Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parc Joliet during CMS and state inspections, most recent first.
Failure to report a resident’s injury of unknown origin: Camera footage showed a resident and a CNA involved in a physical interaction near the elevators, after which the resident was taken to the hospital with a swollen upper lip and dried blood on the lip. Staff later noted blood on the resident’s mouth, but the nurse did not assess the resident, the DON and ADON said they were unaware of the blood, and the Administrator said she did not investigate the incident. The facility could not provide documentation that it notified Public Health that an investigation into the cause of the resident’s injury had been opened.
A resident with severely impaired cognition became aggressive and was involved in a staff intervention while trying to leave the facility. Video showed the resident pushing a CNA into an elevator, after which the CNA grabbed and jerked the resident’s arm. Staff later saw blood on the resident’s mouth and lip, but the nurse did not assess the resident, the injury source was not determined, and the DON, ADON, and Administrator did not investigate or document an investigation.
The facility failed to ensure that new diagnoses of paranoid schizophrenia for two residents were supported by documented clinical findings. In both cases, behavior monitoring was ordered and recorded on the MAR over many months, yet staff consistently documented no hallucinations, paranoia, delusions, or related behaviors, while interviews with nursing, CNAs, and social services confirmed only anxiety or excitability. One resident’s antipsychotic (quetiapine) was continued under the new schizophrenia diagnosis despite the psychiatric note describing her as calm, appropriate, and with linear thought processes, and the resident reporting she was told she needed the diagnosis to stay on the medication. The other resident, already carrying multiple psychiatric diagnoses, also had schizophrenia added without corresponding behavior documentation, even though orders and care plans required tracking of psychotic symptoms.
A resident who was fully dependent for transfers, had multiple comorbidities including muscle wasting, gait abnormalities, lack of coordination, CHF, PVD, osteoarthritis, ESRD, and a history of falls, and used a mechanical lift, was transferred from wheelchair to bed by a single CNA using a mechanical lift instead of the required two-person assist. The CNA reported she acted alone because the resident was light and easy to move, despite knowing that two staff are required, and stated the resident became anxious, shook, and likely bumped his leg on the bed during the transfer. Facility staff and the lift manufacturer’s representative confirmed that two caregivers are required for safe mechanical lift operation, with one operating the remote and the other guiding and supporting the resident. The resident sustained a left leg laceration measuring approximately 7–8 cm that required closure with 11 sutures.
A resident with severe dementia, confusion, and extensive ADL needs was physically abused when a CNA approached her at the dining table and swung a pillow that made contact with her face. Another CNA reported seeing the contact, while the accused CNA denied hitting the resident and said she was removing the pillow for safety. Camera footage showed the CNA grab the pillow and strike the resident, and the facility’s investigation concluded there was credible evidence of the contact.
Multiple residents experienced physical and emotional harm after a resident with a history of aggression was not consistently supervised as required by his care plan. The resident entered other residents' rooms and common areas, resulting in incidents of scratching, attempted choking, and significant fear among affected individuals. Staff and management did not consistently investigate or substantiate abuse allegations, and supervision lapses directly contributed to repeated incidents.
A resident with cognitive impairment and aggressive behaviors was left unsupervised and followed another resident into her room, leading to an alleged physical attack. Although staff intervened and the affected resident reported feeling attacked and fearful, the incident was not investigated or reported to authorities as required by facility policy. The DON and Administrator were notified but did not initiate an investigation, and the facility failed to follow its abuse prevention procedures.
Multiple residents reported being physically attacked or threatened by another resident with a known history of aggression, resulting in injuries and emotional distress. Despite staff witnessing incidents and residents reporting fear, the facility did not thoroughly investigate all allegations or interview all involved parties, and failed to substantiate abuse claims, citing the aggressor's medical condition.
A resident with a history of aggression and behavioral health diagnoses was not consistently provided with required 1:1 supervision, especially during the night shift. This lapse led to multiple incidents where other residents and staff were attacked or placed at risk, including physical assaults and injuries. Facility leadership and staff confirmed that the lack of continuous supervision contributed to these events, despite ongoing aggressive behaviors.
Surveyors observed multiple unsanitary practices in food preparation and service, including staff failing to perform hand hygiene between tasks, using towels improperly to dry dishes, storing clean dishes in dirty racks, and not fully covering hair while working. Food storage areas and equipment, such as refrigerators, freezers, and beverage dispensers, were found with visible stains, sticky substances, and debris. The Dietary Manager confirmed these practices did not follow facility policies for food safety and sanitation.
The facility did not ensure a clean and safe environment by failing to address mold in a shower room and a leaking toilet, despite residents reporting these issues to staff. Maintenance was not notified through work orders, resulting in unresolved environmental hazards affecting multiple residents.
Multiple residents with significant physical or cognitive impairments did not receive necessary assistance with ADLs, including personal hygiene, nail care, and grooming. Observations showed residents with dirty, overgrown fingernails, unshaven facial hair, soiled clothing, and bedding, despite care plans indicating a need for staff support. Staff and DON acknowledged these deficiencies, and residents reported unmet requests for help with hygiene tasks.
Staff failed to provide adequate supervision for residents requiring monitoring during smoking periods, with only intermittent observation and insufficient staff presence. Several residents who required supervision were found to possess and use their own cigarette lighters, contrary to facility policy and their care plans, and staff did not consistently collect or secure these items.
Staff failed to follow infection control protocols during medication administration, wound care, and therapy assessments. This included not replacing IV tubing after it touched the floor, not wearing required PPE such as gowns and gloves during high-contact care for residents on Enhanced Barrier Precautions, and not performing hand hygiene between resident contacts.
A male resident with severe dementia and a history of behavioral issues repeatedly initiated non-consensual kissing of a female resident who was also severely cognitively impaired. Staff observed and intervened in these incidents, but no care plan or assessment was in place to address the female resident's risk for abuse or her ability to consent, despite ongoing occurrences and documentation of inappropriate behavior.
The facility did not complete updated PASRR referrals when new psychiatric or behavioral health diagnoses were identified for three residents after admission. Despite documentation of new conditions such as bipolar disorder, schizophrenia, depression, and dementia, and internal communication processes, no updated PASRR referrals or care plan interventions were initiated as required.
Two residents did not receive care as ordered: one had antifungal ointment applied to unclean skin with visible dead skin and secretions, and another did not receive prescribed Lorazepam for several days despite an emergency supply being available. Staff acknowledged the failures to follow proper medication and treatment protocols.
Two residents with hemiplegia and hemiparesis were not assessed or provided with needed orthotic devices to support their limited range of motion, despite visible weakness and requests for assistance. Occupational therapy later confirmed the need for devices such as a palm protector and resting hand splint, but these were not in place at the time of observation.
A resident with COPD and CHF did not consistently receive continuous oxygen therapy as ordered, with multiple observations of the resident without oxygen while in bed and moving throughout the facility. Staff interviews revealed that portable oxygen tanks were not consistently provided, and documentation showed oxygen saturation was sometimes recorded without oxygen therapy in use, contrary to physician orders and facility policy.
Two residents experienced medication administration errors when a nurse failed to follow label instructions for an ophthalmic suspension and incorrectly programmed an IV medication pump, resulting in an 8% medication error rate during observation.
Surveyors observed that couches in three resident rooms had visible stains, including dark and white marks on seat cushions and armrests. The DON confirmed the couches were in need of cleaning, indicating a failure to provide a clean and homelike environment for residents.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
A resident with severe cognitive impairment and multiple diagnoses, including Multiple Sclerosis, was left unsupervised with a hot beverage, resulting in burns to her thighs. The resident was placed in a geri chair near the nurses' station and given a hot drink by a CNA, who then left to assist others. The resident spilled the drink, causing burns that required hospital treatment.
Two residents were involved in an altercation after one resident, upset by being called a 'mooch,' attempted to punch the other, resulting in both falling and sustaining injuries. The incident, captured on video, revealed a failure to protect residents from abuse, as defined by the facility's Abuse Prevention Program Policy.
A resident was not properly dressed for an outside appointment, being found dirty and in a hospital gown, covered only with a sheet. The resident, who is nonverbal and dependent on staff, was also late to the appointment. The deficiency was due to staff starting their shifts late and a lack of communication, with no policy provided on preparing residents for appointments.
The facility failed to implement fall interventions for two residents at risk for falls. One resident was observed without a reacher and specialized seating mat, while another was found with his bed in a high position and no floor mats, contrary to their care plans. Both the Administrator and DON acknowledged the necessity of these interventions for safety.
The facility failed to properly label, date, seal, and store food items, leading to unsanitary conditions in the kitchen. Observations included undated eggs, unlabeled ground meat, standing water, and flies in the dry storage area. Expired food items and personal food stored with resident food were also noted. The Dietary Manager acknowledged these issues, indicating a lack of adherence to the facility's food safety and cleanliness policies.
The facility failed to provide adequate incontinence care and grooming assistance to several residents, resulting in prolonged periods without necessary hygiene care. One resident was left in soiled briefs for hours, while another had to rely on a visitor for shaving assistance. Other residents were observed with untrimmed nails and unkempt hair, indicating a lack of regular grooming care. Staff interviews revealed a disconnect between residents' needs and the care provided.
The facility failed to provide timely podiatry services to residents, resulting in unmet foot care needs. A resident with quadriplegia had overgrown toenails despite a podiatrist's recommendation for follow-up care. Another resident with a history of stroke experienced a nine-month delay in receiving podiatry care, leading to toenail loss. Additional residents with diabetes and cognitive impairment also had inadequate foot care, with long and jagged toenails observed. The facility's policy for foot assessments and podiatry referrals was not consistently followed.
The facility failed to provide adequate call light access for two residents with severe cognitive impairments, as their call light strings were not connected to the system. Another resident did not receive properly sized incontinence briefs, leading to leakage issues. Additionally, a resident with morbid obesity and hemiplegia was unable to shower due to inadequate and unsafe shower equipment, resulting in only bed baths being documented.
A facility failed to inform and document a resident's Advanced Directives upon admission, as required by policy. The resident, with multiple health issues, was admitted without a POLST or Advanced Directives in his record. He reported not being asked about his wishes for life-sustaining treatments and had not signed any forms, despite expressing a preference against life support. This oversight led to a deficiency in the facility's compliance with its policy.
The facility failed to apply splints for two residents, leading to contractures. A resident with Alzheimer's and other conditions was observed without palm protectors, despite care plans indicating their necessity. Another resident with generalized weakness was found without a left hand splint, which was left on the bedside table. Staff acknowledged the oversight, and the facility's ADL policy emphasized contracture prevention.
The facility failed to ensure a safe environment for two residents, one of whom had to navigate around a blower fan hazard in the hallway, while another was left without necessary fall mats beside their bed. These oversights occurred despite the facility's policy to minimize accident hazards.
A resident receiving oxygen therapy at 2.5 L/M via nasal cannula was not provided with humidification, resulting in nasal dryness. Despite the facility's policy requiring humidification, the resident reported never being offered it, and there was no documentation of refusal. The DON confirmed the lack of documentation and the facility's policy on humidification.
The facility failed to manage food storage in residents' personal refrigerators, leading to expired and unlabeled items. One resident had expired milk and unlabeled cheese, while another had incomplete temperature logs. Staff were unaware of these issues, and no policy for personal refrigerators was provided.
The facility failed to follow Enhanced Barrier Precautions (EBP) and maintain effective hand hygiene. Staff did not wear gowns during wound care for a resident with severe cognitive impairment, despite EBP guidelines. Additionally, CNAs did not perform hand hygiene between glove changes during incontinence care for another resident, contrary to facility policies.
A resident with moderate cognitive impairment reported missing $80.00 from her wallet. The RN claimed to have documented and reported the incident to Social Service, who denied receiving the notification. The Assistant Administrator also denied being informed. The Administrator confirmed the RN should have reported the incident for timely reporting to Public Health, which was delayed. The facility's policy requires immediate reporting of such allegations.
The facility failed to provide menu variety, leading to resident dissatisfaction with frequent pork and egg-based meals. Residents expressed a desire for more diverse options, such as hamburgers, tacos, chili, cereal, and fruit cups. The Dietary Manager acknowledged the issue and indicated plans to address it.
Failure to Report Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to report a resident’s injury of unknown origin within the required timeframes. Camera footage showed the resident and a CNA standing near the elevators, the elevator doors opened, and the resident pushed the CNA into the elevator. The footage then showed the CNA grab the resident’s right arm and jerk it, pulling the resident into the elevator. The resident was transported to the hospital shortly afterward. Emergency room records showed the resident arrived with a swollen upper lip and dried blood on the lip. Staff interviews and record review showed that the resident had blood on his mouth after the incident, but the nurse who was the resident’s nurse at the time did not attend to or assess him. The resident’s cognition was severely impaired per the Minimum Data Set. The DON said she was not informed that the resident was found with blood on his mouth, the ADON said he was unaware of blood on the resident’s mouth, and the Administrator said she did not investigate the incident. The facility was unable to provide documentation that it notified the Illinois Department of Public Health that an investigation had been opened into the cause of the resident’s bloodied and swollen lip, despite the facility policy requiring internal reporting of suspected abuse and external reporting that Public Health be informed when a potential abuse occurrence is being investigated.
Failure to Investigate Resident Injury After Staff Incident
Penalty
Summary
The facility failed to investigate the cause of a resident’s injury after an incident involving staff intervention when the resident was attempting to leave the facility. The resident had severely impaired cognition on the 4/11/26 MDS and, on 5/6/26, was documented as being aggressive toward a nurse and a CNA before being transported to the local community hospital for a psychological evaluation. Camera footage reviewed later showed the resident pushing a CNA into an elevator, after which the CNA grabbed the resident’s right arm and jerked it, pulling the resident into the elevator. After the incident, staff observed blood on the resident’s mouth and lip, but the resident was not assessed by the nurse who saw the blood, and the source of the bleeding was not determined at the time. The resident’s ER records showed a swollen upper lip with dried blood, and the resident returned to the facility early the next morning. The DON, ADON, and Administrator each stated they were not informed of the mouth injury or did not investigate the incident, and the facility could not provide documentation of any investigation related to the resident’s injury. The facility’s Abuse Prevention Program policy required incidents and resident injuries to be reviewed, investigated, and documented, including gathering facts from those with direct knowledge.
Lack of Supporting Documentation for New Schizophrenia Diagnoses
Penalty
Summary
The facility failed to ensure that new diagnoses of paranoid schizophrenia for two residents were supported by documented clinical findings in the medical record. For one resident, a middle‑aged female admitted with bipolar disorder and alcohol abuse, the face sheet showed that generalized anxiety disorder and later paranoid schizophrenia were added as diagnoses. Her MAR reflected a long‑standing order for quetiapine 300 mg at bedtime for bipolar disorder, which was discontinued and then reordered at the same dose and time for the new diagnosis of paranoid schizophrenia. Behavior monitoring was ordered daily on all shifts for more than 15 months, yet the MAR behavior tracking sections showed no documented observations of withdrawal, depression, false beliefs, hallucinations, paranoia, delusions, or mood changes during that entire period. During interviews and record review for this resident, staff and providers described minimal or no psychotic‑type behaviors. The psychiatric NP’s follow‑up note on the date the schizophrenia diagnosis was added documented that the resident was well‑groomed, appropriate, calm, with clear speech, linear thought processes, intact associations, and an upset mood, and that she was being seen for medication management. The resident reported that the NP told her quetiapine and clonazepam might be stopped because of rule changes and that she would need a diagnosis of paranoid schizophrenia to continue the medication. The DON stated that residents on psychotropics or with behavioral health diagnoses receive behavior monitoring, and that all behavior monitoring should be documented in the medical record, including progress notes, MAR behavior templates, and therapy/psychiatric reports. However, nursing, CNA, and social services staff reported only anxiousness and excitability for this resident and denied observing hallucinations, paranoia, or delusions, and there was no behavior documentation supporting the new schizophrenia diagnosis. For the second resident, an older female admitted with multiple psychiatric diagnoses including dementia with behavioral disturbance, bipolar disorder, delusional disorder, recurrent major depressive disorder, generalized anxiety disorder, and shared psychotic disorder, the face sheet showed that paranoid schizophrenia was added as a new diagnosis. Her care plan and physician orders included behavior tracking for depression, withdrawal, false beliefs, hallucinations, paranoia, delusions, and mood changes. Review of MARs over several months showed no documented behavioral symptoms of withdrawal, false beliefs, hallucinations, paranoia, or delusions across all shifts. Social services staff stated they had not observed delusions, hallucinations, or paranoia in this resident and described her as primarily anxious and concerned about her health and dementia, with a habit of writing things down. The psychiatric physician explained that a schizophrenia diagnosis requires at least two core symptoms (such as delusions, hallucinations, disorganized thoughts/behaviors, or paranoia) over a prolonged period and emphasized the need for contemporaneous documentation of observed symptoms, which was not present in these residents’ records to support the new schizophrenia diagnoses.
Inadequate Two-Person Assistance During Mechanical Lift Transfer Causes Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer of a resident using a mechanical lift, resulting in an 8 cm laceration that required 11 sutures. A CNA (V4) reported that on 1/15/26 she transferred the resident (R1) alone from wheelchair to bed with a mechanical lift, despite having been taught that two staff members are required for such transfers. V4 stated she chose to perform the transfer by herself because she believed the resident was light and easy to move, and described that the resident had extreme anxiety with care, “freaks out” during mechanical lift transfers, and was shaking during the transfer. V4 stated she thought the resident may have bumped his leg on the bed while he was “freaking out and shaking.” A nursing progress note from that date documented that during the transfer the resident hit his lower leg on the bed, resulting in an open laceration measuring about 7 cm, and the ER physician report documented an 8 cm left leg laceration closed with 11 sutures. Interviews with the DON, ADON, restorative/QA nurse, LPNs, and CNAs confirmed that facility practice and expectation are that two staff are required for mechanical lift transfers, with one staff operating the lift remote and the other supporting and positioning the resident to prevent contact with surrounding objects. The mechanical lift manufacturer’s representative also stated that two caregivers are required to safely operate the lift, with one operating the lift and the second guiding the patient. The resident’s face sheet and MDS showed multiple diagnoses including muscle wasting and atrophy, gait and mobility abnormalities, lack of coordination, chronic heart failure, peripheral vascular disease, osteoarthritis, end stage renal disease, a history of falling, and that he was completely dependent on the assistance of two or more helpers for transfers. A restorative assessment documented that he was fully dependent on staff for chair/bed transfers and used a mechanical lift. The facility’s Limited Lifting Resident Handling Policy stated that mechanical lifting devices shall be used for any resident needing a two-person assist, but the resident was transferred by only one staff member at the time of the incident.
Failure to Prevent Physical Abuse by CNA
Penalty
Summary
The facility failed to ensure that a resident was not physically abused by a CNA. The resident involved had multiple diagnoses including bipolar disorder, conduct disorder, anxiety disorder, restlessness and agitation, and severe dementia with agitation. Her admission MDS showed severe cognitive impairment and that she required moderate to maximum assistance from staff with most ADLs. At the time of the incident, she was observed in the first-floor dining room with her head resting on the dining table and was confused and responding inappropriately when spoken to. The allegation began when another resident reported that a CNA had struck the resident with a pillow. The facility’s investigation included interviews, review of camera footage, and review of the resident’s condition. One report initially indicated the alleged event occurred in the resident’s room, but later information from the reporting resident identified the dining room as the location. The RN who first received the concern stated he understood from the resident that a CNA had hit the resident with a pillow and immediately notified the DON and assessed the resident, who had no injuries or complaints of pain. The dining room camera footage showed the resident seated at the table with another CNA behind her and a nearby resident standing close by. The footage showed the CNA approach the table, grab a pillow from the table, and swing it toward the resident, making contact with the resident’s face. A second CNA stated she saw the pillow make contact with the resident, while the accused CNA denied hitting the resident and said she was removing the pillow because it was a safety issue. The facility’s investigation concluded there was credible evidence that the pillow made contact with the resident, and the accused CNA and another CNA were terminated after the investigation.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and mental abuse by another resident, resulting in multiple incidents involving three residents. One resident with a history of autism, schizophrenia, and aggressive behaviors, including throwing items, scratching, and hitting, was admitted to the facility and required supervision for safety. Despite documented needs for 1:1 supervision, this intervention was inconsistently implemented, particularly during the night shift, after it was determined the resident was usually sleeping. This lapse in supervision allowed the resident to enter other residents' rooms and common areas, leading to physical altercations and emotional distress among other residents. Several incidents were reported where the aggressive resident physically attacked others. One resident was scratched under the eye while sleeping, another reported being choked and was left emotionally distressed, and a third sustained scratches during an incident in the therapy gym. Staff interviews confirmed that the aggressive resident's behaviors were unprovoked and unpredictable, and that supervision was not consistently maintained as required by the care plan. In some cases, staff intervened after the incidents had already occurred, and residents expressed fear and anxiety following these events. The facility's investigation into these incidents did not substantiate the allegations of abuse, often attributing the aggressive resident's actions to his medical condition rather than willful intent. However, the facility's own abuse prevention policy defines abuse as the willful infliction of injury or mental anguish, regardless of the individual's mental or physical condition, and requires deliberate action rather than intent to harm. The facility did not consistently investigate or follow up with affected residents, and failed to maintain required supervision, directly leading to repeated resident-to-resident abuse and emotional harm.
Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of abuse involving a resident with cognitive impairment and aggressive behaviors (R3) and another resident who was cognitively intact but physically impaired (R1). R1 reported that R3, who required 1:1 supervision due to a history of aggression, followed her into her room after throwing furniture in the hallway and attempted to choke her. Staff responded to R1's screams, and although some staff stated they intervened before physical contact occurred, R1 consistently reported feeling attacked and extremely scared. R1's emotional distress was documented, and she was moved to another unit at her request. Despite these events, there was no documented investigation or reporting of the abuse allegation to the appropriate authorities as required by facility policy. Interviews with staff revealed that the assigned sitter for R3 had left him unsupervised, allowing the incident to occur. The DON and Administrator acknowledged being notified of the incident but did not initiate an investigation or report the allegation, citing staff belief that no physical contact had occurred. The facility's abuse prevention policy required all allegations or suspicions of abuse to be reported and investigated, but this protocol was not followed in this case. No internal investigation or external reporting was conducted regarding R1's allegation, and the facility failed to ensure the safety and proper follow-up for the resident involved.
Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple residents' allegations of abuse by another resident with a known history of aggression. One resident reported being scratched under the eye by the aggressive resident, with staff and medical records confirming the presence of injuries and the aggressive behaviors. Despite these reports and physical evidence, the facility's investigation concluded that there was no credible evidence of abuse, and the incident was not substantiated. Staff interviews confirmed that the aggressive resident had a pattern of violent behavior, including throwing furniture and attacking others, and that interventions such as 1:1 sitters were inconsistently applied. Another resident described being attacked and nearly choked by the same aggressive resident after he followed her into her room. Although staff responded to her calls for help and intervened before physical contact was made, the resident reported significant fear and anxiety following the incident. The resident was not formally interviewed by management, and no investigation was conducted regarding her abuse allegation, despite her request for a room change and ongoing distress. Staff involved in the incident also reported not being interviewed by management. A third resident, who had since been discharged, reported being physically attacked and scratched by the same aggressive resident in the therapy gym, with staff present and confirming the incident. The facility's investigation again concluded that there was no credible evidence of abuse. The facility's abuse prevention policy required thorough investigation and interviews of all involved parties, but interviews with the DON and Administrator revealed that some allegations were not investigated based on their belief that the aggressive resident's actions were not willful due to his medical condition. The facility did not follow its own policy for investigating and substantiating abuse allegations.
Failure to Maintain Adequate Supervision for Aggressive Resident
Penalty
Summary
The facility failed to implement and maintain adequate safety monitoring interventions for a resident with a known history of aggressive behaviors, resulting in multiple incidents where other residents and staff were harmed or placed at risk. The resident in question, a 35-year-old with diagnoses including autism, schizophrenia, anxiety, and developmental delays, was non-verbal, ambulatory, and required supervision for safety due to aggressive behaviors such as throwing items, scratching, and hitting others. The care plan specified the need for a 1:1 sitter, initially provided by the family and later by the facility, but this intervention was inconsistently implemented, particularly during the night shift. Multiple incidents occurred as a result of lapses in supervision. One resident reported being physically attacked in the therapy gym, while another described being followed into her room and nearly attacked after the aggressive resident was left unsupervised. Staff interviews confirmed that the 1:1 sitter was not consistently assigned, especially during the night shift, despite ongoing aggressive behaviors. Staff members also reported being attacked, with one CNA sustaining injuries severe enough to require medical leave. Another resident was scratched on the face during an unsupervised period at night, and staff acknowledged that the aggressive resident's behaviors were unpredictable and difficult to redirect. Facility leadership, including the ADON and DON, acknowledged that the removal of 1:1 supervision during the night shift was a contributing factor to the incidents. Documentation showed that the resident continued to display aggressive behaviors during the night, even after the sitter was removed from that shift. The facility's own policy required continued 1:1 supervision until dangerous symptoms were reduced and aggressive acts minimized, but this protocol was not followed, leading to harm to both residents and staff.
Failure to Maintain Sanitary Food Preparation and Service Conditions
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and served under sanitary conditions for 144 residents receiving meals from the kitchen. Observations revealed that dietary staff did not consistently perform hand hygiene between tasks, such as donning gloves after handling food prep items and moving between handling soiled and clean dishes. Staff were also seen using unsanitary practices, such as drying clean bowls with a towel that was stored on top of a box of gloves and then returning the towel to the same location, as well as placing clean dish racks on visibly dirty roller bases. Dish racks and containers used for clean dishes and napkins were found to be heavily stained with removable film and visible particles, and mugs and cups stored in these racks also contained visible debris. Additional unsanitary conditions were observed in the kitchen and dining areas. Staff were seen working with hair not fully covered by hairnets, and personal items such as car keys and an eyeglass case were stored on the food prep table near food items. The freezer contained a sticky spilled substance on boxes of frozen pizzas, and containers used for food thickener were stained with a sticky yellow residue. Beverage dispensers and carts used in dining rooms had visible stains, sticky substances, and buildup, while mugs stored underneath these carts were wet and stored in racks with thick film stains. A small refrigerator used for resident food items contained visible food particles, sticky substances, and dark buildup on the door rim. Interviews with the Dietary Manager confirmed that these practices and conditions were not in accordance with the facility's own Food Safety and Sanitation policies, which require proper handwashing, clean storage bins, sanitary handling of food and utensils, and regular cleaning of kitchen equipment and surfaces. The Dietary Manager acknowledged that staff should not use towels to dry dishes, should not store towels on glove boxes, and should ensure all items used for food service are clean and free of debris. The facility's policies also require that personal items be stored away from food preparation areas and that staff maintain proper personal hygiene, including fully covering hair while working in the kitchen.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents by not ensuring that a shower room was free of mold and that a resident's toilet was in good repair. One resident reported that the exhaust fan in the shower room was not functioning and had emitted sparks for several months, and also noted the presence of mold along the edges of the shower. The resident stated that she had informed a CNA about the mold, but no work order had been submitted. Upon inspection, surveyors observed a strong musty odor and visible black substance identified as mold by the Director of Maintenance, who confirmed he had not received any work order for the issue. The fan was found to be broken and very loud, and the maintenance director acknowledged responsibility for mold removal, while daily cleaning was assigned to housekeeping. Additionally, another resident reported that his toilet had been leaking urine and water since it was replaced six months prior. Surveyors observed a wet floor with brown fluid around the toilet on multiple occasions. The maintenance director and his assistant confirmed they had not received any work orders regarding the leaking toilet. The Director of Nursing stated that staff are expected to submit maintenance tickets and notify management if there are issues such as mold or leaking toilets, but this protocol was not followed in these instances.
Failure to Provide Assistance with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically personal hygiene, bed baths, showers, nail care, and grooming, to multiple residents who were identified as needing such support. Observations and interviews revealed that several residents with significant physical and cognitive impairments, including those with cerebrovascular disease, hemiplegia, morbid obesity, Parkinson's disease, Huntington's disease, and intellectual disabilities, were left with untrimmed, dirty fingernails, unshaven or overgrown facial hair, and soiled clothing or bedding. These residents were documented as requiring moderate to maximum assistance with ADLs in their care plans and Minimum Data Set (MDS) assessments. Surveyors observed residents with visible hygiene deficits, such as food crumbs on clothing, brown and black substances under fingernails, and accumulation of dead skin and bodily fluids on bedding. Multiple residents expressed a desire for assistance with nail care and shaving, stating that their requests had not been addressed by staff. In several cases, staff and the Director of Nursing acknowledged that the residents required assistance and that the observed hygiene issues were present, confirming that care had not been provided as outlined in the residents' care plans. The lack of assistance was consistent across several days and was observed in both cognitively intact and impaired residents. Documentation and staff interviews confirmed that the facility's standard practice includes providing showers or bed baths, nail care, and grooming at least twice a week and as needed, but these services were not consistently delivered to residents who were dependent on staff for their personal hygiene and grooming needs.
Failure to Supervise Smoking Residents and Control Access to Lighters
Penalty
Summary
The facility failed to ensure that residents who require supervision while smoking were adequately monitored and did not possess their own cigarette lighters. Observations revealed that only one staff member was intermittently supervising residents during designated smoking periods, with supervision occurring through a glass window rather than direct observation on the patio. Multiple residents were seen carrying and using their own lighters, and several admitted to keeping lighters in their rooms or on their person, despite facility policy prohibiting this practice. Staff members confirmed that residents are not allowed to keep lighters due to safety concerns, and that two staff should be present during smoking times—one to distribute cigarettes and another to directly monitor the patio—but this was not consistently implemented. Record reviews indicated that the residents involved had care plans and assessments stating they required supervision for smoking and were non-compliant with turning in smoking materials. During inspections, the cigarette cart contained only two lighters, neither of which belonged to the residents observed with lighters. Staff interviews corroborated that the facility's procedures for monitoring and controlling access to smoking materials were not being followed, resulting in residents who require supervision having unsupervised access to lighters and inadequate staff oversight during smoking periods.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices during several resident care activities. Specifically, a registered nurse prepared intravenous (IV) medication for a resident with a peripherally inserted central catheter (PICC) and multiple diagnoses, including cellulitis and quadriplegia. The nurse allowed IV tubing to touch the floor and did not replace it before administering the medication. Additionally, the nurse entered the resident's room, which was under Enhanced Barrier Precautions (EBP), wearing only gloves and not a gown, as required. In another instance, the same nurse prepared an insulin injection for a resident with diabetes and other chronic conditions, left the needle exposed, and entered the resident's room without activating the safety cap, holding the exposed needle while waiting to administer the medication. Further deficiencies were observed during wound care and therapy assessments. Two wound care nurses provided treatment to a resident with a stage 4 sacral pressure injury, wearing gloves but not gowns, despite EBP signage indicating the need for both. An occupational therapist assessed two residents for range of motion without performing hand hygiene before or between assessments and without wearing gloves. The facility's policies and posted signage required the use of appropriate personal protective equipment (PPE) and hand hygiene during these activities, but these protocols were not followed as observed.
Failure to Prevent and Address Repeated Non-Consensual Intimate Contact Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to prevent a male resident with severe dementia and a history of behavioral issues from repeatedly kissing a female resident who was also severely cognitively impaired. Both residents were unable to consent to intimate contact, as confirmed by their BIMS scores and staff interviews. Multiple staff members, including CNAs and an LPN, observed the male resident initiating and forcing kisses on the female resident, sometimes by grabbing her head or entering her room while she was sleeping. Staff reported that these incidents had been ongoing for over a month, with the male resident also attempting similar behavior with another cognitively impaired resident. Despite these repeated incidents, there was no care plan in place addressing the female resident's risk for abuse or her vulnerability, nor was there an assessment for her ability to consent to intimate behaviors. Interviews revealed that staff were aware of the ongoing inappropriate behavior but believed there was little they could do due to the residents' dementia. The facility's abuse prevention policy required identification of residents at increased risk for abuse and notification of incidents, but the administrator and nurse practitioner were unaware of the ongoing incidents until informed by surveyors. Documentation showed prior instances of sexually inappropriate behavior by the male resident, yet no interventions or care planning were implemented to address or prevent further occurrences.
Failure to Complete Updated PASRR Referrals After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that updated PASRR (Preadmission Screening and Resident Review) referrals were completed when new psychiatric diagnoses were identified after admission for three residents. For one resident, the initial PASRR Level I indicated no severe mental illness, intellectual disability, or related condition, but subsequent diagnoses of bipolar disorder, schizophrenia, and depression were added to the medical record. Despite an email request to complete a new PASRR referral and care plan documentation referencing chronic mental illness, no updated PASRR referral was submitted. Additionally, the care plan did not reflect the new diagnoses. For another resident, new diagnoses of unspecified dementia, major depressive disorder, and dementia in other diseases were entered after admission, but no updated PASRR referral or care plan interventions addressing these diagnoses were completed. A third resident received new diagnoses of major depressive disorder and generalized anxiety disorder, but these were not included in PASRR documentation, and no updated referral was made. Interviews with staff confirmed that the process for initiating PASRR referrals relies on notification of new diagnoses, but despite daily meetings and communication, no updated referrals were initiated for these residents.
Failure to Cleanse Skin Before Treatment and Delay in Psychotropic Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident preferences for two residents. In the first instance, a wound care nurse applied Nystatin ointment to a resident's back, buttocks, and groin without thoroughly cleansing the skin beforehand. Observations revealed multiple areas of redness, clumps of dead skin, sweat, and remnants of old cream on the resident's skin, as well as yellow fluid stains on the bedding. Staff acknowledged that the skin should have been cleansed more thoroughly prior to the application of the antifungal cream, as per the physician's order for treatment of a fungal rash. In the second instance, a resident with a history of schizoaffective disorder and anxiety disorder did not receive her prescribed Lorazepam for several days. The resident reported not receiving the medication for six days, receiving the wrong dose when it was delivered, and experiencing anxiety and anger due to the delay. Facility records confirmed that Lorazepam was not administered as ordered on multiple dates, despite the facility having an emergency supply available. The facility's policy requires medications to be administered within one hour of the prescribed time, but this was not followed for the resident's psychotropic medication.
Failure to Provide Orthotic Devices and Services for Residents with Limited ROM
Penalty
Summary
The facility failed to assess and provide necessary orthotic devices and services to residents with limited range of motion (ROM), resulting in a deficiency. Two residents with significant medical histories, including hemiplegia and hemiparesis following cerebral infarction, were observed to have functional limitations in ROM affecting their upper and lower extremities. Both residents were cognitively intact and expressed difficulty in moving their affected limbs, with one resident specifically requesting a device to support her weak arm and hand, and the other requesting a splint for proper positioning and to prevent further decline. Despite these requests and visible signs of weakness and contracture, neither resident had been provided with the appropriate orthotic devices at the time of observation. Interviews and record reviews revealed that the Director of Nursing was made aware of the residents' conditions and stated that she would request occupational therapy assessments. Occupational therapy screenings subsequently confirmed the need for devices such as a palm protector and a resting hand splint to prevent further contracture and weakness. However, prior to these assessments and recommendations, the facility had not implemented measures to provide the necessary orthotic support, nor had staff reported the residents' conditions in a timely manner to therapy services, resulting in a lack of appropriate care to maintain or improve the residents' ROM and mobility.
Failure to Provide and Monitor Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that continuous oxygen therapy was consistently provided and monitored as ordered for a resident with diagnoses including COPD, CHF, and shortness of breath. The physician's order required continuous oxygen at 3 liters per minute via nasal cannula to maintain SpO₂ above 90%, along with regular oxygen saturation monitoring and equipment maintenance. Despite these orders, the resident was repeatedly observed without oxygen in place while in bed, in the room, and while ambulating in the facility. The resident reported not having a portable oxygen tank and stated that oxygen was not used when moving around the building or attending therapy sessions. Staff interviews confirmed that portable oxygen tanks were available but not consistently provided to the resident for use during transport or movement within the facility. Documentation showed that oxygen saturation levels were sometimes recorded while the resident was not receiving oxygen therapy, and staff were unclear about the resident's oxygen requirements, with one physical therapy assistant stating the resident used oxygen 'as needed.' Facility policy required the use of portable tanks when residents on continuous oxygen needed to move away from their concentrator, but this was not consistently implemented.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 8%, which exceeds the acceptable threshold. During medication administration observation, a registered nurse did not follow the instructions on the medication label for an ophthalmic suspension prescribed for a resident with multiple diagnoses, including bilateral secondary cataract and heart disease. Specifically, the nurse failed to shake the eye drops bottle before administering the medication, as required by the label instructions. In another instance, the same nurse incorrectly programmed an IV medication pump for a resident with cellulitis, quadriplegia, and a history of venous thrombosis. The nurse entered an incorrect infusion volume into the pump, differing from the prescribed amount on the medication label. Both incidents were confirmed through observation, interview, and record review, and were not in accordance with the facility's policy and procedure for administering medications.
Failure to Maintain Clean and Sanitary Resident Room Furnishings
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms, specifically regarding the condition of couches. During observations, three residents' rooms were found to have couches with visible stains: one couch had multiple dark stains on the seat cushion, another had multiple white stains on the seat cushion, and a third had multiple dark stains on both the seat cushion and armrest. The Director of Nursing, present during these observations, acknowledged the presence of stains and confirmed that the couches needed to be cleaned. These findings demonstrate that the facility did not ensure that resident room furnishings were kept clean and in accordance with expectations for a homelike environment.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Inadequate Supervision Leads to Resident Burns
Penalty
Summary
The facility failed to adequately supervise a resident with impaired cognition while she was drinking a hot beverage, resulting in the resident sustaining burns. The resident, who had multiple diagnoses including Multiple Sclerosis and severe cognitive impairment, required supervision or assistance for eating. On the day of the incident, the resident was placed in a geri chair near the nurses' station after a shower and was given a hot beverage by a CNA. The CNA left the resident unattended to assist other residents, during which time the resident spilled the hot beverage, causing burns to her thighs. The incident logs and nursing progress notes indicate that the resident was found with reddened and blistered thighs after the spill. The wound care nurse was informed, and initial treatment was applied. However, the resident's condition worsened, leading to her transfer to a hospital burn center for further treatment. The hospital records confirmed that the resident sustained 5% scald burns with full-thickness wounds on her thighs. Interviews with facility staff revealed that the CNA had heated the water for the tea in a Styrofoam cup and left it on a bedside table next to the resident. The resident's care plans highlighted her need for supervision during meals and her tendency to exhibit physical behaviors such as knocking things over. Despite these documented needs, the resident was left unsupervised with a hot beverage, leading to the accident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents' right to be free from abuse, as evidenced by an altercation between two residents, R4 and R5. On the day of the incident, R4 was sitting outside when R5 approached him after being called a 'mooch.' R5, who was upset, attempted to punch R4 but missed, resulting in both residents losing their balance and falling to the ground. R4 sustained scratches on the right side of his face, while R5 had a scrape on his left forearm. Both residents were described as alert and oriented, and the incident was captured on video, which was reviewed by the Activity Director. Interviews with staff and other residents revealed that R5 had a habit of asking for cigarettes and money, which led to the confrontation. R4 reported that R5's actions were intentional, and another resident confirmed that R5 was not allowed to beg for cigarettes. The facility's Abuse Prevention Program Policy defines abuse as any physical or mental injury inflicted upon a resident other than by accidental means, emphasizing the residents' right to be free from abuse or mistreatment. Despite this policy, the altercation occurred, indicating a failure to protect the residents from abuse.
Resident Not Properly Prepared for Appointment
Penalty
Summary
The facility failed to appropriately prepare and dress a resident for an outside appointment, which was identified during a survey. The resident, who is nonverbal and dependent on staff for activities of daily living, was found to be dirty and dressed only in a hospital gown, covered with a sheet, and without a blanket when being transported for an appointment. The resident's guardian reported that the resident was also 40 minutes late to the appointment. The resident's medical history includes spastic quadriplegic cerebral palsy, dystonia, scoliosis, personal history of traumatic brain injury, protein calorie malnutrition, mild cognitive impairment, dysphagia, oropharyngeal phase, and contractures. The deficiency occurred due to a lack of coordination and communication among the staff. The appointment was scheduled and noted in the facility's electronic medical record system, but on the day of the appointment, both the RN and the CNA assigned to the resident started their shifts late. The CNA, who was not familiar with the first shift, was unaware of the appointment until the resident was already on the stretcher for transport. The facility did not provide a policy on how residents should be prepared for outside appointments, contributing to the oversight in ensuring the resident was dressed appropriately for the weather and the appointment.
Failure to Implement Fall Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents who were at risk for falls. Resident R3, with a history of falls and impaired decision-making, was observed without her reacher and specialized seating mat, both of which were interventions outlined in her care plan to prevent falls. The specialized mat was removed by the Activities Director due to its condition and was not replaced, leaving R3 without necessary fall prevention measures. Resident R5, with moderately impaired cognition, was found in his bed in a high position without floor mats, contrary to his care plan interventions. The bed control was out of his reach, preventing him from adjusting the bed height himself. R5 expressed his preference for a lower bed position, but staff left it high, increasing his risk of falling. Both the Administrator and Director of Nursing acknowledged the necessity of these interventions for the residents' safety.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, as observed during a survey of the kitchen. In the refrigerator, 24 fresh whole eggs were found without a date, and a medium-sized silver bin of unlabeled and undated ground meat was present. In the dry storage area, there was standing water by a drain, which was inadequately managed with a blanket, and small black flies were observed flying around food items. Additionally, several food items, including packages of sandwich cremes, raisins, taco shells, macaroni and cheese, and chicken stuffing, were either improperly sealed or expired. The survey also noted unsanitary conditions, such as a gallon jug of concord grape jelly with visible food debris on the outside, and more flies were seen around powdered cake mixes. In the freezer, a personal item, a water bottle half full of pink liquid, was improperly stored with resident food. By the dishwasher, layers of dirt and debris were visible, along with a pair of used gloves and an opened bottle of water. These observations indicate a lack of adherence to the facility's policies on food labeling, storage, and cleanliness. Interviews with the Dietary Manager revealed that staff were not following the facility's policies on food safety and cleanliness. The manager acknowledged the issues with labeling, sealing, and discarding expired food, as well as the presence of flies and standing water. The facility's policies require that all food items be labeled, dated, and stored properly to prevent contamination, and that the kitchen be cleaned regularly to meet state regulations. However, these procedures were not being adequately followed, leading to the observed deficiencies.
Deficiencies in Incontinence Care and Grooming Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care and grooming assistance to several residents, as observed and reported by both residents and staff. One resident, who is completely dependent on staff for toileting hygiene and bathing, reported that it took too long for staff to provide incontinence care, resulting in her being left in saturated briefs and soiled bedding for several hours. Another resident, who requires assistance with personal hygiene due to multiple sclerosis, was not helped with shaving despite requesting assistance, leading him to rely on a visitor for help. Additional deficiencies were noted in the grooming and hygiene care of other residents. One resident was observed with long, jagged fingernails, which had not been trimmed for months, while another resident had greasy, uncombed hair and an accumulation of facial hair, indicating a lack of regular grooming care. These residents expressed a desire for assistance with their personal hygiene, which was not adequately provided by the facility staff. The facility's failure to adhere to its own policy on Activities of Daily Living, which aims to preserve ADL function and promote dignity, was evident in the lack of timely and appropriate care provided to these residents. Staff interviews revealed a disconnect between the residents' needs and the care provided, with some staff members unaware of the residents' requests for assistance or the facility's expectations for daily grooming and hygiene tasks.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide timely foot care to residents, as evidenced by the lack of regular podiatry services for several individuals. Resident 46, who has quadriplegia and requires maximal assistance for personal hygiene, was observed with thick, discolored, and overgrown toenails. Despite a podiatrist's recommendation for a follow-up visit nine weeks after an initial appointment in February 2024, the resident had not been seen again by September 2024. The resident expressed concern about the infrequency of podiatry visits and mentioned having informed social services about the need for another appointment. Resident 35, who has a self-care deficit due to a history of stroke, experienced a significant delay in receiving podiatry care. It took approximately nine months from her admission for her to have her first podiatry visit, during which the podiatrist noted painful, thick, and discolored nails. The resident reported that the delay resulted in her losing toenails, and she was informed that future visits would occur every two months. Social services acknowledged the delay but could not provide an explanation for the initial lack of podiatry care. Additional residents, including Resident 20 and Resident 13, also experienced inadequate foot care. Resident 20, who has type 2 diabetes, was observed with long and jagged toenails and was not on the list for podiatry services despite a physician's order. Resident 13, with multiple health conditions and moderate cognitive impairment, was found with long and jagged toenails, and there was no documentation of recent or scheduled podiatry visits. The facility's policy requires foot assessments and referrals to a podiatrist as needed, but these were not consistently followed, leading to unmet foot care needs for the residents.
Deficiencies in Resident Care and Equipment Accessibility
Penalty
Summary
The facility failed to provide adequate call light access for two residents with severe cognitive impairments. During an observation, it was noted that the call light strings for both residents were not connected to the call system, rendering them unable to summon assistance. The Maintenance Director confirmed that the call light strings should be connected to the system, as per the facility's policy, which mandates that all residents have accessible call light systems. Another deficiency involved a resident who did not have access to properly sized incontinence briefs. The resident, who is occasionally incontinent, reported that the facility only provided medium-sized briefs, which were too large and caused leakage. Despite being in the facility for a year, the resident never received the correct size. The CNA confirmed that the facility's stock only included larger sizes, and the Scheduler/Supplies staff acknowledged that smaller sizes were not available. Additionally, the facility failed to provide a functioning bariatric shower bed for a resident with multiple diagnoses, including morbid obesity and hemiplegia. The resident, who is completely dependent on staff for hygiene, reported not having showered in over a year due to inadequate equipment. Observations revealed that the available shower carts were too small and had broken side rails, making them unsafe for use. The Director of Nursing noted that the resident was afraid to shower due to a previous fall, and documentation showed only bed baths were provided, with no record of showers.
Failure to Inform and Document Advanced Directives
Penalty
Summary
The facility failed to inform and provide written information about Advanced Directives to a resident upon admission, as required by their policy. The resident, a male with a history of malignant neoplasm of the larynx, spinal stenosis, dysphagia oral pharyngeal phase, suicidal ideations, anemia, and major depressive disorder, was admitted without having a POLST or Advanced Directives documented in his electronic health record. The facility's Advanced Directives book also showed no records for this resident, and his face sheet and physician's order indicated he was a full code. During an interview, the resident stated that he was never asked about his wishes for life-sustaining treatments in case of an emergency and had not signed any Advanced Directives forms. He expressed that he did not want life-sustaining treatment if it meant being on life support or becoming handicapped. The facility's policy requires staff to review advanced directive options and provide information on advanced care planning upon admission, which was not done in this case, leading to the deficiency.
Failure to Apply Splints for Contracture Prevention
Penalty
Summary
The facility failed to apply splints to prevent contractures for two residents, R85 and R95, as observed during the survey. R85, a female resident with Alzheimer's disease, type 2 diabetes, seizures, and neuropathy, was found without her prescribed palm protectors on multiple occasions. Her care plan indicated the need for these devices to prevent further contraction of her hands. Despite this, observations on two separate days revealed that R85 was in bed with her hands contracted and without the necessary devices. A CNA admitted to not knowing the whereabouts of the palm protectors, and the facility administrator confirmed that R85 should have had them on at all times. Similarly, R95, who had a physician's order to participate in restorative programs due to generalized weakness, was observed without his left hand splint on two occasions. The splint was found on his bedside table instead of being worn. A nurse acknowledged that either the restorative or nursing staff should have ensured the splint was applied to prevent further contraction. The facility's policy on ADL emphasized the importance of contracture prevention and management, yet these measures were not implemented for R95, as confirmed by the facility administrator.
Failure to Maintain a Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by two incidents involving residents R135 and R14. R135, who is cognitively intact and uses a walker, was observed maneuvering around a blower fan placed in the middle of the hallway with an electrical cord stretching past two resident rooms. This obstruction was placed by the Director of Nursing to dry the floor from a toilet leak, posing a trip hazard for residents like R135 who require supervision while walking. In another incident, R14, who is cognitively impaired and completely dependent on staff, was found in bed without the required fall mats on either side. Despite the care plan indicating the necessity of these mats to prevent falls, they were repeatedly found against the wall under the television instead of beside the bed. Staff members, including a CNA, failed to ensure the mats were correctly positioned, leaving R14 at risk of falling. The facility's policy emphasizes the importance of maintaining an environment free from accident hazards, yet these lapses in safety interventions were observed.
Failure to Provide Humidification with Oxygen Therapy
Penalty
Summary
The facility failed to provide humidification with oxygen therapy for a resident, leading to nasal dryness. The resident, a female with very mild cognitive impairment, was admitted with diagnoses including asthma, congestive heart failure, sleep apnea, and dyspnea. During observations, the resident was found receiving oxygen therapy at 2.5 liters per minute via nasal cannula without humidification. The resident reported experiencing dry nares and stated that she was never offered humidification with her oxygen therapy. The Director of Nursing confirmed that the facility's policy requires humidification with oxygen therapy and found no documentation indicating that the resident refused humidification. The facility's oxygen therapy policy, dated August 14, includes the use of humidifier bottles as necessary equipment.
Deficiencies in Food Storage and Monitoring in Resident Refrigerators
Penalty
Summary
The facility failed to properly manage and monitor the use and storage of food in residents' personal refrigerators, leading to deficiencies in labeling, dating, and discarding expired food and beverages. Specifically, for one resident, the refrigerator contained expired cartons of chocolate and white milk, as well as two bowls of shredded cheese without labels or dates. Despite the resident's report that staff checked the refrigerator's temperature daily, the expired items remained, and the housekeeping manager was unaware of the expired milk. The dietary manager confirmed that all food should be dated and labeled, acknowledging the risk of residents consuming old food. Another resident's personal refrigerator contained an open bottle of salad dressing, and the temperature logs were incomplete, missing records for several days. The facility administrator confirmed that temperatures should be checked and recorded daily to ensure food safety. The facility did not provide a policy for managing personal refrigerators, contributing to the oversight and potential health risks associated with improper food storage.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) Guidelines during wound care for a resident with severe cognitive impairment. Despite the presence of an EBP sign indicating the need for gloves, gown, and mask, the wound care nurse and a certified nursing assistant did not wear gowns while providing care to the resident's sacral wound. The facility's policy, revised recently, clearly states that gowns and gloves are required during high-contact resident care activities, such as wound care. Additionally, the facility did not maintain effective hand hygiene practices during incontinence care for another resident. Certified Nursing Assistants were observed not performing hand hygiene after removing soiled gloves and before donning clean gloves, leading to potential cross-contamination. The facility's policies on Perineal/Incontinence Care and Hand Hygiene require staff to perform hand hygiene after removing gloves and before handling clean items, which was not followed in this instance.
Failure to Report Allegation of Theft
Penalty
Summary
The facility failed to implement their abuse policy and notify the State Agency of an allegation of theft involving a resident. A [AGE] year-old female resident with moderate cognitive impairment reported to a Registered Nurse (RN) that she lost $80.00 from her wallet. The RN claimed to have documented the incident and reported it to the Social Service, who denied receiving such notification. The Social Service then checked with the RN, who stated he had informed the Assistant Administrator, who also denied being notified. The Administrator confirmed that the RN should have reported the incident to her for timely reporting to Public Health, which was only done on the day of the interview. The facility's Abuse Prevention Program policy requires immediate reporting of such allegations to the resident's representative and the Department of Public Health's regional office by telephone or fax.
Lack of Menu Variety in Resident Meals
Penalty
Summary
The facility failed to provide menu variety to meet residents' meal preferences, potentially affecting all 144 residents consuming food from the kitchen. Observations and interviews revealed that residents frequently received pork-based meals and egg-based breakfasts, leading to dissatisfaction. One resident with moderate cognitive impairment expressed that the food was horrible and often unidentifiable, with too much pork being served. Another resident with mild cognitive impairment complained about the repetitive and unappetizing nature of the meals, particularly the daily serving of eggs for breakfast. Additional residents echoed these sentiments, desiring more variety, including hamburgers, tacos, chili, cereal, and fruit cups. A review of the four-week dietary menu with the Dietary Manager confirmed the residents' complaints, showing a high frequency of pork and egg-based meals. The Dietary Manager acknowledged that some weeks included 2-3 pork meals and that different types of pork were served in various recipes. Despite initial efforts to accommodate dietary preferences, the lack of menu variety persisted. The Dietary Manager recognized the need for a more diverse menu and indicated plans to address the issue.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 664 citations issued within 25 miles in the last 12 months — including the 12 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Joliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Joliet | 0.3 mi | ★★★★★ | 8 | 0 |
| Pearl Of Joliet, The | 0.4 mi | ★★★★★ | 3 | 0 |
| Joliet Living & Rehab Center | 0.7 mi | ★★★★★ | 5 | 0 |
| Sunny Hill Nursing Home Of Will County | 3.4 mi | ★★★★★ | 3 | 0 |
| Renwick Nursing And Rehab | 3.7 mi | ★★★★★ | 15 | 0 |
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