Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Radford Green during CMS and state inspections, most recent first.
Failure to Provide Timely Incontinence Care: Two residents who were dependent on staff for toileting hygiene and incontinent of urine and stool were found with saturated briefs and wet linens during observation. One resident had reddened skin with multiple open wounds and later was diagnosed with MASD to the sacral area; a wound physician stated the wounds were caused by prolonged moisture. A CNA stated the residents had last been changed hours earlier, despite staff stating incontinent residents should be checked and changed every 2 hours.
Failure to complete discharge MDS assessments for four residents. The facility's MDS report showed that discharge assessments were not completed or submitted within the required timeframe for multiple residents, and an MDS nurse confirmed the missed assessments and stated there had been a miscommunication issue with timely discharges.
Failure to provide pressure ulcer care and pressure relief was identified for multiple residents. A resident developed a new coccyx stage 2 wound that was observed without a dressing and without timely documentation or assessment, while other residents were found without heel boots in place, on a low-air-loss mattress that was powered off and deflated, or on a mattress set to an incorrect weight setting despite existing pressure injuries.
Pureed Meal Menu Not Followed: A cook prepared a pureed noon meal, but pureed residents were served BBQ chicken, cowboy beans, and mashed potatoes instead of the full menu. The pureed soup was not served to all residents, and the pureed salad and dessert remained wrapped on the prep table during service. The DON stated the pureed meal should include all menu items unless a resident requests something else.
Pureed meals were not prepared to the required smooth consistency for residents on a puree diet, affecting 5 residents reviewed for therapeutic diets. A cook blended BBQ chicken and cowboy beans with an unmeasured amount of thickener, and the items were later observed as thick, lumpy, and gritty with pieces that required chewing. The DON confirmed the meals were not smooth like pudding, which was the expected consistency per facility recipes.
Failure to document wound assessment and perform ordered daily weights: A resident developed a new back wound, but the facility could not provide a complete wound assessment with characteristics and measurements. Two residents with CHF and daily diuretic orders also missed multiple ordered daily weights, and both stated they had not been weighed every day. Staff and the wound protocol indicated that wound assessments and daily weights were to be documented as ordered.
A resident with Alzheimer's, dysphagia, and hospice status had significant weight loss documented, including a 7.16% loss in less than a month and a 13.01% loss in one week. The RD did not complete a timely nutrition assessment after the weight loss, and the later note did not address the loss or document any recommendation, despite the DON stating residents with significant weight loss should still be assessed by the facility even when on hospice.
Failure to Maintain HOB Elevation During Tube Feeding: A resident receiving enteral feeding had the HOB lowered to flat during incontinence care while the feeding continued. The CNA left the room and later returned with the HOB still flat and the tube feeding still running, despite the resident's care plan calling for HOB elevation during and after feeding and the facility policy requiring HOB elevation during tube feeding.
PPE was not consistently used during high-contact care for residents on EBP, and contaminated oxygen tubing was reused. Two CNAs provided incontinence care to a resident with dementia, dysphagia, a coccyx pressure injury, and EBP without gowns, and another CNA entered a resident’s room on EBP and performed perineal care without a gown. In a separate event, a CNA picked up a resident’s nasal cannula after it fell on the floor and placed it back in the resident’s nares, despite staff stating it should be discarded if contaminated.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
A resident's credit card was stolen and used by a CNA, who accessed the card from the resident's nightstand and made unauthorized purchases at a local liquor store. The theft was discovered after the resident noticed an unfamiliar charge and reported it to both the facility and police. Investigation confirmed the CNA's involvement, leading to criminal charges for theft and unlawful use of the credit card.
A resident suffered second-degree burns from hot coffee served at 187.2°F, exceeding the facility's policy of 180°F. The coffee machine's temperature was not regularly checked. Another resident, at high risk for falls, lacked consistent fall prevention measures, such as floor mats and a low bed position, despite a care plan specifying these interventions.
The facility failed to consistently monitor food temperatures before serving meals to all 76 residents. The Dining Director stated that temperatures should be taken in the kitchen and again on the floors before serving, but records showed multiple instances of missing temperature logs. The facility's policy requires temperatures to be recorded three times per meal service, but this was not followed, leading to a deficiency in food safety and quality.
The facility failed to properly dispose of controlled substances for three residents. A resident with joint replacement had a Tramadol tablet taped back into the medication card, while another with a femur fracture had an Oxycodone pill similarly mishandled. Additionally, a resident with Alzheimer's had a diphenoxylate/atropine pill taped back into the card. The facility's policy requires destruction of such medications if not administered, witnessed by two nurses, which was not followed.
A facility failed to ensure proper PPE use for a resident on droplet precautions for COVID-19. An RN exited the resident's room, removing only her gown and gloves, but continued to wear her face shield and N95 mask in the hallway, risking cross-contamination. The facility's policy requires full PPE removal after leaving the room to prevent germ spread.
A resident at risk for pressure injuries did not receive weekly skin assessments, resulting in full-thickness wounds on the buttocks. Despite being identified as at risk, the facility failed to perform assessments for three weeks, only discovering the injuries after the resident reported pain. The DON confirmed the lapse in monitoring.
A resident with no cognitive impairment experienced a delay in the repair of a broken sink faucet, resulting in no water for personal hygiene. The issue was reported on a Friday and marked as a priority, but was not resolved until the following Monday. The RN Weekend Supervisor provided buckets of water, and the maintenance staff from Assisted Living was unable to fix the faucet over the weekend due to the need for a replacement.
A resident with severe cognitive impairment and right-sided weakness fell during a shower due to inadequate supervision. Despite requiring two-person assistance, a CNA assisted the resident alone and turned away to retrieve clothing, resulting in the resident falling from the shower chair. The incident highlights a failure to adhere to the care plan and safety protocols.
A resident with chronic pain was not informed of a change in her medication from Norco to Extra Strength Tylenol, leading to potential withdrawal symptoms. The DON confirmed the resident was not notified, and the NP assumed nurses would inform her. This oversight violated the resident's rights to be informed of changes in her treatment.
A resident with severe cognitive impairment suffered a left hip fracture after being improperly transferred using a mechanical lift by a CNA without assistance. The incident was not reported immediately, delaying necessary medical evaluation and treatment. The resident's condition worsened over several days before an x-ray revealed the fracture.
A resident with severe cognitive impairment and multiple health issues sustained a femur fracture during a mechanical lift transfer due to inadequate staffing. The CNA attempted the transfer alone, contrary to facility policy requiring two staff members, resulting in the resident sliding out of the sling and being lowered to the ground. The incident led to bruising and a fracture, with the resident's poor bone quality contributing to the injury.
A cognitively impaired resident with a history of stroke and high fall risk was left unsupervised on the toilet by two staff members, resulting in a fall and severe injuries, including a basal ganglia hemorrhage and a frontal scalp hematoma. The facility's policy on resident supervision was not followed, leading to the incident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for 2 of 18 residents reviewed for activities of daily living, resulting in one resident developing moisture associated skin damage with open wounds to the sacral area. One resident’s MDS showed severe cognitive impairment, constant urinary and bowel incontinence, and dependence on staff for toileting and personal hygiene. During observation, the resident’s incontinence brief was saturated, the sheet underneath was wet, and the buttock was reddened with multiple open wounds present. A CNA stated the resident had last been changed with night shift assistance around 6:45-7:00 AM. The wound physician later stated the resident had a cluster of wounds on the bottom caused by MASD and that prolonged moisture could have contributed to the wounds. The second resident’s MDS showed cognitive impairment, urinary and bowel incontinence, and dependence on staff for toileting and personal hygiene. During observation, the resident’s incontinence brief was saturated, the sheet underneath was wet, and the buttock was reddened with an open wound present. The CNA stated the resident had last been changed at breakfast time. Another CNA stated that incontinent residents should be checked and changed every two hours. The second resident’s care plan directed staff to provide incontinence care in a timely manner, and the facility’s ADL policy stated that residents unable to perform ADLs independently are to receive appropriate assistance with hygiene and elimination.
Failure to Complete Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure discharge MDS assessments were completed for discharged residents. In a sample of 18 residents, this applied to 4 of 4 residents reviewed for resident assessments: R29, R54, R81, and R83. R29 was admitted to the facility on an unspecified date and discharged on 12/28/25, but on 4/15/26 her MDS showed the discharge assessment had not been completed, more than 100 days after discharge. R54, R81, and R83 were also discharged from the facility, with discharge dates of 03/16/26 for R54 and 3/20/26 for R81 and R83. The facility's MDS report on 4/15/26 showed their discharge assessments were not completed or submitted within 14 days of discharge. The MDS Nurse stated the facility has 84 certified beds, that residents may not have been discharged timely, that discharge MDS assessments must be submitted within 14 days, and that there had been a miscommunication issue with timely discharges. She also said she runs a monthly report of missed assessments and was in the process of completing missed discharge assessments, and confirmed that R54, R81, and R83 were not completed within 14 days while she was not aware of R29's discharge assessment not being completed.
Failure to Provide Pressure Ulcer Care and Pressure Relief
Penalty
Summary
The facility failed to identify, assess, and implement treatment after a resident developed a stage 2 pressure ulcer, and failed to ensure pressure ulcer prevention interventions were in place for multiple residents. One resident was observed with an open wound on the coccyx during incontinence care, with no dressing present in the brief and no documentation of the wound between the first observation and a later skin check. The resident’s hospice notes later documented a new opening to the coccyx or sacral region as a stage 2 wound measuring 1 cm x 3.5 cm x 0.1 cm with no drainage and 100 percent granulation tissue. The DON stated that when a CNA sees a new wound, the nurse should be notified right away, the nurse should assess it immediately, and the provider should be called for treatment orders. The facility also failed to ensure pressure-relieving interventions were in place for other residents. One resident with a wound to the foot was observed in bed with the heels directly on the mattress while heel protector boots were sitting in a chair, and the boots remained off during a later observation even though the clinical nurse manager stated the resident should wear them at all times in bed. Another resident with stage 3 and stage 2 pressure injuries to the buttocks was on a low-air-loss mattress that was powered off and appeared deflated on two observations. A third resident with a coccyx pressure injury was lying on a low-air-loss mattress that was set for 200 pounds despite the resident weighing 76.2 pounds. The clinical nurse manager stated the mattress settings should match the resident’s weight and nurses were responsible for checking that the device was powered on and set correctly.
Pureed Meal Menu Not Followed
Penalty
Summary
The facility failed to follow the noon meal menu for residents on a pureed diet. During lunch service, the cook prepared the pureed meal using the food processor with bean soup, BBQ chicken, cowboy beans, pea onion salad, and coffee cake, but when the meal was served on the second floor, pureed residents were given BBQ chicken, cowboy beans, and mashed potatoes instead. The pureed soup was not served to all pureed residents, and the pureed pea salad and coffee cake were not served during the meal service. At the time of the meal, the pureed pea salad and pureed coffee cake were still sitting on the prep table behind the serving table with plastic wrap in place. The Dietary Manager stated that the pureed meal should receive what was on the menu, including pureed soup, BBQ chicken, cowboy beans, pea salad, and coffee cake, and that the soup and salad should be served first. A facility list identified five residents on a pureed diet, and the menu for the noon meal listed barley soup, green pea and red onion salad, BBQ chicken, cowboy beans, and assorted desserts. The facility policy stated that the community would provide a comprehensive dining program to meet residents' individual nutritional needs and enhance quality of life.
Pureed Meals Served Lumpy Instead of Smooth
Penalty
Summary
The facility failed to ensure that puree noon meals were prepared in a smooth consistency for residents on a pureed diet, affecting 5 of 5 residents reviewed for therapeutic diets (R11, R23, R42, R91, and R6). During meal preparation, the cook added cubed chicken, BBQ sauce, hot water, and an unmeasured amount of thickener to the food processor and blended the mixture, then placed the pureed BBQ chicken in a steam pan where it appeared thick and lumpy. The cook also pureed cowboy beans and added an unmeasured amount of thickener. When sampled, both the pureed BBQ chicken and cowboy beans appeared lumpy, with small gritty pieces that required chewing. The dietary manager stated the puree meals normally do not look like this and confirmed the items were not a smooth consistency and should be smooth like pudding. Facility recipes for BBQ chicken and pureed cowboy beans directed that the food be blended until smooth and, for the beans, adjusted to a smooth pudding consistency.
Failure to Document Wound Assessment and Perform Ordered Daily Weights
Penalty
Summary
The facility failed to perform and document a wound assessment for a resident with a new wound. R4 had a dressing on the upper back, and nursing notes documented a small open area to the midback that was cleaned with normal saline, patted dry, and covered with a clean, dry dressing. The facility could not provide additional wound assessment documentation showing the wound’s characteristics or measurements. The wound evaluation and management summary later documented a non-pressure wound on the left upper back measuring 0.6 cm x 0.6 cm x 0.1 cm with moderate serous exudate. Staff stated that when a resident develops a wound, the nurse should assess it, call the provider for orders, and document the wound characteristics and measurements, and the facility’s wound assessment protocol required a focused skin and wound assessment when concerns are identified. The facility also failed to ensure daily weights were performed for residents with CHF who had physician orders for daily weights. R13 had CHF and received Torsemide daily, with an order to record weight daily and notify the MD for a gain of more than 2 pounds in one day or 5 pounds in one week. The resident stated she had not been weighed every day, and the weight record showed multiple missed days across March and April 2026. R108 also had CHF and respiratory failure, received daily Furosemide, and had an order to record weight daily with the same notification parameters. R108 stated she had not been weighed daily, and the weight record showed missed weights on several consecutive days in April 2026. The DON stated residents should be weighed as ordered and that residents with CHF and on diuretics are weighed daily to monitor for increased fluid retention.
Failure to Assess Significant Weight Loss
Penalty
Summary
The facility failed to ensure a resident was assessed by a dietician after significant weight loss. The resident had diagnoses including Alzheimer's Disease with early onset and dysphagia, was dependent on staff for feeding assistance, was at risk for nutritional deficit, and had transitioned to hospice care. Her weight record showed 89.4 lbs. on 1/28/26 and 83.0 lbs. on 2/22/26, a 6.4 lb. 7.16% loss in less than one month, followed by 87.6 lbs. on 3/1/26 and 76.2 lbs. on 3/7/26, an 11.4 lb. 13.01% loss in one week. The facility provided dietary progress notes showing the resident was assessed by the Registered Dietician on 10/24/25, but the next dietary/nutrition note was not completed until 3/26/26, about five months later. That note stated the resident was in hospice care related to decline secondary to Alzheimer's, remained on a pureed diet with a supplemental drink three times daily as tolerated, and continued current management, but it did not address the significant weight loss or document any recommendation that may have been implemented. The DON stated residents with significant weight loss should still be assessed by the facility even if they are on hospice, while the hospice nurse stated the facility had not asked to consult hospice dietetics for the required assessments.
Failure to Maintain Head of Bed Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident's head of bed was elevated while tube feeding was being administered for 1 of 3 residents reviewed for tube feeding management. During observation on 4/13/26 at 10:44 AM, a CNA entered R4's room to provide incontinence care while tube feeding was running, lowered the head of the bed to a flat position, and began care. At 10:49 AM, the CNA left the room to get help and left R4's head of bed lowered with the tube feeding still running. At 11:04 AM, the CNA returned and continued incontinence care while the head of bed remained flat and the tube feeding continued. On 4/14/26 at 2:06 PM, another CNA stated that the head of bed should always be elevated for a resident receiving tube feeding and that if it must be lowered for care, the nurse should be notified so the feeding can be stopped. R4's care plan directed that the head of bed be elevated 45 degrees during tube feeding and for 30 minutes after, and the facility's Enteral Feedings-Safety Precautions Policy stated that the head of bed should always be elevated at least 30-45 degrees during tube feeding and at least 1 hour after.
PPE Not Used During EBP Care and Contaminated Oxygen Tubing Reused
Penalty
Summary
The facility failed to ensure required PPE was worn during high-contact care for residents on Enhanced Barrier Precautions (EBP). R24’s record showed diagnoses including dementia and dysphagia, and her care plan indicated she was incontinent of bowel and bladder, dependent on staff for care, had a pressure injury to her coccyx requiring wound care, and was on EBP because of the wound. On 4/13/26, a sign on R24’s door directed staff to wear gloves and gowns for high-contact care, and PPE supplies were available outside the room. Two CNAs entered the room wearing only gloves, used a mechanical lift to place R24 in bed, and then removed her incontinent brief and provided incontinence care without ever putting on gowns. A bandage was noted on R24’s lower back, and an LPN later stated that both gowns and gloves are required when direct patient care is provided to a resident on EBP. The same failure was observed with R4, whose door sign also required gloves and gowns for high-contact care such as hygiene and changing briefs. A CNA entered R4’s room to provide incontinence care without wearing a gown and cleaned R4’s front perineal area. R4’s care plan identified a potential for spread of MDROs during high-contact care and directed staff to apply gloves and gown before performing those activities. In addition, R107, who had diagnoses including acute respiratory failure and COPD and had an order for continuous oxygen via nasal cannula, had oxygen tubing handled in a way that did not prevent cross contamination. During care, R107’s nasal cannula fell onto the floor, and the CNA picked it up and immediately placed it back into R107’s nares. Another CNA stated that a nasal cannula that falls on the floor should be disposed of because it is considered contaminated and could potentially cause an infection.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Resident from Misappropriation of Funds by CNA
Penalty
Summary
A facility failed to protect a resident from misappropriation of funds when a certified nursing assistant (CNA) stole and used a resident's credit card. The resident, who was on isolation for influenza and had limited mobility, reported his credit card missing after noticing an unauthorized charge. The card had been brought to him by his son and was kept in his nightstand, bundled with other cards. The resident discovered the theft after checking his account and immediately canceled the card and notified both the police and the facility. Investigation revealed that the CNA, who worked the day the card was stolen, confessed to using the stolen credit card at a local liquor store. Facility records and staff schedules confirmed that the CNA was present during the relevant timeframe and that no other staff member named by the CNA was working at that time. The CNA's proximity to the liquor store and her frequent visits there were corroborated by a store employee and law enforcement. The CNA initially denied the theft, blaming another staff member, but ultimately admitted to using the stolen card for personal purchases. The facility's own policies require protection of residents from misappropriation of property by staff or others. Despite these policies, the CNA was able to access the resident's personal belongings and use the credit card without authorization. The incident was substantiated by law enforcement, and the CNA was charged with multiple felonies related to the theft and misuse of the resident's credit card.
Failure to Ensure Safe Coffee Temperature and Fall Prevention
Penalty
Summary
The facility failed to ensure that resident coffee was served at a safe temperature, resulting in a resident, identified as R57, receiving second-degree burns on her right arm. The incident occurred when R57, who has severe cognitive impairment and requires substantial assistance for daily activities, spilled hot coffee on herself while in bed. The coffee was dispensed from an automatic machine, and the temperature was measured at 187.2 degrees Fahrenheit, exceeding the facility's policy of not serving hot liquids above 180 degrees. The Dietary Director, V5, admitted that the temperature of the coffee was not regularly checked, and the last service update for the machine was several months prior. Additionally, the facility failed to implement fall preventative measures for another resident, R28, who has a high risk of falls due to severe cognitive impairment and a history of falls. Despite the care plan specifying the use of floor mats and keeping the bed in the lowest position, observations revealed that these interventions were not consistently in place. R28 was found without fall mats next to her bed on multiple occasions, and the bed was not always in the lowest position, increasing the risk of injury from falls. The facility's policies on the safety of hot liquids and fall risk management were not adequately followed, leading to these deficiencies. The lack of regular temperature checks for the coffee machine and the failure to consistently implement fall prevention measures contributed to the incidents involving R57 and R28, respectively. These oversights highlight the need for adherence to established safety protocols to prevent harm to residents.
Failure to Monitor Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were consistently monitored for meals prior to service for all 76 residents. According to the Dining Director, food temperatures are initially taken by a dietary aide in the kitchen and then again on the 2nd and 3rd floors before being served to residents. However, a review of the temperature monitoring sheets for the week of February 2 to February 8 revealed multiple instances where temperatures were not recorded as required. Specifically, on the 2nd floor, there were missing temperature recordings for several meals, including no dinner temperatures on February 6, 7, and 8. Similarly, on the 3rd floor, there were missing temperature recordings for dinner on February 2, and no temperatures recorded for lunch or dinner on February 4, 6, and 8. The facility's policy from 2005 mandates that hot food temperatures be taken three times throughout each meal service: before leaving the kitchen, prior to meal service, and after meal service completion. These temperatures are to be recorded in a log form. The Dining Director emphasized the importance of taking food temperatures to ensure food is cooked properly, prevent food poisoning, and serve hot meals to residents. Despite this policy, the facility did not adhere to the required temperature monitoring procedures, leading to a deficiency in ensuring the safety and quality of food served to residents.
Improper Disposal of Controlled Substances
Penalty
Summary
The facility failed to ensure the safe disposal of controlled substances for three residents, as observed during a survey. Resident R296, admitted for aftercare following joint replacement, had a Tramadol tablet taped back into the medication card instead of being destroyed when not administered. Similarly, Resident R297, admitted for a femur fracture, had an Oxycodone pill taped back into the card. The registered nurse acknowledged that controlled medications should not be taped back into the bubble cards and should be destroyed if refused by the resident. Additionally, Resident R22, with multiple diagnoses including Alzheimer's disease, had a diphenoxylate/atropine pill taped back into the medication card. The registered nurse confirmed that the pill should have been destroyed in the presence of two nurses, who would then sign the medication count sheet. The facility's policy from November 2022 mandates that controlled substances must be destroyed if not administered, with the process witnessed and documented by two nurses. The failure to adhere to this policy was evident in the handling of controlled medications for these residents.
Improper PPE Use Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) to prevent cross-contamination for a resident on droplet precautions due to COVID-19. On February 18, 2025, signs on the resident's door indicated the need for full PPE, including gowns, gloves, face shields, and N95 masks, with instructions for proper donning and doffing. However, on February 19, 2025, a registered nurse (RN) exited the resident's room and removed her gown and gloves at the room door but continued to wear her face shield and N95 mask down the hallway, potentially contaminating the environment outside the isolation room. The Director of Nurses confirmed that full PPE is required when entering a room of a resident on isolation for COVID-19 and that PPE should be removed upon exiting to prevent the spread of germs. The facility's policy, revised in May 2023, states that disposable respirators and eye protection should be removed and discarded after leaving the resident's room. The RN's failure to remove all PPE as per the facility's policy and the potential for cross-contamination were identified as deficiencies in infection control practices.
Failure to Conduct Regular Skin Assessments Leads to Pressure Injuries
Penalty
Summary
The facility failed to conduct regular skin assessments for a resident, leading to the development of full-thickness pressure injuries on the resident's buttocks. The resident, who was admitted with diagnoses including pancreatic cancer, Type 2 diabetes, and chronic kidney disease, was identified as being at risk for pressure injuries according to the Braden scale. Despite this risk, the facility did not perform weekly skin assessments as required, with no assessments documented for three consecutive weeks following the initial assessment upon admission. The deficiency was discovered when the resident complained of pain, prompting a wound nurse to assess and identify open areas on the resident's buttocks. The wounds were subsequently assessed by a wound physician, who documented full-thickness injuries. The Director of Nursing confirmed the lapse in weekly skin assessments, acknowledging that the open areas were only discovered during a progress note on January 9th. This oversight in regular skin monitoring contributed to the progression of the resident's pressure injuries.
Delayed Repair of Resident's Sink Faucet
Penalty
Summary
The facility failed to ensure that a resident's sink faucet was in working order, affecting one resident who was reviewed for environmental services. The resident, who had no cognitive impairment, reported that it took several days for the staff to fix the broken sink faucet in their room, which resulted in no water being available for personal hygiene tasks such as brushing teeth. The issue was initially reported on a Friday, and despite being marked as a priority for same-day repair, the faucet remained unfixed over the weekend. The Registered Nurse Weekend Supervisor was informed of the issue on Saturday and provided buckets of water to the resident for use during care. The Assistant Director of Nursing was also notified, and the maintenance staff from the Assisted Living unit was called to address the problem. However, the maintenance staff member who responded on Sunday was unable to fix the faucet due to the need for a complete replacement. The faucet was eventually replaced and fixed on the following Monday morning. The facility's maintenance policy requires the maintenance department to maintain equipment in a safe and operable manner, which was not adhered to in this instance.
Inadequate Supervision During Shower Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident during showering, leading to a fall. The resident, a male with severe cognitive impairment, right-sided weakness, and a history of falls, was dependent on staff for bathing. On the day of the incident, a CNA was assisting the resident alone, despite the care plan indicating the need for two-person assistance due to the resident's weakness and instability. The CNA turned away to retrieve clothing, leaving the resident unattended, which resulted in the resident leaning forward and falling from the shower chair. The CNA involved in the incident was aware that the resident required two-person assistance but proceeded alone, believing he could manage the task. The resident's care plan and the facility's falls protocol emphasized the need for close supervision and appropriate equipment, such as a reclining shower chair, which was not used. The CNA's decision to turn away from the resident without ensuring items were within reach contributed to the fall, highlighting a lapse in following established safety protocols for residents at risk of falls.
Failure to Notify Resident of Medication Change
Penalty
Summary
The facility failed to notify a resident of a change in her medication, which is a violation of her rights. The resident, who has no cognitive impairment, was not informed when her pain medication was switched from Norco to Extra Strength Tylenol. She noticed trembling after taking her pain medication and suspected a substitution. Upon inquiry, she was informed by a nurse that her medication had been changed to Tylenol without her knowledge. The resident expressed her dislike for Tylenol and reported the issue to the Director of Nursing, who then discontinued the Tylenol order per the resident's request. The Director of Nursing confirmed that the resident was not made aware of the medication change, which should have been communicated to her. The Nurse Practitioner involved assumed that the nurses would inform the resident of the new Tylenol order. The facility's policy states that residents have the right to be notified of any changes in their medical condition or treatment, which was not adhered to in this case. This oversight led to the resident experiencing potential withdrawal symptoms and a lack of informed participation in her treatment plan.
Failure to Timely Assess and Report Incident Leads to Resident Injury
Penalty
Summary
The facility failed to ensure timely assessment and notification of a physician after a resident was lowered to the ground during a mechanical lift transfer, resulting in a left hip fracture. The incident occurred when a Certified Nursing Assistant (CNA) attempted to transfer the resident using a sit-to-stand lift without the required assistance. The resident, who had severe cognitive impairment and required maximum assistance, became agitated and began to slide out of the lift sling. The CNA, who was alone, did not report the incident to the nurse, believing the resident was not hurt. Another CNA witnessed the incident and assisted in lowering the resident to the ground and transferring her to a wheelchair. Despite the resident's complaints of pain and bruising observed on her left shoulder, the incident was not reported to the nurse until the following day. The facility's Director of Nursing confirmed that the staff should have had two CNAs present for the transfer and should have reported the incident immediately for an assessment. The resident's condition worsened over the following days, with increased pain and limited range of motion observed. An x-ray eventually revealed a fracture to the left distal femur, which was linked to the incident. The facility's failure to provide ongoing nursing assessments and timely medical evaluations resulted in the resident not receiving necessary treatment until several days after the incident.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in a femur fracture that required surgery. The resident, who had severe cognitive impairment and required maximum staff assistance for mobility and transfers, was being transferred by a sit-to-stand lift for a shower. During the transfer, the resident became agitated and began to slide out of the lift sling. The CNA, who was alone during the transfer despite the facility's policy requiring two staff members, did not secure the leg band around the resident's legs, leading to the resident hanging from the sling with her arms raised and legs dangling. Another CNA intervened, assisting in lowering the resident to the ground. The incident resulted in bruising and pain, initially noted in the shoulder, but later an x-ray revealed a fracture in the left femur. The Director of Nursing confirmed that the facility's policy mandates two staff members for mechanical lift transfers to ensure resident safety. The orthopedic surgeon noted that the resident's poor bone quality could have contributed to the fracture when being lowered to the ground.
Failure to Supervise Cognitively Impaired Resident Leads to Severe Injury
Penalty
Summary
The facility failed to supervise a cognitively impaired resident (R1) while being toileted, resulting in R1 falling off the toilet and requiring emergent transport to a local hospital. R1 was admitted with a diagnosis of a basal ganglia hemorrhage and a frontal scalp hematoma. R1 had a history of cerebrovascular accident (CVA) which caused weakness in her right arm and leg, and she was nonverbal due to the stroke. R1's care plan indicated she was at risk for falls due to impaired cognition, poor safety awareness, overall weakness, and need for assistance with activities of daily living (ADLs). Despite this, on 5/7/24, two staff members (V9 CNA and V12 LPN) left R1 unsupervised in the bathroom, leading to her fall. V12 admitted to leaving R1 alone to check on a disturbance in the hallway, during which time R1 fell and sustained injuries. Interviews with staff and R1's physician confirmed that R1 was a high fall risk and should not have been left alone. The facility's Safety and Supervision of Residents policy emphasized the importance of resident supervision based on assessed needs and identified hazards. The Director of Nursing (V2) acknowledged that staff should not have left R1 unsupervised given her high fall risk. The incident highlights a failure in adhering to the facility's policy and ensuring adequate supervision for a vulnerable resident, leading to significant injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincolnshire
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Riverwoods | 1.1 mi | ★★★★★ | 3 | 0 |
| Serenity Estates Of Lincolnshire | 1.6 mi | ★★★★★ | 18 | 2 |
| Warren Barr Buffalo Grove | 2.3 mi | ★★★★★ | 2 | 0 |
| Addolorata Villa | 2.7 mi | ★★★★★ | 6 | 0 |
| Greek American Rehab Care Ctr | 2.8 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.