Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Pavilion Of Logan Square, The during CMS and state inspections, most recent first.
Food storage and sanitation practices were not followed in the kitchen. Shelves near the tray line were dirty, a floor fan used near the stove had dirty blades and guards, and multiple foods were found unlabeled, undated, or stored out of FIFO order, including bread ends, cilantro, onions, and canned goods. During tray line prep, a cook did not perform hand hygiene before food prep and was observed handling the microwave and food with gloved hands.
Infection control practices were not followed for a resident on contact isolation when a CNA entered without hand hygiene or gown/gloves and removed the resident’s lunch tray. For another resident on EBP, a family member was observed leaving and re-entering the room without hand hygiene and stated no EBP education had been provided. The facility also had uncovered linen transport, missing EBP signage for a resident with wounds, and an uncovered ice scooper used by residents.
Expired and undated meds and biologicals were found in medication storage areas, including eye meds, insulin, PPD, and Osmolyte. An RN and LPN acknowledged several items should have been discarded or labeled, and a DON stated multi-dose insulin vials should have open and expiration dates.
Call Light Not Accessible to Resident With Hand Contractures: A resident with severe hand contractures, arthritis, and limited upper-extremity function was observed in bed with a call light tied to a heavy stuffed toy positioned behind her shoulder and out of reach. The resident stated she could not pull it with her hands and had been using her mouth to activate it because staff had not provided another device. An RN and the OT director confirmed the setup was not workable for the resident, and the OT director noted the call light needed to be directly in front of her for independent use.
Mismatch in Advance Directive and Code Status Documentation: The facility failed to keep a resident’s physician orders, POLST, and care plan consistent. A resident with severe cognitive impairment and multiple diagnoses had a POLST for DNR/comfort-focused care, but the care plan initially stated Full Code with CPR, IV, AED, EMS, and hospitalization interventions. The DON and DSD stated the physician order, POLST, and care plan should match, and facility policy required the care plan to reflect the resident’s treatment preferences and advance directive.
Care plan failed to address a resident’s language barrier and communication needs. A resident whose preferred language was Spanish and who had moderate cognitive impairment stated that staff could not always explain medications in Spanish and that an interpreter was not always available. The DON/Social Services interview confirmed the language barrier should have been included in the care plan, but it was missed, and the comprehensive care plan did not document the deficit or include measurable communication interventions.
A resident with schizophrenia, hallucinations, and Parkinson’s disease was observed using a retractable blade in the room, and staff were unaware the blade was present even though residents were not allowed to have sharps. The facility also failed to follow fall supervision and prevention interventions for two residents with repeated falls: one resident with dementia and confusion was found on the floor after trying to toilet alone, and another resident with Parkinson’s disease had documented fall-prevention measures that were not in place during observation, including a missing non-skid pad, unattached mattress straps, and personal items out of reach.
A resident on continuous O2 via nasal cannula was observed in bed without an oxygen-in-use/no smoking sign posted on or outside the room. The RN and DON stated the sign is required for residents receiving O2 and confirmed it was missed after the resident returned from the hospital on readmission. The resident had chronic respiratory failure, dementia, severe intellectual disabilities, seizures, epilepsy, OSA, visual loss, dysphagia, and adult neglect or abandonment.
An RN failed to administer a resident's ordered Dilantin dose correctly, giving 1 capsule instead of the prescribed 4 capsules for epilepsy. The resident had epilepsy, delirium, a history of falls, brain disorders, generalized weakness, and cognitive communication deficit. The RN later acknowledged the error, and the DON confirmed the order required 4 capsules and that the incorrect dose could affect the Dilantin level and lead to seizures.
A resident with legal blindness and other conditions did not have his prescribed Latanoprost eye drops available for administration, despite a physician's order and pharmacy documentation of delivery. Nursing staff were unable to locate the medication during review, and the resident reported only receiving the drops when specifically requested. A prior family grievance also noted missed doses, indicating a failure in maintaining medication supply and administration procedures.
A resident prescribed multiple psychotropic medications experienced discrepancies in medical record documentation, including inconsistent diagnoses for Depakote, missing or delayed consent forms for Haldol and Olanzapine, and failures to upload required documents to the electronic record. An LPN confirmed that incorrect diagnoses were selected and that consent documentation was incomplete or not timely.
A resident with intellectual disabilities and Down syndrome fell in her room after being instructed to put on shoes, resulting in hospitalization. The facility failed to implement fall prevention interventions despite the resident's documented need for supervision and assistance. The incident highlights a lack of adherence to the facility's policies and the resident's care plan, contributing to the avoidable fall.
The facility failed to properly manage resident funds, charging dental insurance premiums and haircut fees without proper consent or documentation. Four residents were overcharged for dental premiums, and five residents were charged for haircuts without proper consent, especially those with cognitive impairments. The facility's auditing process for personal funds was inadequate, leading to discrepancies in charges and credits.
The facility failed to provide flu vaccinations and education to two residents, despite the importance of such measures for elderly individuals with medical comorbidities. The Infection Control RN did not document offering the vaccine or providing education, and the refusal form was inaccessible to other staff. This led to a deficiency in the facility's vaccination protocol.
A facility failed to implement care plan interventions and ensure staff followed safety protocols, resulting in injuries to three residents. One resident sustained facial lacerations after being improperly transferred by CNAs, while another suffered neck fractures due to not being secured in a facility van. A third resident also fell in the van due to a lack of seatbelt use, highlighting a pattern of non-compliance with safety protocols.
A facility failed to investigate an abuse allegation for a resident with a known fall risk. The resident sustained injuries consistent with being punched, not from a fall, during care. Two CNAs were involved in transferring the resident, and one left the room before the incident. The facility did not conduct a reportable investigation for abuse, believing it was a fall, despite the hospital's allegation of abuse.
A resident with cognitive impairments unexpectedly slapped another resident in a hallway, despite having no prior history of aggression. The incident was promptly addressed by staff, and no injuries were reported. The aggressive behavior was linked to a mental status change in the resident, possibly due to a urinary tract infection.
The facility failed to prevent employees from storing personal food in the kitchen's walk-in cooler and did not address a leaking ceiling and clogged drain in the dishwashing area, leading to unsanitary conditions. The dietary supervisor was unaware of the source of the personal food items and acknowledged the unsanitary conditions but did not take immediate corrective action.
A resident with severe cognitive impairment was found with unattended medication in their room, highlighting a failure by the facility to assess the resident's ability to self-administer medications. The RN responsible admitted to leaving the medications unsupervised, contrary to facility policy, which requires a competency assessment for self-administration. The DON confirmed that the resident was not assessed for self-administration, indicating a breach in medication administration procedures.
The facility failed to conduct daily checks of the crash cart on the 3rd floor, potentially affecting 57 residents. Observations and staff interviews revealed missing daily checks on several dates, contrary to the facility's policy. An LPN and the DON emphasized the importance of these checks to ensure emergency readiness, as the cart contains essential items like oxygen tubing and IV kits.
The facility failed to secure hazardous items like razors and soap, and did not implement or update fall prevention measures for residents at risk. A resident was found with unsecured soap in their room, and the shower room had dispensers without lids, allowing staff to improperly scoop soap. Additionally, fall interventions were not followed, as a resident was observed barefoot and with an unplanned fall mat. The facility's policies on safety and fall prevention were not adhered to, posing risks to residents.
The facility failed to ensure proper respiratory care by not containing a nebulizer mask and not labeling or changing oxygen tubing and humidifier bottles per policy. This affected several residents with conditions like COPD and diabetes, as equipment was either undated or outdated, contrary to the facility's guidelines.
The facility failed to monitor and maintain personal refrigerator temperature logs for several residents, with some refrigerators lacking thermometers. Staff, including CNAs and the Infection Preventionist, acknowledged the need for daily monitoring to prevent food spoilage. Conflicting statements from the Director of Nursing and Housekeeping Director about responsibility led to lapses in monitoring, posing a risk of food spoilage.
The facility failed to contain cigarette butts, which were found near a generator's fuel tank, posing a fire risk. Staff were unclear about designated smoking areas and proper disposal methods, leading to cigarette waste accumulation near the flammable tank. The maintenance director confirmed receptacles were not near the docking area, and a dietary aide was observed smoking near the fuel tank despite prohibitions.
The facility failed to ensure call lights were within reach for two residents, one with dementia and another with COPD and diabetes. Observations revealed call lights were inaccessible, contrary to care plans and facility policy. Staff confirmed the call lights should be within reach to assist residents in calling for help.
A facility failed to document a resident's code status in the EMR, affecting their treatment preferences. An LPN noted that code status should be visible on the EMR profile screen, but the resident's advance directive was blank, and no physician order was present. The DON confirmed that code status should be entered based on family verification, and until decided, residents are treated as full code. Despite this, the resident's EMR lacked the necessary order, indicating a lapse in policy adherence.
A facility failed to accurately complete a resident's MDS, reflecting inconsistencies in the resident's communication abilities. The resident, with a history of hemiplegia and dementia, was documented as having clear speech, yet observations showed unclear, strained communication. Staff interviews revealed discrepancies in the MDS coding, indicating a failure to properly assess and document the resident's status.
A resident was not referred for a Level II PASARR evaluation after being diagnosed with multiple mental disorders, including Schizoaffective Disorder and Paranoid Schizophrenia. The facility's policy requires a new PASARR with any significant change in status, but this was not done until after the deficiency was identified. The Social Service Director acknowledged the oversight, indicating a communication gap in the process.
A facility failed to complete a pre-admission screening and resident review (PASARR) for a resident with major depressive disorder and unspecified psychosis. The resident was admitted without a Level I PASARR, which was only completed after the survey began, contrary to the facility's policy requiring adherence to state and federal requirements.
A facility failed to include a resident in the development of their care plan, despite the resident's cognitive impairment and desire to participate. The resident, with multiple diagnoses including dementia and hemiparesis, was not invited to care plan meetings, contrary to facility policy. The care plan coordinator confirmed the oversight but could not explain why the resident was excluded.
Two residents who depend on staff for ADL care were not properly groomed, specifically not shaved, despite having visible facial hair. One resident has moderate cognitive impairments and requires maximum assistance, while the other has some cognitive impairments and is dependent on staff for personal hygiene. A CNA admitted to not shaving one of the residents, and the DON confirmed that shaving should be part of daily ADL care for residents with visible facial hair.
The facility failed to implement fall precautions and provide adequate supervision, resulting in multiple resident falls and injuries. Beds were not in the lowest position for two residents, and supervision was lacking during smoking times, with residents found in possession of smoking materials. Staff distractions, such as phone use, contributed to these deficiencies.
A resident's left knee injury was not properly documented or treated according to physician orders in an LTC facility. The injury occurred when an over-bed table fell on the resident's knee, and the facility failed to change the dressing as needed. The wound was inaccurately documented as healed, and the wound care nurse admitted to selecting an incorrect classification due to system limitations.
A resident with moderate cognitive impairment and a history of falls did not receive adequate supervision or effective fall prevention interventions, resulting in two unwitnessed falls and a compression fracture. Despite the facility's fall management policy, necessary updates to the care plan, including frequent monitoring, were not implemented.
Food Storage, Sanitation, and Hand Hygiene Failures
Penalty
Summary
Food was not maintained in accordance with professional standards in the kitchen and storage areas. During an initial tour, shelves near the tray line were observed with dirt that could be scraped off with a finger, and a floor fan near the stove/oven area was in use while its blades and guards were dirty. In dry storage, a transparent bag of bread ends from multiple loaves was found on a shelf with other bread, and it was not dated. Large cans were also stored out of first-in, first-out order, including diced tomato cans dated 07/20/2026 placed in front of cans dated 08/07/2025 and orange cans dated 07/10/2026 placed in front of cans dated 08/11/2026. In the walk-in cooler, a transparent bag of cilantro had no readable date and appeared discolored, and onions were stored in a large box without a label or date. Prepared super cereal was marked with a preparation date of 08/16/2025 and a use-by date of 08/20/2025, although staff stated the product should only last 2 or 3 days. The dietary aide stated the cilantro and bread ends needed to be discarded, and the dietary director later stated the cilantro needed to be removed from the refrigerator and that the bread ends needed to be labeled and dated. During tray line observation, a cook did not perform hand hygiene before starting food preparation, put on gloves, and began handling food. The cook was also observed touching the microwave handle multiple times while preparing food and then removing food from the microwave with gloved hands before resuming food preparation. When the dietary director arrived, she stated staff needed to wash hands before food preparation on the tray line and observed the cook again opening the microwave by pulling the handle, prompting her to call attention to handwashing.
Infection Control Failures With PPE, Family Education, Linen Handling, EBP Signage, and Ice Storage
Penalty
Summary
Infection prevention and control practices were not followed for a resident on Contact Isolation Precautions. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, type 2 diabetes mellitus, acute kidney failure, heart failure, ileus, epilepsy, iron deficiency anemia, and other conditions. The resident’s orders and care plan directed single-room strict contact isolation for ESBL in the urine. On observation, a CNA entered the resident’s room without performing hand hygiene and without putting on a gown and gloves, then exited the room carrying the resident’s lunch tray. The CNA later stated he had gone into the room to collect the finished lunch tray and acknowledged he should have performed hand hygiene and worn a gown and gloves. An LPN stated that anyone entering the room should perform hand hygiene and wear a gown and gloves, and the DON stated the same precautions were required for contact isolation. Enhanced Barrier Precautions were not consistently followed for another resident with an indwelling Foley catheter. The resident had diagnoses including COPD, acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, dementia, moderate protein-calorie malnutrition, asthma, and urinary retention, and the resident’s orders, MDS, and care plan documented EBP for the Foley catheter. Although EBP signage and PPE were observed outside the room, the resident’s family member left the room without performing hand hygiene and later re-entered carrying a lunch tray and began feeding the resident without hand hygiene before entering or after leaving. The family member stated she had not received education or instruction from staff on EBP or hand hygiene. Staff interviews indicated that family education on EBP was expected, but the Infection Preventionist stated education was verbal and not necessarily documented. The facility also failed to follow linen handling procedures and failed to maintain clear EBP signage for another resident. On the laundry walk-through, clean resident clothing was observed being delivered in an uncovered cart, and a large gray bin containing linens and resident gowns was found not bagged and not covered. The facility’s linen policy required contaminated linen to be bagged at the point of use and clean linen to be transported in a clean, covered cart. In addition, a resident with active wound orders and an EBP order for wound care had no EBP signage posted outside the room on two observations, and staff in the room stated there was no sign. The resident’s care plan did not contain a focus for EBP related to wounds, despite the order being active. The facility also failed to maintain the ice supply used by residents for consumption in a sanitary manner. A resident was observed scooping ice cubes from a cooler with a plastic scooper and placing them into a pitcher, while the scooper was uncovered and exposed. The Infection Preventionist stated residents were not supposed to scoop ice because contamination happens and that the scooper was supposed to have a bin and top cover. The facility’s infection control plan stated its policies and practices were intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
Expired and Undated Medications Found in Medication Carts and Medication Room
Penalty
Summary
The facility failed to ensure expired medications and biologicals were removed from medication storage areas and failed to ensure medications were properly labeled and dated in medication carts. On 08/19/25, the Second Floor Short End Medication Cart contained R98’s erythromycin 0.5% eye ointment and azelastine HCL 0.05% eye drops with an open date of 05/11/25 and an expiration date of 06/07/25 written on the boxes, and R174’s lispro insulin multi-dose vial with an open date of 07/21/25 and a discard date of 08/18/25. The RN stated the eye medications and insulin should have been discarded and removed from the cart drawer. On 08/19/25, the Fourth Floor Medication Room contained an open, undated vial of Tuberculin Purified Derivative Mantoux in the refrigerator and ten cartons of Osmolyte 1.5 cal. with an expiration date of 09/24 on a shelf. On 08/21/25, the 1st floor medication cart contained R19’s Basaglar insulin pen with no name or date, R19’s Aspart insulin flex pen with no open date, and R167’s Lantus insulin vial labeled opened 07/20/25 with an expiration date of 08/20/21. The LPN removed the expired Lantus vial from the cart and placed it in the sharps container. The DON stated the PPD should be labeled with an open date, the Osmolyte should not be there if expired, and insulin multi-dose vials should have an open and expiration date.
Call Light Not Accessible to Resident With Hand Contractures
Penalty
Summary
The facility failed to ensure a call light was within reach and accessible based on one resident’s abilities. R118 was observed lying in bed with splints on both hands and visible finger deformities, including fingertips that appeared bent backwards. The resident’s call light switch was attached to a string tied around a large stuffed circular toy that was positioned behind and above the resident’s shoulder, and the resident’s cell phone was also out of reach on the over-bed table. R118 stated that due to arthritis in her hands, she could not reach the call light where it was placed. She reported that staff had added the stuffed toy to the end of the call light string to help her access it, but the object was too thick and heavy for her to move. She stated she did not have the strength to pull it hard enough to activate the switch and said she had been pulling the call light cord using her mouth because that was the only way she could move it enough to call for help. She also stated the string was dirty and that staff were aware of the problem but had not tried any other call light device for her, and that this had been ongoing for about six months. Staff interviews confirmed the issue. An RN observed the call light attached to the stuffed toy and stated he was not aware the resident lacked the strength to pull it, adding that if she needed help she could not get it and that putting the string in her mouth was a high infection risk because it was not clean. The restorative/LPN manager stated she was not aware the resident was having difficulty pulling the call light. The OT director stated the resident’s worsening hand contractures and limited dexterity prevented her from grasping items as before and that she did not have enough shoulder external rotation to reach behind her, so the call light needed to be directly in front of her. The OT director also stated the stuffed toy setup was not working for the resident because she could not grasp it and it was too heavy, and she then removed it and set up a different system that the resident could use independently.
Mismatch in Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure that one resident’s code status matched across the Physician Orders, POLST, and care plan, and failed to update the care plan to reflect the correct code status. The resident had multiple diagnoses including dementia, schizophrenia, generalized anxiety disorder, chronic kidney disease, dysphagia, adult failure to thrive, severe protein-calorie malnutrition, and a BIMS score of 03 indicating severe cognitive impairment. The resident’s POLST form documented No CPR, comfort-focused treatment, allow natural death, and transfer to the hospital only if comfort could not be achieved in the current setting. Record review showed conflicting documentation in the resident’s advance directives and care plan. One advance directives entry documented DNR and Full Code discontinued, while the care plan stated the resident would remain a full code and all life-saving measures must be utilized, with interventions including CPR, oxygen, IV, AED, EMS, 911, and hospitalization as needed. A later updated care plan presented to the surveyor documented the resident’s code status as DNR, but the earlier care plan content had not matched the POLST and physician order information. The DON stated Social Service was responsible for uploading the POLST and updating the advance directives care plan, and that the physician order, POLST, and care plan should match. The Director of Social Service stated social services were responsible for advance directives, that the POLST form was uploaded, the care plan updated, and the forms signed. The facility policy stated advance directives would be respected, the plan of care would be consistent with the resident’s treatment preferences and/or advance directive, and changes or revocations would be documented in the care plan and medical record.
Care Plan Did Not Address Resident’s Language Barrier
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives, timeframes, and interventions to address a resident’s language barrier and communication needs. The resident, who was alert and verbally responsive during the surveyor interview, spoke Spanish and stated that if no one speaks Spanish, staff cannot explain the medications being given to her. She also stated that not all the time there is someone in the facility to interpret in Spanish. The resident’s quarterly MDS identified Spanish as her preferred language and noted moderate cognitive impairment. On interview, the Director of Social Services stated that language barrier and communication needs are assessed on admission and reevaluated quarterly, and that these needs should be addressed in the care plan so staff are aware of what to do for the resident. The Director also stated that communication books are available at the nurses’ stations and that the resident’s language barrier should have been addressed in her care plan, but it was missed. The resident’s comprehensive care plan did not address her language barrier, despite the facility’s Communication Program policy requiring deficits in foreign language to be documented and discussed at the care plan conference and the care plan to indicate what deficits exist and are being addressed.
Unsafe Sharps Access and Inadequate Fall Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing a resident with diagnoses including major depressive disorder, generalized anxiety disorder, schizophrenia, unspecified psychosis, hallucinations, and Parkinson’s disease to keep a retractable blade in the room. On 8/19/2025, the resident was observed using the red retractable blade to cut fruit while the blade was held upright and the resident’s hands were shaking. The resident stated the blade had been obtained from a friend years earlier, had not been reported to staff, and was kept locked in the top drawer of the dresser with the key kept by the resident. Staff members interviewed after the observation stated they did not know the resident had the blade and stated residents were not supposed to have blades because they were not safe. The nurse, social worker, assistant administrator, DON, and ADON all stated they were unaware of the blade before it was found. The nurse practitioner stated there was no current infection causing confusion and did not see a need for the resident to have the blade. The administrator later stated staff searched the resident’s belongings and found no other contraband, and the resident was educated not to have blades or knives and to ask staff for help cutting fruit. The facility also failed to implement and follow fall supervision interventions for residents with repeated falls. One resident with dementia, forgetfulness, confusion, and a history of multiple falls was found on the floor next to the bathroom after attempting to toilet independently. The nurse stated the resident needed extensive one-person assistance for toileting, constant cueing and redirection, and supervision at all times, yet the resident was able to get up without asking for help and the call light was clipped to the bed rather than being used. Another resident with Parkinson’s disease, syncope and collapse, bipolar disorder, and multiple falls had fall-prevention interventions documented, including a non-skid pad under the mattress, the bed in low position, and personal items within reach. During observation, the mattress had no non-skid pad underneath, the straps were not attached to the bed, the mattress could be moved with one hand, the bed was not initially in the lowest position, and personal items were out of reach.
Missing Oxygen-In-Use Sign for Resident on Continuous Oxygen
Penalty
Summary
The facility failed to place an oxygen-in-use/no smoking sign on the door of one resident who was receiving continuous oxygen via nasal cannula. On 08/19/2025 at 12:15 PM, the resident was observed lying in bed with oxygen infusing, but there was no oxygen-in-use sign or no smoking sign posted in or outside the room. The resident, R159, had diagnoses including chronic respiratory failure, unspecified dementia, severe intellectual disabilities, seizures, epilepsy, obstructive sleep apnea, visual loss, dysphagia, and adult neglect or abandonment. The order summary documented continuous oxygen via nasal cannula/mask at 2 liters per minute every shift, and the care plan noted altered respiratory status and difficulty breathing related to chronic respiratory failure and obstructive sleep apnea. During interview, the RN stated that residents on oxygen must have an oxygen-in-use/no smoking sign posted outside the room as a safety precaution and to alert staff and fire personnel that oxygen is in use. The RN stated the sign was missing because the resident had recently returned from the hospital and someone forgot to post it on readmission. The DON also stated that if a resident is receiving oxygen, a no smoking/oxygen-in-use sign should be posted on the outside of the room, and confirmed that the sign should have been in place when the resident was readmitted.
Incorrect Administration of Ordered Seizure Medication
Penalty
Summary
The facility failed to administer medication according to the physician's order for one resident with epilepsy, delirium due to a known physiological condition, a history of falling, disorders of the brain, generalized muscle weakness, and cognitive communication deficit. The resident's order for Dilantin (phenytoin sodium extended) was to give 4 capsules by mouth in the morning for epilepsy, and the care plan directed staff to give seizure medication as ordered and monitor for side effects and effectiveness. During medication administration, an RN prepared the resident's medications and told the surveyor there were 8 pills in the medication cup. The RN then administered the medications to the resident, including phenytoin, but only gave 1 capsule instead of the ordered 4 capsules. On a later observation, the RN stated he would give 8 pills and acknowledged that he gave 1 pill when he should have given 4 pills. The DON stated staff should follow the 5 rights before giving medications and confirmed the Dilantin order was for 4 capsules; the DON also stated that not giving the correct dosage could affect the Dilantin level and that the resident could have seizures.
Failure to Ensure Availability of Routine Medication for Resident
Penalty
Summary
The facility failed to provide and/or obtain a routine medication, Latanoprost Ophthalmic Solution eye drops, for a resident with legal blindness, Parkinson's disease with dyskinesia, major depression, and dry eye syndrome. The resident had a physician's order for the eye drops to be administered daily at 7:00 PM, one drop in both eyes. During an observation, the resident reported that he only received his eye drops if he specifically asked for them and did not receive them otherwise. When nursing staff checked the medication cart and pharmacy medication dispenser, they were unable to locate the resident's prescribed eye drops. Documentation from the pharmacy indicated that the medication had been delivered earlier in the month, and the Medication Administration Record showed daily administration, but the medication was not available at the time of the survey. A prior grievance from the resident's family member had also documented concerns that the resident was not receiving his eye drops. The facility's policies assign responsibility to nursing staff for maintaining medication supplies and to the Director of Nursing for supervising medication administration. Despite these policies, the medication was not available for administration, and the process for ensuring timely medication delivery and availability was not followed, resulting in the resident not having access to his prescribed eye drops.
Failure to Maintain Accurate Medical Records and Obtain Proper Consents for Psychotropic Medications
Penalty
Summary
The facility failed to maintain accurate and accessible medical records for a resident who was prescribed multiple psychotropic medications. Discrepancies were found in the physician orders for Depakote, with different diagnoses listed on separate dates, including mood affective disorder and depression, despite the resident's face sheet not listing depression as a diagnosis. The Medication Administration Record (MAR) documented administration of Depakote for depression, which did not align with the resident's documented diagnoses. Additionally, the psychotropic nurse acknowledged that the wrong diagnosis was selected and that there are differences in side effects between the two diagnoses. Further deficiencies were identified in the management of consent forms for psychotropic medications. Only one consent form was present for two different Haldol orders (tablet and injection), and the consent form was uploaded to the electronic record significantly after it was signed. There was also a lack of consent documentation for Olanzapine, and the consent form for Haldol was not uploaded in a timely manner. The psychotropic nurse confirmed these documentation lapses and noted that medical records staff failed to upload the necessary documents as required.
Failure to Implement Fall Prevention Leads to Resident's Fall
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident, resulting in a fall and subsequent hospitalization. The resident, who has a history of intellectual disabilities, Down syndrome, and other medical conditions, was found to have severely impaired cognition. On the morning of the incident, the resident was walking barefoot in her room when a CNA instructed her to put on her shoes. As the resident turned, she lost her balance and fell, hitting her head on the bathroom door. The CNA reported the incident to a registered nurse, who found the resident sitting on the floor without visible injuries, although the resident later required hospitalization. The resident's care plan indicated a risk of falls due to her medical history and required supervision or assistance for activities such as walking and putting on footwear. Despite these documented needs, the resident was not adequately supervised or assisted at the time of the fall. The facility's policies, including the Falling Star Program and Accidents and Incidents policy, emphasize the importance of monitoring residents at risk of falls and implementing individualized care plans to prevent avoidable accidents. However, these protocols were not effectively followed in this case. Interviews with facility staff revealed that the resident had been exhibiting increased confusion and required more redirection and assistance with daily activities. The primary physician acknowledged the difficulty in preventing falls but emphasized the need for close monitoring. The failure to implement the resident's fall prevention care plan interventions placed her at a higher risk for an avoidable fall, as confirmed by the physician. The facility's lack of adherence to its own policies and the resident's care plan contributed to the incident.
Improper Management of Resident Funds
Penalty
Summary
The facility failed to safeguard resident rights by improperly accounting for and charging resident funds for seven out of nine residents. Specifically, four residents were charged dental insurance premiums that should have been included in the care cost, resulting in significant discrepancies between the amounts deducted and credited back to their accounts. The Assistant Administrator acknowledged that dental insurance premiums should be part of the care cost and not charged separately, yet the residents' accounts showed substantial charges that were not fully credited back. Additionally, five residents were charged for haircuts from their personal funds without proper documentation of consent. Some residents, due to impaired cognition, were unable to give consent, and there were discrepancies in the service dates recorded. The Activity Director signed as a witness for these charges, but the residents' signatures were missing, and the dates of service did not match the dates on the resident fund statements. This lack of proper documentation and consent highlights a failure in the facility's process for managing resident funds. The Business Manager and Assistant Administrator were informed of these discrepancies, and it was noted that the facility's auditing process for personal funds needed improvement. The Director of Nursing acknowledged the issue, particularly for residents with severe cognitive impairment who could not provide consent. The facility's policy mandates the safeguarding and proper management of resident funds, which was not adhered to in these instances.
Failure to Document and Provide Flu Vaccinations
Penalty
Summary
The facility failed to provide flu vaccinations and education to two residents, R1 and R11, as required. R11, a resident with a history of influenza and other significant health conditions, was admitted to the facility and later diagnosed with the flu after being sent to the hospital. Despite the importance of flu vaccinations for elderly residents with medical comorbidities, the facility's Infection Control RN, V6, did not document offering the flu vaccine or providing education to R1. Additionally, although V6 stated that R11 was offered the vaccine, this was not documented in R11's medical records, and the refusal form was kept in a binder inaccessible to other medical staff. The facility's policy requires that flu vaccines be administered by the end of October and continue to be offered as long as influenza viruses are circulating. However, V6 admitted to not documenting the offer or refusal of the vaccine for R1 and R11, nor did she follow up to ensure they understood the importance of the vaccination. This lack of documentation and follow-up led to a deficiency in the facility's vaccination protocol, as the residents' immunization records did not reflect any consent, refusal, or education regarding flu immunizations.
Failure to Implement Care Plan and Safety Protocols Leads to Resident Injuries
Penalty
Summary
The facility failed to implement care plan interventions for a resident, resulting in the resident sustaining facial lacerations. The incident occurred when two Certified Nursing Assistants (CNAs) transferred the resident from a shower chair to a bed using a gait belt. One CNA left the room, and the remaining CNA attempted to reposition the resident, who then rolled off the bed and hit his head on the nightstand. The resident's care plan required substantial/maximal assistance from two staff members for repositioning and turning in bed, which was not followed, leading to the fall and subsequent injuries. Additionally, the facility failed to ensure staff followed their job description and Driver Safety Rules, resulting in another resident sustaining neck fractures. The resident, who had a history of falls involving the facility van, was not properly secured in the van by the bus driver. During transport, the resident fell out of the wheelchair due to the seatbelt not being fastened, leading to a neck fracture. The bus driver admitted to not fastening the seatbelt and failing to reposition the resident properly, which contributed to the fall. A third resident also experienced a fall in the facility van due to the seatbelt not being fastened. The resident slid from the wheelchair onto the van floor when the driver abruptly stopped. The incident highlights a pattern of non-compliance with safety protocols during resident transport, as evidenced by the repeated failure to secure residents properly in the van, leading to multiple falls and injuries.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to follow its policy to investigate an allegation of abuse for a resident who was reviewed for abuse. The incident involved a resident with a known fall risk history who allegedly rolled out of bed onto the floor during care. However, the Emergency Department Physician noted that the resident's injuries were consistent with being punched in the face rather than a fall from a low bed. The resident sustained a complex eyelid laceration that required transfer to another hospital for repair. Despite the hospital's allegation of abuse, the facility did not conduct a reportable investigation for abuse, as they believed it was a fall. The incident occurred when two Certified Nursing Assistants (CNAs) were involved in transferring the resident from a shower chair to bed. One CNA left the room, and the other CNA attempted to adjust the resident's diaper, during which the resident rolled off the bed and hit their head on the nightstand. The bed was raised to waist height for care, contrary to the claim that the resident was in a low bed. The facility's administrator acknowledged the incident and spoke with the involved staff but did not follow the facility's abuse prevention policy to investigate the allegation of abuse, as they concluded it was a fall incident.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by another resident, R1. R1, who was admitted with a medical history including bipolar disorder, Parkinson's Disease, and cognitive impairment, became physically aggressive towards R2. The incident occurred when R1, sitting in the hallway, slapped R2 as she was walking by. This behavior was unexpected as R1 had no prior history of aggression and was generally calm and required no close monitoring. R2, who also has cognitive impairments, reported the incident to staff, stating that R1 accused her of talking about her and then slapped her. Despite the physical contact, R2 did not sustain any injuries or pain and expressed understanding of R1's confusion. Staff members, including a housekeeper and a nurse, witnessed the incident and intervened promptly to separate the residents and assess them for injuries. The facility's administrator and medical personnel were informed, and R1 was sent for a psychiatric evaluation and medication adjustment. Interviews with staff and other residents confirmed that R1's behavior was out of character and attributed to a mental status change, possibly linked to a urinary tract infection. The facility's abuse prevention policy was reviewed, and it was noted that R1's aggression was non-intentional due to her confusion. The incident was reported to the appropriate authorities, and both residents and their families agreed to maintain their living arrangements, indicating no fear or discomfort from the incident.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to ensure that employees' personal food items were not stored in the kitchen's walk-in cooler, which is against the facility's policy. During an observation, it was noted that four small food baskets belonging to kitchen staff were stored inside the walk-in cooler. The dietary supervisor, V8, was unaware of where the staff obtained their food items and believed it was acceptable if the items were labeled, despite the facility's policy prohibiting personal food storage in the dietary department refrigerators or freezers. Additionally, the facility failed to address a leaking ceiling and a clogged drainage pipe in the dishwashing area, which could lead to unsanitary conditions. Observations revealed a puddle of water by the dishwashing area due to a clogged drain, and a leak from the ceiling was noted, with water being collected in buckets. The dietary supervisor acknowledged the unsanitary and unsafe conditions but did not take immediate corrective action. These issues have the potential to affect all residents taking oral nutrition at the facility.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to safely self-administer medications, which led to a deficiency affecting one resident and potentially impacting all residents on the 4th floor. During an observation, a surveyor found a clear medicine cup containing five medication pills on a nightstand in a resident's room. The resident, who has severe cognitive impairment due to dementia and other conditions, was not assessed for self-administration of medications. The Registered Nurse (RN) responsible for administering the medications admitted to preparing and leaving the medications unattended in the resident's room, which is against the facility's policy. The resident in question, identified as having severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6, was not assessed for the ability to self-administer medications. The RN acknowledged that the medications were left in the room unsupervised, which could lead to the resident forgetting to take them or someone else accessing them. The facility's Director of Nursing (DON) confirmed that a medication self-administration assessment is necessary to ensure a resident's cognitive competence to manage their medications independently. The facility's policy requires that medications be administered safely and only by licensed personnel, with residents allowed to self-administer only if deemed competent by the Attending Physician and Interdisciplinary Care Planning Team. The RN's actions of leaving the medications unattended violated this policy, as the resident was not assessed for self-administration competency. The facility's documentation confirmed that the resident was not capable of self-administering medications, highlighting a lapse in adherence to established procedures for medication administration.
Failure to Conduct Daily Crash Cart Checks
Penalty
Summary
The facility failed to ensure that emergency medical equipment stored for use in basic life support was checked daily, as required by their policy. This deficiency was observed on the 3rd floor, potentially affecting all 57 residents residing there. The crash cart checklist showed daily checks were only completed on three specific dates, with several other dates missing. This lack of daily checks was confirmed through observation and interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON). The LPN acknowledged that the crash cart should be checked every day to ensure supplies are available in case of an emergency, emphasizing the potential danger to residents if the cart is not checked. The DON explained that the crash cart contains essential items for emergencies, such as oxygen tubing, IV starter kits, and a suction machine, and highlighted the importance of daily checks to ensure readiness. The facility's policy mandates that the crash cart be checked daily to confirm it is locked and has not been opened, but this procedure was not consistently followed.
Safety Hazards and Fall Prevention Failures
Penalty
Summary
The facility failed to maintain a safe environment by leaving unsecured shaving razors in an unlocked shower room, unsecured liquid body soap in a drinking cup in a resident's room, and an unlocked laundry chute accessible to residents. These oversights were observed during a survey, where a resident was found with a drinking cup containing blue liquid soap in their bathroom, which was confirmed by a registered nurse to be a hazard. Additionally, the shower room on the 4th floor had soap dispensers without lids, allowing staff to scoop soap into cups, which could be left in residents' rooms, posing a safety risk. The facility also failed to implement and update care-planned fall precaution interventions for residents at risk of falls. One resident, identified as a fall risk due to dementia and other health conditions, was observed walking barefoot in their room, which was not their assigned bed, and with a folded-up fall mat not care-planned for them. The resident's care plan included interventions such as wearing shoes or gripper socks and using a low bed, but these were not adequately followed or updated after observed falls. Furthermore, the facility's policies on fall management and accident prevention were not adhered to, as evidenced by the improper storage of hazardous items and inadequate supervision of residents. The Director of Nursing acknowledged the need for proper documentation and adherence to care plans to prevent falls and ensure resident safety. The survey also highlighted the risk posed by an unlocked laundry chute, which could lead to severe accidents if accessed by residents.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents by not adhering to its own policies regarding the containment and labeling of respiratory equipment. Specifically, a nebulizer mask for a resident with chronic obstructive pulmonary disease (COPD) and acute respiratory failure was observed to be left on a nightstand without being contained in a plastic container, as required to prevent cross-contamination. This oversight was acknowledged by the Director of Nursing as an infection control issue. Additionally, the resident's care plan indicated the need for optimal breathing patterns and medication administration, which was not consistently followed. Furthermore, the facility did not ensure that oxygen tubing and humidifier bottles were labeled with the dates they were changed, nor were they changed according to the facility's policy. Observations revealed that several residents had undated or outdated oxygen tubing and humidifier bottles, contrary to the policy that requires weekly changes and proper labeling. The Director of Nursing confirmed that the policy mandates dating the equipment at the time of change, which was not adhered to, affecting residents with various diagnoses including COPD, hypertension, and diabetes.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor and maintain personal refrigerator temperature logs for five residents and did not ensure that three residents' personal refrigerators had thermometers. This deficiency was identified through observations, interviews, and record reviews. Specifically, residents' personal refrigerators were found without thermometers and temperature logs, which are necessary to prevent food spoilage and potential health risks. Staff members, including CNAs and the Infection Preventionist, acknowledged the requirement for daily monitoring and logging of refrigerator temperatures to ensure food safety. The facility's policy mandates monthly tracking sheets for refrigerator temperatures and assigns responsibility to designated employees for checking and recording these temperatures. However, there was a lack of clarity and consistency in the roles of nursing and housekeeping staff regarding this responsibility. The Director of Nursing and the Housekeeping Director provided conflicting statements about who should check and log the refrigerator temperatures, leading to lapses in monitoring. This inconsistency contributed to the failure to maintain proper temperature logs and thermometers in residents' personal refrigerators, posing a risk of food spoilage.
Improper Disposal of Cigarette Butts Near Fuel Tank
Penalty
Summary
The facility failed to ensure that cigarette butts were properly contained and not blown towards the generator's fuel tank, posing a potential fire hazard. During an observation at the facility's docking area, cigarette butts were found inside a trash can adjacent to the fuel tank, under the fuel tank, on the drain cover, and around the docking area. The cook, maintenance staff, and other personnel were unaware of the specific smoking areas and the proper disposal of cigarette butts, leading to the accumulation of cigarette waste near the flammable fuel tank. The maintenance director confirmed that the receptacles for cigarette butts were located upstairs, away from the docking area. Interviews with various staff members revealed a lack of clarity regarding designated smoking areas and the disposal of cigarette butts. The activity director stated that staff were not allowed to smoke on the patio, while the maintenance director and regional maintenance director were unaware of the staff smoking area. Additionally, a dietary aide was observed smoking near the dumpster, which is adjacent to the fuel tank, despite being informed that smoking was prohibited in that area. The assistant administrator confirmed that there was no specific policy regarding smoking near the fuel tank, and staff were expected to dispose of cigarette butts in metal ashtrays provided by the facility.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to maintain residents' call lights within reach, affecting two residents. One resident, diagnosed with dementia and other conditions, was observed with their call light string hanging out of reach behind a nightstand. A Certified Nursing Assistant (CNA) confirmed the call light should be within reach and adjusted it accordingly. The resident's care plan emphasized the importance of having the call light accessible due to their risk of falls and need for assistance with personal care. Another resident, with a diagnosis including Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus, was observed unable to reach their call light, which was attached to a pillow behind their head. Both a Licensed Practical Nurse (LPN) and a CNA acknowledged the call light was out of reach. The resident's care plan also highlighted the necessity of having the call light within reach to prevent falls. The facility's call light policy mandates that call lights be easily accessible to residents in bed or confined to a chair.
Failure to Document Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for a code status in the electronic medical record (EMR), affecting one resident out of a sample of 76 reviewed for advanced directives. During an interview, an LPN indicated that the code status, whether full code or DNR, should be visible on the profile screen of the EMR. However, the resident's advance directive category was found to be blank, and there was no physician order for the resident's code status in the EMR. The resident in question, identified as having severe cognitive impairment, did not have a documented code status, which is essential for determining the appropriate emergency resuscitation measures. The Director of Nursing confirmed that the code status should be entered into the EMR based on the resident's or family's wishes and verified by the family. The facility's policy requires that each resident's plan of care be consistent with their documented treatment preferences and advance directives. The policy also states that until a decision is made about the code status, the resident should be treated as full code, and an order for full code should be in the EMR. Despite these procedures, the resident's EMR lacked the necessary physician order for code status, indicating a lapse in following the facility's policy and ensuring the resident's treatment preferences were documented and accessible to the nursing staff.
Inaccurate MDS Documentation for Resident's Communication Abilities
Penalty
Summary
The facility failed to accurately complete sections of a resident's Minimum Data Set (MDS) to reflect the resident's health status. The resident, identified as R153, has a medical history that includes hemiplegia and hemiparesis following a cerebral infarction, dementia, and unspecified psychosis. The MDS inaccurately documented that R153 has clear speech and is able to be understood, while also indicating that the Brief Interview for Mental Status (BIMS) should not be completed because the resident is rarely/never understood. This inconsistency was noted during a surveyor's review of the MDS and through interviews with facility staff. Observations and interviews revealed that R153's speech was not clear, and the resident communicated in a quiet, strained, raspy whisper, making it difficult for staff to understand. Despite this, the MDS nurse, V44, affirmed that R153 has clear speech and can be understood, which contradicts the observations. The Social Services Director, V38, who was responsible for completing the BIMS, stated that R153 refused the interview, leading to the coding of the resident as rarely/never understood. However, V38 acknowledged that R153 is sometimes able to be understood, and the BIMS should have been conducted. This discrepancy in the MDS documentation highlights a failure to accurately assess and document the resident's communication abilities.
Failure to Conduct Level II PASARR for Resident with New Mental Disorder
Penalty
Summary
The facility failed to refer a resident, identified as R170, for a Level II PASARR evaluation after the resident was diagnosed with a new mental disorder. Initially, R170's PASARR, dated 03/03/23, indicated that no Level II evaluation was required as there was no serious mental illness or intellectual disability. However, after admission on 03/04/23, R170 was diagnosed with several mental disorders, including Schizoaffective Disorder, Paranoid Schizophrenia, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder, among others. Despite these significant changes in mental health status, the facility did not complete a new PASARR evaluation as required by their policy. The facility's policy mandates that a new PASARR Level I screen should be completed with any significant change in a resident's status, and any changes should be reported to the state mental health authority. The Social Service Director (SSD), identified as V38, acknowledged that a new PASARR should have been initiated for R170 following the new diagnoses. The SSD stated that they would only initiate a new PASARR if informed of the need, indicating a communication gap in the process. R170's care plan and physician orders documented various mental health issues and behaviors, yet no new PASARR was conducted until the SSD submitted a new Level I PASARR after the deficiency was identified.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to obtain a pre-admission screening and resident review (PASARR) for a resident diagnosed with major depressive disorder and unspecified psychosis. The resident was admitted to the facility without a completed Level I PASARR, as confirmed by the Assistant Administrator. The PASARR was only submitted and determined after the survey had begun, indicating a lapse in the required pre-admission process. The facility's policy mandates the completion of a Level I screen per state and federal requirements, which was not adhered to in this instance.
Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to invite and conduct care plan conferences to include a resident in the development of their plan of care. This deficiency was identified for one resident in a sample of 76. The resident, who has a diagnosis of hemiplegia and hemiparesis following cerebral infarction, unspecified dementia, protein calorie malnutrition, and osteoarthritis, was found to be cognitively impaired with a mental status score of 11. Despite this, the resident reported never being invited to participate in the development of their care plan and expressed a desire to be involved in such meetings. The facility's care plan coordinator, a Licensed Practical Nurse, confirmed that care conferences are held quarterly and as needed, but acknowledged that the resident had not been invited to a care conference. The coordinator was unable to provide a reason for this oversight. The facility's policy on comprehensive person-centered care plans emphasizes the involvement of the resident and their representative in the care planning process, which was not adhered to in this case.
Failure to Provide Grooming Assistance to Residents
Penalty
Summary
The facility failed to ensure that two residents, R40 and R199, who depend on staff assistance for their Activities of Daily Living (ADL) care, received proper grooming, specifically shaving. R40, with a BIMS score of 08 indicating moderate cognitive impairments, was observed ungroomed with visible facial hair on multiple occasions. R40 has diagnoses including unspecified dementia, major depressive disorder, and bipolar disorder, and requires maximum assistance with personal hygiene. Similarly, R199, with a BIMS score of 6 indicating some cognitive impairments, was also observed ungroomed with facial hair. R199 has diagnoses including the need for assistance with personal care, muscle weakness, and dementia, and is dependent on staff for personal hygiene. The surveyor's interviews with staff revealed a lack of adherence to the facility's policy on grooming and hygiene. A Certified Nursing Assistant (CNA), V34, admitted to not shaving R199 despite being responsible for their care. The Director of Nursing (DON), V2, confirmed that shaving is part of ADL care and should be offered daily if visible facial hair is present, emphasizing its importance for the dignity and hygiene of residents. The facility's policy and job description for CNAs outline the expectation to meet grooming needs with dignity and privacy, yet this was not followed, resulting in the deficiency.
Inadequate Supervision Leads to Falls and Unsafe Smoking Practices
Penalty
Summary
The facility failed to implement fall precaution interventions and provide adequate supervision for several residents, leading to multiple falls and injuries. Two residents, identified as R1 and R3, were observed with their beds in high positions, contrary to their care plans which required beds to be in the lowest position to prevent falls. R1 experienced two falls within the facility, resulting in a facial laceration and a head contusion. R2 also fell in the dining room, sustaining a fracture of the iliac crest. Despite being monitored by CNAs, these incidents occurred, indicating a lack of effective supervision and adherence to fall prevention protocols. Additionally, the facility failed to provide adequate supervision during designated smoking times, compromising resident safety. Residents R4, R5, R6, and R7 were observed smoking without proper supervision, and some were found in possession of smoking materials, which is against the facility's smoking policy. The smoking bin containing lighters and cigarettes was left unlocked and unattended, posing a significant fire hazard. The facility's policy mandates that all smoking materials be kept by the facility and that residents be supervised while smoking, yet these protocols were not followed. The report highlights the facility's inadequate monitoring and supervision practices, both in preventing falls and ensuring safe smoking practices. Staff members were observed using personal phones while on duty, which may have contributed to the lack of attention and supervision. The facility's failure to adhere to its own policies and procedures regarding fall prevention and smoking safety resulted in multiple incidents that could have been prevented with proper oversight and adherence to established protocols.
Failure to Follow Wound Care Procedures and Documentation
Penalty
Summary
The facility failed to follow its policy procedures and physician orders regarding the treatment and documentation of a resident's skin integrity impairment. The resident, who had a BIMS score indicating intact cognition, had physician orders to cover a left knee injury with a foam silicone dressing to be changed every three days or as needed. However, the facility did not document the injury in a timely manner, and the dressing was not changed according to the physician's orders. The resident reported that the injury occurred when an over-bed table was mishandled by staff, causing it to fall on the knee. During the survey, the resident's left knee was observed to have a large, scabbed abrasion with drainage, contradicting the facility's documentation that the wound was healed. The wound care nurse and the Director of Nursing provided inconsistent information regarding the status and classification of the wound. The wound was inaccurately documented as a blister and healed, despite evidence to the contrary. The wound care nurse admitted to selecting an incorrect classification due to limitations in the documentation system. The facility's failure to accurately assess and document the resident's wound, as well as to follow physician orders, was evident. The wound care nurse was unsure when the injury was first assessed, and the Director of Nursing acknowledged that risk management should have been conducted when the injury was first reported. The facility's wound assessment policy was not followed, as the injury was not documented in the electronic medical records or wound rounds as required.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as R1. R1, who had a moderate cognitive impairment and required assistance for transfers and toileting, experienced two unwitnessed falls within a short period. Despite being at risk for falls due to conditions such as encephalopathy and opioid dependence, the facility did not implement effective fall prevention interventions or provide necessary supervision. After the first fall, the staff primarily relied on redirecting the resident and encouraging the use of a call light, without incorporating frequent monitoring or supervision into the care plan. Following the second fall, which resulted in a compression fracture, the facility's interventions remained inadequate, as supervision or frequent monitoring was still not included in the care plan. The Director of Nursing acknowledged the lack of documented supervision and frequent monitoring in the resident's care plan, despite the resident's impulsive behavior and history of unwitnessed falls. The facility's fall management policy requires new interventions and care plan updates after a fall, but these were not effectively implemented for R1, leading to repeated incidents.
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What surveyors actually found near you
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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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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center Home Hispanic Elderly | 1.2 mi | ★★★★★ | 16 | 0 |
| St Joseph Village Of Chicago | 1.6 mi | ★★★★★ | 0 | 0 |
| Winston Manor Cnv & Nursing | 1.6 mi | ★★★★★ | 11 | 1 |
| Paul House & Health Cr Ctr | 2 mi | ★★★★★ | 1 | 0 |
| Avantara Lincoln Park | 2.3 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.