Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Renwick Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain safe and comfortable temperatures for all residents after a power outage and boiler malfunction, resulting in prolonged cold conditions throughout the building. A maintenance director reset the boilers but left after noting the facility was warming, while multiple residents reported being very cold for extended periods, relying on numerous blankets, extra clothing, and room changes. Staff, including CNAs, LPNs, and an RN, acknowledged that the building felt cold, that residents complained, and that they used all available blankets and moved some residents to warmer areas, but they did not consistently notify on-call leadership or maintenance about the ongoing lack of heat. Temperature logs documented readings in the upper 50s to low 60s°F in various areas, and not all residents had body temperatures monitored, despite facility policy requiring notification of administration and maintenance, regular room temperature checks, and observation of residents for adverse effects during loss of heat.
Essential heating equipment was not properly maintained following a power outage, resulting in a period without adequate heat for all residents. The Maintenance Director did not know the boilers required manual resetting after the outage and did not reset all units, and an assistant later had to reset an additional boiler. A heating contractor identified a failed pump motor that was critical for the heat pumps to function and advised immediate replacement, but facility leadership chose to delay the work until normal business hours, despite staff reporting that they were cold. A technician later replaced the defective pump motor and components and confirmed that room temperatures were rising.
Surveyors identified extensive sanitation and hygiene deficiencies in the kitchen, including dirty handwashing stations, stained equipment, spoiled food, and improper staff hygiene practices such as inadequate handwashing and incomplete hair covering. Staff were observed wearing personal clothing in food prep areas and using cracked equipment, while food contact surfaces and storage areas were found with visible residue, stains, and food particles. Facility policies requiring cleanliness and infection control were not consistently followed.
A resident with a history of falls and behavioral challenges was being assisted with toileting when she attempted to pull up her own pants, became unstable, and fell, sustaining a head injury. The staff member assisting did not use a gait belt as required by facility policy, instead attempting to support the resident manually, which was insufficient to prevent the fall.
A resident at high risk for falls, with multiple medical conditions and on blood thinners, was injured after being transferred with a sit to stand lift by a single CNA, despite facility policy requiring two staff for such transfers. The resident fell forward and sustained a bleeding injury to the forehead. The care plan did not specify fall precautions, and staff interviews confirmed the transfer was not performed according to policy.
A resident with moderate cognitive impairment and depression threatened his severely cognitively impaired roommate with a pocketknife, making alarming statements and causing mental distress. Nursing staff moved the threatened resident to another room and later discovered the knife when the resident's family arrived. The facility failed to protect the resident's right to be free from mental abuse, as defined by its own abuse prevention policy.
A resident with schizophrenia and recent elopement attempts was subject to involuntary transfer and discharge procedures initiated by facility staff without the required physician documentation or orders. The DON completed the necessary forms at the direction of corporate staff, but the forms were not signed by a physician and lacked detailed medical justification. Hospital evaluation found no immediate safety concerns, and the resident's medical record did not contain physician progress notes or orders supporting the transfer or discharge.
A resident with hemiplegia and obesity fell from bed during care due to inadequate assistance, resulting in fractures and a knee dislocation. The CNA, working alone, directed the resident to turn onto her affected side, leaving her close to the bed's edge. Despite the resident's care plan requiring two-person assistance, no additional staff were available, leading to the fall and subsequent hospitalization.
A resident with severe cognitive impairment and multiple health issues was injured during a transfer when a CNA used a gait belt instead of the prescribed mechanical lift with two staff members. This improper transfer led to a leg laceration requiring sutures. Facility staff confirmed that the expectation was to follow therapy's recommendations for safe transfers, as outlined in the care plan and facility policy.
The facility failed to maintain sanitary practices during food preparation and service, affecting 92 residents. A cook was observed using a dirty blender and lid, with uncovered facial hair, and storing personal items on prep counters. Uncovered and undated food items were found in storage, and a dietary aide also had uncovered facial hair. Facility policies on food storage and preparation were not adhered to.
The facility failed to follow its Infection Prevention and Control Program, with the ADON not completing infection surveillance tools since October 14, 2024. The Maintenance Director was unaware of the water management plan for legionella, leading to no monitoring of water systems. Staff also neglected hand hygiene and Enhanced Barrier Precautions, with CNAs not wearing gowns or performing hand hygiene between tasks, affecting residents with conditions like ESBL resistance and Candida Auris.
The facility failed to maintain comfortable room temperatures, affecting six residents who reported inadequate heating in their rooms. Temperatures dropped to 58 degrees Fahrenheit at night, forcing residents to use extra blankets. The issue arose from a contractor's error in the electrical system, delaying the installation of new heating units. The facility's policy for loss of heat was not effectively implemented.
The facility failed to assist six residents with personal hygiene, grooming, and incontinence care. Residents with cognitive impairments and physical limitations were observed with dirty fingernails, overgrown facial hair, and inadequate incontinence care. Despite needing total or extensive assistance, their grooming needs were unmet, highlighting a deficiency in maintaining hygiene and dignity.
The facility failed to provide adequate perineum and catheter care for four residents, increasing the risk of UTIs. One resident was not fully cleaned after incontinence, another's uncircumcised penis and groins were not properly cleaned, a third resident's pubic area and labia were inadequately cleaned, and a resident with a suprapubic catheter did not receive proper catheter care. Facility guidelines for incontinence and catheter care were not adhered to.
The facility failed to label and date opened medications, including insulin and inhalers, to determine expiration dates. Additionally, narcotic medications with broken seals were not discarded as required, posing risks of medication diversion and infection. These deficiencies were identified during inspections of medication storage areas.
The facility failed to serve the correct portion sizes for pureed diets as per the menu guidelines, affecting six residents. The cook substituted pureed chicken for pork and mashed potatoes for rice, and dietary aides used an incorrect scoop size, leading to a deficiency in meeting nutritional needs.
The facility failed to provide necessary splint and therapy services to two residents, leading to a decline in their range of motion (ROM). One resident, with hemiplegia, was not wearing the prescribed hand splint for several days, resulting in a decline in ROM. Another resident, with severe contractures, was observed without a splint, and an occupational therapist recommended splinting and an orthopedic consult. These deficiencies highlight the facility's failure to maintain or improve residents' ROM.
A resident with a history of cerebral infarction and rheumatoid arthritis experienced tooth pain for over six months without receiving recommended extractions. Despite multiple dental visits, no action was taken, leading to significant discomfort and a downgraded diet. Communication issues and financial concerns were noted, with the resident's daughter seeking insurance-covered options.
The facility did not follow its antibiotic stewardship policy, impacting all 92 residents. The ADON, newly appointed as Infection Preventionist, had just started reviewing antibiotic use. The facility lacked documentation for tracking antibiotic use since early September, as confirmed by the Regional Nurse Consultant.
The facility failed to implement proper infection control practices following a COVID-19 exposure, affecting 55 residents. Residents were not tested for COVID-19 despite known positive cases, and the facility did not adhere to its COVID-19 policy. A CNA who tested positive had contact with residents and staff without appropriate precautions. The facility lacked documentation of testing and tracking, resulting in inadequate infection control measures.
The facility failed to maintain a safe and comfortable environment for residents due to a malfunctioning air conditioning system. Despite being notified of the issue, the facility did not take timely action, resulting in high room temperatures and resident discomfort. The facility did not follow its hot weather policy, using inappropriate tools to measure air temperature and failing to provide adequate fluids to residents. The HVAC contractor had informed the facility of underground pipe leaks, but temporary cooling solutions were delayed, affecting all 98 residents.
The facility failed to follow hot weather policies when the air conditioning malfunctioned, resulting in room temperatures exceeding 85°F. The administration did not ensure temperature and humidity were monitored every two hours, and residents were left in hot conditions without water. The facility lacked the necessary equipment to measure air temperatures and humidity, and staff were not informed of the procedures to follow during the malfunction.
Failure to Maintain Safe Indoor Temperatures and Monitor Residents During Heating System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe and comfortable indoor temperatures for all 102 residents following a power outage and subsequent heating system malfunction. After a power outage occurred on a Saturday, the Maintenance Director reported that the power was restored within approximately 45 minutes and stated there were no heating issues at that time. The next day, the Administrator notified the Maintenance Director that the heat was not working, and the Maintenance Director manually reset the boiler system, which he stated was required after the outage but had not been done earlier because he was unaware of the need. He reported that after resetting the boilers, the heat began working and temperatures taken throughout the facility showed it was warming up, and he then left the building. Despite this, residents and staff reported that the building remained cold over the weekend and into Monday. One resident stated that heating issues began on Saturday evening when the power went out and that the thermostat in his room read 55–60°F for 18 hours before he was moved to another room on Sunday afternoon. Another resident reported that it was very cold and that his nose was freezing to the touch, and staff provided extra blankets. A third resident’s room temperature was measured at 62.4°F by the Assistant Maintenance staff, and this resident reported that his room had been cold for two to three days, had already had his roommate moved out, and had asked his son to bring winter gloves. Another resident reported that his room was freezing the previous night, that he had 10 blankets on to stay warm, and that multiple people attempted but were unable to fix the heater in his room. A fifth resident reported that the heat was not working, that he used four blankets and two pairs of pants to stay warm, and that he remained in his room during this time. Staff interviews and facility records further demonstrated that the facility did not adequately monitor or respond to the cold conditions. A CNA reported working a morning shift when the building was cold, wearing her winter jacket while assisting residents in the dining room, and hearing residents complain of the cold; she stated that residents were moved to warmer areas but that she did not obtain temperatures on any residents. An LPN working a 12-hour day shift stated the facility was cold when she arrived and that she only took body temperatures on residents who could not verbalize if they were cold. An RN working the night shift reported that the facility felt cold when she arrived, that the previous shift had told her it was getting colder throughout the day, and that she instructed CNAs to add clothing and blankets and repositioned a resident’s bed away from a window, but she did not call anyone about the cold. Another LPN working night shifts over three days stated that heating issues started Saturday night, that staff were told maintenance had done everything possible, and that although it was cold on subsequent nights, she did not notify anyone on Sunday night. Temperature logs for the day of January 19 showed multiple readings below typical comfort levels, with recorded temperatures ranging from as low as 57.8°F to 71.4°F at various times between 8:00 AM and 6:00 PM. The Maintenance Director stated he was not notified by staff or administration on Sunday night into Monday morning that the heat was not working properly and that he did not become aware of the ongoing heating problem until he arrived Monday morning. The Assistant DON, who was the on-call nursing manager Sunday night, reported receiving no calls about the heat not working, and the Administrator similarly reported receiving no calls about the cold conditions that night, while stating that staff should have notified him or the Maintenance Director. The DON stated that staff began taking resident temperatures on Monday evening and acknowledged that not all residents’ temperatures were checked and that all residents should have been monitored, including on Sunday night if staff felt the facility was cold. The facility’s written policy on “Loss of Heat During Cold Weather” required that staff be oriented and educated to procedures for individual room heat malfunction and loss of heat to the entire facility. For individual room malfunctions, the policy directed staff to notify maintenance and to check room temperatures as needed, sampling at least every two hours when residents were in the room, and recommended moving residents if room temperatures fell below 55°F for 12 hours or more. For loss of heat to the facility, the policy required notification of the Administrator and Maintenance Department and observation of residents for signs of adverse effects of cooler temperatures. The report indicates that the facility did not document monitoring of all residents for signs and symptoms of hypothermia, including temperature checks, during the period when the facility lacked adequate heat on Sunday night and Monday, and that staff did not consistently follow the notification and monitoring procedures outlined in the policy.
Failure to Maintain Essential Heating Equipment After Power Outage
Penalty
Summary
Failure to maintain essential heating equipment occurred after a facility-wide power outage that affected all 102 residents. The Maintenance Director reported that power was lost for approximately 45 minutes on a Saturday and was restored before he arrived, and he did not identify any heating issues at that time. The following day, the Administrator notified him that the heat was not working, and he then realized the facility’s boiler system required a manual reset after the outage, which he had been unaware of. An Assistant Maintenance staff member later confirmed that the Maintenance Director did not reset all boilers and that he himself had to manually reset one boiler supplying heat to the Administrator’s office. The Administrator acknowledged that the Maintenance Director, who had started working at the facility the previous month, could not be trained on all aspects of the building and stated that he should have contacted the regional maintenance team after the power outage to determine any additional required tasks. A heating company technician visited the facility on Sunday due to lack of heat and determined that a new motor and spring coupler were needed for the pump, documenting that the pump motor was a pivotal component for the heat pumps to work and needed immediate replacement. The technician recorded that the customer chose to wait until the next day during normal business hours, stating that the building temperature had risen and they preferred to delay the work. On Monday, the Maintenance Director reported that staff were complaining of being cold, and the regional maintenance team identified that the water pump was failing. A heating company technician arrived that afternoon with a replacement pump motor, confirmed the existing motor was bad, and ultimately installed a new motor and spring coupler later that evening after obtaining a functional replacement. The technician documented remaining on-site until staff were comfortable that room temperatures were rising, indicating that essential heating equipment had not been maintained in safe operating condition for a period following the outage.
Widespread Sanitation and Hygiene Failures in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food preparation and sanitation. The kitchen hand washing sink was heavily stained with black residue, and food spatter and particle residue were present on the hand soap and sanitizer dispensers. Dust and stains were also found on the paper towel dispenser and garbage bin. Walls above food prep areas had yellow stains and food spatter, and the deep freezer contained a large box of bagels with a red sticky substance, as well as red spatter on the freezer doors. The ice machine had dark stains and buildup on both the interior and exterior, and the food prep sink faucet was covered in thick white stains. A box of apples stored under the prep table contained multiple rotted apples. Staff were observed failing to follow proper hygiene and infection control practices. One cook touched his mouth and continued handling dishware and meal prep without performing hand hygiene. Another dietary aide wore a personal coat in the kitchen and handled a personal cup in the food prep area. Staff were also seen with hairnets that did not fully cover their hair, and one cook repeatedly touched his lips and placed his hand in his pockets without washing hands before returning to food preparation. The dietary manager and consultant confirmed the presence of visible dust, particles, and stains on various kitchen surfaces and acknowledged the need for improved cleaning practices. Additional observations included cracked and leaking food processor equipment, heavily stained walls and basins, food particles and grease on shelves and stoves, and dirty dish racks and plate warmer cabinets. Beverage pitchers and clean cups were found with thick food particles and stains. The dietary manager stated that hairnets should fully cover hair, outside clothing should not be worn in the kitchen, and all kitchen equipment and surfaces should be clean. Facility policies required thorough cleaning and sanitizing of all kitchen areas and equipment, proper food storage, and strict hand hygiene, but these were not consistently followed.
Failure to Use Gait Belt During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement required safety and fall prevention interventions during the transfer of a resident with a significant history of falls and multiple behavioral and medical conditions, including dementia, seizures, and muscle disorder. The resident, who was known to be noncompliant with care and at risk for falls, was being assisted to the toilet in the shower room. During the transfer from the toilet back to the wheelchair, the resident insisted on pulling up her own pants, became unstable, and fell, resulting in a head injury. Observations confirmed visible bruising above the resident's left eyebrow following the incident. Interviews and record reviews revealed that the staff member assisting the resident did not use a gait belt during the transfer, despite facility policy requiring gait belt use for residents at risk for falls and those needing assistance during transfers. The staff member attempted to support the resident by placing her arms around the resident's back, but was unable to prevent the fall. The facility's policy and statements from supervisory staff confirmed that gait belts are mandatory for such transfers, and the failure to use this safety device directly contributed to the incident.
Failure to Provide Adequate Supervision During High-Risk Transfer
Penalty
Summary
A deficiency occurred when a resident at high risk for falls, with a history of cerebral infarction, dementia, depression, hypertensive heart disease, and protein-calorie malnutrition, was transferred using a sit to stand lift by a single CNA, contrary to facility policy requiring two staff members for such transfers. During the transfer from chair to bed, the resident fell forward and struck her head on the machine, resulting in a bleeding injury to her left eyebrow, which was exacerbated by her use of blood thinners. The resident's care plan did not specify any fall precautions, despite her high fall risk status as indicated in her assessment. Interviews with staff confirmed that the CNA performed the transfer alone and that the facility's policy mandates two staff for sit to stand lift operations. The incident was documented in progress notes, and the DON acknowledged that the transfer was not conducted according to policy. The facility's policy, revised in 2008, clearly states that two staff members are required for the use of portable lifts, but this protocol was not followed in this instance.
Failure to Protect Resident from Mental Abuse Following Threatening Incident
Penalty
Summary
A resident with moderate cognitive impairment and a history of depression was involved in a verbal altercation with his roommate, who has severe cognitive impairment. During the incident, the roommate alleged that the resident threatened him with a small pocketknife. Nursing staff responded by moving the roommate to another room for safety and conducted a room check, but did not initially find a knife. The resident refused a body check at that time. Later, when the resident's family arrived, the resident produced a small knife from his sock, which was then confiscated. Progress notes indicated that the resident was found agitated, holding a knife, and making alarming statements about having killed before and being willing to do so again. The facility's abuse prevention policy defines threats of harm as verbal abuse and mental abuse, including intimidation and threats of punishment. The facility failed to protect the resident's right to be free from mental abuse, as the threatening behavior was not immediately identified or addressed, resulting in a deficiency.
Failure to Obtain Required Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the required physician documentation was included in the medical record to support a resident's transfer and discharge rights. A resident with a history of schizophrenia and elopement behaviors was admitted to the facility and, shortly after admission, attempted to leave the facility twice. Following these incidents, facility staff initiated a Petition for Involuntary/Judicial Admission and a Notice of Involuntary Transfer or Discharge (IVD), citing the safety of individuals in the facility as the reason for the proposed transfer or discharge. However, the forms were completed by the Director of Nursing at the instruction of corporate personnel, and not by a physician. The IVD form indicated that the transfer was not an emergency, and the petition lacked detailed physician input or signature. Review of the resident's medical record and hospital documentation revealed that there were no physician orders for the involuntary psychiatric admission or for discharge. The hospital evaluation found no acute psychiatric or medical condition requiring intervention, and the petition from the facility was deemed invalid due to the lack of clear immediate safety concerns and improper completion. Additionally, the resident's electronic medical record contained no progress notes from a nurse practitioner or physician regarding the need for involuntary discharge or psychiatric admission, and behavioral monitoring documentation by CNAs was incomplete, only noting the resident as "not available." Facility policy requires physician confirmation and documentation in the medical record to support emergency transfers or discharges, as well as clear documentation of the danger posed by the resident. In this case, the required physician documentation and orders were absent, and the forms were not properly completed or signed by a physician, resulting in a failure to meet regulatory requirements for transfer and discharge rights.
Resident Falls Due to Inadequate Assistance During Bed Repositioning
Penalty
Summary
The facility failed to ensure a resident was positioned safely in bed during routine care, resulting in a fall and significant injuries. The resident, who had a history of hemiplegia, hemiparesis, rheumatoid arthritis, and obesity, was being cared for by a CNA who was alone in the room. The CNA directed the resident to turn onto her right side, which was her affected side, for peri-care. During this process, the resident's lower extremities slid off the bed, causing her to fall to the floor and sustain fractures and a knee dislocation. The incident occurred when the CNA, who was on the opposite side of the bed, reached over to the nightstand, leaving the resident closer to the edge of the bed. The resident attempted to alert the CNA that she was slipping, but the CNA was unable to prevent the fall. The CNA had previously cared for the resident with assistance from other staff members, but no additional help was available at the time of the incident. The resident's care plan indicated that she required assistance from two staff members for bed mobility due to her size and hemiplegia. Following the fall, the resident was assessed by a nurse and sent to the hospital for evaluation and treatment. Diagnostic imaging confirmed a posterior dislocation of the right tibial prosthesis, a proximal right tibial fracture, and a right periprosthetic femur fracture. The resident's care plan and CNA charting indicated that she was dependent on assistance for bed mobility, requiring two staff members for safe repositioning, which was not adhered to during the incident.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to adhere to therapy's recommendations for the safe transfer of a resident, resulting in an injury. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and peripheral vascular disease, required substantial assistance for transfers as per their care plan. The care plan specified the use of a mechanical lift with two staff members for transfers. However, on September 28, 2024, a CNA transferred the resident alone using a gait belt, contrary to the prescribed method. During this improper transfer, the resident's leg was scraped against the wheelchair, causing a laceration that required six sutures. Interviews with facility staff, including the Director of Rehab and a Nurse Practitioner, confirmed that the expectation was for staff to follow therapy's recommendations for safe transfers. The facility's policy also mandated the use of mechanical lifting devices for residents needing a two-person assist, except in emergencies. The incident report indicated that the resident was on anticoagulants, which could have contributed to the severity of the bleeding. The failure to follow the established transfer protocol directly led to the resident's injury.
Sanitary Practices Deficiency in Food Preparation and Service
Penalty
Summary
The facility failed to adhere to sanitary practices during food preparation and service, affecting 92 residents who receive meals from the facility kitchen. During an observation, a cook was seen washing a blender in a prep sink that contained food debris and a brownish substance. The cook, who had an uncovered beard, placed the washed lid inside the same dirty sink and used it on the blender, which still had food debris. The cook expressed frustration when informed that the blender and lid needed to be rewashed. Additionally, the cook's phone was on the main prep counter, which also had an opened box of cream of wheat. In the walk-in cooler, several bowls of pudding-like items were uncovered and stored on a rack, along with undated containers of various foods, some of which were past their use-by dates. The reach-in freezer contained an open packet of frozen breaded chicken. Multiple washed domed lids were stacked on a counter with dust and food debris, and some lids still had food and dust on them. A dietary aide with uncovered facial hair was also observed working in the kitchen, and the food service manager from another facility confirmed that dietary staff with facial hair should wear a beard cover. The facility's policies on food storage and preparation were not followed, contributing to the deficiency.
Infection Control and Water Management Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, as evidenced by the lack of infection surveillance and documentation. The Assistant Director of Nursing (ADON), who assumed the role of Infection Preventionist on October 14, 2024, admitted to not having completed any infection surveillance tools since taking over the position. This lapse in surveillance was confirmed by the Regional Nurse Consultant, who noted the absence of Infection Screening Evaluations for resident infections from September 1, 2024, to the present. The facility's policy mandates a system for preventing, identifying, reporting, investigating, and controlling infections, which was not followed. The facility also neglected its water management plan for legionella, as the Maintenance Director, who started on October 7, 2024, was unaware of the plan and had not conducted any monitoring. The facility's water management plan requires daily temperature checks of the hot water tank and weekly checks of chlorine or bromine levels, none of which were documented. The Administrator confirmed that the previous maintenance director also did not perform these necessary checks, indicating a systemic failure in following the water management plan. Additionally, there were multiple instances of staff failing to follow hand hygiene and Enhanced Barrier Precautions (EBP) policies. Certified Nursing Assistants (CNAs) were observed providing care without performing hand hygiene between tasks or wearing the required personal protective equipment, such as gowns, when caring for residents on EBP. Specific cases included residents with conditions like ESBL resistance and Candida Auris, where staff did not adhere to the necessary precautions, potentially compromising infection control efforts.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a comfortable room temperature for residents, compromising their right to a safe and homelike environment. Six residents reported issues with heating and cooling in their rooms, with temperatures dropping as low as 58 degrees Fahrenheit at night. Residents resorted to using extra blankets and clothing to stay warm. Observations confirmed discrepancies in room temperatures, with facility thermometers showing different readings than residents' personal thermometers. The facility's Maintenance Director acknowledged that room temperatures should not fall below 70 degrees Fahrenheit. The facility's Administrator and Vice President of Operations explained that the issues stemmed from a previous contractor's error in stripping the electrical system, which required reinstallation. New heating and cooling units were being installed, but some rooms were not yet connected. The 100 hallway was particularly affected, with delays due to damaged heat pumps. The facility had a policy for loss of heat during cold weather, but it was not effectively implemented, leading to discomfort for the residents.
Deficiency in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene, grooming, and incontinence care for six residents who required such support. Resident 13, with severe cognitive impairment and limited mobility, was observed with dirty fingernails despite needing total assistance with personal hygiene. Similarly, Resident 25, also severely cognitively impaired, had long, jagged fingernails with black substances underneath and overgrown chin hair, indicating a lack of grooming assistance. Resident 76, who is cognitively intact but has impaired range of motion, reported requesting nail care assistance without receiving it, resulting in long, dirty fingernails. Resident 23, with severe cognitive impairment and hemiplegia, was found with overgrown, dirty fingernails and facial stubble, despite requiring total assistance for ADLs. Resident 56, who needs extensive assistance, was found in a room with a strong urine odor and expressed a desire for facial hair removal, which was not addressed. Resident 71, with cognitive impairment, was found tearful and improperly dressed, with dirty fingernails, overgrown facial hair, and fecal smears on her body. Despite being assisted with dressing and incontinence care, her grooming needs were not met. The facility's failure to provide adequate ADL care, including nail and facial care, was acknowledged by the Director of Nursing, highlighting a deficiency in maintaining residents' hygiene and dignity.
Inadequate Perineum and Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide adequate perineum and catheter care to prevent potential urinary tract infections (UTIs) for four residents. One resident, who is cognitively impaired and requires assistance with toileting, was found with fecal matter on her hands and thighs. The CNA assisting her did not clean the frontal perineum and left fecal matter on her thigh. Another resident, who is cognitively impaired and requires total assistance for toileting, was not properly cleaned as the CNA did not retract his uncircumcised penis or clean the inner folds of his groins. A third resident, who is alert and oriented but requires total assistance for toileting, was not properly cleaned as the CNA did not clean the pubic area or the inner folds of the labia. Lastly, a resident with a suprapubic catheter due to neurogenic bladder was not provided with proper catheter care, as the CNA did not clean the catheter tube. The facility's guidelines for incontinence and catheter care were not followed, contributing to the potential risk of UTIs.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and date medications once they were opened, which is necessary to determine their expiration dates. This deficiency was observed in several residents' medications, including Insulin Lispro Kwik Pen, Insulin Glargine-YFGN, and Novolin R Flex Pen, which were opened but not dated. Additionally, Incruise Ellipta inhalers for two residents were also opened and not dated, contrary to the manufacturer's guidelines that specify a discard period after opening. These lapses in labeling and dating medications were identified during inspections of the medication room and carts in various halls of the facility. Furthermore, the facility did not appropriately handle narcotic medications with broken seals. During the inspection, it was found that several narcotic medications, such as Norco and Tramadol tablets, had broken seals that were taped over instead of being discarded as per the facility's policy. The Director of Nursing confirmed that staff are required to discard narcotic medications with broken seals to prevent medication diversion and ensure infection control. The facility's policy mandates the immediate removal and proper disposal of medications in containers that are cracked, soiled, or without secure closures, which was not adhered to in these instances.
Failure to Follow Prescribed Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed portion sizes for pureed diets as outlined in their menu spreadsheets. This deficiency was observed in six residents who were on pureed diets. The Spring Summer Menu 2024 specified the use of a #8 scoop for pureed carrot raisin rice and pureed broccoli, and a #6 scoop for pureed pork chop with apples. However, during meal preparation, the cook substituted pureed chicken for pork chop and mashed potatoes for pureed rice, citing resident preferences. The dietary aides used a #10 scoop, which was not in accordance with the menu specifications, to serve the pureed meat, broccoli, and mashed potatoes. The dietitian confirmed that the correct scoop size is crucial for ensuring the residents receive the appropriate amount of protein and nutrients. The facility's diet order listing confirmed that the six residents were on pureed diets, yet they received meals that did not match the planned menu in terms of both content and portion size. This deviation from the menu and portion guidelines led to the deficiency noted by the surveyors.
Failure to Provide Splint and Therapy Services for ROM Maintenance
Penalty
Summary
The facility failed to assess and provide necessary splint and therapy services to residents, leading to a deficiency in maintaining or improving their range of motion (ROM). One resident, with a history of hemiplegia and hemiparesis following a cerebral infarction, was observed without the prescribed splint for her left hand and wrist over several days. Despite having an active order for a hand orthotic to manage contracture, the resident reported not wearing the splint for at least two days, and staff did not apply it during the observed period. The occupational therapist later confirmed a decline in the resident's ROM, indicating a need for further evaluation and therapy. Another resident, with multiple medical diagnoses including hemiplegia and muscle atrophy, was observed with severe contractures in the right upper extremity, including the shoulder, elbow, and wrist. The resident's hand was flaccid, and fingernails were digging into the skin, yet no splint was applied. An occupational therapist evaluated the resident and noted severe contractures, recommending gentle splinting and an orthopedic consult for potential surgical intervention. These observations and evaluations highlight the facility's failure to provide appropriate care and interventions to prevent further reduction in ROM for these residents. The lack of timely application of prescribed splints and the absence of necessary therapy services contributed to the decline in the residents' conditions, as documented by the occupational therapist.
Failure to Address Resident's Dental Pain and Required Extractions
Penalty
Summary
The facility failed to follow up on dental care recommendations for a resident experiencing tooth pain for over six months, requiring tooth extractions. The resident, an elderly female with a history of cerebral infarction, rheumatoid arthritis, and polyneuropathy, reported persistent mouth and tooth pain. Despite being seen by a dentist three times, no action was taken to address her broken teeth, which caused her significant discomfort and difficulty chewing. Observations noted that the resident had few teeth remaining, with black substance around the base of her upper teeth and a stub on her lower gum. The resident's diet was downgraded to a mechanical soft diet due to her chewing difficulties, as noted in an email from the Social Service Director. A dental assessment recommended extractions of specific teeth due to pain and inflammation, but no extractions were performed. Communication between the Director of Nursing and the business office manager highlighted ongoing concerns about the resident's dental issues and financial considerations for treatment. Despite the resident's repeated complaints and a nursing note indicating her desire to visit the dentist, the facility's administrator was unaware of any extractions in the past six months. The resident's daughter was informed of the situation but declined to pay for the extractions, seeking alternatives covered by insurance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its policy for antibiotic stewardship, affecting all 92 residents. The Assistant Director of Nursing, who assumed the role of Infection Preventionist on October 14, 2024, acknowledged that she had only just begun reviewing which residents were on antibiotics. The Regional Nurse Consultant confirmed that the Infection Preventionist nurse is responsible for the Infection Prevention and Control Program, including the antibiotic stewardship program. However, the facility lacked documentation to demonstrate tracking of antibiotic use from September 1, 2024, to the present.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement proper infection control practices following a COVID-19 exposure, affecting 55 residents. On multiple occasions, residents reported not being tested for COVID-19 despite being informed of positive cases within the facility. The facility did not display a sign indicating outbreak status at the entrance, and the Infection Preventionist Nurse admitted to prematurely removing the outbreak status sign. The facility's COVID-19 policy, which mandates testing and precautions following exposure, was not adhered to. A certified nursing assistant (CNA) who tested positive for COVID-19 had been in contact with residents and staff without appropriate precautions being taken. The CNA reported feeling unwell during her shift and later tested positive for COVID-19. Despite this, the facility did not conduct timely testing of residents and staff who were potentially exposed. The Infection Preventionist Nurse acknowledged the failure to test all potentially exposed residents and staff, citing difficulties in tracking and documentation. The Director of Nursing and Acting Administrator confirmed that the facility's policy required testing and transmission-based precautions for exposed individuals, which were not implemented. The facility lacked documentation of testing and tracking for the affected residents and staff, and the testing that was conducted was insufficient and delayed. The facility's failure to follow its COVID-19 policy and state guidelines resulted in inadequate infection control measures during the outbreak.
Facility Fails to Maintain Safe Environment Due to Malfunctioning Air Conditioning
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents due to a malfunctioning air conditioning system. The issue began when the facility was notified by their HVAC contractor that there would be no heating or cooling capacity without necessary repairs. Despite this notification, the facility did not take timely action to address the problem, resulting in room temperatures reaching as high as 91 degrees Fahrenheit. Residents expressed discomfort and distress due to the heat, with some removing clothing to cool off and others complaining of difficulty sleeping. The facility did not follow its own hot weather policy, which required measuring room temperatures and humidity levels every two hours when the air conditioning was not functioning properly. Instead, the Maintenance Director used an infrared temperature gun, which is not suitable for measuring air temperature, leading to inaccurate assessments of the indoor environment. Additionally, staff did not ensure that residents had access to adequate fluids, further compromising their comfort and safety. The facility's failure to address the air conditioning issues promptly and effectively affected all 98 residents. The HVAC contractor had informed the facility of underground pipe leaks that prevented the system from functioning, but the facility delayed authorizing temporary cooling solutions. The facility's lack of proper monitoring and failure to implement high-temperature procedures as outlined in their policies contributed to the ongoing discomfort and potential health risks for the residents.
Failure to Adhere to Hot Weather Policies During AC Malfunction
Penalty
Summary
The administration of the facility failed to provide adequate oversight and leadership to ensure compliance with hot weather policies and procedures when the air conditioning system was not functioning properly. The facility's administrator, V1, was aware of the malfunctioning air conditioning but did not ensure that temperature and humidity levels were being monitored as required by the facility's policy. The facility did not have the necessary equipment to measure air temperatures and humidity, and the staff was not informed about the need to check these levels every two hours during the malfunction. Observations revealed that room temperatures in the facility were consistently above 85 degrees Fahrenheit, with some areas reaching as high as 91 degrees. Residents expressed discomfort due to the heat, and there were instances where residents were in common areas without access to water, and no staff was present to assist them. The facility's policies required that temperatures and humidity be monitored regularly and that residents be relocated to cooler areas if necessary, but these procedures were not followed. The facility's failure to adhere to its hot weather and extreme high temperature guidelines resulted in prolonged exposure of residents to excessive heat. The administration did not notify the State Agency about the air conditioning issues, and the facility continued to use common areas like the dining room despite high temperatures. The lack of proper monitoring and response to the heat conditions posed a risk to the health and well-being of the 98 residents in the facility.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 708 citations issued within 25 miles in the last 12 months — including the 13 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Joliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakewood Nrsg & Rehab Center | 3.5 mi | ★★★★★ | 2 | 1 |
| Avantara Joliet | 3.7 mi | ★★★★★ | 8 | 0 |
| Parc Joliet | 3.7 mi | ★★★★★ | 29 | 0 |
| Pearl Of Joliet, The | 3.7 mi | ★★★★★ | 3 | 0 |
| Alden Estates Of Shorewood | 4 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.