Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Meadowbrook Manor - Lagrange during CMS and state inspections, most recent first.
The facility failed to provide sufficient CNA staffing to meet residents’ daily care needs, resulting in missed or altered showers, prolonged call light response times, delayed toileting, and incomplete restorative services. Several residents who required mechanical lifts or substantial assistance for bathing and transfers reported not receiving scheduled showers, remaining in bed for long periods, and experiencing late assistance for toileting and dialysis. Staff, including CNAs, LPNs, and restorative aides, reported working short with high resident assignments, difficulty completing showers and monitoring common areas, and frequent pulling of restorative aides to floor CNA duties, which reduced residents’ restorative therapy frequency. Facility documents showed many residents required mechanical lifts and restorative programs, while the staffing plan lacked defined FTE needs for licensed nurses and CNAs.
A resident with a BCC lesion on the left cheek was observed with the wound open to air and long, stained fingernails, while staff reported difficulty keeping a dressing in place due to the resident picking at the area. Dermatology notes from an earlier appointment, which identified the lesion as BCC and ordered nail trimming, use of occlusive dressings or mittens, wound cleansing, and possible Silvadene, were not faxed to the facility or uploaded into the EMR for about 20 days. During this period, the wound NP’s notes reflected incorrect information about the timing of the dermatology visit, and she reported not seeing the dermatologist’s recommendations until much later. Existing orders for daily betadine and later povidone‑iodine applications were documented on the TAR and MAR, but the facility did not timely coordinate and implement the dermatologist’s specific treatment plan in accordance with its own multidisciplinary wound care policy.
A resident with multiple cardiopulmonary conditions, including lung cancer, CHF, COPD, chronic respiratory failure, pulmonary embolism, and asthma, had an EMR order for Prednisone 30 mg once daily for three days followed by Prednisone 40 mg once daily for seven days. The MAR showed the 30 mg dose was given on the first two days but not on the third scheduled day. The DON reported that when a pulmonary NP entered the new Prednisone 40 mg order, it inadvertently cancelled the remaining 30 mg dose, resulting in the missed administration, contrary to the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed.
A resident with significant physical impairments experienced skin irritation and excoriation after being provided with incontinence briefs that were too small, despite repeated requests and staff notifications for a larger size. Staff reported that brief sizing was determined by a list based on weight rather than individual needs or preferences, and the resident was not included on the list for the larger, more suitable briefs. The issue persisted even after multiple staff members communicated the resident's discomfort and skin issues to central supply and nursing management.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Four residents were found with medications at bedside or in their possession, including oral and topical drugs, without documented assessment or physician orders for self-administration. Nursing staff confirmed that required evaluations and orders had not been completed, and care plans did not reflect authorization for self-medication, contrary to facility policy.
Surveyors found that multiple opened medications, including insulin pens, inhalers, nasal sprays, and eyedrops, were not labeled with opened-on dates, and some medications for discharged residents were improperly stored and not disposed of as required. Nursing staff confirmed that multi-use medications should be labeled and stored according to facility policy, which was not followed.
Staff failed to follow required infection control precautions for multiple residents on transmission-based and enhanced barrier precautions. Instances included a physician and CNAs entering rooms without PPE, lack of proper signage, and staff providing high-contact care without gowns or hand hygiene. These actions were inconsistent with facility policies for residents with C. diff, VRE, and indwelling medical devices.
The facility did not complete required antibiotic review forms for several residents who were prescribed antibiotics for infections such as C. difficile, UTIs, and osteomyelitis. The IP Nurse and DON confirmed that antibiotic surveillance was not performed as per facility policy, resulting in a lack of documentation to determine if antibiotic use met established criteria.
A resident's over-bed table remained broken for over two weeks despite multiple requests for repair to nursing staff. The broken molding was observed hanging down and was acknowledged by an RN as a potential cause of injury. The Maintenance Director was unaware of the issue and did not keep a log of work orders, relying on informal communication for repair requests.
A resident and her family requested that she remain in the facility as a private pay resident after her Medicare coverage ended, but facility staff informed them there was no bed available, despite documentation showing available beds. The administrator admitted that the decision was based on a directive from the CFO to limit long-term care admissions for profit reasons, not actual bed availability. The resident's care plan called for increased communication and participation, but her preference to stay was not honored.
Two residents with complex medical histories experienced significant incidents, including a fall and a change in condition, but their care plans were not updated to reflect these events or to include new interventions. Despite facility policy requiring care plan revisions after such incidents, staff did not revise the plans, and one incident was not investigated or reported as a fall.
A resident who is cognitively impaired and fully dependent on staff for incontinence care was found in a soiled state with reddened skin and no barrier cream applied, despite care plans and physician orders requiring frequent checks and use of barrier cream. Staff confirmed that incontinence care had not been provided for several hours, and facility policy mandates regular assistance for residents unable to perform ADLs.
Surveyors found that staff failed to accurately log and reconcile controlled medications for two residents receiving narcotics. Discrepancies were observed between the number of tablets or capsules present and the amounts recorded on proof of use sheets, and some medication punch cards were not properly secured. Nursing staff admitted to not logging administered narcotics as required by facility policy.
Two residents experienced serious falls due to the facility's failure to maintain safe equipment and provide adequate supervision. One non-ambulatory resident was left unattended in a malfunctioning geri-chair, resulting in injury and hospital transfer. Another resident with dementia and a history of wandering was able to leave a supervised area, access a stairwell, and fall, also requiring emergency care. Staff did not follow established policies for fall prevention and monitoring of high-risk individuals.
The facility did not hold quarterly IDT care plan meetings or invite residents and their POA/family to participate, as confirmed by interviews with several residents, family members, and staff. No documentation of care plan meetings was found for the past year, and some residents were unaware of the care planning process. Facility policy requires interdisciplinary involvement and resident/family participation, which was not followed.
Several residents did not have their physician-ordered medications available, including both scheduled and as-needed prescriptions. Family members reported not being notified when medications were running low, and LPNs confirmed that medication reordering was not consistently performed. The DON stated that a three-day supply should be maintained and that nurses are responsible for reordering and notifying families, but this process was not followed, resulting in medication shortages.
A nurse administered potassium to the wrong resident after mishearing a telephone order and failing to verify the resident's identity, resulting in the resident being sent to the hospital for evaluation. The resident, who had a history of cardiac conditions, was found to have normal potassium levels and remained stable, but the error occurred due to not following established procedures for medication administration and order verification.
A resident with cognitive impairment and poor safety awareness eloped from a facility through a faulty door with a non-functioning alarm. The resident was found outside in cold, rainy weather, sustaining injuries from a fall. Staff interviews revealed the door had been in disrepair for some time, with no alarm sounding, and was frequently used by residents and staff to smoke. The facility's elopement policy lacked preventative measures and monitoring processes.
The facility failed to provide adequate care for pressure ulcers in three residents, leading to worsening conditions. A resident with multiple diagnoses developed a Stage 3 pressure ulcer and a DTI, but was not assessed by a wound care specialist, and necessary interventions were not implemented. Another resident developed a DTI and an unstageable ulcer without a care plan or root cause analysis. A third resident's sacral ulcer was inconsistently documented, and treatments were not administered as ordered. The facility did not adhere to its policies, resulting in deteriorating conditions.
A resident sustained a head laceration and thoracic fractures after slipping from a defective mechanical lift sling during a transfer. The incident involved two CNAs and occurred after the resident's shower. The sling had a tear, which may have caused the fall. The resident, with a history of quadriplegia and multiple sclerosis, was hospitalized for seven days and now requires a back brace.
A LTC facility experienced a 25.8% medication error rate due to late administration, missing medications, and failure to follow prescribed parameters. Errors affected five residents with various conditions, including dementia, diabetes, and heart disease. Issues arose from pharmacy order delays and staff scheduling problems, with the DON acknowledging the need for timely administration and clear medication holding parameters.
A resident with multiple diagnoses, including dementia and a stage 4 pressure ulcer, sustained a skin tear that was not assessed or treated in a timely manner. Hospital orders for wound care and suture removal were missed, leading to a delay in treatment. The wound care nurse and DON acknowledged the oversight, highlighting the risk of infection and complications.
A resident with a stage 4 pressure ulcer did not receive the wound care as ordered by the physician, leading to delays in treatment. The resident's care plan required specific treatments to prevent further ulcer development, but these were not implemented timely. Treatment records showed missed wound care sessions without documentation, and interviews revealed a lack of adherence to physician orders, highlighting a breakdown in the facility's process for recording and executing treatment orders.
A resident with multiple health conditions, including chronic atrial fibrillation, did not receive their prescribed apixaban due to the facility's failure to maintain an adequate supply. The staff member acknowledged the error, and the DON confirmed it as significant, noting the medication should have been ordered in advance.
The facility failed to adhere to dietary preferences and planned menus, impacting residents' nutritional needs. A resident with specific dietary preferences was not provided with his preferred breakfast items, and another resident did not receive the soup he ordered. The dietary manager admitted to making menu changes due to staffing issues and ingredient shortages, leading to a failure in providing planned meals.
Two residents experienced missed medication doses due to the facility's failure to ensure timely availability. One resident with severe anxiety did not receive anti-anxiety medication upon admission, while another resident missed doses of eye medication due to unavailability, despite confirmed delivery.
The facility failed to follow standard infection control practices regarding hand hygiene and gloving during incontinence care and medication administration. Staff did not perform hand hygiene between tasks or after glove removal, contrary to the facility's policy. Instances included a nurse and several CNAs who did not adhere to infection control protocols while providing care to residents.
The facility failed to assist two residents with activities of daily living (ADL) care, including shaving and nail clipping, despite their expressed needs and care plans indicating substantial assistance was required. Observations revealed long, dirty fingernails and overgrown facial hair, which were not promptly addressed by the staff.
A resident with multiple diagnoses and cognitive impairment was found attempting to take medications left at the bedside by a nurse, resulting in spilled pills. The nurse admitted to leaving the medications unsupervised, violating the facility's policy on safe medication administration.
A facility failed to follow the physician's order and treatment plan for a resident with stage 3 pressure ulcers. The resident was found with uncovered, untreated wounds and sitting on a urine-saturated bed. The prescribed Triad Ointment was not applied as required, and the resident's care plan indicated a high risk for pressure ulcer development due to decreased mobility and comorbidities.
The facility failed to assess and provide necessary splints and therapy services to two residents, leading to further reduction in their range of motion (ROM). Both residents had significant medical conditions and required maximum assistance with ADLs, but were not initially provided with the recommended devices or therapy, resulting in discomfort and limited ROM.
The facility failed to provide timely and thorough incontinence care for two residents, leading to potential risks of urinary tract infections (UTIs). One resident was found with a heavily saturated incontinence brief and improper cleaning, while another uncircumcised resident did not receive appropriate peri-care. Both residents required total assistance for toileting.
A resident with a Midline catheter had a dressing that was not intact, and the facility failed to change it per their policy. The dressing, dated 5/31/24, was observed to be rolling and loose, and the active order summary did not include instructions for dressing changes. The facility's policy required the dressing to be changed 24 hours after insertion, then weekly, and as needed.
The facility failed to administer medications as prescribed and ensure complete administration via gastrostomy tube. One nurse did not follow the sliding scale for insulin dosage, and another left significant medication residues in cups, requiring surveyor intervention.
The facility dietary staff failed to follow a resident's tray card and served a food item she was known to be allergic to. Despite the resident's documented allergy to eggs, scrambled eggs were served for breakfast. The resident, who has multiple diagnoses and moderate cognitive impairment, reported the error, and the facility's administrator and food service supervisor confirmed the mistake.
Insufficient CNA Staffing Leading to Missed Showers, Delayed Toileting, and Incomplete Restorative Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient CNA staffing to meet residents’ daily care needs, including bathing, transfers, toileting, restorative services, and timely call light response. Multiple cognitively intact residents reported missed or altered showers and prolonged waits for assistance. One resident, who is dependent on staff for transfers and requires substantial/maximal assistance for tub/shower transfers per her MDS, reported not receiving her scheduled shower and instead remaining in bed while staff supervised residents in the TV room. The CNA assigned to her confirmed providing only a quick bed bath and not documenting the shower because there was “too much to do” and that using a mechanical lift for showers was difficult when working short-staffed and responsible for three showers. Other residents described similar impacts from inadequate staffing. One resident stated that a CNA had 15 residents to care for, so she tried not to ask for help and stayed in bed; she reported turning on her call light to request a bedpan and waiting about 50 minutes without response, ultimately soiling herself, and also being late to dialysis because the night CNA was behind with other residents. Another resident, who is cognitively impaired and requires substantial assistance with bathing and is on a restorative program, did not receive his scheduled shower and instead received a bed bath because the CNA could not complete all assigned showers while also feeding five residents and monitoring the TV room. Additional residents who require mechanical lifts for transfers reported not receiving scheduled showers, remaining in bed for extended periods, and not being gotten up for church on time. Several residents on restorative programs reported receiving restorative therapy only once weekly instead of the planned two or three times because restorative aides were being pulled to work as CNAs on the units. Staff interviews and facility documentation further demonstrated systemic understaffing and the diversion of restorative staff to CNA duties. CNAs, LPNs, and restorative aides consistently reported that staffing on certain floors was “horrible,” that they were “working short for weeks,” and that with only three to four CNAs per shift they could not complete showers, answer call lights timely, or safely manage numerous mechanical lift transfers. Restorative aides and the restorative nurse stated that restorative aides were pulled to the floor at least two to three days per week, resulting in residents not walking, restorative exercises not being done, and restorative charting not being completed. The scheduler reported staffing patterns of three nurses and four to five CNAs per floor for a building census of 151 residents, while facility records showed 75 residents required mechanical lifts and 70 residents were supposed to be on restorative programs. The Facility Assessment Tool noted that bathing and sleeping preferences were to be considered in staffing, but the section for listing needed FTEs for licensed nurses and CNAs was left blank, and staff reported that assignments did not adequately account for residents’ acuity and care needs.
Failure to Timely Obtain and Implement Dermatology Orders for Basal Cell Carcinoma
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement a dermatologist’s progress notes and treatment orders in a timely manner for a resident with a basal cell carcinoma (BCC) lesion on the left cheek. During observation, the resident was seen in the activity room with the facial wound open to air and long fingernails stained with a dried red substance. The wound care LPN stated that the resident had a state guardian, was seen weekly by a wound care NP, and that staff attempted to cover the lesion but the resident removed dressings and picked at the area. Dermatology notes from an appointment on 2/4/2026, with a post‑biopsy addendum dated 2/9/2026 identifying the lesion as BCC, documented that the lesion was exacerbated by scratching and that there was bloody residue under the resident’s left fingernails. The dermatologist’s plan included cutting and filing nails short, using an occlusive dressing or mittens at night to prevent manipulation, keeping the ulcer clean, and considering Silvadene applications. These dermatology notes, last updated on 2/9/2026, were not faxed to the facility until 2/23/2026 and were not uploaded into the EMR until 2/24/2026, approximately 20 days after the appointment. Facility wound progress notes dated 1/13, 1/29, and 2/12/2026 by the wound NP all indicated staff reported a dermatology appointment in March, and on 2/26/2026 the wound NP stated she had just seen the dermatologist’s recommendations that day and had not had a chance to review them, noting staff should have notified her earlier. The 2/12/2026 wound assessment documented the carcinoma lesion as 6 x 3.5 x 0.1 cm with 60% eschar and 40% devitalized tissue. The Treatment Administration Record showed an existing order from 9/13/2025 for daily betadine to the left cheek BCC, last signed on 2/21/2026, and the MAR showed a 2/12/2026 order for daily povidone‑iodine, last signed on 2/25/2026. The facility’s Wound Prevention and Healing policy stated that wound care services are to be provided under physician direction using a multidisciplinary approach, with the wound care team responsible for identifying problems, coordinating care, and providing case management, which was not followed in this instance.
Missed Prednisone Dose Due to Order Entry Error
Penalty
Summary
The facility failed to administer a prescribed dose of Prednisone as ordered for one resident. The resident was admitted with multiple serious cardiopulmonary diagnoses, including malignant neoplasm of the lung, tachycardia, congestive heart failure, COPD, chronic respiratory failure, pulmonary embolism without acute cor pulmonale, and asthma. The EMR showed an order for Prednisone 30 mg once daily for three days starting on 1/18/2026 at 5 PM through 1/20/2026, followed by a new order for Prednisone 40 mg once daily for seven days starting on 1/21/2026 at 9 AM. The MAR documented that the resident received the 30 mg Prednisone doses on 1/18/2026 and 1/19/2026, but the 30 mg dose due on 1/20/2026 at 5 PM was not administered. The DON stated that when the pulmonary NP entered the new Prednisone 40 mg order to start on 1/21/2026, it accidentally cancelled the existing 30 mg dose scheduled for 5 PM on 1/20/2026, resulting in the missed dose, and both the DON and NP confirmed the resident should have received that 30 mg dose. The facility’s Medication Administration policy, reviewed in 4/2025, states that medications will be administered in a safe and timely manner and as prescribed.
Failure to Provide Properly Sized Incontinence Briefs Resulting in Skin Irritation
Penalty
Summary
The facility failed to provide appropriately sized incontinence briefs to a resident, resulting in skin irritation and excoriation. The resident repeatedly expressed discomfort with the green incontinence briefs, stating they were too small and caused pain and redness in the perineal and groin areas. Multiple CNAs confirmed that the green briefs did not fit the resident properly and that she preferred the larger, white bariatric briefs, which were not provided because she was not on the supply list for that size. Staff reported that brief sizing was determined by a list based on weight, not on individual body measurements or resident preference, and that requests to central supply for the larger size were denied due to the resident not being on the approved list. The central supply manager and nursing staff indicated that only certain residents were assigned the larger, more expensive briefs, and the resident in question was not included despite staff notifications of her needs. The wound care nurse was unaware of the resident's skin breakdown, and the DON acknowledged that the resident had a pear-shaped body and irritation in the groin area but stated that girth measurements were only taken for residents over a certain weight. The resident's medical record showed significant physical impairments and a need for substantial assistance with hygiene. Facility policy stated that resident preferences should be accommodated unless health or safety would be endangered.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to assess and authorize residents for self-administration of medications, as required by its own policy and regulatory standards. Four residents were observed with medications at their bedside or in their possession, including oral tablets, nutritional supplements, topical creams, and ointments, without documented assessments or physician orders permitting self-administration. In each case, the residents' care plans and electronic medical records did not reflect any evaluation or interdisciplinary team determination that self-administration was safe or appropriate. One resident with moderate cognitive impairment and multiple diagnoses, including dementia and hemiplegia, was found with both facility-supplied and personal Tums at bedside and reported taking them without staff supervision or documentation. Another resident with modified independence in cognitive skills had a cup of red liquid medication left at bedside for an extended period, with no recollection of whether it was taken, and no assessment or order for self-administration. A third resident with severe cognitive impairment had antifungal powder and a cream mixture at bedside, with no evidence of assessment for self-administration. A fourth resident, cognitively intact but with complex medical needs, kept multiple topical medications at bedside and self-applied them as needed, without knowledge of dosing limits and without documented authorization or assessment. Interviews with nursing staff confirmed that the facility's policy requires a physician order and a completed assessment before residents may self-administer medications. However, staff acknowledged that these steps had not been completed for the residents in question, and that medications other than moisture barriers should not be kept at bedside without proper authorization. The facility's own Self Administration of Medication Program outlines the need for interdisciplinary team review, physician order, and care plan documentation, none of which were present for the affected residents.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications for multiple residents. During checks of medication rooms and carts, several opened medication pens, inhalers, nasal sprays, and eyedrops were found without opened-on dates. Specifically, opened Ozempic and Lispro insulin pens, Albuterol inhalers, Fluticasone nasal sprays, and Systane and Latanoprost eyedrops were not labeled with the date they were opened. Additionally, weekly pre-scheduled dosage administration dates for some medications were left blank. These deficiencies were identified for all residents reviewed for medication storage, totaling ten individuals. Further, the survey found that medications belonging to discharged residents, specifically Naloxone nasal sprays, were stored inappropriately under a sink and had not been disposed of as required. Interviews with nursing staff confirmed that multi-use medications should be labeled when opened and that medications for discharged residents should be disposed of properly. The facility's own policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, which was not followed in these instances.
Failure to Implement and Enforce Infection Control Precautions
Penalty
Summary
The facility failed to implement and enforce appropriate infection prevention and control measures for multiple residents requiring transmission-based and enhanced barrier precautions. In one instance, a physician assessed a resident with ongoing diarrhea and pending C. difficile test results without donning any personal protective equipment (PPE), and there was no transmission-based precautions signage posted on the resident's door. The resident confirmed that she was not placed on precautions despite her symptoms, and her care plan later indicated strict contact isolation after a positive C. difficile result. The Director of Nursing acknowledged that the resident should have been placed on contact precautions immediately upon identification of GI symptoms. In another case, a certified nurse assistant entered a resident's room, which had a contact precautions sign due to a VRE wound, without wearing the required gown and gloves. The CNA stated she did not believe adherence to the posted precautions was necessary. Additional deficiencies were observed with residents on enhanced barrier precautions (EBP) due to indwelling medical devices. Staff members, including CNAs and LPNs, provided high-contact care activities such as perineal care, repositioning, and gastrostomy tube checks while wearing gloves but not gowns, and failed to perform hand hygiene or change gloves between tasks. Soiled linens were also removed from rooms without proper containment or hand hygiene. Further, a resident with a history of VRE and orders for EBP did not have any isolation signage or PPE bin near her room. Staff provided incontinence care without wearing gowns and failed to perform hand hygiene after glove removal. Facility policies required the use of gowns and gloves during high-contact care for residents on EBP and specified hand hygiene protocols, but these were not consistently followed by staff, as confirmed by staff interviews and record reviews.
Failure to Implement Antibiotic Stewardship Program and Complete Required Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, specifically by not completing antibiotic review forms for residents who were prescribed antibiotics. The Infection Preventionist (IP Nurse) acknowledged responsibility for completing these forms in the residents' electronic medical records (EMRs) upon admission or when antibiotics were prescribed, using the McGeer Criteria to determine appropriateness. However, for four residents who received antibiotics for various infections, the antibiotic review forms were not completed, and there was no documented determination of whether the antibiotic use met the facility's criteria for appropriate use. The Director of Nursing confirmed that antibiotic surveillance was not completed for these residents, which was contrary to facility policy. The residents involved were prescribed antibiotics for conditions such as Clostridium difficile infection, urinary tract infections, and osteomyelitis. The facility's policy required that antibiotic usage and outcome data be collected and documented using a facility-approved tracking form, but this process was not followed for the residents reviewed.
Failure to Repair Broken Over-Bed Table Creates Unsafe Environment
Penalty
Summary
The facility failed to provide maintenance services necessary for a safe, comfortable, and homelike environment for one resident. Over a period of several days, the molding on the resident's over-bed (cardiac) table was observed to be broken and hanging downwards, with the resident reporting that it had been in this condition for more than two weeks and that multiple requests for repair had been made to nursing staff without resolution. The broken molding remained unrepaired despite repeated observations and resident complaints. A registered nurse acknowledged that the broken table could cause the resident to scrape his skin. The Maintenance Director stated he was unaware of the issue, had not been informed by staff, and did not maintain a log of work orders, relying instead on informal communication methods such as calls or texts. Facility policy indicated that the maintenance department is responsible for keeping equipment safe and operable.
Failure to Honor Resident's Preference for Private Pay Stay After Medicare Coverage Ends
Penalty
Summary
The facility failed to facilitate non-discriminatory discharge planning that met a resident's preferences by not allowing the resident to remain in the facility as a private pay resident after her Medicare coverage ended. Despite the resident and her family expressing a clear desire for her to stay and pay privately, facility staff informed them that there would be no bed available after her Medicare days ran out. Documentation and interviews revealed that the facility was licensed and certified for 140 Medicaid/Private Pay beds, with a current census of 130 residents and 29 available beds. However, the administrator stated that the facility was only accepting up to 82 long-term care residents based on instructions from the CFO, citing profit motives, and had only accepted hospice or respite residents since May 2025. The social service director and admissions director both confirmed that the resident and her family were told there was no bed available, despite documentation showing otherwise. The resident's care plan indicated a need for increased communication and participation in care planning, but the facility did not honor the resident's preference to remain as a private pay resident. The facility's own brochure on residents' rights states that residents have the right to keep living in the facility, yet the resident was scheduled for discharge to an undetermined facility against her and her family's wishes.
Failure to Update Care Plans After Significant Incidents
Penalty
Summary
The facility failed to review and revise care plans to reflect significant incidents or changes in condition for two residents. One resident, admitted with multiple diagnoses including chronic kidney disease, diabetes, morbid obesity, and dependence on renal dialysis, experienced a fall in her room and was sent to the emergency room for evaluation. Despite this incident, her care plan continued to state she was only "at risk" for falls and did not document the actual fall event or update interventions accordingly. The Director of Nursing stated that the incident was not considered a fall and therefore was not investigated or reported as such. Another resident, with diagnoses including dementia and a history of falls, had a care plan indicating risk for elopement and falls, with interventions for wandering and safety. However, after a documented fall, the care plan was not updated to reflect the incident or to include new interventions to prevent future falls. The facility's own policy requires updating care plans and developing fall intervention plans after such incidents, but this was not followed in these cases.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A dependent resident with multiple diagnoses, including cerebral infarction, aphasia, dysphagia, pressure ulcer, hypertension, and anxiety disorder, was found to have not received timely incontinence care. During a head-to-toe skin check, the resident was observed with a saturated undergarment, stool present up through the vaginal area, and reddened buttocks, with no barrier cream noted. The resident had requested butt cream prior to the assessment. The assigned CNA reported that the last incontinence care provided was between 08:00 and 08:30 AM, and although the resident was seen at 10:00 AM to pick up a meal tray, no incontinence care was given at that time. Facility staff, including the DON and wound nurse, confirmed that the resident is incontinent, cognitively impaired, and completely dependent on staff for incontinence care, requiring visual checks every two hours. The resident's care plan and physician orders specify the use of barrier cream and regular changing of disposable briefs. Facility policy also requires appropriate care for residents unable to perform ADLs independently, with special attention to those with cognitive impairment. Despite these protocols, the resident was left in soiled conditions for an extended period, contrary to the established care plan and facility policy.
Failure to Accurately Reconcile and Secure Controlled Medications
Penalty
Summary
Surveyors observed that the facility failed to accurately maintain and reconcile controlled medication logs for two residents receiving narcotics. During medication cart inspections, discrepancies were found between the number of tablets or capsules present in medication punch cards and the amounts recorded on the Controlled Substances Proof of Use sheets. For one resident, the Tramadol punch card was empty while the log indicated one tablet should remain, and the Pregabalin punch card contained 30 capsules while the log showed 31. Additionally, several punch slots were torn with loose, unsecured capsules. For another resident, the Tramadol punch card had one tablet, but the log showed two remaining. The Assistant Director of Nursing was unable to explain the discrepancies, and a Registered Nurse admitted to not logging the administration of scheduled controlled medications for these residents. The facility's policy required that controlled substances be reconciled upon receipt, administration, disposition, and at the end of each shift, and that proper storage and logging be maintained to prevent discrepancies. However, the observed failures to log medication removal and to secure medication cards led to inaccurate records and improper handling of controlled substances. The Director of Nursing confirmed that nurses were expected to ensure accurate storage, disposition, and logging of controlled medications, but these expectations were not met in the cases reviewed.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment and equipment were free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, with multiple diagnoses including chronic kidney disease, diabetes, morbid obesity, and a history of falls, was non-ambulatory and required total assistance with transfers using a Hoyer lift. On the day of the incident, after being transferred to a geri-chair for dialysis, the staff left the resident unattended. The geri-chair malfunctioned, causing the resident to fall and become wedged between the chair and the wall, resulting in a closed head injury, neck strain, and right shoulder contusion. The resident was subsequently transferred to the emergency room for evaluation. The incident was not investigated or reported by the Director of Nursing, despite facility policy requiring a safe environment to reduce fall risk. Another resident, diagnosed with dementia and a history of falls, was identified as an elopement risk and had severe cognitive impairment. The care plan included interventions such as disguising exits and providing diversions, but the resident was able to leave the supervised TV room and access an emergency egress stairwell. Staff last observed the resident in the TV room and by the nurse’s station, but she was later found on the floor at the top of the stairs, with her wheelchair at the base of the stairs. The emergency exit door was propped open and the alarm was sounding when emergency responders arrived. The resident complained of hip pain and was transferred to the emergency room for evaluation. Staff interviews revealed that wandering residents were supposed to be supervised in the TV room, but the resident was able to leave unsupervised. Both incidents demonstrate a failure to maintain a safe environment and provide adequate supervision for residents at high risk for falls and elopement. The facility did not follow its own policies for fall prevention and management, nor did it ensure that residents with known wandering behaviors were properly monitored and redirected, resulting in serious injuries and emergency transfers.
Failure to Conduct and Document Quarterly Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly Interdisciplinary Team (IDT) care plan meetings and did not invite residents or their Power of Attorney (POA) to participate in the care planning process for all six residents reviewed. Multiple residents and their family members reported that they had not attended or been invited to a care plan meeting in over a year, and some were unaware that such meetings were conducted. Staff interviews confirmed that care plan meetings had not been held, and there was no documentation of these meetings for the past year for the residents in question. The Social Services Director acknowledged that care plan meetings should occur quarterly and that residents and families are typically invited by phone, with documentation of their participation or declination. However, she was unable to find any records of care plan meetings for the reviewed residents. The Director of Nursing and Administrator both stated that care plan meetings are expected to include the resident, family, and interdisciplinary team members, but were unaware that these meetings had not been occurring. Facility policy requires the care plan to be developed by an interdisciplinary team and encourages resident and family participation, which was not followed in these cases.
Failure to Ensure Timely Availability of Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure physician-ordered medications were available for three of seven residents reviewed for medication availability. In one case, a family member reported that she is responsible for refilling a resident's medications from an outside pharmacy and that the facility sometimes runs out of medications without notifying her. Upon review of the medication cart, several of the resident's regularly scheduled and as-needed medications, including Ammonium Lactate cream, propylene glycol-glycerin eye drops, and Albuterol Sulfate inhalation aerosol, were not available. The LPN assigned to the resident confirmed that when medications are running low, nursing staff are supposed to inform the family member, but this was not consistently done. Another resident reported that the facility had previously run out of her pain medication, and a review of the medication cart revealed that several of her scheduled and as-needed medications, such as lidocaine cream, fluticasone-umeclidinium-vilanterol inhalation powder, guaifenesin, and hydrocortisone cream, were unavailable. The LPN assigned to this resident stated that medication refill requests can be made electronically or by fax, but had not reordered any medications that day. A third resident also reported previous shortages of her pain medication, and multiple scheduled and as-needed medications were found to be unavailable during the review. The DON stated that a three-day supply of medications should be maintained and that nurses are responsible for reordering medications and notifying family members in advance if a refill is needed. The facility's policy encourages electronic reordering of medications.
Significant Medication Error Due to Resident Misidentification
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered potassium to the wrong resident after mishearing a telephone order from a cardiologist. The nurse, who was working on a different unit than usual, confused two residents with similar first names and last initials. Without verifying the resident's identity or confirming recent lab work, the nurse gave a STAT dose of potassium to a resident who had not had labs drawn and was not the intended recipient of the medication. The resident who received the potassium had a medical history including congestive heart failure, hypertensive heart disease with heart failure, syncope, collapse, and atrial fibrillation. After taking the medication, the resident reported not having had a blood draw, prompting the nurse to realize the error. The resident was assessed and found to be stable, but was sent to the hospital for evaluation, where lab results showed a normal potassium level. Subsequent monitoring showed potassium levels remained within a safe range. Interviews with nursing staff and review of facility policies revealed that standard procedures for verifying resident identity and reading back telephone orders were not followed in this instance. The facility's policies require verification of the resident's name and date of birth, as well as a read-back of orders to ensure accuracy, but these steps were omitted, leading to the administration of medication to the wrong resident.
Resident Elopes Due to Faulty Door and Lack of Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident identified with confusion, poor safety awareness, and a desire to exit the facility. This resident, who had multiple medical conditions including moderate cognitive impairment, was able to elope from the facility through a door that was not in good repair and had a non-functioning alarm system. The door, located on the ground floor leading to a courtyard and main street, was found to be ajar and the alarm did not sound, allowing the resident to leave unnoticed by staff. The resident was found by a bystander on a sidewalk near a busy intersection, approximately 183 feet from the facility entrance, during the early hours of the morning. The resident was wet, without shoes, and wearing only pajamas and socks in cold and rainy weather. The resident sustained injuries from a fall during the elopement and was subsequently taken to a hospital where they were diagnosed with cold exposure and a head injury. Interviews with staff revealed that the door had been in disrepair for some time, with no alarm sounding when opened, and was frequently used by residents and staff to smoke. Staff were unaware of the resident's exit due to the lack of a functioning alarm and supervision. The facility's policy on elopement was found to be lacking in preventative measures and monitoring processes, contributing to the resident's ability to leave the facility undetected.
Removal Plan
- R1 was re-assessed for Elopement risk to complete accurate assessment.
- R1's care plan was reviewed and updated to include: R1 placed on monitoring while out of resident's room; R1 placed on hourly monitoring. There will be a sign off sheet to reflect his behavior, what he is doing, how is acting if he is verbalizing wanting to leave while his family is not in the facility. Wife is in the facility daily. R1's wife was educated to share with the staff to alert the staff when leaving.
- Facility initiated in-service on R1's direct care staff on plan of care to address elopement risk and precautions. This will continue until all direct care staff for R1 have been provided with in-service. The staff will not be allowed to work the shift without being In-serviced prior. Facility Scheduler, Nurse Supervisor, Administrator, and/or Designee will check if in-services are all completed prior to beginning of the shift.
- All residents in the facility who have cognitive impairments have scored moderate BIMS and are at risk high risk for elopement have the potential to be affected by the same deficient practice.
- All residents are being reassessed for elopement. The facility will monitor any resident that is at moderate and high risk and will make sure proper care plan is in place and will monitor resident for any significant changes.
- Facility initiated a binder with photos of residents who are at risk of elopement and will be checked weekly and as needed by Social Service and/or Designee. This will be on an ongoing basis.
- Facility DON and/or Designee will conduct a daily audit of all admissions and readmissions to ensure the elopement assessment has been completed. If a resident is at high risk for elopement, DON and/or Designee will ensure elopement precautions are in place and implemented. This will be conducted daily and will be ongoing.
- Facility initiated the audit of resident elopement assessments of residents who are at risk of wandering and elopement and residents with cognitive impairments to ensure proper care plan is in place.
- Facility removed door lever as well from the problem doors, to ensure doors are locked until alarm company will provide the sensor board. The sensor company will be at the facility to assess the problem in the motherboard.
- Door alarms will be checked daily to be completed by Maintenance, or the Designee or the MOD and audited by Administrator or designee.
- Latch to the door was lubricated and noted functional.
- Facility having door alarms modified to continuously alarm so staff would physically have to go to the location to reset the alarm in the event the alarm triggers.
- Facility initiated in-service on direct staff on Monitoring the Exit Doors, Assessing for Resident Departure, and Reporting to Maintenance Malfunctioning Equipment.
- Any staff member who has not received in-service education by the completion date will be in-serviced before the start of their next shift. Continuing education will be provided on these policies and procedures as needed.
- Facility has contacted low voltage repairer to come to the facility to repair the motherboard on the courtyard doors.
- Facility initiated in-service on direct care staff on residents identified at risk for Elopement along with Elopement Policy. Any staff member who has not received in-service education by the completion date will be in-serviced before the start of their next shift. Continuing education will be provided on these policies and procedures as needed.
- Facility may utilize verbal and in-person methods for in-services.
- The facility has an Elopement Binder with policy and list of residents' high risk for elopement/wandering to ensure appropriate training and in-service is provided.
- Facility will schedule a Resident Council Meeting to discuss facility's policy on going out on pass, utilization of back patio (i.e., smoking, including signing in and out when exiting the building through the front door) and when courtyard patio would be utilized by residents.
- Facility held an emergency QAPI meeting. Medical Director informed of the plan.
- Receptionist received in-service education to ensure all residents who go in and out of the facility follow the sign-in and out protocol.
- Staff to conduct head count on assigned residents during rounds.
- Staff will be assigned to monitor and supervise residents when out in the front of the facility and/or courtyards.
- Administrator will review audits weekly to ensure compliance with the measures put in place to address the safety of residents at high risk for Elopement.
- Administrator will ensure the Abatement Plan will be implemented and completed until compliance date and as indicated.
- QAPI was initiated to discuss with QA Committee the Abatement Plan and ensure all corrective actions and safety measures are consistently implemented. Medical Director notified via phone of the plan.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper care and prevention of pressure ulcers for three residents, leading to the deterioration of their conditions. Resident 1, who was admitted with multiple diagnoses including diabetes and dementia, developed a Stage 3 pressure ulcer on the left heel and a deep tissue injury (DTI) on the right heel. Despite the presence of wound care nurses and nurse practitioners, Resident 1 was not assessed by a wound care specialist, and interventions such as foam heel boots and a low air loss mattress were not implemented. Additionally, the resident's care plan was not updated, and a root cause analysis was not conducted as per facility policy. Resident 2, who was at risk for pressure ulcers, developed a DTI on the left malleolus and an unstageable pressure ulcer on the right heel. The facility did not initiate a care plan or interventions for these pressure ulcers, nor did they conduct a root cause analysis. Furthermore, there was no documentation of wound treatments being administered as ordered on several occasions, indicating a lack of adherence to prescribed care protocols. Resident 3, with a history of Alzheimer's disease and other conditions, developed a Stage 2 pressure ulcer on the sacrum. The facility's documentation was inconsistent, with measurements not recorded accurately, and the care plan was not updated following the development of the pressure ulcer. Similar to the other residents, a root cause analysis was not performed, and there was no evidence of wound care treatments being administered as ordered. The facility's failure to follow its own policies and procedures contributed to the worsening of the residents' pressure ulcers.
Resident Injury Due to Defective Mechanical Lift Sling
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in a significant injury. During a transfer from a shower chair back to bed, the resident slipped out of the shower sling and fell, sustaining a laceration to the head and fractures to the thoracic 8 and 12 vertebral bodies. The incident occurred while two CNAs were assisting the resident, who has a history of quadriplegia, multiple sclerosis, and is dependent on staff for transfers. The resident was subsequently hospitalized for seven days, received staples for the head laceration, and now requires a back brace. The investigation revealed that the shower sling used during the transfer had a small tear in the strap, which may have contributed to the resident slipping out. The CNAs involved in the transfer reported that the incident happened quickly, with the resident's body shifting left out of the sling. The facility's Director of Nursing confirmed the sling's defect, and the Administrator noted that the sling was a personal item purchased a year prior. The facility's policy on safe lifting and movement of residents emphasizes incorporating safety, dignity, and medical condition into lifting decisions, but the defective sling compromised these standards.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications at the ordered times, resulting in a medication error rate of 25.8%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed in five residents during a medication pass. The errors included late administration, missing medications, and failure to adhere to prescribed parameters for holding medications. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not followed in these instances. One resident with multiple diagnoses, including dementia and diabetes, did not receive their medications on time due to a nurse arriving late for her shift. Another resident with pulmonary hypertension and atrial fibrillation did not receive their prescribed apixaban because it was not available. Additionally, a resident with hepatic encephalopathy and chronic kidney disease did not receive rifaximin as it was on order, and the family had been previously providing it. These lapses in medication administration were attributed to issues with pharmacy orders and staff scheduling. Further, a resident with chronic obstructive pulmonary disease and atrial fibrillation received their medications nearly an hour after the allowable timeframe. Another resident with heart failure and Alzheimer's disease had their blood pressure medications held without consulting a physician, despite their blood pressure being within the new parameters. The Director of Nursing acknowledged these issues, emphasizing the importance of timely medication administration and the need for clear parameters for holding medications.
Failure to Initiate Timely Wound Care
Penalty
Summary
The facility failed to properly assess and initiate treatment for a resident's wound as ordered by a physician. The resident, who has diagnoses including heart failure, stage 4 pressure ulcer, anxiety disorder, major depressive disorder, and dementia with behaviors, sustained a skin tear on the right leg while being transferred into bed. The wound was not assessed until four days after the incident, and the treatment was not initiated until 16 days after the resident returned from the hospital. The hospital had provided specific orders for wound care, including cleansing and dressing the wound daily and removing sutures within 7-10 days, which were not followed. The wound care nurse acknowledged that the hospital orders for the resident's skin tear care and suture removal were missed, which could have led to an increased risk of infection and complications with suture removal. The Director of Nursing confirmed that the orders were missed, emphasizing the importance of reviewing discharge orders to ensure proper care. The facility was unable to provide a policy related to non-pressure wounds when requested.
Failure to Administer Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide treatment as ordered by a physician for a resident with a stage 4 pressure ulcer. The resident, who has diagnoses including heart failure, anxiety disorder, major depressive disorder, and dementia with behaviors, was not given the appropriate wound care as prescribed by the wound physician. The resident's care plan indicated a need for specific treatments to prevent further pressure ulcer development, but the treatments were not administered as ordered. The wound physician recommended a specific dressing regimen, but the facility did not implement these orders in a timely manner, leading to a delay in the prescribed care. The treatment administration records showed discrepancies in the implementation of the wound care orders. The resident's wound treatments were not completed on several occasions, with no documentation explaining the omissions. Interviews with the wound care nurse and the Director of Nursing revealed a lack of clarity and adherence to the wound care orders, indicating a breakdown in the process of recording and executing physician orders. The facility's policy on medication orders was not followed, contributing to the confusion and failure to provide the necessary care for the resident's pressure ulcer.
Significant Medication Error Due to Lack of Apixaban
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error. A resident with diagnoses including pulmonary hypertension, anemia, chronic atrial fibrillation, anxiety disorder, and major depressive disorder was prescribed apixaban 2.5mg to be administered at 8:00 AM and 8:00 PM. On a specific day, a staff member was unable to find the medication to administer to the resident during the morning medication pass. The staff member acknowledged this as a medication error, as the resident was unable to receive the ordered anticoagulant medication. The Director of Nursing confirmed that the facility did not have apixaban in their extra supply and recognized the situation as a significant medication error, emphasizing that the medication should have been ordered before the last dose was used to ensure timely delivery from the pharmacy.
Failure to Follow Menus and Respect Resident Preferences
Penalty
Summary
The facility failed to ensure that menus were followed, impacting the nutritional needs and preferences of residents. Specifically, for one resident, R4, the facility did not adhere to the dietary preferences and needs as outlined in his care plan and dietary profile. R4, who was admitted with conditions including hemiplegia, vascular dementia with anxiety, vision loss, and protein-calorie malnutrition, had specific dietary preferences such as oatmeal with brown sugar, bacon, coffee, and juice. On the day in question, R4 was not provided with his preferred breakfast items, as the facility ran out of bacon and did not provide oatmeal in a timely manner, despite it being requested. Instead, R4 was offered sausage, which he disliked, indicating a failure to respect his dietary preferences. Additionally, the facility did not follow the planned menu for the day, as evidenced by the discrepancy in the soup served. The menu indicated that creamy vegetable soup was to be served, but due to a staffing issue, chicken noodle soup was prepared instead. This substitution was not communicated to the residents, and another resident expressed dissatisfaction with not receiving the tomato soup he ordered. The dietary manager admitted to making changes to the menu due to a cook's absence and a lack of ingredients, which led to the failure in providing the planned meals. This highlights a lack of adherence to the facility's policy that meals should respect the client's dignity and preferences.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available for administration to two residents, leading to missed doses. Resident R3, who was admitted with conditions including larynx and glottis cancer, tracheostomy, major depression, and anxiety disorder, did not receive her anti-anxiety medication upon arrival. Despite having severe anxiety, R3 missed several doses of her prescribed medications, bupropion and clonazepam, which were not administered until the day after her admission. The delay was attributed to the time taken for the pharmacy to deliver the medications and the process of obtaining a prescription from the physician. Resident R4, diagnosed with multiple sclerosis and a history of femur fracture, reported missing her eye medication for several days. The medication, erythromycin ointment, was ordered for an eye infection but was not administered on multiple occasions as it was reportedly unavailable. Despite the pharmacy confirming delivery, the medication could not be located within the facility, resulting in missed doses over several days.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to follow standard infection control practices regarding hand hygiene and gloving during the provision of incontinence care and medication administration. Specifically, a nurse and several certified nursing assistants (CNAs) did not perform hand hygiene between tasks or after glove removal, which is against the facility's policy. For instance, a CNA changed gloves multiple times without hand hygiene while providing incontinence care to a resident on isolation for ESBL in urine. Another CNA applied barrier cream and changed briefs without performing hand hygiene in between tasks. Similarly, a nurse administered medications and applied topical cream without changing gloves or performing hand hygiene. The report also highlights specific instances where staff failed to adhere to infection control protocols. One nurse administered medications and checked vital signs without changing gloves or performing hand hygiene. Another CNA provided incontinence care to a resident, including changing soiled linens and applying barrier cream, without performing hand hygiene between tasks. These actions were observed despite the facility's policy, which mandates hand hygiene before and after resident care, after contact with body fluids, and after removing gloves. The Director of Nursing confirmed that these practices were not in line with the facility's infection control policies.
Failure to Assist Residents with ADL Care
Penalty
Summary
The facility failed to ensure that residents requiring assistance with activities of daily living (ADL) care were properly assisted with shaving and nail clipping. Resident R85, who is dependent on hemodialysis and requires substantial assistance with hygiene and grooming, was observed with long, dirty fingernails and overgrown facial hair. Despite expressing a desire for his facial hair to be shaven and nails clipped, these needs were not promptly addressed by the staff. The Director of Nursing confirmed that staff should provide hygiene and grooming during shower days and as needed to promote comfort and good grooming, as indicated in R85's care plan. Similarly, Resident R84, who has dementia and requires maximum assistance with personal hygiene, was observed with long and curling facial hair. Despite requesting assistance with shaving, this need was not met promptly. The Quality Assurance Nurse acknowledged the resident's need for assistance and confirmed that shaving should have been done. The Director of Nursing reiterated that assisting residents with shaving, especially female residents, is part of the nursing care and service to ensure personal hygiene and grooming are maintained. The facility's policy on ADL support emphasizes the necessity of providing services to maintain good grooming and personal hygiene for residents unable to carry out these activities independently.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were administered by a nurse and not left at the bedside for the resident to take on his own. This deficiency was observed in a resident with multiple diagnoses, including metabolic encephalopathy, altered mental status, alcohol dependence with alcohol-induced persisting dementia, cognitive communication deficit, bipolar disorder, and hypocalcemia. The resident's admission MDS indicated moderate cognitive impairment and functional limitations in both upper extremities, requiring maximum to total assistance with most ADLs. On the day of the incident, the resident was found attempting to take his medications from a cup left at his bedside, resulting in spilled pills on the bed. The nurse responsible admitted to leaving the medications at the bedside and subsequently administered the spilled medications to the resident without proper supervision. The facility's Director of Nursing confirmed that all nurses are expected to follow professional standards for medication administration, ensuring that medications are taken by residents in the presence of a nurse and not left at the bedside. The resident did not have an assessment or order to self-administer medications. The facility's policy on medication administration emphasized that medications should be administered safely, timely, and as prescribed, with self-administration allowed only if determined safe by the attending physician and interdisciplinary care planning team. The nurse's actions violated this policy, leading to the observed deficiency.
Failure to Follow Physician's Order for Pressure Ulcer Care
Penalty
Summary
The facility failed to follow the physician's order and treatment plan for a resident with pressure ulcers. On June 4, 2024, a resident was observed sitting on a urine-saturated bed with uncovered wounds on her inner buttocks and posterior thighs. The resident could not recall receiving wound care that day. The wounds appeared tender and raw, with no traces of the prescribed Triad Ointment, which should have been applied three times a day and during every incontinence care. The wound care nurse confirmed that the ointment acts as a barrier and should leave traces even when wet, indicating that the treatment was not administered as required. Further examination on June 5, 2024, revealed that the resident had stage 3 pressure ulcers with significant slough and granulation. The active care plan indicated the resident's risk for pressure ulcer development due to decreased mobility and comorbidities, and it specified the need to administer medications as ordered. The Director of Nursing confirmed that staff should follow wound treatment orders and that prolonged exposure to urine could worsen the pressure wounds, hinder healing, and increase the risk of infection.
Failure to Provide Necessary ROM Therapy and Splints
Penalty
Summary
The facility failed to assess and provide necessary splints and therapy services to residents to prevent further reduction in range of motion (ROM). Resident R34, who had multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with significant left arm and hand weakness. Despite requiring maximum assistance with activities of daily living (ADLs), R34 was not provided with any positioning device or splint. The occupational therapist later recommended a resting hand splint and OT services, but these were not initially provided, leading to discomfort and limited ROM for the resident. Similarly, Resident R40, with multiple diagnoses including end-stage renal disease and severe morbid obesity, was found to have a contracted left hand and was not receiving any therapy services or using any splint. Despite the resident's request for an assessment, no action was taken until prompted by the surveyors. The occupational therapist subsequently recommended a resting hand splint and therapeutic activities to increase flexibility and ROM, but these were not initially provided, resulting in further contracture and limited ROM for the resident. The Director of Nursing (DON) acknowledged that the nursing staff is expected to report any changes in residents' ROM for immediate therapy evaluation and implementation of necessary devices or services. However, this protocol was not followed for both residents, leading to deficiencies in their care and a failure to maintain or improve their ROM as required by their conditions.
Failure to Provide Timely and Thorough Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care and peri-care in a manner that would prevent urinary tract infections (UTIs) for two residents. One resident, aged [AGE], with multiple medical diagnoses including Extended Spectrum Beta Lactamase (ESBL) Resistance in the urine and a urinary tract infection, was found sitting at the edge of her bed with a heavily saturated incontinence brief. The urine had overflowed to the incontinence pad and fitted bedsheet, and there was a brown ring formation at the edge of the wetness. The resident was unable to recall the last time she was checked and changed for incontinence. During incontinence care, the Certified Nursing Assistant (CNA) did not thoroughly clean the resident's buttocks until prompted by the surveyor, revealing fecal matter and urine residue stains that were not initially cleaned properly. The resident's Minimum Data Set (MDS) indicated that she required total assistance for toileting. Another resident, aged [AGE], with multiple medical diagnoses including Hallux Rigidus, Depression, and Tracheostomy Status, was also found heavily saturated with urine that overflowed to the incontinence pad and fitted sheet. The CNA did not retract the foreskin to clean the inner area of the uncircumcised resident, as required by the facility's perineal care procedure. The MDS for this resident also indicated a need for total assistance with toileting. The Director of Nursing (DON) confirmed that proper incontinence care should include cleaning from front to back, ensuring the peri-area is completely cleaned, and retracting the foreskin for uncircumcised males to prevent infection or UTI.
Failure to Change Midline Catheter Dressing Per Policy
Penalty
Summary
The facility failed to change a resident's Midline catheter dressing per their policy and procedure. The resident, who had multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with a Midline catheter on her right inner upper arm. The dressing on the catheter site was dated 5/31/24 and was not intact, with the transparent tape rolling and loose towards the antecubital fossa. The active order summary report did not include instructions on when and how often the Midline catheter dressing should be changed. The resident's care plan indicated that the Midline catheter was inserted on 5/31/24 for the administration of IV antibiotic medication, and the dressing should be changed 24 hours after insertion, then weekly, and as needed if the dressing was not intact, rolling, or soiled. On multiple occasions, the resident was observed with the same dressing that was not intact, and the facility staff acknowledged the issue. The Director of Nursing confirmed that the facility's policy required the dressing to be changed 24 hours after insertion, then weekly, and as needed to prevent contamination or infection. The facility's intravenous therapy policy and procedure, dated April 2016, also stated that Midline catheter dressings should be changed 24 hours after insertion, every 5-7 days, or if the dressing is wet, dirty, not intact, or compromised in any way.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medication as prescribed by the physician and ensure complete administration of medications via gastrostomy tube. In the first instance, a nurse administered only 5 units of Insulin Fiasp to a resident with a blood sugar level of 213 mg/dl, without following the sliding scale that required an additional 2 units. This resulted in an incomplete dosage for the resident, who should have received a total of 7 units of insulin according to the sliding scale instructions on the Medication Administration Record (MAR). In the second instance, another nurse administered multiple crushed medications via gastrostomy tube to a resident but did not ensure that all the medication residues were fully administered. The nurse poured water into the medication cups and swirled them, but significant amounts of medication were left as sediments in the cups. The surveyor had to prompt the nurse to administer the remaining residues to ensure the resident received the full dosage. The Director of Nursing confirmed that all medications should be fully administered, with no residues left in the cups.
Failure to Adhere to Resident's Documented Food Allergies
Penalty
Summary
The facility dietary staff failed to follow a resident's tray card and served the resident a food item she was known to be allergic to. This incident involved a resident (R18) who had multiple diagnoses, including congestive heart failure, peripheral vascular disease, polyneuropathy, and unspecified dementia. R18's electronic medical record (EMR) and physician order summary indicated an allergy to eggs and all egg products, which was also listed on her tray card for all meals. Despite this, scrambled eggs were served to R18 for breakfast on June 3, 2024. R18, who has moderate cognitive impairment and requires substantial assistance with activities of daily living, noticed the error and reported it, stating that consuming the eggs could have resulted in hospitalization. The facility's administrator and food service supervisor confirmed the error upon review of the tray card and menu for that day. On June 3, 2024, R18 was found in her bed with a plate of scrambled eggs on her bedside table, which she pointed out as a mistake due to her egg allergy. R18 expressed frustration, noting that this was not the first time she had been served eggs despite her documented allergy. The facility's administrator and food service supervisor acknowledged the mistake and confirmed that scrambled eggs were indeed served as a breakfast entree on that day. This failure to adhere to the resident's dietary restrictions as documented on the tray card represents a significant lapse in the facility's duty to provide safe and appropriate food options for its residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 2,045 citations issued within 25 miles in the last 12 months — including the 30 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Grange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plymouth Place | 0.9 mi | ★★★★★ | 3 | 0 |
| Bella Terra Lagrange | 1.3 mi | ★★★★★ | 0 | 0 |
| Grove Of Lagrange Park, The | 1.4 mi | ★★★★★ | 12 | 0 |
| British Home, The | 2.3 mi | ★★★★★ | 0 | 0 |
| Aperion Care Westchester | 2.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.