Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Imboden Creek Senior Living during CMS and state inspections, most recent first.
Unqualified dietary leadership and missing Food Protection Manager certification. The Dietary Manager was supervising kitchen operations and reported serving as the full-time PIC, but denied having the qualifications of a clinically qualified CDM or equivalent training and denied holding Food Protection Manager certification. The Dietary Manager also stated no other dietary staff had that certification, and the facility dietician did not work full-time in the building. The Facility Assessment listed a Certified Dietary Manager in the staffing plan, and surveyors also observed nonfunctional sink basins plus an unsanitary can opener and ice scoop.
Kitchen Sink, Can Opener, and Ice Scoop Not Maintained Sanitary: The kitchen three-basin sink would not hold water because the wash and rinse basin drain valves leaked continuously, so staff had to stuff towels into the drain openings and keep adding water to wash and rinse dishes. The table-mounted can opener and receiver were heavily soiled with black food debris and grease, with metal shavings around the blade and gear. An ice scoop stored in a wall-mounted caddy had residue at the bottom of the caddy that the Dietary Mgr said appeared to be mold.
Failure to supervise a resident with dementia, neurocognitive disorder, unsteadiness, and a history of falls led to repeated unwitnessed falls and injuries, including skin tears, abrasions, swelling, pain, a hematoma, and an eyebrow laceration requiring ER transfer and sutures. The resident required substantial to maximal assist with transfers, used a wheelchair, was identified as a fall risk, and had orders for frequent toileting and not getting up alone, but the record and family report indicated the resident did not receive consistent 1:1 supervision despite multiple falls.
An unlabeled eyedrop bottle was found in a med cart drawer, along with opened OTC medications and multiple insulin pens that were not dated when opened. An LPN confirmed the eyedrop bottle had no label and could not verify its contents, and the DON confirmed the opened insulin pens for two residents were undated.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to have a PIC with Food Protection Manager Certification. An individual serving as the dietary manager and full-time food service manager reported not being a CDM, not meeting IL standards for a food service or dietary manager, and not holding the required food protection certification. The survey also found unsanitary food storage areas, food service equipment, and food prep areas, while the staffing plan called for a Certified Dietary Manager and 79 residents lived in the facility.
Unsanitary kitchen equipment, cooler, and food prep areas. Surveyors observed a table-mounted can opener and receiver with heavy food debris and metal shavings, walk-in cooler shelves covered with white fuzzy growth resembling mold, damp flooring with unidentified liquid puddles and scattered debris, and a heavily soiled food prep sink with brown deposits. The Cook did not know when the can opener was last cleaned and said the growth looked like mold; the Dietary Mgr stated kitchen food is available for all residents, and 79 residents lived in the facility.
Failure to implement an antibiotic stewardship program: the facility had incomplete antibiotic use logs and no additional infection control records beyond those provided by the Administrator. The logs did not show resident infection symptoms, use of standardized criteria, when ABX were started, monitoring of response, dose/schedule/duration, or when empiric therapy was changed by a medical provider. The facility application documented 79 residents.
Unnecessary psychotropic medication use was identified for a resident receiving citalopram, lorazepam, risperidone, and zolpidem. The resident’s record had no psychotropic med assessments or behavior tracking, and the care plan did not document specific behaviors, behavior triggers, or non-pharmacological interventions. The DON confirmed the resident had no documented behaviors and was not receiving psych services, and the MDS Coordinator confirmed the care plan lacked targeted behavior information.
Incomplete Person-Centered Care Plans: The facility failed to fully develop and implement care plans for three residents. One resident’s care plan listed Eliquis but omitted ordered Warfarin and monitoring, another resident’s psychotropic regimen was documented without specific behaviors, triggers, or non-pharmacological interventions, and a third resident’s updated care plan did not address discharge planning despite the resident’s request for transfer and documented need for referral packets.
The facility failed to obtain ordered lab diagnostics for a resident with convulsions who was receiving anticonvulsant medications. A neurology provider ordered a CMP, CBC, ammonia level, and medication levels for Lamotrigine, Levetiracetam, and Divalproex sodium, but the DON reported the labs were not obtained until later, and the lab reports show the specimens were not collected and submitted until that time.
Failure to assess self-administration of medication: A resident with intact cognition had Tylenol ordered PRN for pain, but a medication cup with two Tylenol-like caplets was found in the resident’s room. The resident said the meds were left by the nurse the prior evening and were not taken. The DON stated meds should not be left in rooms for unsupervised use, the facility does not allow self-administration, and no self-administration assessment was in the EMR.
A CNA failed to provide privacy during urinary catheter care for a resident with cancer, CVA, severe cognitive impairment, and an indwelling catheter. The curtain was not pulled, and the room door was opened twice during the procedure, exposing the resident to people passing by. The CNA later said she forgot to close the curtain and should have done so for privacy.
A resident's MDS incorrectly documented antipsychotic medication use even though the Physician Order Summary Report did not show any antipsychotic meds. The DON stated the resident had not been on an antipsychotic for months, and the Regional MDS Coordinator confirmed the MDS was incorrect.
A CNA applied Zinc Oxide cream to a resident’s buttocks, between the thighs, and on the glans penis during catheter care, even though the resident’s orders called for zinc to be applied for redness and RN staff confirmed CNAs cannot administer it because it is considered a medication. The resident had cancer diagnoses and an indwelling urinary catheter.
Pressure ulcer care was not provided with a timely care plan for a resident who developed a sacral pressure wound that later was observed as an unstageable coccyx ulcer with slough. The resident’s record and care plan did not include pressure-relieving interventions until weeks after the wound was identified, and the DON confirmed the delay. The facility policies required a care plan with interventions when a pressure ulcer is present.
Incomplete Catheter and Perineal Care: A CNA failed to provide complete catheter and perineal care for a resident with a Foley catheter and multiple diagnoses, including CA of the colon, lung mets, and CVA. During observed care, the CNA reused the same washcloth areas while cleansing the penis and buttocks, did not clean the catheter tubing, and dried the buttocks without rinsing after a large BM. The facility policy required changing the washcloth position with each stroke and cleansing/rinsing the catheter from the insertion site outward.
Failure to provide ordered nutritional supplements. A resident with protein-calorie malnutrition was ordered a high-calorie supplement BID, fortified pudding, and whole milk with meals, and the care plan and meal tray slip reflected those orders. However, the resident was observed eating lunch without the supplements present, and the DON confirmed the supplements were to be given with meals as ordered.
Improper Storage of Respiratory Equipment: A resident with acute respiratory failure with hypoxia, COPD, asthma, and pneumonia had an order for PRN O2. Surveyors observed the O2 concentrator at the foot of the bed with tubing and a nasal cannula in direct contact with the floor, and later found the tubing and cannula coiled on top of the concentrator. The DON stated staff should store resident O2 tubing and nasal cannulas in bags when not in use.
Failure to document medication administration: A resident with intact cognition and a pain order for PRN Tylenol had two Tylenol-like caplets observed at bedside, and the resident said the nurse had provided them the prior evening. The MAR did not show any Tylenol administration during the review period, and the DON stated nurses should document all meds, including PRN orders.
Duplicate Lamotrigine Orders Led to Duplicate Administration: A resident received duplicate doses of Lamotrigine after a new BID order was added without discontinuing the prior BID order. Pharmacy notes repeatedly flagged the duplication, but the MAR showed both doses were administered, and the DON later confirmed the resident received a total daily dose of 500 mg instead of the intended 200 mg.
Incorrect isolation precautions were used for a resident with confirmed COVID-19. Surveyors observed Enhanced Barrier Precaution signage on the resident’s room door while the door was open, even though the resident had been moved to a private room after testing positive. The Administrator said only one resident in the facility was COVID-19 positive, and an RN stated the resident should have had Contact/Droplet precaution signage on the door per facility policy.
Lack of Certified Dietary Manager. The facility failed to employ a Certified Dietary Manager for food services. The Dietary Manager stated he was not certified and was not enrolled in any certification courses, and the Administrator confirmed this. The facility’s job description for the Director of Food Services describes responsibility for directing dietary operations and ensuring daily nutritional services.
Several residents using C-PAP or BI-PAP machines did not have physician orders for their use or cleaning, and staff failed to consistently monitor and document vital signs such as oxygen saturation and respirations. Equipment was not stored or maintained according to policy, and residents or their families often managed the machines themselves without staff assistance.
A resident with multiple medical conditions and Full Code status was found unresponsive by CNAs, but staff failed to initiate CPR or call 911 immediately. Several staff, including CNAs and LPNs, assessed the resident and determined there were no signs of life, yet resuscitative efforts were delayed for about ten minutes while code status was verified and additional staff were sought. The DON eventually began CPR after confirmation, but the delay in emergency response constituted a deficiency.
The facility did not have a qualified Infection Preventionist onsite, as required for its infection prevention and control program. Although a nursing director was designated in documentation, no staff member onsite held the necessary certification, and the Administrator confirmed the absence of an Infection Preventionist in the building. This affected all 70 residents.
Multiple residents at risk for falls did not receive required fall prevention interventions, including missing or improperly used equipment such as non-slip mats, body pillows, bed alarms, and fall mats. Staff failed to complete thorough fall investigations, did not perform required neurological assessments after unwitnessed falls, and improperly transferred a resident after a fall, resulting in an undetected femur fracture. These deficiencies were confirmed through observation, record review, and staff interviews.
Staff were unable to verify completed fall prevention interventions due to the lack of a centralized location in the EMR, and advanced directives and code status were not readily accessible in either the EMR or the facility's emergency binder. Some staff could not locate or were unaware of where to find this critical information, and the administrator acknowledged that records were not easily accessible and the binder was not up to date.
A resident experienced an unwitnessed fall and was found on the floor by staff, who initially noted no injuries. The night shift LPN failed to verbally report the incident to the incoming LPN or notify nursing management, the physician, or the resident's POA. The fall was only discovered by the day shift LPN after the resident exhibited swelling and pain, leading to a delayed assessment and eventual diagnosis of a femoral fracture.
Staff provided post-mortem care and moved a deceased resident's body from the floor to the bed before the coroner arrived, despite not being instructed to do so. CNAs acted at the family's request and were unaware that the body and environment should remain undisturbed until cleared by the coroner. The LPN contacted EMS and the coroner's office but did not recall receiving instructions to leave the scene untouched. The coroner found the body and room had been altered upon arrival, contrary to standard procedures for potential coroner cases.
Two residents with pressure ulcers did not receive required admission or weekly skin assessments, and wound care treatments were missed on multiple occasions. Facility staff failed to follow policies for wound assessment and treatment, resulting in unaddressed changes in wound condition and incomplete care as ordered by physicians.
A resident with cognitive impairment and a history of falls was found on the floor with multiple bruises. An LPN assessed the resident but did not document the incident or notify the family, administrator, or DON, contrary to facility policy requiring family notification after accidents.
A resident with a history of behavioral issues and cognitive impairment struck another resident during an altercation at the nurse's station, despite staff attempts to intervene. Both residents had documented cognitive and behavioral health diagnoses. The facility's abuse policy prohibits such incidents, but the physical contact occurred, resulting in a failure to protect a resident from abuse.
The facility did not ensure timely review and revision of comprehensive care plans for three residents, with care plans not updated as required by policy and regulation. The Administrator stated that care planning was managed at the corporate level, resulting in lapses in the interdisciplinary team's review and update process.
A resident with cognitive impairment, mobility issues, and a history of falls did not have a required chair alarm in place as documented in the care plan and fall risk evaluation. Despite staff awareness of the need for a chair alarm, surveyors observed the resident without the alarm on several occasions, and the resident reported multiple recent falls and was observed with bruising. Staff interviews confirmed the intervention was not consistently implemented.
A resident with severe cognitive impairment and total dependence on staff did not receive timely incontinence care, remaining in a heavily soiled brief for an extended period. Two CNAs performed care using improper infection control practices, including using the same contaminated gloves for multiple tasks and touching various surfaces before performing hand hygiene. The facility's regional RN confirmed that proper technique and universal precautions were not followed.
A nurse left a cup containing 17 medications at a resident's bedside without supervision or a physician's order for self-administration, in violation of facility policy. The resident was asleep and unresponsive at the time, and the nurse later confirmed that medications should not be left at the bedside and must be administered under staff observation unless otherwise ordered.
A resident's medical records were found to be incomplete and inaccurate, with the diagnosis list missing psychosis despite prior psychiatric evaluation and ongoing antipsychotic use. The physician order for Risperdal listed an incorrect indication, and nursing staff failed to document required behavioral monitoring on the MAR for an entire month, resulting in numerous incomplete documentation errors.
A resident with cognitive impairment and mobility issues experienced a significant decline in ability to bear weight and increased pain, which was observed and reported by therapy staff to an LPN. The LPN did not notify the physician or document the change, resulting in a delay in obtaining an x-ray and diagnosing a hip fracture. The issue was only addressed after the resident's family raised concerns, leading to a delayed diagnosis and treatment.
The facility failed to provide timely toileting assistance and implement effective fall interventions for three residents, leading to significant injuries. One resident fell while attempting to use the restroom independently, resulting in a hematoma and femur fracture. Another resident experienced an unwitnessed fall, resulting in a skin tear and bruising, with missing fall prevention measures. A third resident fell out of bed due to ineffective equipment and lack of required footwear.
The facility failed to provide a clinically qualified Director of Food and Nutrition Services, affecting all 69 residents. The Dietary Manager, hired as a Certified Dietary Manager (CDM), was not certified and had not completed the necessary course, despite managing kitchen personnel and food safety. Staff confirmed the manager's role, highlighting a regulatory oversight.
The facility failed to provide timely meals and evening snacks, affecting all 69 residents. Residents reported breakfast served late and no evening snacks for months. The Dietary Manager confirmed meal times and snack availability, but a resident was unaware of evening snacks and had not received lunch by 12:15 PM. Facility policy requires three meals daily and routine evening snacks.
Two residents, both severely cognitively impaired, were involved in a verbal altercation after one resident's wheelchair collided with another's. The incident was not reported as an allegation of abuse to the Abuse Coordinator by the LPN, who viewed it as a behavioral issue. This oversight prevented the necessary investigation and reporting to the State Agency.
The facility failed to manage significant weight loss for two residents, with one losing 10.1 pounds and another 13.5 pounds without proper physician notification or documentation. The second resident was hospitalized and returned with a PEG tube, yet was not weighed upon readmission. Facility protocols for notifying physicians and dieticians of significant weight changes were not followed.
A facility failed to attempt non-pharmacological interventions before administering psychotropic medications to a resident. The resident's care plan lacked documentation of psychotropic medication interventions or non-pharmacological interventions for anxiety, and there was no behavior tracking or notes available. The resident was prescribed Quetiapine for anxiety, despite a diagnosis of unspecified dementia without behavioral disturbance or anxiety.
The facility failed to properly label medications for three residents, resulting in deficiencies in medication administration. An LPN administered medications without proper labels or open dates, and another resident's insulin pen was unlabeled. Additionally, a resident's medication cards had conflicting administration times compared to the MAR.
A facility failed to implement an effective antibiotic stewardship program by not assessing infection criteria for a resident receiving hospice services. The resident's medical records lacked a completed McGeer Criteria Checklist and documentation of testing or cultures to confirm an infection. Despite this, an antibiotic was prescribed for a UTI based on confusion observed by a hospice CNA, without supporting documentation or lab results.
A facility failed to update a resident's Advanced Directive upon readmission from the hospital, resulting in a discrepancy between the resident's documented wishes and their actual treatment preferences. The resident's existing POLST form indicated a preference for CPR, but upon readmission on hospice care, the facility did not obtain a new POLST to reflect the resident's choice for no CPR or extraordinary measures. This led to a failure to attempt CPR when the resident expired, as confirmed by the DON.
A resident with moderate cognitive impairment and total dependence on staff for toilet use was left in a heavily soiled incontinence brief for over an hour after lunch, despite a family member's request for assistance. The delay in care was acknowledged as a dignity issue by facility management, highlighting a failure to adhere to the facility's policy on resident dignity.
The facility failed to provide consistent food portion sizes during meal service, affecting several residents. Observations showed significant variation in portion sizes, unrelated to diet orders, with some residents receiving insufficient food. Staff interviews confirmed ongoing issues with portion sizes, and specific incidents highlighted residents' dissatisfaction. The facility's policy on serving utensils was not followed, leading to these deficiencies.
The facility failed to provide ordered wound care and maintain a pressure sore plan for two residents. One resident did not receive the prescribed treatment for a stage three pressure sore, and the treatment was not documented in the care plan. Another resident's dressing changes were not documented as completed on several occasions, and the Regional Nurse could not confirm if the treatments were done.
Unqualified dietary leadership and missing Food Protection Manager certification
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. On 5/20/2026 at 12:05 PM, V4, identified as the Dietary Manager, was actively supervising dietary operations in the facility kitchen and reported being the full-time manager of the food service and PIC. V4 stated they were not a clinically qualified Certified Dietary Manager and did not have equivalent training, and also denied being a certified Food Protection Manager. V4 further denied that any other dietary staff were certified Food Protection Managers. V4 also reported that the facility dietician does not work in the facility full-time. V4 denied having any of the qualifications listed for the Director of Food and Nutrition Services, including being a dietician, a Certified Dietary Manager, having an associate's or higher degree in food service management or hospitality, having 2 or more years of experience as a director of food and nutrition services in a nursing facility, graduating from an approved dietetic and nutrition program, graduating from an approved pre-7/1/1990 course with required experience, or completing an approved Certified Dietary Manager or Certified Food Protection Professional course. The Facility Assessment (2025) documented that the staffing plan includes a Certified Dietary Manager. On 5/20/2026 at 12:30-12:45 PM, the facility also failed to maintain functional sink basins and failed to maintain a sanitary can opener and ice scoop. The Room Directory dated 5/20/2026 documented that 61 residents reside in the facility.
Kitchen Sink, Can Opener, and Ice Scoop Not Maintained Sanitary
Penalty
Summary
The facility failed to maintain functional sink basins and failed to maintain a sanitary can opener and ice scoop in the kitchen. On 5/20/2026 at 12:45 PM, dishes were stacked beside and inside the kitchen three-basin sink, and the Dietary Manager reported that staff use the sink daily to wash, rinse, and sanitize dishes. The Dietary Manager stated the drain valves on the wash and rinse basins leaked continuously, the basins would not hold water, and staff had to stuff towels into the drain openings and continuously add water to effectively wash and rinse dishes. The Dietary Manager also reported the sink concerns had been shared with facility managers, no repairs were pending, and there was no formal process to submit a work order for maintenance concerns. On 5/20/2026 at 12:30 PM, the kitchen table-mounted can opener and receiver were observed to be excessively soiled with black accumulations of food debris and grease, with metal shavings present around the cutting blade and gear. At the same time, an ice scoop stored in a wall-mounted caddy adjacent to the ice maker had residue at the bottom of the caddy where the scoop tip rested, and the Dietary Manager stated the residue appeared to be mold. The facility Room Directory documented 61 residents.
Failure to Supervise Resident With Repeated Falls
Penalty
Summary
The facility failed to provide effective resident supervision to prevent repeat traumatic falls for a resident with multiple fall-related and cognitive diagnoses, including metabolic encephalopathy, convulsions, muscle wasting and atrophy, lack of coordination, unsteadiness on feet, history of falling, neurocognitive disorder, dementia, repeat falls, major depressive disorder, and anxiety disorder. The resident’s assessment documented the need for substantial to maximal assistance with transfers, wheelchair use for mobility, and bilateral upper extremity range-of-motion impairment, and a fall risk assessment identified the resident as at risk for falls. The facility fall log documented multiple falls in November and December 2025, and facility staff and leadership stated those were the falls documented in the record, although additional fall investigations identified more falls that were not on the fall log. The resident experienced repeated unwitnessed falls with injuries including abrasions, skin tears, swelling, pain, a hematoma, and a laceration to the eyebrow requiring emergency transfer to the hospital for surgical repair and sutures. Progress notes documented the resident being found face down on the floor on multiple occasions, including with a skin tear to the arm, a goose egg to the back of the head, head and body pain, a forehead laceration, and later abrasions to the nose and forehead, swelling to the right hand, and a skin tear to the left arm. The care plan identified the resident as at risk for falls and added a 1:1 safety intervention, and a telephone encounter documented an order to toilet the resident frequently and not allow the resident to get up alone; however, the report states the resident denied ever receiving 1:1 supervision during December 2025 and the representative believed the facility did not have enough staff to provide it.
Unlabeled Medication and Undated Insulin Pens
Penalty
Summary
Drugs and biologicals used in the facility were not consistently labeled and stored as required. During observation, interview, and record review, a medication cart drawer contained a white eyedrop bottle inside a box labeled prednisone suspension 1% with R74's name, but the eyedrop bottle itself had no label. In the same drawer, opened bottles of zinc 50 mg, bisacodyl 5 mg, and multivitamin with minerals were present with expiration dates of 12/2025, 12/2025, and 11/2025, respectively. The LPN who was present confirmed the eyedrop bottle was unlabeled and stated she could not verify its contents because it was not labeled. The facility also had opened insulin pens that were not dated when opened. A medication cart contained an undated Lantus and an undated Lispro multidose insulin pen for R9, as well as an undated Degludec and an undated Lispro multidose insulin pen for R2. The DON confirmed the pens should be dated when opened and acknowledged that the pens for R2 and R9 were opened but not dated. The facility application documented 79 residents residing in the facility.
Unqualified dietary leadership and missing food protection certification
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. On 1/6/2026 at 12:42 PM, V5, identified as the Dietary Manager, was actively supervising dietary operations in the facility kitchen and reported being the full-time manager of the food service since September 2025. V5 stated not being a clinically qualified Certified Dietary Manager and denied meeting Illinois standards to be a food service manager or dietary manager. V5 also denied being a certified Food Protection Manager, as required for a person in charge of a food service. V5 further denied having the qualifications listed in the report, including being a Dietician, being a Certified Dietary Manager, having an associate's or higher degree in food service management or hospitality, having 2 or more years of experience as a director of food and nutrition services in a nursing facility, graduating from an approved dietetic and nutrition program, graduating from an Illinois Department of Public Health approved course before July 1, 1990 with the required experience, or completing an approved Certified Dietary Manager or Certified Food Protection Professional course. The Facility Assessment (2025) listed a staffing plan that included a Certified Dietary Manager. During the survey from 1/6/2026 to 1/8/2026, the facility also failed to maintain sanitary food storage areas, food service equipment, and food preparation areas. The facility application documented that 79 residents resided in the facility.
Unsanitary kitchen equipment, cooler, and food prep areas
Penalty
Summary
The facility failed to maintain sanitary food storage areas, food service equipment, and food preparation areas. On 1/6/2026, surveyors observed the kitchen table mounted can opener and receiver soiled with heavy accumulations of dark, sticky food debris, and the opener also had accumulations of metal shavings. The kitchen walk-in cooler had wire storage shelves covered with white fuzzy biological growth resembling mold, while food was stored on all portions of the shelves. The cooler floor was damp and contained an unidentified brown liquid puddle, an unidentified yellow liquid puddle, scattered debris including plastic wrap, paper, and single-serve condiment packets. The kitchen food preparation sink was also heavily soiled and stained with brown deposits across all surfaces of the sink basins. These same conditions were observed again on 1/7/2026 and 1/8/2026. The Cook reported not being aware of when the can opener was last cleaned or whether kitchen staff cleaned it, and later stated the fuzzy substance on the walk-in cooler shelves looked like mold. The Dietary Manager reported that food from the kitchen is available for all residents in the facility to eat, and the facility application documented 79 residents residing there.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use, systems to monitor antibiotic outcomes, resistance, and adverse events, and use of standardized tools and criteria to assess resident infections. On 1/8/2025 at 10:11 AM, the Administrator provided antibiotic use logs for infections for the previous calendar year, but only June through December 2025 logs were present and no other months were available. On 1/8/2025 at 3:12 PM, the Administrator stated the facility had no additional information related to its antibiotic stewardship or infection control program beyond the records provided. The infection logs did not document resident symptoms indicating infection, whether standardized criteria were used to justify and guide antibiotic use, when antibiotic therapy was first started, whether response to treatment was monitored, the dose, schedule, or duration of antibiotic treatment, or when empiric antibiotic therapy was changed by a medical provider. The facility’s Medicare and Medicaid application dated 1/6/2026 documented 79 residents in the facility.
Unnecessary Psychotropic Medication Use and Missing Assessments
Penalty
Summary
The facility failed to prevent unnecessary use of psychotropic medications for one resident, who had orders for citalopram 10 mg daily, lorazepam 0.5 mg daily, risperidone 0.5 mg at bedtime, and zolpidem at bedtime. The resident’s medical record did not document any psychotropic medication assessments or behavior tracking, and the care plan listed psychotic disorder with delusions, major depressive disorder, delusional disorder, and anxiety disorder along with the psychotropic medications being used. The care plan did not document any specific behaviors or non-pharmacological interventions to manage behaviors. The DON stated she did not know about psych assessments and confirmed the resident was not receiving psychiatric services and had no behaviors documented. The Regional MDS Coordinator also confirmed there were no non-pharmacological interventions, behavior triggers, or targeted behaviors on the resident’s care plan. The facility’s psychotropic medication use policy stated that the interdisciplinary team evaluates the resident when determining whether to initiate, modify, or discontinue medication therapy and that behavioral and other non-pharmacological approaches are used to minimize or eradicate the need for medications, and that residents receiving psychotropic medication are monitored with the response to treatment documented.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for three residents reviewed for care plans. For one resident, the current care plan documented anticoagulant therapy with Eliquis, but the physician order summary showed Warfarin Sodium orders for 2 mg on Wednesday, Thursday, and Friday and 3 mg on Monday, Tuesday, Saturday, and Sunday. The care plan did not include the resident’s Warfarin use or monitoring, and the Regional MDS Coordinator confirmed the omission. For another resident, the care plan documented psychotic disorder with delusions, major depressive disorder, delusional disorder, anxiety disorder, and use of Citalopram, Lorazepam, Risperidone, and Zolpidem, but it did not document any specific behaviors, behavior triggers, or non-pharmacological interventions. For a third resident with flaccid hemiplegia affecting the left non-dominant side and frontal lobe and executive function deficit following cerebral infarction, the record showed dependence on staff for all ADLs, an indwelling urinary catheter, and a BIMS score of 15. Progress notes documented referral packets for transfer were sent at the resident’s request, but the updated care plan after return from the hospital did not address discharge planning, despite the policy requiring inclusion of the resident’s stated preference and potential for future discharge.
Delayed Completion of Ordered Neurology Laboratory Diagnostics
Penalty
Summary
The facility failed to obtain laboratory diagnostics as ordered by a medical provider for R7, who had a diagnosis of convulsions and physician orders for Levetiracetam, Lamotrigine, and Divalproex sodium. A neurology provider faxed orders to the facility on 12/9/2025 for a complete metabolic profile, complete blood count, ammonia level, Lamotrigine level, Levetiracetam level, and Divalproex sodium level. On 1/9/2026, the DON reported that these laboratory diagnostics were not obtained until 12/23/2025. The laboratory reports document that the facility did not collect and submit R7's specimens to the laboratory until 12/23/2025.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to determine whether a medication was appropriate and safe for self-administration for one resident, R59. R59’s assessment documented intact cognition, and the physician orders included Tylenol Extra Strength 500 mg, two tablets by mouth every 8 hours as needed for pain. During observation, R59 was seated in his room with an overbed table nearby, and a medication cup on the table contained two white oblong caplets resembling Tylenol. R59 stated the caplets were Tylenol and said they had been provided by the facility nurse the previous evening but were not taken. The DON stated staff should not leave medications in resident rooms for residents to take unsupervised, that the facility does not allow self-administration of resident medications, and that R59 had not been assessed for self-administration. The electronic medical record did not contain an assessment for medication self-administration, and the facility medication administration policy states residents may self-administer medications only if the attending physician and Interdisciplinary Care Planning Team determine they have the decision-making capacity to do so safely.
Failure to Provide Privacy During Catheter Care
Penalty
Summary
The facility failed to provide privacy during urinary catheter care for a resident with cancer of the colon, CVA with right-side impairment, severe cognitive impairment (BIMS 7), dependence on staff for ADLs, an indwelling urinary catheter, and frequent bowel incontinence while on hospice. During catheter care, the CNA did not pull the curtain before providing the procedure. The resident’s bed was the first bed upon entering the room, and staff knocked on the door and opened it twice during the care, exposing the resident to anyone passing by the room. The CNA later stated that she forgot to close the curtain around the resident and should have closed it for privacy. The facility’s catheter care policy directs staff to provide privacy and cover the resident with a sheet, exposing only the perineal area.
Inaccurate MDS Documentation of Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete a resident's comprehensive assessment. R3's MDS, dated [DATE], documented that R3 was taking an antipsychotic medication, but the Physician Order Summary Report dated 1/8/2026 did not show any antipsychotic medications prescribed or received by R3. During interviews on 1/8/26, the DON stated that R3 had not been on any antipsychotic medication for months, and the Regional MDS Coordinator stated that R3 was not currently on any antipsychotic medications and confirmed that R3's MDS was incorrect.
CNA Applied Zinc Oxide Cream During Catheter Care
Penalty
Summary
The facility failed to ensure qualified staff applied medicated cream to a resident during urinary catheter care for one of two residents reviewed. The resident had diagnoses of malignant neoplasm of the colon and secondary malignant neoplasm of the lung and required an indwelling urinary catheter. During catheter care, a CNA told the resident she was going to apply cream to the resident’s buttocks and red spots, then took the cream from the bedside table, put it on her gloves, and applied it to the resident’s buttocks, between the thighs, and on the glans penis. The cream used was labeled Silicone Cream with Zinc Oxide. The resident’s physician orders directed application of zinc to the buttocks every day and night shift for redness until healed, and the facility policy stated only licensed or permitted persons may prepare, administer, and document medications. RN staff confirmed CNAs cannot apply Zinc Oxide and that it is considered a medication that must be administered by licensed staff.
Pressure Ulcer Care Plan Not Developed Promptly
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a pressure ulcer. On 01/08/2026, a quarter-sized unstageable pressure ulcer with 90 percent slough was observed on the resident’s coccyx, and the wound nurse confirmed it was an unstageable pressure ulcer. The resident had been admitted to the facility on [DATE] for a left shoulder fracture. The resident’s nurse’s note dated 11/19/25 documented a stage 2 pressure wound on the sacrum, but the medical record and care plan did not include a plan of care with pressure relieving interventions until 12/23/25. The DON stated on 1/9/25 that the pressure ulcer plan of care with pressure relieving interventions was not developed until 12/23/25, and confirmed the pressure ulcer was identified on 11/19/25. The facility’s care plan policy required problem areas with interventions, and the pressure ulcer policy stated that when a pressure ulcer is present, a plan of care with interventions will be implemented.
Incomplete Catheter and Perineal Care
Penalty
Summary
The facility failed to perform complete urinary catheter and perineal care for one resident who had diagnoses of malignant neoplasm of the colon, secondary malignant neoplasm of the lung, and a cerebrovascular accident. The resident had a physician order for catheter care twice daily. During observation, a CNA performed catheter care by washing the penis shaft toward the glans with a soapy washcloth, then cleansed the same areas again without changing the area of the washcloth, and cleansed the meatus without changing the washcloth area. The CNA rinsed the areas, dried the resident, and did not clean the urinary catheter tubing. The CNA then turned the resident onto his left side and began cleaning the buttocks while the resident had a large bowel movement that was dark, thick, and smeared each time she wiped. She washed the buttock area with a soapy washcloth and went over the same area two times without changing the area of the cloth, then dried the buttocks without rinsing the area first. The facility policy for male catheter care required cleansing around the meatus with circular strokes, changing the position of the washcloth with each stroke, rinsing with a clean washcloth, and cleansing and rinsing the catheter from the insertion site outward. The DON stated the CNA must have been nervous or scared and said she would be spoken to about correct catheter care, and the CNA stated she did not do a good job and would be retrained.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
Provide enough food/fluids to maintain a resident's health. The facility failed to provide nutritional supplements as ordered for one nutritionally at-risk resident, R1, who had a diagnosis of protein-calorie malnutrition. R1's physician order summary documented orders for a high calorie nutritional supplement twice a day, fortified pudding, and whole milk with meals, and the current care plan stated that R1 was nutritionally at risk and was to receive supplements as ordered. R1's lunch meal tray slip also documented that fortified pudding and whole milk were to be provided with the meal. However, on 1/8/26 at 12:31 PM and again on 1/9/26 at 12:02 PM, R1 was observed eating lunch in the dining room without any nutritional supplements present with the meal. The DON stated that R1 was to receive the high calorie nutritional supplement at lunch and supper and the other supplements at all meals, and the Activity Director stated that residents should receive supplements with their meals if the supplements are on the meal tray slip.
Improper Storage of Respiratory Equipment
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to store respiratory care equipment in a sanitary manner for R7. R7 had diagnoses including acute respiratory failure with hypoxia, COPD with acute exacerbation, asthma, and pneumonia, and had a physician order for two liters of oxygen as needed. During observation, R7’s oxygen concentrator was found at the foot of the bed with oxygen tubing and a nasal cannula attached and lying in direct contact with the floor. On a later observation, the tubing and nasal cannula were coiled on top of the oxygen concentrator. R7 stated that the oxygen concentrator, tubing, and nasal cannula were used in the room, and the DON reported that staff should store resident oxygen tubing and nasal cannulas in bags when not in use.
Failure to Document PRN Tylenol Administration
Penalty
Summary
The facility failed to document administration of a resident's medication. R59 had intact cognition, a diagnosis of pain, and a physician order for Tylenol Extra Strength 500 mg, two tablets by mouth every 8 hours as needed for pain. During observation on 1/6/2026, R59 was seated in a chair with an overbed table nearby, and a medication cup on the table contained two white oblong caplets resembling Tylenol. R59 stated the caplets were Tylenol and said they had been provided by the facility nurse the previous evening but were not taken. Review of the January 2026 MAR showed no documentation that R59 received any Tylenol from 1/1/2026 through 1/8/2026. The DON stated nurses should document all medications administered to residents and that staff probably forgot to document the Tylenol administration, including as-needed orders.
Duplicate Lamotrigine Orders Led to Duplicate Administration
Penalty
Summary
The facility failed to respond timely to multiple pharmacy requests to reconcile duplicate medication orders, resulting in duplicate administration of Lamotrigine for one resident. The resident had a physician order for Lamotrigine 100 mg by mouth twice daily with a start date of 11/8/2025 and discontinuation date of 12/31/2025, and an additional order for Lamotrigine 150 mg by mouth twice daily with a start date of 12/10/2025 and discontinuation date of 12/31/2025. A consulting pharmacy note dated 12/12/2025 stated that the new 150 mg BID order had been added but the previous 100 mg BID order was not discontinued and asked for clarification of the current dose and discontinuation of the previous order if necessary. The resident’s MAR for December 2025 documented administration of both the 100 mg and 150 mg doses twice daily from 12/10/2025 through 12/31/2025. On 1/9/2026, the DON reported believing the medication orders were duplicative and stated the resident did receive duplicate doses during December 2025, resulting in a total daily dose of 500 mg instead of the intended 200 mg. A later consulting pharmacy note sent to the attending medical provider on 12/29/2025 again identified the duplicate Lamotrigine orders and noted that Lamotrigine may contribute to dizziness, ataxia, and impaired balance, increasing fall risk.
Incorrect isolation signage for a resident with COVID-19
Penalty
Summary
The facility failed to ensure droplet isolation infection control precautions were used for a resident with confirmed COVID-19. On 1/6/26 at 11:00 AM, Enhanced Barrier Precaution signage was observed on the resident’s room door, and the door was open. The resident’s progress note dated 1/2/26 documented that the resident tested positive for COVID-19 during routine testing and was moved to a private room. The Administrator stated that only one resident in the facility was COVID-19 positive at that time, and a CNA stated the resident had been residing in that room since 1/2/26 because of COVID-19 but was unsure who was responsible for placing the correct isolation signage. The Regional Corporate Nurse stated residents with COVID-19 are placed on Contact/Droplet precautions and that the resident should have had Contact/Droplet precaution signage on the door. The facility’s COVID-19 policy states residents with confirmed COVID-19 are to be placed in a single room with the door closed if safe to do so and isolated using Transmission-Based Precautions.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ a Certified Dietary Manager for food services. The facility census documented 75 residents currently residing in the facility. During interview, the Dietary Manager stated he is not certified for dietary management and is not currently enrolled in any certification courses. The Administrator also stated that the Dietary Manager is not certified and that the Regional Registered Dietician consults for the facility on a monthly basis. The facility's undated job description for the Director of Food Services states the role is responsible for planning, organizing, developing, and directing the overall operation of the Dietary Department and ensuring nutritional services are provided daily in a clean, safe, sanitary manner.
Failure to Obtain Physician Orders and Monitor C-PAP/BI-PAP Use
Penalty
Summary
The facility failed to obtain physician orders for the use and cleaning of Continuous Positive Airway Pressure (C-PAP) and Bilevel Positive Airway Pressure (BI-PAP) machines for four residents. In each case, the residents were using their own C-PAP or BI-PAP machines, which were brought from home, but there were no corresponding physician orders documented in their medical records. Additionally, the facility did not document orders for the cleaning, monitoring, or settings of these machines, despite the residents' ongoing use and medical needs. The facility also failed to consistently monitor and document vital signs, including oxygen saturation and respirations, for three residents using C-PAP/BI-PAP machines. Medical records showed significant gaps in the documentation of these vital signs, and interviews with residents and family members confirmed that staff were not regularly obtaining or recording this information. Some residents and their families reported that staff did not assist with cleaning the machines or checking the settings, and in some cases, family members or the residents themselves were responsible for these tasks. Observations revealed that C-PAP and BI-PAP machines and their components, such as tubing and masks, were not stored in a sanitary manner, with equipment left uncovered and in direct contact with surfaces. Staff interviews confirmed a lack of oversight regarding the management of these devices, and the facility's own policy required physician orders, regular monitoring, and cleaning by licensed nurses, none of which were consistently followed. The absence of a respiratory therapist and lack of staff involvement in managing the machines further contributed to the deficiency.
Delayed CPR Initiation and Emergency Response for Full Code Resident
Penalty
Summary
Facility staff failed to provide timely emergency resuscitative efforts to a resident who was a Full Code, resulting in a ten-minute delay before CPR was initiated. The resident, who had multiple complex medical diagnoses including sepsis, COPD, heart failure, and diabetes, was found unresponsive in bed by CNAs during morning care. Initial assessment by staff revealed no pulse, no oxygen saturation, no blood sugar, and no measurable blood pressure. Despite the resident's documented Full Code status, no immediate CPR was started by the CNAs or the first LPNs who assessed the resident. Instead, staff left the room to seek verification of the code status and to find additional staff, further delaying the initiation of life-saving measures. Multiple staff members, including CNAs and LPNs, entered the resident's room, assessed the resident, and determined there were no signs of life, but none initiated CPR at that time. The DON was eventually called to the room, and only after confirming the code status as Full Code did the DON and other staff begin CPR, approximately ten minutes after the resident was first found unresponsive. During this period, 911 was not called immediately, and resuscitative efforts were not started as per facility policy, which states that CPR should be initiated immediately if code status is unclear and continued until EMS arrives or a physician provides further instruction. Interviews with staff revealed a lack of prompt assessment and action regarding the resident's change in condition, as well as uncertainty and delays in verifying code status. The night nurse did not report the resident's abnormal condition to management or the physician, and day shift staff did not check on the resident promptly despite being informed the resident was not feeling well. The facility's failure to initiate CPR immediately upon finding the resident unresponsive, and the delay in calling emergency services, directly contributed to the deficiency cited by surveyors.
Removal Plan
- The facility implemented a revised Cardiopulmonary Resuscitation (CPR) policy to instruct staff to call emergency services (911) earlier in the CPR process.
- All facility direct care personnel have been educated to ensure they are aware of the policy related to change of condition assessment, immediate initiation of CPR, and identification of the location where the resident's code status is documented.
- A new ‘acknowledgement' form was introduced for all new employees to sign, indicating they have been trained on the facility CPR policy and where to find a resident's code status.
- Training on location and identification of code status began and will continue with any new staff hired or staff categorized as ‘As needed.’
- Facility management staff received education on the updated CPR policy and procedures.
- Direct care floor staff were trained on the updated CPR policy and procedures.
- The facility updated their CPR policy to incorporate effective CPR procedures for residents who have chosen to be fully resuscitated.
- Every resident chart was reviewed and reconciled with the resident Physician Order Sheet (POS) and face sheet to ensure any resident who chooses to be a ‘Full Code’ has that information easily accessible to staff.
- A Quality Assurance Performance Improvement (QAPI) meeting was held to discuss change of condition assessment, initiation of CPR, and to review policies and procedures.
- Facility staff reviewed 100% of resident charts to ensure proper orders are in place and appropriate chart identification for advanced directives.
- The Interdisciplinary Team (IDT) will continue with reeducation of change of condition assessment, reporting, and initiation of CPR, with education offered for one year, annually, and upon hire.
Failure to Employ Onsite Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist who remains onsite, as required for the infection prevention and control program. Record review showed that while a member of the nursing directors' team was designated as the certified Infection Preventionist in the facility assessment, the facility was unable to provide an Infection Preventionist certificate for any employee working onsite. Observations conducted over several days confirmed that there was no Infection Preventionist present in the building. The Administrator confirmed that the facility does not have an Infection Preventionist onsite and that the corporate Infection Preventionist is never in the building. This deficiency has the potential to affect all 70 residents residing in the facility.
Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for four residents, as evidenced by incomplete fall investigations, failure to perform post-fall neurological assessments, improper transfer techniques after a fall, and lack of implementation of fall prevention interventions. One resident with multiple medical diagnoses, including a history of falls and severe cognitive impairment, was found on the floor and was manually lifted back to bed by staff instead of using a mechanical lift as required by the resident's care plan and facility policy. Neurological assessments were not completed per policy after the unwitnessed fall, and the fall investigation did not include interviews with all involved staff or determination of a root cause. The resident subsequently developed swelling and pain in the right leg, which was later diagnosed as an acute, displaced femur fracture. Another resident, identified as a fall risk and cognitively intact, had a care plan intervention for a non-slip mat in the wheelchair, but repeated observations showed the mat was either missing or improperly placed. This resident had a history of multiple falls and was observed with visible bruising. The Director of Nursing confirmed the absence or improper placement of the non-slip mat during interviews and observations. Two additional residents, both at risk for falls and not cognitively intact, had care plans specifying interventions such as body pillows, bed alarms, overlay bolsters, fall mats, and accessible call lights. Observations revealed that these interventions were not in place as required: body pillows and bed alarms were missing, overlay bolsters were not present, and call lights were out of reach or on the floor. Staff interviews and direct observation confirmed these deficiencies, and the facility's own policies required individualized fall prevention interventions based on resident risk assessments.
Failure to Maintain Accessible and Complete Medical Records
Penalty
Summary
The facility failed to maintain accessible and complete medical records for five residents, as required by accepted professional standards. Staff, including CNAs and LPNs, were unable to verify which fall prevention interventions had been implemented or completed for several residents because the electronic medical record (EMR) system did not have a centralized or easily accessible location for this information. This lack of organization in the EMR compromised staff's ability to deliver consistent care and monitor resident safety effectively. Additionally, the facility's binder intended for emergency use, which should document advanced directives and code status, was not up to date and did not include this information for multiple residents. Staff reported difficulty locating residents' code status and advanced directives in both the EMR and the physical binder, with some staff unaware of the binder's existence or location. The administrator confirmed that while the POLST forms were present in the EMR, they were not easily accessible, and the binder was not current, which could delay emergency care. There was no specific policy ensuring that medical records, including advanced directives, were easily accessible to staff.
Failure to Timely Notify Physician and Responsible Parties After Resident Fall
Penalty
Summary
The facility failed to timely notify the physician and other responsible parties of a resident's fall. According to nurse progress notes, a resident was found on the floor early in the morning and assessed by staff, who found no injuries or pain at that time. The resident was assisted back to bed, and the night shift LPN was informed. However, the night shift LPN did not verbally report the fall to the incoming day shift LPN, instead leaving a written note, which was not received. As a result, the day shift LPN was unaware of the fall until a CNA reported swelling and pain in the resident's right leg later that morning. Upon assessment, the day shift LPN noted swelling, pain, and discoloration in the resident's right leg and administered pain relief and an ice pack before contacting the physician. Further review revealed that the night shift LPN did not report the unwitnessed fall to the next shift, nursing management, the physician, or the resident's power of attorney. The resident was later sent to the emergency room, where an X-ray confirmed an acute, displaced fracture of the distal femoral shaft. The Director of Nursing confirmed that the required notifications were not made following the fall, as was necessary.
Failure to Maintain Undisturbed Environment Prior to Coroner Arrival
Penalty
Summary
The facility failed to maintain an undisturbed environment following the death of a resident prior to the arrival of the coroner. After the resident passed away, video footage showed that four CNAs entered the resident's room and provided post-mortem care, including transferring the resident's body from the floor back to the bed using a mechanical lift. The CNAs reported that they were not instructed not to touch the body or the environment, and stated that they acted at the request of the resident's family to clean up the resident. The LPN on duty contacted EMS and the coroner's office, but did not recall being instructed not to disturb the body or the environment. The LPN acknowledged that staff should not touch the body or environment until cleared by the coroner. When the coroner arrived, the resident's body had already been moved and the room had been cleaned, with no medical supplies present. The coroner stated that in such cases, the body and environment should be left untouched as it is considered a possible crime scene, and that the facility should not have tampered with the body after death. The facility administrator confirmed that there was no policy in place regarding post-mortem care for coroner cases, and that staff were expected to follow the standard of care.
Failure to Assess and Treat Pressure Ulcers as Ordered
Penalty
Summary
The facility failed to assess wounds and complete wound treatments as required for two residents with pressure sores. For one resident, there was no admission skin or wound assessment performed by facility staff, nor were there any weekly skin or wound assessments documented after admission. The resident was admitted with only a surgical wound, but later developed a large, unstageable deep tissue injury on the posterior right upper buttock. The treatment administration record showed that wound care treatments were missed on multiple days, and the resident's family observed that dressings were often not changed as scheduled, with old dressings remaining in place. The Director of Nursing confirmed the lack of required assessments and missed treatments, acknowledging that treatments were not completed as ordered by the physician. Another resident, admitted with multiple diagnoses including Parkinson's disease, dementia, and a history of malignancy, also did not receive required weekly skin or wound assessments. The treatment administration record indicated that wound care for a sacral pressure ulcer was not completed as ordered on several occasions. The last documented skin or wound assessment for this resident was several weeks prior to the survey, despite ongoing physician orders for wound care. During wound care observations, the wound was found to have full-thickness tissue loss with muscle exposed, and the resident experienced pain during the procedure. Facility policy required comprehensive skin assessments upon admission, weekly risk assessments, and completion of wound care according to physician orders. Interviews with the Director of Nursing and review of records confirmed that these policies were not followed for the two residents. The failure to perform timely assessments and complete wound treatments as ordered led to the deficiencies cited in the report.
Failure to Notify Family of Resident Accident
Penalty
Summary
The facility failed to notify a family member of an accident involving a resident who had a history of falls, impaired cognitive function, and decreased mobility. The resident, who had diagnoses including a pelvic fracture, chronic pain, and unsteadiness, was found on the floor by an LPN after being heard yelling. The resident had visible bruising on the right temple, right arm, and left forearm. Despite the incident and the resident's condition, the family was not notified at the time of the accident. Staff interviews revealed that the LPN who assessed the resident after the fall did not document the assessment, vital signs, or any information about the fall, nor did she notify the family, the administrator, or the DON. The LPN stated she believed another nurse would handle the notifications, but that nurse did not go to the resident's room. The facility's policy requires documentation of the date and time a family member is notified of an accident, which was not followed in this case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. According to the facility's initial report and staff interviews, two residents with cognitive and behavioral diagnoses were involved in an altercation at the nurse's station. One resident, who had a history of anxiety, agitation, poor impulse control, and documented behavioral problems, accused the other of stealing a fan and proceeded to strike the other resident on the shoulder with an open hand. Staff present at the time attempted to separate the residents, but the physical contact still occurred. The incident was witnessed by a CNA and corroborated by an LPN, who described the aggressor as having a tendency to become agitated and verbally aggressive. Both residents involved had documented cognitive impairments and behavioral health issues, including dementia, anxiety, and depression. The facility's abuse policy prohibits abuse of any kind and commits to protecting residents from abuse by anyone, including other residents. Despite these policies and the known behavioral risks, the facility did not prevent the physical altercation, resulting in a failure to uphold the resident's right to be free from abuse.
Failure to Timely Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to timely review and revise comprehensive care plans for three residents, as required by their own policy and federal regulations. Specifically, the most current care plans for the affected residents were not updated in accordance with the required schedule, with documented dates showing significant lapses. During an interview, the Administrator confirmed that no one at the facility was responsible for care plans, as this task was handled at the corporate level. The facility's policy mandates that the interdisciplinary team must review and update care plans after significant changes, unmet outcomes, and at least quarterly with the Minimum Data Set (MDS) assessment, but this process was not followed for the residents reviewed.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention for a resident with a history of falls, impaired cognitive function, and decreased mobility. The resident's care plan required the use of a chair alarm due to impulsivity and a high risk for falls, as documented in both the care plan and fall risk evaluation. Despite these documented interventions, surveyors observed on multiple occasions that the resident did not have a chair alarm in place while seated in the wheelchair. The resident reported attempting to transfer independently and having experienced multiple recent falls, and was observed with faded bruising on both arms and the right temple. Staff interviews confirmed awareness of the care plan requirement for a chair alarm, but the intervention was not consistently implemented.
Failure to Provide Timely and Hygienic Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, who is totally dependent on staff for all activities of daily living and is always incontinent of bowel and bladder, did not receive timely and appropriate incontinence care. The resident had a recent history of urinary tract infection (UTI) and was on antibiotic and probiotic therapy. On the morning of the survey, a CNA admitted to not having changed or repositioned the resident since the start of her shift, citing being busy with another resident and the fact that the resident was asleep. The CNAs did not receive a report from the night shift regarding the last time the resident was changed. Upon assessment, the resident was found in a heavily soiled incontinence brief with evidence of prolonged exposure to urine. During the provision of care, the CNAs failed to follow proper infection control practices. After removing the soiled brief, the CNAs continued to use the same contaminated gloves to perform multiple tasks, including cleaning the resident's eyes and mouth, handling supplies, and performing peri-care. One CNA also touched various surfaces in the room with the same contaminated gloves. Both CNAs only removed their gloves and performed hand hygiene after completing all care tasks. The improper technique and lack of hand hygiene during incontinence care were acknowledged by the facility's regional RN as a breach of expected standards.
Medications Left Unsupervised at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a nurse left a medication cup containing 17 medications at a resident's bedside without supervision, contrary to facility policy and without a physician's order permitting self-administration. The resident was found asleep and unresponsive to verbal prompts, with the medication cup still present. The nurse later acknowledged that medications should not be left at the bedside and that staff are required to observe residents taking their medications unless there is a specific order allowing self-administration. The facility's policy states that medications must be administered safely and in a timely manner, with staff required to observe administration unless the attending physician has determined the resident can self-administer. In this case, there was no such order for the resident, and the nurse confirmed that leaving medications at the bedside was not permitted. The resident also reported that this nurse had previously left medications at the bedside for unsupervised administration.
Incomplete and Inaccurate Medical Record Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident reviewed for medical records. The resident's current diagnosis list did not include a diagnosis of psychosis, despite a historic psychiatric evaluation documenting psychosis and irritable/frequent anger, which was the basis for the original order of Risperdal, an antipsychotic medication. The current physician order for Risperdal inaccurately listed the indication as 'prophylaxis' and did not reflect the correct diagnosis. Additionally, the Minimum Data Set indicated the resident received antipsychotic medications on a routine basis. The Medication Administration Record (MAR) required nursing staff to monitor and document specific behaviors every shift, using 'Y' for no behaviors observed and 'N' for behaviors observed, with further documentation in the nurses' notes if needed. However, for an entire month, nurses failed to document either 'Y' or 'N' for each shift and did not record any behaviors in the corresponding nurses' notes, resulting in 93 incomplete documentation errors. The facility's policy requires documentation to be objective, complete, and accurate, which was not followed in this case.
Failure to Promptly Notify Physician of Change in Condition Resulting in Delayed Diagnosis of Hip Fracture
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a physician of a resident's significant change in condition and decline in mobility, resulting in prolonged discomfort and pain. The resident, who was cognitively impaired and had a history of falls, muscle weakness, and difficulty walking, began experiencing new onset pain in her left lower extremity during physical therapy. Over the course of several days, multiple physical therapy assistants observed and documented a marked decline in the resident's ability to bear weight and increased pain, with the resident herself expressing concern that her hip might be broken. Despite these observations, the nursing staff did not promptly notify the physician or obtain an order for an x-ray. A physical therapy assistant reported the change in condition and requested an x-ray to the assigned LPN, but the LPN did not follow through with physician notification or documentation of the change. The Director of Nursing was not made aware of the situation until the resident's daughter raised concerns at the nurses' station, at which point a STAT x-ray was ordered and a left intertrochanteric hip fracture was identified. The facility's policy required prompt notification of the physician and the resident's representative in the event of a significant change in condition. However, the lack of timely communication and documentation by the nursing staff led to a delay in diagnosis and treatment of the resident's hip fracture, as confirmed by interviews with therapy staff, the Director of Nursing, and the resident's daughter.
Failure to Provide Timely Assistance and Implement Fall Interventions
Penalty
Summary
The facility failed to provide timely toileting assistance and implement effective fall interventions for three residents, leading to significant injuries. One resident, who was cognitively intact but had a history of falls and required assistance with toileting, attempted to use the restroom independently after waiting for help. This resulted in a fall that caused a hematoma and a femur fracture, necessitating surgery and hospitalization. The resident was found on the floor, incontinent and without proper footwear, indicating a lack of supervision and timely assistance. Another resident, also cognitively intact but with a history of repeated falls, experienced an unwitnessed fall in their room, resulting in a skin tear and bruising. The resident's care plan included the use of a body pillow, which was not present at the time of the fall, suggesting that fall prevention measures were not adequately implemented. The lack of documentation in the nurse's progress notes further highlights the facility's failure to thoroughly investigate and document the incident. A third resident, with moderate cognitive impairment and a history of falls, fell out of bed while attempting to retrieve an unknown item. The resident was not wearing the required slipper socks, and the overlay bolster on their bed was found to be ineffective. The facility's failure to maintain and replace necessary equipment contributed to the resident's fall. The Director of Nursing acknowledged that the fall investigations lacked sufficient detail and that the fall interventions were not in place at the time of the incidents.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 69 residents residing in the facility. The deficiency was identified through observation, interview, and record review. The facility's Dietary Manager, identified as V15, was actively managing kitchen personnel and directing food sanitation and preparation activities without being a Certified Dietary Manager (CDM). V15 was hired on July 12, 2024, as the CDM, but at the time of the survey, V15 had not completed the necessary Dietary Manager course, although V15 was enrolled in it as of September 2024. Interviews with various staff members, including the Regional Dietary Manager and the facility's Administrator, confirmed that V15 was functioning as the Dietary Manager despite not having the required certification. The facility's documentation, including V15's employee file, indicated that V15 was expected to manage all aspects of the Dietary department, including regulatory oversight related to safe food handling. However, V15 admitted to not being a Certified Dietary Manager at the time of the survey, which constitutes a failure to meet the regulatory requirements for the position.
Failure to Provide Timely Meals and Snacks
Penalty
Summary
The facility failed to provide timely meals and evening snacks to its residents, which has the potential to affect all 69 residents. During a resident council meeting, several residents reported that breakfast was served closer to 9 AM, and evening snacks had not been offered for the past two to three months. The Dietary Manager confirmed that meal times were set at 8 AM, 12 PM, and 5 PM, and stated that snacks were available in the nutrition room for staff to distribute after the kitchen closed. However, a resident who eats in their room reported not receiving lunch by 12:15 PM and was unaware of the availability of evening snacks. The facility's policy requires that residents receive at least three meals daily, with no more than a 14-hour span between the evening meal and breakfast, and that nourishing snacks be routinely offered to all residents, especially if the time span between meals exceeds 14 hours.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident verbal abuse to the Abuse Coordinator for two residents who were both severely cognitively impaired. The incident occurred when one resident, while self-propelling out of the dining room, ran into another resident's wheelchair, leading to a verbal altercation. The staff intervened, and the resident who initiated the movement was taken to the lobby while crying. Despite the incident, the Licensed Practical Nurse (LPN) involved did not report it as an allegation of abuse, viewing it instead as a behavioral issue. The Director of Operations confirmed the incident and identified the residents involved. The Administrator stated that any allegation of abuse should be reported to the Abuse Coordinator to initiate an investigation. However, the LPN did not report the incident, and the Administrator was unaware of it until much later. The LPN acknowledged the oversight, recognizing that the incident could be considered an allegation of abuse that should have been reported. This failure to report prevented the necessary investigation and subsequent reporting to the State Agency.
Failure in Weight Management Services
Penalty
Summary
The facility failed to provide adequate weight management services for two residents experiencing unplanned weight loss. One resident experienced a weight loss of 10.1 pounds, equating to a 9.1% decrease in a month, without any documentation of physician notification. Another resident lost 13.5 pounds, an 8.6% decrease, and was subsequently hospitalized and returned with a PEG tube for continuous feeding. Upon readmission, the resident was not weighed, and there was no documentation of an admission weight. The facility's protocol requires nursing staff to notify the physician and dietician of significant weight changes, defined as a 5% or more loss, and to verify weight changes by obtaining a new weight. However, these procedures were not followed, as evidenced by the lack of documentation and notification in the cases of the two residents. The interdisciplinary team reviews weight changes monthly, but the immediate response to significant weight loss was inadequate, leading to a deficiency in weight management services.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication
Penalty
Summary
The facility failed to implement non-pharmacological interventions before administering psychotropic medications to a resident. The facility's policy, revised in December 2016, requires that psychotropic medications be considered only if behavioral symptoms pose a danger and after behavioral interventions have been attempted and included in the care plan. However, for one resident, there was no evidence of behavior tracking or behavior notes, and the care plan did not include psychotropic medication interventions or non-pharmacological interventions for anxiety. The resident's Medication Administration Record for November 2024 showed an order for Quetiapine to be administered for anxiety, despite the resident's medical diagnosis report indicating unspecified dementia without behavioral disturbance, psychotic disorder, mood disorder, or anxiety. Interviews with the Director of Nursing and a Clinical Nurse revealed they could not find any documentation of behavior tracking for the resident. Additionally, the resident expressed uncertainty about the medications being administered, as staff did not communicate changes in medication to her.
Medication Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly label medications for three residents, leading to deficiencies in medication administration. For one resident, a Licensed Practical Nurse (LPN) administered an inhaler, eye drops, and a cream, none of which had labels indicating the resident's name or the date they were opened. The LPN confirmed that these medications were not labeled and lacked an open date, which is against the facility's policy and professional standards. Another resident received insulin from a pen that was not labeled with the resident's name, medication, or administration directions, and it also lacked an open date. The LPN administering the insulin confirmed the absence of these labels. Additionally, a third resident's medication cards had labels indicating administration at bedtime, conflicting with the Medication Administration Record (MAR) that specified administration at 4:00 PM. These discrepancies highlight a failure to adhere to labeling protocols, potentially impacting the safe administration of medications.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program by not assessing the criteria for determining an infection for a resident (R9) who was receiving hospice services. According to the facility's Antibiotic Stewardship policy, the purpose is to monitor antibiotic use among residents. However, R9's medical records did not include a completed McGeer Criteria for Infection Surveillance Checklist, nor was there documentation of any testing or cultures to confirm the infection. Despite this, an order was placed for the resident to receive Bactrim DS, an antibiotic, for a urinary tract infection (UTI) based on confusion observed by a hospice CNA. Interviews with the Director of Nursing and a Clinical Nurse revealed that there was no supporting documentation or lab results to justify the antibiotic use, indicating a lapse in the facility's infection surveillance and antibiotic stewardship practices.
Failure to Update Advanced Directive for Resident
Penalty
Summary
The facility failed to provide an accurate Advanced Directive for a resident, identified as R5, which led to a deficiency in honoring the resident's treatment preferences. Upon admission, the facility's policy requires that residents be provided with information about their rights to accept or refuse treatment and to formulate an advance directive. The policy also mandates that the Social Services Director or designee inquire about existing advance directives and ensure the plan of care aligns with the resident's documented preferences. However, when R5 was readmitted to the facility from the hospital on hospice care, the facility did not obtain a new Physician Orders for Life-Sustaining Treatment (POLST) form to reflect R5's updated wishes regarding cardiopulmonary resuscitation (CPR) and extraordinary measures. R5's existing POLST form indicated a preference for CPR and selective treatment, but upon readmission, R5 had chosen not to have CPR or extraordinary measures upon death. Despite this change, the facility did not update the POLST form or obtain a new order for a Do Not Resuscitate (DNR) status, as confirmed by the Director of Nursing (DON). Consequently, when R5 was confirmed expired, no attempt at CPR was made, which was inconsistent with the documented POLST form in R5's medical record. This oversight highlights a failure in the facility's process to ensure that the resident's treatment preferences were accurately documented and followed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to maintain resident dignity by not providing timely bowel and bladder incontinence care for a resident with moderate cognitive impairment and a history of congestive heart failure and aspiration pneumonia. The resident, who is totally dependent on staff for toilet use due to weakness and blindness, was left in a heavily soiled incontinence brief for an extended period. The resident's family member reported that the resident had a bowel movement during lunch and requested assistance, but was told by a CNA that they were too busy at the time. The resident was left waiting for care for over an hour after lunch, which was confirmed by the Director of Clinical Operations as too long. When the incontinence care was finally provided, the resident's brief was found to be heavily saturated with urine and feces, with dried feces present on the resident's skin. The CNAs involved in the care performed appropriate hygiene practices during the process. The delay in care was acknowledged by both the Director of Clinical Operations and the President of Clinical Operations as a dignity issue, with the latter noting that residents who are heavy wetters should receive more frequent incontinence care checks. The facility's policy on dignity emphasizes that residents should be treated with dignity and respect, and assisted in maintaining their self-esteem and self-worth.
Inconsistent Food Portion Sizes in Meal Service
Penalty
Summary
The facility failed to accurately measure and serve consistent food portions during meal service, affecting three residents and potentially impacting all 75 residents in the facility. Observations revealed that portion sizes varied significantly, with some residents receiving larger portions while others received much smaller ones. This inconsistency was unrelated to the residents' diet order slips, which did not specify any deviation in portion sizes. Staff involved in meal preparation and service did not identify or address these discrepancies. Interviews with staff and residents highlighted ongoing issues with portion sizes. A Licensed Practical Nurse and Certified Nursing Assistants reported that portion sizes depended on who was cooking, and residents often complained about the inconsistency. Some residents were unable to get seconds, and others were left unsatisfied with the portions they received. A cook confirmed that portion sizes varied based on their knowledge of residents' eating habits, despite using the correct scoop size according to the menu. Specific incidents included a resident who had to eat their family member's food due to insufficient portions and another resident who received a meal with very small portions, prompting their spouse to purchase additional food from a fast-food restaurant. The facility's policy requires staff to demonstrate the ability to read menus and select the correct serving utensils, but this was not adhered to, leading to the observed deficiencies.
Failure to Provide Ordered Wound Care and Document Treatment
Penalty
Summary
The facility failed to provide appropriate wound care and maintain a pressure sore plan of care for two residents. For one resident, identified as R2, the facility did not document a wound on the left buttock in the care plan, despite a physician's order for specific treatment. The wound doctor had ordered the application of Calcium Alginate covered with a hydrocolloid sheet three times per week, along with a protective barrier wipe to the peri wound. However, the treatment record did not include this order, and during an observation, the resident was found without a dressing on the buttock, and the wound was covered with slough. The Licensed Practical Nurse applied zinc oxide and border gauze instead of the prescribed treatment. For another resident, identified as R1, the facility failed to document the completion of dressing changes on the Treatment Administration Record for specific dates. The resident's care plan documented a wound on the left sacrum, and the treatment order required daily dressing changes with a silicone bordered foam dressing. However, the dressing changes were not signed out as completed on three occasions. The Regional Nurse confirmed the lack of documentation and could not verify if the treatments were completed as ordered.
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 205 citations issued within 25 miles in the last 12 months — including the 2 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 Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Havens Senior Living | 1.2 mi | ★★★★★ | 36 | 1 |
| Decatur Rehab & Health Care Ct | 3 mi | ★★★★★ | 0 | 0 |
| Loft Rehab Of Decatur | 3.8 mi | ★★★★★ | 12 | 0 |
| Loft Rehab Of Rock Springs, The | 3.8 mi | ★★★★★ | 5 | 0 |
| Mt Zion Health & Rehab Center | 4.8 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Imboden Creek Senior Living.
100% money-back within 48 hours.
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.