Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Parker Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with a recent CVA and an order for pureed foods with thin liquids, plus mechanical soft upon request, was repeatedly served pureed meals even though staff knew she was not eating them. The resident said she was unaware of the mechanical soft option and had asked multiple times for different food; the Dietary Mgr initially did not recognize the alternate diet order, and the resident experienced significant unplanned weight loss.
Incorrect Meal Portion Sizes Served: The facility failed to serve the correct portion size of turkey tetrazzini for the noon meal, affecting all residents. The cook plated regular and pureed turkey tetrazzini using a #6 scoop, while the meal spreadsheet required an 8-oz portion for regular diets and two #8 scoops for pureed diets. The report states that none of the residents received the correct portion, and mechanical soft diets were served the same as regular diets despite the tray line policy requiring proper portion checks.
Dish machine and 3-compartment sink sanitizer concentrations were not maintained at the required levels. A dietary aide tested the low-temp chlorine dish machine and the strip did not change colors, then the dietary manager retested it and found it barely at 50 ppm, though she stated it should be 100 ppm. The dietary manager also checked the quat solution in the 3-compartment sink and found it at 100 ppm, stating it should be 200 ppm.
Failure to verify CNA annual in-service training. The facility could not provide documentation showing that several CNAs had completed the required 12 hours of yearly in-service education. CNAs interviewed said they had received in-services but were unsure whether they had met the required hours, and the Administrator said the facility was still working on a system to track training completion. The facility policy required annual training in dementia care, abuse prevention, and other resident care topics.
PRN psychotropic meds lacked required stop dates for several residents. Orders for anxiolytic and antipsychotic meds such as alprazolam, lorazepam, Ativan, and olanzapine had no stop dates, and for some residents the EMR did not show the required 14-day assessments and new orders. The DON stated she was responsible for ensuring PRN psychotropic meds had 14-day stop dates and that the physician should be notified if longer use was needed.
A resident on hospice was not treated with dignity and respect when an LPN refused to get the resident up despite the resident wanting to get up, and then argued with the resident's daughter/POA. Another LPN witnessed the argument near the resident's room and said it could be heard in the hallway and at the nurse's station. The DON stated staff should have honored the resident's and family's requests and treated them with respect.
A resident was found with two cups of oral meds left on the bedside table instead of being observed taking them. The resident said this depended on which nurse was working. The ADON stated meds should not be left at bedside and nurses should observe the resident take them. The resident had no order to self-administer, and the MAR listed multiple scheduled AM meds.
Medication administration errors occurred when an ADON failed to give two ordered meds to a resident during a med pass. The meds, Allopurinol and Benztropine, were not in the cart, and the ADON said they had to be reordered from the pharmacy and were not part of the facility’s on-site med supply. Surveyors found 2 errors in 33 opportunities, resulting in a 6.06% med error rate.
Failure to Carry Out Antipsychotic Medication Order: A resident with schizoaffective disorder, dementia, and PTSD had ongoing auditory and visual hallucinations, and an NP increased Latuda to address her psychotic symptoms. The order was not carried over to the POS or MAR, and the resident continued receiving the prior doses, including an 80 mg dose given at 8 AM instead of 8 PM, resulting in 48 missed doses of the increased medication.
Failure to perform hand hygiene during wound care: An ADON and a CNA entered a resident’s room using EBP, but during wound care for a stage 4 sacral pressure ulcer with drainage, gloves were removed and replaced multiple times without hand hygiene between glove changes. The ADON later stated hand hygiene should be done after each glove removal and before donning new gloves unless hands are visibly soiled.
Two residents, both with behavioral and medical diagnoses, engaged in a physical altercation in the dining room, with one resident striking the other multiple times and staff unable to immediately stop the incident. Video surveillance and staff interviews confirmed the abuse, which occurred despite facility policies prohibiting such actions.
Two residents with histories of trauma and mental health conditions reported sexually explicit remarks and unwanted advances from another resident, but staff failed to promptly report or investigate the allegations as required by policy. The affected residents were left unprotected, resulting in their withdrawal from social activities and ongoing distress, while the alleged perpetrator continued to have access to them. Multiple staff members did not escalate the complaints, and management did not initiate an investigation or protective measures until days later, leading to an Immediate Jeopardy finding.
The facility did not follow its discharge planning and unplanned discharge procedures for several residents, including failing to notify APS or emergency contacts when residents left unexpectedly, and not providing active discharge planning for residents who expressed a desire to leave. Staff confirmed that discharge planning was not initiated unless specifically requested, and documentation showed no evidence of required actions being taken.
A resident with multiple comorbidities and a history of falls was found on the floor with a laceration after staff failed to keep the bed in the low position and did not place a floor mat as required by the care plan. The resident, dependent for care and requiring a mechanical lift, attempted to reach for a drink and fell, sustaining an injury that required sutures.
A resident experienced an episode of incontinence and reported being subjected to derogatory remarks and laughter from CNAs during cleanup, leading to emotional distress. The incident was communicated to an LPN and the DON, but was not immediately reported to the facility abuse coordinator as required by policy, resulting in a failure to follow abuse reporting procedures.
A resident reported being subjected to derogatory remarks and laughter from three CNAs during an episode of incontinence. The incident was relayed to an LPN by the resident's daughter and subsequently reported to the DON, but the Administrator was not informed and no investigation was conducted, contrary to facility policy.
A resident with multiple health issues fell from a wheelchair while being lifted into a van, but the LTC facility failed to notify the resident's POA as required. The resident continued to dialysis treatment without the dialysis center being informed of the fall. The dialysis nurse later contacted the facility, which then attempted to reach the POA. The resident was discharged without proper documentation or notification, later admitted to the hospital, and passed away after transitioning to hospice care.
A resident with multiple medical conditions fell from a wheelchair during transport, and the facility failed to conduct timely neurological checks or notify dialysis staff. The resident was later diagnosed with a subdural hematoma and T8 fracture. The facility lacked a system to ensure wheelchair safety during public transport.
A resident with multiple medical conditions experienced a fall, and the facility failed to document the incident accurately and timely. The incident note and progress note were completed days after the fall, and medications were inaccurately documented as administered when the resident was not present. The Director of Nursing and Administrator acknowledged the documentation deficiencies.
A resident with pressure ulcers and MRSA was not provided proper infection control measures during wound care. Staff failed to wear appropriate PPE, and wounds were not cleansed according to facility policy, increasing the risk of cross-contamination.
The facility failed to provide scheduled showers to three residents, leading to a deficiency in maintaining their ability to perform activities of daily living. One resident, moderately impaired for cognition, reported not receiving showers for about two weeks, while another, cognitively intact, had only two showers since admission. A third resident, requiring total assistance, also missed scheduled showers. Staff interviews revealed inconsistencies in shower documentation and adherence to the schedule.
The facility failed to ensure that two residents who required thickened liquids had access to fluids at night. Nursing staff ran out of thickener, and since the kitchen was locked, they could not replenish their supply, leaving the residents without necessary fluids.
Failure to Follow Ordered Diet and Communicate Mechanical Soft Option
Penalty
Summary
The facility failed to ensure that a resident received the diet ordered, including failure to implement and communicate an ordered diet alternative. The resident, who had diagnoses including polyneuropathy, major depressive disorder, bipolar disorder, and a recent cerebral infarction, had an order for a general diet with pureed texture and thin liquids, with allowance for mechanical soft texture upon request. The resident stated that she was not aware she could request mechanical soft foods and reported that she had asked staff multiple times for an alternate diet but was still served pureed food. A CNA stated she knew the resident was not eating pureed foods but was not aware of the mechanical soft option, and the Dietary Manager initially stated there were no alternatives before confirming the order included mechanical soft upon request. Meal observations showed the resident was served pureed meals and ate only mashed potatoes, while the resident stated she disliked pureed foods and therefore did not eat most meals. The Dietician confirmed the resident had weight loss and that interventions included supplements and pureed foods the resident would eat, but also confirmed the double portions were not effective because the resident was not eating pureed food. The resident later stated she was happy because she was served real food and ate all of it. Weight records showed an unplanned 15.8 lb, 11.1% weight loss over approximately six weeks, meeting criteria for significant weight loss. The care plan did not include a focus area or interventions related to nutrition or weight loss, and the facility policy stated it would follow physician orders and provide essential care as ordered.
Incorrect Meal Portion Sizes Served
Penalty
Summary
The facility failed to ensure residents received the correct portion size for the noon meal, affecting all 63 residents in the facility. The menu for the noon meal listed turkey tetrazzini, California blend, a dinner roll, cake, and a beverage of choice. During observation, the cook was plating the meal and used a #6 scoop for both regular turkey tetrazzini and pureed turkey tetrazzini. The facility’s meal spreadsheet stated that regular turkey tetrazzini should be served as an 8-ounce portion using an 8-ounce spoodle or two 4-ounce spoodles, while pureed turkey tetrazzini should be served as two #8 scoops. The report states that none of the residents received the correct portion of turkey tetrazzini, and mechanical soft diets were served the same as regular diets. The cook later stated she should have served two scoops of the #6 scoop for both, although that still did not match the documented portion size. The facility’s tray line policy required all meals to be checked for accuracy and proper portion sizes before serving.
Dish Machine and Sink Sanitizer Concentrations Not Maintained
Penalty
Summary
The facility failed to ensure the dish machine was sanitizing at the appropriate concentration. During observation, a dietary aide was washing silverware in the dish machine, and the cook identified it as a low temperature, chlorine dish machine. When the dietary aide tested the machine, the test strip did not change colors. The dietary manager later tested the dish machine again and the strip changed to a light grey color barely at 50 ppm, while she stated it should be at 100 ppm. When she checked it again, the test strip did not change colors and remained white. The facility also failed to ensure the 3-part sink sanitizing solution was at the proper concentration. The dietary manager checked the quat sanitizing solution in the 3-compartment sink and the test strip showed 100 ppm, while she stated it needed more solution and should be at 200 ppm. The facility’s policies required the dishwashing machine to be operated according to manufacturer instructions and the final rinse to be tested at the beginning of each washing session, and the 3-compartment sink sanitizing solution to be checked frequently using a test strip and prepared according to the chemical manufacturer’s guidelines.
Failure to Verify CNA Annual In-Service Training
Penalty
Summary
The facility failed to have a system in place to verify that Certified Nursing Assistants (CNAs) had completed the required 12 hours of annual in-service training. The deficiency applied to all 63 residents in the facility. During record review on 4/1/26, the surveyor requested training files for V8, V9, V14, V15, and V16, all CNAs, but the facility could not provide documentation showing that these CNAs had received the required annual training. A sign posted by the time clock dated 11/19/25 instructed CNAs, including V8 and V9, to complete required training. When interviewed on 4/1/26, V8, V9, and V14 said they had received in-services but were not sure whether they had met the required training hours. The Administrator stated the facility was in the process of implementing a system to track CNA training hours to ensure completion of the required 12 hours of annual training. The facility policy stated CNAs must complete 12 hours of annual in-service training, including dementia management, resident abuse protection, training addressing areas of weakness or potential weakness, and training needed to carry special needs residents, and that there must be a process to track staff participation in trainings.
PRN Psychotropic Medications Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had stop dates for 4 of 5 residents reviewed for psychotropic medication use. R4 had orders for alprazolam 0.5 mg per PEG tube every 8 hours as needed for anxiety and Ativan 0.5 ml 2 mg/ml every 2 hours as needed for anxiety, as well as Ativan 0.5 ml by mouth every 6 hours for agitation and restlessness, and none of these orders had stop dates. R24 had an order for Ativan oral tablet 1 mg, 1 tablet by mouth every 6 hours as needed for restlessness, with no stop date. The DON stated she was responsible for ensuring PRN psychotropic medications had 14-day stop dates and that the physician should be informed if the medication needed to continue longer than 14 days. R9 had active orders for lorazepam 1 mg by mouth every 4 hours as needed for restlessness and olanzapine 10 mg IM every 8 hours as needed for agitation, with no stop dates. R9’s MAR showed lorazepam was administered on multiple days in March, and the EMR did not show documented assessments and new orders every 14 days for psychotropic or antipsychotic medication. R49 had an active order for olanzapine 5 mg IM every 8 hours as needed for anxiety/agitation with no stop date, and the EMR also failed to show documented assessments and new orders every 14 days for psychotropic or antipsychotic medication. The facility’s Psychotropic Drug Usage policy stated that residents receiving psychotropic medications would have gradual dose reductions and behavioral interventions unless contraindicated, and that residents receiving PRN psychotropic medications would be evaluated if the medication was extended longer than 14 days, with the rationale documented in the medical record.
Failure to Maintain Resident Dignity During End-of-Life Care
Penalty
Summary
The facility failed to treat a resident with dignity and respect for 1 of 17 residents reviewed. The resident was on hospice and actively declining toward end of life, and the resident's daughter/POA reported that when the resident wanted to get up, an LPN refused and ignored the request. The daughter said the LPN argued with her, and she believed the resident heard the argument. Another LPN stated she witnessed the daughter and the LPN arguing near the resident's room, with the argument audible in the hallway and at the nurse's station, and said the resident had been wanting to get up lately. The LPN involved said she thought the resident was not supposed to be up per the DON's direction, and the DON stated staff should have honored the resident's and family's requests and ensured they were treated with respect. The facility policy on dignity states staff will always be polite and respectful and will not speak in a manner that could be interpreted as minimally condescending, critical, or argumentative.
Medication Left at Bedside Without Supervision
Penalty
Summary
The facility failed to ensure a resident was supervised during medication administration for 1 of 17 residents reviewed for pharmacy services. On 3/30/26 at 9:33 AM, R20 was observed lying in bed with 2 clear medication cups on the bedside table containing pills, including one cup with a large white pill and another cup with 7 pills: 2 large white pills, 1 pink pill, 1 green pill, 1 blue pill, and 2 small white pills. R20 stated that sometimes staff leave the pills for her to take and sometimes they do not, depending on which nurse is working. On 3/31/26 at 8:51 AM, the ADON stated that medications should not be left at the resident bedside and that nurses should observe the resident take the medication. The facility reported that no residents had orders to self-administer medications, and R20’s MAR showed multiple 8:00 AM oral medications, including Acidophilus, Amlodipine, Levothyroxine, Lisinopril, Omega 3, Toprol XL, Glyburide, Metformin HCL, and Dicyclomine HCL. R20’s Physician Order Summary did not include any order for self-administration, and the facility’s medication administration policy stated that nurses should remain with the resident during medication administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors occurred when the facility failed to give medications as ordered. During a medication pass observation of V3, the Assistant Director of Nursing, two medications for R37 were not administered at 8:33 AM: Allopurinol and Benztropine. V3 stated the medications were not in the cart and had to be reordered from the pharmacy, and also stated these medications were not part of the facility’s on-site medication supply. R37’s Physician Order Summary showed active orders for Allopurinol 100 mg, 2 tablets daily for gout, and Benztropine Mesylate 1 mg twice daily. R37’s Medication Administration Summary showed Allopurinol due at 8:00 AM and Benztropine due at 8:00 AM and 8:00 PM. Surveyors identified 33 opportunities with 2 errors, resulting in a 6.06% medication error rate.
Failure to Carry Out Antipsychotic Medication Order
Penalty
Summary
The facility failed to carry out a physician order as prescribed and failed to increase a resident’s antipsychotic medication, resulting in a significant medication error. The resident had diagnoses of schizoaffective disorder, bipolar type, unspecified dementia, and post-traumatic stress disorder. Her care plan stated that she had a serious and persistent mental illness, required psychotropic medication to manage anxiety, neurosis, and insomnia, and needed staff to carry out the medication regimen as prescribed. The care plan also identified that she required strategies to deal with hallucinations and delusions. A physician progress note documented that the resident reported auditory and visual hallucinations of deceased people that were causing distress, and that these symptoms had occurred recently despite the current medication regimen. The nurse practitioner increased Latuda from 20 mg to 40 mg in the morning and continued 80 mg in the evening to help alleviate her psychotic symptoms. However, the physician order summary and medication administration record showed the resident continued to receive Latuda 20 mg at 8 AM and 80 mg at 8 AM instead of 8 PM as ordered, and the 40 mg dose increase was not carried onto the order summary or MAR. This resulted in the resident missing 48 doses of the medication increase. The DON stated the order was missed and that nurse practitioners were writing orders on paper and giving them to nurses, and the nurse practitioner stated the medication was increased because the resident was having auditory and visual hallucinations despite the current Latuda dose.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure that staff performed proper hand hygiene after removing gloves during wound care for one resident. The resident had diagnoses that included other specified local infections of the skin and subcutaneous tissue and a stage 4 pressure ulcer of the sacral region. The resident’s order summary required wound care every day shift and as needed, along with enhanced barrier precautions because of the wounds. During observation of wound care, the Assistant Director of Nursing and a CNA performed hand hygiene, donned gloves and gowns, and entered the resident’s room. While positioning the resident and preparing wound care supplies, they removed and replaced gloves multiple times, but hand hygiene was not performed after glove removal before donning new gloves. The ADON removed the dressing from the sacrum and coccyx area, which was saturated with yellowish brown drainage, then continued cleansing, dressing application, and barrier cream application with repeated glove changes but no hand hygiene between glove removals and new glove use. After leaving the room, the ADON stated she would usually bring hand sanitizer but had forgotten it on the wound cart outside the room, and stated that hand hygiene is to be performed after each glove removal and before donning new gloves unless hands are visibly soiled.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents in the dining room. One resident, with a history of hemiplegia, hemiparesis, anxiety, and delusional disorder, approached another resident, who had diagnoses including traumatic subdural hemorrhage, drug-induced Parkinson's, and anxiety disorder. Both residents were alert and able to verbalize their needs. During the incident, one resident began yelling, prompting the other to approach and physically strike him multiple times. The second resident retaliated, and the altercation continued until staff intervened. Video surveillance confirmed that the physical altercation involved multiple strikes and that staff were unable to immediately stop the incident. Staff interviews revealed that the nurse on duty was attending to another resident when the altercation began and responded by yelling and attempting to intervene. Additional staff, including human resources and kitchen staff, arrived after hearing the commotion and assisted in separating the residents. Both residents and staff acknowledged that the physical contact constituted abuse. The facility's policy prohibits resident abuse, including physical abuse such as hitting, slapping, and other forms of corporal punishment. Despite these policies, the incident occurred, and staff were not able to prevent or immediately stop the abuse between the residents.
Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to identify and investigate an allegation of sexual abuse involving two residents who reported that another resident made sexually explicit remarks and unwanted advances toward them. Despite the residents expressing fear and distress, and reporting the incidents to multiple staff members, including an activities aide and several certified nurse aides, the allegations were not promptly reported to management or nursing leadership as required by the facility's abuse prevention policy. The staff members who received the initial complaints either deferred responsibility, failed to escalate the concerns, or dismissed the urgency of the situation, resulting in a lack of immediate protective measures for the affected residents. The residents involved had documented histories of trauma and mental health conditions, including anxiety, schizophrenia, major depressive disorder, and post-traumatic stress disorder. Both were assessed as cognitively intact and had no recent behavioral symptoms according to their medical records. The alleged perpetrator also had a history of sexually inappropriate behavior documented in his care plan, yet no immediate action was taken to separate him from the complainants or to initiate an investigation when the allegations were first reported. Instead, the residents were advised to avoid the alleged perpetrator and to report the matter to management at a later time, leaving them unprotected and causing them to withdraw from social activities and remain isolated in their rooms. Multiple staff statements confirmed that the allegations were not investigated in a timely manner, and that management was not notified promptly. Written statements from the certified nurse aides were not followed up with interviews or further inquiry by facility leadership. The administrator and social services director did not initiate an investigation or increase monitoring of the alleged perpetrator until days after the initial report. This failure to respond appropriately to the allegations resulted in the residents continuing to experience fear and distress, and led to a finding of Immediate Jeopardy by surveyors.
Failure to Follow Discharge Planning and Unplanned Discharge Procedures
Penalty
Summary
The facility failed to follow its own policies and procedures for discharge planning and unplanned discharges for multiple residents. For three residents who left the facility unexpectedly, there was no documentation that Adult Protective Services (APS) were notified or that any attempts were made to locate the residents after they left. In one case, a resident left the facility with all her belongings and was later found at a local fast-food restaurant in a disheveled state, but there was no evidence that the facility contacted emergency contacts, APS, or the police, nor did staff attempt to locate her. Similarly, two other residents left the facility, one after refusing to sign an Against Medical Advice (AMA) form, and no further action was taken by the facility to ensure their safety or notify appropriate authorities. Additionally, the facility did not provide adequate discharge planning for three residents who expressed a desire to return to the community or move to a less structured environment. Care plans and progress notes indicated that these residents were cognitively intact and had self-sufficiency skills, yet there was no evidence of active discharge planning or social service involvement to assist them in transitioning out of the facility. In interviews, these residents reported that although they had communicated their wishes to leave, they were not receiving help from the facility to facilitate their discharge. The Social Service Director and other staff confirmed that discharge planning was not initiated unless specifically requested by the resident, and that no active discharge plans were in place for the residents who had expressed a desire to leave. The facility's own policies require the involvement of social work staff in assessing discharge potential and coordinating community services, but documentation and staff interviews revealed that these procedures were not followed. The lack of action and documentation regarding both planned and unplanned discharges resulted in a failure to ensure safe and appropriate transitions for the affected residents.
Failure to Maintain Bed in Low Position and Use Floor Mat Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was in the low position and that a floor mat was in place as required by the resident's care plan. The resident, who was dependent for care and required a mechanical lift for transfers, was found on the floor next to the bed with a laceration above the right eyebrow after attempting to reach for a drink. The bed was observed to be in a high position and the floor mat was missing at the time of the incident. Staff interviews confirmed that the resident was left in bed with the mechanical lift sling under him, and the required safety interventions were not in place. The resident's medical history included significant risk factors such as a history of CVA with right hemiplegia, COPD, atrial fibrillation, CHF, epilepsy, and other chronic conditions. The care plan specifically directed staff to keep the bed in the lowest position and to apply floor mats to the side of the bed. Despite these interventions being documented, they were not implemented, resulting in the resident sustaining an injury that required sutures and evaluation at the emergency room.
Failure to Immediately Report Alleged Resident Abuse to Abuse Coordinator
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the facility abuse coordinator as required by policy. The incident involved a resident who experienced a significant episode of loose stools, resulting in soiling of her clothes, the toilet, floors, and walls. During the cleanup, the resident reported that one CNA made a derogatory comment about the situation and told her to clean it up herself, while two other CNAs laughed at her. The resident felt embarrassed and upset by the staff's behavior and subsequently called her daughter to report the incident. The daughter then contacted the LPN on duty, who stated she reported the concern to the DON. However, the DON could not recall if the LPN had called her and mentioned that the resident's daughter may have texted her about the incident. The Social Services Director documented the daughter's concern but did not report the potential abuse to the facility abuse coordinator. As a result, the required immediate reporting of the abuse allegation to the administrator did not occur, contrary to facility policy.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident who experienced an episode of incontinence resulting in a significant mess. The resident reported feeling embarrassed and stated that a CNA made a derogatory comment about cleaning up the mess and told the resident to clean it up herself, while two other CNAs laughed at her. The resident did not initially report the incident to nursing staff but called her daughter, who then contacted the LPN on duty. The LPN reported the allegation to the DON, but the Administrator was not made aware of the incident and no investigation was initiated, as required by facility policy. The lack of investigation into the reported abuse constituted a failure to respond appropriately to an alleged violation.
Failure to Notify POA After Resident Fall
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) following a fall incident, which was a requirement according to their guidelines. The resident, who had multiple diagnoses including Hemiplegia, Morbid Obesity, and End Stage Renal Disease, fell out of his wheelchair while being lifted into a public transportation van. Although the resident reported hitting his head, he refused to go to the Emergency Department and proceeded to his dialysis treatment. The dialysis center's nurse noted the fall and contacted the nursing home for more information, discovering that the facility had not informed the POA about the incident. The facility's guidelines required immediate notification of the resident's physician and POA in the event of an accident or significant change in condition. Despite this, the facility did not notify the POA until after the dialysis center's nurse had already done so. Additionally, the facility failed to inform the dialysis center about the fall before the resident's treatment. The resident was later discharged from the facility without documentation of the discharge details or notification to the POA or physician. The resident was admitted to the hospital with septic shock and passed away after being transitioned to hospice care.
Failure to Assess and Intervene After Resident Fall
Penalty
Summary
The facility failed to ensure proper assessment and intervention following a fall incident involving a resident. The resident, who had multiple medical conditions including hemiplegia, morbid obesity, and end-stage renal disease, fell out of a wheelchair while being lifted into a public transportation van. Despite the resident stating they hit their head, no immediate neurological checks or vital sign monitoring were conducted, and the resident was transported to an off-site dialysis unit without notifying the dialysis staff of the fall. The facility's policy required neurological checks for unwitnessed falls, but these were not performed until several hours after the incident, just before the resident was transferred to the hospital for severe pain. The hospital diagnosed the resident with a subdural hematoma and a T8 fracture, indicating significant injuries from the fall. The facility's failure to conduct timely assessments and notify relevant parties contributed to the delay in addressing the resident's injuries. Additionally, the facility did not have a system in place to ensure the safety of residents using public transportation, as evidenced by the lack of intervention to secure wheelchair brakes during transport. The Director of Nursing acknowledged that no intervention was in place to ensure wheelchair brakes were applied for residents using public transportation, and the facility did not communicate with the dialysis staff regarding the resident's fall or the need for safety checks during transport.
Inaccurate and Delayed Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure accurate and timely documentation for a resident who experienced a fall. The resident, who had multiple medical conditions including hemiplegia, morbid obesity, and end-stage renal disease, fell and hit their head. Despite the facility's policy requiring immediate and thorough documentation of such incidents, the incident note was completed more than two days after the fall and the resident's discharge to the hospital. Additionally, the progress note indicating the resident's refusal to be transferred to the hospital was completed three days after the fall. The resident's medical record inaccurately documented the administration of medications and treatments on a day when the resident was not present in the facility, as they had been discharged to the hospital. Furthermore, the facility's report indicated that the resident was monitored post-return from dialysis, but the medical record lacked documentation of the time the resident returned or any ongoing monitoring. The resident was later sent to the emergency department with a thoracic spine fracture and subdural hematoma, yet the medical record did not include details of the resident's condition or assessments related to the transfer. The Director of Nursing acknowledged the lack of documentation for post-fall assessments, the resident's return from the emergency department, and the reason for the emergency department visit. The Licensed Practical Nurse admitted to accidentally charting on the resident's medication administration record, and the Administrator confirmed that the documentation was inaccurate and incomplete, emphasizing the expectation for staff to complete documentation by the end of their shift.
Inadequate Infection Control and Wound Care Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during the care of a resident with pressure ulcers and MRSA in the sputum. The resident, who had diagnoses including metabolic encephalopathy, Down syndrome, and early onset Alzheimer's disease, was observed in a room with a sign indicating droplet precautions. However, the staff did not adhere to the required PPE protocols. The Wound Care Nurse did not wear a mask or eye protection, and the LPN wore a surgical mask but no eye protection while performing a dressing change on the resident's wounds. Additionally, the wounds were not cleansed properly, as the same gauze pad was used on multiple wounds, and the cleansing technique did not follow the recommended inward to outward method. The Director of Nurses confirmed that the resident was still on droplet precautions due to MRSA and required full PPE, including gowns, gloves, N95 masks, and face shields, which was not followed. The sign outside the resident's room was incorrect and did not reflect the necessary precautions. The facility's policies on wound cleansing and infection control were not adhered to, as the wounds were not cleansed individually with fresh pads, and the risk of cross-contamination was not mitigated. The failure to follow these protocols posed a high risk for cross-contamination between residents.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to three residents, R1, R2, and R3, as per their scheduled shower days, which is a deficiency in maintaining the residents' ability to perform activities of daily living. R1, who is moderately impaired for cognition, reported not receiving showers as scheduled, with no documentation of showers from 9/1 to 9/6, 9/8 to 9/13, and 9/15 to 9/21. R1 expressed the need for assistance with showers and stated she had not received a shower for about two weeks. R2, who is cognitively intact, also had no showers documented from 8/27 to 9/18 and 9/21 to 9/24, and reported only having two showers since admission in August. R2 requires setup support for bathing and expressed a need for a shower before an upcoming doctor appointment. R3, who is cognitively intact and requires total assistance for bathing, had no showers documented from 9/8 to 9/14. R3 had previously filed a grievance in June regarding not receiving showers, which was unresolved. Observations and interviews with staff revealed inconsistencies in shower documentation and a lack of adherence to the shower schedule. CNAs and the LPN confirmed that residents are supposed to receive showers twice a week, but documentation was lacking, and there was no evidence of residents refusing showers. The facility's administrator acknowledged the issue with documentation and noted that R1, R2, and R3 were not receiving showers regularly.
Failure to Provide Thickened Liquids at Night
Penalty
Summary
The facility failed to ensure that residents who required thickened liquids had access to fluids at night. Specifically, two residents, R1 and R2, who had physician orders for honey thick and nectar thick liquids respectively, were unable to receive fluids during the night due to a lack of thickener. On the night of 5/1/24, the nursing staff ran out of thickener, and since the kitchen, where the thickener is stored, was locked, they could not replenish their supply. This resulted in R1 and R2 not having access to the necessary thickened liquids throughout the night. Observations and interviews confirmed that both residents were without drinks during the night. R1 was found awake in bed with an empty cup on the overbed table, and R2 was also lying in bed without any drinks available. The nursing staff, including an agency RN and another RN, confirmed they did not have access to thickener and had run out at the beginning of their shifts. The cook confirmed that the kitchen provides the thickener and that nursing staff do not have access to the kitchen at night. The Director of Nursing acknowledged that residents should be offered fresh drinks throughout the shift and that the facility needed to ensure nursing staff had access to thickener for those who require it.
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 85 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Streator
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arc At Streator | 2.1 mi | ★★★★★ | 6 | 0 |
| Pleasant View Luther Home | 13.2 mi | ★★★★★ | 3 | 0 |
| Pavilion Of Ottawa | 13.5 mi | ★★★★★ | 11 | 0 |
| La Salle County Nursing Home | 13.5 mi | ★★★★★ | 0 | 0 |
| Goldwater Care Marseilles | 14.6 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.