service, potentially affecting all 36 residents. On two separate occasions, it was observed that the dietary manager and another staff member were actively involved in food handling without the required certifications. The dietary manager, who was supervising kitchen operations, did not possess a Food Handlers certification or a Food Sanitation certification. Similarly, another staff member was observed plating residents' food without a Food Handlers certification. The facility administrator confirmed the lack of certifications for both individuals. This deficiency is in violation of the Illinois Public Act, which mandates that food handlers in non-restaurant settings, such as nursing homes, must complete the necessary training.
Failure to Honor Dietary Preferences and Provide Substitutes
Penalty
Summary
The facility failed to provide a substitute menu, honor residents' preferences, and provide appropriate condiments, affecting all 36 residents. On one occasion, a resident reported that the facility served beef and noodles with excessive grease, and the only available substitute was a bologna sandwich. The administrator confirmed the absence of a substitute menu, offering only limited options like peanut butter and jelly or lunch meat sandwiches. Additionally, a resident was served orange juice despite their diet card indicating a dislike for it, and the dietary assistant admitted to not checking the diet card due to a lack of apple juice. Another incident involved a resident being served peas, which they disliked according to their diet card. The dietary staff acknowledged the oversight. During a Resident Council Meeting, residents expressed concerns about the lack of condiments with meals, requiring them to request and wait for them. The facility's policy emphasizes providing an exceptional dining experience, but these incidents indicate a failure to adhere to residents' dietary preferences and needs.
Delayed Breakfast Service for Residents
Penalty
Summary
The facility failed to provide breakfast in a timely manner to all 36 residents on the morning of 9/24/24. Residents were observed waiting in the main dining room with beverages but no food, despite breakfast being scheduled to be served between 7:15 am and 7:30 am. A resident expressed frustration, stating they had been waiting for over an hour. The delay was attributed to the cook, who overslept and arrived at the facility at 6:52 am, just 23 minutes before the scheduled breakfast time. The Dietary Manager, who arrived at 5:00 am, did not prepare meals as she was occupied with a food delivery and cleaning tasks. The Administrator acknowledged the delay and confirmed the expectation for breakfast service timing.
Unsanitary Kitchen Conditions and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitization and cleanliness in its kitchen, leading to potential cross-contamination and food-borne illness risks for all 36 residents. During an initial tour, surveyors observed a significant build-up of sticky, dark black and brown grease-like debris on the floors throughout the kitchen, dishwashing station, dry storage, and cooks' food service line. The Dietary Assistant confirmed the condition but was unsure of the cleaning responsibilities. A follow-up tour with the Dietary Manager revealed unchanged conditions, with both the surveyor and the manager's feet sticking to the floor due to the grease build-up. The facility's Registered Dietician had previously noted the need for in-depth mopping in a report dated over a month prior. The kitchen's food preparation areas were also found to be unsanitary. A stainless steel food preparation table had rusted brackets and shelves with a build-up of brown grease-like substance and dust hanging over the table. The commercial table-top can opener was soiled with a build-up of grease, rust, and metal fragments, with a missing blade tip exposing bare metal. The Dietary Manager admitted to not knowing the proper cleaning procedures for the can opener, despite the facility's policy outlining specific cleaning steps. The Registered Dietician had documented the need for cleaning and sanitization of the can opener in two separate inspection reports. Additional issues included two commercial ovens with a significant build-up of charcoal-like food debris and a flat-top grill with a copious amount of grease, including a shoe print from a vent cleaning company worker. The Dietary Manager was unaware of the proper cleaning tools for the grill. Furthermore, dishware was not being air-dried properly, with steam table pans and plates stacked with water between them due to insufficient shelving. These deficiencies were noted in the facility's application for Medicare and Medicaid, which documented the presence of 36 residents.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to establish a comprehensive water management program to prevent the growth of Legionella and other waterborne pathogens, which could potentially affect all 36 residents. The facility's Legionella Policy and Procedure, dated April 20, 2020, requires a risk assessment to identify areas at risk for Legionella growth and the implementation of control measures. However, the facility could not provide documentation of such a risk assessment, nor could it demonstrate a method to monitor and intervene when control limits are not met in the building's water systems. The Maintenance Director, who has been with the facility for six years, admitted to conducting water testing for Legionella risk for the first time recently and identified 17 dead-end pipes where water could stagnate. The Maintenance Director also acknowledged not following the facility's Legionella Policy, including failing to flush the system or clean and disinfect shower heads. There was no familiarity with any monitoring or testing protocols, indicating a significant lapse in the facility's infection prevention and control program.
Kitchen Equipment Malfunction and Inadequate Food Preparation
Penalty
Summary
The facility failed to maintain kitchen equipment in a safe and functional manner, affecting all 36 residents. On one occasion, a strong gas-like odor was detected in the facility's common areas, including the dining room filled with residents. A resident confirmed the odor was coming from the kitchen. The Maintenance Director assessed the kitchen and found no gas leak but identified a malfunctioning range hood exhaust fan as the cause of the odor. The gas company confirmed there were no leaks, and the issue was attributed to a burnt capacitor in the exhaust fan, which had previously caused similar issues. Additionally, the facility's kitchen equipment was inadequate for preparing meals for residents requiring pureed diets. The commercial-sized food processor was non-functional, forcing staff to use a small home-sized processor, which was insufficient for achieving the necessary food consistency. This resulted in improperly pureed meals, as observed with the Salisbury steak, which had a chunky texture. Furthermore, the kitchen's three-well sink was not fully operational, with the sanitization sink unable to hold water, leading to water leakage and requiring pots and pans to be repeatedly run through the dishwasher for cleaning and sanitization.
Facility Fails to Maintain Clean and Comfortable Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in the two resident-shared shower rooms, affecting all 36 residents. Observations revealed black mold-like substances in the mortar between tiles, cracked and chipped concrete slopes, and a build-up of black and brown substances on the walls and baseboards. The shower rooms also had poor ventilation, with corroded ceiling vents covered in thick gray dust and no air movement. Additionally, the shower rooms emitted strong, musty, and foul odors, and the lighting was inadequate, with non-functioning or flickering bulbs. Interviews with the administrator and maintenance director indicated that the previous management was aware of the poor conditions but did not allocate funds for repairs. The maintenance director mentioned that plans for improvements were drawn up but not approved by the previous company. The housekeepers were reportedly responsible for daily cleaning, but the maintenance director acknowledged that this was not happening as it should. The facility's failure to address these issues violated residents' rights to a clean and comfortable home-like environment.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain the dignity of four residents during dining, as observed by surveyors. Residents with severe cognitive impairments, including those requiring substantial assistance for eating, were left to dine at a soiled table. On multiple occasions, food and beverages were smeared across the table and on the residents themselves, with no staff intervention to clean the area or assist the residents. Despite the presence of CNAs and an RN, the mess was not addressed, and the residents continued to eat in an unclean environment. The RN acknowledged the issue, stating that the mess would be bothersome to her, indicating a recognition of the dignity issue. Additionally, one resident with severe cognitive impairment and multiple medical diagnoses, including cerebral palsy and dysphagia, was observed with food smeared on her face and clothing while eating. Despite being in a central location in the dining room, visible to other residents and visitors, staff did not assist her in cleaning her face or changing her soiled clothing protector. This lack of assistance persisted throughout the meal, highlighting a failure to provide a dignified dining experience for the resident.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions for respiratory care equipment for two residents diagnosed with chronic respiratory conditions. For one resident with Congestive Heart Failure and Chronic Obstructive Pulmonary Disease, the oxygen tubing was not changed as per the physician's order, and the tubing was observed coiled on the floor with a date indicating it had not been changed for over two weeks. This resident's treatment administration record noted that the tubing was not changed on one occasion because the resident was asleep, and despite documentation indicating a change, observations showed otherwise. Another resident with Chronic Obstructive Pulmonary Disease and a malignant neoplasm of the lung had similar issues with their oxygen tubing, which was not changed as required and was observed to be discolored and dated from over a month prior. Additionally, this resident's CPAP mask and nebulizer equipment were found to be soiled and undated, with the resident reporting that the CPAP mask was never cleaned and that they had to provide their own replacements. The facility's policies for oxygen and CPAP equipment maintenance were not followed, and the administrator confirmed the lack of documentation and adherence to these policies.
Failure to Provide Palatable and Appealing Meals
Penalty
Summary
The facility failed to provide palatable, resident-preferred temperature, and visually appealing food, affecting four residents. One resident, with no cognitive impairment, reported that the beef and noodles served had an inch-thick layer of grease. Another instance involved the same resident receiving soupy oatmeal, which they refused to eat. Additionally, another resident complained about the food being cold and greasy, particularly the beef and noodles. During a Resident Council Meeting, multiple residents echoed these concerns, describing the food as cold and unappetizing. The facility's policy on dining experience emphasizes that meals should be nourishing, attractive, and palatable, but these standards were not met in the observed instances.
Failure to Provide Advance Beneficiary Notice
Penalty
Summary
The facility failed to provide a resident with an Advance Beneficiary Notice (ABN) at the termination of a Medicare Part A covered stay, which nullified the resident's right to continue therapy services at their own expense or decline therapy services. This deficiency affected one resident out of a sample of three reviewed for Beneficiary Notices. The resident began a Medicare Part A covered stay on November 14, 2023, with the last covered date being March 17, 2024. There was no evidence that the resident received an ABN to inform them of their options regarding therapy services. The facility administrator acknowledged the oversight, stating that the ABN was not given to the resident, although it was provided to other residents. The SNFABN form is intended to inform beneficiaries about their options for care that may not be covered by Medicare, allowing them to decide whether to assume financial responsibility for continued services.
Failure to Issue Bed Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to issue a written bed hold notice to a resident's family member when the resident was transferred to the hospital. This deficiency affected one resident who was reviewed for hospitalization. On August 1, 2024, the resident experienced chest pain, shortness of breath, tachycardia, and low blood pressure, prompting an emergency transfer to a distant hospital via local EMS. The facility's administrator, identified as V1, acknowledged responsibility for sending the written bed hold notice but confirmed that it was not sent to the resident's family member following the hospital transfer. The facility's Bed Hold Guarantee Policy, dated August 1, 2017, mandates that the notice be given at the time of discharge or within 24 hours, which was not adhered to in this instance.
Failure to Monitor and Report Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address a resident's significant weight loss, which was not communicated to the physician as required. The resident, diagnosed with Dementia and Depression, was noted to have a significant weight loss of 5.86% within a month, dropping from 239 pounds to 225 pounds. Despite the Registered Dietician Consultant's recommendation for a nutritional supplement twice daily, there was no documentation indicating that the physician was notified of the weight loss or the dietary recommendations. The Director of Nurses confirmed that nursing staff should track residents' weights and notify the physician of any significant weight loss. The facility's protocol defines significant weight loss as a 5% reduction in one month, which necessitates physician notification and intervention. However, the Administrator acknowledged the absence of documentation regarding the notification of the physician or the implementation of the dietary recommendations, indicating a lapse in following the facility's established protocols.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label and document expiration dates for medications for two residents and did not secure a convenience box after medication removal for another resident. During a medication storage and labeling review, it was observed that a box of Lorazepam suppositories for one resident did not have an expiration date documented, and a container in the refrigerator for another resident lacked both a name and expiration date. The LPN present during the review was unable to provide the expiration dates for these medications. Additionally, the facility's convenience box was found unsecured after a medication was removed for a resident. A form indicated that a medication was taken from the box, but the LPN who removed it did not replace the red tab to secure the box, nor did they document the red tab numbers on the form as required. The Director of Nursing confirmed that the convenience box should be re-locked with a red tab and the tab numbers should be documented on the form.
Failure to Document Follow-Up After Medication Administration
Penalty
Summary
The facility failed to appropriately assess, evaluate, and document a resident's behaviors after administering medications for behaviors. The resident, identified as R29, has diagnoses including Senile Degeneration of Brain, Unspecified Dementia, Psychotic Disturbance, Mood Disorder, and Anxiety Disorder. The care plan for R29 indicates the resident experiences delirium, lethargy, and nonsensical responses. Despite these conditions, the facility did not document follow-up actions after administering medications for behaviors on multiple occasions. On several dates, R29 exhibited behaviors such as socially inappropriate actions, agitation, disruptive sounds, and screaming. The facility's records show that Lorazepam was administered to R29 on multiple occasions, yet there was a consistent lack of documentation regarding follow-up assessments or evaluations of the resident's behavior post-medication. The facility's policy requires staff to document specific details about changes in mental status, behavior, and cognition, but this was not adhered to in R29's case, leading to the deficiency.
Inaccurate Controlled Medication Records
Penalty
Summary
The facility failed to ensure complete and accurate controlled medication records for a resident receiving pain medication, specifically oxycodone. During an audit conducted by the Director of Nursing, discrepancies were found between the resident's pain medication administration record and the controlled medication count sheet. The facility staff did not accurately document all doses administered to the resident on the controlled medication count sheet as reflected in the medication administration record. Additionally, there were errors in calculating the remaining doses of the medication on the controlled medication count sheet. The controlled medication count sheet for May 2024 showed four count corrections on a specific date, a late entry for medication administered earlier in the month, and multiple calculation errors on the same date.
Failure to Update Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to complete a comprehensive Plan of Care with fall interventions for a resident identified as R3, who was at high risk for falls. R3's medical history included a displaced spiral right humeral shaft fracture, traumatic subarachnoid hemorrhage, head laceration, anxiety, depression, and a urinary tract infection. The resident's Fall Risk Evaluation indicated intermittent confusion, a history of falls, and balance problems, among other risk factors. Despite these indicators, the facility's care plan for R3 was not updated to address two falls that occurred in February 2024. The care plan in place was a baseline plan from the resident's admission and did not include specific interventions for the falls that occurred on 2/14/24 and 2/19/24. The plan only included general interventions such as assisting with ambulation and transfer, evaluating fall risk, and initiating fall risk precautions. The Director of Nursing confirmed that the care plan was not up to date and acknowledged the need for a comprehensive plan of care for R3, who had a history of falls prior to admission.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement fall interventions and safety measures for a resident, identified as R3, who was at risk of falling. R3 had a complex medical history, including a displaced spiral right humeral shaft fracture, traumatic subarachnoid hemorrhage, and a history of falls. The resident was frequently incontinent, dependent on staff for transfers and toileting, and had impairments on the right side. Despite these conditions, the facility did not update R3's Plan of Care to include fall prevention strategies after two documented falls in February 2024, which occurred when R3 attempted to get out of bed to use the bathroom. The Director of Nursing (V2) confirmed that R3's Plan of Care was not updated from admission and lacked interventions for the falls that occurred. V2 acknowledged that the root cause of R3's falls was the resident's need to use the toilet and confirmed that frequent toileting should have been implemented as an intervention. The failure to update the Plan of Care and implement necessary fall prevention measures contributed to the deficiency identified in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 175 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartland Nursing & Rehab | 9.2 mi | ★★★★★ | 4 | 0 |
| Casey Rehab And Nursing | 9.6 mi | ★★★★★ | 3 | 0 |
| Heartland Senior Living | 16.7 mi | ★★★★★ | 4 | 0 |
| Charleston Rehab And Nursing | 16.7 mi | ★★★★★ | 21 | 0 |
| Helia Healthcare Of Newton | 18.2 mi | ★★★★★ | 9 | 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.