Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Landmark Of Hyde Park Rehabilitation And Nursing C during CMS and state inspections, most recent first.
A resident approved for an independent green pass was told he could not go out on pass after staff said his pass was revoked for coming in late, but there was no documentation of late return or physician notification, and the MD stated he had not been informed. Another resident with moderate cognition reported his voter registration card was missing after voicing the concern to Social Services; staff initially said he had never been registered, then later confirmed he was already registered but still did not replace the card.
Failure to protect a resident from physical abuse: staff and resident statements described one resident entering another resident's room, grabbing her arm, and fighting with her, with one witness reporting the resident was beaten up and may have been bleeding. An RN said a CNA reported the assault, police were called, and the resident was placed on 1:1 and given Haldol; the facility abuse policy defines physical abuse as hitting, slapping, pinching, kicking, and similar acts.
Failure to report allegations of theft and abuse timely: A cognitively intact resident reported that people were coming into her room and taking her money and belongings, but staff did not report the allegation to the administrator. In a separate incident, two residents were involved in an assault, and although staff were notified and police were called, the initial report to the State Survey Agency was not submitted within the required 2 hours after notification.
Failure to complete necessary post-fall interventions occurred when a resident with multiple chronic conditions, including ESRD, heart disease, and thromboembolism, had an unwitnessed fall from bed, reported hitting his head, and was found with a leg caught in the bed rails and his body on the floor. The resident was on an anticoagulant, but no hospital transfer, stat x-ray, or CT scan was ordered; the DON stated the fall was not reported to her until days later, and the MD noted that residents on blood thinners may need immediate CT imaging to rule out bleeding.
Failure to Offer COVID-19 Vaccine on Readmission: A resident with moderate cognition stated the facility did not offer the COVID-19 vaccine when he was readmitted, despite his request to receive it. The ID nurse said she did not re-offer the vaccine because he had refused it earlier in the same season, and the vaccine order and documentation were not in the EMR until later. The DON stated residents are to be offered the vaccine on admission, readmission, and upon request, with consent or refusal documented.
Multiple residents with known psychiatric and behavioral issues were not adequately protected from physical abuse by other residents, leading to several assaults and injuries. In separate incidents, one resident was attacked in bed by a roommate who hit, scratched, and bit her, causing facial injuries, a bitten finger, and a fractured tooth; another resident was struck repeatedly on the hand with a cane by a roommate, resulting in fractures of two fingers; two residents in the dining area engaged in a physical altercation after one threw a cell phone, leaving one with altered skin integrity that required emergency transport; and a resident in a wheelchair waiting for an elevator was suddenly punched in the face by another resident with a history of violent behavior, causing a scratch near the mouth. These events occurred despite existing care plans and documentation of aggressive or conflictual behaviors, and they demonstrate that residents were not kept free from physical abuse as required.
A resident with dementia, anxiety, a history of falls, and moderate cognitive impairment was identified as high risk for falls and had a care plan including neuro‑checks, bilateral floor mats, a special mattress, and other safety measures. Despite this, the resident sustained multiple falls over a short period, including one with a forehead skin injury requiring hospital transfer, and was repeatedly found on the floor near the bed. Staff interviews revealed that the resident was anxious, restless, impulsive, unable to use a call light, and required frequent supervision, yet the resident’s room remained mid‑hallway and not near the nurse’s station, and the care plan did not include a room change or enhanced supervision. This failed to align with the facility’s fall prevention policy, which called for reassessment and modification of interventions after falls.
A cognitively intact resident with depression and schizophrenia, who shared a room with a cognitively intact spouse diagnosed with schizoaffective disorder and alcohol abuse, reported to a social worker that the spouse’s behavior was frightening, that the spouse sometimes drank alcohol, and that the spouse had dumped the resident’s wallet contents into a toilet. The resident appeared fearful, stated the spouse did not want anything disclosed, and reported feeling afraid and nervous around the spouse. The social worker, despite prior abuse training and knowing the administrator was the abuse coordinator, did not immediately report these concerns to the administrator as required by the facility’s Abuse Prevention Program, instead delaying to "gather facts," resulting in a failure to promptly report suspected abuse or mistreatment.
A resident with intact cognition reported that their room was not clean, and surveyors observed that the resident’s bathroom had a hole in the lower wall, a hanging baseboard, a black substance between the floor and wall, and an area of unpainted plaster that did not match the other walls. The Maintenance Director confirmed these conditions and acknowledged they were not homelike, despite facility policies and maintenance job descriptions requiring that resident rooms be kept safe, clean, comfortable, and attractively maintained.
A resident’s right to retain and use personal possessions was not honored when the facility failed to implement its own policy for inventorying and tracking belongings. The DON and Administrator confirmed there was no inventory sheet for the resident, despite a policy requiring CNAs to list personal items at admission and have the list placed in the chart. A CNA reported that staff are supposed to log belongings on admission and bag and store items at discharge, but new items brought in later are not recorded. During the survey, the Administrator found an unlabeled bag containing the resident’s personal items, including a Bible, stored on a floor of the building and not returned to the resident.
The facility failed to prevent resident-to-resident physical abuse when a resident with multiple psychiatric diagnoses and a documented moderate risk for aggression, including prior episodes of agitation and aggression, slapped another resident on the back of the head during a behavioral episode. Staff, including the administrator and an RN supervisor, were aware of the aggressor’s history of anger and aggressive behavior, yet the incident still occurred, resulting in physical contact that met the facility’s own definition of abuse. The affected resident was assessed with no visible injuries and denied pain, but the event violated the care plan expectation that residents remain safe, treated with dignity, and free from mistreatment.
Failure to Maintain Fall Precautions and Supervision: A resident with dementia, repeated falls, and a high fall risk score was found on the floor with a head laceration after staff left him sitting on the bed. Interviews and records showed the bed was not in the lowest position, floor mats were not observed in place, and the resident’s helmet was on the floor beside him. The resident was sent to the hospital, where imaging showed a large SDH with mass effect and a facial fracture.
A CNA was found asleep on duty in an unauthorized basement laundry area during the overnight shift while assigned to care for 16 residents on the 2nd floor. The DON said the CNA had been caught sleeping for the second time, and a laundry aide and the Director of Housekeeping reported seeing her with a blanket over her and her head down on a folding table instead of completing final rounds.
A resident with OSA, COPD, morbid obesity, and sleep-related hypoventilation had a physician order for BIPAP at night, but the MAR/TAR did not show it was scheduled or administered and progress notes were not consistent. The resident said the BIPAP was at the bedside but had not been put on since admission until recently, and the DON acknowledged the order was not entered in the EMAR with scheduled details and that documentation was inconsistent.
Two residents became involved in a verbal altercation that escalated to physical abuse when one resident pushed the other, causing a head injury that required stitches and hospital evaluation. Staff attempted to intervene but were unable to prevent the assault, resulting in a violation of the facility's abuse prevention policy.
Staff did not immediately report an allegation that a CNA hit a resident during an altercation between two residents. The incident was not brought to the administrator's attention until two days later, despite facility policy requiring immediate reporting of suspected abuse. Multiple staff members either failed to report or were unaware of the allegation until after the fact.
A resident with a urostomy and two roommates experienced repeated incidents of urine on the floor and strong urine odors in their shared room. Despite awareness by nursing and housekeeping staff, the spills and odors persisted over several days, and the environment was not kept clean or safe as required by facility policy.
A resident with a urostomy and cognitive impairment was left without appropriate urostomy supplies, leading to repeated episodes of urine leakage onto the resident's body and bedroom floor. Staff confirmed the resident was out of urostomy bags, and attempts to use a colostomy bag were unsuccessful. Communication lapses and supply management failures contributed to the deficiency, despite facility policies requiring adequate stock and regular care.
A resident with diabetes was not provided the physician-ordered diabetic diet during a special occasion meal, receiving foods high in sugar such as a frosted cookie and pie. Staff confirmed that all residents were served the same meal regardless of dietary restrictions, and there was no physician order to alter the therapeutic diet for the event. Facility policy and care plans required adherence to prescribed diets unless otherwise ordered by a physician.
The facility failed to maintain proper food safety and sanitation standards. Open and unlabeled food items were found in the refrigerator, and the kitchen area was unsanitary with uncovered garbage cans, a dirty mop bucket, and personal items on food preparation tables. These practices risk cross-contamination and foodborne illness.
The facility failed to properly dispose of kitchen garbage and maintain a sanitary dumpster area. Observations revealed uncovered dumpsters surrounded by debris and foul odors, with squirrels eating the garbage. The Dietary Manager and housekeeping staff acknowledged the lack of a cleaning schedule and the shared responsibility for maintaining the area. The facility's policy requires cleanliness and contacting garbage services when dumpsters are full.
The facility failed to maintain an effective pest control program, as evidenced by multiple resident reports and observations of cockroaches and mice in rooms and common areas. Despite weekly visits from a pest control company, residents continued to report infestations, and Pest Control Sighting Logs documented numerous sightings across different floors. Housekeeping staff and the Assistant Director of Nursing acknowledged the ongoing pest problem, indicating a failure to adhere to the facility's policy to keep the environment free of insects and rodents.
A facility failed to implement proper infection control measures for a resident with a surgical wound and PICC line by not placing them on Enhanced Barrier Precautions (EBP) and lacking necessary signage and isolation setup. Additionally, an LPN did not disinfect a blood pressure monitor between uses for three residents, despite EBP signage indicating the need for such precautions. These actions were contrary to the facility's policies on equipment cleaning and infection control procedures.
The facility failed to provide timely pneumonia vaccinations to five residents and did not offer the influenza vaccine to a resident. Additionally, the facility administered the flu vaccine to a resident without obtaining written consent. The planned pneumonia clinic was not conducted, and consents were incomplete, leading to these deficiencies.
The facility failed to accommodate the preferences of two residents regarding their daily care routines. One resident, with end-stage renal disease, wanted to be out of bed daily but was only assisted during shower times. Another resident, with chronic heart failure and dementia, requested a shower due to itchiness but was given a bed bath instead. These actions did not align with the facility's policies on resident preferences and quality of life.
The facility failed to notify a physician when a resident's blood pressure was outside ordered parameters, did not follow proper procedure for blood pressure measurement, and neglected to maintain a dressing on a resident's permacath. These deficiencies involved residents with conditions such as End Stage Renal Disease and Hypertension, and the facility's policies for accurate blood pressure readings and catheter care were not adhered to.
A resident with a history of pressure ulcers and multiple health conditions was found on a low air loss mattress set incorrectly for their weight, posing a risk for skin breakdown. The mattress was set at 350 pounds, while the resident weighed 79.6 pounds, contrary to facility policy requiring settings based on weight.
A facility failed to apply a splint as ordered for a resident with limited range of motion, leading to a contracted right hand. The resident's care plan incorrectly indicated a splint for the left wrist, while the order specified the right hand. The discrepancy and absence of a restorative nurse contributed to the oversight.
The facility failed to prevent the storage and administration of expired dialysis nutritional supplements to two residents. An inspection revealed an opened box of expired Nova Source Renal 19% in the medication room, which was used for dialysis residents. Two residents with end-stage renal disease received the expired supplements, despite facility policy requiring proper storage and expiration checks. The oversight was acknowledged by the ADON, who initiated staff education on checking expiration dates.
A facility failed to reassess the appropriateness of a PRN antipsychotic medication for a resident with Schizoaffective Disorder and other mental health diagnoses. Despite no documented negative behaviors, the PRN order for Haloperidol was not reevaluated or discontinued after 14 days, contrary to facility policy. Staff interviews confirmed that non-pharmacological interventions should precede medication use, and PRN orders should be reassessed within 14 days.
A resident with left-sided weakness fell from their wheelchair due to the absence of a footrest, causing their foot to drag on the floor. The resident, who is cognitively intact, was being pushed by a CNA when the incident occurred. Staff interviews revealed the resident had not been assessed for a footrest after returning from the hospital. The care plan indicated a risk for falls, and the facility's policy assigns therapy the responsibility for ensuring proper wheelchair fit.
The facility failed to maintain a pest-free environment, with residents reporting mice and roaches in their rooms. Despite weekly exterminator visits and the use of traps and bait, pest issues persisted, indicating insufficient measures. The Housekeeping Director acknowledged complaints over several months, and pest control reports highlighted ongoing treatments and sanitation recommendations. The deficiency potentially affected all 229 residents, as pests were reported in multiple areas.
A resident in an LTC facility was found with long, dirty fingernails, indicating a failure in providing adequate nail care. The LPN confirmed the need for trimming and cleaning, while the CNA admitted to not checking the nails during her shift. The ADON emphasized the importance of regular nail care as part of ADL, which was not followed for this resident.
A facility failed to maintain hot food temperatures during meal service, affecting a resident and potentially impacting 60 others. A resident reported receiving cold food, confirmed by surveyor observations. The steam table was not plugged in, leading to inadequate food temperatures. The dietary director acknowledged the oversight, which violated facility policy requiring hot foods to be held at a minimum of 135°F and served at no less than 125°F.
A resident with multiple health conditions, including dementia and pressure ulcers, did not receive timely incontinence care as required by the facility's policy. The resident's incontinence brief was not checked or changed every two hours, resulting in the resident being found with a soiled brief. The CNA responsible for the resident had last changed the brief at 7:00 am, and it was not checked again until nearly five hours later, leading to a deficiency in care.
A resident with multiple pressure ulcers did not receive proper aseptic wound care or timely repositioning in a facility. The resident's low air loss mattress was set incorrectly for their weight, and the wound care nurse failed to perform hand hygiene between glove changes. The facility's policies on pressure ulcer prevention and infection control were not adhered to, leading to deficiencies in care.
The facility failed to provide the prescribed pureed diet to two residents, serving a whole banana instead of a pureed one, contrary to physician orders. This oversight was observed during a meal, with the Dietary Manager acknowledging the error and the need for staff training.
A resident with mental illness was physically assaulted by another resident, resulting in a facial injury requiring sutures. Despite a history of inappropriate behavior, the supervising psychiatric technician failed to prevent the escalation of an argument on the smoking patio, leading to the incident. The facility's abuse prevention policy was not effectively implemented to protect the resident.
A facility failed to monitor residents on the patio, leading to safety risks, especially for those in wheelchairs and at high risk for falls. During an observation, no staff were present to supervise residents, including one who had previously fallen and sustained injuries. The facility's policy requires supervision while smoking, but this was not adhered to, posing a risk to residents with severe cognitive impairments and other conditions.
The facility failed to follow provider orders for Hepatitis C treatment for three residents, leading to significant health consequences. One resident developed hepatocellular carcinoma due to untreated Hepatitis C, while two others did not receive necessary laboratory tests. The facility did not document any attempts to follow through with the orders, despite multiple directives from physicians and a nurse practitioner.
A resident with a history of substance abuse eloped from the facility by climbing over the smoking patio fence due to inadequate supervision and monitoring. The game room and patio doors were left open and unsupervised, and the alarm system failed to sound. The facility did not report the elopement to the state agency, believing it was only necessary for residents with altered mental status.
Failure to Honor Community Pass Rights and Replace Voter Registration Card
Penalty
Summary
The facility failed to follow its policy for outside community passes for one resident who was approved for an independent green pass. The resident stated he was not allowed to go out on pass and that his pass had been revoked on 04/28/2026 without explanation. Social Services stated the resident had an independent pass, but also stated he had come in late twice past curfew and that the doctor ordered his passes suspended for two weeks. However, the surveyor verified there was no documentation showing the resident returned late from pass, and the physician stated he had not been notified about the resident coming back late or about the pass being revoked. The resident’s progress notes showed he had previously gone out on pass with family and returned in good condition, and his community skills assessment documented that he was approved for a green pass and able to navigate the community independently. The facility also failed to replace a voter registration card for another resident after the concern was voiced to staff and documented on a grievance form. The resident, who had a BIMS score of 13 indicating moderate cognition, was observed alert and oriented to person, place, and time and stated he had been in the facility since March 2026 and noticed his voter registration card was missing. He reported that he notified Social Services but still did not have the card. The Administrator stated the resident had raised the concern and that a concern form had been completed, with Social Services following up. Social Services stated the resident had filled out a concern form and that staff had checked the Illinois voter registration website. Social Services initially stated the resident had never registered to vote and therefore could not be issued a replacement voter registration card, and said they were still working on obtaining an identification card and eventually a voter registration card. When shown the registration lookup results, Social Services confirmed the resident was already registered to vote in Illinois but stated she did not know how to get him a replacement voter registration form. The facility policy stated residents have the right to a dignified existence, to communicate with representatives of choice, and to voice grievances without fear of reprisal and with prompt resolution.
Failure to Protect a Resident from Physical Abuse
Penalty
Summary
Facility failed to ensure residents were free from physical abuse involving one resident, R10, in a sample of 21. Multiple interviews described an incident in which R12 went into R10's room and fought with her. R16, who had a BIMS score of 15 and was cognitively intact, stated he heard R12 go into R10's room and beat her up, and said he heard R10 was bleeding a little bit. R16 also stated the whole floor knew R12 beat up R10. R16's written statement dated 02/21/2026 documented that R12 went into R10's room and started fighting her. Staff interviews confirmed the incident involved physical aggression toward R10. An RN stated he was R12's nurse when the incident with R10 occurred and reported that a CNA told him R12 hit R10; he also stated R12 was placed on 1:1 and given Haldol, and that police were called. The Assistant Administrator stated he investigated the incident and that R10 told him R12 came to her room, grabbed her arm, and fought her. The facility's abuse policy defined physical abuse as hitting, slapping, pinching, kicking, and similar acts, and required immediate reporting and separation of the alleged perpetrator to assure resident safety.
Failure to Report Allegations of Theft and Abuse Timely
Penalty
Summary
The facility failed to properly report an allegation of misappropriation of property involving a cognitively intact resident with a BIMS score of 15. The resident stated that people had been coming into her room and taking her belongings and money, and that she had mentioned this to CNAs and nurses, but she could not recall their names. The social worker stated she had heard about a staff member taking residents’ things from people talking in the halls, but she did not report it because it was never actually reported to her. The administrator stated that all staff are expected to report any theft immediately and that any allegation of abuse or theft should be reported to her right away, but no staff member had reported the allegation to her. The facility also failed to report an abuse allegation within 2 hours of notification for two residents involved in an altercation. One resident stated that he heard another resident go into the room of a second resident and beat her up, and that the second resident was bleeding a little bit, although he did not see the injury. An RN stated he received report from a CNA that the resident hit the other resident, placed the resident on 1:1, gave Haldol, and called police, and he notified his supervisor. The assistant administrator stated he investigated the incident and submitted the initial reportable later that day, but the report to the State Survey Agency was not submitted within 2 hours of notification. The facility policy stated that alleged abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator or DON, and incidents involving crimes or significant injury must be reported within 2 hours.
Failure to Complete Post-Fall Evaluation for Resident on Anticoagulant
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred when the facility did not ensure necessary post-fall interventions were completed for a resident after an unwitnessed fall. The resident was a [AGE]-year-old male with multiple diagnoses including cerebral infarction, muscle wasting and atrophy, weakness, end stage renal disease, anemia, vitamin D deficiency, hypothyroidism, NSTEMI, atherosclerotic heart disease, systolic and diastolic heart failure, osteoarthritis of the knee, and thromboembolism. The physician progress note documented that the resident was found on the floor with his right leg caught in the bed rails, his upper body on the floor, and that he reported hitting his head. Another note stated the resident was not ambulatory at baseline, was alert and oriented, had PERRLA, denied pain, and the physician was informed and recommended fall precautions and neuro checks per facility guidelines. The resident’s physician order sheet showed an order for an anticoagulant, but there was no order to send him to the hospital and no order for a stat x-ray. The Director of Nursing stated the resident had an unwitnessed fall, was not sent to the hospital, and no x-rays or CT scans were ordered; she also stated she did not learn of the fall until Monday after the Friday incident. The Medical Doctor stated that after a fall it is important to take vital signs and complete an assessment, and that a resident on anticoagulants and blood thinners may require immediate transfer for a CT scan to rule out bleeding. The facility’s accident/fall policy stated that if an incident is significant and requires outside emergency intervention or treatment, the Administrator and DON are to be notified immediately.
Failure to Offer COVID-19 Vaccine on Readmission
Penalty
Summary
The facility failed to follow its policy to provide COVID-19 vaccination upon readmission for one resident in a sample of 20 residents reviewed. The resident’s MDS dated May 6, 2026 documented a BIMS score of 13, indicating moderate cognition. On May 26, 2026, the resident was observed in a wheelchair, alert and oriented to person, place, and time, calm, and free from pain. The resident stated he had been in the facility since March 2026 and reported that when he first arrived about 6 months earlier, the facility did not offer the COVID-19 vaccine. He stated he requested the vaccine and was told by the DON that it had to be requested from the lab, and he had still not received it but remained interested in receiving it. The Infectious Disease Nurse stated she was responsible for offering vaccinations and providing education, and that residents are to be offered vaccinations upon admission, readmission, every 6 months after the initial COVID-19 vaccination, or per request. She stated the resident had been readmitted in early March and that she had offered the COVID-19 vaccine before discharge, but did not offer it again upon readmission because he had refused in February and she would not ask again within the same season. She also stated the resident requested the vaccine, but there were no vaccines available at that time. Review of the provider order sheet showed a new order for the COVID-19 vaccination entered on May 27, 2026. The DON stated residents are to be offered the vaccine during admission, readmission, and if they inquire about receiving it, and that consent or refusal is to be documented in the electronic medical record.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Injuries
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known behavioral histories and documented conflicts. One cognitively intact resident with a fractured ankle reported being asleep in bed when her roommate, also cognitively intact and care planned for conflictual and difficult behaviors, became angry about a wheelchair blocking the pathway. The aggressor called her derogatory names, climbed onto her in bed, hit her in the face and head, scratched her face, bit her finger, and caused a swollen lip. Staff later observed the aggressor on top of the resident in bed and noted bleeding, facial scratches, a swollen lip, and a bitten, painful finger. Emergency department documentation confirmed a closed fractured tooth, human bite, and swollen lip. The aggressor acknowledged initiating the physical contact, stating she hit and bit the roommate after an argument about the wheelchair. Another incident involved two cognitively intact roommates with psychiatric and behavioral diagnoses. One resident, who used a cane and an electric wheelchair, reported arguing with his roommate, whom he described as not in his right mind and talking to himself. Believing the roommate had a fork in his hand, he began hitting him with his cane. The roommate stated that the aggressor had been bothering his television volume, and during an argument, drove his electric wheelchair over and struck him repeatedly with the cane, causing him to block the blows with his hand. Staff did not witness the initial altercation but observed the victim’s swollen hand. Progress notes documented that the aggressor allegedly made contact with the roommate, that the residents were separated, and that the victim had swelling and redness of the right hand. Subsequent hospital records showed displaced fractures of the distal phalanx of the right ring finger and proximal phalanx of the right little finger. A further altercation occurred in the dining area between two cognitively intact residents with significant psychiatric and behavioral histories, including anxiety, homicidal ideations, stimulant use, and schizoaffective disorder. One resident reportedly threw a cell phone through the dining room door, and another resident informed staff of this behavior. According to the social services director’s investigation, the first resident then began hitting the reporting resident, who hit back. Nursing documentation recorded that one resident made contact with a co-peer in the dining area, that both were immediately separated, and that one resident had altered skin integrity requiring 911 transport, while the other had no altered skin integrity noted. Both residents were described as exhibiting very aggressive behavior and not easily redirected. In a separate incident near the elevator area after a smoke break, a cognitively intact resident in a wheelchair was waiting in line when another resident with schizoaffective disorder, psychosis, violent behavior, homicidal and suicidal ideations, and a history of bizarre aggressive behavior approached from the back of the line. Witnesses, including a psych tech and the assistant administrator, stated that the aggressive resident came “out of nowhere,” ran to the front, and punched or swung at the seated resident’s face. Staff observed the aggressor striking the resident’s face with bare hands and then physically removed and escorted the aggressor away. The victim reported being hit in the head and stabbed in the face with an unknown object, falling backward in the wheelchair, and bleeding from the face. Nursing assessment documented a skin tear or scratch near the mouth/lip area and no other injuries on body check. Facility documentation, including incident reports and a petition for involuntary admission, described the aggressor’s bizarre aggressive behavior and physical aggression toward the peer, with the victim noted to have a scratch to the right side of the mouth. Across these events, the facility’s own records and care plans show that several residents had known histories of aggressive, violent, or conflictual behaviors, including prior physical aggression toward staff or peers, restlessness, agitation, and difficulty coping. Despite this, residents with such behavioral profiles were placed in shared rooms or common areas where altercations occurred, resulting in physical injuries such as fractures, bites, scratches, and altered skin integrity. The facility’s abuse policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish and states that the facility will not tolerate abuse or mistreatment by anyone, including other residents. The documented resident-on-resident assaults, injuries, and staff and resident accounts demonstrate that multiple residents were not kept free from physical abuse as required by the facility’s own policy and regulatory standards.
Failure to Implement Fall Care Plan and Provide Adequate Supervision for High‑Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow a high‑risk resident’s fall care plan and to provide adequate supervision to prevent accidents. The resident was admitted with multiple diagnoses including heart failure, anemia, GERD, history of falling, dementia, anxiety, bipolar disorder, schizoaffective disorder, and major depressive disorder. An MDS with a BIMS score of 10 documented moderate cognitive impairment, and a fall risk assessment identified the resident as high risk for falls with three or more falls in the prior three months. The care plan dated 03/02/2026 included interventions such as neuro‑checks, bilateral floor mats, a reclining chair, a special mattress, bilateral bed bolsters, and education of family and caregivers about safety and what to do if a fall occurs. Despite these identified risks and planned interventions, the resident experienced multiple falls on 2/28/2026, 3/15/2026, 3/17/2026, and 3/27/2026. Progress notes describe the resident being found on the floor by the bedside with a forehead skin alteration on 2/28/2026, requiring first aid and transfer to the hospital. Subsequent notes document the resident being found on the floor to the right of the bed with the safety mattress in place on 3/15/2026, and again rolling from the bed onto the floor mat on 3/17/2026, with assessments and neuro‑checks completed after the falls. The fall risk assessment confirmed the resident’s ongoing high fall risk and repeated falls over a short period. Interviews and observations showed that staff recognized the resident’s anxiety, restlessness, impulsiveness, and inability to use a call light, and acknowledged that the resident required frequent supervision. The DON stated that interventions such as keeping the resident up in the dayroom and moving the resident closer to the nurse’s station were being considered, but review of the care plan showed no room change intervention, and the resident remained in a room not near the nurse’s station. Multiple staff, including an LPN, an agency RN, and another LPN, confirmed that the resident’s room was mid‑hallway and not near the nurse’s station, and that this location made it difficult to keep the resident under frequent observation. The facility’s fall prevention policy required reassessment and modification of interventions after falls, but the record and interviews showed that the care plan was not updated to include a room change or other enhanced supervision measures despite the resident’s repeated falls and high risk status.
Failure to Report Resident’s Fear and Possible Abuse by Spouse to Administrator
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Prevention Program policy requiring that any alleged violations involving mistreatment, abuse, neglect, exploitation, or reasonable suspicion of a crime against a resident be immediately reported to the Administrator. One cognitively intact resident (R1), a 48‑year‑old with major depressive disorder, depression, and schizophrenia, was married to and shared a room with another cognitively intact resident (R2), a 42‑year‑old with schizoaffective bipolar disorder and alcohol abuse. R1 reported a history of several physical altercations with R2 prior to admission, though her trauma screening at admission indicated she denied any prior abuse history. While in the facility, R1 described escalating concerning behavior by R2, including renewed alcohol and marijuana use, increased aggression, and reports of hearing voices, which she did not report to nursing. R1 stated that on one occasion R2 became angry, grabbed her wallet, dumped all her cards into the toilet, urinated on them, forced her to retrieve the cards from the toilet, tore up her Social Security card, and called her derogatory names. R1 also reported that on another day, which she identified as a Monday, she went to the social worker (V4) and told her that R2 was scaring her and making her feel nervous, and that R2 had dumped her wallet into the toilet. R1 stated that V4 told her that R2 was her spouse and that they needed to work it out as a married couple. R1 did not tell V4 at that time that R2 had physically abused her in the past. R1 later reported that on a subsequent day, in their room with the door closed, R2 punched her in the cheek/face after telling her not to talk about him to anyone. She did not yell for help, did not report this incident to facility staff, and stated that her face did not bruise or swell. V4 confirmed that R1 came to her office earlier in the week and reported that R2 sometimes drank alcohol. V4 observed that R1 kept looking out the door and stopped talking when someone walked past, and that R1 said she felt afraid and nervous with R2 and that R2 did not want her to say anything. V4 stated that R1 then ended the conversation and left the office, and that later that same day R1 and R2 together requested and were granted a community pass, appearing calm and peaceful before and after the pass. V4 stated she was confused by the information and intended to report it to the Administrator but wanted to gather her facts first. She did not immediately report R1’s expressed fear and nervousness about R2 to the Administrator, despite having received abuse training and knowing the Administrator was the abuse coordinator. The Administrator later stated she had not been made aware that R1 felt afraid or nervous being in the room with R2 or that R1 was being abused by R2, and that her expectation was that any staff member who learned a resident was afraid or nervous around another resident or staff member would notify her immediately. The facility’s written Abuse Prevention Program policy requires that any alleged or suspected incident of resident abuse be promptly reported to the Administrator, which did not occur in this case.
Failure to Maintain a Safe, Clean, and Homelike Resident Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for one cognitively intact resident. During an observation of the resident’s bathroom, surveyors noted a hole in the lower left wall, a baseboard hanging off the same wall, a black substance between the floor and the lower left wall, and an area of wall covered with white plaster that was not painted to match the rest of the bathroom. The resident, who was alert, oriented, and had an intact BIMS score, stated that their room was not clean. When the Maintenance Director was brought to the bathroom, he confirmed the presence of the hole, the loose baseboard, the black substance, and the unpainted plastered wall, and acknowledged that this did not represent a homelike environment. Facility documents, including the Resident Rights policy, stated that the environment must be safe, clean, comfortable, and home-like. The job descriptions for the Maintenance Staff and Maintenance Director specified responsibilities for maintaining the building and residents’ rooms in a safe, comfortable, and attractive manner, underscoring that maintenance staff were responsible for repairs such as fixing holes in walls and ensuring baseboards were properly attached.
Failure to Inventory and Return a Resident’s Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for inventorying and tracking a resident’s personal belongings. The facility’s policy titled “Resident Personal Clothes and Belongings Handling” states that upon admission and annually, personal belongings such as clothing and items like TV, recliner, and bookcase are to be listed, with the CNA submitting the list to the charge nurse so it becomes part of the resident’s chart. During interviews, the DON stated there was no inventory list for resident R4’s belongings, and the Administrator confirmed that inventory sheets are supposed to be completed, uploaded to the system, and used to track what residents bring into the facility. However, the Administrator acknowledged that there was no inventory sheet for R4. A CNA explained that for new admissions, a staff member, usually a CNA, is supposed to record the resident’s belongings on a form, have the resident sign it, and then give it to the nurse, but also stated that new items brought in after admission are not logged. The CNA further described that upon discharge, belongings should be bagged by the CNA and taken to a storage area by housekeeping. The Administrator stated that belongings are packed up when residents leave, stored, and either returned when they come back or held for 30 days while the facility contacts family if the resident does not return. During the survey, the Administrator located a bag of R4’s personal belongings, including a Bible, on the third floor with no name on it, still in the facility and not returned to R4, demonstrating that the facility did not implement its inventory and tracking procedures for this resident’s personal property.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to assert residents’ rights and prevent resident-to-resident abuse when one resident physically struck another. Resident 1 had multiple psychiatric and substance use diagnoses, including schizoaffective disorder, bipolar disorder (current manic episode), schizophrenia, anxiety disorder, depression, and psychoactive substance abuse, and had been assessed as at moderate risk for aggression with a documented need for re-evaluation of services due to recent behavior. Resident 1’s care plan noted persistent anger toward self and others related to feelings of abandonment and psychotic symptoms. On the day of the incident, progress notes documented that Resident 1 became physically aggressive toward a peer without provocation, exhibited increased agitation, and was unable to be redirected. The Administrator (who also served as abuse coordinator) reported that during a morning meeting staff heard a noise, came out, and observed Resident 1 in a behavioral episode; the Administrator personally witnessed Resident 1 slap Resident 2 across the back of the head. The Nursing Supervisor stated he was aware that Resident 1 hit Resident 2 and that he had previously observed Resident 1 upset and aggressive on other occasions. Resident 2’s progress notes documented that Resident 2 received physical contact from a peer, that the residents were immediately separated, and that a head-to-toe assessment revealed no visible bruises or injuries, with Resident 2 denying pain or discomfort and vital signs stable. Resident 2’s care plan stated that the resident would remain safe, be treated with respect and dignity, and reside free from mistreatment, including abuse and neglect, and that a safe environment and emotional support would be provided, especially during investigations. During interview, Resident 2 did not recall the incident but confirmed that Resident 1 had been a girlfriend and was no longer in the facility. The Administrator stated she believed Resident 1 did not hit Resident 2 willfully and was just having an episode, despite the facility’s abuse policy defining abuse as the willful infliction of injury and clarifying that “willful” means the individual acted deliberately, not that they intended to inflict harm. The facility’s own Facility Reported Incident documented that Resident 1 made physical contact with Resident 2, and the abuse prevention policy identified physical abuse as including hitting and slapping, underscoring that the resident-to-resident physical contact met the facility’s definition of abuse that should have been prevented.
Failure to Maintain Fall Precautions and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and failed to ensure fall prevention interventions were in place for a resident with a history of falls, weakness, unspecified dementia, and cognitive impairment. The resident’s records showed a high fall risk score, and the care plan included interventions such as a low bed, floor mats, and wearing a helmet at all times as tolerated. The resident also had a history of multiple falls at the facility and required close monitoring due to impulsive attempts to stand and ambulate without assistance. On the day of the incident, staff found the resident lying on the floor in his room with a laceration above the right eyebrow and bleeding. The resident was sent to the hospital after the fall. The hospital record documented that he was transferred as a trauma activation after an unwitnessed fall from bed and that imaging revealed a large right subdural hematoma with mass effect, effacement of the right lateral ventricle, and a right zygomatic facial fracture. The resident later returned to the facility on hospice care. Staff interviews and record review showed that the resident had been observed sitting on the edge of the bed shortly before the fall, but the bed was not in the lowest position when staff left him. One staff member stated that he went to get socks while the resident remained on the bed, and another stated that the resident was found on the bare floor between the dresser and bed. Staff also reported that the resident’s helmet was beside him on the floor and that floor mats were not observed in place at the time of the fall. The facility’s own statements identified the resident as alert and confused, impulsive, and requiring close supervision because he would attempt to stand and ambulate without assistance.
CNA Slept on Duty in Unauthorized Area
Penalty
Summary
The facility failed to ensure resident care needs were being met when a CNA was permitted to sleep while on duty during the overnight shift. V15 was assigned to the 2nd floor from 11:00 PM to 7:00 AM and was responsible for 16 residents in that assignment. According to the DON, V15 was terminated after being caught sleeping on duty for the second time, and the incident occurred around 5:59 AM when she should have been completing final rounds. A laundry staff member found V15 asleep in the basement laundry room, which was an unauthorized area, with a blanket over her and her head down on a folding table. V15 reportedly asked to be given 10 to 15 minutes, and the laundry aide later reported seeing her sleeping and took a picture. The Director of Housekeeping also reported that a CNA was found sleeping at the folding table and that the incident was reported to the DON. The disciplinary form documented that sleeping while on duty was a Category One offense under the union working agreement.
Failure to Consistently Document and Provide Ordered BIPAP Therapy
Penalty
Summary
The facility failed to consistently administer BIPAP therapy as ordered for one resident with obstructive sleep apnea, COPD, morbid obesity, and sleep-related hypoventilation. The resident’s physician order set directed BIPAP at 15 cm H2O on at night and off while awake, and physician notes documented BIPAP trial at night along with oxygen at 2 liters per minute and head-of-bed elevation. However, the resident’s MARs and TARs for August and September 2025 did not document the BIPAP as scheduled or administered, and progress notes did not show consistent documentation that the therapy was provided as ordered. During interview, the resident stated that the BIPAP machine was at the bedside but that no one had been putting it on since admission until recently, and the resident reported asking about the BIPAP and being told by a nurse, "I can't bother with this, it is too hard." The DON stated that BIPAP administration should be documented in the EMAR or progress notes and acknowledged that the order was not entered in the EMAR with scheduled details and that documentation was not consistent. An RN stated that if BIPAP is not documented, then it is not done. The resident’s care plan identified respiratory risks related to COPD, CHF, and OSA, but it did not include BIPAP therapy interventions.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a physical altercation between two residents. One resident, who had a history of TIA, cerebral infarction, osteoarthritis, COPD, heart disease, schizophrenia, and bipolar disorder, and was moderately cognitively impaired, was physically assaulted by another resident who was cognitively intact and had multiple chronic conditions. The incident occurred when the assaulted resident was walking toward the nursing station and became involved in a verbal altercation with the other resident. Despite attempts by a CNA to separate them, the aggressor pushed the other resident, causing a fall and a laceration to the head that required stitches and hospital evaluation. Staff interviews and documentation confirmed that the residents were engaged in a verbal dispute, and staff intervention was insufficient to prevent the physical assault. The facility's abuse prevention policy requires residents to be free from abuse, neglect, and mistreatment, but this policy was not effectively implemented in this instance. The incident was captured on camera, and statements from staff and residents corroborated that the physical contact led to injury. The event was reported to the police, and the injured resident received medical attention for the head wound.
Failure to Immediately Report Alleged Abuse to Administrator
Penalty
Summary
Facility staff failed to immediately report an allegation of abuse involving a resident to the administrator as required by facility policy. On the date of the incident, two residents were involved in an altercation, and a CNA intervened. Subsequently, one resident alleged that the CNA hit him in the face. The CNA denied the allegation and stated that the incident was reported to the nurse. However, interviews and record reviews revealed that the administrator was not informed of the allegation until two days later, despite the facility's policy requiring immediate reporting of any suspected abuse to the administrator or, in their absence, the DON. Multiple staff members, including the charge nurse, social service director, and nurse supervisor, confirmed that they either did not report the incident immediately or were unaware of the physical abuse allegation until after the fact. The initial incident report documented that the CNA made contact with the resident, but an addendum later concluded the allegation was unsubstantiated. Both initial reports were faxed to the state health department two days after the incident. The facility's abuse prevention policy clearly outlines the requirement for immediate reporting of any abuse allegations, which was not followed in this case.
Failure to Maintain Clean and Odor-Free Resident Room
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in the shared room of three residents, all of whom had significant medical conditions including urostomy, overactive bladder, and mobility issues. On multiple occasions, a strong odor of urine was noted both inside and outside the residents' room. Direct observation revealed one resident with urine leaking from a urostomy site and a puddle of yellow fluid on the floor next to the bed. Despite staff acknowledging the presence of urine and the odor, the issue persisted over several days, with repeated observations of urine on the floor and ongoing odor. Interviews with staff confirmed that both nursing and housekeeping were aware of the urine spills and the associated odor, but the spills were not consistently or promptly addressed. The Housekeeping Director stated that cleaning urine spills is a shared responsibility between housekeeping and nursing staff, depending on availability. The Director of Nursing and Administrator acknowledged the ongoing problem, noting the resident's behaviors and the difficulty in maintaining cleanliness. Facility policies and job descriptions require maintaining a clean and safe environment, but these standards were not met in this instance.
Failure to Provide Urostomy Supplies Resulting in Urine Leakage
Penalty
Summary
The facility failed to ensure the availability of appropriate urostomy supplies for a resident with a history of bladder cancer, dementia, and other urinary tract conditions. The resident, who was cognitively impaired and required assistance with activities of daily living, was observed multiple times with urine leaking from the urostomy site and a strong odor of urine present in and around the room. On several occasions, the resident was found without a functioning urostomy bag, resulting in urine saturation of the lower abdomen and the bedroom floor. Staff confirmed that the resident was completely out of urostomy bags and that attempts to use a colostomy bag as a substitute were unsuccessful, as it was not compatible with the resident's needs. Interviews with nursing and supply staff revealed a breakdown in communication and supply management. The nurse supervisor acknowledged that the resident had requested a new bag, but the correct supplies were not ordered in a timely manner. Central supply staff indicated they were not informed of the shortage until after supplies had run out, and there was difficulty obtaining the correct size. Facility documentation and policies required maintaining adequate stock of medical supplies and providing regular urostomy care, but these were not followed, resulting in the resident's needs not being met.
Failure to Provide Physician-Ordered Diabetic Diet During Special Occasion Meal
Penalty
Summary
A resident with multiple diagnoses, including diabetes mellitus, was not provided with the physician-ordered diabetic diet during a special occasion meal. The resident, who is cognitively intact, reported not receiving a diabetic diet. Observation of the resident's lunch tray revealed items inconsistent with a controlled carbohydrate or no concentrated sweets diet, such as a large sugar cookie with frosting and a slice of lemon meringue pie. The resident's diet order specified a low concentrated sweets diet, and the care plan indicated the need to prepare and serve the prescribed diet due to the risk of hyper/hypoglycemia. Interviews with facility staff, including the Dietary Director, Administrator, DON, and Dietitian, confirmed that the physician's order for the therapeutic diet was not followed during the special occasion meal. The Dietary Director stated that all residents received the same meal on special occasions, regardless of dietary restrictions, and could not confirm if there was a physician's order to alter therapeutic diets for such events. Facility policies and job descriptions reviewed indicated that residents without physician approval should follow their normal diet restrictions, and staff are responsible for serving food according to dietary orders.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation protocols, as observed during a kitchen tour. In the walk-in refrigerator, there were open and uncovered food items, such as chopped lettuce and turkey slices, without any labels or expiration dates. This lack of labeling and covering of food items poses a risk of foodborne illness to residents. The Dietary Cook acknowledged that food should be covered, dated, and labeled with an expiration date once opened, and prepared food must be stored at the appropriate temperature to prevent cross-contamination. Additionally, the facility's food preparation area was found to be unsanitary. There were uncovered garbage cans filled with trash, a mop bucket with dirty water left in the dishwashing area, and garbage bags tied to food preparation tables. Personal items, such as a cell phone, were also found on a food preparation table. The Dietary Manager confirmed that these practices could lead to cross-contamination and foodborne illness. The facility's policy documents emphasize the importance of using food before expiration dates, proper labeling, and maintaining cleanliness in food preparation areas.
Improper Garbage Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to properly dispose of kitchen garbage in contained dumpsters and maintain the dumpster area in a sanitary condition. During an observation, the dumpsters were found uncovered, surrounded by food garbage packages, papers, Styrofoam plates, food bones, cigarette butts, and emitting foul odors. Squirrels were observed eating the debris around the dumpsters. The Dietary Manager was unaware of why the dumpsters lacked lids and stated that dietary and housekeeping staff are responsible for closing the lids and cleaning the area. A housekeeping staff member confirmed that the garbage and dumpster area are a shared responsibility between housekeeping and kitchen staff, but noted there is no cleaning schedule or logbook. The open lids attract squirrels, raccoons, and rodents, which tear open garbage bags, creating a mess around the dumpsters. The facility's policy requires keeping the dumpster and surrounding area clean and free of debris, and contacting the garbage service for removal when dumpsters are full.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to provide an effective pest control program, as evidenced by multiple resident reports and observations of pest infestations. On January 28, 2025, several residents reported seeing cockroaches and mice in their rooms and common areas. One resident mentioned asking family members to bring bug spray to manage the infestation in their room, where sticky traps with bugs and droppings were observed. Another resident reported a mouse sighting in their bedroom and occasional sightings of roaches, despite the facility's efforts to spray for pests. Additional residents confirmed the presence of mice and roaches in various locations, including hallways and dining areas, with sticky traps capturing multiple bugs. The facility's Pest Control Sighting Logs documented numerous instances of roach and mouse sightings across different floors, with specific reports dating back to December 2024. Housekeeping staff confirmed resident complaints about pests and personal observations of roaches and a trapped mouse on the third floor. The Assistant Director of Nursing acknowledged the ongoing pest problem, despite weekly visits from a pest control company. The facility's undated Pest Control Policy mandates keeping the facility free of insects and rodents, yet the persistent pest issues indicate a failure to adhere to this policy effectively.
Infection Control Deficiencies in Equipment Disinfection and EBP Implementation
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident with a surgical wound and a peripherally inserted central catheter (PICC) line. The resident, who was admitted with a right foot wound infection and receiving intravenous antibiotics, was not placed on Enhanced Barrier Precautions (EBP) as required. There was no EBP signage or isolation cart set up outside the resident's room, which is necessary to inform staff and visitors of the need for protective personal equipment. The infection preventionist acknowledged the oversight and confirmed that residents with open wounds or indwelling medical devices should be on EBP. Additionally, the facility did not ensure the disinfection of blood pressure equipment between use for three residents. A Licensed Practical Nurse (LPN) was observed using a wrist blood pressure monitor on multiple residents without disinfecting it between uses, despite the presence of EBP signage indicating the need for such precautions. The LPN admitted that the equipment should be sanitized between residents to prevent the transfer of infectious diseases, and the Assistant Director of Nursing confirmed the requirement for cleaning the equipment between uses. The facility's policies on cleaning durable medical equipment and blood pressure measurement procedures were not followed, contributing to the deficiencies observed. The lack of adherence to these policies and procedures resulted in potential exposure to infectious microorganisms for residents, staff, and visitors, as the necessary precautions and disinfection protocols were not consistently implemented.
Deficiency in Timely Vaccination and Consent Procedures
Penalty
Summary
The facility failed to provide timely pneumonia vaccinations to five residents, as evidenced by the consents obtained on 12/16/24, but the vaccines were not administered. The Infection Preventionist (V16) acknowledged that the pneumonia clinic planned for December did not occur due to the Director of Nursing (V27) taking an early leave. Additionally, the facility had not completed obtaining consents from all eligible residents, particularly those on the second floor. One resident, R486, was discharged before receiving the vaccine, despite having consented to it. Furthermore, the facility did not offer the influenza vaccine to one resident, R24, and failed to obtain written consent before administering the influenza vaccine to another resident, R486. The facility's records showed that R24 refused the vaccine in March 2024, but there was no recent consent for the current flu season. R486 received the flu vaccine on 9/11/24, but the consent form lacked the resident's signature. The facility's guidelines require that consent and education about the risks and benefits of the vaccines be documented, which was not adhered to in these cases.
Failure to Accommodate Resident Preferences in Daily Care
Penalty
Summary
The facility failed to accommodate the preferences of two residents, R65 and R194, regarding their daily care routines. R65, who has medical diagnoses including end-stage renal disease, weakness, and obesity, expressed a desire to be out of bed every day. Despite being alert and oriented, R65 reported that staff only assisted with getting out of bed during shower times and did not offer daily assistance as preferred. On multiple occasions, R65 requested to be helped out of bed, but staff delayed or ignored these requests, leaving R65 in bed for extended periods. R194, diagnosed with chronic systolic heart failure, dementia, and other conditions, expressed a preference for a shower due to feeling itchy. Despite this request, staff did not provide a shower, citing that R194 was not scheduled for one until later in the week. Instead, R194 received a bed bath, which did not meet the resident's expressed needs and preferences. R194's care plan indicated a need for extensive assistance with bathing, yet the staff did not accommodate the resident's request for a shower. The facility's policies on Activities of Daily Living and Resident Rights emphasize the importance of accommodating resident preferences and providing care that enhances quality of life. However, the actions and inactions of the staff in these instances did not align with these policies, resulting in a failure to meet the residents' needs and preferences as documented in their care plans.
Deficiencies in Blood Pressure Monitoring and Permacath Care
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure was not within the ordered parameters. A Licensed Practical Nurse (LPN) recorded a blood pressure reading of 99/56 for a resident diagnosed with End Stage Renal Disease and Hypertension, but did not notify the physician as required by the resident's care plan. The care plan specified that the physician should be notified if the systolic blood pressure was less than 100 or the diastolic was less than 60, which was not adhered to in this instance. Another deficiency was observed when an LPN took a resident's blood pressure while the resident was standing, contrary to the facility's policy that requires blood pressure to be measured with the resident sitting and the arm at heart level. This resident had a history of elevated D-dimer and was at risk for cardiac distress, making accurate blood pressure readings crucial. The Assistant Director of Nursing confirmed that the proper procedure was not followed, which could affect the accuracy of the blood pressure reading. Additionally, the facility failed to maintain a dressing on a resident's permacath, which was left open to air without a dressing for an extended period. The resident, who was on hospice and had refused dialysis, reported that the dressing had been removed due to it being filthy, and staff did not replace it. The facility's policy required that central venous catheter dressings be changed at specific intervals to prevent infection, but this was not done. The Assistant Director of Nursing acknowledged that there was no ongoing plan for the permacath's removal, despite it being a potential entry point for infection.
Incorrect Mattress Setting for Resident with Skin Integrity Risk
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set correctly for a resident with a history of skin integrity issues. The resident, who has multiple diagnoses including Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and impaired mobility, was observed lying on a low air loss mattress set at 350 pounds, despite weighing only 79.6 pounds. This discrepancy in the mattress setting was identified during an observation by a surveyor and confirmed by a registered nurse and the Assistant Director of Nursing. The incorrect setting could potentially lead to skin breakdown, as the mattress was too firm for the resident's weight. The resident had a history of pressure ulcers, which had healed, but remained at high risk for skin integrity issues due to factors such as incontinence, impaired mobility, and comorbidities. The facility's policy requires that low air loss mattresses be set according to the manufacturer's recommendations, primarily based on the resident's weight. Despite this policy, the mattress setting was not adjusted to match the resident's current weight, posing a risk for the recurrence of pressure ulcers.
Failure to Apply Splint as Ordered for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that anti-contracture devices were applied as ordered and did not update the care plan to reflect the correct area of splint application for a resident with limited range of motion. The resident, who has a history of multiple medical conditions including psychosis, epilepsy, hemiplegia, and cerebral infarction, was observed without the necessary splint on their right hand, which was contracted. The resident reported that the splint had been missing for about four months, indicating a significant lapse in care. The care plan for the resident indicated the need for a splint on the left wrist due to monoarthritis, but the order summary specified that the splint should be applied to the right hand. This discrepancy in documentation contributed to the failure to apply the splint correctly. The Assistant Director of Nursing confirmed that the splint was supposed to be on the right hand and acknowledged the potential for increased contracture and weakness if the splint was not worn as ordered. The Restorative Nurse Consultant recognized the error in the care plan and intended to correct it. The facility's policy requires a comprehensive assessment and care plan updates to address residents' range of motion needs, but these procedures were not followed adequately in this case. The lack of a restorative nurse at the time may have contributed to the oversight, as the facility was actively seeking to fill this position.
Expired Dialysis Supplements Administered to Residents
Penalty
Summary
The facility failed to ensure that expired dialysis nutritional supplements were not stored and administered to residents, specifically affecting two residents who were part of a sample reviewed for nutrition. During an inspection of the second-floor medication room, an opened box containing twenty 8-ounce cartons of Nova Source Renal 19% with an expired use-by date was found. A registered nurse confirmed that this was the only box available for the dialysis residents on the floor, which included three or four individuals. Two residents, identified as receiving the expired supplements, were R177 and R183. R177, who has multiple health conditions including end-stage renal disease and dependence on renal dialysis, confirmed consuming the expired supplement. Similarly, R183, who also has end-stage renal disease and other health issues, was documented to have received the expired supplement. The facility's policy requires that medications and biologicals be stored safely and properly, following manufacturer recommendations. However, the expired supplements were not discarded or returned to central supply as they should have been. The Assistant Director of Nursing acknowledged the oversight and mentioned that staff education was being conducted to ensure expiration dates are checked before administration. The failure to adhere to these protocols resulted in the administration of expired nutritional supplements to residents, which could potentially lead to adverse effects.
Failure to Reassess PRN Antipsychotic Medication
Penalty
Summary
The facility failed to evaluate the appropriateness of antipsychotic medication for a resident and did not ensure that PRN orders for antipsychotic medications were limited to 14 days. The resident, who was admitted with diagnoses including Schizoaffective Disorder Bipolar type, Generalized Anxiety Disorder, and Major Depressive Disorder, had moderately impaired cognition. The resident's physician orders included Haloperidol to be administered as needed for agitation, but there was no documentation of negative behaviors from the resident during the month of January. Despite this, the PRN order for Haloperidol was not reassessed or discontinued after 14 days, as required. Interviews with facility staff revealed that non-pharmacological interventions should be attempted before resorting to psychotropic medications, and any PRN psychotropic medication should be discontinued after 14 days if not used. The facility's policy required that the rationale for extending a PRN order beyond 14 days be documented, but this was not done in the resident's case. The lack of documentation and reassessment of the PRN order for antipsychotic medication led to the deficiency identified by the surveyors.
Failure to Provide Wheelchair Footrest Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a footrest was placed on the wheelchair of a resident with left-sided weakness, resulting in the resident's left foot dragging on the floor and causing a fall. The resident, who is cognitively intact with a BIMS score of 13, has a medical history including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. During an observation, the resident was being pushed by a CNA when the left foot was noted on the floor, leading to the resident falling forward out of the wheelchair. At the time of the incident, no footrests were visible on the wheelchair. Interviews with staff revealed that the resident had just returned from the hospital and had not been assessed for a footrest. The LPN acknowledged the purpose of the leg rest was to support the resident's leg and prevent falls. The DON stated that residents with left-sided weakness should have a leg rest to prevent dragging. The resident's care plan indicated a risk for falls due to muscle wasting and atrophy in the lower extremities, and the MDS documented the need for substantial assistance with wheelchair use. The facility's policy on wheelchair usage assigns therapy the responsibility to ensure appropriate fit and appliance application.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain a pest and rodent-free environment, as evidenced by multiple reports and observations of mice and roaches in resident rooms and common areas. Residents reported sightings of mice and roaches, with one resident describing mice as being the size of hamsters and appearing at night. Another resident reported seeing mice in his room and informed the nursing staff. The Housekeeping Director acknowledged receiving complaints about mice and roaches over the past three to four months, and the Maintenance Director confirmed sightings of roaches in common areas. Despite weekly visits from an exterminator and the use of glue traps and bait, residents continued to report pest issues, indicating that the measures taken were insufficient to resolve the problem. The pest control reports documented ongoing treatments and recommendations for improving sanitation and addressing structural issues that could contribute to pest infestations. However, the persistence of pest sightings and resident complaints suggests that these efforts were not effectively implemented or monitored. The facility's policy to keep the environment free of insects and rodents was not adequately enforced, as evidenced by the continued presence of pests and the lack of effective communication and follow-up on resident complaints. The deficiency potentially affected all 229 residents in the facility, as the pest issues were reported in multiple rooms and common areas.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as R2, who was dependent on staff for activities of daily living (ADL). On December 22, 2024, R2 was observed in the dining room with long fingernails that had a thick build-up of black debris. Despite being awake and alert, R2 did not comment on the state of his nails. A Licensed Practical Nurse (LPN), identified as V9, confirmed that R2's nails were long and dirty, acknowledging that they needed to be trimmed and cleaned. The LPN noted that since R2 was not diabetic, a Certified Nursing Assistant (CNA) could perform the nail care. The CNA assigned to R2, identified as V10, admitted to not checking R2's nails during her shift, which began at 7:00 AM. The Assistant Director of Nursing (ADON), identified as V11, stated that residents' nails should be clipped weekly and cleaned during ADL care, with staff expected to check residents' hands before meals and during care. R2's medical record indicated a moderate cognitive impairment and a need for assistance with ADL care. The facility's policy on routine care emphasized the importance of personal care, including nail care, to promote hygiene and comfort, which was not adhered to in this instance for R2.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain hot foods at the required temperatures during meal service, affecting a resident and potentially impacting 60 others on the same floor. On the specified date, a resident reported receiving cold food in their room, which was confirmed by the surveyor's observations. The resident, who is cognitively intact and on a renal with dialysis diet, expressed that CNAs had to reheat the food, which should not have been necessary. During the survey, it was observed that the steam table used for meal tray assembly was not plugged in, leading to inadequate food temperatures. The dietary aide did not ensure the steam table was connected to maintain the required heat. Temperature checks revealed that some food items, such as sliced turkey and pureed broccoli, were below the acceptable serving temperature of 125 degrees Fahrenheit. The dietary director acknowledged that hot foods should be held at a minimum of 135 degrees Fahrenheit and served at a palatable temperature, but this was not achieved. The facility's policy mandates that hot foods be held at a minimum of 135 degrees Fahrenheit during tray assembly and served at temperatures not less than 125 degrees Fahrenheit. However, the failure to plug in the steam table and maintain proper food temperatures during service led to a deficiency in food service standards. The dietary director admitted that the steam table should have been plugged in to retain heat, and the oversight could potentially lead to foodborne illness if not addressed.
Failure in Timely Incontinence Care for a Resident
Penalty
Summary
The facility failed to perform timely incontinence checks and care for a resident (R2) who was unable to manage their own toileting hygiene due to multiple health conditions, including dementia and pressure ulcers. R2's care plan indicated a need for extensive assistance with activities of daily living, including toileting, as R2 was totally dependent on staff and non-ambulatory. On the day of observation, R2 was found in bed with a soiled incontinence brief, indicating that the brief had not been checked or changed every two hours as required by the facility's policy. R2 confirmed that the incontinence brief was not checked every two hours by staff. The observation revealed that the CNA responsible for R2 had last changed the incontinence brief at 7:00 am, and it was not until 11:57 am that the CNA returned to check and change the brief, which was found to be soaked with urine and soiled with a bowel movement. The CNA required assistance from another staff member to turn R2 for cleaning, and during the process, R2's bandage came off, necessitating intervention from the wound care nurse. The Director of Nursing confirmed that CNAs are expected to perform incontinence checks every two hours, which was not adhered to in this instance, leading to the deficiency in care for R2.
Improper Wound Care and Repositioning for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide aseptic wound care treatments for a resident with pressure ulcers, failed to ensure timely repositioning, and did not set the low air loss mattress to the appropriate weight setting. The resident, who has multiple medical conditions including dementia and pressure ulcers, was observed with a low air loss mattress set for a weight over 400 pounds, despite the resident's actual weight being significantly lower. The resident reported having sores and discomfort, and it was noted that the resident was not being repositioned with pillows or wedges as required. During an observation, a Certified Nursing Assistant (CNA) was seen providing incontinence care to the resident, but the resident was not properly turned or repositioned, and the CNA had to seek additional help. The wound care nurse, identified as V5, was observed performing wound care without proper hand hygiene between glove changes, and using a bedside table for treatment supplies without sanitizing it. The nurse also failed to perform hand hygiene between treating different wounds, which could lead to cross-contamination. The Director of Nursing (DON) confirmed that residents with pressure ulcers should be repositioned every hour and that a low air loss mattress should be set according to the resident's weight. The DON also stated that hand hygiene is necessary between glove changes during wound care. The facility's policies on pressure ulcer prevention and infection control were not followed, as evidenced by the improper wound care and lack of repositioning for the resident.
Failure to Provide Prescribed Pureed Diet
Penalty
Summary
The facility failed to provide the diet prescribed by the physician to residents, specifically affecting two residents who were supposed to be on a pureed diet. During a meal observation, it was noted that one resident was served a whole banana instead of a pureed banana, which was not in accordance with their prescribed pureed diet. This resident, along with others on the same diet, did not receive the pureed banana as indicated in the facility's Menu Spreadsheet. The dietary aide confirmed the number of residents on a pureed diet, and the LPN acknowledged the error and removed the banana from the resident's tray, later replacing it with yogurt. The facility's policies require that diets ordered by the physician be followed, and pureed foods be served as ordered to reduce the risk of aspiration. The Dietary Manager confirmed that a whole banana should not have been served to a resident on a pureed diet and acknowledged the need for CNAs to be in-serviced to check tray contents. The deficiency was observed to potentially affect additional residents who also had orders for a pureed diet, as per the facility's undated list of residents on such diets.
Failure to Prevent Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where a resident sustained a physical injury. The incident involved a female resident with a history of mental illness, including bipolar disorder and schizoaffective disorder, who was physically assaulted by a male resident with schizophrenia and other mental health issues. Both residents were alert and oriented, with a BIMS score of 15/15. The altercation occurred on the smoking patio, where the male resident struck the female resident in the face, causing a laceration that required three sutures. The male resident had a documented history of inappropriate behaviors and was on a 'Red pass' due to previous offenses. Despite this, the psychiatric technician supervising the area did not effectively intervene to prevent the escalation of the argument between the two residents. The technician initially attempted to stop the argument but walked away, allowing the situation to escalate to physical violence. The male resident's actions resulted in the female resident being transferred to the hospital for treatment of her injuries. The facility's final incident report and progress notes indicate that staff intervened after the altercation began, separating the residents and providing immediate medical attention. The female resident was assessed and treated for her injuries, which included a laceration on her cheek and superficial scratches on her neck. The facility's policy on abuse prevention, revised in 2019, emphasizes the prohibition and prevention of resident abuse, yet this incident highlights a failure in effectively implementing these measures to protect residents from harm.
Lack of Supervision on Patio Leads to Safety Risks
Penalty
Summary
The facility failed to adequately monitor residents on the outside patio, which posed a risk for falls and other unsafe conditions. During an observation, a surveyor noted that several residents, including those using wheelchairs and at risk for falls, were on the patio without staff supervision. This lack of supervision was confirmed by a psychiatric technician who was unsure of who was supposed to be monitoring the residents. The facility's policy requires that residents be supervised while smoking, with staff maintaining a close distance to ensure safety. The deficiency was highlighted by a previous incident where a resident, identified as R8, fell from his wheelchair on the patio, resulting in a laceration that required hospital treatment. R8, along with other residents such as R16, R17, and R18, were identified as being at high risk for falls due to their medical conditions, which include severe cognitive impairment and other diagnoses. Despite the facility's policy and the residents' care plans indicating the need for supervision, the lack of staff presence on the patio during the surveyor's visit and the previous fall incident demonstrate a failure to adhere to these guidelines.
Failure to Follow Hepatitis C Treatment Orders
Penalty
Summary
The facility failed to follow provider orders for Hepatitis C treatment for three residents, leading to significant health consequences. Resident R2 was diagnosed with Hepatitis C, but the facility did not carry out the necessary laboratory tests or arrange for an infectious disease consultation as ordered by the physicians. This oversight resulted in R2 developing hepatocellular carcinoma, which progressed to carcinomatosis, ultimately leading to the election of hospice care due to the advanced state of the disease. The facility's records did not document any attempts to follow through with the orders for Hepatitis C treatment, despite multiple orders from the physicians and nurse practitioner. Resident R3, who had a diagnosis of chronic viral Hepatitis C, also did not receive the necessary laboratory testing for Hepatitis C genotype and viral load as ordered by the physician. Despite being aware of the diagnosis and expressing a desire for treatment, R3 did not receive the appropriate care, and the facility had no documentation of the required tests being completed. The physician confirmed that orders were given but not carried out, which could lead to severe health complications if left untreated. Similarly, Resident R4, with a diagnosis of chronic viral Hepatitis C, did not receive the ordered laboratory work for Hepatitis C genotype and viral load. The resident was unaware of the diagnosis and treatment, and the facility failed to document any follow-up on the physician's orders. The Director of Nursing confirmed the lack of documentation and affirmed that the facility's expectation is to follow and carry out provider orders, which was not met in these cases.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to supervise and monitor a resident, resulting in the resident eloping from the facility by climbing over the fence surrounding the smoking patio. The resident, who had a history of substance abuse and was admitted for wound care, was not eligible for an independent community pass due to the short duration of their stay. Despite this, the resident managed to leave the facility without staff noticing, indicating a lapse in supervision and monitoring protocols. On the day of the incident, the smoking monitor/psych tech locked the game room door leading to the smoking patio during meal times, as per protocol. However, the surveyor observed that the game room door and the door to the smoking patio were left wide open and unsupervised multiple times during the inspection. Additionally, the alarm system on the patio door did not sound when the door was opened, further compromising the security measures in place. Interviews with staff revealed that the facility did not report the elopement to the state agency, as they believed it was only necessary to report elopements involving residents with altered mental status. The interim director of nursing and other staff members confirmed that the resident was cognitively intact and capable of signing an AMA form. However, the lack of adequate supervision and failure to secure the smoking patio area allowed the resident to elope, highlighting deficiencies in the facility's monitoring and reporting procedures.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,743 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery Place | 1 mi | ★★★★★ | 20 | 0 |
| Pavilion Of South Shore | 1 mi | ★★★★★ | 1 | 0 |
| South Shore Rehabilitation | 1.8 mi | ★★★★★ | 11 | 0 |
| Kenwood Vlge Nrsg And Rhb Ctr | 2.1 mi | ★★★★★ | 10 | 0 |
| Wentworth Rehab & Hcc | 2.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.