Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Pearl Pointe Nursing Rehab & Care during CMS and state inspections, most recent first.
Insufficient CNA Staffing and Delayed Resident Care: The facility failed to schedule enough CNA coverage to meet resident needs, with times when only one aide covered a unit. Residents and staff reported delayed call light response, missed showers, delayed toileting/incontinence care, and difficulty completing mechanical lift transfers and feeding. A resident who was fully dependent for care and another resident weighing 576 lbs both described long waits for assistance, while staff confirmed frequent short staffing and working alone on heavy care units.
Failure to Provide Scheduled Showers: Two residents who were dependent on staff for bathing assistance did not receive showers as scheduled. CNAs stated showers could not be completed when only two CNAs were assigned to the unit, and one CNA said the residents had gone without showers for a couple of weeks. One resident reported missing her Monday and Friday showers at times and receiving bed baths instead, while the other said she had not gotten a shower in a couple of weeks and her hair appeared greasy and unwashed. The facility policy stated residents would be provided showers as requested or per schedule protocols.
A resident with all four extremities amputated, experiencing phantom pain, neuropathy, and back pain, did not receive ordered Oxycodone 5 mg BID for several days, resulting in severe, uncontrolled pain rated 10/10 despite Tylenol administration. MAR review showed multiple missed doses, including one dose falsely documented as given when the medication was not available. Nursing staff reported that the medication supply had run out, pharmacy records showed that 60 tablets had been delivered, and facility leadership later identified that one card of Oxycodone was missing. This occurred despite an active pain management care plan and a facility policy requiring assessment and administration of pain medications as ordered.
A facility failed to safeguard and accurately document controlled narcotic medications for three residents, resulting in missing oxycodone for a resident with quadruple amputations who went several days without his ordered pain medication, unexplained hydromorphone administrations documented for a cognitively intact resident who reported not taking that drug during the period in question, and inconsistent morphine ER documentation and missing hydrocodone/APAP records for a resident with a stage 4 sacral pressure ulcer. MAR entries, narcotic count sheets, and pharmacy delivery records did not reconcile, controlled drug receipt forms were missing or incomplete, and nurses signed out doses when medications were unavailable or after orders were discontinued, while the facility’s abuse policy lacked a definition for misappropriation of resident property.
The facility failed to immediately report suspected misappropriation of a resident’s oxycodone to the state survey agency and local law enforcement. After being informed that the resident’s oxycodone refill was being denied as too early and that an entire card of oxycodone 5 mg tablets was unaccounted for, facility leadership initiated an internal investigation but did not promptly notify the Illinois Department of Public Health or the police, despite facility policy requiring immediate reporting of suspected crimes involving resident property.
The facility failed to maintain accurate receipt, documentation, and reconciliation of controlled substances for three residents. For one resident with multiple chronic conditions and an amputation, one entire card of Oxycontin and its corresponding narcotic sheet were missing, and numerous Oxycodone doses were subtracted on controlled drug forms but not documented on the MAR, while extra medications were stored in an uncounted cupboard. For a second resident receiving hydromorphone, several delivered cards lacked controlled drug forms, and multiple doses were signed out on narcotic sheets without matching MAR entries. For a third resident with a stage 4 sacral pressure ulcer, morphine ER 15 mg tablets were inconsistently signed out and destroyed around the time of a dose change to 30 mg, and two cards of Hydrocodone/APAP documented on the pharmacy manifest had no corresponding receipt or destruction records.
Two residents with histories of substance abuse and behavioral issues were not adequately protected from accident hazards related to illicit substance use. One resident with multiple psychiatric and seizure-related diagnoses, prior poisoning, and known THC positivity was able to obtain and ingest cannabis gummies, leading to confusion, lethargy, and hospital transfer, while her care plan did not reflect her substance abuse history and staff only reported rumors of drug use. Another resident with cirrhosis, alcohol abuse, insomnia, and depression was allowed to leave independently on community passes despite refusing a urine drug screen, admitting to drinking alcohol when out, staff reports that he "does his own thing" and goes to bars, and psych documentation of ongoing alcohol and possible cocaine use during passes. Although facility policy prohibited alcohol/illicit substances and allowed revocation of passes for violations, the resident’s outside pass privileges were not reassessed or restricted.
Two residents with significant mental health and medical histories did not receive adequate, documented discharge planning and social services support. One resident with complex psychiatric and seizure disorders repeatedly expressed a desire to move to a group-home-like setting, and clinical staff agreed she would benefit from a specialized mental health environment; however, social service notes over several months contained no documentation of discharge planning efforts or contacts with potential placements, despite a care plan directing ongoing discharge assessment. Another resident with cirrhosis, alcohol abuse, and depression, who was independent in ADLs and had an independent community pass, reported discussions about alternative placement, yet social service records over several months similarly lacked any discharge planning documentation, even though facility policy required social work to assess discharge potential and document related activities.
The facility did not consistently take or document cooking and serving temperatures for multiple meals over several days, leaving many meals without any recorded temperature checks. The dietary manager reported that temperatures should be taken at cooking and just before service, but also confirmed that meals are delivered on open carts covered only with cloths and without heated plates or warming equipment. Several residents reported that their food is often cold, sometimes leading them to obtain food from outside the facility, and that hot items such as coffee are sometimes served cold and condiments are not always included. Resident council minutes documented repeated complaints about cold food and beverages over multiple meetings.
Surveyors found that kitchen staff did not document required cooking and serving temperatures for multiple meals over several days, leaving both cooking and holding temperatures blank on the facility’s logs. The Dietary Manager reported that temperatures are supposed to be taken when food is done cooking and again before service, with results logged at those times, and facility policy requires hot foods to be maintained at or above 135°F and reheated to 165°F if below that threshold. This lapse in temperature monitoring and documentation had the potential to affect nearly all residents who consumed meals prepared by the facility kitchen.
Two cognitively intact residents experienced unresolved equipment issues affecting their bed and wheelchair. One resident with multiple chronic conditions and a stage 4 sacral pressure injury reported a loose bed siderail needed for repositioning, which was observed to move side to side despite the concern having been reported earlier. Another resident with type II DM, CKD, anemia, restless legs syndrome, glaucoma, and a right below-knee amputation reported a defective wheelchair armrest; observation showed a partially detached cushion exposing metal and a scrape on the resident’s forearm. The Maintenance Director stated the facility does not use work orders or track repair requests and acknowledged awareness of both issues, despite a written preventative maintenance policy requiring resident equipment, including bed rails, to be in working order.
Misappropriation of Resident Jewelry: A resident’s ring went missing after she reported waking up and finding it gone, with a visible indentation remaining on her finger where the tight-fitting ring had been worn. The resident said she never removed the ring and described it as a large yellow gold ring with multiple diamonds. Her roommate and another resident said they had seen the ring regularly, and the resident’s POA/sister and daughter confirmed she had the ring before the loss was discovered. The resident’s inventory listed one ring, and the facility policy stated residents have the right to be free from misappropriation of property.
A resident reported that her ring was missing, describing it as a large yellow gold ring with diamonds that she always wore, and her roommate and another resident confirmed they had seen her wearing it regularly. A housekeeping manager searched the room but did not report the missing item, and a CNA said she told the nurse about it; the administrator later learned of the missing ring from the resident’s POA and nephew. The facility’s abuse policy required immediate reporting of suspected misappropriation of resident property to the administrator or supervisor.
Failure to immediately report a missing resident ring: A resident said her large diamond ring disappeared after she noticed it missing and told the first person who entered her room. A roommate and another resident confirmed she always wore the ring, and staff members acknowledged hearing about the missing item, but a housekeeping mgr did not report it and the admin first learned of it from the resident’s POA/nephew. Facility policy required immediate reporting of suspected misappropriation of resident property.
A resident with a history of falls and balance issues tripped and fell in her cluttered room while using a walker, due to overcrowding caused by multiple visitors and chairs. The incident resulted in a left ankle and foot fracture. Staff interviews confirmed that the room was not free from accident hazards at the time of the fall, despite the resident's care plan identifying her fall risk and the need for a hazard-free environment.
Staff failed to follow proper hand hygiene and sanitation protocols during food preparation and service, including not changing gloves after handling raw chicken, not sanitizing a thermometer between use on different foods, and leaving a meat slicer uncovered and soiled with food debris. These lapses in food safety practices had the potential to affect all residents receiving meals from the kitchen, except for two on NPO orders.
The facility did not complete updated PASRR referrals for several residents who developed new mental health diagnoses after admission, including conditions such as schizophrenia and major depressive disorder. Despite changes in diagnoses and the initiation of psychiatric medications, required referrals to the state authority were not made, and the facility's policy lacked guidance on this process.
Staff did not consistently follow infection control protocols, including proper hand hygiene and use of PPE, when caring for residents on Enhanced Barrier Precautions. For example, a CNA failed to perform hand hygiene between resident care activities and handled meal trays without cleaning hands, while other staff exited rooms wearing PPE or provided care to residents with chronic wounds without required gowns. These actions were not in line with facility policies for infection prevention.
A resident's urinary catheter bag was observed without a privacy covering on two occasions, once in a public dining area and once in a location visible from the hallway. Staff and the DON confirmed that facility policy requires dignity bags for catheter bags in public or visible areas, but this was not followed.
A resident with multiple chronic conditions was found self-administering several medications and a supplement without a physician's order or documented assessment of their ability to do so. Staff confirmed that no assessment or physician authorization was in place, and the care plan did not address self-administration, contrary to facility policy.
A resident who had a completed POLST form indicating a preference for Do Not Resuscitate (DNR) did not have a corresponding physician's order entered into the medical record. A registered nurse confirmed that the resident's code status was not documented in the electronic system, contrary to facility policy requiring such information to be included in the Physician Order Sheet.
A resident with documented developmental delay and childlike behavior was admitted after a PASARR Level I screening indicated no intellectual disability, despite medical records and observations suggesting otherwise. The facility relied solely on the hospital's PASARR and did not further assess or question the findings, resulting in the resident's developmental disability not being properly identified in the screening.
A resident with significant medical conditions and limited mobility was not provided with weekly showers as scheduled. Despite being dependent on staff for assistance with activities of daily living, the resident was not offered a shower for 12 days after initially refusing one, resulting in poor personal hygiene. Staff and administrative interviews confirmed the lapse in care and lack of adherence to the facility's shower schedule.
Two residents at risk for pressure ulcers did not receive appropriate prevention interventions, including proper use of heel protectors and air mattresses. Observations showed inconsistent application of physician orders and care plan interventions, such as incorrect mattress settings and use of fitted sheets that interfere with mattress function. Staff interviews revealed confusion about proper procedures, resulting in inadequate pressure ulcer prevention.
A resident with an indwelling urinary catheter and a recent UTI was observed multiple times with catheter tubing and a drainage bag in contact with the floor beneath his wheelchair. Staff acknowledged that the drainage system should not touch the floor, and facility policy requires proper positioning to prevent this.
Two residents receiving oxygen therapy did not have proper physician orders for oxygen administration, and oxygen tubing was not changed as required. Additionally, humidifying jars on oxygen concentrators were not consistently filled with water, and a resident was observed with an improperly placed nasal cannula and shortness of breath. Staff interviews confirmed lapses in monitoring and maintaining respiratory equipment according to facility policy.
A resident with multiple chronic conditions, including diabetes, became more lethargic than usual. An LPN attributed the lethargy to a urinary tract infection but did not document vital signs, blood sugar, or a full assessment at the time. The resident was sent to the hospital, but only outdated vital signs were recorded, and there was no recent blood sugar check. Staff interviews confirmed uncertainty about whether proper assessments were completed, and facility policy requiring assessment and documentation during a change in condition was not followed.
The facility failed to provide timely incontinence care for three residents dependent on staff assistance. One resident with diarrhea and a pressure ulcer waited nearly an hour for care after a bowel movement, while another with kidney failure experienced long delays in bathroom assistance, leading to urination in briefs. A third resident with a pressure ulcer reported waiting up to 11 hours for care. The facility's DON acknowledged the importance of timely care, but staff did not seek additional help during these incidents.
A resident with COPD did not have their albuterol nebulizer order transcribed into the MAR, and there was a discrepancy in the administration of Norco, with three doses dispensed within a 10-hour period instead of two. The DON confirmed the errors and noted that controlled substances should be documented on both the MAR and count sheet.
The facility did not follow its menu requirements by serving burgers that were smaller than the specified 2 ounces of protein. The Registered Dietitian and Certified Dietary Manager confirmed the deficiency, and residents expressed dissatisfaction with the portion size. The cook estimated the burger size instead of measuring it, leading to the deficiency.
The facility failed to serve the correct menu items and portion sizes for residents on mechanical soft and pureed diets, affecting nearly all residents. The dietary manager and cook did not adhere to the prescribed menu and portion sizes due to time constraints and lack of awareness, resulting in inconsistencies in meal service. The facility lacked a policy to ensure adherence to menu items and portion sizes.
The facility failed to maintain proper kitchen sanitation and food storage practices, potentially affecting 63 residents. Observations included improperly stored bulk food items, crusted substances on containers, and inadequate dishwasher sanitizer levels. The dietary aide was unable to check sanitizer levels, and the dietary manager acknowledged the lack of a cleaning schedule. These issues violated the facility's food storage policy.
The facility failed to provide a homelike dining environment by serving meals on trays without removing items onto the table, affecting several residents. Residents expressed feeling institutionalized, and staff confirmed that management did not allow them to make changes to improve the dining experience. The facility had considered offering a more homelike option but had not implemented any changes.
The facility failed to provide a mechanical soft diet to residents who required it, affecting several individuals. The cook did not prepare the food to the necessary consistency, opting to hand-shred turkey instead of grinding it, which was easier and saved time. The dietary manager was unaware of the medical necessity of the prescribed diet and attempted to accommodate residents' preferences without proper understanding. The interim administrator recognized the risk of choking due to this oversight.
The facility failed to implement proper infection control protocols, including contact isolation and enhanced barrier precautions, for residents with conditions like C-diff, urinary catheters, and gastrostomy tubes. Staff frequently entered rooms without PPE, and there was confusion about the required precautions, leading to a significant lapse in infection control practices.
The facility failed to provide appropriate wound care for a resident with an arterial wound, as the treatment plan was not updated in the TAR, resulting in missed daily dressing changes. Additionally, another resident was sent to the ER twice without proper documentation or notification to the physician and family, violating the facility's policy for change in condition documentation.
Two residents in an LTC facility were not provided with adequate supervision and safe transfer practices. One resident, with moderate cognitive impairment, was lifted unsafely by CNAs without using a gait belt, contrary to facility policy. Another resident, with a history of falls, was found walking unassisted without proper supervision or a gait belt, and her care plan was not updated after a previous fall. The facility failed to adhere to its policies on fall prevention and care plan updates.
A resident with a suprapubic catheter did not receive proper catheter care, as the dressing was changed only weekly, and the catheter tubing secure device was not used. Facility staff confirmed that catheter care should be performed daily, and the secure device should be applied to prevent trauma. The facility's policy and the resident's care plan required daily dressing changes and catheter care every shift, which were not followed.
A resident with significant weight loss did not receive prescribed dietary supplements, such as fortified potatoes, despite orders and available recipes. The dietary manager acknowledged the absence of these supplements, and the facility's policy for timely intervention was not followed, contributing to the resident's continued weight decline.
The facility failed to ensure proper respiratory care for two residents requiring oxygen therapy. One resident had tangled and kinked oxygen tubing, a dusty concentrator, and an empty humidification bubbler. Another resident's oxygen tubing was outdated, and the concentrator filter was found on the floor. Staff acknowledged that equipment checks and cleaning were not performed as required by facility policy.
A facility failed to establish policies and procedures for dialysis care for a resident with end-stage renal disease. The resident's dialysis access site was not regularly assessed, and inappropriate food items were provided, contrary to her renal diet. There was no communication with the dialysis center, and no emergency kit was available for potential hemorrhage events. The Director of Nursing admitted to inconsistencies in information exchange and training gaps among staff.
Two residents in an LTC facility were found with medications left at their bedside, contrary to facility policy. One resident had a cup of pills left due to nausea, while another had Norco tablets and an insulin pen from home. Staff confirmed that medications should not be left unattended and must be administered under supervision.
A medication error rate of 28.5% was identified when a new LPN, under the supervision of an RN, administered medications to a resident 1 hour and 20 minutes past the scheduled time. The facility's policy requires medications to be given within one hour of the prescribed times, which was not adhered to in this instance.
The facility failed to ensure safe storage and handling of medications, with an unlocked medication refrigerator and unmonitored temperature logs since April 2024. Liquid lorazepam was found in the unlocked fridge, and 36 unidentified pills were scattered in a medication cart. An LPN admitted the fridge was left unlocked due to key issues, and the Interim Administrator confirmed the need for locked storage and daily temperature checks.
A facility failed to provide adequate hygiene care for three residents, resulting in deficiencies in their activities of daily living. One resident was hospitalized with poor hygiene, including matted hair and a dirty catheter. Another resident, with multiple medical conditions, reported not receiving scheduled showers, confirmed by gaps in documentation. A third resident, dependent on staff for hygiene, received infrequent bed baths, with incomplete hair washing documentation. The facility's policy required weekly hygiene care, which was not consistently followed.
A resident's wound dressings were not changed as per physician orders, despite family requests. The LPN stated they were waiting for ordered supplies, and the DON assumed the LPN forgot to change the dressing. The TAR lacked documentation of the dressing change, and the care plan did not address the wound.
The facility failed to implement pressure ulcer prevention measures for two residents. One resident with a pressure ulcer on the left heel did not have an offloading boot, contrary to the care plan and physician's orders. Another resident with a deep tissue injury to the right heel had no offloading devices in place, and the care plan lacked interventions for the injury. The facility's policy on pressure ulcer prevention was not followed.
Two residents in an LTC facility received inadequate catheter care, leading to hygiene issues and potential infection risks. One resident's catheter tubing had sediment, and the drainage bag was improperly positioned on the floor. The resident reported not receiving catheter care from staff, and records showed missed care. Another resident was sent to the hospital with a clogged catheter bag and poor hygiene, requiring intervention by hospital staff. The facility failed to follow care plans and policies for catheter maintenance.
A resident with multiple diagnoses left the facility AMA and requested her funds, but the facility failed to refund her Social Security payment within 30 days of discharge. The Business Office Manager and Corporate Director of Accounts Receivable did not ensure the timely closure of the resident's account, leading to financial distress for the resident living in a women's shelter.
The facility failed to assess and document a resident's venous wounds and did not follow up with the resident's physician or adhere to physician orders. This resulted in no wound assessments since January 2024, exposed and bleeding wounds, and an 18-day delay in increasing pain medication. The resident refused prescribed treatments and used cornstarch on her wounds against medical advice.
Insufficient CNA Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was scheduled to provide resident care for all 64 residents in the building, and failed to have enough aides on certain shifts to meet resident needs. The census showed 30 residents on the first floor and 34 on the second floor. Review of the nursing and CNA schedules and timecards showed that on one day a single CNA was the only aide on the first floor from 6 AM through 2 PM, and on another day a single CNA was the only aide on the floor from 6 PM through 10 PM. The facility also did not have a staffing policy and procedure. Residents and staff described delays and difficulty providing basic care when staffing was short. The Resident Council President said staffing shortages were often discussed at monthly resident council meetings. One resident with no cognitive impairment and total dependence for all care, including mechanical lift transfers with 2 assists, said call light response depended on staffing and had taken 30 to 45 minutes at times; the resident also reported going two weeks without a shower and said there were times when only one CNA was on the unit. Another resident, who was dependent for toileting, showers, lower body dressing, and bed mobility and weighed 576 pounds, said it could take 1 to 2 hours to be changed after a bowel movement when only one CNA was working on the second floor. Staff confirmed the staffing problems. A CNA said that when someone called off, the unit was "stuck," and that about once a week they were asked to work with only 2 CNAs on a very heavy floor. An LPN said there were times when only one CNA was scheduled for the first floor, with one CNA often expected to float from the second floor. Another CNA said they had worked by themselves many times on the first floor, where several residents required mechanical lifts and two-person assistance, and said call lights could not be answered on time and baths were missed when the unit was short-handed. The administrator stated the facility typically scheduled 2 to 3 CNAs upstairs and 1 to 2 downstairs on day and evening shifts, and 2 upstairs and 1 downstairs on nights.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for residents who were dependent on staff for bathing assistance. R1 was admitted with diagnoses including COPD, seizures, legal blindness, schizophrenia, and depression, and her MDS showed moderate cognitive impairment with dependence on staff for showering. R2 was admitted with diagnoses including COPD, diabetes, and bipolar disorder, and her MDS showed moderate cognitive impairment with substantial to maximal assistance needed for showering. During interviews, CNAs stated they were unable to complete showers when only two CNAs were assigned to the first floor, and one CNA said R1 and R2 had not received showers for a couple of weeks. R1 stated she was supposed to receive showers on Monday and Friday mornings, but sometimes did not get either shower and had gone an entire week without one. She said staff told her they were too busy and would give a bed bath instead, but it was not the same and did not include washing her hair. R1's shower history showed only three showers over a one-month period, with one refusal documented, despite her stated preference for two showers per week. R2 stated she was supposed to get a shower at least once a week but had not received one in a couple of weeks, and that staff told her the reason was short staffing. On observation, R2's hair appeared greasy and unwashed. The facility policy stated residents would be provided showers as requested or per schedule protocols based on resident safety.
Failure to Provide Ordered Oxycodone Resulting in Uncontrolled Phantom Pain
Penalty
Summary
The facility failed to provide effective pain management to a cognitively intact resident with all four extremities amputated who experienced phantom pain, neuropathy, and back pain. The resident had an active care plan for pain and physician orders for scheduled and PRN pain medications, including Oxycodone 5 mg twice daily. Medication Administration Records (MARs) for January and February showed that the last documented dose of Oxycodone was given at bedtime on 1/31/26, with the next dose not administered until 2/6/26, resulting in 11 missed doses. During this period, the resident reported being without his pain medication for several days, stated he was in a lot of pain rated 10/10, and described his amputation sites as feeling like they were on fire. He reported that Tylenol was given but did not adequately relieve his pain. Record review and staff interviews revealed documentation and medication availability issues that contributed to the missed doses. The February MAR showed that on multiple days the resident did not receive Oxycodone, and one RN acknowledged signing for a dose on 2/2/26 in error when the medication was not actually available. An LPN reported that when she worked on 2/6/26, the resident did not have Oxycodone, and a prior nurse had documented a code indicating the medication was not given. When the LPN attempted to obtain a dose from the medication dispensing machine, pharmacy access was denied pending management notification, and pharmacy records indicated that 60 Oxycodone tablets had been delivered on 1/17/26, with one card of 30 tablets later reported missing by facility leadership. The facility’s pain management policy required assessment, monitoring, and administration of medications as ordered, but the resident did not receive his prescribed Oxycodone for several days, despite ongoing severe pain and the absence of any documented change in the physician’s order.
Misappropriation and Poor Control of Narcotic Medications for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of narcotic medications and to accurately document and safeguard controlled drugs. For one resident with multiple serious diagnoses and quadruple amputations, the controlled drug record for oxycodone 5 mg showed a discrepancy between the documented count and the actual pills on hand, with two tablets unaccounted for and no administration entries explaining the reduction. Later, pharmacy records indicated that two full cards (60 tablets) of oxycodone had been delivered, but the resident had no oxycodone available for several days. The MAR showed doses signed out as given on days when the medication was not available, and one nurse acknowledged signing for a dose in error. The resident reported being without his prescribed pain medication for four days, experiencing severe pain rated 10/10, with amputation sites feeling like they were on fire, and stated he was only given Tylenol during this period. For a second resident, the January MAR documented several administrations of hydromorphone 4 mg by two nurses, but there was no corresponding controlled drug receipt/record/disposition form for reconciliation of these doses. Pharmacy delivery records showed that two cards of hydromorphone 4 mg (60 tablets total) had been delivered in early December, yet the narcotic count sheet for one of the cards was missing. The resident, who was cognitively intact and had multiple complex medical conditions including multiple myeloma and chronic kidney disease, stated he had stopped taking hydromorphone in December and confirmed he did not receive hydromorphone doses in January, despite the MAR entries indicating otherwise. For a third resident with a stage 4 sacral pressure ulcer and severe pain requiring morphine ER, the controlled drug record for morphine sulfate ER 15 mg showed that on one date a nurse signed out two tablets, noted an increased dose to 30 mg, then marked the entry as an error and crossed out the entire line, leaving the count unchanged. The same nurse then documented a single 15 mg tablet at an earlier time that same day, and the card was later destroyed with 19 tablets remaining. A separate controlled drug sheet for morphine ER 30 mg showed a 30 mg dose signed out that same day. Additionally, pharmacy records showed delivery of 60 tablets of hydrocodone/APAP 5-325 mg for this resident, but the facility could not produce any controlled drug receipt records documenting receipt or destruction of these tablets. The facility’s abuse policy defined abuse, including deprivation of necessary goods or services, but did not define misappropriation of resident property.
Failure to Immediately Report Suspected Misappropriation of Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the Illinois Department of Public Health (IDPH) and local law enforcement of suspected misappropriation of a resident’s controlled medication. Record review showed that on 2/2/26 the Administrator (V1) was notified that a resident’s oxycodone could not be refilled by the pharmacy because it would be refilled too soon, prompting concern for a potentially missing card of oxycodone. An internal investigation into unaccounted-for controlled medication was initiated on 2/6/26, and the Administrator was unable to locate the card. Despite this, the facility’s initial report to the IDPH Regional Office was not made until 2/10/26, and local law enforcement was also not notified until 2/10/26. Interviews confirmed that facility leadership recognized the missing oxycodone as misappropriation of resident property and acknowledged that it should have been reported immediately to IDPH and the police. The President of Operations (V5) stated that she was notified on 2/6/26 that the resident’s oxycodone was missing and that it was considered misappropriation, yet it was not reported at that time. The Administrator later stated that theft is to be reported immediately to IDPH and the police. The facility’s Abuse Prevention Program policy, dated 10/2023, requires contacting local law enforcement when there is reasonable suspicion that a crime has been committed in the facility by a person other than a resident. These findings show that, although there was reasonable suspicion of drug diversion and misappropriation of a resident’s oxycodone, the required immediate notifications to IDPH and law enforcement were delayed.
Failure to Accurately Account for and Document Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate receipt, documentation, administration, and reconciliation of controlled substances for multiple residents. For one resident with extensive medical conditions including COPD, major depressive disorder, alcohol abuse, diabetes, traumatic lower leg amputation, and malnutrition, the pharmacy manifest showed two cards of Oxycontin 5 mg (30 tablets each) were delivered, but one card and its corresponding controlled drug receipt/record/disposition form were missing. The President of Operations confirmed that card one and sheet two for this Oxycontin order could not be located and acknowledged that extra medications from the cart had been stored in a medication cupboard that was not included in shift-change narcotic counts. For the same resident, controlled drug forms for Oxycodone 5 mg tablets showed numerous doses subtracted as given on specific dates and times, but these administrations were not documented on the resident’s MAR. For a second resident receiving hydromorphone HCL 4 mg tablets, the November controlled drug receipt/record/disposition form indicated two cards of 30 tablets each were delivered, but only one card’s form was present. On that form, six doses were signed out as administered on specific dates and times, yet these doses were not documented on the November MAR. Additional hydromorphone deliveries in December and January were documented on manifests, but the facility lacked controlled drug receipt/record/disposition forms for several of the cards delivered, and for some periods there were hydromorphone doses signed out on the controlled drug forms that were not recorded on the MAR. The President of Operations stated that pharmacy did not reconcile narcotics beyond current medications, that clinical managers such as the DON were expected to perform random monthly audits comparing manifests, narcotic sheets, and MARs, and that no records of such audits were available. For a third resident admitted with multiple diagnoses including a stage 4 sacral pressure ulcer, the December MAR showed an order for Morphine Sulfate ER 15 mg twice daily that was discontinued and later replaced with Morphine Sulfate ER 30 mg three times daily. The controlled drug receipt/record/disposition form for Morphine Sulfate ER 15 mg documented 30 tablets dispensed, and on one date a nurse signed out two tablets at 9:00 AM, noted an increase from 15 mg to 30 mg, and then crossed out the entire line as an error, leaving the count at 20, followed by signing out one tablet at 7:00 AM and ultimately destroying the card with 19 tablets. The 30 mg morphine controlled drug sheet showed an additional tablet signed out at 9:00 AM the same day. The President of Operations stated that controlled medications should not be signed out after discontinuation. Additionally, the manifest showed two cards (60 tablets total) of Hydrocodone/APAP 5-325 mg delivered for this resident, but the facility could not provide any controlled drug receipt records documenting receipt or destruction of these tablets.
Failure to Control Resident Substance Use and Reassess Community Pass Privileges
Penalty
Summary
The deficiency involves the facility’s failure to prevent and supervise a resident from ingesting cannabis and to reassess another resident’s community pass privileges for safety. A posted safety and security notice at the reception desk stated that personal items may be inspected when there is reasonable cause for concern about prohibited or unsafe items such as illegal substances and contraband. One resident (R1) had diagnoses including seizures, schizoaffective bipolar disorder, post-traumatic stress disorder, suicidal ideations, prior poisoning by unspecified drugs with intentional self-harm, unspecified mood disorder, and epilepsy, as well as a known history of substance abuse and prior positive THC screens. Hospital records from a recent transfer documented that R1 appeared more confused, was slurring her words, and had a urine toxicology screen positive for marijuana; R1 reported she may have taken “gummies or something” and later told surveyors she was getting gummies from another resident (R2). R1’s current care plan did not include her history of substance abuse. Staff interviews showed that CNAs were aware of rumors of residents using illegal substances in the facility but had not personally observed contraband, and management had not discussed the posted contraband sign with them. Nursing staff reported that on the day of R1’s hospital transfer, she was very lethargic and not acting like herself, leading to her being sent out and again testing positive for THC, with uncertainty about how she obtained the substance. The DON acknowledged R1’s history of substance abuse and prior positive THC tests but stated she was not sure how R1 was getting the substance and was not aware of residents using substances in the facility. The Administrator stated that R1 reported getting gummies from another resident, while that resident denied providing them. Staff also reported that R1 frequently attempted to go into R2’s room without a clinical reason, and nursing staff redirected her back to her own room. The facility also failed to reassess and manage community pass privileges for R2 despite documented concerns about substance use. R2 had diagnoses including unspecified cirrhosis of the liver, alcohol abuse, insomnia, and major depressive disorder, and his record showed an order for a urine drug screen that was never completed because he was either out of the building or unable to provide a specimen. R2’s community survival skills assessment indicated he was capable of outside pass privileges, and he reported going out independently, consuming alcohol on occasion when out, and being able to leave when he pleased. Staff, including a CNA and an RN, stated that R2 “does his own thing,” leaves the facility when he wants, and that they had heard he goes to bars and drinks. The DON stated R2 was independent and did not need supervision, and social services reported that residents who violate pass standards should lose independent pass privileges but was not aware of R2 using substances. A psych NP documented that R2 had a history of alcohol abuse, was currently using illicit substances such as alcohol and possibly cocaine, refused urine drug screening, was refusing antipsychotic medication, and might be using substances during community passes. The facility’s community pass policy stated that using alcohol or illicit substances or bringing them into the facility is prohibited and may result in forfeiture of pass privileges, and that the facility reserves the right to revoke passes if a resident is assessed as a threat to self or others.
Failure to Provide and Document Discharge Planning Social Services
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services and discharge planning for two residents who expressed or required consideration for alternative placement. One resident with a history of seizures, schizoaffective bipolar disorder, PTSD, suicidal ideation, intentional self-harm, mood disorder, and epilepsy stated she wanted to be discharged to a setting similar to her prior residential group home. She reported that social services were trying to find a place for her but had not informed her of the status, and that social services staff told her no one would accept her if she was lying. The social services worker confirmed the resident had lost her apartment during the facility stay, that the prior group home refused readmission without giving a reason, and that developmental disability homes indicated they could accept the resident when she was able to walk, noting she had recently started walking. The psych NP and RN both stated the resident would benefit from a setting specializing in mental health services with peers her own age, and the RN noted staff were not trained to care for psychiatric residents. Despite a care plan stating that discharge planning should be continually assessed and that social services would assist in finding a group setting, social service notes from September through late January contained no documentation of discharge planning or contacts with group homes or facilities for placement. The second resident was admitted from an acute care hospital with cirrhosis, alcohol abuse, restless leg syndrome, insomnia, and major depressive disorder, and reported being independent with care and ambulation. He stated there had been discussion about finding alternative placement, while social services reported that the plan was for him to remain at the facility and that he became defensive when asked about discharge planning, confirming he was independent and not receiving therapy. The administrator described him as a young male resident who goes out on pass independently and stated he was at peace and complacent at the facility but had nowhere else to go. Social service documentation described him as alert, oriented, able to communicate needs, ambulating independently with a walker, a smoker, and having an independent community pass. However, social service notes from November through January contained no documentation of discharge planning, and the regional nurse consultant confirmed there was no documentation of discharge planning or attempts to find alternative placement for either resident, despite facility policy requiring social work involvement in assessing discharge potential, documenting significant discharge information, and coordinating community services.
Failure to Monitor and Maintain Food Temperatures Leading to Ongoing Resident Complaints
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable and safe temperatures by not consistently taking and documenting cooking and serving temperatures for multiple meals. Review of kitchen food temperature logs on January 20, 2026 showed that no food temperatures were recorded for all three meals on January 8, for breakfast and lunch on January 9–11, for supper on January 12, for all three meals on January 13, for breakfast and lunch on January 14, for all three meals on January 15, and for breakfast and lunch on January 16–17. Both cooking and serving temperatures were missing on these dates. The facility census data indicated 65 residents, with corporate staff clarifying that one resident did not eat food from the facility kitchen, leaving 64 residents potentially affected. The Dietary Manager stated that food temperatures should be taken when food is cooked and again right before serving, and that staff should log these temperatures as they are taken. Residents reported concerns about food quality and temperature. One resident stated that the food is always cold when served. Another resident reported that the food is not good, orders out often because the food is bad, and that the food is cold most of the time, depending on when the meal is received. A third resident reported that some meals are good and some are not, and that hot food is sometimes served cold. The Dietary Manager described that food trays are delivered on an open metal cart covered with a cloth, without heated plates, closed carts, or any heating apparatus to keep food warm during delivery, and acknowledged that such equipment would be helpful to keep food warm. Resident Council minutes from October and December 2025 documented ongoing complaints under “Dietary old business,” including that residents wanted to keep the issue of cold food open, reported that coffee is cold at times, and that condiments are not always provided on meal trays.
Failure to Document Food Cooking and Serving Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that final cooking and serving temperatures of food were taken and documented in accordance with its own food safety policy. Review of kitchen food temperature logs on January 20, 2026 showed that no food temperatures were recorded for all three meals on multiple dates, including January 8, 13, and 15, and for breakfast and lunch on January 9–11, 14, 16, and 17, as well as supper on January 12. Both cooking temperatures and serving temperatures were missing for these meals. At the time of the survey, the facility census data sheet showed 65 residents in the facility, with corporate staff indicating that one resident did not eat food from the facility kitchen, leaving 64 residents potentially affected. During an interview, the Dietary Manager stated that food temperatures are supposed to be taken when food is finished cooking and again immediately before serving, and that these temperatures should be logged as they are taken. The facility’s written policy on Food Safety and Sanitation: General Preparation and Cooking Practices, revised September 18, 2023, states that the facility will follow sanitary practices in food preparation and cooking, including maintaining hot food at a minimum of 135°F on the steam table and prior to service, and reheating food to 165°F if it falls below 135°F. The absence of documented cooking and serving temperatures on the identified dates shows that these required practices were not followed or recorded as required by facility policy.
Failure to Maintain Safe Bed Rail and Wheelchair Equipment for Two Residents
Penalty
Summary
The facility failed to maintain resident equipment in safe working order for two cognitively intact residents. One resident, admitted with chronic respiratory failure, venous insufficiency, lymphedema, morbid obesity, fluid overload, cellulitis of the right lower limb, bed confinement, and a stage 4 sacral pressure injury, reported that the right siderail on his bed was loose. During observation, the siderail moved side to side when the resident manipulated it, and he stated he needed the siderails to roll from side to side. He reported having notified the facility about this problem about a week earlier, but it had not been fixed at the time of the surveyor’s observation. Another resident, admitted with type II DM, chronic kidney disease, anemia, restless legs syndrome, adjustment insomnia, glaucoma, and an acquired absence of the right leg below the knee, reported waiting for maintenance to fix the right armrest on his wheelchair. Observation showed the right armrest’s cushioned piece was hanging off the back by about 5–6 inches, exposing metal underneath, and the resident had a scrape on his right forearm, which he attributed to using his arms to propel the wheelchair. The left armrest lacked a cushioned piece. The resident stated he had reported this concern a couple of weeks earlier. The Maintenance Director stated the facility does not use work orders or track when repairs are requested or completed, acknowledged awareness of the loose siderail and the armrest concern, and indicated he was waiting for a replacement armrest. The facility’s Preventative Maintenance Program Policy requires that resident equipment, including bed rails, be in working order during environmental and safety audits.
Misappropriation of Resident Jewelry
Penalty
Summary
The facility failed to ensure that one resident was free from misappropriation of property when the resident’s ring went missing. The resident stated she woke up one morning and noticed her ring was gone, and she pointed to a visible indentation and lighter-colored skin on her left ring finger where the ring had been worn. She said the ring was tight-fitting, had never been removed, and was a large yellow gold ring with numerous diamonds, including two large diamonds. She also stated that she was very upset and told the first person who entered the room when she discovered it missing. The resident’s roommate said the resident always wore the ring and that she and another resident had seen it at meals. The other resident said the resident wore a wedding band on her left hand and told them at breakfast that the ring was missing; she also said housekeeping was looking for it. The resident’s sister and power of attorney stated the resident had the ring when she came to the facility from the hospital, and the resident’s daughter confirmed on a later visit that the ring was still on her finger. The resident’s inventory of personal effects listed one ring, and the facility’s Abuse Prevention Policy stated residents have the right to be free from misappropriation of property.
Failure to Report Missing Resident Property
Penalty
Summary
The facility failed to follow its Abuse Policy when a resident reported a missing ring and the loss was not immediately reported to the administrator or an immediate supervisor. The resident stated she woke up and found her ring missing, described it as a large yellow gold ring with numerous diamonds, and said she had always worn it and never took it off. She pointed to an indentation and lighter-colored skin on her left ring finger where the ring had been worn. Her roommate and another resident both stated they had seen the resident wearing the ring regularly, including at meals, and the roommate said the resident came to breakfast and reported the ring missing. A housekeeping manager said the resident told her the ring was missing and that she searched under the bed, in the wheelchair, and in the resident’s pajama pants, and asked another housekeeper to strip the bed and look in the covers, but she did not report the missing ring to anyone even though she said she should have. A CNA said the resident told her about the missing ring and that she told the nurse on duty and discussed it with another CNA. The administrator stated she first became aware of the missing ring when the resident’s POA and nephew reported it to her, and she stated staff are to report a resident’s missing item right away to the administrator or supervisor according to the abuse policy. The facility policy required employees to report any incident, allegation, or suspicion of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property immediately to the administrator or to an immediate supervisor who must then immediately report it to the administrator.
Failure to Immediately Report Missing Resident Ring
Penalty
Summary
The facility failed to ensure an allegation of misappropriation of resident property was reported immediately for one resident who reported that her ring was missing. The resident stated she woke up and noticed the ring was gone, pointed to an indentation and lighter-colored area on her left ring finger where the ring had been worn, and said it was a tight-fitting yellow gold ring with numerous diamonds, including two large diamonds. She said she was very upset, had never taken the ring off, and told the first person who came into her room when she noticed it was missing. Other residents and staff confirmed the resident regularly wore the ring and that she reported it missing while at breakfast. Her roommate said the resident always wore the ring and that both she and another resident had seen it at meals. A housekeeping manager said the resident told her the ring was missing and that she searched the room but did not report the missing ring to anyone, stating she should have. A CNA said the resident told her about the missing ring and that she told the nurse on duty at the time. The administrator stated she first became aware of the missing ring when the resident's POA and nephew reported it to her, and the facility policy required employees to report any suspected misappropriation of resident property immediately to the administrator or an immediate supervisor.
Failure to Maintain Safe Walkway Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that a resident's walkway path in her room was free from accident hazards, resulting in a fall and injury. One resident, who was at moderate risk for falls due to a history of falls, balance problems, and use of an assistive device, attempted to walk through her room using a walker. At the time, her roommate had several visitors, and the visitors were sitting in chairs across the roommate's bed, creating a crowded and cluttered environment with limited walking space. As the resident tried to navigate the narrow space, she tripped and fell. Following the fall, the resident sustained a left ankle and foot fracture, requiring her to be non-weight bearing on her left leg. Interviews with staff, including an LPN and the DON, confirmed that the room was overcrowded and did not provide enough space for safe ambulation. The resident's care plan identified her fall risk and included interventions such as proper footwear, use of a walker, and keeping the call light within reach, as well as ensuring her room was free from safety hazards and clutter. Despite these interventions, the environmental hazard of overcrowding was not addressed at the time of the incident.
Failure to Maintain Hand Hygiene and Sanitation in Food Service
Penalty
Summary
The facility failed to ensure proper hand hygiene and sanitation practices in the kitchen, as observed during food preparation and service. A cook was seen handling raw chicken with gloved hands and, without changing gloves or washing hands, proceeded to touch a seasoning container and a sheet pan, only removing the soiled gloves and washing hands after these tasks. The Food Service Director confirmed that gloves should be changed and hands washed when switching tasks or after handling raw meat, in accordance with the facility's handwashing policy. Additionally, another cook was observed using a thermometer to check food temperatures, rinsing it under water between different food items without using a sanitizing wipe or rag, as required by facility policy. Sanitizing wipes were not available at the prep table during this process. Further, the meat slicer on the prep counter was found uncovered and had caked-on food debris behind the blade and on the housing. The Food Service Director was unsure if the blade was removable for cleaning and stated that the machine did not come with a specific cover. The facility's policy requires all preparation and serving equipment to be cleaned and sanitized after contact with raw foods to prevent cross-contamination. These failures in hand hygiene, equipment cleaning, and sanitization have the potential to affect all residents receiving food from the kitchen, except for two residents on NPO orders.
Failure to Update PASRR Referrals for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that residents with new diagnoses of mental health disorders were referred to the state-designated authority for Pre-admission Screening and Resident Review (PASRR) as required. Specifically, four residents were identified who had new or updated mental health diagnoses, such as schizophrenia, major depressive disorder, schizoaffective disorder, and insomnia, after their initial admission and original PASRR screenings. Despite these new diagnoses, there was no evidence that updated PASRR screenings or referrals were completed for these residents. Interviews with the facility liaison confirmed that these omissions were discovered during an audit, and the liaison was previously unaware that new diagnoses required updated PASRR referrals. Record reviews showed that the original PASRR or OBRA screens for these residents did not reflect their subsequent mental health diagnoses. For example, one resident was prescribed antipsychotic medication following reports of aggressive behavior and mood swings, and another had a diagnosis of schizophrenia added years after admission, yet neither had an updated PASRR. The facility's PASRR policy also lacked guidance on updating screenings when new qualifying diagnoses are identified.
Failure to Adhere to Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols for residents on Enhanced Barrier Precautions (EBP). In one instance, a CNA entered a resident's room, applied gloves, assisted the resident, removed gloves, and then transported the resident to the dining room without performing hand hygiene before or after glove use. The same CNA then handled another resident's meal tray and proceeded to provide care to a different resident, again without performing hand hygiene. Facility policy requires hand hygiene before and after glove use and after contact with inanimate objects in the resident's vicinity. Additionally, staff did not properly use or remove personal protective equipment (PPE) as required for residents on EBP. One CNA exited a resident's room while still wearing PPE, retrieved a blanket from the hallway, and re-entered the room, contrary to facility policy that mandates removal of PPE before exiting the room. In another case, two CNAs provided perineal care to a resident with multiple chronic wounds while only wearing gloves and not gowns, despite policy requiring both gown and gloves for high-contact care activities for residents on EBP. Interviews with staff and review of facility policies confirmed these practices were not in accordance with established infection control procedures.
Failure to Provide Privacy Covering for Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain resident dignity by not providing a privacy covering for a urinary catheter bag for one resident. On two separate occasions, the resident's catheter bag was observed without a privacy covering: once when the resident was transferred to a wheelchair and brought into the dining room with other residents present, and again when the resident was lying in bed with the catheter bag visible from the hallway. Interviews with CNAs and the Director of Nursing confirmed that facility policy requires the use of dignity bags for urinary catheter bags, especially when residents are in public areas or when the bag is visible from the hallway. The facility's own dignity policy includes the use of privacy coverings for urinary catheter bags as an example of promoting dignity and respect.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medications, as required by policy and physician oversight. One resident, who had diagnoses including Alzheimer's disease, dementia, COPD, chronic respiratory failure, schizoaffective disorder, chronic hepatic failure, scoliosis, and pneumonia, was observed with multiple medications and supplements at his bedside. These included an albuterol inhaler, fluticasone inhaler, beet root supplement, and diclofenac cream. The resident reported self-administering these medications as needed or as part of his routine. However, the physician's order sheet did not include an order for the beet root supplement, nor did it document any authorization for the resident to self-administer any medications. Interviews with facility staff confirmed that there was no assessment conducted to determine the resident's ability to safely self-administer medications, and no physician order was obtained to permit self-administration. The resident's care plan also lacked documentation regarding self-administration. Facility policy requires an assessment and physician approval before a resident may self-administer medications, with appropriate documentation in the care plan and medication record. These steps were not followed for this resident, resulting in a deficiency.
Failure to Document DNR Order per Advanced Directives Policy
Penalty
Summary
The facility failed to follow its advanced directives policy by not obtaining a physician's order for Do Not Resuscitate (DNR) for one resident who had indicated a preference for DNR status. The resident's Do-Not Resuscitate/Practitioner Orders for Life-Sustaining Treatment (POLST) form, dated several years prior, clearly documented the resident's wish to not have cardiopulmonary resuscitation attempted. However, a review of the resident's current Physician's Order Sheet did not show any documentation of a DNR order. During an interview, a registered nurse explained that the standard procedure involves social services discussing code status with the resident upon admission, completing the necessary forms, and obtaining signatures from both the resident and physician before entering the order into the electronic medical record. Upon reviewing the resident's electronic record, the nurse confirmed that there was no DNR order present and nothing indicating the resident's code status in the system. The facility's policy requires that advance directive information be added to the Physician Order Sheet, but this was not done for the resident in question.
Failure to Accurately Reflect Developmental Disability in PASARR Screening
Penalty
Summary
The facility failed to ensure that the required Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected a resident's possible or suspected developmental disability. One resident, a 33-year-old female, was observed to be very childlike, expressed confusion about her placement, and had a documented history of developmental delay and mild cognitive impairment. Despite these observations and documentation from the emergency room physician indicating a developmental delay and behavior significantly younger than her stated age, the PASARR Level I screening completed at admission indicated that there was no diagnosis or suspicion of intellectual disability. The facility relied on the PASARR completed by the hospital and did not conduct further assessment or question the findings, even though the resident's records and observed behavior suggested otherwise. The facility's policy requires review of PASARR documents to assess resident needs, but in this case, the documentation and observations indicating a developmental disability were not reflected in the PASARR screening outcome.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident admitted with a history of falls, pneumonia, myocardial infarction type 2, and nonrheumatic aortic valve stenosis was observed to have unkempt, oily hair and overgrown facial hair. The resident reported feeling weak, unable to walk or stand independently, and stated that he had not been offered a shower since admission. Staff interviews confirmed that residents are scheduled to receive weekly showers, with a shower schedule indicating the resident's designated shower day. Documentation showed the resident refused a shower on one occasion, but was not offered another shower until 12 days later. The facility's policy on activities of daily living did not specify shower frequency. The administrator confirmed the resident did not receive a weekly shower as required.
Failure to Implement Pressure Ulcer Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate pressure ulcer prevention interventions for residents identified as at risk for pressure ulcers. For one resident, the Braden Scale indicated risk, and physician orders required heel protectors on both feet while in bed. However, observations showed the resident only had a heel protector on the left foot and was placed on an air mattress with a fitted sheet, which is not recommended as it can interfere with the mattress's function. The air mattress was also set to 'firm, normal pressure' rather than being adjusted to the resident's weight as required. The care plan for this resident included repositioning every two hours, use of pillows, heel protectors, and a specialty mattress, but these interventions were not consistently implemented as observed by surveyors. For another resident at risk for pressure ulcers, physician orders specified the use of a pressure reduction mattress. Observations revealed the resident was on an air mattress with a fitted sheet and the mattress was set to the maximum weight setting, which did not correspond to the resident's actual weight. Staff interviews indicated a lack of understanding regarding proper mattress settings and sheet usage, with some staff believing fitted sheets were acceptable and that mattress settings did not need adjustment. The care plan for this resident included use of a pressure-reducing mattress and wheelchair cushion, but the interventions were not properly individualized or implemented according to the resident's needs and manufacturer guidelines.
Failure to Maintain Proper Positioning of Catheter Drainage Bag and Tubing
Penalty
Summary
A resident with multiple sclerosis, hypertension, neuromuscular dysfunction of the bladder, and emphysema, who has an indwelling urinary catheter and a recent history of urinary tract infection, was observed on multiple occasions with his catheter drainage tubing and urinary drainage bag either dragging on the floor or resting on the floor beneath his wheelchair. Staff interviews confirmed that the drainage bag and tubing should not be in contact with the floor, and that the dignity bag straps had to be re-secured because they were not properly attached. The facility's catheter care policy requires that urinary drainage bags and tubing be positioned to prevent them from touching the floor, but this was not followed in the resident's care.
Failure to Ensure Safe and Ordered Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents requiring oxygen therapy. For one resident with chronic respiratory failure, COPD, and pneumonia, oxygen was administered via nasal cannula without a physician's order, and the oxygen tubing in use was not changed according to the facility's policy, as evidenced by tubing dated several weeks prior. The resident's medical record did not contain any physician's order for oxygen administration or tubing changes, contrary to facility policy requiring such orders and weekly tubing changes. For another resident, the oxygen nasal cannula was not properly in place, and the resident was observed to be out of breath and self-administered an inhaler. The oxygen concentrator's humidifying jar was found empty during one observation, and only later was it refilled. Staff interviews confirmed that nurses are responsible for checking and refilling humidifying jars, and that humidifying jars should not be empty while in use. Facility policy also requires that the humidifying jar contains enough water to bubble as oxygen flows through, which was not consistently maintained.
Failure to Assess and Document Change in Condition for Diabetic Resident
Penalty
Summary
A resident with multiple diagnoses, including COPD, dementia, atrial fibrillation, heart failure, and diabetes, experienced increased lethargy while admitted to the facility. On the day of the incident, a nurse documented the resident's lethargy and attributed it to a urinary tract infection for which the resident was being treated. However, the nurse did not document any vital signs, blood sugar checks, or a complete head-to-toe assessment at that time. The resident was subsequently sent to the hospital via 911, but the transfer assessment only included vital signs from the previous day, and there was no documentation of a current blood sugar measurement or comprehensive assessment. Interviews with staff revealed uncertainty about whether vital signs or blood sugar were checked at the time of the change in condition, with the last documented blood sugar recorded several days prior. The facility's policy requires appropriate assessment and documentation when a resident experiences a change in condition, but this was not followed. The Director of Nursing confirmed that lethargy in a diabetic resident should prompt a blood sugar check and a thorough assessment, neither of which were documented in the resident's electronic health record.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for residents who were dependent on staff assistance, as observed in three residents. One resident, admitted with conditions including diarrhea and a sacral pressure ulcer, required substantial assistance for toileting hygiene. Despite activating the call light after a bowel movement, the resident was left waiting for nearly an hour before being attended to, during which time they were served lunch while still soiled. The CNAs assigned to the resident's care were occupied with other tasks and did not prioritize the resident's hygiene needs, despite the resident's expressed discomfort and the facility's policy on maintaining personal hygiene. Another resident, with diagnoses including diabetes and kidney failure, reported frequent urination due to a medical condition requiring high fluid intake. This resident experienced delays in staff response to call lights, particularly during shift changes, resulting in the resident urinating in their brief instead of using the bathroom. The resident expressed frustration over the long wait times, which sometimes exceeded an hour, impacting their ability to maintain personal hygiene and dignity. A third resident, with a stage four pressure ulcer and bladder dysfunction, also experienced significant delays in receiving incontinence care. This resident reported waiting up to 11 hours for staff assistance after a bowel movement, with staff turning off the call light and failing to return. The resident expressed understanding of the staff's workload but noted the standard wait time for assistance was typically an hour. The facility's Director of Nursing acknowledged the importance of timely incontinence care, especially for residents with pressure sores, but no staff sought additional help during the observed incidents.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to accurately transcribe a resident's hospital discharge medication list and did not follow a physician's medication order for narcotics, as well as their policy for controlled substances. A resident, who was admitted with chronic obstructive pulmonary disease (COPD), did not have an order for albuterol nebulizer transcribed into their Medication Administration Record (MAR) despite it being listed on the hospital discharge medication list. The Director of Nursing acknowledged that the albuterol nebulizer was likely overlooked and not entered into the resident's medications for the facility, which is used to treat shortness of breath and wheezing. Additionally, there was a discrepancy in the administration of hydrocodone/acetaminophen (Norco) for the same resident. The Controlled Drug Receipt/Record/Disposition Form showed that three doses of Norco were dispensed within a 10-hour period, while only two doses should have been given according to the physician's orders. The Director of Nursing confirmed that the 8:00 AM dose on 3/6/25 was administered too soon and that controlled substances should be documented on both the MAR and the count sheet, as per the facility's policy.
Facility Fails to Provide Correct Portion Size for Burgers
Penalty
Summary
The facility failed to adhere to its menu requirements by serving hamburgers that did not meet the specified portion size of 2 ounces of protein. This deficiency was observed during a lunch meal where the burgers appeared small and shrunken. The Registered Dietitian (V5) and Certified Dietary Manager (V4) both confirmed that the burgers should be 2 ounces, and it was noted that the cook (V6) estimated the size of the burgers rather than measuring them. A test patty was weighed and found to be less than 2 ounces, confirming the deficiency. Residents expressed dissatisfaction with the portion size, with one resident sarcastically commenting on the size of the burger and others noting that the burgers were small. The facility's menu for the day specified a cheeseburger with 2 ounces of protein, and the Tray Accuracy Policy and Procedure required adherence to specified portions. The failure to follow the menu and provide the correct portion size affected the majority of residents receiving a regular diet, as 83.8% of the facility's residents were on a regular diet texture.
Failure to Serve Correct Menu Items and Portion Sizes
Penalty
Summary
The facility failed to serve the correct menu items and portion sizes for residents on mechanical soft and pureed diets, potentially affecting 63 of the 64 residents. The dietary manager, V4, was observed slicing turkey in random portions without knowledge of the required portion sizes. Additionally, the cook, V6, prepared instant mashed potatoes instead of the prescribed mashed sweet potatoes due to time constraints and did not measure the portions for pureed meals, instead splitting them between the two residents receiving pureed diets. This resulted in all residents on mechanical soft diets receiving mashed potatoes instead of skinned sweet potatoes. The facility's daily spreadsheet outlined specific portion sizes and menu items, which were not adhered to during meal preparation and service. V4 and V6 admitted to not following the menu due to time constraints and a lack of awareness regarding portion sizes, leading to inconsistencies in the meals served. The facility was unable to provide a policy regarding adherence to menu items and portion sizes, further contributing to the deficiency.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper sanitation and food storage practices in the kitchen, which could potentially affect 63 of the 64 residents. During an initial tour, surveyors observed several issues, including a split-open bulk bag of sugar, crusted substances on beef and chicken base containers, and scoops improperly stored inside these containers. The floors beneath the dry storage area were littered with crumbs and cereal, and several bulk food items, such as pinto beans and bread crumbs, were found opened. Additionally, cooler doors had dried, crusted substances, and the walk-in freezer contained small puddles of dried, melted ice cream. Further inspection revealed that the dishwasher was cluttered with a screwdriver, random parts, dust, and crumbs, and the sanitizer levels were below the required 50ppm. A dietary aide was unable to check the sanitizer levels despite having documented them as correct earlier. The dietary manager admitted to not having a set cleaning schedule and was unaware of the issues with open bags and containers, which could attract pests. The facility's policy on food storage emphasized the need to protect food from contamination and maintain cleanliness, but these standards were not met.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for residents during meal times. On November 13, 2024, it was observed that residents were served their meals on trays in the dining room, without the items being removed and placed on the table. This practice was noted for five residents within the sample and five residents outside the sample. Residents expressed dissatisfaction, stating that being served on trays made them feel like they were in an institution rather than a home. One resident specifically mentioned that while they did not mind meals being brought on trays, they preferred the items to be placed on the table to create a more homelike atmosphere. Interviews with staff revealed that the practice of serving meals on trays without removing items was due to management's instructions. A Certified Nursing Assistant acknowledged that removing items from trays would create a more homelike environment but stated that they were not allowed to make such decisions. The Interim Administrator confirmed that the facility had considered changing this practice and offering residents the option to have their meals served in a more homelike manner, but no changes had been implemented yet. The facility's policy on dignity emphasized caring for residents in a manner that promotes quality of life, dignity, respect, and individuality.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to prepare and serve a mechanical soft diet to residents who required it, affecting three residents within the sample and seven additional residents outside the sample. The facility's documentation indicated that these residents were prescribed a mechanical soft diet, which requires food to be ground or chopped to a specific consistency to accommodate individuals with limited or difficulty in chewing regular textured foods. However, during an observation, it was noted that the cook did not prepare the mechanical soft food as required. Instead, the cook shredded turkey by hand, believing it was already soft enough, and served it with mashed potatoes and gravy. The dietary manager admitted to not following the prescribed diet preparation, stating that hand-shredding the turkey was easier and saved time. The manager also expressed uncertainty about the impact of not providing the correct diet, as they were not part of the nursing department. Additionally, the manager mentioned that residents sometimes complained about the ground diet, so they attempted to accommodate their preferences without understanding the medical necessity of the prescribed diet. The interim administrator acknowledged the risk of choking if residents received the incorrect diet, highlighting the potential danger of the facility's failure to adhere to dietary prescriptions.
Infection Control Deficiencies in PPE and Precaution Protocols
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically regarding contact isolation and enhanced barrier precautions for several residents. Resident R214 was admitted with a diagnosis of enterocolitis due to Clostridium difficile (C-diff) and had orders for contact precautions. However, staff frequently entered R214's room without wearing personal protective equipment (PPE), and the signage on the door incorrectly indicated enhanced barrier precautions instead of contact isolation. Despite the facility's policy requiring gowns and gloves for contact precautions, staff were observed not following these protocols, and there was confusion among staff about R214's C-diff status. Resident R57, who had a urinary drainage catheter, was supposed to be on enhanced barrier precautions, which require gown and gloves during high-contact care activities. However, staff were observed providing care without wearing the necessary PPE. Similarly, Resident R38, who had a suprapubic catheter, did not have enhanced barrier precautions in place, and staff were unaware of the need for such precautions. The facility's policy clearly outlines the need for gown and gloves during high-contact activities, but this was not implemented for R38. Additionally, Resident R52, who had a dressing on her ankle, and Resident R17, who had a gastrostomy tube, were also not provided with the required enhanced barrier precautions. Staff were observed providing care without the necessary PPE, and there was a lack of signage and PPE availability outside their rooms. The facility's failure to implement these precautions as per their policy indicates a significant lapse in infection control practices, potentially putting residents and staff at risk of infection transmission.
Deficiencies in Wound Care and Change of Condition Documentation
Penalty
Summary
The facility failed to provide appropriate wound care for a resident, R52, who had an arterial wound on the right medial ankle. The wound care physician's note dated 11/11/24 indicated a treatment plan requiring daily application of santyl ointment and dressing changes. However, the Treatment Administration Record (TAR) was not updated to reflect these new orders, and the resident did not receive the necessary daily dressing change on 11/12/24. The error was only corrected after facility staff were notified. The resident's care plan also lacked documentation for the vascular wound, despite the resident's history of venous ulcers and other comorbidities. Another deficiency involved resident R23, who was sent to the emergency room on two occasions without proper documentation or notification of the physician and family. On 8/6/24, there were no nursing notes or assessments recorded when the resident was sent out. Similarly, on 10/29/24, the resident was sent to the ER for severe pain without any documented assessment or notification to the physician and family. The facility's policy requires thorough documentation of any change in condition, including vital signs, symptoms, and notifications, which was not followed in these instances. The facility's failure to adhere to its own policies and procedures for wound care and change in condition documentation resulted in deficiencies in the quality of care provided to the residents. The lack of proper documentation and communication with the physician and family could have impacted the continuity of care and the residents' overall well-being.
Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to transfer a resident, identified as R25, in a safe manner. R25, who has moderate cognitive impairment and requires substantial assistance with transfers, was observed being lifted by two CNAs, V14 and V15, without proper use of a gait belt. Instead, they lifted R25 under her arms and by her pants, which is against the facility's policy and could potentially cause injury. The CNAs admitted that R25 dislikes the gait belt, leading them to use her pants for support. The Director of Nursing confirmed that lifting residents under their arms is not safe and that therapy staff should be consulted for safer transfer methods. Another deficiency involved a resident, R52, who was not adequately supervised while ambulating. R52, who has a history of falls and requires extensive assistance, was found walking unassisted to the nurse's station and later in the common area without a gait belt. The CNAs involved, V10 and V11, acknowledged that R52 should not be walking alone and requires assistance. Despite this, R52's care plan was not updated following a fall on 9/27/24, and the necessary precautions were not implemented to prevent further incidents. The facility's policies on fall prevention and care plan updates were not adhered to, as evidenced by the lack of updated interventions in R52's care plan after her fall. The Director of Nursing acknowledged the oversight and the need for increased supervision and appropriate use of assistive devices for R52. The facility's failure to follow its own policies and provide adequate supervision and safe transfer methods contributed to the deficiencies identified in the report.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with a suprapubic catheter. Observations revealed that the resident had a thin, improperly cut 4 x 4 dressing around the catheter, which was not secured with tape. The resident reported that the dressing was changed only once a week, and the catheter tubing was cleaned with the same frequency. Additionally, the catheter tubing secure device was not in use, despite being available in the resident's room. The resident expressed willingness to have the secure device applied, but it was not being utilized. Interviews with facility staff, including an LPN and the DON, confirmed that catheter care should be performed daily, and the secure device should be used to prevent trauma and tension. The facility's catheter care policy also mandates daily dressing changes and securing of the catheter. The resident's care plan and medication review report indicated a need for daily dressing application and catheter care every shift, which was not being adhered to, leading to the deficiency.
Failure to Implement Dietary Interventions for Resident with Weight Loss
Penalty
Summary
The facility failed to implement dietary interventions for a resident, identified as R3, who experienced significant weight loss. R3 was admitted with multiple diagnoses, including paranoid schizophrenia and mood disorder, and was on a weekly weight monitoring plan. Despite having dietary supplements ordered, such as fortified potatoes and ready care shakes, these were not provided during meals. Observations on two consecutive days showed that R3's lunch trays did not include the prescribed fortified potatoes, and the dietary manager admitted that they do not serve them, despite knowing residents are supposed to receive them. The facility's policy requires monitoring for undesirable weight changes and implementing timely interventions, which was not adhered to in R3's case. The registered dietician confirmed that the kitchen has recipes for fortified potatoes, and the Director of Nursing expected the kitchen to serve dietary supplements as ordered. However, the failure to provide these supplements contributed to R3's continued weight loss, as evidenced by a 42-pound decrease over 11 months.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident, the oxygen tubing was excessively long, tangled, and kinked, which could impede the flow of oxygen. The oxygen concentrator was covered in a thick layer of dust, and the humidification bubbler was empty, which could lead to nasal dryness. The Licensed Practical Nurse (LPN) acknowledged that the equipment should be checked and cleaned weekly, but it was evident that this had not been done. The Director of Nursing (DON) confirmed that there was no regular cleaning schedule for the oxygen concentrators. For the second resident, the oxygen tubing had not been changed since the previous month, and the concentrator filter was found on the floor. The Maintenance Director stated that he only replaced the filter when informed by staff and did not regularly check the concentrators. The DON confirmed that the tubing and filters should be checked and changed weekly. The facility's policy required weekly cleaning and changing of oxygen equipment, but these procedures were not followed, leading to deficiencies in the care provided to the residents.
Lack of Dialysis Care Policies and Procedures
Penalty
Summary
The facility failed to have policies and procedures in place for the care of a dialysis resident, specifically for one resident (R13) who was dependent on renal dialysis and had end-stage renal disease. The resident's admission records indicated that she required dialysis three times a week, with an access site in her right arm that needed daily assessment for bruit and thrill. However, the Medication Administration Record (MAR) lacked orders for these assessments, and there was no Treatment Administration Record (TAR) for the resident. Additionally, the resident reported receiving inappropriate food items that did not align with her renal diet, such as potatoes and regular milk, and the facility did not provide lactose-free milk. The facility also lacked communication with the dialysis center, as no information was sent with the resident, and there was no documentation of dialysis-related information in her records. Nurses were not consistently checking the dialysis shunt for patency, and there was no emergency kit available in the resident's room for potential hemorrhage events. The Director of Nursing acknowledged the inconsistency in information exchange with the dialysis center and noted that not all nurses were trained in the care and treatment of dialysis patients. The Interim Administrator confirmed the absence of a facility policy and procedures for dialysis care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were taken by residents at the time of administration for two residents. Resident R18, who has multiple diagnoses including osteomyelitis, diabetes, congestive heart failure, pressure ulcers, and gastroparesis, was observed with a medication cup half full of pills on her bedside table. The resident reported that the nurse left the medications because she was nauseous, and she could not identify the medications. The nurse confirmed that no pills should be left at the bedside and that residents must be observed taking their medications. The Medication Administration Record indicated that R18 had multiple morning medications scheduled, including antibiotics and blood pressure medications. The Director of Nursing acknowledged that R18 is known for not taking her medications as ordered. Resident R13 was found to have a glucometer, blood pressure cuff, and a cup with an insulin pen and multiple medication cups on her bedside table, including two Norco tablets. The LPN stated that R13 was not a resident who self-medicates and was unaware of the insulin pen's origin. The RN confirmed that R13 should not have these items by her bedside and that the insulin pen, which was brought from home, had no identifying information and would need to be discarded. R13 admitted to saving the Norco for after dialysis. The facility's policy requires documentation and physician notification if medication is withheld or refused, which was not adhered to in these cases.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medications at the ordered times, resulting in a 28.5% medication error rate. This deficiency was observed in one of three residents during a medication pass. The resident, identified as R16, had physician's orders to receive apixaban 5mg at 9am and 5pm, and baclofen 10mg at 9am, 1pm, and 5pm. On November 12, 2024, at 10:20 AM, a Licensed Practical Nurse (V7) administered both medications 1 hour and 20 minutes past the scheduled time. V7, a new nurse, was being trained by a Registered Nurse (V8), who admitted she should have intervened but was allowing V7 to learn her routine. Both nurses acknowledged that medications should be administered within one hour before or after the scheduled time. The Director of Nursing (V2) confirmed that medications should adhere to this timing policy, as outlined in the facility's medication administration policy dated March 2024.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and handling of medications, particularly narcotics, as observed in one of the medication rooms and carts. During an inspection, it was found that the medication refrigerator was not locked, and the temperature log had not been updated since April 2024, despite the presence of liquid lorazepam inside. A Licensed Practical Nurse (LPN) admitted that the refrigerator was usually locked, but due to the presence of two nurses and only one set of keys, it was left unlocked. Additionally, the temperature of the medication refrigerator had not been monitored as required, which is crucial for maintaining the efficacy of the medications stored within. Furthermore, a review of one of the medication carts revealed 36 unidentified pills scattered throughout the cart, indicating a lack of proper medication handling and storage practices. An LPN acknowledged that these pills might have been dropped during medication passes or inadvertently popped out of medication cards. The Interim Administrator confirmed that the medication room and refrigerator should be locked to prevent diversion and that the temperature should be checked daily. The facility's policy on medication storage emphasized the importance of maintaining proper temperatures and keeping medication carts clean, which was not adhered to in this instance.
Deficiency in Resident Hygiene Care
Penalty
Summary
The facility failed to provide adequate hygiene care for three residents, resulting in deficiencies in their activities of daily living. Resident 1 was admitted to the hospital with poor hygiene, including matted hair with food, a clogged and dirty urinary catheter, and a pungent smell. The facility's records showed that Resident 1 did not receive a shower or bed bath for extended periods, with the last documented hygiene care occurring 34 days before hospital admission. The Director of Nursing acknowledged the protocol for handling shower refusals but admitted to not monitoring the shower tracking, and no issues were reported for Resident 1. Resident 2, who has multiple medical conditions and an amputation, reported not receiving weekly showers as scheduled. Observations confirmed greasy hair and facial hair growth, which the resident preferred to be clean-shaven. The facility's records indicated gaps in shower documentation, with a 20-day period without a shower. The care plan for Resident 2 lacked specific details on the assistance required for showers, contributing to the deficiency. Resident 6, who is dependent on staff for hygiene care, reported receiving bed baths only every couple of weeks and expressed dissatisfaction with the infrequency. Observations noted greasy hair, and records showed incomplete documentation of hair washing during bed baths. The facility's policy required weekly showers or bed baths, but the records for Resident 6 indicated non-compliance with this policy, leading to inadequate hygiene care.
Failure to Change Wound Dressings as Ordered
Penalty
Summary
The facility failed to ensure that a resident's wound dressings were changed as per the physician's orders and the resident's needs. The resident, who had been admitted to the facility with a wound on the right elbow, was observed with an undated dressing that had not been changed despite requests from the family. The resident's daughter and son reported that the dressing was not changed even after multiple requests, and the dressing was found to have dirty, crusty drainage. The Licensed Practical Nurse (LPN) responsible for wound care stated that the facility was waiting for the ordered silver rope packing to arrive and had received an order to use iodoform packing in the meantime. However, the Treatment Administration Record (TAR) did not document the dressing change on the specified date. The Director of Nursing (DON) acknowledged that the family had reported the dressing was not changed, but assumed the LPN had forgotten to do it. The Physician Order Summary Report indicated specific orders for wound care, which were not followed as documented in the TAR. Additionally, the resident's care plan did not include interventions related to the wound on the right elbow. The facility's policy required daily checks of dressings for cleanliness and signs of infection, which were not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers had appropriate pressure-reducing measures in place. For one resident, who had an amputation of the right lower leg and multiple health conditions including diabetes and heart disease, the left heel was observed lying directly on the bed without any offloading device. Despite the presence of a small black area on the heel, indicating a pressure ulcer, the resident did not have an offloading boot, and the care plan required offloading the heel. The wound care physician's orders also specified offloading the heel, but these were not followed, as the resident's heel was not properly offloaded during the surveyor's visit. Another resident was observed sitting in a chair with heels resting on the floor and later in bed with heels on the mattress, without any offloading devices. This resident had a deep tissue injury to the right heel upon admission, but the care plan did not include interventions for this pressure injury. The physician's orders required offloading the heel while in bed, but this was not implemented, as observed by the surveyor. The facility's pressure ulcer prevention policy mandates the use of positioning devices to relieve pressure, which was not adhered to in these cases.
Inadequate Catheter Care and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, leading to deficiencies in maintaining hygiene and preventing infection. For one resident, the catheter tubing was observed with sediment, and the drainage bag was improperly positioned on the floor, which is against the facility's policy. The resident's catheter dressing was not secured properly, and the catheter site was not cleaned, resulting in encrustation around the tubing. Despite the care plan indicating that catheter care should be provided every shift, the resident reported that staff had not performed catheter care for a long time, and records showed missed catheter care on several dates. Another resident was sent to the hospital with poor hygiene, including a clogged catheter bag with large sediment and a visibly dirty exterior catheter. The resident had a pungent smell, indicating a lack of proper hygiene care. The hospital nurse had to change the catheter and bathe the resident. The facility's Director of Nursing acknowledged that there was an order for the catheter to be changed due to obstruction, but there was no record of when the catheter was last changed at the facility. Both residents had care plans and physician orders that outlined the need for regular catheter care and monitoring for signs of infection. However, the facility's failure to adhere to these plans and policies resulted in inadequate care, as evidenced by the observations and reports from the hospital. The facility's catheter care policy emphasized the importance of maintaining downhill flow of urine and preventing the drainage bag from touching the floor, which was not followed in these cases.
Failure to Refund Resident's Funds Timely
Penalty
Summary
The facility failed to refund a resident's funds within 30 days of discharge. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, diabetes, and bipolar disorder, left the facility against medical advice (AMA) and requested her money. Despite the resident's repeated calls to the facility, her account was not closed until over a month after her discharge, resulting in her Social Security payment being sent to the facility instead of to her directly. The Business Office Manager (BOM) and Corporate Director of Accounts Receivable were both involved but did not ensure the timely closure of the resident's account. The resident's account showed a Social Security deposit and care cost withdrawal on the day of her discharge, leaving a balance that was not refunded promptly. The BOM admitted to not knowing the process for handling funds after a resident's discharge and relied on corporate to manage it. The Corporate Director of Accounts Receivable acknowledged that the account should have been closed earlier to prevent the Social Security payment from being sent to the facility. The delay was partly attributed to a religious holiday that affected the office's operations. The facility's policy requires the safeguarding and management of resident funds, but the process was not followed correctly in this case. The Administrator in Training and other staff members were unclear about the procedures for closing accounts upon discharge, leading to the resident's financial distress. The resident, who was living in a women's shelter, repeatedly contacted the facility about her funds, highlighting the urgency of the situation. The facility eventually issued checks to the Social Security Administration to rectify the issue, but the delay caused significant inconvenience to the resident.
Failure to Assess and Document Venous Wounds and Follow Physician Orders
Penalty
Summary
The facility failed to assess and document a resident's non-pressure (venous) wounds and did not follow up with the resident's physician after a visit to his office. Additionally, the facility did not adhere to physician orders written during that visit. This resulted in the resident having no wound assessments since January 2024 for four venous wounds on her legs, exposed open and bleeding wounds to the backs of her thighs, and an 18-day delay in increasing her pain medication. The resident's electronic medical record shows that she was admitted with diagnoses including morbid obesity, mood disorder, chronic kidney disease stage 4, and non-pressure chronic ulcers of the left and right leg. The last wound assessment was dated January 15, 2024, indicating four venous wounds with varying degrees of serous drainage. Despite this, the facility's non-pressure injury list was undated and showed only two venous wounds, with incorrect treatment and physician information. The treatment administration record for April and May 2024 showed that the resident allowed dressing changes only 10 times in 37 days, missing opportunities for wound assessments. Observations and interviews revealed that the resident had a strong ammonia odor, open and bleeding wounds, and was using cornstarch on her wounds against medical advice. The resident refused the facility's prescribed treatment, preferring her own methods, and had limited interaction with facility physicians. Staff reported difficulties in providing care due to the resident's refusals and non-compliance. The facility's policies required weekly assessments and clear documentation of physician orders, which were not followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 87 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Freeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor Court Of Freeport | 2.9 mi | ★★★★★ | 31 | 0 |
| Stephenson Nursing Center | 3.2 mi | ★★★★★ | 1 | 0 |
| The Citadel At Saint Joseph Village | 3.3 mi | ★★★★★ | 5 | 0 |
| Serenity Estates Of Lena | 9.9 mi | ★★★★★ | 3 | 0 |
| Allure Of Stockton | 18 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.