Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Princeton Rehab & Hcc during CMS and state inspections, most recent first.
Failure to Protect Residents from Physical Abuse: A resident with serious mental illness struck another resident in the head and face after misinterpreting a fist bump, and multiple staff described the act as physical abuse. The assaulted resident, who had cognitive impairment and legal blindness, reported he did not fight back and was separated immediately. Records showed the aggressor was sent for psych eval and later returned with a right-hand fracture, with documentation noting he hit another resident and started swinging during the incident.
A CNA covered a resident’s in-room electronic monitoring camera while providing perineal care, despite family consent for the device and no restriction to turn it off during care. The resident had COPD, dementia, and severe cognitive impairment. The CNA stated staff usually covered the camera, there was no door signage, and she had not been educated on how to handle video surveillance in resident rooms. The Administrator stated the CNA knew it was wrong to cover the camera but felt uncomfortable with the recording.
Improper Sanitizing of Food Thermometer: A Dietary Aide checked temperatures of multiple lunch items with the same thermometer and cleaned it by wiping with a napkin and rinsing with water between foods instead of sanitizing with alcohol. The Dietary Mgr stated the probe should be wiped with alcohol between uses, and the facility policy required sanitizing the probe after taking food temperatures to reduce cross contamination.
A facility failed to maintain a homelike environment when two residents’ room ceiling tiles were observed with brown stains and loose panels linked to a recurring leak, despite both residents being cognitively intact and aware of the condition. The facility also failed to keep a dryer lint screen attached in the laundry room, and the lint trap log showed multiple missed entries; staff stated the lint trap should be cleaned each shift and that lint buildup is a fire hazard.
Missing Privacy Curtains in Shared Resident Rooms: Surveyors observed that four residents had rooms without privacy curtains, including residents with diagnoses such as schizophrenia, bipolar disorder, anxiety, and mood disorders. Two residents were cognitively intact and two had some cognitive impairment per BIMS. One resident said he had been without a curtain for months and changed clothes only in the bathroom because he lacked privacy, while others stated they wanted a curtain for privacy. The rooms remained without curtains on follow-up observation, and the Housekeeping Supervisor Director said housekeeping was responsible for ensuring privacy curtains were in place for residents sharing rooms.
Failure to Develop Individualized Activity Care Plan: A resident with Alzheimer’s disease and severe cognitive impairment did not have an individualized activity care plan reflecting her needs. Staff and family reported she was not meaningfully engaged unless family visited, and the activity staff described that she would benefit from 1:1 activities because she becomes overstimulated in groups and drifts off to sleep during larger group settings. The care plan instead focused on her sometimes refusing to wear her ID wristband and did not include activity interventions or tasks for staff.
Failure to provide and document shaving during ADL care affected two residents who depended on staff assistance. One cognitively intact resident with schizophrenia and bipolar disorder reported not being shaved for three weeks despite wanting it done, while another resident with multiple chronic conditions and dementia was observed with facial hair and stated she wanted it removed. The MDS and care plans identified both residents as needing assistance with personal hygiene, including shaving, and the ADON stated staff do not document whether shaving was completed or declined.
Failure to provide individualized activity care planning for a resident with severe cognitive impairment. A resident with Alzheimer’s disease and dementia had no care plan reflecting her specific activity needs, and staff observed her in common areas without 1:1 activities. The activity aide and activity director both stated she would benefit from individualized 1:1 programming, but the care plan only addressed her refusal to wear an ID wristband.
A resident who was NPO and fully dependent on enteral tube feeding experienced multiple episodes of significant weight loss, as documented in weight records and dietitian assessments, without corresponding updates to the care plan. Despite clear evidence of more than 5% weight loss in one month and over 10% across several months, the care plan did not address weight loss, and a recommended change to an Expedite enteral formula was not implemented due to lack of availability. The RD noted the losses but at one point documented the weight as stable and advised continuing the current POC, while also stating she does not complete care plans. The DON and MDS coordinator acknowledged that significant weight loss should have been care planned but was not. The resident’s guardian reported being told by a hospital physician that the resident was not being fed properly, and facility lab results showed critically elevated BUN, sodium, and chloride levels prior to hospital transfer.
A resident with a history of aggression and intact cognition physically pushed another resident with severe cognitive impairment and a history of violent behavior, resulting in a head injury that required sutures and hospitalization. Staff and documentation confirmed prior incidents of aggression and that care plans identified risks, but the facility failed to prevent the altercation.
A resident with multiple chronic conditions experienced repeated roof leaks and a lack of running water in their room, leading to an unsafe and uncomfortable environment. Maintenance logs and staff interviews confirmed ongoing water intrusion, stained ceiling tiles, and delays in repairs, affecting all residents on the third floor.
Several residents were administered psychotropic medications without documented informed consent or individualized care plans, despite facility policy requiring these steps. Staff interviews confirmed that consent and care planning are expected before medication administration, but the necessary documentation was not found in the residents' health records.
A resident with multiple health conditions and moderate cognitive impairment did not receive a physician-ordered PT/OT evaluation due to a breakdown in communication between nursing and therapy staff. The therapy department was not notified of the order, and the evaluation was not completed as required by facility policy.
A resident with dementia and mobility limitations, requiring substantial assistance with ADLs, was left unattended and soiled in the dining room for an extended period after a meal. Staff did not follow care plan interventions or facility policies for feeding and grooming, resulting in the resident remaining with food stains and in need of repositioning and clothing change.
Multiple residents dependent on staff for ADLs, including incontinence and oral care, did not receive timely or adequate assistance. Observations included residents with significant oral debris, soiled briefs and linens, and a leaking urostomy pouch that was not promptly addressed. Staff interviews confirmed inconsistent provision of care and lack of clear facility policy.
A resident with multiple complex medical conditions did not receive timely physical and occupational therapy evaluations as ordered by a physician, due to a lack of communication and absence of a system to ensure physician orders were carried out. The resident's family and an external rehab nurse repeatedly requested updated therapy evaluations to facilitate a transfer, but staff were unaware or did not act promptly, resulting in delays and incomplete documentation needed for insurance and transfer processes.
The facility failed to maintain a safe and homelike environment, as observed by surveyors. Issues included clogged and continuously running sinks, missing call device covers, and a missing floor tile. Residents involved had varying levels of cognitive impairment, and maintenance issues were not promptly addressed, compromising safety and comfort.
The facility failed to provide adequate ADL care, specifically nail care, for five residents with cognitive and physical impairments. Despite care plans and policies indicating the need for regular nail maintenance, residents were observed with long, untrimmed nails. Staff confirmed that nail care was supposed to be provided on shower days and as needed, but this was not consistently done.
The facility failed to perform daily checks on the crash cart as required by policy, potentially affecting all 61 residents on the third floor. An LPN confirmed the importance of these checks to ensure equipment functionality in emergencies, and the DON stated that daily checks verify the cart's readiness. The facility's policy mandates these checks to ensure all emergency supplies are available and functional.
A janitor closet on the second floor [NAME] Wing, where residents with dementia reside, was found unlocked, containing hazardous items like an electric circuit breaker and chemical solution dispenser. Despite facility policy requiring locked doors to hazardous areas, the closet was accessible, posing a risk to 25 residents. The issue was acknowledged by the Housekeeping Supervisor and Building Manager, highlighting the potential dangers of residents accessing the closet.
The facility failed to label opened multi-dose vials with an open date, affecting two residents. During a medication storage observation, it was found that vials of Fluticasone Propionate Nasal spray, Azelastine HCl Nasal Solution, and Prednisolone Acetate Ophthalmic Suspension were opened without an open date label. The RN and DON confirmed the absence of labels, acknowledging the requirement to label medications upon opening to track their shortened lifespan. This oversight could impact the care of residents with conditions like Type 2 Diabetes Mellitus and hypertension.
A facility failed to label a container of blood glucose test strips with an open date, as required by policy, potentially affecting ten residents receiving glucose monitoring. An RN acknowledged the oversight, and the DON was unaware of the specific policy. The facility's policy mandates dating test strips upon opening and discarding them after ninety days.
The facility failed to maintain functional call lights in the third-floor shower room, affecting 61 residents. An LPN and RN found three call lights inoperable, with the RN unaware of the issue. The Building Manager was informed and initiated contact with an electric company for repairs. Facility policies emphasize the importance of operational call lights for resident safety and assistance.
The facility failed to maintain effective pest control on the third floor, affecting three residents. Observations included live and dead roaches in resident rooms and the dining area. Residents expressed ongoing concerns about rodents during a council meeting. The facility had a pest control agreement with services twice a week, but issues persisted.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to request assistance. One resident, with a history of falls and using a wheelchair, had the call light on the floor behind the bed, while another resident found it under the bed, making it inaccessible. Both residents were cognitively intact but unable to reach the call lights, which are essential for requesting help. The facility's policy requires call lights to be within reach at all times.
A resident with multiple diagnoses, including hearing difficulties, was not scheduled for a follow-up ENT appointment due to a lapse in documentation by an LPN. The resident's appointment, initially set for December, was only scheduled for February after the oversight was discovered.
A facility failed to ensure proper respiratory care for a resident by not labeling oxygen tubing with change dates, not containing the oxygen tubing and Bipap mask when not in use, and lacking an order for oxygen per nasal cannula. The resident, with multiple health conditions including COPD, was observed with uncontained and undated respiratory equipment. The DON and ADON acknowledged the lapses, noting the absence of required orders and adherence to equipment change policies.
A facility failed to monitor a resident's personal refrigerator temperature, leading to missing log entries and foul-smelling food. The resident, with multiple health conditions, confirmed that staff did not check the refrigerator. Staff interviews revealed confusion about responsibility, despite facility policy requiring temperature monitoring to prevent foodborne illness.
The facility failed to post accurate daily nurse staffing information, affecting all 185 residents. A surveyor found the posted staffing information was outdated, and the receptionist acknowledged the need to update it. The Lead Receptionist confirmed the receptionist's responsibility for daily updates, and the Administrator mentioned following state regulations without providing a specific policy.
The facility's pest control program is ineffective, as evidenced by multiple residents reporting mice in their rooms, causing discomfort and distress. Staff confirmed the presence of mice droppings, particularly on the third floor, where food attracts pests. Despite regular visits from a pest control company, the issue persists due to gaps around radiator pipes allowing mice entry. The facility's logs document ongoing pest sightings, indicating a significant lapse in pest control measures.
A resident at high risk for pressure ulcers was found on a non-functional Low Air Loss Mattress (LALM) without a sheet, leaving their skin in direct contact with the mattress. The LPN was unaware of how to adjust the mattress settings, and the issue was corrected by the Wound Care Technician. The resident's medical history includes hemiplegia and morbid obesity, necessitating the use of a properly set LALM as per facility policy and care plan.
A facility failed to ensure two staff members assisted in mechanical lift transfers, leading to a resident's injury. Despite policies requiring two caregivers, a CNA performed a transfer alone, resulting in a laceration and fracture to the resident's foot. Interviews revealed that single-staff transfers were common, despite care plans and training emphasizing the need for two staff members.
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in common areas and a resident's room. The Housekeeping Supervisor acknowledged the issue, and the facility's policies emphasize the importance of a pest-free environment.
The facility failed to maintain a safe and comfortable environment for several residents, with issues including a non-functioning call light, damaged or missing furniture, a noisy heater, and a torn window screen. These problems were reported by the residents but were not addressed by the facility.
The facility failed to provide adequate ADL care to five dependent residents, including those with severe cognitive impairment, paraplegia, and legal blindness. Observations revealed unshaven residents, soiled clothing, unattended mechanical lift slings, and unmet personal hygiene needs, indicating significant neglect in meeting basic care requirements.
The facility failed to provide sufficient nursing staff on the 3rd floor, leading to several deficiencies in resident care, including unattended residents, unmet hygiene needs, and delayed assistance with mobility and toileting. The staffing levels were significantly lower compared to other floors, contributing to the observed deficiencies.
The facility failed to ensure dual signatures for controlled substance counts at shift changes and incorrectly administered medication to a resident. Discrepancies in Tramadol counts and improper dosing of Sodium Chloride were observed, indicating non-compliance with established protocols.
The facility failed to label an opened multi-dose vial of Fluticasone Propionate Nasal spray for a resident and did not ensure that the 3rd-floor medication cart was locked while unattended. The LPN admitted to forgetting to lock the cart, and the facility's policies require multi-dose vials to be labeled with the open date. The failure to secure the medication cart has the potential to affect 52 residents on the 3rd floor.
The facility failed to label an opened container of blood glucose test strips with the open date, potentially affecting six residents who receive blood glucose monitoring tests. The LPN discarded the strips upon realizing the oversight, and the DON was unaware of the policy regarding labeling the strips.
A facility failed to provide a mobility device for a resident with paraplegia, despite the care plan indicating the need for a trapeze for repositioning. The resident reported that staff had stopped providing range of motion exercises about a year ago, and the Restorative Nurse admitted that the resident had not been given a trapeze, as required by the care plan.
The facility failed to follow safety procedures for two residents, one with an unlocked and angled bed and another left unattended in a high-positioned bed on a mechanical lift sling. The facility's policy on managing falls was not adhered to, leading to potential hazards.
The facility failed to follow physician orders, care plan interventions, and policy procedures for a resident with neuromuscular bladder dysfunction and paraplegia. The resident's catheter bag had not been emptied since the previous day, and the Director of Nursing was unaware of the specific policy, which required emptying the bag at least once each shift.
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies such as unlabeled and improperly stored nasal cannulas, nebulizer masks, and tubing. The equipment was found dirty, on the floor, and on a roommate's dresser, indicating non-compliance with established procedures.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. Two medication errors were identified: a resident was given non-enteric coated Aspirin instead of the prescribed enteric coated version, and another resident received only one tablet of Sodium Chloride instead of the prescribed two tablets. These errors were observed during medication administration by two LPNs, who acknowledged the mistakes upon inquiry by the surveyor.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to follow its abuse policy and affirm residents’ right to be free from abuse when one resident struck another resident on the face and head. The involved resident had diagnoses including bipolar disorder, schizoaffective disorder, and anxiety disorder, and was documented as cognitively intact. The other resident had diagnoses including bipolar disorder, schizophrenia, legal blindness, developmental and psychotic disorders, restlessness and agitation, and was documented as moderately cognitively impaired. According to interviews and record review, the incident occurred near the nurse’s station when the second resident attempted to give the first resident a fist bump. Multiple staff members stated that the first resident then punched or hit the second resident with a closed fist, striking the head and face. The second resident reported that he did not hit back and that staff separated them immediately. Staff interviewed, including an LPN, an activity aide, another LPN, the resident’s physician, a PMHNP, the DON, and the Administrator, all described the act of hitting or punching as physical abuse. The record showed that the first resident was sent to the hospital for psychiatric evaluation after the altercation and later returned wearing a brace on the right hand. Facility documentation and radiology findings showed a fracture of the proximal shaft of the fifth metacarpal of the right hand. Progress notes documented that the resident hit another resident and started swinging when the other resident tried to give him a fist bump. The facility’s final investigation report stated that the second resident had attempted to greet the first resident with a fist bump, and the first resident misperceived it as threatening and hit the peer in self-defense.
Electronic Monitoring Camera Covered During Care
Penalty
Summary
The facility failed to ensure a resident’s right to maintain family-authorized oversight when a CNA covered an in-room electronic monitoring camera while providing care. The resident, who was no longer in the facility during the investigation, had diagnoses including COPD with acute exacerbation, unspecified dementia, and severe cognitive impairment as shown by a BIMS score of 00/00. The resident’s family member had signed the electronic monitoring consent agreement, and the agreement did not indicate that the camera should be turned off during patient care. During a phone interview, the CNA stated she and other staff usually covered the camera when in the resident’s room and that she covered it while changing the resident’s perineal area to prevent exposing the resident’s private area to anyone watching the camera. She stated there was no signage on the door indicating video surveillance, that the facility did not notify her there was a camera in the room, and that she had not received education on video surveillance in resident rooms or what to do. The Administrator stated the CNA knew it was wrong to cover the camera but felt uncomfortable providing perineal care with the camera recording. The facility’s policy stated staff may not touch the electronic surveillance device, and the resident rights policy stated staff shall demonstrate knowledge of residents’ rights by respecting them at all times.
Improper Sanitizing of Food Thermometer
Penalty
Summary
The facility failed to ensure staff followed proper food safety procedures when checking food temperatures during the lunch meal on the third floor dining area. A Dietary Aide used a thermometer to check a Western Style Burger, then wiped the thermometer with a white napkin, shook excess food from it into a sink, and rinsed it under water before placing it into broccoli. The same process was repeated after checking broccoli and then French fries, and again after checking pureed meat and then pureed broccoli. When interviewed, the Dietary Aide stated he did not need to use alcohol to sanitize the food thermometer between food items and said he sanitized it by wiping it and rinsing it with water. The Dietary Manager stated the thermometer should be wiped with alcohol between taking food temperatures and explained that if it is not properly sanitized it can cause cross contamination of the food. The facility’s policy stated that after taking the temperature of any food, the probe should be sanitized to reduce the risk of cross contamination, and the facility had 181 residents receiving an oral diet.
Stained Ceiling Tiles and Improper Dryer Lint Trap Maintenance
Penalty
Summary
The facility failed to maintain a homelike environment for three residents, including two cognitively intact residents with diagnoses of paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and insomnia for one resident, and paranoid schizophrenia and bipolar disorder for another. During observation, the ceiling tiles in their room were noted to have multiple brown stained spots, were loose, and were building throughout the room ceiling. Both residents stated that the ceiling tiles were always stained. The Maintenance Director stated he was responsible for inspecting and replacing stained or damaged ceiling tiles, explained that the damage was caused by a leak in the ceiling, and acknowledged that the leak had previously been repaired but had recurred. He also stated that stained or damaged ceiling tiles can become weak, fall down, and injure a resident. The facility also failed to maintain the laundry room equipment in safe condition when the lint screen on one dryer was observed hanging and not attached, with lint present near a vent. The Laundry Aide stated the lint screen should be attached to catch lint and that lint traps are cleaned at the end of each shift and documented in the lint trap cleaning book. Review of the book showed multiple blank dates across January, February, and March 2026. The Maintenance Director stated the lint screen should not be hanging, that staff should have notified him immediately, and that lint buildup can catch fire. Facility policy stated dryer lint traps must be cleaned each shift and that a clogged lint trap is a fire hazard.
Missing Privacy Curtains in Shared Resident Rooms
Penalty
Summary
The facility failed to ensure that four residents had privacy curtains that extended around their beds. R141, R146, R157, and R159 were identified in the sample of 67 residents. Their records showed diagnoses including paranoid schizophrenia, bipolar disorder with hypomanic episode, insomnia, anxiety, schizoaffective disorder, unspecified mood disorder, and bipolar disorder. BIMS scores documented that R141 and R157 were cognitively intact, while R146 and R159 had some cognitive impairments. During observations, surveyors found that R146, R159, R157, and R141 each had rooms without privacy curtains. R146 stated he had not had a privacy curtain for six months and wanted one in his room. R159 was unable to say how long the curtain had been missing but said he wanted one. R157 stated he had been in the room for five months without a privacy curtain and said he only changed clothes in the bathroom because he did not have privacy by his bed. R141 was unable to state how long he had been without a privacy curtain and said he wanted one for his privacy. On a later observation, the rooms for all four residents still did not have privacy curtains. The Housekeeping Supervisor Director stated the housekeeping department was responsible for ensuring residents had privacy curtains and explained that residents sharing a room were required to have them for privacy.
Failure to Develop Individualized Activity Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for activities for one resident, R140, and did not develop an individualized activity care plan with interventions and tasks for staff to meet her psychosocial and clinical care needs. R140 was admitted with diagnoses including Alzheimer's disease, dementia, disorders of the lung, rhabdomyolysis, hyperlipidemia, essential hypertension, history of falls, and edema. Her MDS dated February 25, 2026 showed a score of 01 in section C, indicating severe cognitive impairment. R140's care plan dated March 3, 2026 did not show a care plan specific to her individualized activity needs. The only focus documented was that the resident chooses not to wear the identification wrist band at times, with an intervention for staff to allow personal choices whenever possible and safe and to avoid power struggles. During observation on March 15, 2026, R140 was sitting in her wheelchair with family at bedside, alert and responsive to her name but unable to respond to open- or closed-ended questions about activity participation. She denied pain by nodding her head and then stopped responding to further questions. R140's family member stated that she only responds to closed-ended questions on most days because of her cognitive impairment and that the family was concerned there were no activities centered around R140's current care needs to keep her stimulated and engaged. The family member stated that if family did not visit, R140 was not engaged much by staff. The activity aide stated R140 would benefit from 1:1 activities because it would keep her from becoming overstimulated in a crowded room and provide 10 to 20 minutes of individualized activity based on her preferences. The activity director stated that 1:1 activity is for residents who do not come out of their rooms much and have dementia, and that R140 would benefit from 1:1 activities because she drifts off to sleep at times in larger group settings. The activity director also stated that the activity aide was responsible for reviewing care plans and that it was an oversight that R140's care plan was not implemented to reflect her individualized activity care needs.
Failure to Provide and Document Resident Shaving During ADL Care
Penalty
Summary
The facility failed to ensure that two residents who depended on staff assistance for ADL care received shaving. One resident with diagnoses including paranoid schizophrenia and bipolar disorder had a BIMS score of 15, indicating cognitive intactness, and was observed at the nurses station with visible facial hair. When asked, the resident stated he had not been shaved for three weeks and said he wanted to be shaved, but that CNAs shaved him only when they said they had time. The resident’s MDS showed he required supervision or touching assistance with personal hygiene, including shaving, and his care plan directed staff to assist with ADL tasks as needed. Another resident with diagnoses including chronic diastolic heart failure, dementia, bipolar disorder, chronic kidney disease, hypertension, peripheral vascular disease, and pulmonary hypertension had a BIMS score of 14 and was coded as dependent for personal hygiene, including shaving. The resident was observed in bed with hair on the chin and stated she did not want hair on her face and wanted it removed. The ADON stated that staff do not document when ADL care is provided if shaving was done or declined by the resident. Facility policies described shaving as part of grooming and emphasized maintaining residents’ dignity, self-esteem, privacy, and confidentiality.
Failure to Provide Individualized Activity Care Planning
Penalty
Summary
The facility failed to provide individualized activities for one resident with cognitive impairment. R140 was admitted with diagnoses including Alzheimer's disease, dementia, disorders of the lung, rhabdomyolysis, hyperlipidemia, essential hypertension, history of falls, and edema. The MDS dated February 25, 2026, showed a Section C score of 01, indicating severe cognitive impairment. R140's care plan dated March 3, 2026, did not show a care plan specific to her individualized activity needs or interventions for staff to implement to meet her psychosocial and clinical care needs. The only documented focus was that the resident chooses not to wear the identification wrist band at times, with an intervention for staff to allow personal choices whenever possible and safe and to avoid power struggles. During observation on March 15, 2026, R140 was sitting in her wheelchair with family at bedside, alert and responsive to her name but unable to respond to open- or closed-ended questions about activity participation. On March 17, 2026, R140 was observed sitting in a wheelchair near a table in the dining room, and no 1:1 activities were observed at that time. The activity aide stated that R140 would benefit from 1:1 activities because it would keep her from becoming overstimulated in a crowded room and would provide 10 to 20 minutes of individualized activity based on her preferences. The activity director stated that 1:1 activity is for residents who do not come out of their rooms much and have dementia, and that R140 would benefit because she drifts off to sleep at times in larger group settings. The activity director also stated that the care plan was not implemented to reflect R140's individualized activity care needs.
Failure to Address Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document interventions to address significant weight loss for one resident who was entirely dependent on enteral nutrition. The resident, admitted with diagnoses including intracerebral hemorrhage, encephalopathy, and dysphagia, was NPO and received all nutrition via tube feeding. Weight records show a decline from 165.0 lbs at admission to 142.5 lbs over several months, including multiple episodes of significant weight loss as defined by the facility’s own Nutrition Care Significant Weight Loss policy (e.g., 7.3% loss in 28 days and 4.84% loss in 7 days). Despite these documented losses, the resident’s comprehensive care plan did not include or address significant weight loss. Dietitian enteral nutrition assessments identified significant weight loss on multiple occasions but did not result in effective changes to the resident’s nutritional management. One assessment documented an 11.8% loss in one month, yet described the weight as stable and recommended continuing the current plan of care without additional interventions. A later assessment documented a 10.26% loss over three months and a total loss of 13.0% over five months, and recommended starting an Expedite enteral feeding formula for six weeks; however, this recommendation was not implemented due to lack of product availability. The dietitian stated that she does not complete care plans and did not address the absence of a weight loss care plan for the resident. Interviews with facility staff confirmed that the significant weight loss was not incorporated into the resident’s care plan and that required interdisciplinary collaboration and care plan updates did not occur as outlined in the facility’s nutrition policy. The DON acknowledged that weight loss should have been addressed in the plan of care but was not, and the MDS coordinator confirmed that newly identified problems such as significant weight loss are supposed to be care planned, yet no such care plan existed for this resident. The state guardian reported being informed by a hospital physician that the resident was not being fed properly at the facility, and facility lab results showed critically abnormal BUN, sodium, and chloride levels prior to the resident’s transfer to the hospital. These findings demonstrate that the facility did not ensure adequate nutritional interventions and care planning to prevent or address the resident’s significant weight loss.
Failure to Protect Resident from Peer-to-Peer Physical Abuse
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, as evidenced by an incident involving two residents with histories of mental illness and aggression. One resident, with diagnoses including schizophrenia, bipolar disorder, and major depressive disorder, and an intact cognitive status, was documented as having a history of physical aggression and poor impulse control. This resident became involved in a physical altercation with another resident who had severe cognitive impairment and a history of violent behavior. The altercation resulted in the second resident being pushed to the floor, sustaining a head laceration that required sutures and hospitalization. Multiple staff interviews confirmed that the first resident pushed the second resident, leading to the injury. The facility's records and staff statements indicate that there were prior documented incidents of agitation, aggression, and altercations involving the resident who initiated the push. Despite care plans noting the risk for aggression and abuse, the measures in place were insufficient to prevent the incident. The facility's abuse policy affirms the right of residents to be free from abuse and outlines procedures for prevention, but the occurrence of this event demonstrates a failure to protect residents from physical abuse by peers.
Failure to Maintain Safe and Homelike Environment Due to Roof Leaks and Lack of Running Water
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, specifically on the third floor, by not addressing ongoing issues with leaking roofs and lack of running water in resident rooms and bathrooms. Maintenance logs and staff interviews confirmed repeated incidents of water leaks from the ceiling, stained and falling ceiling tiles, and flooding in resident rooms and common areas. One resident, who was cognitively intact and had multiple medical diagnoses including polyarthritis, diabetes, and dementia, experienced a leaking roof in their room, water in the light fixture, and a non-functioning bathroom sink. The resident reported these issues to nursing staff, and nurse aides had to leave the room to obtain water for personal care due to the lack of running water. Observations during a facility tour revealed brownish stains on ceiling tiles throughout the building, with the Maintenance Director confirming that leaks occurred during heavy rain and that water traveled through the metal roof to various areas. Staff interviews corroborated that roof leaks were a recurring problem, especially during storms, and that repairs were only made after significant delays. The facility's policy and job description for the building manager require prompt maintenance and high safety standards, but these were not met, resulting in an environment that was neither safe nor comfortable for residents.
Failure to Obtain Consent and Develop Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to follow its own policy regarding the use of psychotropic medications by not obtaining informed consent and not developing individualized care plans for several residents. Specifically, five residents with various diagnoses, including schizoaffective disorder, depression, schizophrenia, and dementia, were administered psychotropic medications such as Olanzapine, Mirtazapine, Quetiapine, Risperidone, Lithium Carbonate, and Sertraline without documented consent. In multiple cases, the electronic health records lacked both the required consent forms and care plans for these medications, despite facility policy mandating these steps prior to administration. Direct interviews with staff, including registered nurses, the Director of Nursing, the care plan coordinator, and the Social Service Director, confirmed that the expectation is to obtain consent before administering psychotropic medications. Staff acknowledged that medications should not be given without consent and that care plans should be individualized and documented in the resident's health record. However, when surveyors requested documentation, the facility was unable to provide the necessary consents for the affected residents, and in some cases, care plans were also missing. One resident, who was cognitively intact, reported that neither she nor her family gave consent for a newly prescribed psychotropic medication and that she received the medication without their approval. Staff confirmed that the medication was on hold due to the lack of consent. The facility's own policies require informing residents or their representatives about psychotropic medications, obtaining verbal or written consent prior to initiation, and developing a comprehensive care plan that includes treatment goals and non-drug interventions. Despite these requirements, the facility did not adhere to its policies for the residents identified in the report.
Failure to Follow Physician Orders for Therapy Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for a resident who required evaluation and possible treatment by physical and occupational therapy. The resident had a history of diverticulosis, syncope, congestive heart failure, chronic kidney disease, and alcohol abuse, and was noted to have moderate cognitive impairment with a BIMS score of 8. The resident required mobility devices and partial to moderate assistance with activities of daily living. Despite a physician order dated 4/9/25 for PT/OT evaluation and treatment, there was no evidence that the therapy department was notified or that the evaluation was completed. Interviews with the DON, occupational therapist, and physical therapy assistant revealed that the therapy department relies on nursing staff to communicate therapy orders, typically through verbal communication or morning meetings. In this case, the therapy staff were not informed of the order, and as a result, the resident was not evaluated by therapy. Review of facility policies and job descriptions confirmed that both nursing and therapy staff are responsible for communication and implementation of therapy orders, but the process failed, resulting in the resident not receiving the ordered therapy evaluation.
Failure to Provide Timely ADL Assistance After Meal
Penalty
Summary
A deficiency occurred when a resident with osteoarthritis, muscle atrophy, and dementia, who required substantial assistance with activities of daily living (ADLs), was not provided appropriate care following a meal. The resident was observed seated in the dining room with dried red sauce on her shirt and pants, and a large ravioli on her thighs, approximately 1.5 hours after lunch had been served. Staff interviews revealed that the resident required maximal assistance with eating and dressing, and her care plan specified assistance with ADL tasks as needed due to impaired cognition and limited mobility. Despite these documented needs, the resident remained unattended, soiled, and in need of repositioning and clothing change for an extended period after the meal. Certified Nursing Assistants (CNAs) assigned to the dining room and to the resident did not provide the necessary assistance or ensure the resident's hygiene and comfort were maintained. Staff acknowledged the resident's need for maximal assistance and confirmed that her appearance and condition had not been addressed. Facility policies required the use of clothing protection during meals and individualized dressing/grooming assistance, but these procedures were not followed, resulting in the resident remaining soiled and improperly cared for after eating.
Failure to Provide Timely Incontinence and Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including incontinence care and oral hygiene, for five residents who required such support. Observations revealed that one resident, who had multiple medical diagnoses including stroke, aphasia, and dysphagia, was found with significant oral debris and reported not receiving oral care or bed baths. This resident was dependent on staff for personal hygiene and grooming, as documented in the care plan and minimum data set, but did not receive the required assistance. Another resident with a urostomy and hemiplegia reported a leaking urostomy pouch that was not changed in a timely manner, despite staff being aware of the issue. The certified nurse assistant stated she was not permitted to change the pouch and only placed a towel to catch the urine, while the LPN delayed changing the pouch due to lack of supplies and workload. The resident's care plan and physician orders required regular urostomy care and monitoring, which was not provided as ordered. Additional residents were observed with poor oral hygiene, including thick debris on teeth and gums, and one was found with a heavily soiled brief and bed linen due to incontinence. Staff interviews confirmed that oral care and incontinence care were not consistently provided, with one resident stating oral care was only given two to three times per week and supplies were not always made available. The Director of Nursing acknowledged that ADL care, including oral and incontinence care, should be provided regularly, but the administrator stated there was no specific policy in place for these services.
Failure to Follow Physician Orders and Communicate Therapy Needs
Penalty
Summary
The facility failed to follow a physician's order and did not implement a system to ensure that required treatments or procedures needing a physician's order were carried out for one resident. The resident in question had multiple complex medical diagnoses, including hypertension, syphilis, gastrostomy, asthma, COPD, heart failure, use of anticoagulants, epilepsy, HIV, pulmonary embolism, ventricular tachycardia, polyneuropathy, dysphagia, adjustment disorder, vascular dementia, sepsis, hypoxemia, and hypotension. The resident was cognitively impaired, as indicated by a BIMS score of 00, and had a history of receiving physical and occupational therapy, with the last documented therapy sessions occurring nearly a year prior to the events described in the report. Despite a physician's order dated for physical and occupational therapy evaluation and treatment, there were no documented therapy notes or evaluations corresponding to this order. The resident's family and a nurse from a requested rehabilitation facility repeatedly sought updated therapy evaluations to facilitate a transfer and insurance approval, but these were not provided in a timely manner. Multiple staff interviews revealed confusion and lack of communication regarding the need for new therapy evaluations, with some staff unaware of the family's request and others unsure of the process for obtaining the necessary physician orders. The facility did not have a policy on effective communication or timely notification for obtaining physician orders, and there was a breakdown in communication among staff, including the social service director, certified nurse assistant, and resident care coordinator. This led to significant delays in obtaining the required therapy evaluations, which were necessary for the resident's transfer to another facility and for insurance processing. The deficiency was identified through interviews, record reviews, and observations, highlighting the facility's failure to ensure physician orders were followed and communicated appropriately.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as observed by surveyors. In one instance, the bathroom sink shared by two residents was clogged with brownish water and hair, indicating a lack of timely maintenance. The residents involved had cognitive impairments, with one having a BIMS score indicating moderate impairment and the other severe impairment. Despite the presence of housekeeping staff, the issue was not immediately resolved, highlighting a gap in communication and responsibility between housekeeping and maintenance. In another case, the bathroom faucets in a shared room were found to be continuously running, and attempts to shut them off were unsuccessful. The residents in this room also had cognitive impairments, with one having a severely impaired BIMS score. The maintenance staff was informed of the issue but did not address it promptly, leading to potential safety hazards and water damage. The facility's policy requires prompt mitigation of environmental hazards, which was not adhered to in this situation. Additionally, two residents had call device plates with missing covers, exposing internal fixtures. Although the call devices were functioning, the missing covers compromised the homelike appearance of the room. The maintenance director was aware of the issue but faced delays in obtaining replacement covers due to purchasing restrictions. Another resident reported a continuously running faucet and a missing floor tile in their room, which had not been addressed despite being reported to staff. These deficiencies reflect a failure to maintain the facility in good repair and ensure a safe and comfortable environment for residents.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for five dependent residents, resulting in deficiencies in personal hygiene, specifically nail care. Residents R30, R34, R70, R91, and R95 were observed with long, untrimmed fingernails, some with dark substances underneath, indicating a lack of regular nail maintenance. Despite care plans indicating the need for assistance with personal hygiene and ADLs, including nail care, these residents did not receive the necessary support. The facility's policy and staff statements indicated that nail care should be provided on shower days and as needed, yet this was not consistently implemented. Resident R70, with a diagnosis including Schizoaffective Disorder and hemiplegia, expressed a desire for nail trimming, highlighting the unmet need. Similarly, residents R95, R30, R34, and R91, all with varying degrees of cognitive impairment and physical limitations, were found with long nails despite care plans specifying the need for assistance. The observations and interviews with staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed the inconsistency in providing nail care, which is a critical component of ADL support for these residents.
Failure to Perform Daily Crash Cart Checks
Penalty
Summary
The facility failed to ensure that emergency medical equipment, specifically the crash cart, was checked daily as required by their policy. This deficiency was identified during a survey when it was observed that the Emergency Cart Daily Review document for February 2025 had a missing entry for a daily crash cart check on a specific date. The Licensed Practical Nurse (LPN) confirmed that the crash cart should be checked daily to ensure all equipment is functional and ready for use in emergencies. The Director of Nursing (DON) also stated that the crash carts are checked daily to verify that they are locked, contain oxygen, a backboard, and a working suction machine. The facility's policy on emergency carts mandates daily checks to ensure the lock tab is intact, supplies are complete and not expired, the oxygen tank is filled, the suction machine is set up, and the CPR board is present. The failure to perform these checks could potentially affect all 61 residents residing on the third floor of the facility. The facility's job description for staff nurses emphasizes the responsibility to follow nursing procedures and protocols to maintain the highest degree of quality care, which includes ensuring emergency equipment is ready for use.
Unlocked Janitor Closet Poses Risk to Dementia Residents
Penalty
Summary
The facility failed to ensure that the janitor closet on the second floor [NAME] Wing, where residents with dementia reside, was locked at all times. This deficiency was observed on multiple occasions, with the janitor closet found unlocked and accessible. The closet contained potentially hazardous items, including an electric circuit breaker and chemical solution dispenser. The Housekeeping Supervisor acknowledged the issue, noting that a piece of paper had been used to prevent the door from locking properly. The Building Manager confirmed the potential risks, stating that residents could shut off the power or access harmful chemicals if the closet remained unlocked. The deficiency was identified during a survey, which included observations, interviews, and record reviews. The facility's policy requires that all doors to hazardous areas be kept locked to ensure the safety of residents and staff. Despite this policy, the janitor closet was found unlocked, posing a risk to the 25 residents on the second floor, many of whom have a dementia diagnosis. The Director of Nursing confirmed that the second floor is a skilled floor, and the elevator requires a key for access due to the residents' conditions. The facility's failure to secure the janitor closet compromised the safety of the residents, as documented in the survey findings.
Failure to Label Opened Multi-Dose Vials
Penalty
Summary
The facility failed to label opened multi-dose vials with an open date, which is a requirement to ensure the safe use of medications. During an observation of medication storage, it was found that a resident's vials of Fluticasone Propionate Nasal spray and Azelastine HCl Nasal Solution were opened but not labeled with an open date. Similarly, another resident's vial of Prednisolone Acetate Ophthalmic Suspension was also opened without an open date label. The Registered Nurse (RN) present during the observation confirmed the absence of the open date labels and acknowledged that these medications should have been labeled upon opening, as some medications have a shortened expiration period once opened. The Director of Nursing (DON) further confirmed that multi-dose medications should be labeled with an open date to track their shortened lifespan after opening, in accordance with the facility's policy and pharmacy recommendations. The facility's policy on multi-dose vials, dated January 2022, specifies that opened vials should be labeled with the opened and beyond-use date. The failure to adhere to this policy was observed in the cases of two residents, both of whom are cognitively intact and have medical conditions such as Type 2 Diabetes Mellitus and hypertension. This oversight in medication management could potentially affect the quality of care provided to these residents.
Failure to Label Blood Glucose Test Strips with Open Date
Penalty
Summary
The facility failed to ensure that the container of multi blood glucose test strips was labeled with an open date, which is a requirement according to the facility's policy. This oversight was observed during a survey on the first floor, team 2 medication cart, where an opened container of test strips lacked the necessary labeling. The Registered Nurse (RN) acknowledged the omission, noting that while one container was properly labeled, the other was not. The absence of an open date on the test strips container could lead to inaccurate blood glucose readings if the strips are outdated. The deficiency potentially affected ten residents who receive blood glucose monitoring, as identified in a document titled 'Diagnosis Report' listing residents with Type 2 Diabetes Mellitus Without Complications. The Director of Nursing (DON) was unaware of the specific policy regarding the dating of glucose strips containers and indicated a need to review it. The facility's policy, dated August 2024, mandates that test strips and control solutions be dated upon opening and discarded after ninety days. This failure to adhere to established protocols could compromise the quality of care provided to residents requiring blood glucose monitoring.
Inoperable Call Lights in Shower Room
Penalty
Summary
The facility failed to ensure that the call lights in the third-floor shower room were functioning properly, affecting all 61 residents residing on that floor. During an observation, it was noted that three call lights were inoperable. A Licensed Practical Nurse (LPN) and a Registered Nurse (RN) both attempted to activate the call lights without success. The RN was unaware of the malfunction and stated the importance of functioning call lights for residents to request assistance from staff. The Building Manager was informed of the issue and acknowledged that some call lights could be fixed internally, while others required external assistance. An email was sent to an electric company to address the problem. The facility's maintenance log documented the issue, and the Director of Nursing emphasized the necessity of call lights being within residents' reach to meet their needs. The facility's policy and job descriptions highlight the importance of maintaining communication systems in good working order for resident safety and comfort.
Pest Control Deficiency on Third Floor
Penalty
Summary
The facility failed to maintain effective pest control on the third floor, affecting three residents in a census of 61. Observations included a live roach crawling across the floor and multiple dead roaches on glue traps and mouse traps under a wall heater in the rooms of the affected residents. A resident was also seen stepping on an insect in the dining room during lunchtime, which was confirmed to be a small roach by the Business Office Manager. The housekeeper reported that sightings of pests are communicated to maintenance, but this was not the first occurrence of roaches being seen. During a resident council meeting, attendees expressed concerns about rodents, indicating that the issue had been ongoing but was perceived to be improving. The facility had a Pest Control Agreement with services provided twice a week, targeting various pests, including cockroaches and mice. However, the facility was in the process of finding another pest control company due to service area limitations. Documentation from previous months showed multiple instances of pest sightings and actions taken by the pest control vendor, but concerns persisted among residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, R59 and R84, which is necessary for them to request staff assistance. R59, who has a history of falls and uses a wheelchair, was observed with the call light on the floor behind the head of the bed, out of reach. Despite being cognitively intact, R59 was unaware of the call light's location and expressed reliance on it for assistance to get into a wheelchair. The facility's Director of Nursing confirmed that the call light should always be within the resident's reach, and the care plan for R59 included an intervention to promote the placement of the call light within reach. Similarly, R84, who also has a history of falls and uses a wheelchair, was found with the call light on the floor under the bed, making it inaccessible. R84, who is cognitively intact, was unable to reach the call light to request assistance for eating. A registered nurse acknowledged the call light's location under the bed and secured it to the bed sheet. The facility's policy mandates that call lights be positioned conveniently for residents' use and within reach at all times. The Director of Nursing reiterated the importance of call lights being within reach to meet residents' needs.
Failure to Schedule Follow-Up Hearing Appointment
Penalty
Summary
The facility failed to ensure that a resident, identified as R91, was scheduled for a follow-up appointment for hearing services. R91, who has multiple diagnoses including bipolar disorder, major depressive disorder, psychosis, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and anxiety, was observed to have difficulty hearing and expressed the need for loud communication in his right ear. Despite being scheduled for a follow-up appointment with an Ear, Nose, and Throat (ENT) clinic on December 18, 2024, after a hospital visit on December 4, 2024, this appointment was not scheduled by the facility. The Director of Nursing (DON) stated that nurses are expected to document follow-up appointments in the electronic health record and inform the scheduler to arrange transportation. However, the Licensed Practical Nurse (LPN) responsible for R91 on December 4, 2024, failed to document the follow-up appointment in the electronic medical record, resulting in the appointment not being scheduled. This oversight was acknowledged by the LPN, who admitted to missing the appointment scheduling. Consequently, the follow-up appointment was only scheduled for February 27, 2025, after the deficiency was identified.
Failure to Ensure Proper Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R43, by not labeling oxygen tubing with dates when changed, not containing the oxygen tubing and Bipap mask when not in use, and not obtaining an order for oxygen per nasal cannula. R43, who has a diagnosis of peripheral vascular disease, hypertension, diabetes, COPD, dependence on supplemental oxygen, cerebral infarction, and flaccid hemiplegia, was observed with a Bipap mask and nasal cannula left uncontained and undated. The resident, who is cognitively intact with a BIMS score of 15, expressed concern about whether the mask should be covered. The Director of Nursing (DON) acknowledged that oxygen tubing and masks should be in a bag when not in use and dated after being changed, although the policy does not specify dating. The Assistant Director of Nursing (ADON) confirmed there was no order for oxygen per nasal cannula, which should have been present if the resident was receiving oxygen this way. The facility's policy requires oxygen equipment to be changed monthly and as needed, but the staff nurse's job description mandates adherence to established nursing procedures and protocols, which were not followed in this case.
Failure to Monitor Resident's Refrigerator Temperature
Penalty
Summary
The facility failed to monitor the temperature logs of a personal refrigerator for a resident, identified as R43, who has multiple diagnoses including peripheral vascular disease, hypertension, diabetes, COPD, dependence on supplemental oxygen, cerebral infarction, and flaccid hemiplegia. Despite being cognitively intact, as indicated by a BIMS score of 15, R43's personal refrigerator had missing temperature log entries for most of February, with only two days recorded. During an observation, food items in the refrigerator emitted a foul odor, and R43 confirmed that staff did not check the refrigerator. Interviews with various staff members revealed confusion about who was responsible for monitoring the resident's personal refrigerator temperatures. The Director of Nursing was unsure of the responsible party, while housekeeping staff stated that CNAs were supposed to check the refrigerators. The facility's policy requires staff to monitor and record refrigerator temperatures to reduce the risk of foodborne illness, but this was not adhered to in R43's case. The CNA's job description also includes ensuring that nursing procedures and protocols are followed, which would include checking refrigerator temperatures.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nursing staffing information was accurate, affecting all 185 residents. On 2/23/2025, a surveyor observed that the Nurse Staffing information posted on the wall was dated 2/21/2025, indicating it was not updated daily as required. The receptionist, responsible for updating and posting this information, acknowledged the need to update the form before posting it. The Lead Receptionist confirmed that the receptionist is tasked with updating the Nurse Staffing information daily. When asked for a policy or procedure regarding the completion of nurse staffing, the Administrator stated that they follow state regulations, but no specific policy was provided.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a deficiency that potentially affects all 178 residents. Observations and interviews revealed that residents have been experiencing issues with mice in their rooms. One resident, who is bedridden, reported seeing mice and expressed discomfort due to his inability to move away from them. Another resident, who is paralyzed from the waist down, stated that he frequently sees mice in his room and feels uncomfortable because he cannot protect himself. A third resident also reported hearing mice at night, which causes distress. Staff observations confirmed the presence of mice droppings in residents' rooms, particularly on the third floor, where food left by residents attracts pests. Housekeeping staff reported frequent sightings of mice droppings and noted that the pest control company regularly applies treatments. However, the treatments appear ineffective as mice sightings and droppings persist. The Maintenance Director acknowledged the issue, attributing it to gaps around radiator pipes that allow mice to enter the building. He mentioned ongoing efforts to seal these gaps but admitted that the problem remains unresolved. The facility's pest control policy requires the administrator to address sanitation, maintenance, and food storage issues based on the pest control contractor's recommendations. Despite the pest control company visiting twice a week, pest sightings continue, as documented in the facility's logs. The administrator believes the treatments are working, citing fewer complaints, but the evidence suggests otherwise. The deficiency highlights a significant lapse in the facility's pest control measures, impacting residents' comfort and potentially their health.
Failure to Ensure Functional Low Air Loss Mattress for Resident at Risk
Penalty
Summary
The facility failed to ensure that a Low Air Loss Mattress (LALM) was functional for a resident at high risk for pressure ulcers. During an observation, it was noted that the LALM was not inflated and lacked a sheet, leaving the resident's skin in direct contact with the mattress. The LPN present was unaware of how to adjust the mattress settings according to the resident's weight. The Wound Care Technician later set the mattress to the correct weight setting, indicating that the issue arose from the staff not adjusting the mattress after the resident's recent return from the hospital. The resident involved has a medical history that includes hemiplegia, morbid obesity, and dependence on enabling devices, making them highly susceptible to pressure ulcers. The facility's policy requires that LALMs be set up and covered with a sheet, which was not adhered to in this instance. The resident's care plan and physician orders also specified the use of a LALM, highlighting the importance of this intervention for the resident's care. The deficiency was identified through a combination of observation, staff interviews, and record reviews.
Failure to Provide Adequate Supervision During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that a second staff member was present to assist in a mechanical lift transfer for three residents, resulting in an accident involving one resident. This resident sustained a laceration to the right foot requiring five sutures and a fracture to the right great toe. The incident occurred when a CNA attempted to transfer the resident using a mechanical lift without the assistance of another staff member, as required by the facility's policy. The CNA admitted to performing the transfer alone after waiting for assistance that did not arrive. Interviews with the residents revealed that it was common for only one CNA to perform mechanical lift transfers, despite the care plans indicating the need for two staff members. The residents expressed concerns about the safety of these transfers, with one resident reporting previous minor incidents and another expressing fear during transfers. The facility's policy and training materials clearly state that two caregivers are required for operating mechanical lifts, and staff members confirmed their awareness of this requirement. The injured resident had a history of medical conditions including flaccid hemiplegia, convulsions, and diabetes, and was cognitively intact with a BIMS score of 15. The care plan for this resident specified the need for two staff members during mechanical lift transfers due to impaired mobility. Despite this, the CNA proceeded with the transfer alone, leading to the resident's injury. The facility's policies emphasize the importance of maintaining a safe environment and providing adequate supervision to prevent accidents, which was not adhered to in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches. On two separate occasions, surveyors observed cockroaches in the second-floor shower room and the lower-level women's bathroom. Additionally, a resident reported and showed evidence of a smashed cockroach on their wall. The Housekeeping Supervisor acknowledged the issue and mentioned that the pest control company visits the facility once a week. The facility's Pest Control Policy and Infection Prevention and Control Manual both emphasize the importance of maintaining a pest-free environment. Despite these policies, the presence of cockroaches was confirmed through direct observation and resident reports. The facility's census at the time of the report was 159 residents, all of whom could potentially be affected by this deficiency.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for several residents. Specifically, the call light in one resident's room was not functioning properly, and multiple residents had damaged or missing furniture in their rooms. For instance, one resident's dresser had a leaning drawer and a missing drawer, another resident's wardrobe and dresser had missing drawers, and several other residents had dressers with missing front panels, handles, or drawers. These issues were reported by the residents and observed by the surveyor, but the necessary repairs had not been made. Additionally, one resident's heater was making a loud noise, and their window screen was torn and dangling, which had been an issue for over a year. The facility's building manager job description and facility assessment tool both emphasize the importance of maintaining furnishings in a safe and operable condition and performing scheduled maintenance to prevent malfunctions. However, these guidelines were not followed, as evidenced by the numerous unresolved maintenance issues reported by the residents. The facility's nurse call downtime procedure policy also states that residents affected by a nurse call component failure should be offered a room change immediately, but this was not done for the resident with the non-functioning call light.
Failure to Provide Adequate ADL Care to Dependent Residents
Penalty
Summary
The facility failed to provide adequate ADL (Activities of Daily Living) care to five dependent residents. Resident R138, diagnosed with metabolic encephalopathy and severe cognitive impairment, was observed unshaven with discolored, thick toenails and soiled clothing. Despite requiring assistance for personal hygiene and dressing, R138's appearance indicated neglect, and staff were unsure when his clothes were last changed or why he was unshaven. Similarly, Resident R55, who has paraplegia and requires moderate assistance for dressing and total assistance for transfers, was found lying in bed on a mechanical lift sling for over an hour without being attended to by staff, and a soiled gown was observed at the foot of the bed. Resident R7, diagnosed with dementia and unable to complete a BIMS interview, was seen with soiled clothing and long, thick toenails, and staff failed to address these issues even when the resident was served lunch in the dining room in a visibly wet and soiled shirt. Resident R37, who is legally blind and has bilateral leg amputations, was found wearing a shirt that had not been changed for two days, despite requiring moderate assistance for dressing. Lastly, Resident R78, with severe cognitive impairment and dependent on staff for personal hygiene, was observed with facial hair that had not been shaved despite the resident's request and the facility's policy stating that shaving should be done as needed. The facility's failure to provide necessary ADL care to these residents indicates a significant deficiency in meeting their basic care needs.
Inadequate Staffing and Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the individualized needs of residents on the 3rd floor, which has a census of 52 residents. On the day of the survey, only one nurse and two CNAs were assigned to the 3rd floor, which is significantly lower compared to the staffing levels on the 1st and 2nd floors. This inadequate staffing led to several deficiencies in resident care, including unattended residents, unaddressed hygiene needs, and delayed assistance with mobility and toileting. For instance, a resident with dementia and a history of falls was found unattended in the bathroom, and another resident with metabolic encephalopathy was observed with soiled clothing and an unlocked bed, posing a fall risk. Several residents were observed with unmet hygiene needs, such as long and untrimmed toenails, soiled clothing, and unshaven appearances. One resident with paraplegia was found lying in bed with a soiled gown at the foot of the bed and reported that staff had not returned to assist with a transfer for over an hour. Another resident with an indwelling urinary catheter had a catheter bag containing 1900cc of urine, indicating that it had not been emptied since the previous day, contrary to the facility's policy of emptying drainage bags at least once per shift. The facility's assessment tool and management of falls policy were not adequately implemented, as evidenced by the lack of individualized care plans and interventions for fall prevention. The daily staffing schedule showed a significant disparity in the ratio of CNAs per resident on the 3rd floor compared to the other floors, which contributed to the observed deficiencies. The PBJ report also documented excessively low weekend staffing, further highlighting the staffing inadequacies that led to the deficiencies in resident care on the 3rd floor.
Deficiencies in Controlled Substance Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This deficiency was observed on multiple occasions, including the second shift on 4/13/24 and the first and second shifts on 4/14/24, where only one signature was present instead of the required two. Additionally, a discrepancy was found in the count of Tramadol 50mg tablets for a resident, where the recorded count was 10 tablets, but only 9 tablets were present. The LPN acknowledged the discrepancy and stated that the physician and DON would be notified as per protocol. Another deficiency was observed during the medication administration for a resident on the 3rd floor. The resident was prescribed Sodium Chloride Tablet 1 gram, with instructions to take 2 tablets by mouth three times a day. However, the LPN administered only one tablet instead of the prescribed two. When questioned, the LPN admitted to administering the incorrect dose and was unsure of the correct prescription. The facility's policies and procedures for controlled substance documentation and medication administration were not followed, as evidenced by the lack of dual signatures during shift changes and the incorrect administration of medication. The facility's job descriptions for nursing staff and the DON emphasize the importance of adhering to established protocols to ensure the highest degree of quality care, which was not maintained in these instances.
Failure to Label Multi-Dose Vial and Secure Medication Cart
Penalty
Summary
The facility failed to label an opened multi-dose vial of Fluticasone Propionate Nasal spray for a resident, identified as R132, which was observed in the medication cart without an open date. The Licensed Practical Nurse (LPN) stated that the medication did not need to be labeled with an open date, despite acknowledging that it is a multi-dose medication. The Director of Nursing (DON) confirmed that multi-dose medications should be labeled with an open date according to policy and procedure. The facility's policies require that multi-dose vials be labeled with the date they are opened and that medications be properly labeled and monitored for expiration dates. The manufacturer's instructions for the nasal spray also specify that the unit should be discarded after 120 metered sprays, indicating the importance of tracking the open date to ensure proper usage and expiration management. R132 has diagnoses including chronic obstructive pulmonary disease, shortness of breath, essential hypertension, and hyperlipidemia, and is cognitively intact with a BIMS score of 15. Additionally, the facility failed to ensure that the medication cart on the 3rd floor was locked while unattended. An LPN was observed leaving the medication cart unlocked and unattended at the nurse's station while retrieving medication from the dining room. The LPN admitted to forgetting to lock the cart. The facility's medication administration policy does not include specific instructions for medication storage or nurse supervision of the medication cart when it is unlocked. The facility's policy regarding drug storage was requested but not received during the survey. This failure has the potential to affect 52 residents on the 3rd floor.
Failure to Label Blood Glucose Test Strips with Open Date
Penalty
Summary
The facility failed to ensure that the container of multi blood glucose test strips was labeled with the open date, which is necessary to track the expiration of the strips. During an observation of medication storage, an opened container of the test strips without an open date was found in the medication cart used for six residents who receive blood glucose monitoring tests. The LPN acknowledged the oversight and discarded the strips, noting that using expired strips could result in incorrect readings. The Director of Nursing was unaware of the policy regarding labeling the strips with an open date and could not explain the potential effects of using expired strips. The facility's documentation and job descriptions emphasize the importance of following established policies and procedures to ensure high-quality care. The manufacturing manual for the test strips specifies that the open date should be written on the vial label and that the strips should be used within three months of opening. Despite these guidelines, the facility did not adhere to the protocol, potentially affecting the accuracy of blood glucose monitoring for the six residents involved.
Failure to Provide Mobility Device for Resident with Paraplegia
Penalty
Summary
The facility failed to provide a mobility device for a resident diagnosed with paraplegia, which was necessary to maintain or improve the resident's range of motion and mobility. The resident's care plan, updated in May 2021, indicated the use of a trapeze for repositioning due to a history of multiple gunshot wounds resulting in paraplegia. However, during an observation in April 2024, the resident reported that the staff had stopped providing active or passive range of motion exercises about a year ago and that he no longer had a trapeze, which made him feel weak and unable to reposition himself in bed. When questioned, the Assistant Director of Nursing and the Restorative Nurse both acknowledged that the resident's care plan included the use of a trapeze but stated that the resident had not requested one. The Restorative Nurse admitted that the resident had not been provided with a trapeze, despite it being listed in the care plan. This failure to implement the care plan intervention was a clear deficiency, as the facility's policies required recording any problems or complaints made by the resident and providing assistive devices for mobility as appropriate.
Failure to Ensure Bed Safety and Proper Supervision
Penalty
Summary
The facility failed to follow policy procedures and take preventative safety measures to ensure residents' beds reduced the risk of falls or injuries. One resident, diagnosed with metabolic encephalopathy and ataxic gait, was observed with an unlocked and angled bed, which moved when the resident sat on it. A Certified Nursing Assistant confirmed the bed was not locked and subsequently locked it. Another resident, diagnosed with paraplegia and dependent on staff for bed-to-chair transfers, was found lying in a high-positioned bed on top of a mechanical lift sling. The resident stated that staff had placed the sling an hour prior but had not returned to assist with the transfer. The facility's management of falls policy requires developing a care plan addressing risk factors and monitoring the resident's environment for potential hazards, which was not adhered to in these cases.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to follow physician orders, implement care plan interventions, ensure staff awareness of policy procedures, and provide appropriate catheter care for a resident with neuromuscular bladder dysfunction and paraplegia. The resident's physician orders required daily and as-needed catheter care, and the care plan specified monitoring output every shift. However, the resident reported that the catheter bag had not been emptied since the previous day, and the surveyor observed 1900cc in the bag. The Director of Nursing was unaware of the specific policy for emptying catheter bags, which stated that they should be emptied at least once each shift and as needed. This failure to adhere to the policy and care plan resulted in inadequate catheter care for the resident.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to several deficiencies. For one resident, the nasal cannula was not labeled or dated, and the nebulizer mask and tubing were not contained or labeled. The nebulizer mask and tubing were found to be dirty and were disposed of by the Resident Care Coordinator. Additionally, the Assistant Director of Nursing confirmed that the nebulizer mask should be contained in a self-sealing bag and labeled with the date of change, which was not done in this case. The resident's care plan indicated the need for oxygen therapy due to chronic obstructive pulmonary disease (COPD) and acute respiratory illness, but the facility did not adhere to the established procedures for changing and labeling respiratory equipment. For another resident, the nebulizer tubing was observed on the floor, and the nebulizer machine and CPAP mask were found on the roommate's dresser. The Registered Nurse confirmed that the equipment was supposed to be bagged and labeled, but it was not properly stored. The resident's respiratory equipment was not contained as required, and the nebulizer tubing was not off the floor. These deficiencies indicate a failure to follow the facility's policies and procedures for respiratory care, potentially compromising the residents' health and safety.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. Two medication errors were identified out of 26 opportunities. One resident was given non-enteric coated Aspirin instead of the prescribed enteric coated version, and another resident received only one tablet of Sodium Chloride instead of the prescribed two tablets. These errors were observed during medication administration by two LPNs, who acknowledged the mistakes upon inquiry by the surveyor. The facility's medication administration policy requires drugs to be administered according to the physician's written orders, which was not followed in these instances.
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 1,936 citations issued within 25 miles in the last 12 months — including the 25 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 Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wentworth Rehab & Hcc | 0.1 mi | ★★★★★ | 5 | 0 |
| Landmark Of Hyde Park Rehabilitation And Nursing C | 2.2 mi | ★★★★★ | 16 | 0 |
| Bria Of Forest Edge | 3 mi | ★★★★★ | 4 | 0 |
| Montgomery Place | 3.1 mi | ★★★★★ | 8 | 0 |
| Pavilion Of South Shore | 3.1 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.