Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Midway Neurological / Rehab Center during CMS and state inspections, most recent first.
Failure to Protect Resident from Assault by Another Resident: A resident with dementia and multiple medical diagnoses was found with facial lacerations, bruising, a left arm injury, and other serious trauma after another resident entered his room and assaulted him. Staff described the other resident as confused, delusional, wandering, and repeatedly attempting to elope, and records showed prior behaviors including profanity, attempted elopement, and an attempt to hit staff. Night staff reported routine rounds, but the assault occurred overnight and was discovered only after noise and screaming were heard from the room. Records also showed no abuse care plan or abuse assessment for either resident.
The facility failed to include abuse care plans in the comprehensive care plans for four residents reviewed for abuse. The SSW Director stated that abuse care plans were expected for new admissions and after significant changes in status, but none were in place for the residents reviewed. Records also showed a resident-to-resident battery in which one resident struck another with a wheelchair leg, and another resident had documented verbal inappropriate language and attempted to hit staff while trying to leave the unit.
The facility failed to obtain complete informed consent, including required second witness signatures and timely resident signatures, before administering psychotropic medications to two residents. One cognitively intact resident with COPD, suicidal ideations, and psychosis received Vistaril, Mirtazapine, and Seroquel while consent forms were either missing a second witness or were signed by the resident only after medication administration. Another resident with bipolar disorder, psychosis, and insomnia, and moderate cognitive impairment, received Lexapro, Trazodone, and Risperdal based on consent and psychotherapeutic drug evaluation documents signed only by an LPN without a second witness. Medication administration records confirmed ongoing administration of these psychotropic drugs despite incomplete consent documentation.
A resident with COPD and a history of acute on chronic respiratory failure was admitted with orders to maintain SpO2 above 93% using continuous O2 at 3–4 L/min via nasal cannula, but the hospital discharge paperwork lacked a specific O2 flow rate and the facility relied on nurse-to-nurse report. Earlier documentation showed the resident stable on 4 L/min with SpO2 at 97%, yet later the resident was found pale, slow to respond, and in respiratory distress on 3 L/min, with EMS recording SpO2 at 80% and the nurse unable to state the resident’s baseline O2 needs. The family reported the resident was usually on higher O2 and BiPAP, and also that the correct O2 orders and BiPAP were not available on arrival. EMS increased O2 to 6 L/min, after which the resident’s breathing, color, and SpO2 improved to 93%. The DON stated the goal was to keep SpO2 above 93% on 3–4 L/min, confirmed the order came via nurse-to-nurse report, and acknowledged the nurse did not complete an assessment or remain with the resident despite a report of chest pain, and no vitals were documented for that shift.
A resident who sustained a fall and was later observed with Battle sign and facial bruising did not receive immediate EMS activation as required by facility policy. Instead, the resident was placed on observation and allowed to leave the unit unaccompanied, leading to a second fall and subsequent acute change in mental status. EMS was only called after the resident became unresponsive, and she was later diagnosed at the hospital with a large subdural hematoma and herniation.
A resident with a history of psychosis, mood disorder, and suicidal ideation became aggressive and was sent to the hospital for a psychiatric evaluation. The facility did not notify the resident's family of the change in condition or the transfer prior to the resident leaving, and there was no documentation of family notification at the time. Staff interviews revealed confusion about notification responsibilities, and the family only learned of the transfer from the resident after the fact.
The facility did not comply with its policy requiring face-to-face physician visits within the first 30 days of admission and at least every 60 days thereafter. This affected four residents, with some not having documented visits since 2022, and others having no visits recorded at all. The DON confirmed the inconsistency in documentation practices among physicians.
A resident with COPD did not receive scheduled CT scans or a pulmonologist evaluation due to the facility's failure to schedule appointments and document actions. Insurance denial and lack of documentation contributed to the delay, leaving the resident without necessary care.
A resident with a history of schizoaffective disorder reported being sexually abused by another resident. Despite being informed of the allegation during a meeting with a health insurance case manager, the facility's management did not document the incident or report it to the appropriate authorities as required by their abuse policy. The administrator acknowledged the failure to report the incident.
The facility staff failed to follow food safety and sanitation protocols, including not wearing beard covers, maintaining improper sanitizing solution levels, and not labeling food in the refrigerator. Additionally, improper cleaning of kitchen equipment was observed, with a cook using the wrong sink for washing utensils. These actions indicate non-compliance with the facility's policies.
The facility failed to refrigerate unopened insulin medications for two residents, storing them at room temperature instead. An LPN acknowledged the error, and the DON emphasized the importance of following manufacturer guidelines for medication storage. The facility's policy requires refrigerated storage for such medications, but this was not adhered to.
A resident with multiple medical conditions experienced complications with an indwelling urinary catheter, including leakage and pain, which were not promptly addressed by the facility staff. Despite the resident's repeated requests for assistance, the staff delayed intervention, leading to the resident calling 911 and being hospitalized for urinary retention and a UTI. Interviews revealed that the staff was aware of the issue but did not treat it as an emergency.
A resident with a history of mental health disorders was hospitalized for destructive behaviors and discharged from the facility without a documented discharge summary or plan of care. The facility did not provide necessary documentation or establish a continuation of care to another LTC facility, despite the resident's need for assistance with daily living activities. The facility's policy required a transfer form and communication with the receiving facility, which was not completed.
The facility failed to develop an individualized care plan for a resident at risk for aspiration, resulting in the resident becoming unconscious and being admitted to the hospital due to complications of choking. The resident was discharged from speech therapy before meeting short-term goals, and staff were inconsistent in their knowledge of the resident's needs during meals.
A resident experienced significant unplanned weight loss due to the facility's failure to implement and document prescribed dietary interventions. The resident's meal tickets did not reflect the physician's orders for double portions at breakfast and a sandwich at night, and the dietary staff did not communicate missed meals to the nursing staff. The care plan and dietary progress notes indicated necessary interventions, but these were not consistently followed, leading to continued weight loss.
The facility failed to prevent incidents of staff-to-resident verbal and mental abuse, affecting four residents. Multiple residents reported that a nurse, V20, made derogatory comments, laughed at patients, and refused to help them. Despite these complaints being raised during a resident council meeting, the facility did not document or thoroughly investigate the allegations, leading to a failure in protecting residents from abuse.
The facility failed to report allegations of abuse by a registered nurse, affecting four residents. Despite residents raising concerns about the nurse's derogatory and disrespectful behavior during a council meeting, the Director of Nursing did not document or investigate the allegations properly, and the Administrator did not report the incident as required by the facility's abuse prevention policy.
The facility failed to enforce its smoking and contraband policies, resulting in a visually impaired resident with multiple mental health diagnoses bringing unauthorized smoking materials into the facility. The resident, who required supervision while smoking, dropped a lit cigarette into a garbage can, causing a fire in the bathroom. This incident had the potential to affect 84 residents on the fifth floor.
A resident with multiple diagnoses, including Bipolar Disorder and Suicidal Ideations, was moved to a different unit due to disruptive behavior without receiving prior written notice. The facility's policy requires written notice before room changes, but the Social Services Director confirmed that this practice was not followed.
A resident with multiple diagnoses reported $800 missing from an envelope after a room change. The resident alleged that a social worker returned the envelope with less money and claimed the facility did not provide proof of the missing funds. Interviews with staff revealed inconsistencies, and the police were called. The facility's investigation found no proof of the amount of money, and a resolution was agreed upon to provide the resident with $400 in retail purchases over four months.
Failure to Protect Resident from Assault by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The resident who was harmed had diagnoses including encephalopathy, cerebral infarction, epilepsy, heart failure, osteoarthritis, dementia, anxiety, hypertension, major depressive disorder, and hemiplegia, and had a BIMS score of 6. During the investigation, surveyors observed the resident in bed with a wrapped left arm and noted multiple facial lacerations and bruising. Staff interviews confirmed that the resident had sustained serious injuries during an incident in which another resident entered his room and assaulted him. The resident who caused the harm was described by staff as confused, delusional, wandering, and repeatedly attempting to elope. Staff reported that he had been moved to the 4th-floor secured dementia unit because of repeated exit-seeking behavior and close monitoring needs. Interviews showed that night shift staff were expected to complete rounds every two hours and as needed, and staff stated they were monitoring residents on the unit. However, the nurse on duty stated that she checked on the wandering resident around 1:00 AM and later heard noise and screaming from the injured resident's room at about 2:15 AM, then found the wandering resident holding the injured resident's hand while the injured resident was bleeding from the head and arm. Record review showed multiple prior notes documenting the wandering resident's repeated elopement attempts, delusions, profanity, and inappropriate behavior, including an attempt to hit staff while trying to leave the unit. The resident was later petitioned for involuntary discharge and described as having a violent temper and being a danger to self and others. The facility's records also showed that neither resident had an abuse care plan on the comprehensive care plan and no abuse assessments were completed. The social service director acknowledged that the injured resident should not have experienced harm and that additional measures could have been implemented to better ensure safety.
Failure to Include Abuse Care Plans for Residents with Abuse-Related Behaviors and Incidents
Penalty
Summary
The facility failed to follow its Abuse Prevention Program by not implementing the care planning process for four residents reviewed for abuse. Record review showed that R1, R2, R3, and R4 did not have abuse care plans included in their comprehensive care plans and did not have abuse assessments. The Social Service Director stated that an abuse care plan should be included in a resident’s comprehensive care plan, should be added for new residents and after a significant change in status, and should be revised and updated as necessary. The director also stated that R1, R2, R3, and R4 did not have an abuse care plan implemented, and that an abuse care plan was expected for these residents. The record review also showed events involving resident behavior and resident-to-resident abuse. A police report documented that local police were dispatched to the facility on 5/12/2026 regarding a battery between R3 and R2, and that R3 used a wheelchair leg to strike R2. Social service notes for R3 dated 4/28/2026 documented that R3 presented with verbal inappropriate language and attempted to hit staff while trying to leave the unit door. The report also stated that R2 sustained multiple injuries from R3, and V12 stated that R2’s care plan should have been in place after that incident.
Incomplete Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain proper informed consent, including required second witness signatures and timely resident signatures, prior to administering psychotropic medications. For one resident with COPD, suicidal ideations, and psychosis, who was cognitively intact and responsible for their own decisions, multiple Psychoactive Medication Therapy Informed Consent forms were either missing a second witness signature or were signed by the resident only after the medications had already been administered. Specifically, consent forms for Vistaril at both 50 mg and 100 mg doses and for Mirtazapine 15 mg were signed only by the psychotropic nurse (V8) without a second witness. The consent form for Seroquel 50 mg was signed by the nurse on one date, but the resident did not sign until a later date, despite the medication having been administered in the interim, as documented on the medication administration records. A second resident, with diagnoses including bipolar disorder, psychosis, and insomnia and a BIMS score indicating moderate cognitive impairment, also received psychotropic medications without complete informed consent documentation. The Psychoactive Medication Therapy Informed Consent for Lexapro was signed only by the psychotropic nurse (V8) with no second witness signature. Additionally, a Psychotherapeutic Drug Evaluation listing Trazodone, Escitalopram, Lorazepam, and Risperdal was signed only by the same nurse, again without a second witness. Medication administration records showed that this resident was receiving Lexapro, Trazodone, and Risperdal during the review period, despite the incomplete consent documentation. These findings show that the facility did not ensure residents were fully informed and that consent procedures, including required signatures, were completed before psychotropic medications were administered.
Failure to Maintain Ordered Oxygen Saturation and Flow for Resident With COPD
Penalty
Summary
The deficiency involves the facility’s failure to maintain ordered oxygen saturation parameters for a resident with COPD and chronic respiratory needs. The resident’s hospital discharge paperwork documented a principal problem of acute on chronic respiratory failure with hypoxia and hypercapnia and COPD with acute exacerbation, with an increased oxygen demand in the emergency department and eventual weaning back to baseline supplemental oxygen needs. The discharge medication list did not specify the oxygen amount to be administered upon discharge, and the facility relied on nurse-to-nurse report to obtain oxygen orders. The physician order sheet at the facility documented that oxygen saturation was to be checked every shift and kept above 93%, with oxygen at 3–4 L/min via nasal cannula continuously. On the morning of the incident, a nurse’s note documented the resident as alert and oriented, with non-labored breath sounds, oxygen at 4 L/min via nasal cannula, head of bed elevated, and SpO2 at 97%. Later, EMS was dispatched for breathing problems. The EMS run sheet documented that upon arrival, the crew found the resident pale, with labored, tachypneic breathing, in respiratory distress, and on 3 L/min of oxygen via nasal cannula, with an SpO2 of 80%. The EMS crew reported that the RN stated the resident was on 3 L/min of supplemental oxygen but was not aware of the resident’s baseline oxygen status or whether 3 L/min was the baseline amount. The family at bedside reported the resident was usually on 6 L/min via nasal cannula and 10 L/min of BiPAP, and also indicated that when the resident arrived the previous day, the facility did not have the resident’s medications, BiPAP, or correct oxygen orders. The complainant reported that when the resident was assessed, the resident was slow to respond, pale, and had difficulty breathing, and that an unnamed nurse confirmed the resident was on 3 L/min of oxygen. The complainant stated the resident was then placed on 6 L/min of oxygen and improved immediately. The EMS run sheet documented that after the crew increased the oxygen to 6 L/min, the resident’s breathing rate and effort normalized, skin color returned to normal, SpO2 increased to 93%, and responsiveness improved. The DON stated that the resident’s oxygen order was not sent with the discharge paperwork but was given in nurse-to-nurse report, that the resident was to be on 3–4 L/min via nasal cannula with a goal to maintain oxygen level above 93%, and that the orders were verified with the physician and entered into the computer. The DON also stated that the nurse did not assess the resident because the resident refused, and that if a resident complained of chest pain, he would expect the nurse to stay with the resident. The nurse identified as the discharging nurse reported that the resident had oxygen via nasal cannula but could not recall the liter flow, stated that vitals were within normal limits but could not recall them, and that the resident was not in distress, while the electronic record contained no documented vitals for that shift. The facility’s oxygen administration policy stated that oxygen is to be provided to maintain saturation levels as needed and as ordered by the attending physician.
Failure to Recognize and Respond to Critical Head Injury Following Resident Fall
Penalty
Summary
The facility failed to accurately assess a critical clinical sign (Battle sign) and did not implement its change in condition policy by failing to immediately activate EMS for a resident who exhibited an acute change in mental status following a fall. The resident was first observed by an LPN with discoloration around the left eye and behind the left ear after reporting a fall during the previous night. The LPN assessed the resident, initiated neurological checks, and notified the physician, who ordered a routine facial x-ray. The resident was placed on observation, and staff were instructed not to allow her to leave the nursing unit alone. Despite these instructions, the resident was later allowed to go to the patio for a smoke break without staff accompaniment. While on the patio, the resident fell again, hitting her head. After being brought back to the nursing unit in a wheelchair, she was lethargic, had abnormal vital signs, and required supplemental oxygen. The nurse on duty called EMS only after the resident became unresponsive in her room, at which point CPR was initiated. EMS arrived to find the resident unresponsive but with a pulse, and noted significant head trauma, including Battle sign and a hematoma. The EMS report indicated that staff had observed the resident with these injuries earlier in the day, following a previous fall. Upon arrival at the hospital, the resident was minimally responsive, with fixed and dilated pupils, and was diagnosed with a large acute subdural hematoma with midline shift and herniation. The hospital record confirmed the presence of Battle sign and severe brain injury. The facility's director of nursing acknowledged that the resident should have been transferred to the hospital when the initial injuries were observed. The facility's policy required immediate EMS activation in medical emergencies, but this was not followed, resulting in a delay in treatment for the resident.
Failure to Notify Family of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to follow its change in condition policy by not notifying a resident's family member of a significant change in the resident's condition and subsequent transfer to the hospital. The resident, who had diagnoses including psychosis, mood disorder, suicidal ideation, and anxiety disorder, became verbally and physically aggressive with staff, resulting in a behavioral code and 1:1 monitoring. The following day, the resident continued to display aggressive behavior and expressed suicidal ideation, leading to a decision to send the resident to the hospital for a psychiatric evaluation. Documentation in the medical record did not show that the family was notified of the resident's behavior or transfer prior to the resident leaving the facility. A late entry note was made several days later, stating that all responsible parties, including family, were notified, but this was not entered until after the event. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for notifying the family, with one nurse assuming another had made the call and another nurse stating that documentation was not completed due to a personal emergency. The DON confirmed that family notification and documentation are required by facility protocol, but there was no evidence that this occurred at the time of transfer. The resident's family member reported learning of the hospital transfer only after being contacted by the resident and was unable to reach the facility for confirmation despite multiple attempts. The family member also visited the facility and was not provided with information about the resident's whereabouts due to the absence of management on the weekend. The facility's policy requires prompt notification of family or representatives in the event of significant changes or transfers, but there was no documentation of such notification or completion of required forms at the time of the incident.
Failure to Conduct Required Physician Visits
Penalty
Summary
The facility failed to adhere to its physician services policy, which mandates that attending physicians conduct face-to-face visits with residents within the first 30 days of admission or re-admission, and at least once every 60 days thereafter. This deficiency affected four residents. The Director of Nursing (DON) acknowledged that some physicians still use paper charting, while others document in the electronic medical record. Upon review, it was found that one resident was last seen by the attending physician in 2022, despite being admitted in 2022. Another resident, admitted in 2023, had no documented face-to-face visits. A third resident, admitted in 2022, had sporadic visits with significant gaps, and a fourth resident, admitted in 2023, also had no documented visits. The facility's policy clearly states the frequency of required visits, which was not followed in these cases.
Failure to Schedule Necessary Medical Appointments for Resident
Penalty
Summary
The facility failed to schedule necessary outside appointments and testing for a resident with chronic obstructive pulmonary disease (COPD). The resident had multiple physician orders for a CT scan with contrast of the lungs and a pulmonologist evaluation, which were not fulfilled. Despite orders dating back to November 2023, the resident had not received the CT scan or seen a pulmonologist by January 2025. The resident expressed frustration over the delay in receiving care, stating they had waited a long time for the pulmonologist appointment. The appointment scheduler indicated that the CT scan was denied by the resident's insurance due to insufficient information, and the nurse was responsible for notifying the physician and documenting any refusals or rescheduling needs. The Director of Nursing acknowledged the lack of documentation and attempts to reschedule the missed pulmonologist appointment. Despite efforts to schedule the appointments, including contacting a pulmonology office that did not accept the resident's insurance, there was no documentation in the resident's medical record to reflect these actions, and the orders remained active without resolution.
Failure to Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to adhere to its abuse policy by not reporting an alleged resident-to-resident sexual abuse incident. A female resident, who has been residing at the facility since 2022 and has a medical history including schizoaffective disorder and delusional disorders, reported that another resident forced her to have sex. The incident was brought to the attention of the facility's management during a meeting with a health insurance case manager, the administrator, the Director of Nurses (DON), and a social worker. Despite the resident's allegations, the facility did not document the meeting or initiate an investigation, and no report was made to the appropriate authorities as required by their abuse policy. The facility's administrator and DON were aware of the allegation on the day it was reported by the health insurance case manager. However, they did not take immediate action to report the incident to the state licensing and certification agency, the resident's representative, or the attending physician, as outlined in their abuse reporting policy. The administrator acknowledged that the allegation should have been reported. The facility's failure to act promptly and follow their established procedures for handling abuse allegations resulted in a deficiency being noted by the surveyors.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to adhere to proper food safety and sanitation protocols, as observed during a survey. Two staff members with beards were seen in the kitchen without wearing beard covers, which is against the facility's policy for maintaining personal hygiene. Additionally, a Certified Nursing Assistant was observed in the kitchen without a beard cover while handling water jugs. These actions indicate a lack of compliance with the facility's policy that requires food service employees to maintain good personal hygiene, including covering beards with appropriate hair restraints. The facility also failed to maintain the required sanitizing solution concentration in the three-compartment sink. During dishwashing, the sanitizing solution was tested at 100 ppm, below the required 200 ppm of Quaternary Ammonium solution. This discrepancy was noted by a Dietary Aide, who acknowledged the need for a higher concentration. Furthermore, a clear container with salad was found in the refrigerator without a label, and the Dietary Manager later confirmed it belonged to a staff member, which is against the facility's policy for labeling and dating food in storage. Improper cleaning and sanitizing practices were also observed. A cook was seen rinsing a blender and spatula used for meal preparation in the food preparation sink, which is not designated for washing dishes or utensils. The cook admitted to not using soap and acknowledged that the items should have been cleaned in the three-compartment sink. The Dietary Manager confirmed that the food preparation sink is only for rinsing vegetables and filling pans with water, not for cleaning equipment. These actions demonstrate a failure to follow the facility's procedures for cleaning and sanitizing kitchen equipment and utensils.
Improper Storage of Unopened Insulin
Penalty
Summary
The facility failed to properly store unopened medications that required refrigeration, specifically affecting two residents. During an inspection of the medication cart on the second floor, an LPN was present when it was discovered that unopened insulin medications, which were labeled to be refrigerated before opening, were stored at room temperature in the medication cart. The medications involved were Lantus pens for one resident and a Novolin R vial for another resident, both of which are used for managing diabetes. The LPN acknowledged that the medications should have been refrigerated to maintain their durability. The Director of Nursing also confirmed the importance of refrigerating unopened insulin to preserve its integrity, as per the manufacturer's recommendations. The facility's pharmacy medication storage policy requires that refrigerated products be stored in the appropriate refrigerator upon delivery, with the responsibility falling on the nurse and/or Director of Nursing to follow drug-specific guidelines. However, this protocol was not followed, leading to the deficiency.
Failure to Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide timely assessment and adequate intervention for a resident experiencing complications with an indwelling urinary catheter. The resident, a male with multiple medical diagnoses including Multiple Sclerosis and quadriplegia, was admitted to the facility and required substantial assistance for all activities of daily living. Despite being cognitively intact, the resident experienced a leaking urinary catheter, abdominal fullness, and pain, which were not promptly addressed by the facility staff. On the day of the incident, the resident reported the leaking catheter and associated pain to the nursing staff multiple times. However, the staff did not take immediate action to change the catheter or alleviate the resident's discomfort. The resident was instructed to wait until after medication pass, and when he requested emergency assistance, he was told to call 911 himself. Eventually, the resident called 911 and was taken to the hospital, where a large amount of urine was drained, and he was treated for urinary retention and a urinary tract infection. Interviews with facility staff revealed that the resident had been requesting a catheter change for several days, and the issue was known to the staff. The facility's Director of Nurses acknowledged that the situation was not treated as an emergency, and the attending physician noted that routine catheter care was not adequately performed. The facility's failure to provide timely catheter care and intervention led to the resident's hospitalization and treatment for a urinary tract infection.
Failure to Document Discharge Summary and Plan of Care
Penalty
Summary
The facility failed to adhere to its resident discharge policy by not documenting a discharge summary and plan of care for a resident who was hospitalized for destructive behaviors and did not return to the facility. This deficiency was identified during a review of the discharge procedures for a resident with a history of Schizoaffective disorder, Dementia, Attention-Deficit Hyperactivity Disorder, and bipolar disorder. The resident, who required staff assistance with activities of daily living, was admitted to the hospital for acute behaviors and subsequently discharged from the facility without proper documentation or a continuation of care plan to another long-term care facility. The facility's Director of Nursing and Administrator acknowledged the situation, indicating that the resident was sent to the hospital due to destructive behaviors and that there was a delay in deciding whether to readmit the resident. Despite the facility's stated intention to take the resident back if no other facility would, the hospital ultimately found another placement for the resident. The facility's policy required a transfer form with pertinent medical information and communication with the receiving facility to maintain continuity of care, which was not completed in this case.
Failure to Develop Individualized Care Plan for Resident at Risk for Aspiration
Penalty
Summary
The facility failed to develop an individualized plan of care for a resident identified to be at risk for aspirations and assessed to have impairments while eating. The resident, who had a history of alcohol dependence with alcohol-induced persisting dementia, heart failure, and atherosclerotic heart disease, was discharged from speech therapy before reaching the short-term goals identified in the evaluation. This failure resulted in the resident becoming unconscious, with CPR being initiated, an excessive amount of food found in the resident's airway, and the resident being admitted to the hospital where he later expired due to complications of choking. The incident occurred when the resident was observed with jerky movements in the dining room after finishing lunch. Staff initiated CPR and called paramedics when the resident became unconscious and stopped breathing. The emergency room records and fire department report confirmed that a significant amount of food was found in the resident's airway, leading to a suspected hypoxic arrest and cardiac arrest. Interviews with staff revealed inconsistencies in their knowledge of the resident's needs and the level of assistance required during meals. The speech therapy evaluation had identified several issues with the resident's swallowing and eating behaviors, including difficulties with labial closure, rapid mastication, incomplete bolus formation, and poor attention to the task. Despite these findings, the resident was discharged from speech therapy without meeting the short-term goals for improving oral clearance and bolus control. The facility's care plan did not reflect the identified issues or provide a plan to ensure safe oral intake and reduce the risk of aspiration for the resident.
Failure to Implement and Document Weight Loss Interventions
Penalty
Summary
The facility failed to develop, implement, evaluate, and reevaluate a plan to prevent continued unplanned weight loss for a resident (R14). This resulted in R14 experiencing a significant weight loss of 18.55% over 90 days. The deficiency was identified through observations, interviews, and record reviews. R14's family member (V25) reported that R14 had lost about 30 pounds and mentioned that R14 had complained about not being fed adequately by the facility. Observations on different dates confirmed that R14's meal tickets did not reflect the physician's orders for double portions at breakfast and a sandwich at night, which were intended to address the weight loss issue. Additionally, the dietary staff did not inform the nursing staff if a resident missed meals, and the CNA (V47) was unaware of R14's significant weight loss and the dietary interventions required for R14. The dietary assistant (V26) and the dietitian (V48) confirmed that the diet slips did not include the prescribed double portions and sandwich at night. The dietitian acknowledged that R14 had been reviewed for unplanned weight loss and that the plan included double portions at breakfast, a sandwich at night, consultation with the psych physician, and weekly weights. However, the psych physician (V49) stated that he does not deal with weight loss and that psych medications typically result in weight gain, not loss. The dietitian could not explain why the planned weight loss interventions were not documented on the diet slips and did not respond when asked when the planned weight loss became unplanned. R14's care plan and dietary progress notes indicated that the resident had experienced significant weight loss and outlined interventions such as double portions at breakfast, a sandwich at night, and regular weight monitoring. However, these interventions were not consistently implemented or documented, leading to continued weight loss. The facility's policy on care plans emphasized the need for comprehensive assessments and individualized care plans, but this was not effectively executed for R14, resulting in a failure to prevent further weight loss.
Failure to Prevent Verbal and Mental Abuse by Staff
Penalty
Summary
The facility failed to prevent incidents of staff-to-resident verbal and mental abuse, affecting four residents. Resident R10 reported that staff, particularly V20, claimed they did not need help and made derogatory comments about their blindness. R10 has multiple diagnoses, including Schizoaffective Disorder, Schizophrenia, and Blindness, and is cognitively intact. Resident R21 stated that V20 laughed at patients, called them derogatory names, and refused to help them. R21 also has significant mental health diagnoses and is cognitively intact. Resident R22 described V20 as arrogant and problematic, and this concern was raised during a resident council meeting. R22 has multiple mental health diagnoses and is cognitively intact. Resident R23 reported that V20 talked down to residents and argued with them, which was also discussed in a resident council meeting. R23 has several chronic conditions and is cognitively intact. The facility's Director of Nursing (DON) acknowledged that concerns about V20's behavior were raised during a resident council meeting, but no formal investigation was documented. The DON believed that V20 was simply firm with residents and dismissed the complaints as a result of a specific incident involving another resident, R24, who was not listed in the meeting notes. The facility's Administrator, who is also the abuse coordinator, confirmed that verbal and mental abuse includes derogatory remarks and mocking residents. Despite being aware of the allegations, the facility did not document or thoroughly investigate the complaints, leading to a failure in protecting residents from verbal and mental abuse as per their Abuse Prevention Program Policy and Procedure.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state surveying agency, affecting four residents. Residents R21, R22, and R23 reported that a registered nurse, V20, exhibited abusive behavior, including laughing at patients, calling them derogatory names, and having a generally bad attitude. These concerns were raised during a resident council meeting, but the Director of Nursing (V13) did not document or investigate the allegations properly. V13 dismissed the concerns, attributing them to a misunderstanding and did not follow the facility's abuse prevention policy, which mandates immediate reporting and investigation of any abuse allegations. The Administrator (V5), who is the abuse coordinator, acknowledged that verbal and mental abuse includes derogatory remarks and disrespectful behavior. Despite this, V5 did not report the allegations from R24 about V20 in February 2024. The facility's abuse prevention policy requires all incidents or allegations of abuse to be documented and investigated, but this procedure was not followed. The facility's failure to document and investigate the allegations of abuse led to a deficiency in their compliance with abuse reporting regulations.
Failure to Enforce Smoking and Contraband Policies
Penalty
Summary
The facility failed to have an effective smoking policy and contraband policy to prevent unauthorized items and smoking materials. This deficiency affected two residents, one of whom, a visually impaired resident with multiple mental health diagnoses, brought unauthorized smoking materials from a home visit. The resident, who required supervision while smoking, dropped a lit cigarette into a garbage can, causing a fire in the bathroom. This incident had the potential to affect 84 residents on the fifth floor. The incident report and interviews reveal that the resident was legally blind and had auditory hallucinations, schizoaffective disorder, post-traumatic stress disorder, bipolar disorder, and anxiety. The resident admitted to smoking in the bathroom and stated that she received the cigarette and lighter from her brother during a visit. The facility's staff detected smoke, evacuated the resident, and extinguished the fire. The resident's care plan indicated that she was a supervised smoker and not capable of handling her own smoking materials. Interviews with staff members confirmed that the resident had brought smoking materials back to the facility after a visit with family. The facility's smoking policy and contraband policy were reviewed with the family upon admission, but the resident still managed to bring unauthorized items into the facility. The facility's policies stated that no lighters or matches were allowed in the building and that unsafe smokers should be supervised. Despite these policies, the resident was able to bring and use smoking materials unsupervised, leading to the fire incident.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to notify a resident (R11) in writing prior to performing a room change. R11, who has diagnoses including Chronic Pain Syndrome, Bipolar Disorder, Psychotic Disorder, Depression, and Suicidal Ideations, was cognitively intact with a score of 15 on the cognitive patterns assessment. On 12/4/23, R11 was moved to a different unit due to disruptive behavior in the common area. However, the resident was not given any written notice or paper regarding the room change. The Social Services Director confirmed that the facility does not provide residents with a copy of the written room change notice. The facility's policy states that residents have the right to receive written notice, including the reason for the change, before their room or roommate changes. The Notification of Room Change form was completed the day after the room change occurred, indicating non-compliance with the policy.
Failure to Prevent Loss of Resident's Funds During Room Change
Penalty
Summary
The facility failed to prevent the loss of a resident's funds during a room change, affecting one resident diagnosed with Chronic Pain Syndrome, Bipolar Disorder, Psychotic Disorder, Depression, and Suicidal Ideations. The resident, who was cognitively intact, reported that $800 was missing from an envelope containing $1332 after giving the locker key to a social worker. The resident alleged that the social worker returned the envelope with only $532 and claimed that the social worker said, 'you ain't getting that back.' The resident had received a $1900 check, which was cashed by the facility, and the funds were kept in an envelope in the resident's coat pocket in a locked closet. During the room change, the resident was made to stay in the dining room, and the social worker retrieved the envelope from the coat pocket. Interviews with various staff members, including the Business Office Manager, Social Services, Security Staff, and the Director of Nursing, revealed inconsistencies in their accounts of the events. The Business Office Manager confirmed that the resident managed his own funds and was only allowed $100 in cash at a time. The Social Services staff involved in the room change denied seeing or handling the envelope with the money. The Security Staff and the Director of Nursing also provided conflicting statements about the handling of the envelope and the resident's behavior during the incident. The facility's investigation found no proof of the amount of money the resident claimed to have had, and the resident was unable to provide proof of the missing funds. The police were called, and a report was filed, indicating that the resident was alert and coherent and reported $800 missing from the envelope. The facility's abuse investigation included a signed document by the Administrator, the resident, and Social Services, agreeing to a resolution of the matter by providing the resident with $400 in retail purchases over four months. The facility's Abuse Prevention Program Policy and Procedure defines misappropriation of resident property as the wrongful use of a resident's belongings or money without consent.
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Nursing homes near Bridgeview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion Of Bridgeview, The | 0.6 mi | ★★★★★ | 11 | 0 |
| Hickory Vlg Nrsg & Rhb | 1.3 mi | ★★★★★ | 0 | 0 |
| Aperion Care Oak Lawn | 1.4 mi | ★★★★★ | 17 | 0 |
| Aliya Of Oak Lawn | 1.6 mi | ★★★★★ | 11 | 2 |
| Landmark Of Oak Lawn Rehabilitation And Nursing Ce | 2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.