Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Neighbors Health Center during CMS and state inspections, most recent first.
A resident who engaged in self-harm was sent to a hospital behavioral unit, and on the same day the facility issued an involuntary discharge notice stating the resident’s needs and welfare could not be met and that safety was endangered. The hospital psychiatric NP later documented that the resident was A&O x4, denied SI/HI, expressed remorse, was on low suicide precautions, and only required routine psychiatric follow-up and medication monitoring, and reported that the facility declined to readmit the resident despite her being cleared for discharge. The Administrator and a general NP expressed concerns about supervision and lack of onsite psychiatry, but the facility did not perform or document any clinical or psychosocial assessment of the resident between transfer and the proposed return, nor did it document specific needs that could not be met, contrary to its own involuntary discharge policy.
Multiple residents on one hall experienced prolonged cold room temperatures below the stated comfort range, with blankets placed over windows and AC units to block drafts and residents sleeping under several blankets or in coats and hoodies. Cognitively intact residents reported that it had been cold for weeks to months, described feeling sad, angry, disappointed, and depressed, and some refused showers or washed quickly because their rooms were too cold. Staff, including CNAs and an LPN, confirmed that the hall was "freezing" for an extended period, that residents complained continuously, and that they responded mainly by providing extra blankets and notifying maintenance. A representative payee monitor and the ombudsman observed or were aware of ongoing heating complaints, including residents in bed with multiple blankets and coats, and noted that heating concerns raised in resident council were not reflected in the minutes. The maintenance director and administrator reported boiler blockages and flow issues, acknowledged that a boiler remained down, and documented room temperatures in the mid-60s, which did not meet the expected comfortable temperature range.
Staff were observed distributing ice water to several residents using unsanitary practices, including placing a wet scoop on the water cart and holding cups above an open cooler, contrary to facility policy and increasing the risk of cross contamination.
A resident with severe cognitive impairment and a stage 4 pressure ulcer experienced a significant change in condition, including unusual inactivity and possible blood in urine. CNAs reported these changes to an LPN, who checked vital signs but did not perform or document a full assessment or notify the nurse practitioner as required by facility policy. The lack of timely assessment, documentation, and communication resulted in delayed care until the resident was sent to the hospital.
Multiple residents were subjected to physical abuse by other residents, resulting in serious injuries including a head laceration, subdural hematoma, and a spinal fracture. Staff and medical documentation confirmed that altercations occurred in common areas and resident rooms, with staff sometimes unable to intervene in time to prevent harm. The facility's abuse prevention policy was not effectively implemented, leading to residents being harmed by peers.
Mechanical lift equipment was not kept in safe working order, as multiple CNAs reported frequent battery failures and malfunctioning emergency release mechanisms during resident transfers. In several cases, a resident was left suspended in the air when the lift lost power, and staff had to manually lower the individual due to nonfunctional emergency releases. Staff and residents described ongoing problems with unreliable batteries and broken lift components, while maintenance and safety checks were not consistently performed.
During a shift change, an LPN, another LPN, and the Dietary Manager engaged in a loud argument at the nurses' station, using profane and insulting language about the facility's menu planning. A resident was present and witnessed the altercation, which violated the facility's policy on resident dignity and privacy.
Two residents were involved in a physical altercation, resulting in one being knocked down and kicked, with subsequent bruising documented. Despite the incident and later disclosure of physical contact, the facility did not report the abuse allegation to the state agency or police until months later, only after receiving an anonymous hotline call. The facility's policy requiring immediate reporting of abuse was not followed.
A resident sustained a head injury when their wheelchair flipped backwards during transport by non-clinical staff. The incident was not reported to clinical staff, and upon return, the acting DON/ADON assessed the resident but failed to document the assessment, perform or document neuro checks, or notify the physician. The RN assigned to the resident did not complete or document neuro checks, and the event was not recorded in the medical record, contrary to facility policy.
Staff transferred multiple residents using a mechanical lift with a non-functioning emergency release and unreliable batteries. In one case, a CNA had to manually lower a resident when the lift failed, and the broken equipment was not removed from use. Staff continued to use the malfunctioning lift for other residents, and transfers were performed without proper assessment or care plan updates for residents with cognitive and physical impairments.
The facility did not maintain accurate and up-to-date medical records for three residents following significant incidents, including a transport van fall, an elopement, and a mechanical lift malfunction. In each case, staff were aware of the events but failed to document them in the residents' records as required by facility policy.
The facility failed to accurately monitor and record the weights of several residents, resulting in significant discrepancies without reweighs or physician notifications. Despite the facility's policy requiring investigation of significant weight changes, this was not followed, leading to a deficiency in maintaining residents' nutritional status.
The facility failed to securely store medications when the ADON found the nurse's keys under a binder on the medication cart. The DON confirmed that keys should always be with the nurse to ensure medication security, as per the facility's policy revised in August 2023.
A facility failed to follow proper infection control practices during incontinence care and linen handling. A CNA transported soiled linens without bagging them, contrary to policy, and another CNA did not change gloves between dirty and clean tasks while caring for a resident with multiple health issues. The DON confirmed the importance of these practices to prevent cross-contamination.
Two residents in an LTC facility did not receive adequate ADL assistance, leading to deficiencies in personal hygiene and incontinence care. One resident, with Alzheimer's and other conditions, did not receive oral care or shaving assistance as required. Another resident, with severe malnutrition and dementia, did not receive proper incontinence care from a new CNA. The DON confirmed that these care practices are standard and all aides are trained accordingly.
A resident with a catheter was observed with the urinary drainage bag improperly placed on his thighs, contrary to the care plan and facility policy requiring it to be below bladder level to prevent backflow and UTIs. The DON confirmed the importance of proper bag positioning, especially since the resident had recently been treated for a UTI.
Failure to Assess and Document Needs Before Involuntary Discharge After Psychiatric Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for return from an acute care psychiatric hospitalization and to document specific needs that could not be met upon the resident’s proposed return, prior to issuing an involuntary discharge. The resident had been found in her room cutting her arm with cuticle scissors and was sent to the hospital. On the same day as the transfer, the Administrator completed an Involuntary Discharge (IVD) form and had it delivered to the emergency room, citing that the resident’s self-harm indicated she would require additional support services the facility could not provide. The Administrator stated that the facility did not have onsite behavioral health services and only had a psychiatric NP visit every two weeks, and that they believed they lacked the resources to keep the resident safe. Following the resident’s transfer, the hospital’s psychiatric NP evaluated the resident and documented that the resident was alert and oriented, denied suicidal or homicidal ideation, expressed regret for the self-harm incident, and requested to return to the nursing home where she felt safe. The hospital NP reported that the resident’s anxiety medication was adjusted but remained essentially the same as before, that the resident was on low suicide precautions, and that 15-minute checks were a standard hospital protocol not required at the nursing home. The hospital NP stated that the only ongoing psychiatric need was follow-up for medication monitoring and management, and that the resident no longer met criteria for inpatient admission and was cleared for discharge back to the facility. The hospital NP also stated that the facility did not have the resident evaluated by a medical professional prior to providing the involuntary discharge and that the facility immediately decided not to take the resident back. The Administrator reported that when the hospital first called to discharge the resident back, she referenced hospital documentation indicating 1:1 supervision, moderate suicide risk, and new medications needing monitoring, and used this as a basis to refuse readmission. The Administrator also stated that a general NP agreed it was not safe for the resident to return, although that NP later clarified she did not recommend the IVD and that the facility makes discharge decisions. The facility’s contracted psychiatric NP indicated she had not evaluated the resident or spoken with hospital staff and therefore could not comment on the resident’s safety to return. Review of the resident’s EMR showed no assessments documented between the date of transfer and the later survey date, and no notes regarding the proposed return or specific needs that could not be met by the facility. The facility’s own Involuntary Discharge Policy requires a thorough clinical and psychosocial assessment, documentation of current status and needs, behaviors prompting discharge, interventions tried, and evidence that the facility cannot meet the resident’s needs, but such assessment and documentation were not present in the resident’s record. The IVD notice given to the resident stated that the transfer or discharge was due to the resident’s welfare and needs not being able to be met in the facility, as documented by the physician, and that the safety of individuals in the facility was endangered. The notice listed the hospital as the relocation site and indicated that the transfer/discharge date was the same day as the emergency transfer. The hospital psychiatric NP reported that many facilities typically come to the hospital and assess residents once stabilized to determine if they can meet their needs, but that this facility did not do so for this resident. Overall, the record review and interviews showed that the facility did not perform or document a clinical assessment of the resident’s condition and needs at the time of the proposed return from the hospital, nor did it document specific unmet needs in the EMR, despite issuing an involuntary discharge and asserting that the resident’s needs and safety could not be managed at the facility.
Prolonged Inadequate Room Temperatures and Resident Discomfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within a comfortable range, resulting in prolonged cold conditions on the 100 hall for most residents reviewed. Multiple resident rooms had blankets placed on windowsills and over air conditioning units to block drafts. Residents consistently reported that their rooms had been cold for weeks to months, particularly during the winter, and that the problem persisted whenever the outside temperature was low. Facility temperature logs for the 100 hall documented room temperatures ranging from approximately 62.6 to 68.1 degrees Fahrenheit on specific dates, with a baseboard temperature as low as 54.6 degrees Fahrenheit, which is below the stated comfortable range of 71 to 81 degrees Fahrenheit. Cognitively intact residents described needing multiple blankets to stay warm, with some sleeping under three to five blankets or wearing coats and hoodies in bed. Several residents stated that it had been cold “all winter” or for “months,” and some reported specific low temperatures such as 61 degrees. Residents reported feeling sad, angry, disappointed, depressed, and as though they were not being heard because of the ongoing lack of heat. Some residents refused showers or had to wash quickly due to the cold in their rooms, and at least one resident’s shower refusal was documented on a shower sheet. Residents also reported that while they were offered the option to move to other, warmer units, they declined because they did not want to move their belongings or change rooms. Staff interviews corroborated the residents’ reports, with CNAs and nursing staff describing the 100 hall as “freezing” and cold for about a month to several months, noting that residents complained all day about being cold and often stayed in bed. Staff reported that they responded by providing extra blankets, wearing hoodies themselves while working, and notifying maintenance, but they were not informed why the hall remained so cold. A representative payee monitor and the ombudsman both observed or were aware of ongoing heating issues, with the monitor noting a clear temperature difference between administrative and resident areas and seeing residents in bed with multiple blankets and wearing coats. The ombudsman stated that residents had been complaining about no heat for most of the winter and that these concerns were raised in a resident council meeting, although the meeting minutes did not reflect the heating complaints. The maintenance director acknowledged receiving complaints about cold temperatures on specific dates and identified problems with the facility’s boiler system, including a blockage in the fourth boiler and flow issues throughout the building, with the 100 wing being the most concerning. He stated that the fourth boiler remained down and that room temperatures were being kept at 68–69 degrees, which is below the 71–81 degree comfort range cited in the deficiency. Blankets were intentionally placed on windowsills and air conditioners to reduce drafts. The administrator reported that there were blockages in the boiler system and that a new heating and cooling system had been ordered but not yet installed. The facility’s own severe cold weather procedures required assuring that heating systems were working correctly in residents’ rooms, and the Illinois Department on Aging residents’ rights booklet stated that the facility must be safe, clean, comfortable, and homelike, underscoring that the prolonged cold conditions and substandard room temperatures constituted a failure to provide a comfortable environment.
Unsanitary Water Distribution Practices Identified
Penalty
Summary
Facility staff failed to provide water to residents in a sanitary manner, as observed during the distribution of ice water to five residents. An activity aide used a scoop to fill residents' cups from a cooler containing water and ice, placing the wet scoop back onto the water cart after each use, rather than storing it in a sanitary location. Additionally, the aide held residents' water cups, which had been removed from their rooms, directly above the open cooler while filling them. The food service director confirmed that these practices were not in accordance with facility policy, which prohibits placing the scoop on the cart and holding cups above the cooler due to the risk of cross contamination. These actions were observed during the survey and were inconsistent with the facility's policy on ice dispensing, which requires food and beverages to be stored, prepared, distributed, and served in a sanitary manner to prevent foodborne illness.
Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of a stage 4 sacral pressure ulcer was properly assessed and monitored following a change in condition. Staff observed that the resident, who was typically confused but active and frequently attempted to get up unassisted, was unusually inactive, did not use her call light, and did not attempt to get out of bed. Certified Nursing Assistants (CNAs) reported these changes to the nurse on duty, who responded only by checking vital signs multiple times throughout the shift but did not perform or document a comprehensive assessment or follow-up. Additionally, possible blood in the resident's urine was reported during the morning shift, but there was no documented assessment or notification to the nurse practitioner until the resident was sent to the hospital later that night. The facility's policy required prompt assessment, documentation, and notification of changes in a resident's condition, but these steps were not followed. The nurse on duty did not recall being informed of the possible blood in urine and did not document any assessment or communication regarding the resident's change in status. The Director of Nursing and Nurse Practitioner both confirmed that, according to facility policy and standard practice, a full assessment and notification should have occurred, and all actions should have been documented in the resident's medical record. The lack of timely assessment, documentation, and communication led to a delay in appropriate care for the resident.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in significant injuries. In one incident, a resident in the memory care dining room sustained a posterior head laceration and an acute subdural hematoma after an altercation with another resident. Staff accounts indicate that two residents were struggling over a chair, leading to both falling, with one resident landing on top of the other and causing a head injury that required hospital treatment. Witnesses described one resident shoving a chair into another, causing a fall and head trauma, with visible damage to the wall and significant bleeding. Documentation from the hospital confirmed the head injury and subdural hematoma, and staff noted that the aggressor had previously shown aggression toward staff but not other residents. Another incident involved two roommates who had a history of disagreements. During an altercation, one resident fell from his wheelchair and was then kicked multiple times by his roommate. Staff intervened to separate them, and subsequent medical assessment revealed bruising consistent with defensive injuries and a fracture in the lower spine. The resident reported being kicked while on the floor, and staff and nurse practitioner documentation supported the account of physical abuse. The aggressor admitted to kicking the other resident after a verbal threat, and the victim was later discharged from the facility. The facility's records and staff interviews indicate that these incidents were not isolated and involved failures to prevent resident-on-resident abuse. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the documented events show that residents were subjected to physical harm by other residents, with staff sometimes unable to intervene in time to prevent injury. The incidents were reported to the state agency and local authorities, but the documentation reveals gaps in preventing and documenting abuse between residents.
Mechanical Lift Equipment Not Maintained in Safe Working Order
Penalty
Summary
The facility failed to ensure that mechanical lift equipment was maintained in safe and operable condition for five residents who required mechanical lifts for transfers. Multiple CNAs reported that batteries for the mechanical lifts frequently failed to hold a charge, resulting in situations where residents were left suspended in the air or unable to be safely lowered during transfers. In one instance, a CNA described attempting to lower a resident onto the toilet when the lift battery died, and after trying several replacement batteries that also failed, the emergency release mechanism did not function. The CNA ultimately had to manually lower the resident using a gait belt and her own knees for support. The same lift was later observed to have a broken emergency release ring that was not attached to the shaft, rendering it ineffective. Other staff members confirmed ongoing issues with lift batteries, malfunctioning emergency releases, and damaged wheels on some lifts. Residents who regularly used the sit-to-stand machines also reported repeated incidents where lifts lost power while they were suspended. The facility's maintenance policy assigns responsibility for equipment upkeep to the maintenance department, but interviews revealed uncertainty about whether safety checks had been performed and that staff continued to use lifts with known safety issues.
Resident Exposed to Undignified Staff Altercation at Nurses' Station
Penalty
Summary
Staff members, including two LPNs and the Dietary Manager, engaged in a loud verbal altercation at the nurses' station during shift change. The argument involved the use of profane and insulting language, with one LPN calling the dietitian derogatory names and using explicit language. The altercation was witnessed by other staff, including a CNA who attempted to intervene and de-escalate the situation. During this incident, at least one resident was present and seated by the nurses' station, within earshot of the argument. The facility's policy on resident privacy and dignity specifically instructs staff to avoid discussing private or personal issues in public and to refrain from using patronizing or insulting language. Despite this, the staff's conduct during the altercation failed to uphold these standards, resulting in a situation where a resident was exposed to undignified and inappropriate staff behavior.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving two residents was reported to the state surveying agency in a timely manner. In December 2023, two residents were involved in a physical altercation in their shared room, which resulted in one resident being knocked down and kicked by the other. Progress notes indicated that one resident initially denied physical contact but later reported being kicked while on the floor, with visible bruising to his right upper arm, elbow, and head. Despite these allegations and physical findings, the incident was not reported to the state agency or local police at the time it occurred. The facility's administrator stated that the incident was not reported initially because it was determined that no contact had occurred. However, months later, after receiving an anonymous compliance hotline call, the administrator reported the incident to the state agency and local police, eight months after the original event. The facility's own abuse prevention policy requires immediate reporting of abuse allegations, but this protocol was not followed in this case. Documentation shows that the facility only submitted a report after the anonymous call, and no further information was provided to the state agency beyond the original late report.
Failure to Assess, Document, and Notify After Resident Head Injury During Transport
Penalty
Summary
A resident was transported to an orthopedic appointment by the facility's former Maintenance Director, who was not clinical staff. During transport, the resident's wheelchair flipped backwards, causing the resident to hit his head and sustain a scrape. The Maintenance Director did not notify the facility of the incident, relying on the resident's statement that he was fine and the fact that he was at a doctor's office. The resident's daughter discovered the injury at the appointment and contacted the facility, expressing concern about not being informed of the incident. Upon return to the facility, the acting DON/ADON, who had a background in neurology trauma, assessed the resident and determined he was fine but did not document the assessment, perform or document neuro checks, or notify the physician as required by facility policy. The RN assigned to the resident was instructed to perform hourly neuro checks but did not complete or document them, citing being busy with nursing students. The resident's electronic medical record contained no documentation of the incident, neuro checks, or physician notification, despite facility policies requiring such actions following a fall or head injury.
Failure to Ensure Safe Resident Transfers Due to Faulty Equipment
Penalty
Summary
The facility failed to ensure that residents were transferred safely using properly functioning equipment, as evidenced by multiple incidents involving three residents. Staff used a sit-to-stand machine and a mechanical lift with a non-functioning emergency release and unreliable batteries. In one instance, a CNA attempted to lower a resident onto the toilet using the sit-to-stand machine, but the battery died and the emergency release did not work. The CNA had to manually lower the resident to a wheelchair, and the broken equipment was not removed from use or labeled as defective. Staff reported that management had been informed about the unreliable equipment, but no immediate action was taken to prevent further use. Additionally, staff continued to use the same malfunctioning mechanical lift to transfer other residents, despite being aware that the emergency release was not operational. The care plan for one resident specified the use of a mechanical lift due to cognitive impairment and physical limitations, but staff attempted a sit-to-stand transfer without a proper assessment or care plan update. Maintenance staff later confirmed the emergency release was not attached as required, and the facility's maintenance policy indicated responsibility for keeping equipment safe and operable at all times.
Failure to Document Resident Incidents in Medical Records
Penalty
Summary
The facility failed to ensure that resident records were up to date and accurate for three residents. In the first instance, a resident was involved in an incident where he flipped backwards in his wheelchair while being transported in a van and hit his head. This event was confirmed by the resident, his daughter, and the former Maintenance Director, but there was no documentation of the incident in the resident's electronic medical record. The facility's fall prevention and management policy requires documentation of such events, including outcomes, observations, and notifications. In the second case, a resident exited the building through a dining room door and was found outside on the sidewalk. Staff responded to the alarm and brought the resident back inside without injury. The LPN involved stated she was told by the Administrator to hold off on charting, and no documentation of the event was found in the resident's record. The facility's policy requires reporting and documentation of missing residents. In the third case, a resident experienced a malfunction with a sit-to-stand machine during toileting, requiring manual assistance to be safely lowered. The CNA, LPN, and Social Service Director were aware of the incident, but no documentation was made in the resident's record, contrary to the facility's charting and documentation policy.
Failure to Ensure Accurate Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate weights were obtained and recorded for five residents, leading to a deficiency in monitoring their nutritional status. The report highlights significant discrepancies in daily weight recordings for these residents, with no reweighs conducted or physicians notified of the changes. For instance, one resident experienced a 21.8-pound weight loss in one day, and another had a 26.6-pound weight gain in a single day, yet there was no documentation of reweighs or physician notification. The Director of Nursing acknowledged that a weight change of five or more pounds in a day should prompt a reweigh, but this standard was not met. The facility's policy on weight management requires investigation of significant or trending weight changes, but this was not adhered to. The Assistant Director of Nursing noted that notification to a physician would depend on specific parameters, but expected reweighs for large discrepancies. Despite these expectations, the report shows a lack of action in response to significant weight changes, indicating a failure to follow the facility's policy and standard care practices.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to securely store medications, as observed during a survey. During a medication storage review, the Assistant Director of Nursing (ADON) had to locate the nurse to obtain the keys to the medication cart. Upon returning, the ADON found the narcotic count binder on the cart with the nurse's keys underneath its cover. The ADON used these keys to open the medication cart. The ADON acknowledged that the keys should be with the nurse at all times and not left on the cart. The Director of Nursing (DON) confirmed that the keys should always be with the nurse to ensure medication security and prevent residents from accessing the cart. The facility's policy, revised in August 2023, mandates that drugs and biologicals be stored safely, securely, and orderly.
Infection Control Deficiencies in Linen Handling and Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during incontinence care and linen handling. A Certified Nursing Assistant (CNA) was observed transporting soiled linens without bagging them, holding them against her body, which is against the facility's policy. The CNA admitted to being aware of the correct procedure but did not follow it due to nervousness. The Director of Nursing confirmed that the facility's policy requires soiled linens to be transported in a bag or using a soiled linen cart to prevent cross-contamination. Additionally, during incontinence care for a resident with multiple health issues, including cerebral infarction and urinary tract infection, two CNAs failed to change gloves and perform hand hygiene between dirty and clean tasks. One CNA continued to wear contaminated gloves while handling clean items and performing various tasks, contrary to the facility's gloves policy. The Director of Nursing emphasized the importance of changing gloves between dirty and clean areas to prevent the transfer of germs, feces, and urine to clean areas.
Deficiencies in ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, leading to deficiencies in personal hygiene and incontinence care. One resident, diagnosed with Alzheimer's disease, major depressive disorder, dementia with psychotic disturbance, and type 2 diabetes, required maximum assistance for oral and personal hygiene. During a morning care session, a CNA provided incontinence care, dressing assistance, and hair brushing but failed to offer or provide oral care or shaving assistance, despite the resident's care plan indicating a risk for ADL decline. The resident expressed dissatisfaction with the lack of shaving assistance, indicating a preference for having facial hair removed. Another resident, with severe protein-calorie malnutrition and dementia with behaviors, was found to have moderate cognitive impairment and incontinence issues. A new CNA provided toileting assistance but failed to perform incontinence care after removing a soiled brief, instead applying a new brief without cleaning the resident. The Director of Nursing confirmed that incontinence care is standard practice for infection prevention, dignity, and cleanliness, and all aides are trained to perform these tasks. The facility's policies on ADLs and incontinence care emphasize the importance of maintaining hygiene and preventing infection.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure proper positioning of an indwelling urinary drainage bag for a resident with a catheter, leading to a potential risk of urinary tract infections (UTIs). The resident, who had diagnoses including cerebral infarction, heart disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and a UTI, was observed with the catheter bag placed on top of his thighs while lying in bed. This placement was contrary to the care plan and facility policy, which required the bag to be positioned below the bladder level to prevent backflow of urine. During an observation, the Director of Nurses (DON) and a Certified Nursing Assistant (CNA) transferred the resident using a mechanical lift, and the DON acknowledged the need to hold the bag below the bladder during the transfer. The DON later confirmed that the resident had required antibiotics for a UTI a few weeks prior and emphasized the importance of keeping the catheter bag below the bladder to prevent backflow and potential UTIs. The facility's policy also specified that the drainage bag should be attached to the bed frame below the bladder level, not touching the floor, to ensure proper urine flow and avoid backflow.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 268 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Byron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oregon Living And Rehabilitation Center | 9.1 mi | ★★★★★ | 28 | 0 |
| Allure Of Pinecrest | 10.2 mi | ★★★★★ | 10 | 0 |
| Manor Court Of Rochelle | 14.1 mi | ★★★★★ | 3 | 0 |
| Amberwood Care Centre | 14.6 mi | ★★★★★ | 2 | 0 |
| Mercyhealth Javon Bea Hospital -snf | 14.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Neighbors Health Center.
100% money-back within 48 hours.
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.