Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeside Health & Rehab Center during CMS and state inspections, most recent first.
Delayed Incontinence Care and Call Light Response: Two cognitively intact residents who were dependent on staff for toileting hygiene reported being left in wet or soiled briefs for extended periods while waiting for call lights to be answered. One resident was observed with urine-soaked brief and red, excoriated peri-area/abdominal folds, and the other reported sitting in urine and feces for up to an hour and feeling anxious and upset. Resident council minutes and grievances also documented concerns about CNA call light response times.
Delayed ER transfer after physician order: A resident with HIV, toxoplasma meningoencephalitis, cryptococcosis, and pneumonia did not receive IV ganciclovir because the pharmacy could not deliver it due to stability issues. The MD ordered ER transfer if the medication could not be obtained, but the resident was not sent out for more than 8 hours after the order. Hospital records showed the resident later decompensated and required ICU transfer and oral intubation.
Improper Nephrostomy Care and Infection Control: A resident with bilateral nephrostomy tubes, ESBL in the urine, and a history of recurrent UTI/sepsis received nephrostomy care with repeated glove changes without hand hygiene and without sterile technique. The nurse removed and replaced dressings, cleaned the tube sites, and flushed the tubes while not maintaining a sterile environment. The resident’s record showed multiple hospitalizations for complicated UTI, nephrostomy tube malfunction/failure, sepsis, and septic shock.
A facility failed to follow infection control practices for residents on contact precautions and for a resident with nephrostomy tubes and recurrent UTIs. Staff were observed entering rooms without PPE, failing to perform hand hygiene between glove changes, and providing wound, incontinent, meal delivery, and medication care without following the posted isolation instructions. During nephrostomy care, an LPN/wound nurse did not use sterile technique or maintain a sterile field, and the resident involved had a history of complicated UTI, sepsis, septic shock, and repeated hospitalizations.
Insufficient CNA staffing delayed resident care and call light response. A resident who was incontinent reported being left wet for extended periods and waiting over 30 minutes for help, and surveyors observed staff entering and leaving the room while the call light remained on. The resident’s brief was saturated with urine and her abdomen and folds were red and excoriated. Other residents and a family member reported long call light waits, being left in urine or feces, and not having enough CNAs on the hall.
Failure to obtain and supervise medication administration: one resident with HIV and serious infections missed three scheduled IV doses of Ganciclovir because the facility did not have the medication available and did not document administration, and the resident was later sent to the hospital. In a separate event, an LPN left a resident alone with medications on the bedside table instead of staying to ensure the meds were taken, contrary to the facility's medication administration policy.
Surveyors found that the facility failed to timely report and properly assess a fall, did not consistently use gait belts during one-assist transfers, and did not ensure call lights were within residents’ reach. A resident with osteoporosis and high assistance needs for toilet transfers fell after being left on the toilet, was helped from the floor by a CNA who did not immediately report the fall, and was later found to have multiple pelvic fractures requiring surgery. Two other residents at risk for falls were observed being transferred to the toilet without gait belts, despite staff and therapy stating that gait belts are required for such transfers. One resident was also observed in a wheelchair without access to a call light, which was found buried in bed linens across the room.
A resident with severe cognitive impairment and dependent on staff for mobility was transferred by a CNA without the required two-person assistance and gait belt, as specified in the care plan. This improper transfer resulted in bruising and a skin tear to the resident's hands and wrists, which was reported and documented by nursing staff. Facility investigation confirmed the transfer did not follow established protocols.
A resident with a history of self-decannulation was not provided with individualized interventions to prevent removal of her tracheostomy tube, despite repeated behaviors of pulling on medical devices. Staff failed to update the care plan after initial incidents and did not consistently communicate or document the resident's behaviors. Additionally, nursing staff lacked training and confidence in emergency tracheostomy recannulation, and the facility's policy did not address emergency procedures, leading to inadequate response when the resident self-decannulated and required hospital transfer, where she later died from complications.
Multiple residents and CNAs reported ongoing shortages of essential supplies such as incontinence products, linens, and blankets, resulting in residents being left without appropriate items, kept in bed, or made to use ill-fitting products. Staff confirmed that these shortages were frequent and management was aware but had not resolved the issue, leading to compromised resident comfort and dignity.
Two residents at risk for pressure ulcers developed new or worsening pressure injuries due to the facility's failure to consistently implement preventative measures. Despite care plans requiring turning, repositioning, and the use of heel protectors, observations showed these measures were not consistently followed, leading to the development of stage 3 pressure ulcers.
A resident with multiple medical conditions experienced several falls, including a hip fracture, due to the facility's failure to implement progressive interventions and update care plans. Despite repeated incidents, staff did not consistently follow fall prevention protocols, leading to inadequate management of the resident's fall risk.
The facility failed to provide sufficient nursing staff, resulting in delayed care for residents. Multiple residents reported inadequate CNA staffing, leading to prolonged waits for assistance with toileting and unmet care needs. A resident council meeting highlighted these concerns, and the facility's CMS report showed a one-star staff rating. An LPN and the administrator acknowledged staffing challenges, with the latter using a state-based staffing calculator.
The facility failed to date two opened multi-dose vials of Tuberculin Serum in the medication storage room refrigerator. The Tuberculin Product Information specifies that opened vials should be discarded after 30 days. The Director of Nurses confirmed that multi-dose vials should be dated when opened. This oversight could potentially affect all 62 residents in the facility.
A resident's package was opened by staff without permission, mistaking it for medication. The resident, who is cognitively intact, had informed staff about his orders and declined authorization for the facility to open his correspondence. The facility lacks a policy on resident mail.
A resident with severe cognitive impairment sustained a skin tear of unknown origin, which was not reported to the IDPH as required by the facility's abuse policy. Despite documentation and treatment by medical staff, the incident was not communicated to the proper authorities, resulting in a deficiency in reporting suspected abuse or neglect.
A resident with severe cognitive impairment sustained a skin tear of unknown origin, which was not investigated in a timely manner by the LTC facility. The injury was discovered by activities personnel and reported to nursing staff, but the investigation was delayed, with staff interviews conducted nearly two weeks later. The facility's abuse policy requires immediate investigation of such incidents, which was not adhered to in this case.
A facility failed to administer enteral feeding properly, risking foodborne illness for a resident with a feeding tube. The resident, dependent on tube feeding due to medical conditions, received Jevity 1.2 formula that was not dated or timed, contrary to facility policy. Observations showed the formula was administered beyond the 24-hour limit, despite staff acknowledging the requirement to discard it after 24 hours.
The facility failed to provide necessary behavioral health care for three residents with behavioral health needs. One resident with anxiety and depression exhibited verbal aggression and inappropriate behavior, but their care plan lacked interventions. Another resident with a criminal history of sexual assault had no behavior monitoring or interventions in their care plan. A third resident with dementia and PTSD required reminders to stay out of female residents' rooms, indicating inadequate behavior monitoring. The facility's policies on behavioral health services were not effectively implemented.
A resident with hemiplegia and hemiparesis suffered an injury to the right second toe during transport from the hospital to the facility when the foot struck the door plate, resulting in a wound and toenail removal. The LPN cleansed the wound and applied a dressing upon arrival. The facility lacked a transport safety policy.
A facility failed to provide timely assessment and treatment for a resident's wound on the right second toe. The resident's toe was observed with the toenail off and dried blood, without any dressing. Physician orders required cleansing and dressing changes, but the Treatment Administration Record did not document these treatments until days later. Additionally, the resident's foot was injured during transport, causing bleeding. The facility's policies require implementing physician orders and verifying them before dressing changes, highlighting a deficiency in care practices.
The facility failed to respond to call lights promptly for several residents, leading to unmet needs and discomfort. One resident reported waiting up to an hour during supper and nighttime, while another experienced a delay of an hour and a half, risking incontinence due to medication. Concerns about call light response times were also documented in Resident Council Minutes, and the facility's policy requires timely responses.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, affecting all 57 residents. Staff were observed not wearing appropriate PPE, and visitors were not adequately educated on PPE usage. PPE carts were often empty, and hand hygiene protocols were not followed, compromising safety protocols.
A facility failed to implement fall prevention measures for a high-risk resident with dementia. The resident was observed without necessary safety interventions, such as a chair alarm and accessible call light, as outlined in their care plan. The resident's daughter expressed concerns about safety, noting the absence of alarms during visits. Additionally, a CNA left the resident unattended on the toilet without a reachable call light, violating facility policies.
The facility failed to prevent and treat pressure ulcers for two residents, leading to severe complications. One resident developed osteomyelitis due to untreated ulcers, while another had a heel ulcer that went untreated for nine days. Observations revealed improper dressing handling and lack of pressure-relieving devices. The facility's documentation system and policy adherence were inadequate, contributing to the deficiencies.
The facility failed to provide an RN on duty for 8 hours a day, 7 days a week, affecting all 51 residents. Nursing schedules from 3/10/24 to 4/14/24 showed multiple days without an RN. The DON confirmed the lack of daily RN coverage and the absence of a staffing policy, with staffing based on census needs.
The facility failed to post daily nurse staffing information, affecting all 51 residents. The information was not posted in a prominent place and was not readily accessible to residents and visitors. Both the new Administrator and the DON were unaware of who was responsible for this task.
A facility failed to implement fall prevention measures for a resident after a room transfer. The resident, with diagnoses including cerebral infarction and Parkinson's disease, was observed without non-skid strips and necessary signage in the new room. The resident confirmed the absence of these interventions, which were previously effective in preventing falls. The administrator acknowledged the oversight.
The facility failed to ensure fall interventions were in place for a resident with a history of falls. Despite the care plan and fall investigation indicating the need for non-skid strips and signage, these were not implemented in the resident's new room after she was moved. The resident has a history of cerebral infarction, Parkinson's disease, and dementia, and requires partial assistance with daily activities.
The facility failed to justify why a GDR was not attempted per a pharmacy recommendation and did not ensure the proper diagnosis for psychotropic medications for two residents. One resident's documentation lacked a diagnosis of depression or anxiety despite being prescribed Sertraline and Trazodone. Another resident had not had a medication reduction in the past year and had no psychiatric evaluation. The facility did not follow its policy on psychotropic medications and GDR, resulting in deficiencies in resident care.
The Facility failed to ensure medications were stored safely until administration and not left at the bedside for a resident. A pill was found on a resident's bed sheet, which the resident admitted to forgetting to take. The Director of Nursing later identified the pill as Torsemide, prescribed for edema. The Facility's policy requires nursing staff to ensure medications are swallowed before leaving, which was not followed.
The facility failed to collect stool samples for occult blood testing for a resident, missing four opportunities due to miscommunication and improper handling of the specimen collection process. The DON confirmed the lapses in following the physician's order.
The Facility failed to follow proper hand hygiene and glove usage protocols in an Enhanced Barrier Precaution room for two residents. Staff did not sanitize hands before donning gloves, between glove changes, or after resident contact, violating the facility's policies on hand washing and transmission-based precautions.
Delayed Incontinence Care and Call Light Response
Penalty
Summary
The facility failed to provide timely and complete incontinent care for 2 residents who were dependent on staff for toileting hygiene and frequently or always incontinent of bladder and/or bowel. R7’s record showed cognitive intactness, dependence on staff for toileting hygiene, frequent bladder incontinence, and a care plan for assistance with ADLs related to decreased mobility from a right lower leg fracture. R15’s record showed cognitive intactness, dependence on staff for toileting hygiene, bathing, transfers, frequent bladder incontinence, and always incontinent bowel, with care plan interventions requiring two-person physical assistance for bathing and toilet use. During observation and interview, R7 stated she had pressed the call light because she was incontinent of urine and was unsure how long she had been wet because she had fallen asleep. She stated she had been left in a wet brief for extended periods and had waited over 30 minutes for staff to answer her call light. Staff were observed entering and leaving her room without providing immediate care, and later two CNAs entered to provide care. The resident and her family member stated staff response times were slow and that R7 was left wet due to long call light times. The family member observed R7’s urine-soaked brief, and R7’s abdominal folds and peri-area were red and excoriated; R7 stated the area was sore. R15 stated call light wait times were an issue and reported sitting in urine and feces for an hour before staff answered her light and cleaned her up. She stated that when she told a staff member her light had been on for an hour and she was wet and dirty, the staff member responded, “Well how about I make you wait for the next shift then,” and she then waited another hour to be cleaned up. R15 stated this made her anxious, upset, and feel like crying. The Medical Director stated it is possible for a resident to feel a lack of dignity and sadness when left in urine and feces for extended periods of time. The DON stated residents should be cleaned up as soon as staff are made aware and expected call lights to be answered within 2-3 minutes. Resident council minutes and grievance summaries also documented concerns that CNAs were not answering call lights in a timely manner.
Delayed ER Transfer After Physician Order
Penalty
Summary
The facility failed to provide timely ER transport for one resident after a physician ordered transfer if the facility could not obtain the resident’s IV ganciclovir sodium. The resident was admitted with diagnoses including HIV, toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia, and was documented as cognitively intact but very thin with orbital wasting. The physician was notified that the pharmacy could not deliver the IV medication because of stability issues, and later ordered that the resident be sent to the ER if the medication could not be obtained. Despite that order, the resident was not sent to the ER for more than eight hours after the order was given. Facility documentation showed the resident had not yet been sent out hours later, and a progress note documented the resident was not transported until 6:45 AM. Hospital records showed the resident was admitted and later decompensated, requiring transfer to the ICU and oral intubation. Staff interviews stated that when a physician orders a resident to be sent to the ER, the resident should be sent immediately or as soon as possible, and the DON stated residents should be sent immediately when the physician wants hospital transfer.
Improper Nephrostomy Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate nephrostomy care to prevent infections for one resident with bilateral nephrostomy tubes. During observation, the wound nurse removed and replaced nephrostomy dressings and handled the tubes while changing gloves multiple times without performing hand hygiene between glove changes. The nurse also discarded a dressing in the regular trash, brought gloves into the room after entering, and did not maintain sterile technique or a sterile environment during the care. The resident had multiple relevant diagnoses, including multiple sclerosis, ESBL resistance, urinary retention, neuromuscular dysfunction of the bladder, and a history of urinary tract infection and mechanical complication of a urinary catheter. The resident’s care plan documented nephrostomy drain tubes related to complications of kidney stones, and physician orders included daily and as-needed dressing changes and flushing the nephrostomy tubes with normal saline twice daily and as needed. The resident’s record also showed moderate cognitive impairment and an indwelling urinary catheter. The resident experienced repeated urinary infections and hospitalizations. Records documented admissions for complicated UTI, hydronephrosis, malfunction and failure of the nephrostomy tube with urinary leak, septic shock, UTI, sepsis, and septic shock. Facility notes also documented episodes of foul-smelling dark amber urine from the nephrostomy tubes, confusion, fever, low blood pressure, and transfer to the hospital for evaluation and treatment of UTI and sepsis.
Failure to Follow Infection Control and PPE Procedures
Penalty
Summary
The facility failed to utilize infection control techniques for multiple residents reviewed for infection control, including residents with contact precautions, urinary infections, wounds, and nephrostomy tubes. During observed nephrostomy care for a resident with bilateral nephrostomy tubes, ESBL in the urine, moderate cognitive impairment, and a history of recurrent UTIs and hospitalizations for complicated UTI, sepsis, and septic shock, the wound nurse removed dressings, changed gloves repeatedly, and performed site care and flushing without completing hand hygiene between glove changes. The nurse also did not use sterile technique or maintain a sterile environment during the procedure. Housekeeping staff were observed entering a room for two residents on contact precautions without PPE, despite signage outside the room directing staff to clean hands and wear gloves and gowns before entry and to remove PPE before exiting. Staff later stated they were to follow the signs outside resident rooms regarding PPE, and one housekeeper stated staff should wear a mask, gown, and gloves while cleaning an isolation room. The facility’s isolation policy required appropriate signage and a waste container with a red bag in the resident’s room, and the infection preventionist stated that residents on contact precautions are to have gown and gloves worn before entering the room. Additional observations showed a CNA delivering a meal tray to a resident on contact precautions without PPE, an LPN entering a room with medications and later administering medications to a resident on contact precautions without PPE, and a CNA providing incontinent care to a resident with urine- and stool-soiled brief and excoriated skin while failing to change gloves or perform hand hygiene after emptying a bedpan and between cleaning soiled and clean areas. Another wound care observation showed an LPN/wound nurse performing wound care for a resident on contact precautions and ESBL isolation, changing gloves and performing hand hygiene at one point but then applying skin prep and a dressing without changing gloves or performing hand hygiene. The DON stated hand hygiene is required before and after care, between glove changes, and when moving from a soiled to clean area, and stated improper hand hygiene can lead to residents developing UTIs.
Insufficient CNA Staffing Delayed Resident Care
Penalty
Summary
The facility failed to provide a sufficient number of CNAs to meet resident needs and ensure timely care. During observation, R7 used the call light because she was incontinent of urine and stated she was unsure how long she had been wet, but knew she was wet at the time. R7 reported that she is sometimes left in a wet brief for extended periods and has waited over 30 minutes for her call light to be answered. While the surveyor observed the room, an activity aide entered, asked what R7 needed, and left with the call light still on. A CNA later entered, turned off the call light, and then left the room after taking clothes from the closet and turning on the sink water. When CNAs returned, R7’s brief was found saturated with urine, and her abdomen and abdominal folds were red and excoriated. Additional interviews and observations supported ongoing delays in resident response and staffing concerns. R15 stated call light wait times were an issue and reported waiting over an hour for help, including times when she sat in urine and feces for an hour before being cleaned up. During the resident council meeting, residents stated there were not enough staff, that call lights took a long time at night, and that they sometimes had to use bedpans because staff could not return quickly enough. Another resident stated there were often only one or two CNAs on the hall and that more staff were needed. A family member also reported that R7 was left wet due to long call light times and slow staff response. The Administrator stated staffing numbers were based on census, while the staffing sheets showed 3 to 4 CNAs scheduled on day shifts for the facility’s 54 residents, and the facility assessment listed an average or range of 7 nursing aides.
Failure to Obtain and Supervise Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when it did not obtain and properly administer prescribed medications for two residents. One resident, admitted with diagnoses including HIV, toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia, was ordered Ganciclovir Sodium IV every 12 hours for four weeks after hospital discharge. The resident stated he did not receive his IV medications for a couple of days after admission and ended up in the ICU. The MAR documented the numeral 7 for three scheduled doses of IV Ganciclovir on the first two days after admission, and staff stated the code meant refer to a progress note, but no progress note documentation was found for those doses. The facility administrator stated the pharmacy did not have the IV medication on hand, and the pharmacist stated the order was faxed after the pharmacy had closed and the facility did not contact a backup pharmacy or attempt to obtain the medication from the hospital. The medical director was notified that the medication was not stable enough for delivery and documented that the resident would need to be sent to the ER if the facility could not get the medication; the resident was later sent to the hospital because he was already very sick and complex and would have gone the entire weekend without the medication. In a separate event, an LPN entered another resident's room with medications, handed over the medication cup, and left the room while the resident had medications spread on the bedside table. The resident stated staff sometimes do not watch her take medications and leave them on the table, and the nurse later told her to take the medications that were on the table.
Failure to Timely Report Fall, Ensure Safe Transfers, and Maintain Call Light Access
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and safe transfer assistance, including timely reporting and assessment of falls. One resident (R2), cognitively intact and care planned as a substantial/maximal assist for toilet transfers and sit-to-stand, fell in her bathroom after being taken to the toilet by a CNA and left there. R2 reported that the male CNA told her to pull the string when she was done but did not tell her not to get up, and she waited without anyone returning. She became uncomfortable and in pain, attempted to transfer herself, and fell just outside the bathroom door. R2 stated the CNA found her on the floor, helped her back to bed, and told her not to tell anyone what happened. R2’s family members corroborated that R2 reported waiting a long time on the toilet, attempting to get up alone, falling, and then being told by the CNA not to report the fall. The facility did not have the fall reported or assessed in a timely manner. The CNA (V8) acknowledged finding R2 on the floor, assisting her up at her request, and not reporting the fall immediately because R2 asked him not to tell anyone. He stated that R2 did not complain of pain at that time and that he reported the fall about an hour later when she used her call light and reported pain. The nurse (V15, LPN) stated she was first notified of the fall by the CNA and did not recall whether R2 had already been gotten up. V15 stated she did not assess R2 immediately but later saw her in bed. The DON and Medical Director both stated their expectation that falls be reported immediately and that residents not be moved before a nurse assesses them, consistent with the facility’s Accidents and Incidents policy, which requires immediate reporting, completion of an incident report on the shift of occurrence, and that victims not be moved until examined for possible injuries. R2 was later sent to the hospital with pelvic injuries and diagnosed with minimally displaced fractures of the right superior and inferior pubic rami, with orthopedic notes documenting two (possible three) pelvic fractures and a recommendation for pelvic implant surgery. Additional deficiencies were identified related to unsafe transfer practices and call light accessibility. R2, observed sitting in a wheelchair, did not have her call light within reach; she reported that a CNA had left earlier to prepare for a shower and did not ensure the call light was accessible, and the call light was later found buried under sheets on the opposite side of the bed from where R2 was seated. For R1, who was cognitively intact, at high risk for falls, and had multiple recent falls, a CNA (V5) assisted her from wheelchair to restroom using a walker but did not apply a gait belt, despite R1 being described as a standby assist with recent falls and observed unsteady gait. For R3, who was moderately cognitively impaired and care planned as at risk for falls, a CNA responded to her call light while she was waiting in the bathroom and assisted her from wheelchair to toilet by holding the back of her pants without using a gait belt. Therapy staff (COTAs) and nursing staff stated that a gait belt should be used for one-assist transfers and that R1 and R3 should have had gait belts applied, and the facility’s Transfer policy requires the use of gait belts or mechanical lifts as appropriate, with nursing staff responsible for safe transfer techniques. The combined observations, interviews, and record reviews show that the facility failed to follow its own policies and accepted practices for fall reporting, post-fall assessment, resident movement after a fall, use of gait belts during transfers, and ensuring call lights were within reach. These failures affected multiple residents, including R2, whose fall was not reported immediately and who was moved before a nurse assessment, and R1 and R3, who were transferred without gait belts despite being at risk for falls and requiring assistance.
Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, and dementia, who was dependent on staff for all mobility except rolling in bed, did not receive a safe transfer as required by her care plan. The resident's care plan and therapy recommendations specified that she required two-person physical assistance and a gait belt for transfers. Despite these documented requirements, an investigation revealed that a Certified Nurse Aide (CNA) likely transferred the resident alone, contrary to the established plan of care and facility policy. Following this transfer, the resident was found to have reddish discoloration and bruising on both hands and wrists, as well as a small skin tear on the top of her left hand. These injuries were first reported by the resident's daughter/Power of Attorney and subsequently assessed by nursing staff, who documented the presence of bruising, discoloration, and a skin tear. The incident was reported to the Medical Doctor, Director of Nursing, and Administrator, and the injuries were treated according to standard wound care procedures. The facility's investigation concluded that the CNA, who was working her last shift and had already resigned, did not follow the resident's care plan by transferring her without the required second staff member and without using a gait belt. The CNA denied the allegation, but the facility marked her as ineligible for rehire. The transfer policy in place at the facility required adherence to the care plan and proper transfer techniques, which were not followed in this instance, resulting in the resident's injuries.
Failure to Prevent Tracheostomy Self-Decannulation and Inadequate Staff Training
Penalty
Summary
The facility failed to assess, monitor, and provide necessary interventions to prevent self-decannulation for a resident with a known history of removing her own tracheostomy tube. Despite documentation from the resident's infectious disease physician and staff interviews indicating a prior history of self-decannulation, the resident's care plan did not include any interventions to prevent further incidents. The resident exhibited behaviors of pulling on her tracheostomy tube, G-tube, and colostomy bag, which were observed by multiple staff members and therapy personnel, but these behaviors were not consistently documented or communicated to the physician for further evaluation or intervention. On two separate occasions, the resident self-decannulated her tracheostomy tube while in the facility. After the first incident, the resident was transferred to the emergency room for tracheostomy tube replacement and subsequently readmitted to the facility. However, no new interventions were added to her care plan to address the risk of repeated self-decannulation. Staff continued to observe the resident pulling on her medical devices, but there was no evidence of increased monitoring, behavioral interventions, or medication review to address potential agitation or restlessness. Additionally, staff interviews revealed a lack of awareness regarding the resident's history of self-decannulation and the absence of specific interventions to prevent recurrence. The facility also failed to ensure that nursing staff were adequately trained in emergency tracheostomy recannulation. Multiple nurses and CNAs reported not having received training on reinserting a tracheostomy tube and expressed discomfort or lack of competence in managing such emergencies. The facility's tracheostomy care policy did not address emergency reinsertion procedures, and staff were unclear about the availability of necessary supplies or their roles in such situations. This lack of training and preparedness contributed to delays in appropriate emergency response when the resident self-decannulated her tracheostomy tube, ultimately resulting in her transfer to the hospital, where she experienced complications and subsequently died.
Failure to Maintain Adequate Resident Supplies and Dignity
Penalty
Summary
The facility failed to accommodate the needs and preferences of residents by consistently running out of essential supplies such as towels, pads, sheets, adult briefs, pull-ups, gloves, and blankets. Multiple residents reported frequent shortages, with some stating that they were left without appropriate incontinence products or had to use items that did not fit, causing discomfort, especially for those with existing skin issues. Staff interviews corroborated these accounts, indicating that supply shortages were a persistent issue, particularly at night, and that management was aware but had not resolved the problem. Staff sometimes had to purchase supplies with their own money or leave residents in bed due to lack of necessary items. Observations during the survey confirmed the lack of supplies, with supply rooms and carts found nearly empty of essential items. Residents were sometimes kept in their rooms or beds when supplies ran out, and some reported being cold due to a lack of blankets. Documentation also showed that grievances had been filed regarding the unavailability of appropriately sized incontinence products. The facility's own policy states that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity, which was not maintained due to these ongoing supply shortages.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement preventative measures to reduce the development and worsening of pressure injuries in two residents, R55 and R39. R55, who was admitted with conditions including hemiplegia, dysphagia, and diabetes, was at moderate risk for pressure ulcers. Despite being dependent on assistance for mobility and having documented maceration on the buttocks upon admission, R55 developed a stage 3 pressure ulcer on the sacrum. Observations revealed that R55 was not consistently provided with heel protectors or proper positioning to offload pressure, contributing to the deterioration of the wound. R39, admitted with severe cognitive impairment and multiple diagnoses including encephalopathy and chronic kidney disease, was also at risk for pressure ulcers. R39's care plan required assistance with turning and repositioning, and the use of heel protectors. However, observations showed that R39's heels were not floated as required, and the resident developed a new pressure ulcer on the left heel and sacrum. The facility's policy required turning and positioning for at-risk residents, but this was not consistently implemented for R39. The facility's failure to adhere to its own prevention program and care plans for residents at risk of pressure ulcers resulted in the development and worsening of pressure injuries for both R55 and R39. The lack of consistent implementation of preventative measures, such as turning, repositioning, and the use of heel protectors, directly contributed to the deficiencies observed in the care of these residents.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide progressive interventions and prevent multiple falls for a resident, identified as R47, who was at risk for falls due to various medical conditions including dementia, diabetes, and osteoporosis. The resident experienced several falls, some of which resulted in significant injuries such as a right hip fracture and surgical incision dehiscence. Despite these incidents, the facility did not consistently implement new interventions or update the resident's care plan to address the ongoing risk of falls. R47's medical records indicate a series of falls over several months, with inadequate or absent interventions following each incident. For example, after a fall on 10/09/24, no new interventions were noted, and subsequent falls on 10/10/24 and 10/17/24 also lacked appropriate follow-up actions. The resident's care plan was not updated to reflect necessary changes to prevent further falls, and interventions were often delayed or insufficient, such as the addition of a bed alarm only after multiple falls had occurred. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans and implementing fall prevention strategies. New staff members were unsure of their roles, and the MDS Coordinator acknowledged that care plans were not up to date when she assumed her position. The facility's policies on accidents and fall prevention were not effectively followed, contributing to the repeated incidents and the resident's injuries.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews and record reviews. Residents reported inadequate staffing levels, particularly a shortage of Certified Nursing Assistants (CNAs), which resulted in delayed response times to call lights and unmet care needs. One resident expressed frustration over having to wait for assistance with toileting, leading to prolonged periods of sitting in urine. Another resident noted that during a specific night shift, only two CNAs were available for the entire building, making it difficult to receive timely care, especially when needing urgent assistance due to medication effects. During a resident council meeting, several residents reiterated concerns about insufficient CNA staffing, which hindered timely care. The facility's CMS Payroll Based Journal Report indicated a one-star staff rating, and the facility's assessment acknowledged the need for sufficient staff to maintain residents' well-being. A Licensed Practical Nurse also expressed the need for more CNAs, citing high acuity levels and the challenges of working short-staffed. The facility administrator mentioned using a staffing calculator based on state ratios for scheduling, but the current staffing levels were inadequate to meet the residents' needs.
Failure to Date Opened Multi-Dose Vials of Tuberculin Serum
Penalty
Summary
The facility failed to properly date two opened multi-dose vials of Tuberculin Serum, which were observed in the medication storage room refrigerator. This oversight was identified during an inspection of medication storage and labeling practices. According to the Tuberculin Product Information, a vial of Tubersol (Tuberculin) that has been opened should be discarded after 30 days. The facility's Medication Storage Policy mandates that all drugs and biologicals be stored safely, securely, and in accordance with state and federal regulations, and that medications be administered before their expiration date. During an interview, the Director of Nurses confirmed that multi-dose vials used on multiple residents should be dated when opened. This failure to date the vials has the potential to affect all 62 residents residing in the facility, as documented by the CMS report.
Resident's Package Opened Without Permission
Penalty
Summary
The facility was found to have opened a package belonging to a resident without their permission. The incident involved a resident who had ordered a wireless charger, which was mistakenly opened by staff under the assumption that it contained medication. The resident, who is cognitively intact with a BIMS score of 15, had previously informed the staff about his orders to prevent such occurrences and had declined authorization for the facility to inspect and open his official correspondence as documented in his admission contract. Despite this, the package was opened, indicating a breach of the resident's right to privacy in communication. The facility's administrator stated that resident mail/packages are not opened by staff, and the Director of Nurses confirmed the absence of a policy on resident mail.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R265, who was severely cognitively impaired and dependent on mobility. R265 was admitted with diagnoses including unspecified dementia and metabolic encephalopathy. On a specific date, a skin tear was discovered on R265's right arm by activities personnel and reported to a registered nurse (RN). The resident was unable to explain how the injury occurred, and the care plan did not address the risk of abuse and neglect. Despite the injury being documented and treated by medical staff, it was not reported to the Illinois Department of Public Health (IDPH) as required by the facility's abuse policy. Interviews with staff members, including a CNA and an Activities Assistant, revealed that the skin tear was noticed after the resident was taken to the dining room and then brought back to the nurse's station. The Director of Nursing (DON) confirmed that the incident was not reported to IDPH. The facility's abuse policy mandates that all staff report any allegations or witnessed abuse immediately to the Administrator and timely to the proper authorities, including IDPH. However, this protocol was not followed in the case of R265's injury, resulting in a deficiency in reporting suspected abuse or neglect.
Delayed Investigation of Resident's Injury
Penalty
Summary
The facility failed to investigate an injury of unknown origin in a timely manner for a resident with severe cognitive impairment and mobility dependency. The resident was admitted with diagnoses including unspecified dementia and metabolic encephalopathy. On a specific date, a skin tear was discovered on the resident's right arm by activities personnel, who then brought the resident to the nurse's station. The resident was unable to explain how the injury occurred. The initial progress note documented the injury and treatment orders were given by the Medical Director. However, the facility's investigation into the incident was delayed, as interviews with relevant staff were not conducted until nearly two weeks later. The Director of Nursing provided an undated investigation report, which included interviews with several staff members who had interacted with the resident on the day of the incident. However, discrepancies were noted in the staff's recollections, and some staff members were not interviewed until much later. The facility's abuse policy mandates immediate and thorough investigation of all allegations of abuse, including injuries of unknown origin, but this protocol was not followed. The investigation was not initiated promptly, and the resident's nurse from the day of the incident was not interviewed, indicating a failure to adhere to the facility's policy on timely investigation of potential abuse or neglect.
Failure to Properly Administer Enteral Feeding
Penalty
Summary
The facility failed to ensure that enteral feeding was administered in a manner that prevents foodborne illness for a resident with a feeding tube. The resident, who was admitted with diagnoses including brain stem stroke, functional quadriplegia, dysphagia, and gastrostomy status, was dependent on tube feeding for nutrition. Observations revealed that the Jevity 1.2 formula being administered via a pump was not dated or timed, which is against the facility's procedure that requires formula to be labeled with the date and time it was hung. This was observed on multiple occasions, with the formula hanging for more than 24 hours without being discarded, contrary to the facility's policy. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that tube feedings should be dated, timed, and discarded after 24 hours. Despite this, the Jevity 1.2 formula continued to be administered beyond the 24-hour limit, as evidenced by the label indicating it was hung the previous day. This oversight in adhering to the facility's enteral feeding procedure posed a risk of foodborne illness to the resident.
Failure to Address Behavioral Health Needs in Residents
Penalty
Summary
The facility failed to identify and address specific behavioral health needs for three residents, leading to a deficiency in providing necessary behavioral health care and services. Resident 2, diagnosed with Anxiety Disorder and Major Depressive Disorder, exhibited verbal aggression and inappropriate behavior towards female staff and residents. Despite these behaviors, the resident's care plan did not include interventions to address these issues, and there was no evidence of behavior monitoring in the resident's records. Resident 3, with a history of criminal offenses including sexual assault, also had a diagnosis of Anxiety Disorder. The care plan for this resident did not address the diagnosis or any behaviors related to the criminal history. The resident was observed engaging in inappropriate behavior, such as peeping into a female resident's room, but there was no behavior monitoring documented in the records. Staff reported that both Resident 2 and Resident 3 made sexually inappropriate comments to female staff, leading to the implementation of one-on-one observation and rooming them together. Resident 8, diagnosed with Dementia and PTSD, had a criminal history of sexual assault. The care plan failed to include specific interventions related to the resident's PTSD and criminal history. The resident required reminders to stay out of female residents' rooms, indicating a lack of appropriate behavior monitoring and interventions. The facility's policies on behavioral health services and behavior monitoring were not effectively implemented, resulting in a failure to provide adequate care for residents with behavioral health needs.
Injury During Transport Due to Lack of Safety Measures
Penalty
Summary
The facility failed to prevent an injury to a resident's right second toe during transport from the hospital to the facility. The incident occurred when the resident's foot struck the plate at the bottom of the door while being pushed into the facility by a transport staff member. This resulted in the removal of the toenail and a wound on the second toe, which was bleeding upon arrival at the facility. The resident, who has a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, is dependent on staff for locomotion with a wheelchair. Upon arrival, the Licensed Practical Nurse (LPN) on duty cleansed the wound and applied a dressing. The resident's care plan, updated after the incident, noted an actual impairment to skin integrity of the right second toe related to the abrasion. The facility's transport staff did not provide safe assistance during the transport, as expected by the wound nurse. Additionally, the facility lacked a policy on facility transport, as confirmed by the regional nurse.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide timely assessment and treatment for a wound on a resident's right second toe. On observation, the resident's toe was found with the toenail off and dried blood, without any dressing in place. The physician orders dated 1/15/2025 and 1/17/2025 required the toe to be cleansed, skin prep applied, and covered with a dry dressing three times a week and as needed. However, the Treatment Administration Record (TAR) from 1/1/2025 to 1/31/2025 did not document any treatment orders for the toe until 1/17/2025, indicating a delay in implementing the prescribed care. Additionally, a facility transport staff member reported that the resident's foot was injured during transport when it hit the plate at the bottom of a door, causing bleeding. The wound nurse confirmed the current treatment plan but noted that dressings should be done as ordered. The facility's policies require obtaining, processing, and implementing physician orders and verifying them before performing dressing changes. The lack of documentation and timely treatment for the resident's wound represents a deficiency in the facility's care practices.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner for four out of six residents reviewed, leading to unmet needs and discomfort. Resident R3 reported that during supper time and at night, the wait time for call light responses could extend to an hour. On one occasion, a CNA turned off R3's call light without providing assistance, leaving R3 wet with urine for an extended period. R3's MDS indicated she was cognitively intact, with a BIMS score of 15. Similarly, R2 experienced a delay of an hour and a half for call light response at night, which posed a risk of incontinence due to his use of a water pill. R2 also had a BIMS score of 15, indicating cognitive intactness. Resident R5 expressed concerns about the long wait times for call light responses, especially when only one CNA was available for 30 residents. R5 was cognitively intact with a BIMS score of 15. R6 also reported long wait times for call light responses, resulting in incontinent episodes. R6's BIMS score was 13, indicating she was cognitively intact. The Resident Council Minutes from December 2024 documented concerns about call light response times, and the Activity Director confirmed these concerns were voiced during a council meeting. The facility's Call Light Guidance Policy mandates that call lights be responded to within a reasonable time, but the Administrator acknowledged that response times could vary depending on staff availability and resident needs.
Inadequate Infection Control and PPE Usage During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during a COVID-19 outbreak, affecting all 57 residents. Staff members were observed not wearing appropriate PPE when caring for residents on isolation precautions. For instance, a CNA was seen sitting at a resident's bedside with only an N-95 mask, despite the resident being on contact isolation due to MRSE. Additionally, PPE carts outside residents' rooms were often empty or lacked necessary items like gowns, compromising the safety protocols. Visitors were not adequately educated on PPE usage, leading to instances where they entered isolation rooms without proper protective gear. One visitor was seen in a resident's room with a surgical mask under her chin, unaware of the need for additional PPE. The facility's signage and communication with visitors were insufficient, as evidenced by visitors not being informed about the required precautions when entering rooms of residents on contact and droplet precautions. Staff members also failed to adhere to hand hygiene protocols, which are critical in preventing the spread of infections. An LPN was observed passing medications without performing hand hygiene before or after entering isolation rooms. Another staff member was seen handling soiled items and performing resident care without changing gloves or washing hands. These lapses in infection control practices highlight significant deficiencies in the facility's adherence to established guidelines and policies.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate care plan interventions to prevent falls for a resident identified as a high fall risk. The resident, who has a medical diagnosis of dementia and is mildly cognitively impaired, was observed multiple times without the necessary safety measures in place. These measures included a chair alarm and a call light within reach, as outlined in the resident's care plan. On several occasions, the resident was found in a wheelchair without the chair alarm activated, and the call light was not accessible, which are critical interventions for preventing falls. Additionally, there was no fall risk signage outside the resident's room, which is a standard practice for identifying high fall risk residents. The resident's daughter expressed concerns about the safety of her mother, noting that the chair alarm was often not in place during her visits. The daughter reported an incident where the resident was found slumped over in her wheelchair without the chair alarm or call light within reach. Furthermore, a CNA left the resident unattended on the toilet without the call light in reach, further compromising the resident's safety. The facility's policies require that call lights be within reach and that fall prevention protocols be followed, but these were not adhered to, leading to the deficiency.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, resulting in significant health complications. One resident, identified as R3, had multiple pressure ulcers that were not properly identified, assessed, or treated. The staff was unaware of a pressure ulcer on R3's left medial foot, and another ulcer on the left great toe went untreated and unassessed for nine days. This neglect led to the development of osteomyelitis, requiring intravenous antibiotics. Observations revealed improper handling of soiled dressings and a lack of pressure-relieving devices, contributing to the deterioration of R3's condition. The wound nurse, V4, admitted to not having seen R3's wound recently and acknowledged the presence of slough and infection signs. Despite being seen by infectious disease and plastic surgery specialists, the facility's internal processes failed to ensure timely and effective wound care. The facility's documentation system was also cited as a barrier, with discrepancies between observed wound sizes and those recorded in the electronic medical records. The lack of consistent and accurate documentation further hindered appropriate care and monitoring of R3's pressure ulcers. Another resident, R2, experienced a similar lack of care, with a pressure ulcer on the left heel going untreated for nine days. The facility's records did not document any treatment orders or assessments for R2's heel ulcer before a certain date, indicating a lapse in care. Observations showed R2 without pressure-relieving boots, and the wound nurse admitted to not considering the resident's needs while in a wheelchair. The facility's policy on pressure ulcer prevention and treatment was not followed, leading to inadequate care and monitoring of pressure ulcers for both residents.
Failure to Provide RN Coverage 8 Hours a Day, 7 Days a Week
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for 8 hours a day, 7 days a week, which has the potential to affect all 51 residents. The facility's nursing schedules from 3/10/24 to 4/14/24 documented multiple days without an RN on duty. The Director of Nursing (DON) confirmed that the facility does not have an RN on duty every day and that the full-time RN recently changed to PRN (as needed). Both the DON and the Administrator stated that the facility does not have a staffing policy and staffs according to census needs. The Resident Census Report and CMS 671 form dated 4/15/24 confirmed there were 51 residents in the facility.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, which has the potential to affect all 51 residents. On 4/15/24 at 10:20 AM, the daily nurse staffing was not posted. At 10:25 AM, a CNA stated that the information is normally posted by the front door but was not visible that day. At 10:30 AM, the Administrator, who is new, did not know who was responsible for posting the daily staffing. At 10:34 AM, the DON, who started working at the facility in January, also did not know who was responsible for posting the daily nurse staffing. On 4/17/24 at 1:15 PM, the daily nurse staffing information was observed on a bulletin board in the hallway behind the nurse's station, which was not a prominent place and not readily accessible to residents and visitors. The facility's policy, dated 7/1/23, requires the daily staffing information to be posted in a prominent location within two hours of the beginning of each shift.
Failure to Implement Fall Prevention Measures After Room Transfer
Penalty
Summary
The facility failed to implement care plan interventions related to falls after a resident was moved to a new room. The resident, who has diagnoses including cerebral infarction, Parkinson's disease, and dementia, was observed without the necessary fall prevention measures in place. Specifically, non-skid strips were not present beside the bed, and signs reminding the resident to use the call light and not to bend over to pick up objects were missing. These interventions were previously in place in the resident's former room and had been effective in preventing falls. The resident confirmed that the non-skid strips and signs were helpful in her previous room and noted their absence in the new room. Despite the resident's cognitive intactness and ability to recall the fall prevention measures, the facility did not ensure these interventions were transferred to the new room. The administrator acknowledged that all interventions should have been in place when the resident was moved, indicating a lapse in the facility's adherence to its care plan policy dated 07/01/23.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure fall interventions were in place to prevent further falls for a resident (R19) who was reviewed for falls/accidents. Upon observation on two separate occasions, it was noted that R19's room lacked non-skid strips beside the bed and signage reminding her to call for help or not to bend over and pick up objects. R19 had a history of falls, including a recent incident where she slipped off the side of her bed, resulting in a skin tear. Despite the care plan and fall investigation indicating the need for these interventions, they were not implemented in her new room after she was moved. R19's medical history includes diagnoses such as cerebral infarction, Parkinson's disease, and dementia. She is cognitively intact with a BIMS score of 15 out of 15 and requires partial assistance with daily activities. The facility's policy mandates immediate investigation and implementation of appropriate interventions following an accident, but these were not followed in R19's case. The administrator acknowledged that all interventions should have been in place when the resident was moved to the new room.
Failure to Justify GDR and Ensure Proper Diagnosis for Psychotropic Medications
Penalty
Summary
The facility failed to justify why a Gradual Dose Reduction (GDR) was not attempted per a pharmacy recommendation and did not ensure the resident had the proper diagnosis for psychotropic medications for two residents. For one resident, the face sheet and order summary did not include a diagnosis of depression or anxiety, despite the resident being prescribed Sertraline and Trazodone for depression. The care plan also failed to include the use of psychotropic medication or plans for a decrease in dosage. The attending physician disagreed with the pharmacist's recommendation for GDR but did not provide a rationale. The resident was observed to be excessively sleepy and incontinent of urine, indicating potential side effects of the medications. The Director of Nursing confirmed that a GDR should be attempted within 30 days of admission and quarterly, but this was not done for the resident in question. The Licensed Practical Nurse and Regional Nurse Consultant also verified the lack of proper documentation and care planning for the resident's psychotropic medication use and reduction goals. Another resident had not had a medication reduction in the past year and had not undergone a psychiatric evaluation. The resident was receiving multiple psychotropic medications for generalized anxiety and other conditions, but the care plan did not document any medication reduction plan. The facility's policy on psychotropic medications states that residents should not be given unnecessary medications and that GDR should be attempted unless clinically contraindicated. However, this policy was not followed for the resident, as there was no documentation of a GDR plan or alternative interventions in the care plan. The Director of Nursing confirmed the lack of a medication reduction plan and psychiatric evaluation for the resident. The facility's failure to follow its own policy and federal regulations regarding psychotropic medication use and GDR resulted in deficiencies in the care of the residents. The lack of proper documentation, care planning, and adherence to GDR guidelines contributed to the unnecessary use of psychotropic medications for the residents.
Medication Storage Deficiency
Penalty
Summary
The Facility failed to ensure medications were stored safely until administration and not left at the bedside for one resident reviewed for medication storage. During an observation, a pill was found on the bed sheet of a resident who admitted to forgetting to take it. The Director of Nursing was unable to immediately identify the pill but later confirmed it was Torsemide, a medication prescribed for edema. The resident's medication order confirmed the daily administration of Torsemide. The Facility's Medication Administration Policy requires nursing staff to ensure medications are swallowed before leaving, which was not adhered to in this instance.
Failure to Collect Stool Samples for Occult Blood Testing
Penalty
Summary
The facility failed to obtain stool samples for occult blood testing for one resident, despite multiple opportunities. The resident had a physician's order for stool occult blood tests dated 4/11/2024. However, the facility missed four opportunities to collect the required samples. On 4/17/2024, a CNA noted that the resident had a small bowel movement but was unable to collect the sample because the specimen collection container had been removed from the toilet prior to the resident using it. The Director of Nursing confirmed that there was a miscommunication regarding the stool collection and acknowledged the missed opportunities. The facility's policy mandates that physician orders be processed and implemented by licensed healthcare workers, but this was not adhered to in this case.
Failure to Follow Hand Hygiene and Glove Usage Protocols
Penalty
Summary
The Facility failed to adhere to proper hand hygiene and glove usage protocols in an Enhanced Barrier Precaution room for two residents. In the first instance, the Director of Nursing (DON) did not use gloves while handling a potentially contaminated bed sheet and pill in a resident's room. The DON then left the room and proceeded to the nurse's station without performing hand hygiene. The resident involved was occasionally incontinent of bladder and frequently incontinent of bowel, which increased the risk of contamination. In the second instance, during a pressure sore treatment for another resident, multiple staff members, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), failed to sanitize their hands before donning gloves and between glove changes. The LPN also did not sanitize hands before leaving the resident's room. The facility's policies on hand washing and transmission-based precautions were not followed, as staff did not perform hand hygiene as required before and after resident contact and between glove changes.
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Illustrative
What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carlinville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hallmark Hc Of Carlinville | 0.4 mi | ★★★★★ | 0 | 0 |
| Carlinville Rehab & Hcc | 0.7 mi | ★★★★★ | 3 | 0 |
| Gillespie Health & Rehab Ctr | 13.1 mi | ★★★★★ | 3 | 0 |
| Litchfield Health & Rehab Center | 14.6 mi | ★★★★★ | 0 | 0 |
| Avenues At Litchfield | 15 mi | ★★★★★ | 2 | 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.