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 Lakewood Nrsg & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and an indwelling urinary catheter was not properly monitored, as staff failed to document urinary output for over 13 hours and did not assess the catheter's patency. The resident was later hospitalized with urinary retention and a UTI, and emergency room findings revealed a dry catheter and a significantly distended bladder. Staff interviews indicated inconsistent catheter care practices and lack of adherence to facility policy requiring regular output documentation and assessment.
Residents in the facility expressed fear of retaliation when voicing grievances, with reports of delayed assistance and rough handling after complaints. During a resident council meeting, multiple residents confirmed their fear of reporting issues due to potential staff retaliation, contradicting the facility's policy that ensures residents can voice grievances without fear of reprisal.
The facility failed to assist residents with personal hygiene and grooming, as observed in five residents who required help with ADLs. Despite being alert and oriented, these residents had unkempt facial hair and long, jagged fingernails, and expressed their need for staff assistance, which was not provided. Additionally, a resident with multiple health issues reported not receiving regular bed baths and had a urinal left on the tray table next to their meals. The Director of Nursing acknowledged the need for grooming and hygiene assistance during observations.
The facility failed to ensure accurate accounting and proper storage of controlled medications, affecting several residents. Discrepancies in medication counts and improper handling of narcotic packaging were observed, with nurses failing to document administration and taping over broken seals, contrary to facility policy.
The facility failed to label and manage medications properly for four residents, resulting in deficiencies in medication storage and expiration tracking. Medications were either not dated upon opening or not removed after their use-by date, as observed during an inspection. The DON confirmed that staff must date all medications upon opening to comply with guidelines.
The facility did not follow the menu extension sheet for mechanical soft and pureed diets, resulting in incorrect portion sizes for six residents. The dietary manager was unaware of the correct portions, and the dietitian later confirmed the discrepancies. This affected the dietary service process for residents requiring specific diet consistencies.
The facility failed to follow infection control practices, including leaving a urinal on a resident's tray table during meals, therapists not wearing PPE for a resident on Enhanced Barrier Precautions, and nurses using contaminated syringes and handling medications with bare hands. These actions indicate non-compliance with infection control protocols.
The facility failed to maintain a functioning electronic monitoring alarm system for residents at high risk for elopement. During an observation, a resident with an electronic monitoring device approached the main exit door, but the alarm did not activate due to a power issue with the control panel. Four residents with cognitive impairments and high elopement risk were affected, highlighting a lapse in the facility's protocol for daily checks of these safety devices.
A facility failed to update the smoking assessment and care plan for a resident who resumed smoking. Despite the resident's cognitive intactness and history of serious health conditions, the facility did not conduct a current smoking assessment or revise the care plan, as required by policy. Staff interviews revealed a lack of awareness about the resident's smoking status, and the resident was observed smoking with the assistance of a hospice volunteer and nursing staff.
A resident with severe cognitive impairment and Alzheimer's disease was found with overgrown and misaligned toenails, indicating a failure in providing necessary foot care. The facility's LPN and DON acknowledged the need for regular assessment and podiatry consults, which were not conducted as per the facility's policy.
A facility failed to follow a physician's order for oxygen administration for a resident with respiratory issues, providing one liter per minute instead of the prescribed two liters. Additionally, the facility did not maintain the oxygen equipment as per policy, with outdated tubing and an empty humidifier bottle, which was acknowledged by the DON.
A nurse administered incorrect doses of Lactulose and Novolog to a resident, resulting in a medication error rate of 7.69%, exceeding the acceptable 5% threshold. The resident was given 10 ml of Lactulose instead of 30 ml and 6 units of Novolog instead of 4 units, as per the MAR. The DON confirmed the need to follow physician orders and the facility's medication administration policy.
The facility failed to provide meal options of similar nutritive value to the main entree for two residents. During lunch, they received a grilled cheese sandwich with a side of zucchini instead of Lemon Baked Tilapia. The dietitian confirmed the substitute meal lacked sufficient protein compared to the main entree, contrary to the facility's policy on selective menus.
A resident with limited upper extremity mobility was not provided with appropriate adaptive eating equipment, leading to difficulties in eating independently. The resident, diagnosed with dementia and cerebral conditions, was observed dropping food while eating with a fork using only the right hand. Initially, no staff assistance was provided, but later assessment determined the need for a scoop plate to aid in self-feeding. The DON emphasized the importance of staff reporting such needs for timely assessment and provision.
A resident with a tracheotomy experienced severe respiratory distress due to inadequate suctioning at a facility. Despite having a history of chronic respiratory failure and requiring frequent suctioning, the resident was found struggling to breathe for up to 90 minutes before EMS intervened. The facility's disorganization and reliance on agency nurses contributed to the deficiency, as noted by EMS and the Ombudsman.
A resident with complex medical conditions experienced a decline in health, marked by lethargy and decreased oral intake. Despite instructions from the physician to closely monitor the resident, the facility failed to consistently document vital signs and neurological checks. The resident's condition worsened, leading to hospitalization with seizures and encephalopathy.
The facility failed to provide adequate personal hygiene for six residents dependent on ADL care. Observations revealed long, jagged fingernails, oily hair, and dry, flaking skin. Interviews with residents and staff confirmed inconsistent performance of personal hygiene tasks, leading to potential health risks. The facility's policy emphasized necessary care, but the observations indicated a failure to adhere to this policy.
The facility failed to update physician orders to reflect a resident's DNR status, despite the resident's POLST requesting comfort-focused treatment and allowing a natural death. Staff interviews confirmed the inconsistency, and the facility's policy on Advanced Directives was not followed.
A resident with chronic respiratory failure, type 2 diabetes, tracheostomy, and gastrostomy received medications via his G tube without the nurse verifying the tube's placement. The nurse admitted to not checking the placement, which is necessary to prevent fluids and medications from entering the lungs. The Director of Nursing confirmed that the nurse should have verified the G tube placement before administering any medications or flushes, as per the facility's policy.
The facility failed to provide adequate respiratory care for four residents requiring continuous oxygen therapy and proper storage of respiratory equipment. Observations included residents without connected oxygen supply, uncovered nebulization masks, and a BIPAP mask, posing a risk of infection and compromised respiratory health.
A resident with swallowing difficulties was given unthickened coffee and juice despite physician orders for nectar thick liquids. The error was acknowledged by the LPN and DON, but the responsible staff member was not identified. The dietician confirmed the risk of aspiration from thin liquids.
Failure to Monitor Catheter Output and Assess Urinary Status
Penalty
Summary
The facility failed to properly assess and monitor the urinary status of a resident with an indwelling urinary catheter, resulting in urinary retention and subsequent hospitalization for a urinary tract infection (UTI). The resident, who was severely cognitively impaired and had diagnoses including chronic kidney disease, benign prostatic hyperplasia, and neuromuscular dysfunction of the bladder, had an order for catheter care and for urinary output to be recorded every shift. However, documentation showed that the last recorded catheter output was at 10:30 PM on one day, with no further documentation for approximately 13 hours prior to the resident's discharge. During this period, there was no evidence that staff assessed the catheter's patency or the resident's urinary output, despite facility policy requiring output to be recorded every shift and the collection bag to be emptied at least every eight hours. When the resident was being transferred, paramedics diverted him to the hospital due to concerning vital signs and mental status. In the emergency room, the catheter was found to be dry, and the bladder was exceptionally full, with about 1.9 liters of urine drained after catheter replacement. The ER diagnosis included UTI associated with the indwelling catheter, urinary retention, and possible acute kidney injury. Interviews with staff revealed a lack of recall regarding the resident's catheter status and inconsistent practices regarding catheter assessment and documentation. The facility's own policy emphasized the need for regular monitoring and documentation of urinary output, as well as observation for signs of infection or retention, which were not followed in this case.
Residents Fear Retaliation for Voicing Grievances
Penalty
Summary
The facility failed to ensure that residents felt safe voicing grievances without fear of retaliation. This deficiency was identified through interviews and record reviews involving ten residents. Several residents expressed fear of retaliation if they reported grievances, with some stating that they had been advised by other residents not to complain about care. Specific incidents included a resident who reported that after complaining about delayed assistance, the staff's response worsened, and they experienced rough handling. Another resident mentioned being told by a CNA that they could not be changed every time they urinated, and they felt the staff were not nice when requests were made. During a resident council meeting, multiple residents expressed fear of reporting grievances due to potential retaliation by staff. They reported that retaliation included staff not answering call lights timely, not assisting with care, and being rough when providing assistance. One resident mentioned that the fear of retaliation was always present when they had concerns, and others in the meeting agreed. The facility's resident rights guidelines, revised in October 2023, state that residents have the right to voice grievances without fear of discrimination or reprisal, yet the residents' experiences contradicted this policy. The facility's failure to uphold its grievance policy and ensure a safe environment for residents to voice concerns was evident in the testimonies of the residents. The fear of retaliation was a common theme, with residents feeling that their complaints would lead to negative consequences, such as delayed assistance or rough handling. This environment of fear and intimidation prevented residents from exercising their rights to voice grievances, as outlined in the facility's resident rights guidelines.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents who required help with personal hygiene and grooming. Five residents were identified as needing assistance, yet they were observed with unkempt facial hair and long, jagged fingernails. These residents, despite being alert and oriented, expressed their desire for staff assistance, which was not provided. The Director of Nursing (V2) acknowledged the need for grooming and hygiene assistance during observations. One resident, with a diagnosis of muscle disorder, was observed with long facial hair and expressed a desire for staff to shave him. Another resident, with a displaced fracture and muscle atrophy, had long and jagged fingernails and reported asking staff for assistance multiple times without receiving help. Similarly, other residents with various diagnoses, including acute respiratory failure and multiple sclerosis, were observed with long, unkempt fingernails and expressed their need for staff assistance, which was not provided. Additionally, a resident with multiple health issues, including respiratory failure and morbid obesity, reported not receiving regular bed baths and had a urinal left on the tray table next to their meals. This resident expressed that hygienic care was not offered on non-shower days, contrary to the facility's expectations. The Director of Nursing confirmed that staff are expected to provide daily hygienic care, including shaving and nail care, as needed, but these services were not consistently provided to the residents.
Controlled Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications and proper storage of narcotic medications, affecting four out of five residents reviewed for controlled medications. On April 1, 2025, discrepancies were noted during medication counts with various nurses. For instance, a nurse failed to sign out a tablet of Tramadol administered to a resident, resulting in a discrepancy between the actual count and the record. Another nurse was found to have taped over a broken seal of a Tramadol blister pack, which is against the facility's policy. Further observations revealed that a blister pack of Lorazepam had a torn tablet, and a nurse failed to document the administration of Methylphenidate, leading to a discrepancy in the count. The Director of Nursing confirmed that nurses are required to sign out narcotic medications immediately after administration and that damaged packaging should not be taped over but discarded with a witness. The facility's policy mandates accurate accountability and documentation of controlled substances, which was not adhered to in these instances.
Medication Labeling and Expiration Tracking Deficiency
Penalty
Summary
The facility failed to properly label and manage medications for four residents, leading to deficiencies in medication storage and expiration tracking. During an inspection, it was observed that medications for residents R315, R32, R4, and R33 were either not dated upon opening or not removed after their use-by date. Specifically, R315's and R32's Trelegy Ellipta inhalers were opened but not dated, which is crucial for determining their expiration as they should be discarded six weeks after opening. R4's Fluticasone propionate/Salmeterol inhaler was opened on January 20, 2025, but not discarded by its expiration date of February 20, 2025, and R4's Incruse Ellipta was also opened without a date. Similarly, R33's Arnuity Ellipta was opened and not dated. The Director of Nursing confirmed that staff are required to date all medications upon opening to ensure compliance with manufacturer's guidelines.
Failure to Follow Menu Extension Sheet for Diet Consistency
Penalty
Summary
The facility failed to adhere to the menu extension sheet for providing appropriate portion sizes for residents on mechanical soft and pureed diets. During a lunch meal service, the cook used incorrect scoop sizes, resulting in residents on mechanical soft diets receiving less than the required portion of Lemon Baked Tilapia. Additionally, a resident on a pureed diet with double protein did not receive the correct portion sizes for Lemon Baked Tilapia and zucchini, nor did they receive pureed soup or bread, which are standard offerings for all consistency diets. The dietary manager was unaware of the correct portion sizes and expressed dissatisfaction with the menu program, indicating a lack of familiarity with the facility's dietary procedures. The dietitian later confirmed the correct portion sizes and scoop sizes that should have been used, highlighting the discrepancies in the meal service. The facility's failure to follow the menu extension sheet affected six residents who were reviewed for dining, indicating a systemic issue in the dietary service process.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices during the provision of care to residents, as observed in multiple instances. One resident, who was dependent on staff for activities of daily living, had a urinal with urine left on their overbed tray table during meal times, which was not removed by staff. This practice was observed on multiple occasions, indicating a lack of proper hygiene and infection control measures. In another instance, two therapists failed to wear the required personal protective equipment, such as gloves and gowns, while providing therapy to a resident on Enhanced Barrier Precautions due to an indwelling catheter. This was despite clear signage and facility policy requiring such precautions to prevent the transmission of multi-drug resistant organisms. Additionally, a nurse administered insulin using a syringe that had been dropped and contaminated, and another nurse handled medications with bare hands after they were dropped, both actions contrary to infection control protocols. Further deficiencies were noted when a nurse failed to change gloves and perform hand hygiene between handling a urinary catheter bag and a PICC line, risking cross-contamination. Another nurse used bare fingers to handle medication and failed to change gloves and perform hand hygiene between resident contact and medication handling. These actions demonstrate a pattern of non-compliance with established infection control guidelines, potentially compromising resident safety.
Failure to Maintain Functioning Elopement Alarm System
Penalty
Summary
The facility failed to ensure the proper functioning of the electronic monitoring alarm control panel, which is crucial for the safety of residents at high risk for elopement. This deficiency was identified during an observation on April 1, 2025, when a resident with an electronic monitoring device on his ankle approached the main exit door, and the alarm did not activate. The alarm control panel was found to be without power, and the Maintenance Director confirmed that the transformer was not working and needed replacement. Four residents, all identified as high risk for elopement, were affected by this deficiency. These residents had various diagnoses, including dementia and cognitive impairments, and were equipped with electronic monitoring devices as per physician orders. The facility's guidelines require that these devices and the exit door alarms be checked daily for functionality, but the failure of the alarm system indicates a lapse in this protocol. The deficiency was observed in the context of the facility's elopement and search guidelines, which mandate the use of elopement prevention devices for residents assessed as high risk. Despite these guidelines, the malfunctioning alarm system compromised the safety measures intended to prevent elopement, as evidenced by the non-functioning alarm when tested with a resident at risk.
Failure to Update Smoking Assessment and Care Plan
Penalty
Summary
The facility failed to conduct a smoking assessment and revise the care plan for a resident who resumed smoking. The resident, who has a history of type 2 diabetes mellitus, cerebral infarction, and liver cancer, was admitted to hospice care in February 2025. Despite being cognitively intact, the resident's electronic medical records did not reflect a current smoking assessment or care plan, even though the resident had signed a smoking contract in April 2024. The facility's policy requires smoking assessments to be performed upon admission, quarterly, or with any changes affecting the resident's safety, but this was not adhered to when the resident resumed smoking. Interviews with facility staff revealed a lack of awareness regarding the resident's current smoking status. The Social Service Assistant and Director were unaware that the resident had resumed smoking, despite the resident's own admission and observations of the resident smoking outside the facility. The resident's smoking activities were facilitated by a hospice volunteer and nursing staff, who provided access to cigarettes and a lighter. The facility's policy mandates that all residents desiring to smoke must have a smoking assessment and care plan developed by the interdisciplinary team, which was not updated in this case, leading to the deficiency.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident who requires total assistance with personal care. The resident, who is non-verbal and has severe cognitive impairment due to Alzheimer's disease, was observed with overgrown toenails and very dry skin on the feet. The toenails were noted to be growing sideways, with the left big toenail slightly misaligned and separated from the nail matrix, creating a gap with an unknown black substance. The right big toenail was also sticking sideways and measured 1.8 cm in length. The nurse (LPN) acknowledged that the facility's CNAs or hospice CNA staff should notify nurses when a podiatry consult is needed for toenail clipping. However, the nurse was unable to confirm when the resident was last seen by a podiatrist. The Director of Nursing stated that toenails should be assessed by staff and referred for podiatry consult if needed, with consent obtained from the resident or family member. The facility's policy on nail care emphasizes daily cleaning and regular trimming to prevent infections and skin problems, which was not adhered to in this case.
Failure to Follow Oxygen Administration Orders and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen administration for a resident with multiple diagnoses, including acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The resident was observed receiving oxygen at one liter per minute via nasal cannula, contrary to the physician's order for two liters per minute. This discrepancy was acknowledged by the Director of Nursing, who confirmed that oxygen is considered a medication and must be administered as per the physician's order. Additionally, the facility did not follow its policy regarding the maintenance of oxygen equipment. The oxygen tubing, dated March 23, 2025, was not changed weekly as required, and the humidifier bottle was nearly empty with no bubbles, indicating a lack of moisture being provided to the resident. The Director of Nursing acknowledged these oversights, which are contrary to the facility's policy that mandates regular checks and maintenance of the oxygen equipment to ensure proper infection control and adequate moisture delivery to residents.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to adhere to physician's orders during medication administration, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the administration of medications to a resident (R15) by a nurse (V8). The nurse administered 10 ml of Lactulose Solution and 6 units of Novolog to the resident, despite the Medication Administration Record (MAR) indicating that the resident was supposed to receive 30 ml of Lactulose and 4 units of Novolog based on a blood sugar reading of 213 mg/dl. The Director of Nursing (V2) confirmed that medications must be administered according to physician orders, following the facility's policy and the 5 rights of medication administration, which include the right dose.
Failure to Provide Nutritive Meal Substitutes
Penalty
Summary
The facility failed to provide lunch meal options of similar nutritive value to the main entree for two residents. During a lunch meal service, two residents received a grilled cheese sandwich with a side of zucchini as a substitute for the main meal of Lemon Baked Tilapia, Wild Rice Blend, and Sliced Zucchini. The meal tickets indicated that the residents had ordered the grilled cheese sandwich as a substitute. The cook prepared the sandwiches using two slices of American cheese and two slices of bread. The dietitian confirmed that the Lemon Baked Tilapia portion provided 21 grams of protein, while the grilled cheese sandwich only provided 6 grams of protein due to the use of two slices of cheese. The dietitian agreed that the facility should have offered an additional item to meet the nutritional needs of the substitute meal. The facility's policy on selective menus, effective June 2023, states that selections should be provided within allowed dietary modifications to create nutritious menus and portion control.
Failure to Provide Adaptive Eating Equipment for Resident
Penalty
Summary
The facility failed to assess and provide appropriate adaptive eating equipment for a resident with limited range of motion in the upper extremities, leading to difficulties in eating independently. The resident, who had multiple diagnoses including dementia and cerebral conditions, was observed on two separate occasions struggling to eat independently due to the inability to use the left arm and hand. During these observations, the resident was seen dropping food on the table, floor, and protective clothing while attempting to eat with a fork using only the right hand. Despite these challenges, no staff assistance was provided during the initial observations, and the resident continued to struggle with self-feeding. The Director of Nursing was informed of the situation and acknowledged the need for an assessment of adaptive equipment. Subsequently, the Restorative Nurse assessed the resident and determined that a scoop plate would aid in preventing food spillage and improve the resident's ability to eat independently. The assessment also noted that the resident could grip regular utensils and did not require special utensils. The Director of Nursing emphasized the expectation for nursing staff to report any resident needing adaptive equipment to ensure prompt assessment and provision of necessary tools to maintain nutritional intake.
Failure to Provide Timely Tracheotomy Care
Penalty
Summary
The facility failed to provide timely tracheotomy care to a resident, leading to severe respiratory distress and hospitalization. The resident, a male with a history of cerebral infarction, hemiplegia, chronic respiratory failure, tracheotomy, and gastrostomy, required frequent suctioning to maintain airway patency and oxygen levels. On the night of the incident, the resident experienced breathing difficulties, with oxygen saturation dropping to 86%. Despite the presence of a suction setup at the bedside, there is no documentation that the agency nurse on duty suctioned the resident during this period of distress. Interviews with staff and emergency medical services (EMS) personnel revealed that the resident was found in severe respiratory distress, with significant mucus and secretions obstructing the tracheotomy. The EMS crew had to perform extensive suctioning, which significantly improved the resident's condition. The resident's roommate reported that the resident had been struggling to breathe for an extended period, up to 90 minutes, before receiving appropriate care. The facility's Director of Nursing acknowledged the lack of documentation regarding suctioning during the critical period. The facility's tracheotomy care policy requires suctioning as needed, yet the agency nurse on duty did not provide the necessary care, resulting in the resident's condition worsening. The report highlights the disorganization within the facility, as noted by EMS personnel, and the frequent use of agency nurses who may not be familiar with the residents' specific needs. The Ombudsman also received complaints about the facility's failure to provide adequate suctioning, leading to the resident's severe respiratory distress and subsequent hospitalization.
Failure to Monitor Resident's Decline in Health
Penalty
Summary
The facility failed to adequately monitor a resident experiencing a decline in health condition, leading to a deficiency in care. The resident, who had multiple complex medical diagnoses including heart failure, end-stage renal disease, and cognitive communication deficit, was admitted to the facility in July 2024. On September 23, 2024, the resident exhibited signs of lethargy and a decreased ability to eat independently, which was a significant change from their normal alert and oriented state. Despite these changes, there was a lack of consistent monitoring and documentation of the resident's condition by the nursing staff. The resident's condition continued to deteriorate over the following days, with reports of increased lethargy, refusal to eat, and confusion. Although the nursing staff was instructed by the primary physician to closely monitor the resident's condition, including vital signs and neurological checks, there was insufficient documentation to show that these instructions were followed. The resident was eventually sent to the hospital on September 25, 2024, after becoming unresponsive and was admitted to the ICU with a diagnosis of seizures and encephalopathy. Interviews with staff and family members revealed that the resident's decline was noted by multiple caregivers, yet there was a failure to consistently communicate and document these observations. The lack of timely and thorough monitoring and documentation contributed to the delay in addressing the resident's worsening condition, ultimately resulting in the resident's hospitalization.
Failure to Provide Adequate Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene for six residents who were dependent on assistance for activities of daily living (ADLs). Observations revealed that residents had long, jagged fingernails, oily hair, and dry, flaking skin. For instance, one resident was observed with long, jagged fingernails and was noted to be dependent on staff for all personal care due to severe cognitive impairment and physical disabilities. Another resident had long, oily hair and severely dry, flaking skin on his feet, and reported receiving only occasional sponge baths and no lotion for months despite being bedridden and dependent on staff for personal care. Interviews with residents and staff further highlighted the deficiencies. One resident mentioned not receiving a scheduled shower due to a lack of available help, while another expressed frustration over not having their nails cut despite repeated requests. Staff interviews confirmed that personal hygiene tasks such as nail trimming and applying lotion were not consistently performed, which could lead to potential health risks like infections and skin tears. The Director of Nursing and Assistant Director of Nursing acknowledged that ADLs should be performed as needed and that the current state of residents' hygiene was unacceptable. The facility's policy on activities of daily living, dated February 2023, emphasized the importance of providing necessary care and services to ensure residents' mobility and ADLs do not diminish. However, the observations and interviews indicated a failure to adhere to this policy, resulting in inadequate personal hygiene care for the affected residents. The residents' medical records and care plans consistently showed a need for substantial assistance with personal hygiene, yet the facility did not meet these needs, leading to the identified deficiencies.
Failure to Update Physician Orders for Resident's DNR Status
Penalty
Summary
The facility failed to update physician orders to reflect a resident's resuscitation choice of DNR (Do Not Resuscitate). This deficiency was identified for a resident with multiple diagnoses including dementia, anxiety, dysphagia, morbid obesity, hypertension, bradycardia, pain, and weakness, who was admitted to hospice care. Despite having a signed POLST (Practitioner Order for Life Sustaining Treatment) requesting comfort-focused treatment and allowing a natural death, the resident's current physician order in the EMR (Electronic Medical Record) incorrectly listed the resident as full code. The resident's care plan goal for hospice was to experience death with dignity and physical comfort, and their advanced directive wishes were to be honored. During interviews, staff members including an LPN, a CNA, and a restorative aide/CNA indicated that the resident's code status should be DNR and that the code status could be found in various locations such as the computer, the crash cart, and the EMR. However, the inconsistency between the POLST and the physician's order was confirmed by the DON and the Administrator, who stated that the physician's order should be consistent with the resident's choice on the POLST. The facility's policy on Advanced Directives, dated November 2016, requires the care plan team to initiate the necessary process to modify the status change in the resident's record and secure appropriate orders to reflect the status change, which was not followed in this case.
Failure to Verify G Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to verify the placement of a gastric tube (G tube) for a resident before administering medications. The resident, a male with chronic respiratory failure, type 2 diabetes, tracheostomy, and gastrostomy, was observed receiving medications via his G tube without the nurse checking for residual or verifying the tube's placement. The nurse admitted to not verifying the placement and acknowledged that this step is necessary to prevent fluids and medications from entering the lungs. The Director of Nursing confirmed that the nurse should have verified the G tube placement before administering any medications or flushes. The facility's policy on Enteral Tube Medication Administration mandates the safe and effective administration of medications via enteral tubes, which was not followed in this instance.
Failure to Provide Adequate Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide adequate respiratory care for four residents who required continuous oxygen therapy and proper storage of respiratory equipment. One resident was observed being wheeled to the therapy room without their oxygen supply connected, resulting in the resident gasping for breath. Additionally, the same resident's nebulization mask was repeatedly found uncovered on the bedside table. Another resident's nebulization mask was also observed uncovered on multiple occasions, and the resident's son reported that the facility staff never cleaned or changed it. The Assistant Director of Nursing confirmed that the nebulization containers should be washed and dried for the next use and that all respiratory masks should be bagged when not in use. However, the Director of Nursing admitted that there was no specific policy for storing nebulization masks to avoid contamination. A third resident's BIPAP mask was found uncovered on the bedside table, and the Director of Nursing acknowledged the high risk of bacterial contamination if respiratory equipment is not properly stored. The fourth resident's nebulizer mouthpiece was also observed uncovered on multiple occasions. These deficiencies were observed despite the residents having significant medical conditions such as chronic obstructive pulmonary disease, dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. The facility's failure to ensure proper respiratory care and equipment storage posed a risk of infection and compromised the residents' respiratory health.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to provide thickened drinks as ordered by the physician for a resident with swallowing difficulties. The resident, who has diagnoses including dementia, anxiety, dysphagia, morbid obesity, hypertension, bradycardia, pain, and weakness, was observed receiving unthickened coffee and juice from a family member. The resident's physician had ordered a puree diet with nectar thick liquids due to the resident's swallowing difficulties, which included loss of liquids/solids from the mouth and coughing or choking during meals. Despite this, the resident was given thin liquids, which was confirmed by the LPN and the DON, who acknowledged the error but could not identify the staff member responsible. The dietician also confirmed that residents requiring thickened liquids should not be served thin liquids due to the risk of aspiration.
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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.
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Nursing homes near Plainfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Renwick Nursing And Rehab | 3.5 mi | ★★★★★ | 15 | 0 |
| Alden Estates Of Shorewood | 5.5 mi | ★★★★★ | 6 | 0 |
| Alden Courts Of Shorewood | 5.5 mi | ★★★★★ | 0 | 0 |
| Avantara Joliet | 6.9 mi | ★★★★★ | 8 | 0 |
| Parc Joliet | 7.1 mi | ★★★★★ | 29 | 0 |
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