Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Rehab & Care Center during CMS and state inspections, most recent first.
A facility failed to follow infection control practices during a medication pass, incontinent care, linen handling, and CPAP storage. A staff member moved between residents during med administration without hand hygiene and used the same gloves while handling medications and resident care tasks. CNAs provided incontinent care to residents on EBP without complete PPE and with soiled gloves, and soiled linens were carried unbagged or handled with contaminated gloves. A resident’s CPAP machine was also observed uncovered, unlabeled, and dusty while not in use.
A resident with vascular dementia, HF, and partial paralysis after a stroke was repeatedly unable to find his call light when he needed to use the bathroom. Surveyors observed the call light on the floor behind the bed, wrapped around the bed frame, and it remained there on repeat checks. The resident’s care plan indicated he required a mechanical lift with 2-person assist for transfers, and the DON stated the call light should be accessible at all times because he was bed bound and needed staff help with all care.
Failure to Ensure Ordered Hand Splint Was in Place: A resident with hemiplegia/hemiparesis and limited movement of the affected arm and hand did not have the ordered carrot splint in place as directed. Staff observed the resident multiple times without the splint, the resident said he did not know where it was, and the Rehab Director and OTR could not find it in the room. The OTR stated the splint was used for functional positioning and to decrease further contraction, while the DON noted there was no care plan for the splint and no documentation that the resident refused it.
A resident with urinary incontinence was found with a heavily saturated brief and strong urine odor after staff had not changed him in a timely manner, despite a care plan and toileting policy calling for regular checks and incontinent care as needed. In a separate event, a resident with an indwelling urinary catheter had the drainage bag hung above the bladder during a mechanical lift transfer, with urine flowing back toward the resident and sediment noted in the tubing; the care plan required the bag to remain below bladder level.
A resident receiving IV antibiotics through a PICC line had a transparent dressing that was not dated and was peeling at the edges, and the resident stated it needed to be changed. Staff documentation showed dressing changes were recorded, but there was no documentation of arm circumference measurements, and staff interviews indicated the RN did not measure the arm and the care plan for IV antibiotics was not in place. The facility’s policy required sterile PICC dressing changes and labeling of the dressing with date, time, and initials.
Unsafe Storage and Disposal of Controlled Medications: Two residents’ hydrocodone-acetaminophen doses were not handled per policy during a controlled substance count. One resident’s blister pack had an open compartment that could allow the tablet to fall out, and another resident’s tablet was placed in a clear unsealed plastic pouch with the resident’s name handwritten on it instead of being wasted right away with two nurses and documented appropriately. The DON confirmed both doses should have been destroyed immediately.
Medication administration errors resulted in a 12% error rate, above the required threshold of less than 5%. A nurse gave one resident inhalers too close together and without following the inhaler procedure, and gave another resident 5 ml of levetiracetam via g-tube when the MAR ordered 2.5 ml. The DON stated nurses are expected to follow physician orders and the five rights of medication administration.
Multiple residents who required assistance with ADLs did not receive their ordered or scheduled showers or baths, as shown by resident interviews, observations of body odor and unkempt or greasy hair, and review of POC documentation showing long gaps with no bathing care or only a few bed baths over entire months. Physician orders and facility policy required twice-weekly showers, but staff reported high resident assignments and acknowledged that when staffing was short, showers were not always provided or documented, and refusals were not consistently recorded in the EMR.
Two residents at high risk for falls, one cognitively intact with multiple comorbidities and a history of falls and another with vascular dementia and repeated prior falls, were not adequately supervised, leading to multiple unwitnessed falls with fractures. One resident, who required assistance with bathing, was left alone in a shower room, attempted to self-transfer, fell, and later was found to have an acute L1 compression fracture; CNAs assisted him from the floor but did not promptly notify an LPN, contrary to facility policy. The other resident, described as very impulsive with dementia and care-planned for alarms and visual monitoring, sustained several falls over time, including events that caused a tibia fracture, rib fractures, and a femur fracture, despite staff awareness that he often needed 1:1 support. These events reflect failures to implement and follow fall-prevention interventions and post-fall assessment procedures for high-risk residents.
Two residents at high risk for pressure ulcers did not receive appropriate wound care or preventive interventions. One resident's wounds worsened after staff failed to document, communicate, and follow provider orders for wound care consultation and treatment, resulting in hospitalization for sepsis and pressure injuries. Another resident with a coccyx ulcer was not regularly repositioned as required, and both lacked individualized care plans for skin or wound care.
A resident with multiple medical conditions repeatedly requested therapy medical records from the Director of Rehab and submitted a written request to the Administrator, seeking paper copies for her attorney. Despite these requests and documentation by the Business Office Manager, the records were not provided in a timely manner due to miscommunication and lack of follow-through among staff.
A resident with multiple complex medical conditions developed a new wound on the sacrum, which was documented and treated by an LPN, but the family/POA was not notified as required by facility policy. The family only learned of the wound during a subsequent hospital visit, and there was no documentation of any notification in the medical record.
A resident with a history of falls and muscle weakness, who required one-person assist and was identified as a fall risk, was not properly assisted during a transfer to a transport van. The CNA did not use a gait belt as required by facility policy and physical therapy recommendations, resulting in the resident's legs giving out during the transfer, causing bruising and pain. Therapy staff confirmed that a gait belt was necessary for this resident's safety during transfers and stair navigation.
The facility failed to maintain proper food safety and hygiene standards in the kitchen, affecting all residents receiving oral nutrition. Staff were observed not wearing hair coverings, and several food items were found opened and undated, violating facility policies. Additionally, the sanitation bucket lacked the required chemical levels, compromising sanitation standards.
The facility failed to update its Infection Control Policy and conduct infection surveillance, leading to inadequate infection prevention measures. Improper handling of linens, lack of PPE use, and failure to implement Enhanced Barrier Precautions for residents with medical devices or wounds were observed. These deficiencies increased the risk of infection spread among residents and staff.
The facility failed to provide adequate hygiene and grooming care to residents dependent on staff for ADL assistance. One resident was found with saturated undergarments due to a lack of timely incontinence care, while another expressed dissatisfaction with unaddressed grooming needs. Two residents did not receive scheduled showers, despite one having a portable oxygen tank for use during bathing. The DON confirmed that residents should receive regular care, but the facility's policies were not followed.
The facility failed to document essential information about pacemakers and defibrillators for three residents, including physician orders, manufacturer details, and monitoring frequency. The absence of this information was confirmed by the DON, who noted the lack of a relevant policy and the importance of having such details for emergency situations.
A facility failed to follow physician orders for a resident with severe contractures, as restorative devices were not applied to prevent worsening. The resident, who is nonverbal and in a comatose state, was observed without the necessary splints or carrots in her hands, contrary to her care plan and physician orders. The facility lacked a restorative nurse and aides, and there was no documentation of the resident's husband removing the devices, which was not care planned.
A resident with a history of UTIs and urinary retention was observed with a leg bag attached while in bed, contrary to the facility's policy requiring the drainage bag to be lower than the bladder. The DON confirmed this practice could lead to UTIs and improper drainage.
A facility failed to follow proper procedures for checking g-tube placement when administering medications to a resident. An RN used auscultation with air instead of aspirating stomach contents, contrary to the facility's policy and physician orders. The resident, with a history of dysphagia and other conditions, required specific methods for g-tube placement verification, which were not followed.
The facility failed to secure and contain respiratory equipment for four residents, leading to a deficiency in infection control. Nebulizer masks were left uncovered, and tubing was found on the floor, contrary to facility policy. Residents with significant respiratory conditions were not provided with bags for their equipment, as confirmed by their statements and the Director of Nursing.
The facility failed to secure medications for three residents, leading to a deficiency in medication management. One resident kept several medications at her bedside without orders, expressing distrust in staff. Another resident had prescription Nystatin powder on her overbed table, using it without recalling the proper application frequency. A third resident had fluticasone nasal spray in a bag attached to his wheelchair. The facility's policy requires medications to be stored securely and accessed only by authorized personnel, which was not followed.
A resident's surgical procedure was rescheduled due to the facility's failure to follow physician orders to hold a blood thinner. Despite the resident's awareness and attempts to communicate the need to hold the medication, the facility did not document or implement the order, resulting in the medication being administered within the preoperative timeframe. The oversight was attributed to a lack of communication and documentation among staff.
The facility failed to complete quarterly MDS assessments within the required timeframe for five residents, with delays ranging from 123 to 140 days. The MDS Coordinator attributed the delays to assisting the acting DON, causing her to fall behind on her duties.
The facility failed to provide proper peri-care and catheter care, leading to potential risks of UTIs for several residents. Instances included inadequate cleaning of the inner labia and urethra, unsecured catheter tubing causing pulling during transfers, and improper hygiene practices during incontinence care. These deficiencies were observed in residents requiring extensive assistance or total dependence on staff for toileting hygiene.
The facility failed to follow standard infection control practices, including hand hygiene and gloving, during perineum and catheter care. Staff members were observed changing gloves without sanitizing hands and handling soiled items improperly, compromising infection control protocols.
A facility failed to notify the physician, obtain treatment orders, and update the care plan for a resident with a new skin wound. Despite the wound being observed by a hospice CNA, it was not properly documented or communicated to the facility nurse or physician, leading to a lack of timely treatment.
The facility failed to assess and provide proper adaptive devices to a resident with multiple medical diagnoses, leading to ineffective hand rolls and lack of documented rehabilitation evaluation, raising concerns about potential hand contractures.
The facility failed to document the reason for the use of an antipsychotic medication and develop interventions for dose reduction for a resident with multiple medical diagnoses. Despite being on Risperidone, there was no documentation justifying its use, and the care plan did not include any targeted behavior. Staff interviews indicated the resident experiences forgetfulness but no aggressive or unusual behaviors.
The facility failed to follow the standardized recipe for pureed butternut squash during meal preparation for two residents on pureed diets. The cook used incorrect amounts of broth and thickener, resulting in a watery mixture that required additional thickener. The dietitian confirmed that not following the recipe could compromise nutrient values.
The facility failed to serve pureed braised beef in the desired consistency for two residents on pureed diets. The cook prepared the beef, but the resulting product had shreds and appeared granular, requiring chewing. The Dietary Manager acknowledged the inconsistency, and the Dietitian confirmed that pureed products should be smooth and pudding-like. The residents' meal tickets indicated they were on pureed diets for chewing or swallowing difficulties.
Infection Control Failures During Medication Pass, Resident Care, Linen Handling, and CPAP Storage
Penalty
Summary
The facility failed to follow infection prevention and control practices during medication administration, incontinence care, linen handling, and storage of respiratory equipment. During a medication pass, a staff member administered medications to multiple residents with the same gloves, touched different surfaces and medication cart drawers, checked vital signs, handled medications with gloved hands, and moved from one resident to another without performing hand hygiene between tasks or residents. The facility’s medication administration policy stated that hand washing or sanitizing is required before beginning a medication pass, before handling medications, after direct contact with a resident, and before and after certain medication preparations and enteral tube administration. The facility also failed to ensure complete PPE use and proper glove and hand hygiene practices during care for residents on EBP. One resident had an arterial wound to the left foot and had EBP signage posted outside the room. Two CNAs provided incontinent care while wearing the same soiled gloves throughout the care and without wearing a gown. Another CNA provided extensive personal care to a cognitively impaired resident with multiple diagnoses, including ESRD, CKD, obesity, hypertension, and peripheral vascular disease, while wearing gloves that were kept in a pocket, touching the resident’s room surfaces, clothing, bathroom fixtures, washcloths, and personal items with the same gloves, then removing and replacing gloves without hand hygiene. The DON stated staff are expected to perform hand hygiene before care, before putting on gloves, between dirty and clean tasks, between residents, and after glove removal, and that staff caring for a resident on EBP should wear complete PPE such as a gown and gloves. Additional infection control failures involved soiled linen handling and storage of a CPAP machine. One resident with severe cognitive impairment and dependence for toileting, bathing, dressing, transfers, and personal hygiene had soiled linens carried out of the room unbagged and taken into the soiled utility room. Another resident with moderate cognitive impairment had saturated linens and incontinent products placed in a plastic bag, but the same soiled gloves were used to touch the resident’s personal items and glasses, and hand hygiene was not performed after care. A CPAP machine used nightly by a resident with vascular dementia, sleep apnea, heart failure, stroke-related paralysis, atrial fibrillation, and a history of infections was observed on the nightstand with the mask uncovered and unlabeled and visible dust on the machine base. The DON stated that when not in use, the CPAP machine should be clean, dry, bagged, and labeled with the resident’s name, and the facility’s respiratory tubing policy stated tubing is placed in the container when not in use.
Call Light Not Accessible to Bed-Bound Resident
Penalty
Summary
The facility failed to ensure that a resident assessed to need assistance with all ADL care needs had access to his call light to request help. The resident, who had a history of vascular dementia, heart failure, and partial paralysis following a stroke and was admitted on January 30, 2024, was observed on May 4 and May 5, 2026 stating that he needed to use the bathroom and could not find his call light. During these observations, the call light was found sitting on the floor behind the resident’s bed, wrapped around the bed frame, and remained there on repeated checks. The resident’s care plan stated that he was usually able to make his needs known and understand when spoken to, and that he required a mechanical lift with two-person assistance for transfers. The DON stated that the call light should be accessible at all times because the resident could not get out of bed on his own, was bed bound, and required staff assistance with all areas of care. The facility did not provide a policy regarding call light accessibility when requested.
Failure to Ensure Ordered Hand Splint Was in Place
Penalty
Summary
The facility failed to ensure that an adaptive device was in place according to the physician order for a resident with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The resident’s physician order summary dated April 30, 2026, directed staff to apply a splint (carrot) to the left hand daily as tolerated. The resident’s MDS showed he was alert and oriented, and during unit rounds on May 4, 2026, he was observed resting in bed with limited movement of the left arm and hand, with the left hand and fingers described as very stiff. No splint was in place at that time, and the resident stated he did not know where his splint was. The resident was observed multiple times on May 5 and May 6, 2026, without a splint on the left hand, and no carrot splint was noted anywhere near him. The Rehab Director and OTR stated the carrot splint was for functional positioning and to decrease the likelihood of further contraction. When they went to the resident’s room to apply it, they were unable to find the splint and the Rehab Director left and returned with another carrot splint. The OTR stated the resident had been non-compliant with the splint because of low tolerance for pain or discomfort when it was in place. The DON stated staff should ensure the splint was in place as ordered and check skin integrity of the hand, and also stated there was no care plan for the carrot splint and no documentation that the resident refused to wear it.
Incontinence Care Not Timely and Catheter Bag Positioned Above Bladder
Penalty
Summary
The facility failed to provide timely incontinence care for a resident with urinary incontinence. The resident had multiple diagnoses including type 2 diabetes mellitus with chronic kidney disease, uncontrolled, and congestive heart failure, and was receiving Torsemide 20 mg twice daily. The resident was observed sitting in a wheelchair and stated he had heart failure and renal failure. Later, the resident was assisted to the toilet by two CNAs, and his incontinence brief was found heavily saturated with urine with a strong urine odor when removed. The resident stated the brief had last been changed early that morning and said he did not know when he was voiding, but asked staff to change his disposable brief because it had been a while since he was last changed. His care plan identified urinary incontinence and directed staff to keep him dry and clean as much as possible and provide incontinent care as needed. The facility’s toileting policy stated residents should be checked every two hours and changed if found incontinent, with perineal care after each incontinent episode. The facility also failed to ensure an indwelling urinary catheter bag remained below the resident’s bladder. A resident with chronic kidney disease, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, calculus of kidney, and urinary tract infection was transferred from bed to wheelchair using a mechanical lift. During the transfer, the urinary catheter bag was hung on the sling hook bar of the lift above the resident’s bladder, and sediment was noted in the catheter tubing. Urine was observed flowing back toward the resident during the transfer, and a CNA later confirmed seeing the urine flow back. The resident’s care plan required an indwelling urinary catheter related to neurogenic bladder and included positioning the urinary bag below bladder level. The DON stated staff should check incontinent residents every two hours and as needed, and that the catheter should always be positioned below the bladder so it drains by gravity and urine does not backflow to the bladder.
Failure to maintain PICC line dressing care and IV therapy care plan
Penalty
Summary
The facility failed to implement physician orders for IV PICC line dressing changes as needed and failed to have a care plan in place for management of the IV site for one resident receiving IV therapy. The resident was admitted with multiple diagnoses including a non-pressure chronic ulcer of the right heel and midfoot, pressure ulcer, UTI, pain, type 2 diabetes mellitus with foot ulcer, and neuropathy, and was cognitively intact. The resident’s physician orders showed IV vancomycin therapy that was started, placed on hold, resumed, and later changed to a different IV antibiotic order. On observation, the resident had a PICC line in the left arm covered by a transparent dressing that was not dated, had faded illegible initials, and had peeling, curling edges. The resident stated the dressing was changed every 7 days and that it was last changed on April 25, 2026, and also stated that it needed to be changed. The record review showed the PICC line dressing and caps were documented as changed on April 18, April 25, and May 2, 2026, but the MAR had no documentation of arm circumference measurements. Staff interviews showed the RN who performed the dressing change believed she did not use the measuring tape or measure arm circumference, and the DON stated she was not sure whether the facility had a policy regarding arm circumference measurement. The MDS coordinator stated no care plan was created for the resident’s antibiotics because he assumed the therapy had been discontinued, and he also stated the facility’s antibiotic care plan template did not include dressing change details or arm circumference measurement. The facility policy required PICC line care with a transparent dressing change 24 hours after insertion and then every 7 days, and required transparent dressing labeling with the device type, gauge, length, date, time, and nurse’s initials.
Unsafe Storage and Disposal of Controlled Medications
Penalty
Summary
The facility failed to ensure safe storage of controlled medications for 2 residents reviewed for medication storage. R18 was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, spinal stenosis, low back pain, muscle spasms, unspecified pain, pain in the right arm, and migraine, and had an order for hydrocodone-acetaminophen 5-325 mg twice daily. During the controlled substance count, R18’s blister punch card had 20 tablets remaining, but the compartment marked 20 was open and large enough for the tablet to come out. The RN verified the compartment was open and stated the tablet should have been discarded and wasted with two nurses and documented on the controlled drug receipt/record/disposition form. R6 was admitted with diagnoses including osteomyelitis, obesity, pain in the left foot, pain in the right knee, and osteoarthritis, and had an order for hydrocodone-acetaminophen 10-325 mg four times daily. During the same controlled substance count, the record showed 21 tablets remaining, but only 20 tablets were in the blister punch card. One tablet had been placed in a clear unsealed plastic pouch with R6’s name handwritten on it, and the RN confirmed it was hydrocodone-acetaminophen and stated she had popped it out earlier but did not realize another tablet had already been placed in the medication cup. She stated she did not know the tablet had to be disposed of right away. The DON confirmed the tablet should not have been placed in a plastic bag and should have been wasted immediately with two nurses. The facility policy stated controlled drugs must be accurately accounted for and that doses removed but not given are to be destroyed in the presence of two licensed nurses or a pharmacist and nurse, with disposal documented on the accountability record.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors resulted in a 12% medication error rate, exceeding the required threshold of less than 5%. During a medication pass observation, a nurse administered Advair HFA and Incruse Ellipta inhalers to R18 without following the facility’s inhaler administration procedure. The nurse handed the Advair inhaler to the resident without instructions, the resident took 2 puffs one after another, and the Incruse Ellipta was then given within 5 seconds of the Advair, despite the facility policy stating that if another puff of the same or different medication is required, at least 1 to 2 minutes should pass between administrations. R18’s MAR showed an order for Advair HFA 230-21 mcg/actuation, 1 puff once daily. A second medication error occurred with R62 when the nurse administered 5 ml of levetiracetam solution via g-tube, although the MAR ordered 250 mg (2.5 ml) twice daily. The nurse gave 500 mg instead of the ordered dose. The DON stated that nurses are expected to follow physician orders and the principles of medication administration, including the right patient, dose, medication, route, and time. The facility’s medication administration policy also required adherence to the five rights and a triple check during preparation, including the right dose.
Failure to Provide Ordered and Scheduled Showers/Baths
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or baths as ordered and as documented in facility policy for multiple residents who required assistance with activities of daily living. One resident reported not receiving the two weekly showers he was supposed to get on designated days and stated that only two staff members would shower him when he requested it; during interview he had a foul body odor, and POC documentation showed only four showers in February and gaps of six and seven consecutive days without a shower in February and March, despite physician orders for twice-weekly showers. Another resident stated he did not get showers but bed baths instead and could not recall his last bath; he had a stale body odor and unkempt hair, and his orders called for twice-weekly showers, yet POC documentation reflected only four bed baths in February and three in March for the entire months. A third resident stated he was not getting his ordered twice-weekly showers and had been washing up at the bathroom sink despite preferring showers; his POC documentation showed only four showers in February and an eight-day period in March with no documented bath or shower, contrary to orders for twice-weekly showers. A fourth resident reported not having had a shower in over three weeks and had greasy hair; the facility could not provide any shower documentation for this resident for February and had only one documented bed bath at the end of March. The administrator stated that CNAs are to document refusals in the POC, and confirmed there was no other shower documentation for this resident. CNAs reported caring for as many as 18–22 residents and acknowledged that when staffing was short, residents did not always receive showers, even though the facility’s bathing policy requires residents to receive regularly scheduled and as-needed showers or baths.
Failure to Supervise High-Risk Residents Resulting in Falls and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for residents at high risk for falls, resulting in falls with fractures for two residents. One resident (R1), who had diagnoses including CHF, shortness of breath, Type 2 DM, morbid obesity, anxiety disorder, and a prior wedge compression fracture of the first lumbar vertebra, required one‑person assistance with bathing and had a care plan noting a history of multiple falls. On the day of his fall, R1 went to the shower room in his wheelchair with clean clothes. He reported that while in the bathroom he finished and told a CNA (V3) he was ready to get up, but she told him to wait; he stated he had already been sitting for 25 minutes and did not want to wait, so he attempted to transfer himself to his wheelchair and fell. R1 stated that V3 was on the phone, that she and another CNA (V20) helped him up, and that V3 did not report the fall to the nurse. Nursing and CNA statements and documentation show inconsistent but related accounts of the same event, all indicating that R1 was not properly supervised in the shower room and that the fall was not promptly reported to nursing for assessment. The LPN (V4) on duty saw R1 pass the nurses’ station with clean clothes, later saw the shower room call light and confirmed V3 was in the room with R1, and then saw V3 wheel R1 back to his room. R1 then told V4 he had fallen in the shower room, had severe back pain, and wanted to go to the hospital. V4 documented that V3 had not informed him of the fall and that when questioned later, V3 said she was going to tell him and that she had told R1 not to remove his rubber shoes. V3’s own written statement said she told R1 not to take his shoes off in the shower and that he stood up and slipped; another CNA (V20) stated that V3 had told R1 to go to the shower room alone, that she knew he could not shower independently, and that V3 later asked her to help get him up after he fell. The facility’s incident report and hospital records confirm that R1 slipped and fell in the shower, was not with a CNA at the time of the fall per the final investigation addendum, and was later found to have an acute compression fracture of L1. The second resident (R3) also experienced multiple falls with serious injuries in the context of high fall risk and inadequate supervision. R3 had diagnoses including vascular dementia, major depressive disorder, Type 2 DM, and right knee pain, and his care plan identified him as at risk for falls due to vascular dementia, with interventions including chair and bed alarms and keeping him in visual range of floor staff. His records show a fall resulting in a right tibia fracture, two additional falls on the same later date that led to two separate ED visits and rib fractures, and another fall on a subsequent date where he was found on the floor on his left side outside his room, reporting pain to his back, left shoulder, and left hip. The facility’s serious injury incident report for that later fall states that the final investigation determined he sustained a left femur fracture. The administrator and an RN both described R3 as very impulsive, with dementia, and noted that he needed 1:1 support and that staff tried to keep him with someone or provide 1:1 “as much as they could,” but they were not able to provide continuous 1:1 care. Despite his repeated falls, documented cognitive impairment, and identified need for close supervision, he continued to experience falls with fractures, indicating that the planned interventions and supervision were not effectively implemented to prevent these events. The facility’s own falls management policy requires that residents identified as high risk have fall prevention addressed on the plan of care and that when a resident falls, reports falling, or is suspected of falling, staff must assess for injury, provide treatment, and document in the EHR. In R1’s case, the resident was left alone in the shower room despite requiring assistance with bathing and having a history of falls, and the CNAs who assisted him from the floor did not immediately notify the nurse, contrary to policy. In R3’s case, although his care plan called for alarms and keeping him within visual range, he was repeatedly found on the floor after unwitnessed falls, including outside his room, despite staff awareness of his impulsivity and dementia. These actions and inactions demonstrate a failure to provide adequate supervision and to consistently follow the facility’s fall prevention and post‑fall assessment procedures for residents at high risk for falls.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to follow a nurse practitioner's order to consult a wound care doctor for a newly acquired wound and did not implement appropriate pressure ulcer prevention and care for two residents. One resident, who had multiple significant medical diagnoses including encephalopathy, end stage renal disease, and dementia, was identified as high risk for pressure ulcers and required substantial assistance for repositioning. Upon readmission, redness was noted on the resident's buttocks and heels, but the heel assessment was not documented, and only the buttocks redness was communicated to the next shift. When an open area was later found, the nurse notified the doctor via a messaging system but did not enter any orders or document the wound in wound rounds. The nurse practitioner's directive to consult wound care was not entered into the system, resulting in no treatment or wound care consult being provided. The resident's care plan lacked any skin or wound care interventions, and the resident was not listed among those with facility-acquired wounds, despite clear evidence of wound progression and subsequent hospitalization for sepsis and pressure wounds. Another resident, with diagnoses including rhabdomyolysis and chronic kidney disease, was also at risk for pressure ulcers and required maximal assistance for repositioning. This resident developed a coccyx ulcer, which was first identified by a wound doctor over a month after it appeared on the facility's wound list. Observations showed the resident remained in the same position for extended periods, contrary to the facility's policy requiring repositioning every two hours for bedbound residents. Staff stated the resident was kept on her right side to avoid pressure on the coccyx ulcer, but there was no evidence of regular repositioning or a care plan addressing skin or wound care. Both residents lacked individualized care plans for skin or wound care, and the facility did not follow its own wound management and repositioning policies. The failures included lack of documentation, communication, and follow-through on provider orders, as well as absence of preventive and treatment interventions for residents at risk for or experiencing pressure ulcers.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with requested medical records in a timely manner. The resident, who had diagnoses including myopathy, inflammatory and immune myopathies, leg pain, anxiety, atherosclerotic heart disease, and a history of falls, made multiple requests to the Director of Rehab for therapy medical records. Despite assurances from the Director of Rehab that the records would be provided, the resident did not receive them. The resident also submitted a written request for medical records to the Administrator, who did not fulfill the request after being informed by the Business Office Manager that the resident allegedly no longer needed the paperwork. Further interviews revealed that the Business Office Manager had spoken with the resident, who clarified that she wanted paper copies of her medical records to provide to her attorney and did not wish to review them with staff. The Business Office Manager documented this request and communicated it to the Administrator, but was waiting for the Administrator to provide the records. The Director of Rehab, after consulting with her supervisor, deferred the request to the facility and did not inform the resident of the proper procedure. As a result, the resident's request for medical records was not fulfilled in a timely manner.
Failure to Notify Family/POA of New Wound
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's family or Power of Attorney (POA) of a new wound that developed on the resident's sacrum. The resident, who had multiple significant medical diagnoses including encephalopathy, malignant melanoma, end stage renal disease, epilepsy, chronic congestive heart failure, and dementia, was found to have skin breakdown with redness and open areas on the buttocks, as documented by an LPN in the progress notes. The wound was treated and documented in the medical record, but there was no evidence that the family or POA was informed of this new condition. The resident's family member and POA later stated that they were not notified of the wound and only became aware of it during a hospital visit. The LPN who discovered and documented the wound confirmed that the family was not notified and acknowledged that both the physician and family should have been informed and that such notifications should be documented. Review of the facility's policy confirmed the requirement for immediate notification of significant changes in a resident's condition to the family or representative, but no such documentation or notification was found in this case.
Failure to Use Gait Belt and Provide Safe Transfer During Van Transport
Penalty
Summary
A deficiency occurred when a resident with a history of myopathy, leg pain, anxiety, atherosclerotic heart disease, and a history of falls was not properly assisted during a transfer to a transport van for a medical appointment. The resident, who was identified as a fall risk and required one-person assist with transfers, expressed to the CNA that she could not walk to the van and needed a wheelchair. After retrieving a wheelchair, the CNA was unable to place the resident in the designated wheelchair area of the van due to equipment blocking the space and instead attempted to assist her into the front seat without the use of a gait belt. Despite the resident's repeated statements that she lacked the strength to ascend the van stairs, the CNA encouraged her to try and attempted to assist her manually. During the transfer, the resident's legs gave out, resulting in her legs flopping and hitting objects, and the CNA pushed her from behind into the seat. The same process was repeated on the return trip, during which the resident again experienced her legs giving out and was physically lifted and pushed into the seat, resulting in bruising to her knees, legs, and chest. The resident reported pain and bruising, and subsequent imaging showed no fractures. Physical therapy documentation indicated that the resident was a fall risk, experienced dizziness during ambulation, and required contact guard assistance with a gait belt for stair training. Therapy staff confirmed that a gait belt was always used for her safety during such activities. The facility's safe handling program also required the use of gait and transfer belts when manual assistance was needed for ambulation and transfers. The CNA involved admitted to not using a gait belt during the transfer, contrary to facility policy and the resident's care needs.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards in the kitchen, affecting all residents who receive oral nutrition from the facility. During a kitchen tour, it was observed that staff members, including the Culinary Director and a cook, were not wearing hair coverings while preparing food, which is against the facility's Personal Hygiene & Uniform Appearance Policy. Additionally, several food items in the dry storage room, freezer, and chiller were found opened and undated, including bags of gravy mixes, panko, tater tots, potato wedges, and jars of peanut butter, as well as cans of corn and mandarin oranges that were dented. This lack of proper labeling and dating of food items violates the facility's Food and Supply Storage Policy, which requires all foods to be covered, labeled, and dated. Furthermore, the facility failed to maintain proper sanitation levels in the kitchen. During the inspection, the sanitation bucket was tested twice and found to have no sanitation chemical present, as indicated by the test strip's color. The manufacturer's guidelines require a specific ppm level for effective sanitation, which was not met. The Culinary Director was unable to explain the deficiency in the sanitation bucket, which is a violation of the facility's Sanitizing and Disinfectant Solutions Policy. This policy mandates that employees prepare sanitizer solutions according to manufacturer guidelines to prevent contamination in food preparation areas.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain and update its Infection Control Policy, which was last revised in August 2018, and did not conduct infection surveillance since October 2024. This lack of surveillance meant the facility was unable to track infections and implement necessary prevention measures. The Director of Nursing (DON) and the newly appointed Infection Preventionist (IP) acknowledged these deficiencies, highlighting a significant gap in infection control practices. The facility also demonstrated improper handling and storage of linens, with dirty linens left on the floor and clean linens stored in soiled utility rooms, increasing the risk of cross-contamination. Staff members were observed not wearing appropriate Personal Protective Equipment (PPE) when required, such as during contact precautions, and failed to perform proper hand hygiene between resident interactions. These actions were contrary to the facility's policies and contributed to the potential spread of infections among residents. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as required by their policy. There was a lack of signage and PPE bins outside residents' rooms, and staff did not wear the necessary PPE during high-contact care activities. This oversight in following EBP protocols further compromised infection control efforts, putting both residents and staff at risk of infection transmission.
Deficiencies in Hygiene and Grooming Care for Residents
Penalty
Summary
The facility failed to provide adequate hygiene and grooming care to residents who were dependent on staff for assistance with activities of daily living (ADL). This deficiency was observed in four residents, including one resident who was found with saturated undergarments and bed linens due to a lack of timely incontinence care. The Certified Nursing Assistant (CNA) responsible for the resident admitted to not providing care since early morning, despite the facility's policy requiring checks every two hours. The Director of Nursing (DON) confirmed that staff should perform hourly rounds and provide necessary care, even if the resident is asleep. Another resident expressed dissatisfaction with her personal grooming, specifically her long, jagged nails and facial hair, which she stated had not been attended to by the staff. The resident's Minimum Data Set (MDS) indicated that she was cognitively intact but dependent on staff for personal hygiene. The DON acknowledged that staff should provide daily personal hygiene, including shaving and nail care, as needed. The facility's policies emphasized the importance of accommodating residents' needs to maintain their dignity and well-being. Additional deficiencies were noted in the care of two other residents who did not receive their scheduled showers. One resident reported not having received a bath or shower since admission, despite having a portable oxygen tank that could be used during showers. The resident's MDS indicated a need for substantial assistance with bathing. Another resident's fiancé reported missed showers on scheduled days, and the resident confirmed this account. The DON stated that residents should receive showers twice a week, and the facility's failure to provide this care was evident in the lack of documentation and adherence to the care plan.
Failure to Document Pacemaker and Defibrillator Information
Penalty
Summary
The facility failed to obtain and document vital information regarding residents' pacemakers and implanted defibrillators, affecting three residents. For Resident 3, the medical record lacked a physician order for the defibrillator, including details on how often it should be checked. There was no documentation of the manufacturer, model, or serial number of the defibrillator, nor was there any record of when it was last assessed. The Director of Nursing confirmed the absence of a policy on pacemakers and defibrillators. Similarly, for Residents 27 and 30, there were no physician orders documenting the pacemakers or their monitoring frequency. The medical records did not include the manufacturer, model, or serial number of the pacemakers, and it was unknown when they were last assessed. The facility's policy on cardiac pacemaker monitoring did not require obtaining this information. The Director of Nursing acknowledged the lack of necessary details in the care plans, emphasizing the importance of having this information available for troubleshooting in case of an emergency.
Failure to Apply Restorative Devices for Resident with Contractures
Penalty
Summary
The facility failed to follow physician orders and apply restorative devices to prevent further worsening of contractures for a resident identified as R23. During observations, it was noted that R23, who is nonverbal and in a comatose state, had severely contracted hands without any assistive restorative devices. The resident's care plan and physician orders specified the use of splints or carrots in the hands to prevent contracture worsening, but these were not in place during the surveyor's visits. The RN, V8, was unaware of the location of these devices and found a soiled carrot under the bed, which was not being used. The facility lacked a restorative nurse and aides, relying on CNAs to perform restorative therapy, which was not being adequately executed. The Director of Nursing (DON) confirmed that R23 was supposed to have rolled towels in both hands, but these were not consistently applied. The facility's policy on restorative nursing indicated that such services should be provided by trained staff under nursing supervision, which was not happening effectively. Additionally, there was no documentation to support the claim that R23's husband was removing the restorative devices, and this behavior was not included in the care plan. R23's medical history includes severe cognitive impairment and dependence on staff for all functional abilities, highlighting the critical need for adherence to restorative care protocols.
Improper Catheter Positioning for Resident
Penalty
Summary
The facility failed to ensure proper positioning of indwelling catheters for a resident, identified as R33, who was observed with a leg bag attached while in bed. This practice was contrary to the facility's policy, which mandates that the urinary drainage bag must be positioned lower than the bladder to prevent backflow and potential urinary tract infections (UTIs). The Director of Nursing (DON) confirmed that the leg bag should not be used when the resident is in bed, as it can lead to improper drainage and increase the risk of UTIs. R33 has a history of UTIs and benign prostatic hyperplasia with lower urinary tract symptoms, making him particularly vulnerable to complications from improper catheter care. His care plan highlighted the risk of UTIs due to catheterization and included approaches such as monitoring for signs of infection and providing good perineal and catheter care. Despite these measures, the improper use of the leg bag while in bed was observed, which could contribute to the resident's risk of developing UTIs and other complications.
Improper G-Tube Placement Check for Medication Administration
Penalty
Summary
The facility failed to adhere to current standards for checking the proper placement of a gastrostomy tube (g-tube) when administering medications to a resident. During an observation, a registered nurse (RN) was seen checking the g-tube placement by instilling air and auscultating with a stethoscope, rather than aspirating stomach contents as per the facility's policy and physician orders. The Director of Nursing acknowledged that the proper method should involve checking for residual stomach contents, not by auscultating air passage. The resident involved, identified as R23, has a medical history that includes dysphagia, gastro-esophageal reflux disease, and other complications. The resident's care plan and physician orders specifically required checking tube placement by aspirating stomach contents before meals and by auscultating air passage every shift. However, the RN's method of checking placement did not align with these orders or the facility's policy, leading to a deficiency in the care provided to the resident.
Failure to Secure and Contain Respiratory Equipment
Penalty
Summary
The facility failed to properly contain and secure respiratory equipment for four residents, leading to a deficiency in infection control practices. Observations revealed that nebulizer masks for residents were left uncovered on dressers, and in one case, nebulizer tubing was found touching the floor. These residents, who have various respiratory and other health conditions, were not provided with bags to store their nebulizer equipment, as confirmed by their statements. The facility's policy requires that respiratory equipment be bagged and dated when not in use to prevent infection. The residents involved have significant medical histories, including chronic obstructive pulmonary disease, Parkinson's disease, and acute respiratory conditions, which necessitate the use of nebulizers. Despite these needs, the facility did not adhere to its own policy of bagging and dating respiratory equipment, as confirmed by the Director of Nursing. This oversight was observed during a survey, highlighting a lapse in maintaining proper infection control measures for residents requiring respiratory care.
Medication Security Deficiency in LTC Facility
Penalty
Summary
The facility failed to properly secure medications for three residents, leading to a deficiency in medication management. For one resident, several medications, including Preservision AREDS 2, Nasal Mist, ABC Plus Senior Multivitamin, and Magnesium with Zinc, were found on the bedside table and nightstand without any orders for self-medication or bedside storage. The resident expressed distrust in staff administering her medication, which led to her keeping them at her bedside. The facility's policy clearly states that medications should be stored securely and only accessed by authorized personnel, which was not adhered to in this case. Another resident was found with a bottle of prescription Nystatin powder on her overbed table, which she used without recalling the proper application frequency. The resident did not remember which nurse left the medication with her, and there were no assessments allowing her to self-administer medications. Additionally, a third resident had two bottles of fluticasone nasal spray in a bag attached to his wheelchair, which he stated were given to him by a nurse. The facility's Director of Nursing confirmed that no residents were assessed to keep medications at the bedside, and staff were expected to secure medications in a locked place.
Failure to Hold Blood Thinner Leads to Procedure Rescheduling
Penalty
Summary
The facility failed to follow physician orders to hold a blood thinner medication for a resident prior to a scheduled surgical procedure, resulting in the procedure being rescheduled. The resident, who has a complex medical history including chronic congestive heart failure, morbid obesity, and type 2 diabetes, was aware that her blood thinner needed to be held for 72 hours before the procedure. However, the facility did not document or implement the necessary order to hold the medication, leading to the cancellation of the procedure. The resident expressed frustration and emotional distress over the repeated rescheduling of her procedure, which she feared could delay critical findings related to a potential cancer diagnosis. Despite the resident's attempts to provide information from her electronic hospital chart to the facility, the order to hold the blood thinner was not entered. The facility's records showed that the blood thinner was administered within the 72-hour preoperative timeframe, contrary to the physician's instructions. The breakdown in communication and documentation within the facility contributed to the oversight. The MDS Coordinator admitted to not documenting or communicating the verbal preoperative orders received from the physician's office. Additionally, the Administrator and Director of Nursing acknowledged that the fax containing the physician's orders was not reviewed or acted upon in a timely manner, leading to the failure to hold the blood thinner as required.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for five residents. Specifically, the assessments for residents R14, R20, R21, R34, and R39 were all transmitted significantly late, ranging from 123 to 140 days past the required date. The MDS Coordinator, identified as V3, acknowledged the delays and attributed them to assisting the acting Director of Nursing (DON) with her responsibilities, which caused her to fall behind on her own duties. The facility's policy, titled 'Resident Assessment Schedule' dated May 2022, mandates that assessments be completed on admission and every 90 days thereafter. Despite this policy, the quarterly MDS assessments for the five residents were not completed in a timely manner. V3 confirmed the transmission dates and acknowledged that the assessments were late, indicating a failure to adhere to the facility's established assessment schedule.
Inadequate Peri-Care and Catheter Care Leading to Potential UTIs
Penalty
Summary
The facility failed to provide proper peri-care and catheter care, leading to potential risks of urinary tract infections (UTIs) for several residents. For instance, a CNA did not adequately clean the inner labia and urethra of a resident during incontinence care, and another resident's catheter was not secured, causing it to pull during transfers. These actions were observed during specific instances where residents required extensive assistance or were totally dependent on staff for toileting hygiene. In one case, a resident with multiple medical diagnoses, including end-stage renal disease and a history of UTIs, was not properly cleaned by a CNA who failed to separate the labia and clean the inner corners and urethra. Another resident with an indwelling urinary catheter had the catheter tubing unsecured, which was observed to pull during transfers, and the resident's husband confirmed that the facility had lost the leg strap used to secure the catheter. Additionally, other residents were observed receiving inadequate peri-care. For example, a resident with severe cognitive impairment and a history of UTIs was not properly cleaned by a CNA who used the same gloves throughout the process and did not clean the inner labia. Another resident with multiple wounds did not receive proper incontinence care after wound care was completed, and protective ointment was applied in a manner that did not follow proper hygiene protocols. The facility's policy on perineal care was not adhered to in these instances, leading to potential risks of infection and skin irritation.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to follow standard infection control practices regarding hand hygiene and gloving during the provision of perineum and catheter care. On multiple occasions, staff members were observed changing gloves without performing hand hygiene and handling soiled items without proper sanitization. For instance, a CNA provided incontinence care to a resident without sanitizing hands between glove changes and did not disinfect the peri-care cleansing spray after use. Additionally, the same CNA and another staff member transferred a resident without wearing gloves and handled soiled linens without hand hygiene or proper containment, further compromising infection control protocols. Another incident involved a CNA emptying a urinary catheter bag and changing gloves without performing hand hygiene before repositioning the resident. Similarly, during incontinence care for another resident, the CNA changed gloves between dirty and clean tasks without sanitizing hands, thereby increasing the risk of infection. The facility's Regional Director confirmed that staff must wash or sanitize hands between glove changes and disinfect any items touched with soiled gloves to prevent the spread of infection. Further observations revealed that staff members continued to neglect hand hygiene protocols during resident care. For example, a CNA and another staff member used the same gloves for multiple tasks, including perineal care and repositioning a resident, without sanitizing hands. Additionally, during wound care rounds, the Director of Nursing failed to perform hand hygiene between glove changes and touched various items with soiled gloves. These actions were contrary to the facility's infection control policies, which mandate hand hygiene before and after each care contact and the disinfection of items used during care to prevent infection spread.
Failure to Notify Physician and Update Care Plan for New Skin Wound
Penalty
Summary
The facility failed to notify the physician of a new skin wound, obtain orders for treatment, and update the care plan for a resident. The resident, a male with severe cognitive impairment and multiple diagnoses including cerebrovascular disease and vascular dementia, was observed with a bruise and a deep, open wound on his left upper arm. Despite the wound being noticed by a hospice CNA, it was not properly documented or communicated to the facility nurse or physician. The wound was first observed on a Friday, but no action was taken until the following Tuesday when it was noted to have worsened. The facility's wound care policy requires immediate assessment, documentation, and physician notification for new skin conditions, which was not followed in this case. Interviews with various staff members, including the hospice CNA, facility RN, and hospice nurse, revealed a lack of communication and documentation regarding the resident's wound. The hospice CNA claimed to have notified the facility nurse, but the nurse denied receiving any such information. The primary physician and the Director of Nursing were also unaware of the wound until it was brought to their attention days later. The facility's wound care policy mandates weekly skin assessments and immediate action for new wounds, but these protocols were not adhered to, resulting in a lack of timely treatment and care for the resident.
Failure to Provide Proper Adaptive Devices for ROM
Penalty
Summary
The facility failed to assess and provide proper adaptive devices to a resident (R30) to prevent further reduction in range of motion (ROM). R30, who has multiple medical diagnoses including non-traumatic intracerebral hemorrhage, altered mental status, and aphasia, was observed multiple times with tightly clenched hands and hand rolls that were too large and not placed correctly. Despite the presence of hand rolls, they were ineffective due to their size, and there was no documented rehabilitation evaluation for R30. The Rehab Director acknowledged the issue and provided a smaller hand roll but confirmed the lack of a documented evaluation by an occupational therapist. R30's husband expressed concern about the potential development of hand contractures and was observed giving passive range of motion (PROM) exercises to R30. He mentioned that a friend, who is a therapist, recommended the use of hand roll splints to prevent contractures. The facility's Regional Director/RN stated that it is routine for residents requiring extensive assistance to be evaluated by a therapist upon admission to determine the need for physical or occupational therapy. However, this evaluation was not conducted for R30, leading to the deficiency in care.
Failure to Document Antipsychotic Medication Use and Develop Dose Reduction Interventions
Penalty
Summary
The facility failed to document the reason for the use of an antipsychotic medication and develop interventions for dose reduction for a resident. The resident, who is [AGE] years old, was admitted with multiple medical diagnoses including unspecified psychosis and depression. Despite being on Risperidone since April 5, 2023, there was no documentation in the physician notes from February 2024 to the present addressing the use of this medication. Additionally, the psychotropic care plan dated April 6, 2023, did not include any targeted behavior to justify the use of Risperidone. Interviews with staff revealed that the resident experiences periods of forgetfulness but does not exhibit aggressive or unusual behaviors such as hallucinations or paranoia. The resident is also at high risk for falls due to occasional loss of balance. The Regional Director acknowledged that the resident should have been seen by a psychiatrist to evaluate the appropriateness of the medication and that the care plan should have been reviewed and adjusted within 21 days.
Failure to Follow Standardized Recipe for Pureed Diets
Penalty
Summary
The facility failed to follow the standardized recipe for pureed butternut squash during meal preparation for two residents on pureed diets. On April 15, 2024, the Dietary Manager confirmed that only two residents were on pureed diets. During the preparation of the pureed lunch meal, the cook used two #8 scoops of cooked butternut squash and added three ladles of broth, resulting in a total of 6 ounces of broth. This mixture appeared watery, prompting the cook to add a tablespoon of thickener to achieve a more cohesive consistency. The standardized recipe, however, required specific amounts of low sodium chicken base, hot water, and food thickener, which were not followed. The facility's diet manual emphasized the importance of using a standardized recipe when adding liquids and other items during pureeing to ensure nutritional values are maintained. The dietitian confirmed that following the recipe is crucial to prevent compromising nutrient values. The facility's scoop size equivalent chart indicated that a #8 scoop equals 4 ounces. The meal tickets for the two residents confirmed they were on pureed diets. The failure to adhere to the standardized recipe for pureed butternut squash was observed, documented, and confirmed by the dietitian, highlighting a deficiency in the facility's meal preparation process for residents on pureed diets.
Failure to Serve Pureed Beef in Desired Consistency
Penalty
Summary
The facility failed to serve pureed braised beef in the desired consistency for two residents on pureed diets. During an observation of the pureed lunch meal preparation, the cook placed cooked braised beef and beef broth into a blender and pureed the mixture. However, the resulting product had shreds of beef and appeared granular, which required chewing. The Dietary Manager, who was present, acknowledged the inconsistency and mentioned that another blender pureed food better. The facility's recipe for pureed beef tips and directives for pureed diets indicated that the food should be smooth and pudding-like in consistency to be easily swallowed without chewing. The deficiency was identified during an interview with the Dietitian, who confirmed that pureed products should be smooth and close to pudding consistency. The meal tickets for the two residents indicated that they were on pureed diets, which are intended for individuals with chewing or swallowing difficulties or dysphagia. The facility's failure to provide pureed beef in the correct consistency posed a risk to these residents, as the food was not safe to be served in its irregular form.
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.
Illustrative
What surveyors actually found near you
We read the 368 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Yorkville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearl At The Tillers | 5.6 mi | ★★★★★ | 2 | 0 |
| Sandwich Living & Rehab Center | 8.3 mi | ★★★★★ | 1 | 0 |
| Pearl Of Orchard Valley | 8.4 mi | ★★★★★ | 7 | 2 |
| Pavilion On Main Street, The | 8.8 mi | ★★★★★ | 17 | 0 |
| La Bella Of Aurora | 9.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.