Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Landmark Of Cicero Rehabilitation And Nursing Cent during CMS and state inspections, most recent first.
A resident with multiple psychiatric and medical diagnoses, including schizoaffective disorder, heart failure, and hypertension, had repeated MDS assessments showing a BIMS score of 3, indicating severely impaired cognition. Admission and clinical records listed only the resident as the responsible party, with no family contacts, POA, surrogate, or guardian documented, despite a physician’s written opinion that the resident was totally incapable of making personal or financial decisions and required full guardianship. Staff, including Social Services, the Admissions Director, and the DON, acknowledged that a BIMS of 3 meant the resident could not make decisions and that Social Services was responsible for initiating surrogacy or guardianship, but no such process was completed, and the state guardian’s office had no record of a referral. Facility policies and resident rights documents required appropriate representation and guardianship processes, yet the resident continued without an identified decision maker while staff continued to list the resident himself as the contact for condition changes, leading to the cited deficiency.
A resident with bipolar disorder, anxiety, and intact cognition repeatedly refused prescribed psychotropic medications, as documented on the MAR and in nursing notes describing verbal refusal and resistant behavior. The resident reported telling an LPN she was allergic to an antipsychotic and that the LPN continued to offer it while documenting refusals. Despite multiple documented refusals and facility guidelines stating that declined treatments must be reflected in the comprehensive care plan, the interdisciplinary team did not develop a care plan problem, goal, or interventions for medication refusal, and the staff member responsible for such care plans acknowledged that no medication-refusal care plan had been created.
The facility failed to maintain an effective pest control program, as evidenced by visible dirt, spilled food, and numerous mice droppings observed on the floor of the kitchen dry storage area, which staff identified as mouse waste. A regional operations leader acknowledged ongoing mouse problems related to the building’s proximity to an alley, despite regular pest control visits. During a resident council meeting, residents unanimously reported ongoing issues with rodents and roaches, and a resident reported rats and mice running through their room several times a week, with a recent sighting reported. The Dietary Manager stated that the kitchen floor is supposed to be cleaned daily by staff but had not been, and the facility’s pest policy requires an effective pest control program and staff vigilance to keep the environment free of pests and rodents.
Dish machine sanitizer concentration was not at the required level when the chlorine test strip read less than 10 ppm instead of the expected 50 ppm, and the chlorine container was empty during the kitchen observation. The dry storage room floor also had accumulated dust, dirt, spilled dried grits, and about 22 pieces of mice droppings under a shelf, with the DQM and RDO acknowledging the sanitation and pest issues.
Open Dumpsters Not Kept Covered: Surveyors observed 2 of 3 outside dumpsters left open without lids, including during a kitchen observation with the Dietary Mgr. The Dietary Mgr stated the open dumpsters could attract rodents and said the dumpsters were mostly used by Housekeeping and Laundry. The facility policy required garbage and refuse to be placed in sealed dumpsters to prevent rodents and pests.
The facility assessment was incomplete because it did not document participation by the governing body, direct care staff, or residents/representatives, and it did not include CNA staffing needs by unit and shift or a recruitment and retention plan for direct care staff. The Administrator confirmed the assessment was developed by leadership only, while staffing on the 4th floor was described as limited and affected by call-offs, with staff being pulled to other floors.
The facility failed to create and implement individualized, measurable fall care plans for four residents with documented fall risks and prior falls. One resident with dementia, a high fall risk score, and a wrist fracture from a fall had only a generic, system-generated goal stating that a safe environment would be maintained, with no resident-specific, measurable outcomes. Another resident with a history of falls, epilepsy, bilateral lower extremity amputations, and dementia had the same broad fall goal without customization. A third resident with dementia, schizoaffective disorder, a right femur fracture, and documented episodes of throwing himself from a chair and leaping to the floor was monitored but not provided enhanced supervision before the fall, and his fall care plan also contained only the generic safe-environment goal. A fourth resident with arthritis, chronic pain, syncope, weakness, a high fall risk score, and a prior fall while attempting to transfer to a chair had a longstanding fall care plan with the same non-specific goal, and staff interviews confirmed that this broad goal was routinely used for all residents instead of person-centered, measurable fall goals.
Surveyors identified multiple unsecured and loose handrails in 3rd-floor hallways, including those near a bathroom and outside several rooms, which could be displaced several inches and in one case had a screw protruding from the bracket. An LPN twice observed and confirmed the looseness of the handrails and acknowledged they are used for safety and to assist residents with gait abnormalities, while the Maintenance Director confirmed the expectation that handrails in common areas be secured and promptly repaired. Despite these acknowledgments and a written preventative maintenance policy requiring inspection of all handrails for loosened fasteners and immediate repair, the same handrails remained loose on subsequent observations.
Delayed meal service and unavailable dining room seating: The facility did not serve lunch on time for several residents, including residents waiting for alternate hamburgers, and one resident had to stand in the dining room holding a meal tray because no chair was available. The ADON stated the facility did not have a seating chart with resident names, despite policy calling for Nursing to provide Food Service with a seating chart and for residents in open dining to be served after being seated.
Failure to Identify, Document, and Repair Maintenance Concerns: A bent baseboard heater, large holes in the shower ceiling, and broken closet doors/locks were observed on the 4th floor men’s unit. An LPN was unsure about the heater concern, and the maintenance director stated the shower ceiling issue was due to a plumbing leak and that the work order had not been entered. Broken closet hardware was also observed, and the maintenance director said the 4th floor issues were not entered in the maintenance tablet.
A resident with cognitive impairment and multiple psychiatric diagnoses was observed in the dementia unit while Christmas music videos played loudly after the holiday had passed. The resident made confused statements about Santa and displayed flight of ideas, and the DUC and ADM confirmed the seasonal music was no longer appropriate and could confuse residents. Christmas decorations were also still up in office areas.
Medication administration and documentation were not completed timely for multiple residents. An LPN and RN were observed giving or documenting meds after the fact, with some 9:00 a.m. doses not documented when due and other scheduled doses given earlier than the ordered time. Staff stated meds should be given within the 1-hour window and documented when administered, and the facility policy required MAR initials for the specific dose and administration within 60 minutes of the scheduled time.
Medication storage was not secured in the 5th and 6th floor med rooms. An LPN and an RN found med room doors that could be opened without a key, unlocked med refrigerators with no lock present, and open med cabinets containing OTC meds. The 6th floor med refrigerator also showed a freezing temperature, while the posted log indicated it should be 32-41F.
Food service was not maintained at safe and appetizing conditions during lunch service on the 4th floor. A dietary aide reported plates were delayed because the facility ran out, the thermometer was not working, and steam table lids were old and bent. The RD of Kitchen Ops found rice at 119F, hamburgers at 100F and covered in water with a pale appearance, and grilled cheese at 106.5F. The steam table was observed with food residue and soiled scoops before service, and the facility policy required hot foods to be held at 135F during tray assembly.
Hand hygiene was not performed between passing meal trays to multiple residents. A Rehab Aide sanitized hands once at the start, then served trays to several residents without cleaning hands between each resident, and stated hand washing was only needed if the resident was touched while serving the tray. The IP and facility leadership stated staff should use hand sanitizer between each resident while passing trays to prevent transfer of contaminants.
Unsanitary conditions were found in a 6th-floor men's shower room and an 8th-floor east wing community shower room, along with an exposed electric wire on the wall. An LPN observed malodorous liquid around a toilet, a urine odor, and rust-stained ceiling tiles in the 8th-floor shower room, while a CNA observed a door held open with a plastic bag, pooled yellow liquid on the floor, and a heavily soiled rag in the 6th-floor shower room. The Housekeeping Director stated shared bathrooms and shower rooms are cleaned daily, but no housekeeping staff are assigned overnight.
Two residents at high risk for falls did not receive adequate accident prevention measures. One resident with motor coordination issues and a history of falls had a care-planned self-releasing seat-belt alarm that was not functioning when tested, and staff acknowledged it was not working and had not ensured it was repaired or replaced. Another resident with dementia, schizoaffective disorder, high fall-risk score, and a right hip fracture repeatedly attempted to get out of a wheelchair and throw himself from a chair in the dining room while only routine supervision was provided. Staff were positioned at a distance, responsible for monitoring multiple residents, and were unable to intervene before the resident leaped from the chair and fell. Despite documented behavioral symptoms, impaired mobility, and repeated attempts to exit the wheelchair, no enhanced or 1:1 supervision was implemented, and facility policies on fall prevention, individualized interventions, and incident reporting were not effectively followed.
Surveyors found that the facility exceeded the acceptable 5% medication error rate when an LPN prepared incorrect medications for a resident during a routine med pass. The resident’s POS specified Folic Acid 400 mcg once daily and Aspirin 81 mg once daily at 9 a.m., but the LPN prepared chewable Aspirin 81 mg, which was not prescribed, and Folic Acid 1,000 mcg instead of the ordered 400 mcg. Upon questioning, the LPN confirmed both the incorrect formulation of Aspirin and the incorrect Folic Acid dose, contrary to the facility’s policy requiring medications to be administered exactly as ordered by the physician.
Inaccurate MDS Coding for Diagnosis and Communication Assessments: The facility inaccurately coded MDS items for a resident with documented schizophrenia and schizoaffective disorder, including an incorrect No response for schizophrenia despite active diagnoses, antipsychotic use, and PASSR findings. Two other residents had communication-related MDS coding that did not match the recorded B0700 findings or the decision to skip the BIMS interview, with staff observations showing significant language and cognitive barriers.
The facility failed to provide needed hygiene and nail care for two residents who required ADL assistance. One resident was observed with food on the face and beard and long, jagged nails, and an LPN confirmed the nails needed trimming. Another resident with a self-care deficit had long, broken fingernails and soiled, wet socks, and stated nobody cut the fingernails. The ADL care policy required nails to be kept at a smooth, safe length, and the CNA role included assisting with nail care and dressing.
A resident was served lunch in the 4th floor dining room but had to carry the tray around while looking for a seat because no chairs were available. The resident stood while holding the meal and ate part of the sandwich before staff provided a chair. The Maintenance Director stated the facility had enough chairs and that extra chairs would be brought to the floor if needed.
A resident with a history of bipolar disorder and recent traumatic fall resulting in multiple fractures did not have their falls care plan updated with new interventions. Despite increased fall risk and functional decline, the care plan remained unchanged, and staff failed to document the recent fall or implement additional fall prevention measures as required by facility policy.
A resident with psychiatric and neurological conditions, requiring supervision for ambulation, was left unsupervised in the dining room. The lack of staff presence led to an altercation with another resident over spilled coffee, resulting in a fall and serious injuries, including a fractured humerus and nasal bone. Staff interviews confirmed no supervision was provided, and documentation showed discrepancies in staffing assignments.
Several residents were not served lunch at the same time as their tablemates, with some not having their names called and their trays left on the cart until later. Two residents also did not have diet tickets with their trays. Facility policy requires that all trays be served in order at each table to ensure a dignified dining experience.
Several cognitively intact and moderately impaired residents received Descovy for HIV pre-exposure prophylaxis without being informed or providing consent. Medical records lacked documentation of consent, education, or individualized care plans, and staff confirmed that written consent was not obtained prior to administering the medication.
The facility did not consistently hold quarterly care plan meetings with residents and their representatives, nor did it ensure residents were involved in the development and review of their care plans. Several residents lacked documentation of care plan meetings or discharge planning, and one resident who smoked was not identified as such in their care plan, despite having a smoking assessment and being observed smoking. The DON confirmed that smoking should be care planned, but this was not done.
During a lunch meal service, all residents on one unit were served food items that were below the required minimum temperature, with some items as low as 90 degrees Fahrenheit. Dietary staff measured and documented these temperatures but did not reheat the food before serving, contrary to facility policy.
A dependent resident was left without an accessible call light cord for an extended period, requiring her to use her pillow to activate the wall switch behind her bed. Despite full cognitive function, the resident's need for assistance was not promptly addressed, and maintenance was not made aware of the issue until the day of the survey, contrary to facility policy requiring daily checks and immediate reporting of call light defects.
A resident alleged to a RN that CNAs had hit her after an incident of agitation, but the RN did not notify administration or report the allegation to the state agency as required by facility policy. The administrator confirmed that no abuse report was filed, and record review showed the incident was not reported.
Staff failed to accurately code MDS assessments for three residents, including incorrect documentation of anticoagulant use, omission of dialysis status for a resident with chronic kidney disease, and misclassification of a resident's absence as a hospitalization instead of a pass. These errors were identified through record review and staff interviews.
A resident who was identified as a smoker and observed participating in smoking activities did not have smoking addressed in their care plan. Although a smoking assessment was completed and staff confirmed the resident's smoking status, the resident was not included on the facility's smoking list, and the care plan failed to address this behavior, contrary to the DON's expectations.
A resident with a history of wandering and hoarding was observed entering other residents' rooms and taking their belongings without staff supervision. Interviews confirmed this was a recurring issue, and while the care plan addressed hoarding, it did not specifically address wandering or ensure adequate monitoring.
A resident with multiple psychiatric diagnoses and documented malnutrition experienced significant unplanned weight loss after staff failed to provide double portions at meals as ordered by the RD. Despite clear recommendations and documentation, dietary tickets did not reflect the intervention, and the resident continued to lose weight over several months.
A resident was administered heparin injections for VTE prophylaxis without a documented diagnosis to support its use. Despite being ambulatory and having no recorded VTE or related condition, the resident continued to receive the anticoagulant, as confirmed by physician orders and medication records. Review of medical records and interviews with staff verified the absence of a clinical indication for the medication.
A resident with a documented mushroom allergy was served beef stroganoff containing mushrooms, as their allergy was not indicated on the diet ticket used by dietary staff. The Dietary Manager confirmed the omission, and facility policy requires that food allergies be clearly documented and not liberalized.
Staff failed to follow infection control protocols by using the same gloves to access a multi-use petroleum jelly container during incontinence care and then placing the contaminated jar with clean linens. Additionally, a CNA shared a drink with two residents in the dining area, contrary to facility policy and standard precautions, increasing the risk of cross-contamination.
Surveyors found that the facility did not consistently post up-to-date nurse staffing data in a location accessible to residents and visitors. On several checks, the required information was either missing or outdated, potentially impacting all residents.
A resident with multiple medical and behavioral diagnoses alleged being physically assaulted by another resident in the presence of two LPNs. The incident was reported to several staff members, but no immediate action was taken, and the administrator delayed filing an abuse report for eight days, contrary to facility policy requiring prompt reporting of abuse allegations.
A resident with multiple medical and behavioral conditions alleged being physically assaulted by another resident with a history of violent behavior. The incident, witnessed by two LPNs and reported to clinical staff, was not promptly investigated, as the administrator did not interview the resident, contact police, or file an incident report until eight days later, contrary to facility policy requiring thorough investigation of abuse allegations.
A resident with brittle diabetes reported symptoms of low blood sugar and requested a blood glucose check from an LPN, who did not perform the test, stating she was busy. The resident called 911, and paramedics found his blood sugar to be dangerously low. Staff interviews confirmed that glucometers were available and that the resident was able to communicate his needs, but the blood glucose check was not performed as ordered.
A cognitively impaired resident on a pureed diet at an LTC facility accessed a regular sandwich, leading to a fatal choking incident. Despite staff and EMS efforts, the resident died from asphyxiation. The resident had severe cognitive impairment and required supervision while eating, but was able to ambulate independently. The facility failed to prevent the resident from accessing non-pureed food, contributing to the incident.
A resident with a rash did not receive prescribed treatments from an infectious disease practitioner and a dermatologist. The resident's MAR showed no administration of recommended antifungal and antiparasitic medications. The ADON acknowledged that orders were not communicated to staff, and the facility's policy for verifying and documenting new orders was not followed, resulting in a deficiency in care.
A resident with diabetes was not served the correct therapeutic diet as ordered by their physician. Instead of receiving mandarin oranges, the resident was served mandarin orange fluff, which contained excessive sugar, contrary to the facility's dietary guidelines for a Consistent Carbohydrate, Limited Concentrated Sweets (CCHO LCS) diet. The Dietary Manager acknowledged the error, noting that the dessert served was inappropriate for the resident's dietary needs.
The facility's kitchen was found to have significant sanitation and food safety deficiencies, including sticky floors, uncovered food exposed to contamination, and appliances laden with grease and food debris. Expired and unlabeled food items were discovered in the refrigerator, and the cook reported being overworked and short-staffed, with the administration aware of these issues.
A resident with a history of bipolar disorder and substance abuse had his pass privileges revoked after an incident but was not reassessed for reinstatement despite compliance with medication and lack of recent behavioral issues. Facility staff provided inconsistent information, and there was no recent documentation to justify the continued restriction. The facility's policy on pass privileges was not followed, resulting in a deficiency in honoring the resident's rights.
A facility failed to refund a discharged resident's personal funds, totaling $518.39, due to uncertainty about where to send the money. The resident was admitted under Medicaid/social security and had a balance that included a $20 check from the family. Despite being the designated representative payee, the facility did not take action to refund the money, and no inquiries were made by the family.
The facility did not serve spiced peaches as planned in the noon meal, affecting residents' nutritional intake. Observations and interviews confirmed that residents received chicken and noodles, green beans, and ice cream, but no spiced peaches, despite being on the menu. Dietary staff acknowledged the oversight, and the facility's policy requires adherence to the planned menu unless unavoidable circumstances arise.
Failure to Obtain Decision Maker for Resident With Severely Impaired Cognition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with severely impaired cognition had an appropriate decision maker or legal representative identified and in place. The resident was admitted with diagnoses including epilepsy, bipolar disorder, hypertensive heart disease, schizoaffective/psychotic disorder, schizophrenia, and other medically complex conditions such as heart failure and hypertension. Admission records listed only the resident himself as the responsible party, and the census showed he had been in the facility for an extended period. Multiple Minimum Data Set (MDS) assessments, including those dated 09/30/2025 and 02/02/2026, documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired mental status. Despite this, the clinical record showed no power of attorney (POA), surrogate, or guardian, and the resident’s contact information listed no family or other representative. A physician’s report dated 12/19/2025, prepared for potential probate court guardianship proceedings, documented that the resident suffered from schizoaffective disorder which impaired his ability to make decisions and function independently. The physician explicitly opined that full guardianship was needed because the resident was totally incapable of making personal or financial decisions. A hospital discharge summary from 03/31/2026 further noted that there was no family available for consent, that they were awaiting a public guardian, and that legal guardianship would be pursued after discharge at the nursing home. Facility documentation, including a 03/12/2026 change in condition note, continued to list the resident himself as the person notified as the “resident representative,” and a 09/04/2025 progress note recorded that there was no family member contact on the face sheet. Interviews with staff confirmed that the resident was unable to communicate effectively and could not make decisions. During an observation on 04/02/2026, the resident was lying in bed, mumbling and vocalizing, and did not respond to questions; the LPN stated the resident could not communicate or hold a conversation and had no POA, and that he should have one because he was not able to make decisions. The Social Services/Memory Care Coordinator, who completed the BIMS, acknowledged that a BIMS score of 3 meant severely impaired mental status and that, once this was determined, the facility should have initiated the process of obtaining a guardian or surrogate; he admitted he did not initiate guardianship and may have missed this in the admission packet review. The Assistant Social Services Director similarly stated that a BIMS of 3 indicated the resident could not make decisions and that a surrogate or guardian should have been obtained promptly. The Admissions Director stated that Social Services was responsible for determining decision-making capacity at or shortly after admission. The DON stated that Social Services should have initiated surrogacy or guardianship when the BIMS assessment showed incapacity and acknowledged a failure to obtain a decision maker. A representative from the Office of the State Guardian confirmed that the resident’s name was not on file for guardianship. The facility’s own adult guardianship policy required working with residents and others to secure appropriate representation and indicated that guardianship is typically initiated by the attending physician, with guardian contact information and documentation to be maintained in the clinical record; however, there was no documentation that the facility attorney or staff had actually initiated guardianship for this resident. The resident rights document in the facility materials stated that residents have the right to make their own decisions, to have a legal guardian who can review medical records and make important decisions on their behalf, and to have their legal representative or an interested family member notified when their physical, mental, or psychosocial status worsens or when treatment changes significantly. Despite these stated rights and the facility’s guardianship policy, the resident’s record lacked any identified legal representative or decision maker, and staff interviews confirmed that no surrogate or guardian had been secured. The surveyor’s findings, including record review, staff interviews, and confirmation from the state guardian’s office, showed that the facility failed to provide a decision maker for a resident with severely impaired mental status and documented need for full guardianship, thereby failing to honor the resident’s rights to appropriate representation and advocacy as outlined in facility policy and resident rights documents.
Failure to Care Plan Repeated Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan addressing a cognitively intact resident’s repeated refusal of prescribed psychotropic medications. The resident had diagnoses including bipolar disorder, restlessness and agitation, and anxiety disorder, and a recent MDS BIMS score of 15 indicating intact cognition. Medication Administration Records for February documented multiple instances of drug refusal for two psychotropic medications, with code "2 - Drug refused" recorded on several dates. Nursing documentation also described the resident cursing at the nurse and refusing morning medications, and a nurse’s note recorded that the resident refused medication despite education, stating, "I don't care to take medication from you or anyone." The resident reported that an LPN continued to offer an antipsychotic medication despite the resident stating she was allergic, and that the LPN said she would document the refusal. Despite these repeated refusals and associated behavioral documentation, the resident’s care plan, as reviewed on March 2, did not include a problem, goal, or interventions related to refusal of medications. The Assistant Social Services Director, who was responsible for completing care plans for behaviors and refusal of medications, confirmed that there was no care plan addressing medication refusal and acknowledged that a resident with three or more refusals should be care planned so interventions could be put in place. She also stated she did not review the MAR but instead relied on the 24-hour report to identify behaviors. Facility policy on comprehensive care plans required that the comprehensive care plan include problems/needs identified in the comprehensive assessment and that care plans be reviewed and updated at least quarterly and more often with changes in condition or newly developed issues. Facility guidelines for resident refusal of treatment/services/medications stated that declined services must be documented in the medical record and included in the resident’s comprehensive care plan, but this was not done for this resident’s repeated medication refusals.
Failure to Maintain Effective Pest Control in Kitchen and Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent and eliminate rodents in the kitchen dry storage area, with the potential to affect all 266 residents. During an observation of the dry storage area with the Dietary Manager, surveyors noted visible dirt, spilled dried grits, and approximately 22 pieces of mice droppings on the floor by the wall under the bottom shelf. When asked, the Dietary Manager identified the droppings as mice droppings. The Regional Director of Operations also observed the area and acknowledged that the facility has problems with mice, attributing this to the kitchen’s proximity to an alley. The Regional Director stated that the pest control company comes regularly to the building. In a resident council meeting, residents unanimously reported that pest control, including rodents and roaches, is an ongoing concern throughout the facility. One resident stated that their room has rats and mice running through it a few days a week and reported last seeing rodents in the facility the previous day. When the Dietary Manager was later asked why there were so many mice droppings and why staff who accessed food items for breakfast did not clean the dirty floor and droppings, she stated she had been off work for several days and had just returned, and that the kitchen floor should be cleaned every day by staff. The facility’s undated Pest Policy states that an effective pest control program must be in place and that maintenance staff and all staff are responsible for maintaining a clean, safe, and comfortable environment free of pests or rodents.
Dish Machine Sanitizer and Dry Storage Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the dish machine had the correct concentration of chlorine to sanitize dishes, trays, and utensils. During observation of the kitchen with the Dietary Manager, the low-temperature dish machine was tested with the chlorine sanitizer test strip and the reading was less than 10 ppm on the first test. The test strip was tested two more times in different parts of the dish machine, but it still did not change color. The Dietary Manager stated the sanitizing solution should be 50 ppm and the test strip should be purple. The chlorine chemical container was empty, and staff replaced it during the observation. The Dietary Manager stated the test strip did not change because the container that dispensed the chemical was empty and would now dispense from the full chemical container. The facility also failed to keep the floor of the dry storage room clean and free of visible debris, mice droppings, and spilled grits. The dry storage area floor was observed with accumulated dust, visible dirt, spilled dried grits, and about 22 pieces of mice droppings along the wall under the bottom shelf. The Dietary Manager stated the floor of the whole kitchen is supposed to be cleaned daily and identified the waste on the floor as mice droppings. The Regional Director of Operations stated the facility has problems with mice because the alley is very close to the kitchen.
Open Dumpsters Not Kept Covered
Penalty
Summary
The facility failed to ensure that 2 of 3 outside dumpsters were covered with lids. On 1/5/26 at 9:10am, surveyors observed 2 of 3 outside dumpsters open without lids. During a kitchen observation later that day at 11:10am with the Dietary Manager, the same dumpsters were again observed without covers. The Dietary Manager stated that leaving dumpsters open could cause rodents to come around the building and that the 2 open dumpsters were mostly used by the Housekeeping and Laundry departments. On 1/7/26, the Administrator stated she would speak with laundry and housekeeping staff and added that there was no reason to leave the dumpsters open because they have covers. The facility policy titled Garbage and Refuse Disposal, dated 9/17/23, states that garbage and refuse will be stored and disposed of daily in a sanitary manner and deposited in sealed dumpsters to prevent the harborage and feeding of rodents and pests.
Facility Assessment Missing Required Staffing and Participation Elements
Penalty
Summary
The facility failed to ensure the facility assessment was developed in accordance with all required information. The assessment, dated 12/18/2025, was reviewed and found to be missing documentation that the governing body participated in its development, that any direct care staff were involved, and that residents or their representatives participated in its development. The Administrator confirmed the assessment was developed by the Administrator, the DON, the CNO, and the Medical Director, and confirmed that no direct care staff, residents, or representatives were included or documented as involved. The facility assessment also did not include CNA staffing needs by unit and shift, and it did not contain a recruitment and retention plan for direct care staffing. During the survey, the DON stated that staffing on the 4th floor was affected by call-offs and that staff were pulled to other floors, with a security director who is also a CNA sent to the 4th floor. The Administrator confirmed that CNA needs were not broken down by unit and shift and affirmed there was no plan for recruitment or retention of direct care staff in the assessment. The facility census documented 266 residents in the facility.
Failure to Develop Individualized, Measurable Fall Care Plans for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered, and individualized fall care plans for multiple residents with known fall risks and/or fall histories. For one resident with dementia, a high fall risk score, and a documented fall resulting in right distal radial and ulna fractures, the fall care plan contained only a generic goal that the resident would have a safe environment maintained through the next review. This goal was system-generated, not customized, and did not include measurable, resident-specific outcomes despite the resident’s recent fall and injury. Another resident with a history of falling, epilepsy, bilateral lower extremity amputations, dementia, and altered mental status also had a fall care plan with the same broad, non-individualized goal, without specific, measurable objectives tailored to that resident’s complex conditions and fall risk. A third resident with dementia, schizoaffective disorder, low back pain, and a nondisplaced intertrochanteric fracture of the right femur had progress notes documenting repeated attempts to throw himself out of a chair in the dining area and then leaping onto the floor. Staff documented monitoring the area and assisting the resident back to a chair, but no enhanced or one-to-one supervision was implemented prior to the fall. Despite these behaviors and the fall event, this resident’s fall care plan also contained only the generic goal that a safe environment would be maintained through the next review, without individualized, measurable goals addressing his specific behavioral and fall risks. A fourth resident with generalized arthritis, chronic pain, left knee pain, syncope and collapse, weakness, and an unspecified fall had a high fall risk score and a documented incident in which the resident was found lying on the floor after stating they had tried to get into a chair and fell. This resident’s fall care plan, in place for several years, likewise contained only the broad goal of maintaining a safe environment through the next review, without measurable, person-centered outcomes related to the resident’s identified fall risks and prior fall. Interviews with the MDS Coordinator and Restorative Nurse Consultant confirmed that the facility routinely used this system-generated fall goal for all residents, acknowledged that it was broad and general, and that goals should be measurable, person-centered, and tailored to each resident’s specific needs, but the care plans reviewed did not reflect such individualized, measurable fall-related goals.
Unsecured Hallway Handrails Not Repaired per Preventative Maintenance Policy
Penalty
Summary
The facility failed to ensure that hallway handrails on the 3rd floor were firmly secured as required by its own preventative maintenance policy. On a floor with 32 residents, surveyors observed that the handrail next to the bathroom and across from a resident room was unsecured, loose, and able to be displaced approximately 3 inches up or down. An LPN observed the loose handrail, confirmed it was loose, and stated it needed to be tightened, acknowledging that handrails are used for safety and to assist residents with gait abnormalities. The Maintenance Director later affirmed that the facility’s expectation is that handrails in common areas are secured and promptly repaired when needed, and that they are installed for resident safety and assistance. Subsequent observation showed that the same handrail next to the bathroom and across from a resident room remained unsecured and loose with approximately 3 inches of movement, and additional handrails across from and outside other resident rooms were also unsecured, loose, and able to be displaced approximately 3 to 5 inches, including one bracket with a screw protruding about 1.5 inches. Another LPN confirmed these observations and affirmed that handrails are for resident safety. The facility’s preventative maintenance policy directed staff to inspect all handrails throughout the facility for loosened fasteners or connectors and to make any needed repairs immediately. This deficiency arose from the presence of multiple unsecured and loose handrails in resident-accessible hallways, repeated observations of the same unresolved condition over several days, and the facility’s failure to adhere to its written preventative maintenance policy requiring immediate repair of loosened handrails.
Delayed meal service and unavailable dining room seating
Penalty
Summary
The facility failed to ensure meals were served timely and failed to ensure dining room seating was available for four residents identified in the sample. The facility meal-time schedule stated that the 4th floor lunch was scheduled for 12:15pm-12:30pm, but on 1/5/26 lunch was not delivered to the 4th floor dining room until 12:53pm. At 1:38pm, the RN confirmed that three residents had not yet received lunch, and most residents had already finished their meals and left the dining room. Those residents had requested the alternate meal of hamburgers per their dietary cards, and at 1:39pm one resident asked about lunch while an activity aide stated they were waiting on hot burgers because they had not arrived yet. The hamburgers were not delivered until 1:45pm. The facility also failed to ensure seating was available in the dining room. On 1/5/26 at 1:25pm, one resident was served lunch on a tray at the steam table and carried the tray around the dining room looking for a seat, but no chairs were available. The resident stood in the dining room while holding the meal tray and ate part of a grilled cheese sandwich before staff provided a chair. On 1/7/26, when surveyors requested the 4th floor dining room seating chart, the ADON presented a drawing of tables numbered 1-15 without resident names and stated the facility did not have a seating chart with resident names. The facility policy stated Nursing would provide Food Service with a seating chart and that residents in open dining would be served in a timely manner after being seated.
Failure to Identify, Document, and Repair Maintenance Concerns
Penalty
Summary
The facility failed to identify, document, and repair multiple maintenance concerns affecting the 4th floor men's unit, including damaged ceilings, a bent and falling baseboard heater, and broken closet doors and locks. During observation, a metal baseboard heater in one resident’s room was severely bent away from the wall, and the LPN stated she was not sure about the concern and then said she could call maintenance. In the 4th floor shower/bathroom, large gaping holes were observed in the ceiling of both showers, and a blanket and toilet paper were also seen on the floor in the toilet stall. The broken hinge on one resident’s closet door and another resident’s dangling closet door with a broken bottom bracket were also observed.
Inappropriate seasonal activities on dementia unit
Penalty
Summary
The facility failed to provide activities appropriate for the season on the 3rd floor dementia unit. During observation, residents were participating in activities in the dining room while Christmas music videos were playing on the television and could be heard throughout the room. R71, who had diagnoses including epilepsy, schizophrenia, schizoaffective disorder, bipolar disorder, cataracts, major depressive disorder, and asthma, had a BIMS score of 10 and was documented as oriented only to self with an active interest in listening to music. R71’s activity assessment and quarterly review noted a preference for activities in the room or day room and enjoyment of listening to music, and the care plan called for simple, structured activities and a program of activities that accommodated the resident’s abilities. While the Christmas music videos continued to play, R71 approached the surveyor and made statements about Santa coming next week and began having flight of ideas, including references to breaking out of prison, fast food, paranoia of other girls outside, and homeless shelters. The dementia unit coordinator confirmed that Christmas music was still playing even though Christmas had passed over a week and a half earlier and stated that playing music after a holiday can increase confusion and disrupt residents’ sense of time. The administrator also confirmed that Christmas music was no longer appropriate for the time of year and that playing it after the holiday may confuse residents. Christmas decorations were also still observed hanging in the administration offices and conference rooms.
Medication administration and documentation were not completed timely
Penalty
Summary
The facility failed to ensure medications were administered within regulatory requirements and failed to document medication administration timely for 8 of 59 residents, including R24, R30, R88, R159, R245, R267, R276, and R286. During observation on 1/6/26, an LPN stated she was done with the morning medication pass but had not yet signed out the EMAR. While reviewing the EMAR, R245 approached and reported not receiving scheduled 9:00 a.m. medications; the EMAR showed Aspirin, Folic Acid, and Divalproex Sodium were due at 9:00 a.m. and had not been documented as given, and the LPN then dispensed them. At another observation, an RN stated the 6th floor 9:00 a.m. medication administration was completed while she was seated at the nurse’s station documenting R30’s 9:00 a.m. medications, and she said her internet was acting up so she may have skipped documenting them at the time they were given. A separate observation showed an LPN documenting R159’s 9:00 a.m. medications while the resident was not present, and she stated the resident had received them after breakfast at about 8:20 a.m. The same LPN stated R286’s 9:00 a.m. medications were not documented because they were on another nurse’s cart. Record review also showed medications scheduled for 1:00 p.m. or 2:00 p.m. were administered earlier than the scheduled time: R24’s Benztropine Mesylate and Divalproex Sodium were given at 11:37 a.m., R276’s Carbidopa-Levodopa at 11:40 a.m., R88’s Sodium Chloride at 11:43 a.m., and R267’s Clonidine at 12:30 p.m. The LPNs stated medications should be given within one hour before or after the scheduled time, and the Administrator stated medications should be documented right when they are given. The facility’s drug administration policy stated medications are administered as prescribed, the MAR is initialed in the space provided for the specific dose, and medications are administered within 60 minutes of the scheduled time except before or after meal orders.
Unsecured medication rooms, cabinets, and refrigerators with improper refrigerator temperature
Penalty
Summary
Medication storage was not kept secure in the 5th floor medication room when the door was observed ajar and could be entered without a key. The 5th floor medication refrigerator was unlocked because no lock was present, and the unlocked medication cabinet contained multiple OTC medications. V31 stated the medication room should have a locked door and the refrigerator should have a lock, but the room was not locked at the time of inspection. On the 6th floor, the medication room door could also be pushed open without a key, and the strike plate was misaligned with the door latch. V37 stated the door seemed stuck and that the refrigerator had no lock. The unlocked medication refrigerator contained IV Vancomycin, Brinzolamide eye drops, and numerous insulins, and the temperature was observed at about 19 degrees, which V37 described as freezing. The posted temperature log indicated the refrigerator should be 32-41F, and the unlocked medication cabinet on the 6th floor also contained numerous OTC medications.
Food Service Failures During Lunch Service
Penalty
Summary
Food and drink were not maintained in a palatable, attractive, and safe temperature during lunch service on the 4th floor, affecting 54 residents. The facility census for 1/4/26 included 54 4th-floor residents, and the lunch meal was scheduled for 12:15pm-12:30pm. On 1/5/26 at 12:53pm, lunch items including pot pie, mashed potato, rice, hamburgers, and grilled cheese sandwiches were delivered to the 4th floor dining room via steam table. At 1:00pm, lunch had not yet been served, and clumps of pot pie and smeared mashed potatoes were observed on the steam table. The pot pie remained covered with plastic wrap, and three serving scoops were observed covered in clumped pot pie, mashed potato, and rice on foil placed atop the mashed potato lid. The dietary aide stated the scoops had been used on another unit and that another scoop would be called for. The dietary aide also stated the steam table lids were old and not straight, and plates were not delivered until 1:07pm because the facility ran out of plates. The thermometer was reported as not working. The Regional Director of Kitchen Operations stated hot foods should be above 135F. On 1/5/26 at 1:10pm, the rice temperature was 119F and the dietary aide was directed to put it in the microwave. The hamburgers were 100F, completely covered in water, notably pale in color, and did not appear palatable. The grilled cheese sandwich temperature was 106.5F. The steam table was not cleaned prior to meal service, and the Regional Director stated, "We don't clean in between because we don't put chemicals before service." When asked about the damaged steam table lids, the Regional Director stated they were meant to hold temperature and said there was nothing wrong with the notably damaged lids. The food temperature resident service policy stated hot foods will be held at a minimum of 135F during tray assembly and served at a temperature palatable and acceptable to the resident, with general practice not less than 125F.
Hand Hygiene Not Performed Between Meal Tray Passes
Penalty
Summary
The facility failed to conduct hand hygiene prior to passing meal trays for four residents reviewed for infection control. On 1/05/26 at 12:07 PM, a Rehab Aide performed hand hygiene once at the start, then retrieved and served a tray to one resident, returned to the steamtable without performing hand hygiene, retrieved and served trays to additional residents, and continued this pattern without hand hygiene between residents while passing meal trays to four residents. The aide stated on 1/05/26 at 12:24 PM that hand washing was only needed between tray passing if the resident was touched while serving the tray, and otherwise hand hygiene was only done before starting to pass trays. On 1/07/26 at 12:03 PM, the Infection Preventionist stated that staff are required to perform hand hygiene after assisting with setting up for meals, and the facility stated staff should use hand sanitizer between each resident while passing trays to prevent transfer of contaminants. Review of the facility's Hand Hygiene Program stated that hand hygiene is the single most important method for reducing the risk of cross contamination and infection in the healthcare setting. The report also included the Residents' Rights pamphlet stating residents must be treated with dignity and respect and cared for in a manner that promotes their quality of life and keeps them safe, clean, comfortable, and homelike.
Unsanitary Shower Rooms and Exposed Electrical Wire
Penalty
Summary
The facility failed to maintain the sixth-floor men's resident shower room and the eighth-floor east wing community shower room in a clean and sanitary condition, and failed to cover an open electric wire on the wall of the eighth floor. On 1/5/26, the east wing community shower room on the 8th floor was observed with malodorous liquid on the floor around the handicapped toilet commode, a pervasive urine odor in the room, and ceiling tiles in the first shower stall that were brownish with rust-like stains. An open electric wire was also observed sticking out on the wall near a room on the east wing. An LPN stated she was not sure whether the toilet commode was leaking or if the liquid was urine, and said she would notify Maintenance staff. On 1/5/26, the sixth-floor men's resident shower room was observed with the door secured open using a clear plastic bag, a dark yellow liquid pooled in the center of the bathroom floor, and a bundled white rag heavily soiled with a brown substance on the floor next to a toilet. A CNA stated that all male residents on the floor use the shower room, that residents tie the door open with trash bags even though staff tell them not to, and that the puddle looked like water mixed with urine and the rag looked like it had poop on it. The CNA removed the plastic bag holding the door open and disposed of the soiled rag. The Housekeeping Director stated that shared bathroom and shower rooms are cleaned daily and monitored during the day, but there are no housekeeping staff assigned overnight, limiting the facility's ability to promptly address unsanitary conditions after hours.
Failure to Maintain Functional Alarms and Provide Adequate Supervision for High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that adequate supervision and fall-prevention interventions were provided for residents at risk for falls. For one resident with autistic disorder, developmental motor disorder, and lack of coordination, the care plan identified a history of actual falls and included a self-releasing seat alarm belt as an intervention. The resident’s functional assessment showed a need for partial to moderate assistance with sit-to-stand and transfer activities, and the BIMS score indicated intact cognition. During observation, the resident was seated in a wheelchair with an alarm box behind the seat. When an LPN asked the resident to stand, the chair alarm did not sound. The LPN acknowledged the alarm was not working and appeared to be in the seatbelt, and there was no indication that defective equipment had been reported as required by the CNA job description and the facility’s fall prevention program, which identifies missing or broken equipment as a fall risk factor. The facility also failed to implement appropriate fall-prevention interventions and supervision for another resident with dementia, schizoaffective disorder, a high fall risk score, and a nondisplaced intertrochanteric fracture of the right femur. Progress notes documented that this resident repeatedly attempted to throw himself out of a chair in the dining area while staff were monitoring the area. Later the same day, another note recorded that the resident leaped from the chair to the floor, after which he was assisted back to the chair and staff continued monitoring the dining area without initiating enhanced or one-to-one supervision. Subsequent notes described the resident being kept near the nurses’ station and requiring constant redirection due to restlessness and attempts to propel himself to his room, as well as repeated attempts to get out of his wheelchair in the dining room despite redirection. The resident’s care plans documented a history of actual falls, high fall risk related to cognitive impairment and mental illness with behavioral symptoms, and a need for extensive assistance with ADLs and one-person support for transfers. Staff interviews confirmed that, at the time of the dining room fall, the resident was known to be impulsive, confused, and frequently attempting to stand or put himself on the floor. The CNA and LPN present in the dining room stated they were aware the resident was repeatedly trying to get out of the wheelchair but were positioned near the dining room doors rather than directly next to him. Both reported that by the time they reached the resident, he had already fallen, and the CNA acknowledged that if staff had been positioned directly next to the resident, the fall could have been prevented. The DON stated that when monitoring is increased, staff are expected to directly observe the resident, but also confirmed that a single staff member was responsible for monitoring several residents in the dining room and that the resident was not provided direct or constant one-to-one supervision despite his repeated attempts to exit the wheelchair. Facility policies on fall prevention and incidents/accidents/falls emphasized identifying fall risk factors, implementing individualized interventions, visually checking residents for safety, and reporting significant incidents and injuries, but the documented practices and staff accounts showed that these measures were not effectively implemented for the residents involved. Additional documentation related to the second resident showed ongoing pain complaints and subsequent hospital evaluation revealing an age-indeterminate mildly displaced periprosthetic fracture of the right greater trochanter and displaced rib fractures, along with soft tissue swelling of the left humerus. Facility leadership and the attending physician acknowledged uncertainty about when the fractures occurred and whether they predated admission or were related to the documented fall, and the DON and Chief Nursing Officer indicated that no reportable incident was filed because the fracture was considered not acute and records from prior facilities were incomplete. The facility’s fall prevention and residents’ rights documents stated a commitment to safety, individualized fall risk assessment, appropriate interventions, and care that promotes quality of life, but the failures to ensure a functioning alarm for one resident and to provide adequate, individualized supervision and fall-prevention interventions for the other resident led to the cited deficiency.
Medication Administration Errors Exceed Acceptable Error Rate
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were administered as prescribed, resulting in a medication error rate of 8% (2 errors out of 25 opportunities), which exceeded the 5% threshold. For one resident (R245), the Physician Order Sheets documented an order for Folic Acid 400 mcg once daily and Aspirin 81 mg once daily, scheduled for 9:00 a.m. During a medication pass observation at 9:12 a.m., an LPN (V27) prepared and was ready to administer chewable Aspirin 81 mg and Folic Acid 1,000 mcg to this resident. When questioned, the LPN confirmed that chewable Aspirin had not been prescribed for the resident and acknowledged that the Folic Acid dose in hand was 1,000 mcg instead of the ordered 400 mcg. The facility’s undated drug administration policy requires that medications be administered as prescribed, in accordance with written physician orders and good nursing principles and practices, and within 60 minutes of the scheduled time. These observations, interviews, and record reviews demonstrated that the nurse did not follow the resident’s current physician orders or the facility’s medication administration policy when preparing the incorrect formulation of Aspirin and the incorrect dose of Folic Acid for administration.
Inaccurate MDS Coding for Diagnosis and Communication Assessments
Penalty
Summary
The facility failed to accurately code MDS assessments in accordance with the RAI for three residents reviewed for assessment accuracy. The deficiency involved inaccurate coding of resident conditions and communication abilities on the MDS, including schizophrenia coding for one resident and BIMS-related interview decisions for two residents. For one resident, the MDS dated 9/10/2025 and 12/10/2025 coded item I6000, Schizophrenia, as No even though the resident had routine antipsychotic medication use, item S1200 identified schizophrenia as a secondary SMI diagnosis, and the admission record listed active diagnoses of schizophrenia and schizoaffective disorder. The resident’s physician progress notes stated that all diagnoses were active and ongoing as per the facesheet and approved by the attending physician. The PASSR dated 9/6/2025 also documented schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, cognitive impairment, and that the resident met PASRR criteria for a serious mental illness. The resident’s MDS also documented hallucinations, delusions, verbal behavioral symptoms directed toward others, and other behavioral symptoms during the lookback period. When interviewed, the MDS Coordinator stated schizophrenia was not coded because the facility did not have enough documentation and believed DSM-V criteria were required; the RAI manual reviewed by surveyors did not indicate that DSM-V criteria were required to code schizophrenia. For the other two residents, the MDS coding for communication ability did not align with the assessment decisions made. One resident’s MDS documented unclear speech and indicated the resident was sometimes understood, yet C0100 was not conducted because the resident was coded as rarely or never understood. Another resident’s MDS documented B0700 as sometimes understood, but C0100 was also not conducted because the resident was coded as rarely or never understood. In both cases, staff observations and interviews showed the residents had communication limitations, but the coding did not match the documented B0700 responses. One resident was observed unable to answer questions, and staff stated that inability to understand and answer questions was baseline. The other resident was observed in the dining room, could not respond in English, and required Spanish interpretation; staff stated the resident did not understand English well and would need interpretation, while the MDS still listed English as the preferred language and indicated no interpreter was needed.
Failure to Provide Needed Hygiene and Nail Care
Penalty
Summary
The facility failed to ensure personal hygiene care was provided to two dependent residents who required assistance with activities of daily living. One resident was documented as dependent on staff for personal hygiene and, during observation, was seen sitting in the dining room with a face and beard covered in brown food particles, food stains on the shirt, and long nails, including a right thumbnail that was approximately 1.5 to 2 cm long, partially missing, jagged, and sharp. A licensed practical nurse observed the resident and confirmed the nails needed trimming and that there was food on the resident's face. A second resident had a care plan identifying a self-care deficit and need for supervision to limited assistance with ADLs, including dressing as needed. During observation, the resident's fingernails were notably long and broken, and the resident stated that nobody cut the fingernails and that the resident broke them, while also stating that toenails were cut by a provider. The resident was wearing light blue socks with soles that were notably soiled, discolored black, and appeared wet, and the resident stated the socks were wet because staff had mopped the floor. The facility's ADL care policy stated nails should be maintained at a smooth and safe length, and the CNA job description included assisting residents with dressing and nail care.
Insufficient Seating in Dining Room
Penalty
Summary
The facility failed to ensure adequate seating was available for a resident in the 4th floor dining room. On 1/5/26 at approximately 1:25 PM, the resident was served lunch on a tray at the steam table and carried the tray through the dining room looking for a seat, but no chairs were available. The resident stood in the dining room while holding the meal and ate half of a grilled cheese sandwich before staff provided a chair. On 1/7/26, the Maintenance Director stated that the facility had enough chairs in each dining room and said extra chairs would be brought to the floor if needed. The facility policy on the order of meals served states that dining rooms with open dining will serve the resident in a timely manner after being seated.
Failure to Update Falls Care Plan After Resident Injury
Penalty
Summary
The facility failed to update a resident's falls care plan with new interventions following a significant fall event. The resident, who had a history of bipolar disorder with mood and behavioral disturbances, was initially not identified as being at risk for falls, and the only intervention listed was for nursing staff to complete a fall risk assessment per facility protocol. Despite the resident experiencing a traumatic fall resulting in multiple fractures and requiring maximum staff assistance with activities of daily living, the care plan was not revised to reflect the increased fall risk or to include additional interventions. The fall risk review completed after the incident did not acknowledge the recent fall or the resident's new health conditions that predisposed them to further falls. Staff interviews revealed confusion regarding the documentation of fall history and risk status, with the DON indicating that the fall risk review did not consider the most recent fall. The facility's policies require care plans to be reviewed and updated with any significant change in condition and mandate additional interventions after a fall, but these procedures were not followed for this resident. The lack of timely and appropriate updates to the care plan contributed to the deficiency identified during the survey.
Failure to Supervise Resident in Dining Room Leads to Serious Injury
Penalty
Summary
The facility failed to provide adequate supervision in the dining room, resulting in an avoidable accident involving a resident with multiple psychiatric and neurological diagnoses, including generalized anxiety disorder, paranoid schizophrenia, drug-induced secondary Parkinsonism, and moderate cognitive impairment. The resident required supervision or assistance with ambulation, as documented in their functional abilities assessment. Despite these needs, the resident was left unsupervised in the dining room, where an altercation occurred after the resident took another resident's coffee, leading to a fall. Staff interviews revealed that on the day of the incident, there was no CNA assigned to the unit, and both nurses present stated that no staff were supervising the dining room. Multiple staff members described the resident as delusional, disoriented, and prone to pacing and talking to himself, with a baseline of confusion. The fall resulted in significant injuries, including a comminuted fracture of the right humerus and a nasal bone fracture, requiring surgical intervention. The incident was not witnessed by staff, and there was uncertainty among staff about which residents were present in the dining room at the time. Documentation and interviews further indicated that staff on the unit considered the residents to be independent and did not monitor them in the dining room. The facility's fall prevention policy required additional interventions after a fall, but the lack of supervision and failure to recognize the resident's need for monitoring directly contributed to the incident. The staffing assignment sheet also showed discrepancies between staff assignments and actual coverage, with a CNA denying working on the unit despite being listed as assigned.
Failure to Serve Lunch Simultaneously to All Tablemates
Penalty
Summary
The facility failed to provide a dignified dining experience by not serving lunch to all residents seated at the same tables at the same time. During lunch service in the 8th floor common dining room, four residents were not given their lunch trays when other residents at their tables received theirs. Staff did not call the names of two residents who were present in the dining room, and their trays were left on the cart until staff later provided them. Two other residents were also served late and did not have diet tickets with their trays. The facility's dignity policy requires that trays be served in order at each individual table so that residents are not left waiting while others at the same table are eating.
Failure to Obtain and Document Consent for HIV Prophylaxis Medication
Penalty
Summary
The facility failed to obtain and document consent for participation in a pharmacy program involving the administration of Descovy for HIV pre-exposure prophylaxis for four residents. These residents, who had varying diagnoses including hypertension, kidney disease, schizoaffective disorder, epilepsy, diabetes, and depression, were all found to have received Descovy as per physician orders. Despite being cognitively intact or only moderately impaired, none of the residents were aware they were taking this medication, nor had they received any information or education about it. Interviews with the residents confirmed their lack of awareness and consent, with some explicitly stating they would not have agreed to take the medication if informed. Record reviews revealed that there was no documentation of consent, education, or individualized care plans related to the pharmacy program or the administration of Descovy in any of the residents' medical records. The Certified Nurse Consultant acknowledged that written consent was not obtained and that there was no documentation of resident agreement in the medical records. Additionally, there were no separate assessments documenting risk factors for each resident, and individualized care plans were still in development. The facility's Medical Doctor stated that consent, education, and explanation of risks and benefits should have been provided prior to administering the medication, which was not done.
Failure to Conduct Timely Care Plan Meetings and Address Smoking in Care Plans
Penalty
Summary
The facility failed to conduct care plan meetings with residents and/or their representatives on a quarterly basis and did not provide residents with the opportunity to participate in the development, review, and revision of their care plans. This deficiency affected six out of seven residents reviewed for care planning. Interviews with social services staff revealed that while care plan meetings are scheduled quarterly and annually, there were lapses in communication and documentation, including not inviting or updating residents and their families about care plan meetings or discharge planning. Medical record reviews showed that several residents did not have documented care plan meetings with their families in the past twelve months, and in some cases, there was no evidence of a discharge care plan or updates provided to families regarding referrals to other facilities. Additionally, the facility failed to develop a comprehensive care plan for a resident identified as a smoker. Despite the resident having a documented smoking assessment and being observed smoking on the patio, the resident was not included on the facility's smoking list, and their care plan did not address smoking. The DON confirmed that smoking should be included in care plans, but this was not done for the resident in question.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve lunch meals at the required safe and appetizing temperature to all 10 residents on the eighth floor nursing unit. During observation, dietary staff measured food temperatures on the steam table and found that several items, including chuckwagon beef stroganoff, noodles, buttered cabbage, and hamburgers, were below the facility's minimum required serving temperature of 125 degrees Fahrenheit, with some items as low as 90 degrees. Despite these findings, the dietary staff proceeded to serve the food without reheating it to the appropriate temperature. The facility's policy requires hot foods to be held at a minimum of 135 degrees during tray assembly and not served below 125 degrees, but this protocol was not followed during the observed meal service.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A dependent resident was found in bed without a call light cord attached to the call light switch on the wall, making it difficult for her to summon assistance. The resident reported having to raise her bed and use her pillow to repeatedly hit the wall switch behind her head to activate the call light, a situation that had persisted for one month. The resident was assessed as having full cognitive function with a BIMS score of 15 out of 15. Nursing staff indicated that maintenance requests are documented in a binder at the nurse's station, but the last recorded maintenance report was from the previous year. Although the nurse stated that maintenance had been notified about the missing call light cord, maintenance staff reported only being informed of the issue on the day of the survey. The facility's policy requires daily checks of call lights, immediate reporting of defects, and ensuring residents have access to a functional call light at all times.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency as required by its abuse policy. A registered nurse (RN) was informed by certified nursing assistants (CNAs) that a resident was spitting and swearing at them, and when the RN assessed the resident, the resident stated that the CNAs had hit her. The RN questioned the CNAs, who dismissed the allegation as a recurring behavior from the resident, and the RN did not notify administration of the allegation, later stating it slipped his mind despite knowing the reporting requirement. The administrator confirmed that no abuse report was filed for the incident, and a review of facility records showed no report for the resident on the relevant date. The facility's policy requires all alleged violations involving abuse to be reported to the state agency immediately, or within 24 hours if there is no serious bodily injury, and to ensure thorough investigation of all allegations.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS indicated the use of high-risk anticoagulant medications, but a review of the physician order sheet showed no such medications were ordered. Another resident, diagnosed with chronic kidney disease and dependent on renal dialysis, was not marked as receiving dialysis on the MDS, despite care plan documentation and staff interviews confirming regular dialysis treatments. A third resident, who was out on pass in the care of a family member, was incorrectly coded on the MDS as having been hospitalized, contrary to progress notes documenting the actual situation. These inaccuracies were identified through record review and staff interviews, revealing errors in the completion of MDS assessments for all three residents reviewed in this sample.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as a smoker. Observations showed that the resident participated in smoking activities, and staff confirmed the resident's smoking status and possession of cigarettes. Despite a completed smoking assessment indicating the resident smokes, the resident's name was not included on the facility's smoking list, and the care plan did not address smoking. The DON stated that smoking should be included in care planning, along with other health conditions and behaviors, but this was not done for the resident in question. This deficiency was identified through observation, staff and resident interviews, and record review, which confirmed the lack of a care plan addressing the resident's smoking behavior.
Failure to Supervise Resident with Wandering and Hoarding Behaviors
Penalty
Summary
A resident with a known history of wandering and hoarding behavior was observed entering other residents' rooms without staff supervision. The resident took personal belongings, including a pair of blue sweat pants and an orange tee shirt, from two different residents and added them to her own possessions. No staff were present to monitor or redirect the resident during these incidents. Interviews confirmed that this behavior was ongoing, with one resident stating that the wandering resident frequently entered her room and took belongings. The Director of Nursing acknowledged that the resident's care plan addressed hoarding but did not specifically address wandering behavior. The care plan included interventions such as familiarizing staff with the resident's patterns, providing tasks to redirect her, and checking her room for hoarded items, but did not ensure adequate supervision to prevent the resident from entering other residents' rooms.
Failure to Provide Prescribed Double Portions for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of major depressive disorder, schizophrenia, autism, anxiety, delusional disorder, and paranoid disorder experienced significant unplanned weight loss over a six-month period. Despite a registered dietician's assessment identifying a 7.5% weight loss in three months and recommending double portions at all meals, the facility failed to implement this intervention. Review of dietary tickets and direct observation confirmed that double portions were not provided, and the resident continued to lose weight, totaling a 12.5% loss in six months. The resident's nutritional assessment documented malnutrition, and progress notes indicated that the plan included double portions, staff supervision at meals, and monitoring of intake and weights. However, the dietary manager confirmed that the resident's meal tickets did not reflect the double portion order, and the dietician stated that she expected her recommendations to be followed. The facility's policy required assessment and intervention for significant weight changes, but the recommended intervention was not carried out, resulting in continued unplanned weight loss for the resident.
Failure to Ensure Unnecessary Drug Use Was Avoided for Anticoagulant Therapy
Penalty
Summary
A resident with multiple diagnoses, including unspecified dementia, bipolar disorder, schizoaffective disorder, and other chronic conditions, was found to be receiving heparin injections for VTE (venous thromboembolism) prophylaxis. The physician order sheet indicated that the resident was to receive heparin 5000 units subcutaneously every eight hours, and the medication administration record confirmed that the resident received this medication multiple times in June. However, a review of the resident's medical diagnoses and the Minimum Data Set (MDS) revealed no documented diagnosis of VTE or any other condition justifying the use of heparin. During interviews, the medical doctor stated that the resident was on heparin because it was started in the hospital and to prevent blood clots, particularly in non-ambulatory patients. However, the resident was observed to be ambulatory and able to transfer independently. The administrator confirmed that there was no current diagnosis supporting the use of heparin for this resident, and documentation from a nurse practitioner visit also did not provide a diagnosis for the continued use of the anticoagulant.
Failure to Prevent Serving Allergen-Containing Food to Resident with Documented Allergy
Penalty
Summary
A resident with documented allergies to mushrooms was served beef stroganoff containing mushrooms during lunch. The resident noticed mushrooms in the sauce and informed staff of his allergy. Review of the resident's diet ticket for the following day showed that the mushroom allergy was not listed, and the facility's recipe for the dish confirmed the inclusion of mushrooms. The Dietary Manager confirmed that the resident's food allergy was not indicated on the diet ticket, which is the facility's process for alerting staff to dietary concerns. The facility's policy states that food allergies and intolerances will not be liberalized.
Failure to Maintain Infection Control Practices and Prevent Cross-Contamination
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices, resulting in cross-contamination risks. In one instance, a CNA provided incontinence care to a resident who was frequently incontinent of bowel and bladder. The CNA, while wearing the same gloves used for incontinence care, inserted her fingers into a multi-use container of petroleum jelly, applied it to the resident's buttocks, and then replaced the lid on the jar. The same jar was then placed in the clean linen cart with briefs and clean linen, despite facility policy stating that such containers should not be used for multiple residents to prevent cross-contamination. Additionally, a CNA was observed in the dining room supervising residents while drinking a slushee. The CNA shared her drink with two residents, which was confirmed by both an LPN and the DON as being against facility policy and inappropriate. The facility's infection prevention policy requires standard precautions for all residents to prevent the spread of infection, considering all body fluids, excretions, and secretions as potentially infectious.
Failure to Consistently Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to consistently post daily nurse staffing data in an area accessible to residents and visitors. On multiple occasions, surveyors were unable to locate the required staffing data sheet at the front desk, and when it was eventually presented, it was not current. Specifically, the staffing data sheet was missing on one occasion and, on subsequent days, the posted information was outdated, with postings reflecting dates several days prior. This deficiency was observed through interviews and record reviews, and it has the potential to affect all 267 residents in the facility.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a female resident with multiple diagnoses, including COPD, anxiety, PTSD, and insomnia. The resident alleged that she was physically assaulted by another resident in the elevator, with two LPNs present and aware of the incident. The resident reported that she informed a psychotherapist and a physician's assistant, but no action was taken, and she was not interviewed by the administrator or the director of nursing. No incident report was filed, and the police were not contacted following the allegation. The administrator acknowledged being informed of the allegation by an LPN, who reported that the resident claimed to have been beaten and had broken dentures. Despite this, the administrator did not file an abuse report immediately, citing the resident's unwillingness to discuss the incident and lack of physical marks. The initial facility-reported incident was not filed until eight days after the alleged event, which was not in accordance with the facility's abuse policy requiring immediate reporting of abuse allegations to the state agency.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse involving a female resident with multiple medical and behavioral diagnoses, including COPD, anxiety, PTSD, and insomnia. The resident reported being physically assaulted by another male resident, who also has a history of violent and psychotic behavior, while in the elevator. The incident was witnessed by two LPNs, and both a psychotherapist and a physician's assistant were informed. Despite the allegation, the resident stated that she was never interviewed by the administrator or the director of nursing, the police were not contacted, and no incident report was filed at the time. The administrator confirmed being notified of the allegation by an LPN, who reported that the resident was sobbing and claimed her dentures were broken. The administrator noted that the resident had no visible injuries and would not speak further about the incident. The initial facility-reported incident was not filed until eight days after the alleged event, and no documentation related to the investigation was provided for the period prior to the report. The facility's abuse policy requires thorough investigation of all alleged violations, but there was no evidence that this was done in this case.
Failure to Perform Blood Glucose Check for Symptomatic Diabetic Resident
Penalty
Summary
A diabetic resident with a history of brittle diabetes, bilateral above-the-knee amputations, and other medical conditions reported symptoms consistent with hypoglycemia, including feeling lightheaded and sweaty. The resident requested that his blood sugar be checked by the assigned LPN, but the nurse stated she was busy and did not immediately perform the blood glucose check. The resident, feeling unwell and concerned, returned to his room and called 911 for assistance. Paramedics arrived and found the resident exhibiting signs of hypoglycemia, such as pallor and sweating. The paramedics checked the resident's blood sugar, which was found to be dangerously low at 42 mg/dL. The LPN told the paramedics that she had not checked the resident's blood sugar and claimed she did not have an order to do so, despite the resident having physician orders for blood sugar monitoring as needed and specific instructions for hypoglycemia management. The resident was given a Glucerna drink and transported to the hospital, where his condition improved. Facility staff interviews confirmed that glucometers were available and that the resident was cognitively intact and able to communicate his needs. The Director of Nursing and other staff acknowledged that the resident's request for a blood sugar check should have been prioritized, especially given his symptoms and medical history. Documentation showed a gap in blood glucose monitoring during the relevant time period, and the facility was unable to provide a specific policy for diabetic management when requested.
Failure to Prevent Access to Non-Pureed Food Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident, who was on an altered diet, did not have access to regular consistency food. This deficiency resulted in a tragic incident where the resident, who was on a pureed diet due to severe cognitive impairment and other medical conditions, was found choking on a regular sandwich. Despite efforts by the staff and emergency services to perform the Heimlich maneuver and provide emergency care, the resident was pronounced dead at the hospital due to asphyxiation from a food bolus. The resident, who was under hospice care with a diagnosis of frontotemporal neurocognitive disorder, dementia, and other conditions, had a BIMS score indicating severe cognitive impairment and required supervision while eating. On the day of the incident, the resident was observed by staff to be choking after reportedly consuming a turkey sandwich, which was not consistent with the prescribed pureed diet. The staff attempted to perform the Heimlich maneuver and called emergency services, but the resident ultimately succumbed to the choking episode. Interviews with staff revealed that the resident was ambulatory and had behaviors of pacing and wandering. The dietary manager confirmed that the resident was served a pureed diet during dinner, but regular sandwiches were available as bedtime snacks for other residents. The facility's failure to supervise and prevent the resident from accessing non-pureed food directly contributed to the choking incident and subsequent death.
Removal Plan
- Assessed the residents on a pureed diet and ensured that they cannot obtain food that is not on their pureed diet.
- Speech therapy is reevaluating all residents who are on a pureed diet to ensure that it is still the most appropriate diet for them.
- In-servicing has been initiated which included all Nursing, dietary and activity staff regarding residents on Pureed diets and supervision of the residents on pureed diets that they do not have access to other food. In servicing is on-going and will continue until all staff in serviced.
- Dietary staff must get a signature from nursing for the snacks that were delivered. All snacks delivered to the floors will be held in the locked Nutrition Room on each floor.
- An audit tool was created to supervise residents on pureed diets - auditing will be conducted.
- Policy and Procedure/System Revision: Food delivery and Care of residents on pureed diets.
- QAPI is held and the DON, ADON and Dietary Manager will be responsible for reporting on the on-going audit tools.
- In-servicing began and is on-going. The following staff are included in the in-servicing: Licensed nursing staff, certified staff, dietary staff, restorative staff, social services, and activity staff. In-servicing topics are as follows: New Policy and Procedures as it relates to providing Pureed diet to those residents that are on a Pureed diet and safeguarding that they do not have access to regular foods.
- The IDT Team have been educated on the IJ.
- New Policy Resident Access to food.
- Care of residents on Pureed Diets.
Failure to Implement Treatment Plans for Resident with Rash
Penalty
Summary
The facility failed to implement treatment plans from an infectious disease practitioner and a dermatologist for a resident with a rash. The resident, identified as R3, was observed with multiple red spots on the upper body, which were reported to itch at times. The infectious disease practitioner recommended an oral antifungal medication, Fluconazole, and an antifungal cream, but these were not administered as per the resident's Medication Administration Record (MAR). Additionally, a dermatology consult recommended treatment with permethrin cream, which was also not administered according to the MAR. The Assistant Director of Nursing (ADON) and Infection Preventionist acknowledged that the infectious disease nurse practitioner enters her own orders into the system, and if not communicated to the staff, they remain unaware of the orders. Furthermore, it was noted that if a resident returns from a specialist without orders, the nurse should verify the orders with the specialist's office, which was not done in this case. The facility's Physician's Orders Policy outlines the process for receiving and documenting new orders, but it appears this process was not followed, leading to the deficiency in care for the resident.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure a resident was served a no concentrated sweets diet as ordered by the physician. A resident with a diagnosis of diabetes mellitus with hyperglycemia had a physician's order for a No Concentrated Sweets diet dated 8/4/22. However, during a noon meal on 11/8/24, the resident was served and consumed a dessert of mandarin orange fluff, which was not in accordance with their dietary restrictions. The facility's Diet Spreadsheet for that day indicated that residents on a Consistent Carbohydrate, Limited Concentrated Sweets (CCHO LCS) diet should have received mandarin oranges instead of mandarin orange fluff. The Dietary Manager confirmed that the dessert served was incorrect for the resident's diet, as the fluff contained a lot of sugar. The facility's policy and guidelines for CCHO diets, which replaced the No Concentrated Sweets Diet, were not followed in this instance.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation practices in the kitchen, which could potentially lead to foodborne illnesses affecting all 239 residents receiving prepared foods. During the survey, the kitchen was observed to have sticky floors with a grease-like substance and food debris, creating trip hazards without any warning signs. A large industrial fan was used to dry wet floors, but it also blew towards uncovered food, potentially contaminating it. Kitchen appliances, including a large stove and dual deep fryers, were found to be covered in grease and food debris, with no record of when the fryer oil was last changed. The cook, V9, admitted to not having cleaned the fryers due to being overworked and short-staffed, and stated that the administration was aware of these issues. Additionally, the surveyor found several food items in the walk-in refrigerator that were either expired, unlabeled, or improperly stored. These included a block of Swiss cheese, cooked bacon, shredded carrots, mozzarella cheese, cooked pinto beans, and scrambled egg mix, some of which were past their expiration dates or lacked proper labeling. The kitchen also had a metal deli meat slicer with dried food remnants and ovens with baked-in grease. The dietary manager was not present during the survey, and the administrator later acknowledged that the kitchen had not been cleaned according to the established deep cleaning schedule.
Failure to Reassess Resident's Pass Privileges
Penalty
Summary
The facility failed to reassess a resident's right and privileges to go out on pass, which affected one of the nine residents reviewed for resident rights. The resident, identified as R3, is a male with a history of bipolar disorder, mood disorder, and psychoactive substance abuse. He was previously allowed to leave the facility independently with a green pass but was placed on a red pass, restricting his ability to leave, after an incident where he violated the rules. Despite his compliance with medication and lack of recent behavioral issues, his pass privileges were not reassessed in a timely manner. Interviews with facility staff revealed inconsistencies in the handling of R3's pass privileges. The Psychosocial Security Director and Licensed Practical Nurse both indicated that R3 had been on a red pass for some time, but there was no recent documentation of behaviors that would justify this restriction. The Psychiatric Rehabilitation Service Coordinator mentioned that assessments are conducted on admission, quarterly, and annually, and that R3's pass privileges were revoked due to a past incident of intoxication. However, there was no clear documentation or recent assessment to support the continued restriction of R3's pass privileges. The facility's policy on outside community pass privileges outlines specific procedures for revoking and reinstating pass privileges based on resident behavior. According to the policy, R3 should have been reassessed and potentially reinstated to a green pass after a specified restriction period, provided he complied with facility procedures. However, the facility failed to follow these procedures, as evidenced by the lack of documentation and reassessment of R3's pass privileges, leading to a deficiency in honoring the resident's rights to self-determination and communication.
Failure to Refund Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to refund a discharged resident's personal funds, resulting in a deficiency. The resident, who had been admitted under Medicaid/social security, was owed a balance of $518.39 in their account. Despite the resident's discharge, the Business Office Manager acknowledged that the funds remained in the account because there was uncertainty about where to send the money. The resident's family had contributed to this balance with a $20 check. The facility had been designated as the resident's representative payee by the Social Security Administration, yet no action was taken to refund the money, and no inquiries were made by the family regarding the funds.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to adhere to the planned menu, resulting in residents not receiving spiced peaches with their noon meal. On the specified date, a Diet Type Report indicated that 247 residents had diet orders, with one resident being NPO and another on enteral feeding. During lunch service on the 6th floor, observations revealed that residents, including two specific individuals, were served chicken and noodles, green beans, and ice cream, but no spiced peaches were present on their trays. A test tray provided to the survey team also lacked the spiced peaches, confirming the menu was not followed. Interviews with dietary staff, including a Dietary Aide and the Director of Dietary, confirmed that spiced peaches were not served, despite being listed on the menu. The Director of Dietary acknowledged the oversight after reviewing the menu. The Assistant Director of Nursing and the Registered Dietician both emphasized the importance of following the menu to meet residents' nutritional needs. The facility's policy mandates adherence to a cycle menu planned by a Registered Dietician, with changes only allowed under unavoidable circumstances, which were not documented in this instance.
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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 Cicero
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Town Manor Rehab & Hcc | 1.3 mi | ★★★★★ | 9 | 0 |
| Austin Oasis, The | 1.4 mi | ★★★★★ | 10 | 0 |
| Ryze West | 2 mi | ★★★★★ | 3 | 0 |
| Complete Care At The Boulevard | 2.2 mi | ★★★★★ | 7 | 0 |
| Nexus At Berwyn | 2.4 mi | ★★★★★ | 12 | 2 |
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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.