Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearl Of Joliet, The during CMS and state inspections, most recent first.
Dishwasher temperatures were not consistently maintained at the required level to sanitize dishware for all residents receiving dietary services. During a kitchen observation, the final rinse temperature was below the minimum 180 degrees Fahrenheit on multiple cycles, and staff reported the machine had been having problems for some time. The maintenance director said the repair company had been contacted but the dishwasher repair was still pending a part, and the dishwasher said he had not been told to use the 3-compartment sink for dishes and utensils while waiting for repairs.
Pest Control Program Failed to Address Kitchen Insect Infestation: Black flying insects were observed at the kitchen sink and in the dry storage area during a kitchen tour, affecting residents who received meals from the facility kitchen. Dietary and maintenance staff reported seeing bugs or a pest control visit, but there was no documentation of treatment for the kitchen insects, and the pest control report only noted a Norway rat in the laundry room. The facility policy did not provide direction for what to do when pest activity was discovered.
A resident’s requested transfer was delayed because the facility did not timely provide documentation the receiving facility wanted regarding C. Auris status. The resident said she kept calling the outside facility and was told the transfer was on hold pending proof she was not contagious. The SS director did not review the ID note stating the resident was safe for discharge from an infectious disease standpoint, did not document follow-up after the discharge summary, and relied on the ADON’s information instead.
Failure to Provide Personal Hygiene and Grooming Assistance: Three residents who required help with ADLs were observed without needed hygiene and grooming care. One resident had long fingernails with brown substances underneath them on repeated observations, another had two-inch facial hair on her chin and said she wanted it removed, and a third had an accumulation of facial hair with long, greasy, uncombed hair and said he had repeatedly asked for a shave and hair care. Staff stated nail, facial hair, and grooming care should be provided on shower days and as needed.
Failure to provide foot care for a diabetic resident. A resident with DM2, CHF, ESRD, morbid obesity, and bilateral knee OA was observed with dry, crusty feet and long, jagged toenails that had not been cut in months. The resident said she had asked multiple staff to see the podiatrist but had not been seen. Staff gave inconsistent accounts of how nail care and podiatry referrals were handled, and the resident was not listed for the monthly podiatry visit.
Failure to assess and manage limited ROM and contractures for two residents. One resident with a CVA was found with a tight fist and no splint or other intervention in place, and later assessment showed decreased ROM in the right elbow, wrist, and fingers. Another resident with impaired extremity function and documented hand contractures was observed with both hands closed and no splints, palm protectors, or rolled towels in place despite orders for hand devices; staff also reported OT had not evaluated the resident and the OT order had not been communicated.
Failure to assess safe smoking and secure smoking materials: A resident with multiple diagnoses including dementia, COPD, and heart disease was observed with cigarettes and a lighter on his person and additional cigarettes in his room, and he said he had more lighters in his bag. Record review showed he had never been assessed for safe smoking and had no smoking care plan, while the SSD stated she had not completed the required smoking assessment and that residents must turn in cigarettes and lighters after the last smoking time.
A facility failed to verify G-tube placement before flushing tubing and starting tube feedings for two residents. One RN administered G-tube medication and began feeding for a resident with dysphagia, ventilator dependence, and a G-tube without checking placement first, and later flushed and restarted feeding for another resident with respiratory failure, dementia, paraplegia, and a G-tube without verifying placement. The RN stated she forgot to check placement, and the DON said nurses are expected to verify placement before flushing and feeding.
Hemodialysis VAD Dressing Not Maintained or Changed Using Sterile Technique. A resident receiving hemodialysis was observed without a dressing over her left chest VAD, and the site showed redness. An RN assessed the site without hand hygiene or gloves, then performed a dressing change without a gown; the resident’s shirt tag contaminated the gauze, but the RN applied the clear dressing over it. The chlorhexidine cleansing was also incomplete, and the hemodialysis RN and DON stated the site should always be covered and dressing changes require full PPE and sterile technique.
A resident with dementia, DM, HTN, and HLD had an order for losartan 100 mg daily after BP readings remained variable despite multiple antihypertensives. However, the pharmacy delivered 50 mg tablets, the MAR and med card reflected 50 mg tablets, and an LPN administered only one 50 mg tablet daily instead of the ordered dose; the DON stated the resident was receiving 50 mg daily as shown on the card.
Failure to use required PPE occurred during care for two residents. A resident with a hemodialysis VAD and MRSA history was observed without a dressing over the access site, and an RN entered the room without hand hygiene or gloves and performed the dressing change without a gown despite EBP requirements. Another resident on contact isolation for a tracheostomy had a visitor in the room without a mask, gown, or gloves, even though staff stated visitors must wear PPE for contact isolation.
A resident with multiple comorbidities was admitted with an unstageable sacral pressure ulcer and placed on Medi-Honey dressings three times weekly. Over several weeks, the wound enlarged and remained covered with slough, but a wound specialist NP was not consulted until the ulcer had significantly worsened. When the NP did evaluate the wound, she performed debridements and ordered daily Dakin’s solution and later Dakin’s with Silvadene and calcium alginate, but the facility’s TAR showed staff largely continued Medi-Honey three times weekly, applied Dakin’s on only a few days, and never administered Silvadene. The wound progressed to a stage 4 ulcer with odor and signs of infection, later cultured positive for MRSA and diagnosed in the hospital as an infected stage 4 decubitus ulcer with osteomyelitis requiring surgical debridement, contrary to the facility’s own policy requiring timely reassessment and implementation of MD/NP-directed wound care.
A resident receiving tube feeding was observed lying flat in bed while the feeding was infusing, contrary to physician orders and facility policy requiring the head of bed to be elevated 30-45 degrees. CNAs indicated they believed elevation was only necessary when turning the resident, while the DON confirmed elevation is required during tube feeding to prevent complications.
A resident being treated for a UTI did not receive the ordered initial dose of Levofloxacin IV or a scheduled dose of Meropenem due to medication unavailability and lack of documentation. Nursing notes indicated the antibiotic was not available and would be delivered later, but there was no record of administration, and the DON confirmed the absence of documentation or pharmacy authorization requests as required by facility policy.
The facility did not maintain hot food temperatures during meal service, as observed through interviews and direct temperature checks. Multiple alert and oriented residents reported receiving lukewarm or cold meals, and food items were found to be served well below the required holding temperature. Staff delivered meals using non-insulated carts and without plate warmers, contrary to facility policy requiring food to be served at safe and appetizing temperatures.
Staff did not consistently wear gowns during high-contact care activities for residents on Enhanced Barrier Precautions (EBP), including those with a history of Candida Auris, end stage renal failure with IV access, and multidrug-resistant organisms. Despite posted EBP signage and facility policy requiring gown and glove use for such care, CNAs and a nurse were observed providing hygiene, incontinence care, and vital sign checks without proper protective equipment.
A resident with complex medical needs developed extensive skin rashes and redness in the groin, perineal area, buttocks, and under the breasts, which were not properly assessed, monitored, or treated by staff. Orders from a wound care NP for barrier and antifungal creams were not consistently implemented, and required documentation and physician notification were not completed. The resident experienced prolonged pain and discomfort due to these failures.
The facility failed to conduct thorough abuse investigations, affecting all residents. In one case, a CNA reported an LPN being verbally discourteous to a resident, but the investigation lacked interviews and documentation. Another case involved an alert resident, but there was no documentation of interviews. A third investigation also lacked evidence and documentation, despite the facility's policy requiring comprehensive investigations.
The facility failed to maintain proper kitchen sanitation and food storage, affecting 133 residents. Observations revealed dusty vents, improper sanitizing solution levels, and a dishwasher not reaching the required temperature. Unlabeled and spoiled food items were found in the walk-in cooler, and resident refrigerators lacked thermometers and temperature logs. Dented cans were improperly stored, posing a risk of foodborne illness.
The facility failed to provide necessary care for residents with decreased ROM, as evidenced by the lack of application of prescribed splints and supportive devices. Residents with conditions such as hemiplegia and contractures were observed without their required devices, despite having physician orders. The restorative staff were often reassigned, leading to a lack of consistent care and potential worsening of residents' conditions.
The facility failed to maintain a safe environment by not securely storing oxygen cylinders and cleaning supplies, and by not keeping residents' beds at a safe height. Several residents, including those at risk for falls, had their beds and overbed tables left in high positions. Unrestrained oxygen tanks were found in residents' rooms and the medication room, and cleaning chemicals were accessible in unlocked closets, contrary to facility policies.
A resident with severe cognitive impairment was found with hemorrhoidal cream at her bedside, which she used for lubrication rather than its prescribed purpose. The facility failed to assess her ability to self-administer medication, as required by policy. Staff confirmed the resident did not have orders to self-administer or store medications at her bedside.
The facility failed to ensure call lights were within reach for three residents, including one with hemiplegia and another with a self-care deficit. Despite care plans and facility policy requiring accessible call lights, they were placed out of reach, forcing residents to scream for help.
The facility failed to protect residents from verbal and mental abuse, involving an LPN who allegedly yelled at a resident with cognitive impairment and hearing loss, criticized another resident's toileting habits, and belittled a third resident over outside medication. The facility's investigation was incomplete, and the LPN's behavior did not meet facility standards.
A facility failed to report an allegation of verbal abuse involving a resident to the Illinois Department of Public Health. A CNA reported that a nurse was verbally discourteous to a resident, including shouting and telling the resident to 'shut up.' Despite the facility's policy requiring immediate reporting, the administrator confirmed that neither the initial nor final reports were sent to IDPH.
A resident with multiple medical conditions was found wearing both an incontinence brief and pad, without being on a toileting program. The facility's staff confirmed this practice, which contradicts the facility's policy and could lead to skin breakdown. The resident's care plan did not include a scheduled toileting program, despite the facility's policy to maintain personal hygiene for dependent residents.
A resident with a midline IV catheter experienced inadequate care, as the dressing was saturated with blood and lacked documentation of changes. The facility's policy requires dressing changes every 48 hours if gauze is present, but this was not followed. The DON confirmed no documentation of dressing changes, and the resident's POS showed no orders for catheter care, leading to a deficiency in maintaining the catheter.
The facility failed to document the pharmacy's monthly Medication Regimen Reviews (MRR) recommendations and physician responses for two residents. The ADON admitted to missing recommendations and a lack of a proper tracking system, while the DON emphasized the need for escalation if no response is received. The facility's policy requires timely communication and documentation, which was not followed.
A resident with multiple health conditions was found storing opened bottles of Miracle Whip and horseradish sauce on her windowsill, despite needing refrigeration. The facility had removed personal refrigerators, leaving the resident without proper storage options. The administrator acknowledged the issue, noting that the facility's policy requires regular inspections and proper food storage.
A CNA failed to wear a gown when entering the room of a resident on contact precautions for MRSA, despite facility policy and signage indicating the need for full PPE. The resident had multiple diagnoses, including MRSA, requiring strict adherence to infection control protocols. The CNA realized the mistake after entering, and the DON confirmed the necessity of wearing both a gown and gloves in such situations.
The facility failed to use an antibiotic use protocol tool for two residents on antibiotics, as confirmed by the IP and DON. One resident was on Ciprofloxacin for a UTI, and another on Meropenem for a positive sputum culture, without the McGeer's tool being completed. This tool is essential for ensuring appropriate antibiotic use, as per the facility's policy.
A resident's bed was found with side rails extending five inches on both sides, creating a potential entrapment hazard. An LPN confirmed the risk of the resident becoming stuck between the rails due to the space between the bed rail and mattress. The DON acknowledged the need for regular inspections to prevent such safety risks.
A resident at high risk for skin breakdown developed a Stage 3 pressure ulcer due to the facility's failure to conduct effective skin assessments and address skin issues. Despite orders for regular skin checks, staff did not notice or report the resident's skin condition, resulting in untreated open and bloody skin areas.
A resident's family requested information to install a camera in the resident's room during a care conference, but the facility failed to provide the necessary information or follow up on the request. The resident, who required assistance with daily activities, was moderately impaired. Despite the facility's policy allowing cameras, the request was not addressed within the expected timeframe, resulting in a violation of the resident's rights.
A resident with anxiety disorder did not receive scheduled doses of Buspirone, Clonazepam, and Hydroxyzine over several days due to a failure in the medication reordering process. Despite the resident's reports and staff awareness, the medications were not reordered in time, leading to increased stress for the resident.
A resident with a history of pressure injuries developed new stage 2 and stage 3 pressure injuries on the right hip, which were not promptly reported or treated by the facility staff. The CNA initially failed to report the wounds, and the LPN was unaware until later notified. The facility's protocols for immediate reporting and treatment of skin alterations were not followed, resulting in a deficiency.
A resident with fragile skin and a history of skin tears did not receive proper assessment and treatment orders for her wounds. The Wound Care Nurse was unaware of the resident's active wounds, and the facility failed to document or obtain treatment orders in the EMR. The Hospice RN changed dressings without access to the EMR, and the Director of Nursing expected staff to report skin issues, but the EMR lacked active wound care orders, leading to a deficiency.
The facility failed to maintain a clean and homelike environment for residents, as observed during an inspection. The bedroom floors were found to be dirty, with accumulated dirt, dust, and debris, including plastic pieces from PPE packaging. Residents and a family member expressed dissatisfaction with the cleanliness, and a housekeeper acknowledged that some rooms had not been swept for days, despite daily cleaning expectations. Resident Council Meetings had previously documented concerns about the need for cleaning.
The facility failed to provide timely incontinence care and assistance with ADLs for three residents. Two residents were found with saturated briefs, with the last change occurring several hours prior. Another resident was left in bed for an extended period without being offered assistance to get up, despite expressing a desire to do so. The DON confirmed that staff are required to check and change residents every two hours and assist them in getting up unless medically contraindicated.
A facility failed to monitor and check glucose blood sugar levels for a resident with a history of Diabetic Ketoacidosis, resulting in hospitalization for DKA. The resident's blood glucose levels were consistently elevated despite insulin doses, and there was no documentation of rechecking sugar levels or notifying the physician.
A resident scheduled for eye surgery was fed toast and cereal despite having an NPO order, leading to the rescheduling of the surgery. Interviews confirmed the staff's failure to follow the physician's order.
The facility failed to maintain a resident's bed equipment, specifically the bed control cord, which had approximately two inches of exposed wires. The resident involved is a [AGE] year old female with osteoarthritis, type 2 diabetes, and bilateral cataracts. The issue was observed on two separate occasions, and the Director of Maintenance was notified on the same day as the second observation.
Dishwasher Did Not Consistently Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to assure the dishwasher consistently reached the required temperature to disinfect dishware for the 125 residents receiving dietary services. During a kitchen tour, four dish load cycles were observed and the final rinse temperatures were 174 degrees Fahrenheit, 185 degrees Fahrenheit, 164 degrees Fahrenheit, and 175 degrees Fahrenheit. The regional operations-dietary staff stated the dishwasher disinfected by temperature and the final rinse should be a minimum of 180 degrees Fahrenheit, and also stated dishes would need to be sanitized manually until the dishwasher is serviced. The dishwasher stated he had tested the final rinse that morning but did not remember the reading, and said he watched the digital reading while washing dishes and it was fine. He also stated that when the dish machine is not working properly, he should inform his supervisor. The maintenance director stated kitchen staff had reported a problem with the dishwasher the prior month, that the repair company had been contacted, and that a part was still needed before repairs could be completed. He also stated he had no documentation of the call or the repair company’s visits. The dishwasher stated he had previously informed maintenance of problems with the dishwasher but was not told to use the three-compartment sink to sanitize dishes and utensils while waiting for repairs; the three-compartment sink had only been used for pots and pans. Dish machine logs for February through May 2026 documented wash temperatures of 160 degrees Fahrenheit, rinse temperatures of 160 degrees Fahrenheit, and final rinse temperatures of 180 degrees Fahrenheit for breakfast, lunch, and dinner each day.
Pest Control Program Failed to Address Kitchen Insect Infestation
Penalty
Summary
The facility failed to prevent and treat an insect infestation in the kitchen area, affecting all 125 residents who received dietary services from the kitchen. During a kitchen tour, black flying insects were observed at the kitchen sink and a swarm of flying black insects was seen in the dry storage area. The Regional Operations-Dietary staff member denied being informed of problems with flying insects in the kitchen and stated she was unaware whether the pest control company had previously noted or treated for any flying insects. A Dietary Aide stated he had seen the flying bugs in the kitchen but did not report them to anyone. The Maintenance Director stated pest control had come out the day before for bugs seen in the kitchen, but he had not received a report and had no documentation of the visit. The pest control service inspection report dated 04/29/2026 documented a Norway rat in the laundry room, but no other pest activity and no product application to treat pest activity. The facility's Pest Control policy stated the intent was to provide a healthy environment for residents, but it did not give direction on what to do when pest activity was discovered.
Delayed Resident Transfer Due to Missing Discharge Documentation
Penalty
Summary
The facility failed to prioritize a resident’s discharge goals and preferences and did not facilitate a timely discharge for one resident who wanted to transfer to another facility. The resident stated she had repeatedly contacted the receiving facility and was told the transfer was delayed because documentation was still needed showing she was not contagious. The resident’s discharge summary, dated 4/1/26, documented that she would be discharged to a facility in another city and state on 4/2/26 per her request, but the social service director did not document any follow-up after 4/1/26 explaining why the transfer did not occur. The social service director stated she was told the receiving facility needed documentation related to a test result, but she did not review the infectious disease note in the resident’s record. That note stated the resident had tested positive for C. Auris in urine in October 2024, had no acute symptoms of infection, had negative urinalysis, culture, and sensitivity results in 11/2024 and 9/2025, and was safe for discharge from an infectious disease standpoint with no concern for acute candidal infection. The social service director said she relied on information from the ADON, did not have other documentation in the chart regarding the discharge planning after the discharge summary, and acknowledged she should have documented follow-up notes. The administrator stated it was important to document the discharge planning process and said the resident’s transfer could have and should have been arranged sooner.
Failure to Provide Personal Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide personal hygiene for residents who required assistance with activities of daily living. For R93, who had diagnoses including lack of coordination, cognitive communication deficit, emphysema, type 2 diabetes mellitus, dementia, and adjustment disorder, surveyors observed long fingernails with brown substances underneath them on two separate occasions. R93 stated she could not see the dirt under her fingernails and later said she did not like having dirt underneath her nails and asked who would clean them. Her MDS showed mild cognitive impairment and moderate assistance was needed for personal hygiene, and her care plan identified an ADL self-care performance deficit related to activity intolerance, fatigue, limited mobility, weakness, decreased strength, and low activity tolerance. The facility also failed to provide grooming care for R48 and R34. R48, who had diagnoses including polyosteoarthritis, peripheral vascular disease, paranoid schizophrenia, and bipolar disorder, was observed with facial hair about two inches long on her chin on two occasions, and she stated she did not like having facial hair and wanted it removed. R34, who had diagnoses including COPD, diabetes, end stage renal disease, major depressive disorder, and osteoarthritis, was observed in bed with an accumulation of facial hair and hair that was long, greasy, and uncombed on two occasions; he stated he had asked several times for a shave and had not gotten one in a long time, and later said he wanted to be shaven and have his hair washed and trimmed. Staff interviews stated residents should receive nail, facial hair, and grooming care on shower days and as needed, and the facility's ADL support policy stated residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Failure to Provide Foot Care for a Diabetic Resident
Penalty
Summary
The facility failed to provide foot care to a diabetic resident with congestive heart failure, type two diabetes, muscle wasting and atrophy, morbid obesity, end stage renal disease, and bilateral osteoarthritis of the knees. On observation, the resident was sitting on the side of the bed with bare feet exposed, and her feet were dry and crusty. Her toenails were long and jagged, and her toes had a black-tipped French polish that had grown out well past the nail bed. The resident stated she had not had her nails cut in about five months and had requested multiple staff to see the podiatrist for some time without being seen. Staff interviews showed inconsistent awareness and follow-through regarding the resident’s toenail care. A CNA stated he did not cut toenails and marked residents needing nail care on shower sheets, which were signed by the nurse and submitted to the DON; he also said there was a podiatrist list at the nursing station where residents’ names could be added. An LPN stated the Social Worker usually set up podiatry appointments and that no one had informed her the resident’s toenails needed to be cut. The Social Services Director stated nursing staff add residents’ names to a podiatrist list kept at the nursing station, but the resident was not on the May 2026 list and had not been seen by a podiatrist since admission. The DON stated toenails are part of foot care and diabetic toenails should be kept cut to prevent infection or ingrown nails. The facility’s Foot Care policy stated it is the facility’s policy to identify and provide needed care and services in accordance with resident preferences, goals for care, and professional standards of practice.
Failure to Assess and Manage Limited ROM and Contractures
Penalty
Summary
The facility failed to assess and address limited ROM for two residents with impaired mobility. One resident with a history of CVA was observed with the right hand formed into a tight fist and stated he could not stretch or open the hand because of the stroke. He reported he did not have a splint or any intervention to keep the hand from remaining in that position. The CNA assigned to him confirmed he did not have a splint. The restorative nurse later assessed the resident and found she was unable to extend the right hand and fingers past thirty degrees. The resident’s earlier mobility assessment documented full ROM to the right elbow, wrist, and fingers, while the updated assessment documented decreased ROM in the right elbow and poor flexion and extension of the right wrist and fingers. The care plan for the resident’s CVA included monitoring and documenting mobility status and obtaining PT and OT evaluation and treatment if problems or paralysis were present. A second resident with diagnoses including aphasia, Wernicke’s encephalopathy, major depressive disorder, and neuromuscular dysfunction had impaired functional limitation to both upper and lower extremities and a documented contracture to the right hand/wrist, with slight contraction of the left middle finger. Orders called for palm protectors or rolled towels to both hands daily, with skin checks and removal for ADLs, hygiene, and at night. However, the resident was observed sitting in a wheelchair and later in bed with both hands closed and was not wearing splints, palm protectors, or rolled towels. The resident stated she did not wear splints or palm protectors and did not receive hand exercises. Therapy staff stated the resident had not been evaluated by OT and was not receiving therapy services, and nursing staff stated they were unaware of an NP order for OT and that the order had not been communicated to therapy. The restorative nurse stated the splints and palm protectors were expected to be applied as ordered and that failure to do so could result in contracture or further decline to an existing contracture.
Failure to assess safe smoking and secure smoking materials
Penalty
Summary
The facility failed to assess and care plan for a resident to ensure he was a safe smoker and failed to ensure his smoking materials were kept unsecured. The resident was admitted with diagnoses including atherosclerotic heart disease, type II diabetes mellitus, hyperlipidemia, dementia, chronic obstructive pulmonary disease, hypertension, major depressive disorder, anxiety disorder, and delusional disorder. His MDS dated 4/12/26 showed intact cognitive functions and independence with transfers. On 5/5/26, he was observed sitting on his rolling walker with a pack of cigarettes and a lighter in his shirt pocket, and three more packs of cigarettes were on a shelf on top of his nightstand. He stated he had more lighters in his blue bag and said his girlfriend brought him cigarettes and lighters. Record review showed the resident had never been assessed for safe smoking since admission and did not have a care plan for smoking. The Social Service Director stated she was responsible for safe smoking assessments and had never completed one for this resident. She said the assessment is done upon admission, quarterly, and as needed to determine whether a resident can smoke independently. She also stated the resident should not have more than a pack of cigarettes in his room and that smokers must turn in all cigarettes and lighters to the receptionist after the last smoking time at night. The facility later provided a Smoker's Program care plan created on 5/6/26, and its smoking policy states newly admitted or re-admitted residents are to be assessed and monitored for safe and responsible smoking guidelines.
Failure to Verify G-Tube Placement Before Flushing and Feeding
Penalty
Summary
The facility failed to verify G-tube placement before flushing the gastrostomy tube and before administering tube feedings and medication for two residents. R6 was admitted with diagnoses including gastrostomy, dysphagia, acute and chronic respiratory failure with tracheostomy and ventilator dependence, diabetes mellitus, atherosclerotic heart disease, and cachexia. His orders included Glucerna 1.5 tube feeding, scheduled G-tube flushes, and Ferrous Sulfate via G-tube three times daily. During the observed feeding start, the RN set the flow rate, primed the tubing, returned to the medication cart, then flushed the tubing, gave the medication, and started the feeding without checking G-tube placement first. R13 was admitted with diagnoses including acute and chronic respiratory failure, COPD, dementia, epilepsy, paraplegia, and presence of gastrostomy and tracheostomy. Her orders included Jevity 1.5 tube feeding and scheduled G-tube flushes. When the feeding machine alarmed, the RN disconnected the resident from the machine, flushed the tubing with water, re-primed the tubing, and restarted the feeding without checking G-tube placement first. The RN later stated she forgot to check placement before flushing and before providing the feeding, and the DON stated nurses are expected to check G-tube placement prior to flushing and feeding.
Hemodialysis VAD Dressing Not Maintained or Changed Using Sterile Technique
Penalty
Summary
The facility failed to ensure a dressing remained in place over a resident’s left chest venous access device (VAD) used for hemodialysis, and the resident was observed without a dressing covering the site with redness at the insertion area. The resident stated she had a history of MRSA infection at her hemodialysis site and that her site had recently been changed from the right chest to the left chest. Her MDS dated 4/10/26 indicated intact cognition, and physician orders included in-house renal dialysis three times a week. During the dressing change, the RN entered the resident’s room without washing her hands or putting on gloves and assessed the VAD site with bare hands. The RN then returned with a sterile dressing change kit, but the resident’s shirt tag touched the gauze covering the insertion site and the gauze was not replaced before the clear dressing was applied. The RN did not wear a gown during the sterile dressing change, and the chlorhexidine cleansing was performed in a side-to-side motion over only the superior aspect of the VAD site rather than cleansing the full site. The hemodialysis RN and the DON stated that hemodialysis VAD sites should always be covered with a dressing and that dressing changes require full PPE and sterile technique.
Significant medication error with losartan dose mismatch
Penalty
Summary
A significant medication error occurred for a resident admitted with dementia, diabetes, hypertension, and hyperlipidemia. The resident’s order summary for May 2026 showed losartan 100 mg daily, and a progress note documented that losartan had been increased to 100 mg daily because blood pressure readings had been variable, with intermittent systolic elevations into the 160s while the resident was also receiving multiple antihypertensives, including amlodipine, carvedilol, and hydralazine. Record review and observation showed the pharmacy delivered losartan 50 mg tablets, quantity 30, on 04/08/26, while the MAR listed losartan potassium oral tablet 50 mg with instructions to give 100 mg by mouth daily. On 05/06/26, an LPN prepared the resident’s morning medications and placed one losartan 50 mg tablet in the medication cup, and the medication card also showed losartan 50 mg with directions to give one tablet daily. The DON stated that the resident’s current order was for losartan 100 mg daily, that the pharmacy had delivered only 30 tablets of 50 mg, and that the nurses were only administering 50 mg daily as shown on the card rather than the ordered dose.
Failure to Use Required PPE During Isolation and VAD Care
Penalty
Summary
The facility failed to follow infection prevention and control practices related to PPE use for two residents. R9, who had end stage renal disease, dependence on renal dialysis, a complication of a vascular dialysis catheter, and a history of MRSA infection, was observed without a dressing covering her left chest venous access device and with redness at the insertion site. Although EBP signage and a PPE cart were outside the room, V4 entered R9’s room without washing hands or putting on gloves, pulled back the neck of R9’s shirt with bare hands to assess the VAD site, and later performed the sterile dressing change without wearing a gown. R9’s record included an order for enhanced barrier precautions, and the care plan directed staff to wash hands before entering and leaving the room and to wear gloves and gown for high-contact care activities, including central line device care. R1, who had hemiplegia, type II diabetes, chronic respiratory failure, encephalopathy, dysphagia, a tracheostomy, and a gastrostomy, was on contact isolation due to the tracheostomy and had moderate cognitive impairment with total dependence for ADLs and transfers. V12, a family member, was observed inside R1’s room without a surgical mask, gown, or gloves. R4 stated that visitors entering rooms with Contact Isolation signage must wear gowns, gloves, and a surgical mask, and said she did not educate V12 before he entered the room. V8, the IP, stated that all residents with tracheostomy are on contact isolation due to history of MDRO and that visitors must wear gowns, gloves, and a mask when entering such rooms. R1 was also receiving antibiotics for a UTI and positive sputum culture.
Failure to Obtain Timely Wound Consultation and Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely wound specialist involvement and adherence to ordered wound treatments for a resident admitted with an existing unstageable sacral-coccygeal pressure ulcer. The resident, a 75-year-old with multiple comorbidities including type 2 diabetes mellitus, prior necrotizing fasciitis, hemiplegia, DVT, and hypothyroidism, was admitted with an unstageable sacral pressure ulcer measuring 1.5 cm x 1.5 cm, fully covered with slough but documented as clean, without odor or signs of infection. The admission physician orders indicated the resident may be seen by a wound care physician, and the initial treatment ordered on admission was cleansing the coccyx area, applying skin prep, Medi-Honey, fluff gauze, and a dry dressing three times weekly and as needed. Despite this, the wound care nurse did not obtain a wound specialist consultation until approximately five weeks after admission, during which time the wound measurements increased and remained unstageable with slough covering the wound bed. Over the ensuing weeks, the wound care nurse documented weekly assessments showing progressive enlargement of the wound, which by early November measured 4.3 cm x 3.8 cm with excoriation around the wound and a bed fully covered with slough. The treatment administration record for November showed the resident continued to receive the same Medi-Honey treatment three times a week. The wound specialist NP first evaluated the resident on a date in early November, documenting an unstageable/unclassified pressure ulcer measuring 5.0 cm x 6.0 cm x 0.2 cm with 100% slough, moderate serosanguinous drainage without odor, and no signs of infection in the peri-wound area. The NP recommended cleansing, Medi-Honey, calcium alginate, and foam dressing three times weekly and as needed, and performed a bedside debridement to remove slough and necrotic tissue. A second debridement was performed one week later, after which the NP ordered Dakin’s 1/4 strength solution with wet-to-moist gauze and foam dressing daily and as needed. The NP later documented that Dakin’s was ordered as a debriding agent and antiseptic to help prevent infection and that daily treatment was important. Despite the NP’s subsequent orders and recommendations, the facility did not consistently implement the updated wound care regimen. The NP’s note on a mid-November visit documented the wound as now a stage 4 pressure injury measuring 6.5 cm x 4.5 cm x 2.0 cm, with moderate serosanguinous drainage and odor, 100% slough, and peri-wound signs and symptoms of infection. The NP ordered a wound culture and topical antibiotics, including Dakin’s solution and Silvadene cream with calcium alginate and foam or dry dressing daily and as needed. However, the treatment administration record showed the resident continued to receive Medi-Honey three times weekly, with Dakin’s solution applied only on three specific days and no documentation that Silvadene was ever provided. The wound nurse acknowledged that she typically received verbal orders from the NP and did not read the NP’s written notes for one to two days, and that the only change she recalled was increasing Medi-Honey frequency and later changing to Santyl. The primary physician stated he relied on consultants’ recommendations, but the record showed the resident was not seen by the wound specialist until the wound had significantly deteriorated. Ultimately, the wound culture was positive for MRSA, and hospital records documented an infected stage 4 sacral decubitus ulcer with osteomyelitis requiring operative excisional debridement of skin, subcutaneous fat, muscle, and fascia. The facility’s own wound prevention and healing policy required nurses to provide wound care per physician orders, notify the physician of lack of progress, and have the wound MD/NP evaluate and change treatment when the patient was not responding, which was not followed in this case.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
Facility staff failed to maintain the head of bed at the required 30-45 degree elevation while a resident's tube feeding was infusing. During an observation, the resident was found in a flat position in bed with tube feeding of Nepro 1.8 Cal infusing at 40 mL per hour via feeding pump. Certified Nursing Assistants (CNAs) present during care stated that they believed it was acceptable for the resident to remain flat during tube feeding unless the resident was being turned side to side. The Director of Nursing (DON) later clarified that the head of bed should be elevated during tube feeding to prevent vomiting or aspiration. Review of the resident's physician orders and facility policy confirmed that the head of bed should be elevated to 30-45 degrees during tube feeding unless otherwise ordered.
Missed Antibiotic Doses Due to Medication Unavailability and Documentation Lapses
Penalty
Summary
The facility failed to administer the ordered initial dose of an antibiotic to a resident being treated for a urinary tract infection (UTI). The nurse practitioner's progress note documented a plan to treat the resident with Levofloxacin IV, starting with a 750 mg dose, followed by a 500 mg dose every 48 hours, and Meropenem 500 mg IV daily. The Medication Administration Record (MAR) showed a missed dose of Meropenem on 9/14/25 and no documentation of the administration of the initial Levofloxacin 750 mg dose on 9/13/25 or 9/14/25. Nursing notes indicated that Levofloxacin was not available and would be delivered later, but there was no documentation that the dose was ever administered. The Director of Nursing confirmed there was no documentation of the administration of either the Meropenem dose or the initial Levofloxacin dose, and no authorization requests were received from the pharmacy for the one-time Levofloxacin dose. Facility policy requires prompt reporting of medication discrepancies and omissions, but this was not documented in this case.
Failure to Serve Meals at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to maintain palatable and appetizing food temperatures when serving meals to residents. Observations and interviews with several alert and oriented residents revealed consistent complaints that food was being served lukewarm or cold. A family member also reported that a former resident frequently complained about cold food. During meal service observations, food carts were delivered to the dining room and resident rooms using non-insulated carts covered with plastic zippered covers. Staff were seen setting up trays and serving food without the use of plate warmers or metal heating plates, which are important for maintaining food temperature. Temperature checks of food trays revealed that hot foods, such as turkey with gravy and cornbread dressing, were served at temperatures significantly below the required holding temperature of 135°F, with some items measured as low as 50.1°F. The Dietary Manager confirmed that food temperatures are checked in the kitchen before delivery, but acknowledged that the lack of metal heating plates and insulated carts contributed to the inability to maintain appropriate temperatures during transport and service. Facility policy requires that food be served at safe and appetizing temperatures, but this standard was not met during the survey period.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to adhere to standard infection control practices regarding the use of gowns during care for residents on Enhanced Barrier Precautions (EBP). Observations revealed that staff did not wear gowns while providing high-contact care to three residents who were on EBP due to conditions such as a history of Candida Auris, end stage renal failure with IV access, and a history of multidrug-resistant organisms. Specifically, two CNAs provided hygiene care to a resident with a history of Candida Auris without donning gowns, despite EBP signage being present. Another CNA provided incontinence care to a resident with an AV fistula and IV midline catheter, who was also receiving IV antibiotics, without wearing a gown. Additionally, a nurse checked vital signs at the bedside of a resident with a wound, indwelling urinary catheter, and history of KPC, again without wearing a gown, even though EBP signage was posted. Interviews and record reviews confirmed that these residents were on the facility's EBP list and that staff were expected to wear gowns and gloves during high-contact care activities, as outlined in the facility's EBP policy and posted signage. The policy specifically required gown and glove use for activities such as dressing, bathing, hygiene, incontinence care, and device care for residents on EBP. Despite these clear expectations and procedures, staff failed to consistently implement the required infection control measures during the observed care activities.
Failure to Assess, Treat, and Monitor Resident Skin Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who developed significant skin abnormalities, including a rash and redness in multiple areas. Despite the presence of a care plan and specific orders from a wound care nurse practitioner to keep the skin clean and dry, apply barrier and antifungal creams, and monitor the affected areas, staff did not consistently implement these interventions. Documentation shows that the resident's skin issues, including redness and rash in the groin, perineal area, buttocks, and under the breasts, were present for several months without adequate assessment, monitoring, or treatment. Staff did not complete required wound or skin event documentation in risk management, nor did they notify the physician or wound care nurse of changes or worsening conditions. Direct observations revealed that the resident, who was dependent on staff for all activities of daily living and had multiple complex medical diagnoses, was left in a soiled incontinence brief for over four hours. The resident's skin was found to be bright red, with extensive rash and evidence of pain during care. Staff failed to apply barrier cream as ordered, citing lack of access to supplies, and did not follow through with timely application of zinc oxide ointment. The wound care nurse practitioner's recommendations for antifungal and barrier cream application, as well as regular reassessment, were not documented as being followed, and there was no evidence of ongoing measurement or evaluation of the skin condition. The facility's own policies required head-to-toe skin assessments by licensed nurses upon admission, weekly skin checks, daily CNA observations, and prompt documentation and follow-up of any abnormalities. However, there was no documentation of physician notification, wound or skin event completion, or follow-up assessments for the resident's ongoing and worsening skin issues. The lack of adherence to care plans, provider orders, and facility policies resulted in the resident experiencing prolonged pain and discomfort due to untreated and unmonitored skin conditions.
Inadequate Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough abuse investigations, which has the potential to affect all residents. In one instance, a CNA reported hearing an LPN verbally discourteous to a resident, R81, who is legally deaf and moderately cognitively impaired. The facility's investigation was incomplete, as there was no evidence of an interview with R81 or a written statement from the LPN involved. The investigation included statements from other staff, but these were related to a separate Human Resources incident. Additionally, resident interviews conducted were undated, lacked specific questions about the incident, and did not include staff names. In another case, the facility's investigation into an abuse allegation involving R29 was insufficient. The final report indicated that R29 was alert and oriented, yet there was no documentation of an interview with R29 or any other residents. The administrator claimed to have spoken with R29, but this was not documented. The investigation relied on random patient and staff interviews, which did not yield any complaints, but lacked thorough documentation and evidence. A third investigation concerning R252 was similarly inadequate. The facility provided initial and final reports but no other investigatory evidence. The administrator stated that there were no staff interviews and that resident interviews were verbal and undocumented. The final report mentioned staff interviews and random resident inquiries about safety, but these were not substantiated with documentation. The facility's abuse policy requires comprehensive investigations, including interviews with all relevant parties and documentation, which were not adhered to in these cases.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 133 residents receiving dietary services. During an inspection, it was observed that the vents over the stove were dusty, and the sanitizing solutions in the red buckets and the three-compartment sink were not within the manufacturer's recommended range of 200-400 ppm. The dishwasher failed to reach the required sanitizing temperature of 180 degrees Fahrenheit, with the highest recorded temperature being 99 degrees Fahrenheit. The Dietary Manager and Morning Cook confirmed these discrepancies, noting that the automated sanitizer dispenser was not functioning properly, and the dishes could not be verified as sanitized. In the walk-in cooler, several food items were found unlabeled or improperly dated, including cheese, pickles, sandwiches, and various meats. Some items, such as tomatoes and green peppers, were visibly spoiled. The facility's policy requires that leftovers and open foods be clearly labeled with a discard date, but this was not adhered to. Additionally, staff personal food was stored in the kitchen refrigerator without proper labeling, contrary to the facility's policy. The resident refrigerators on the first and second floors lacked thermometers, and temperature logs were not maintained. The first-floor refrigerator contained expired chocolate milk and unlabeled take-out containers, while the second-floor refrigerator also had unlabeled containers and felt warm. The Maintenance Director confirmed the absence of thermometers and blank temperature logs. Furthermore, the dry storage area contained dented cans that were not marked, posing a risk of botulism if used. The facility's policy requires dented cans to be stored separately or returned to the vendor, which was not followed.
Failure to Provide ROM Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for residents with decreased range of motion (ROM), as evidenced by the lack of assessment, treatment, services, devices, and care planning. Five residents were identified as not receiving the necessary interventions to manage their conditions, which included hemiplegia, hemiparesis, and contractures. Despite having physician orders for splints and other supportive devices, these were not consistently applied, leading to potential worsening of their conditions. Resident R114, who was admitted with hemiplegia and hemiparesis following a stroke, had a physician order for a resting hand splint to manage contractures. However, observations over several days showed that the splint was not applied, and the resident's left hand remained closed into a fist. The Director of Rehab and Restorative Aide confirmed the necessity of the splint to prevent contractures, yet it was not utilized as ordered. Similarly, Resident R86, with a history of cerebral infarction, had orders for a resting hand splint, but it was not applied consistently. The restorative staff, who were responsible for applying the splints, were often reassigned to work as CNAs, leaving the residents without the necessary restorative care. This lack of adherence to physician orders and care plans was also evident in the cases of Residents R46, R94, and R99, who were observed without their prescribed splints or other supportive devices, indicating a systemic issue in the facility's management of residents with impaired mobility.
Unsafe Storage and Bed Positioning in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment for residents by not securely storing oxygen cylinders and cleaning supplies, and by not maintaining residents' beds at a safe height. Several residents, including those at risk for falls, were found with their beds and overbed tables in high positions, contrary to their care plans which specified that beds should be kept low to minimize fall risk. Staff members, including CNAs and LPNs, were observed leaving beds in high positions, and there was a lack of communication and understanding among staff regarding the importance of maintaining beds at a safe height for all residents, regardless of their fall risk score. Additionally, oxygen tanks were found unrestrained and unholstered in residents' rooms and the second-floor medication room, posing a potential hazard. The facility's policy requires oxygen tanks to be stored in holders to prevent mechanical shock and combustion risks. Furthermore, the housekeeping closet and soiled utility room were left unlocked, with unsecured cleaning chemicals accessible, despite the facility's policy that such areas should be locked to prevent resident access. These oversights indicate a failure to adhere to safety protocols designed to prevent accidents and ensure resident safety.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically hemorrhoidal ointment. The resident, who had severe cognitive impairment, was observed with a tube of hemorrhoidal cream on her bedside table. She reported using the cream for lubrication between her butt cheeks to help her sit, rather than for its intended use as prescribed. The resident stated she did not have hemorrhoids and was unaware of who provided her with the cream. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is safe, which was not conducted in this case. The resident's medical history included gastrointestinal hemorrhage, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, congestive heart failure, gout, and repeated falls. Despite having an order for hemorrhoid cream to be applied rectally, the resident had not received assistance with its application since the previous year. Facility staff, including an LPN and RN, confirmed that the resident did not have orders to self-administer or store medications at her bedside. The Director of Nursing stated that residents with severe cognitive impairment should not have medications at their bedside, and the cream should not be used as a barrier cream.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating their needs and preferences. Resident R114, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was found with her call light placed on a side dresser, out of her reach. Despite her care plan indicating that the call light should be within reach due to her limited mobility and weakness, she was unable to use it and had to resort to screaming for help. The Director of Nursing confirmed that call lights should be attached to the bed linen or wrapped around the side rail to ensure accessibility. Resident R2, who is cognitively intact and at risk for falls, had her call light placed near her shoulder, making it difficult for her to reach. She expressed the need for the call light to be closer to her hand. Similarly, Resident R44, also cognitively intact with a self-care deficit and decreased mobility, had her call light wedged between the bed frame and side rail, making it inaccessible. Despite multiple observations, her call light remained out of reach, and she reported having to scream for assistance. The facility's policy requires that call lights be accessible to residents capable of using them, but this was not adhered to in these cases.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse, as evidenced by incidents involving three residents. One resident, who is moderately cognitively impaired and legally deaf, was allegedly verbally abused by an LPN during a medication pass. The CNA reported overhearing the LPN yelling at the resident to 'stop that' and 'shut up.' The facility's investigation into the incident was incomplete, as there was no written statement from the LPN, and the resident was not properly interviewed due to his hearing impairment. Another resident, with intact cognition, reported being verbally criticized by the same LPN regarding his toileting habits. The resident described the interactions as hostile and found the LPN's behavior to be inappropriate and offensive. The facility's report acknowledged that the LPN's demeanor did not meet facility standards and noted similar negative interactions with other residents, but it did not specify whether the abuse allegation was substantiated. A third resident, also with intact cognition, recounted an incident where the LPN yelled at her for having outside medication in a package from her sister. The resident felt belittled and humiliated by the LPN's actions. The facility's abuse policy defines verbal and mental abuse and emphasizes a no-tolerance philosophy, yet the incidents suggest a failure to adhere to these standards, resulting in the residents' experiences of verbal and mental abuse.
Failure to Report Verbal Abuse Allegation to IDPH
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the Illinois Department of Public Health (IDPH). The incident involved a Certified Nursing Assistant (CNA) who alleged that a facility nurse was verbally discourteous to a resident, identified as R81. The CNA reported overhearing the nurse speaking disrespectfully to the resident, including shouting and telling the resident to 'shut up' loudly. Despite the facility's policy requiring immediate reporting to the state licensing agency after assessing the resident and removing the alleged perpetrator, the initial and final incident reports were not sent to IDPH. The facility's administrator, who also serves as the Abuse Coordinator, acknowledged that neither the initial nor the final reports were sent to IDPH, despite believing they had been. The administrator confirmed that the fax verifications provided did not include the necessary details to show that the reports were actually sent. The facility's abuse policy mandates that a complete written report of the investigation's conclusion, including the steps taken in response to the allegation, be sent to the Department of Public Health within five days of the occurrence. This failure to report constitutes a deficiency in the facility's handling of the abuse allegation.
Inadequate Incontinence Care and Lack of Toileting Program
Penalty
Summary
The facility failed to properly assess and implement a toileting program for a resident, identified as R32, who was incontinent of bowel and bladder. During an observation, it was noted that R32 was wearing a disposable incontinence brief with an additional disposable incontinence pad inside the brief. This practice was confirmed by R32, who stated that she wore the briefs and pads for protection and was not on a toileting program or schedule. The Certified Nursing Assistant (CNA) assisting R32 mentioned that the resident drinks a lot of coffee and water, which was used to justify the use of both the pad and the brief due to heavy urine output. The Restorative Nurse, identified as V15, acknowledged that residents should not wear both an incontinence brief and a pad inside the brief, as it could lead to skin breakdown. It was confirmed that R32 was not on a toileting program. R32's medical history includes conditions such as hemiplegia, hemiparesis, diabetes, hypertensive chronic kidney disease, chronic obstructive pulmonary disease, major depressive disorder, and dysphagia. The facility's policy on Supporting Activities of Daily Living (ADL) emphasizes the necessity of providing services to maintain good nutrition, grooming, and personal hygiene for residents unable to perform these activities independently, yet R32's care plan lacked a scheduled toileting program.
Failure to Maintain Midline IV Catheter
Penalty
Summary
The facility failed to provide necessary care for a resident with a midline intravenous (IV) catheter, leading to a deficiency in maintaining the catheter. The resident, who has a diagnosis of unspecified hearing loss, was observed with a midline IV catheter in the right upper arm, where the dressing was saturated with serosanguinous blood. The dressing lacked documentation of the time, date, or staff initials indicating when it was last changed. The resident communicated that the catheter had been in place for about a month, was last used and flushed the previous month, and could not recall the last dressing change. The Director of Nursing (DON) confirmed that there was no documentation of midline catheter dressing changes in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The facility's policy requires dressing changes every 48 hours if gauze is present under the transparent dressing, but the DON was unaware of this requirement. The resident's Physician Order Sheet (POS) indicated an order for IV antibiotic infusion, but no IV medications were administered in February, and there were no orders for dressing changes or catheter care. The facility's policy outlines the need for regular dressing changes and documentation, which was not adhered to in this case.
Incomplete Documentation of Medication Regimen Reviews
Penalty
Summary
The facility failed to provide completed documentation of the pharmacy's monthly Medication Regimen Reviews (MRR) recommendations along with the physician or prescriber responses for two residents, R55 and R64, out of a sample of 30. For R55, the consultant pharmacist completed MRRs on several occasions, but the facility did not provide the referenced reports or documentation of the physician's responses. The Assistant Director of Nursing (ADON) acknowledged the need for a better tracking system and admitted that some recommendations were missing and not always scanned into the Electronic Medical Record (EMR). The Director of Nursing (DON) stated that the ADON should escalate the issue to the Medical Director if there is no response from the physicians. Similarly, for R64, the facility did not provide the referenced reports or documentation of the physician's responses to the pharmacist's recommendations. The facility's policy requires that comments and recommendations concerning medication therapy be communicated in a timely fashion, enabling a response before the next MRR. The policy also states that if the prescriber does not respond in a reasonable time, the DON or consultant pharmacist may contact the Medical Director. However, the facility failed to adhere to these guidelines, resulting in incomplete documentation of the MRR process.
Improper Storage of Resident's Personal Food Items
Penalty
Summary
The facility failed to ensure proper storage of a resident's personal food items, leading to a deficiency. A resident, identified as R45, was observed with opened bottles of Miracle Whip and horseradish sauce stored on the windowsill in her room, despite both items requiring refrigeration after opening. The resident, who was cognitively intact and had multiple diagnoses including chronic obstructive pulmonary disease and heart failure, stated that she used to have a refrigerator in her room, but it was removed by the facility. As a result, she had no alternative storage for her personal food items. The facility's administrator confirmed that personal refrigerators were no longer available and acknowledged that the condiments should be refrigerated to prevent potential health issues. The facility's Food Storage policy mandates regular inspections and immediate disposal of improperly stored food, which was not adhered to in this instance.
Failure to Use Proper PPE in Isolation Room
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols by not wearing the appropriate personal protective equipment (PPE) before entering an isolation room. This deficiency was observed when a Certified Nursing Assistant (CNA), identified as V11, entered the room of a resident diagnosed with MRSA without wearing a gown, despite the presence of a sign indicating contact precautions. The resident, identified as R447, had multiple diagnoses including an infection of an amputation stump and MRSA, necessitating contact precautions as per the physician's order sheet and care plans. The CNA acknowledged the oversight, stating that they realized the mistake after entering the room to assist the resident. The Director of Nursing (DON), identified as V2, confirmed that MRSA requires contact precautions, which include wearing both a gown and gloves before entering the isolation room. The facility's policy on transmission-based precautions also mandates the use of a disposable gown upon entering and removing it before leaving the room to prevent contamination. This incident highlights a lapse in following established infection control protocols, specifically regarding the use of PPE in isolation settings.
Failure to Utilize Antibiotic Use Protocol Tool
Penalty
Summary
The facility failed to utilize an antibiotic use protocol tool for residents who were placed on antibiotics, affecting two out of five residents reviewed for antibiotic stewardship. The Infection Preventionist (IP), identified as V4, acknowledged that the McGeer's tool, which is used to screen for infections and guide antibiotic use, was not completed for these residents. Resident R27 was receiving Ciprofloxacin for a urinary tract infection, and the tool was not used to assess the necessity of the antibiotic. Similarly, Resident R120 was on Meropenem for a positive sputum culture, and again, the McGeer's tool was not utilized to determine if the antibiotic was warranted. The Director of Nursing (DON), identified as V2, confirmed that the McGeer's tool is a critical component of the facility's antibiotic stewardship program, intended to ensure antibiotics are prescribed appropriately. The facility's policy, reviewed in June 2024, mandates the use of a surveillance tracking form to document antibiotic usage and outcomes, which was not adhered to in these cases. This oversight indicates a lapse in following established protocols for antibiotic stewardship, potentially impacting the quality of care provided to the residents involved.
Failure to Identify Bed Entrapment Hazard
Penalty
Summary
The facility failed to identify a potential entrapment hazard on a resident's bed, which was observed during a survey. Specifically, the bed and overbed table of a resident were left in a very high position, and the side rails extended approximately five inches on both sides of the bed. This created a risk of the resident rolling over and becoming stuck between the rails. A Licensed Practical Nurse (LPN) confirmed that the bed rails were too far apart from the mattress and bed frame, posing a safety risk. The Director of Nursing (DON) acknowledged that both Maintenance and Nursing staff should ensure there is no space between the bed rail and mattress to prevent injury or entrapment. The facility's policy, dated January 17, 2025, mandates regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment areas.
Failure to Identify and Address Skin Breakdown
Penalty
Summary
The facility failed to identify and address a resident's skin breakdown, resulting in the development of a Stage 3 pressure ulcer. The resident, who was admitted with multiple diagnoses including hemiplegia, hypertension, and respiratory dependence, was at a very high risk for skin breakdown according to assessments. Despite orders for daily and weekly skin checks, the resident's skin issues went unnoticed until a Wound Care Coordinator observed several areas of open, broken, and bloody skin on the resident's buttocks. The resident's care plan aimed to maintain clean and intact skin, but no skin assessments for impaired or open skin were completed since admission. Staff interviews revealed that CNAs providing incontinence care did not notice any skin issues, and the resident's skin was not dressed or treated prior to the discovery of the ulcer. The CNAs did not report any concerns to the nursing staff, and the LPN on duty had not been treating the resident for any skin concerns. The facility's Wound Prevention and Healing policy required skin inspections during showers and as scheduled, but these were not effectively carried out, leading to the oversight of the resident's skin condition.
Failure to Provide Information for Camera Installation in Resident's Room
Penalty
Summary
The facility failed to provide necessary information to a resident's family regarding the installation of a camera in the resident's room, which is a violation of the resident's rights to a dignified existence and self-determination. The resident, who was moderately impaired and required assistance with various activities of daily living, had a care conference on December 5, 2024, where the family expressed the desire to have a camera installed in the resident's room. Despite this request, the facility did not follow through with providing the necessary information or addressing the request in a timely manner. The family member, V31, reported that they had contacted the Director of Social Services, V6, on December 11, 2024, to request information about the camera installation policy, but did not receive a follow-up. The facility's staff, including V5 and V6, were unclear about the status of the request, and the Administrator, V1, was not aware of the request. The facility's policy allowed for cameras, but the request was not addressed within the expected 72-hour timeframe. The lack of communication and follow-up resulted in the failure to honor the resident's rights, as the family was not provided with the necessary information to proceed with the camera installation.
Failure to Provide Scheduled Anxiety Medications
Penalty
Summary
The facility failed to provide a resident with his scheduled anxiety medications as ordered, affecting one resident reviewed for pharmacy services. The resident, who was cognitively intact and had a history of anxiety disorder among other diagnoses, did not receive his prescribed doses of Buspirone, Clonazepam, and Hydroxyzine over several days in December 2024. The resident reported being out of these medications and expressed increased stress due to the lack of medication. Despite communicating with staff and a Nurse Practitioner, the issue was not resolved promptly. Interviews with facility staff revealed a breakdown in the medication reordering process. Licensed Practical Nurses (LPNs) acknowledged the importance of timely reordering to prevent medication shortages, yet the resident's medications were not reordered in time. The Director of Nursing confirmed that communication with the pharmacy began only after the medications had run out, leading to a delay in receiving the necessary medications. The facility's policy required controlled substances to be reordered when a five-day supply remained, but this protocol was not followed, resulting in the deficiency.
Failure to Report and Treat New Pressure Injuries
Penalty
Summary
The facility failed to report and address new skin alterations for a resident with a known history of pressure injuries. The resident, who had multiple diagnoses including a history of pressure injuries, was found to have new facility-acquired pressure injuries on the right hip, specifically a stage 3 and a stage 2 cluster. These injuries were not assessed or treated promptly upon identification, as required by the facility's protocols. During an observation, the resident was found in the same position for an extended period, and a Certified Nurse Assistant (CNA) initially reported no wounds. However, upon further inspection, the CNA discovered open areas on the resident's right hip, which had been observed earlier in the shift but not reported. The CNA then notified a Licensed Practical Nurse (LPN), who was unaware of the wounds until that moment. The LPN assessed the wounds, identified them as pressure injuries, and initiated basic wound care. The Wound Care Nurse (WCN) and Wound Care Aide (WCA) later assessed the wounds, confirming the presence of newly acquired pressure injuries. The facility's policy required immediate reporting and treatment of skin alterations, which was not followed in this case. The resident's care plan and orders emphasized the need for daily skin assessments and prompt notification of wound care staff for any issues, which were not adhered to, leading to the deficiency.
Failure to Assess and Obtain Treatment Orders for Resident's Skin Tears
Penalty
Summary
The facility failed to assess and obtain treatment orders for a resident with known skin tears, leading to a deficiency in providing appropriate treatment and care. The resident, who was at risk for skin integrity impairment due to fragile skin and a history of skin tears, was observed with multiple dressings on her extremities. The Wound Care Nurse was unaware of the resident's active wounds and found that the resident did not have treatment orders in her Electronic Medical Record (EMR). The resident's wounds were not assessed or documented by the facility prior to the surveyor's observation. The facility's staff, including the Registered Nurse and Hospice RN, were involved in changing the resident's dressings but did not ensure proper documentation or treatment orders were in place. The Hospice RN did not have access to the facility's EMR and relied on previous dressings for treatment. The Director of Nursing expected staff to assess and report skin abnormalities, but the resident's EMR lacked active wound care orders. The facility's policies required wound assessment and documentation, but these were not followed, resulting in the deficiency.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for six residents, as observed during an environmental inspection. The inspection revealed that the bedroom floors of these residents were dull, dirty, and covered with accumulated dirt, dust, and debris, including small pieces of plastic from personal protective equipment packaging. The floors also had stains and patches of dry, unidentified fluids. Interviews with residents and a family member confirmed the dissatisfaction with the cleanliness of the floors. A housekeeper admitted that some bedrooms had not been swept for days, despite the expectation that floors should be swept and mopped daily. Documentation from Resident Council Meetings from June through August 2025 also indicated ongoing concerns about the need for bedroom and floor cleaning.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living (ADL) for three residents. On September 25, a CNA provided incontinence care to a resident who was found saturated with urine and had a pasty bowel movement, with the last change occurring around 9 AM. Another resident was also found with a saturated brief, with the last change also occurring after breakfast. Both residents' urine was dark in color, indicating a lack of timely care. Additionally, a third resident was observed in bed for an extended period without being offered assistance to get up, despite expressing a desire to do so. The resident reported that staff often made excuses for not assisting her, leading her to stop asking for help. The Director of Nursing confirmed that staff are required to check and change residents every two hours and assist them in getting up unless medically contraindicated. All three residents were noted to be alert and oriented, requiring extensive to total assistance with ADL care.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to monitor and check glucose blood sugar levels for a resident with a known history of Diabetic Ketoacidosis (DKA) and elevated blood sugars. This failure resulted in the resident needing hospitalization for DKA. The resident's blood glucose levels were consistently elevated, ranging from 345 mg/dL to 400 mg/dL, despite routine insulin doses and sliding scale orders. There was no documentation of rechecking the resident's sugar levels after dinner and at bedtime, nor was there any record of notifying the resident's physician about the consistent elevation of sugar levels despite the insulin doses. The resident, who has multiple diagnoses including type 2 diabetes mellitus with ketoacidosis, acute kidney failure, and congestive heart failure, was admitted to the facility after suffering a cardiac arrest. The resident's blood glucose monitoring log showed consistently elevated readings from May 21 to May 22, 2024. On May 23, 2024, the resident's blood sugar level was 600 mg/dL, and he displayed lethargy and slurred speech, leading to hospitalization with a diagnosis of DKA. The hospital report indicated that upon admission, the resident's blood glucose level was 810 mg/dL, and his ketones were very high. Interviews with facility staff and the resident's physician revealed that the standard glucose monitoring for brittle diabetics is 3-4 times a day and as needed. The staff should have rechecked the resident's sugar levels 2 hours after dinner and at bedtime and reported the resident's condition to the physician for potential new orders and medication adjustments. The lack of proper monitoring and communication with the physician contributed to the resident's hospitalization for DKA.
Failure to Implement Physician's NPO Order
Penalty
Summary
The facility failed to implement a physician's order for a resident who was scheduled for eye surgery. The resident, a [AGE] year old female with diagnoses including bilateral cataracts, had a physician's order to be NPO (Nothing by Mouth) from midnight and could only have clear liquids until 6:30 AM, along with specific medications with a sip of water. On the morning of the scheduled surgery, the resident was fed toast and cereal by the staff, leading to the rescheduling of the surgery. Interviews with the resident and various staff members confirmed that the NPO order was not followed, resulting in the delay of the medical procedure. The facility's policy requires Licensed Professional Nurses/Registered Nurses to follow physician orders, which was not adhered to in this instance.
Failure to Maintain Bed Equipment
Penalty
Summary
The facility failed to maintain a resident's bed equipment, specifically the bed control cord, which had approximately two inches of exposed wires. This deficiency was observed on two separate occasions, with the Administrator present during one of the observations. The resident involved is a [AGE] year old female with diagnoses including osteoarthritis, type 2 diabetes, and bilateral cataracts. The resident's daughter also reported the frayed wires. The Director of Maintenance was notified of the issue on the same day as the second observation. The facility's Safe Environment policy mandates maintaining all essential equipment in safe operating conditions, which was not adhered to in this instance.
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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.
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Nursing homes near Joliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parc Joliet | 0.4 mi | ★★★★★ | 12 | 0 |
| Avantara Joliet | 0.7 mi | ★★★★★ | 8 | 0 |
| Joliet Living & Rehab Center | 1 mi | ★★★★★ | 5 | 0 |
| Sunny Hill Nursing Home Of Will County | 3.1 mi | ★★★★★ | 3 | 0 |
| Spring Creek | 3.7 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.