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 Silvis Center For Nursing Rehab & Care during CMS and state inspections, most recent first.
A resident with chronic kidney disease, bladder incontinence, and a compromised immune system developed suprapubic pain, hematuria, dysuria, and dark, foul-smelling urine, but antibiotics were not started until about a week after symptoms began and more than a day after an ESBL-positive urine culture was reported. Nursing notes documented worsening UTI symptoms, yet this information was not communicated effectively to the NP, who waited for culture results before ordering Levaquin. The resident’s toileting and hygiene needs increased from supervision to dependence, but the care plan was not updated to reflect higher incontinence care needs or UTI monitoring, and a family member reported the resident remained in soaked incontinence briefs and was not cleaned adequately.
The facility failed to provide sufficient nursing staff to meet residents’ needs, as shown by repeated reports of prolonged call light response times and unmet care needs. Several residents, including one with a history of falls and another with limited arm function, reported routinely waiting 30–60 minutes or more for assistance with toileting, transfers, and other care, sometimes resulting in incontinence accidents and extended discomfort. Multiple staff, including LPNs and a CNA, described frequent CNA call-ins that were not consistently replaced, shifts with as few as two CNAs for about 50 residents, missed showers, incomplete charting, and an inability to provide timely care due to high patient-to-staff ratios. The DON acknowledged ongoing concerns with call light response and agreed that the length of time some residents waited for toileting assistance was excessive.
The facility failed to ensure two residents received ordered specialist care when transportation was not properly arranged, causing missed pulmonology and neurology appointments. One resident with obstructive sleep apnea, CHF, and lung cancer was prepared for a pulmonology visit, with a CNA arranged to accompany her, but contracted transport services reported no pickup was scheduled and she did not attend. Another resident with confusion, high fall risk, and a history of alcoholism had a neurology consult ordered and scheduled, with referral paperwork faxed and family agreement, yet missed at least one neurology appointment because transportation was not set up, leaving the consult outstanding while the resident later exhibited stroke-like symptoms and was sent to the ER. Staff, including an LPN, the NP, and the DON, acknowledged ongoing transportation issues with outside contracted services.
Multiple residents, family members, and visitors reported that call lights were routinely left unanswered for at least an hour, with some instances extending to an hour and a half. Staff were observed turning off call lights and promising to return without providing assistance. The issue persisted despite facility policies and was only temporarily improved when state agency representatives were present, prompting management and additional staff to assist with call light responses.
The facility did not consistently serve meals as listed on posted menus, frequently substituting planned items with alternatives without prior notice. Multiple residents reported dissatisfaction with the quality, variety, and predictability of meals, and facility records confirmed numerous menu changes affecting all residents. Staff acknowledged difficulties in obtaining menu items, leading to repeated substitutions.
A resident with Parkinson's Disease and anxiety, who frequently exhibited physical and self-injurious behaviors, did not have an updated care plan reflecting her current condition or interventions to reduce injury risk. Staff observed the resident being anxious, aggressive, and sustaining injuries, but the care plan lacked documentation of her behaviors or triggers, and staff confirmed it was not revised to address her needs.
A resident with CHF and severe cognitive impairment did not receive daily weights as ordered, and significant weight gains were not communicated to the physician. Orders for daily weights were inconsistently entered and followed, with multiple days lacking documentation and no evidence of physician notification when weight thresholds were exceeded. The care plan and facility policies did not address daily weight monitoring or CHF-specific care, leading to repeated hospitalizations for CHF exacerbations.
A resident with multiple respiratory and cardiac conditions was not provided with a physician-ordered BiPAP machine for several days after returning from the hospital, despite clear discharge orders. Facility records and assessments did not consistently reflect the need for BiPAP, and the device was not available until days after the resident's return, resulting in hospitalization for respiratory failure.
Multiple residents with complex medical needs experienced significant delays in call light response, assistance with toileting, and medication administration due to insufficient staffing. Residents and their families reported frequent incontinence episodes, missed showers, and staff turning off call lights without providing help. Staff and meeting records confirmed ongoing staffing shortages, high resident acuity, and missed care tasks, while a physician cited poor communication and care continuity. Facility policies for prompt response and timely medication administration were not followed.
The facility failed to maintain the independence of resident council meetings by allowing non-residents to attend without clear documentation of their purpose. Additionally, the facility did not record the names of residents attending or address concerns raised in the meetings, such as environmental and maintenance issues, in subsequent meetings. This oversight affects all 62 residents as their grievances are not being effectively managed.
A facility failed to protect a resident's privacy during nursing care when the door to their room was left open while they were vomiting and complaining of stomach pain to an LPN. The resident's daughter, present in the hallway, noted the need for the door to be closed. The LPN later acknowledged that the door should have been closed to maintain privacy.
A facility failed to reweigh a resident after a significant weight change was recorded, with the resident's weight increasing from 125.8 to 173 pounds within a month. The Registered Dietician questioned the accuracy of the weight, suspecting it was taken with the resident in her wheelchair, and did not make new dietary recommendations. The DON acknowledged the need for reweighing despite the lack of a specific policy.
A facility failed to administer medications on time to five residents due to staffing issues. Medications scheduled for 8 AM were given several hours late, affecting treatments for hypertension, neuropathy, COPD, pain, and anxiety. The delay was caused by an absent agency nurse, leaving only two nurses to cover both skilled and LTC units. The DON's directive to reassign a nurse to the LTC unit was delayed, leading to late medication administration.
The facility failed to respond to call lights in a timely manner for eight residents, with wait times ranging from 5 minutes to over an hour. Staffing cuts following a change in ownership led to increased workloads and stress among staff, contributing to the delays. Residents reported incidents of prolonged waits for assistance, including one who waited nearly two hours after an accident. Staff confirmed the staffing issues, and the DON acknowledged the responsibility to respond promptly.
A resident with severe cognitive impairment slid out of a wheelchair while being assisted by a CNA, resulting in a left leg fracture. The incident occurred during a routine change into a gown, and the resident's pain was not immediately recognized as an injury. The facility's policies lacked specific guidance on safe wheelchair positioning, contributing to the deficiency.
The facility failed to ensure that the Medical Director attended the QA meetings, as required by their policy. The QAPI sign-in sheets for a meeting did not include the Medical Director's signature, which was confirmed by the Administrator. This deficiency has the potential to affect all 72 residents in the facility.
The facility failed to ensure that the designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP) was certified. The Care Plan Coordinator, who has the certification, did not oversee the IPCP, while the Assistant Director of Nursing, who is halfway through certification training, was acting as the IP. This deficiency has the potential to affect all 72 residents in the facility.
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications for four residents. The facility did not attempt GDRs, identify target behaviors, or document behaviors justifying the use of psychotropic medications. This was confirmed through record reviews and interviews with the Director of Nursing (DON).
The facility failed to perform proper hand hygiene during care for two residents. An RN administered an insulin injection without changing gloves or performing hand hygiene, and a CNA performed catheter care without changing gloves or performing hand hygiene before touching other items and the resident.
A facility failed to incorporate hospital discharge instructions for a cervical neck brace and skin care into a resident's care plan and treatment plan. Despite detailed instructions, skin checks were inconsistently documented and performed, leading to frustration from the resident and their spouse. The DON acknowledged the oversight.
The facility failed to ensure all doors were alarmed, leading to a resident with an electronic monitoring bracelet exiting the building without triggering the alarm. The ambulance door was not regularly checked due to maintenance staff not having the key to reset the alarm, a lapse attributed to changes during the COVID-19 pandemic.
Delayed UTI Treatment and Failure to Update Incontinence Care Plan
Penalty
Summary
The facility failed to ensure timely initiation of antibiotic treatment and appropriate care planning for a resident with signs and symptoms of a urinary tract infection (UTI). The resident had chronic kidney disease, hypertensive chronic kidney disease, bladder incontinence related to impaired mobility, and was undergoing cancer treatments with a compromised immune system. The facility’s algorithm for antimicrobial management of UTIs required treatment when new or marked incontinence, suprapubic pain, hematuria, and other symptoms were present, and the resident’s care plan directed staff to monitor and document for UTI signs such as pain, burning, blood-tinged urine, foul-smelling urine, and changes in behavior or eating patterns. On one date in December, the nurse practitioner assessed the resident, who complained of fatigue, cough, and suprapubic pain, and ordered a urinalysis. The following day, nursing documentation showed hematuria and suprapubic pain, and the urinalysis revealed dark brown urine, extra turbid clarity, protein, blood, and leukocytes. Over the next days, nursing notes documented dark brown, odorous urine, suprapubic pain, dysuria, and incontinence, and the urine was sent for culture and sensitivity. The final culture, completed several days later, showed ESBL-producing Klebsiella pneumoniae and Proteus mirabilis, and the resident was placed on contact isolation. However, the nurse practitioner stated she waited for culture results before starting antibiotics and was not informed that additional symptoms and worsening signs were being documented by nursing staff. The nurse practitioner ordered Levaquin after reviewing the culture results, and the first dose was administered approximately seven days after the resident’s urinary symptoms were first identified and more than 28 hours after the positive ESBL culture result was reported. During this period, the resident experienced suprapubic pain, burning with urination, blood and odor in the urine, and incontinence of dark brown odorous urine. The resident’s family member reported that the resident was not being cleaned adequately, sat in soaked incontinence briefs for too long, and required more help toward the end of her stay. The Minimum Data Set assessments showed a decline from supervision/touching assistance for toileting and hygiene to dependence and substantial/maximal assistance for toilet transfers, but the care plan at discharge did not reflect increased care needs for toileting, hygiene, or UTI monitoring. The DON confirmed the resident had a rapid decline after the December UTI, that care plan interventions for incontinence and toileting were not updated to match her increased dependence, and that there was no documentation to show the change in condition or altered incontinence care and monitoring needs.
Failure to Provide Sufficient Nursing Staff Resulting in Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, as evidenced by prolonged call light response times and unmet care needs. The facility census showed 73 residents, and the facility assessment stated staffing was adequate based on resident population, acuity, and regulatory requirements. However, multiple residents reported waiting extended periods after activating call lights, including reports of waiting 30 minutes to an hour or more for assistance, particularly with toileting and transfers. One resident with a history of falls, dizziness, and passing out stated that call lights sometimes took an hour to be answered. Another resident council president reported frequent staffing and call light concerns, including waiting from 11:00 PM to 12:00 AM for help to the bathroom, resulting in accidents and describing the experience as humiliating and painful. Staff interviews corroborated these concerns and described chronic understaffing. An LPN reported that on one occasion there were only two CNAs for 50 residents, leading to missed showers and long waits for assistance, and that a resident complained of waiting over an hour to go to bed and have a call light answered. Another LPN stated there were not enough nurses and staff to complete required tasks or charting, and that the patient-to-nurse ratio made it impossible to provide adequate help. A CNA reported daily CNA call-ins that were not always replaced, especially on second shift, resulting in residents waiting longer to be changed and cleaned up and increased frustration for some residents. During observation, a resident with a flaccid arm was seen waiting with a call light on for help with incontinence care and reported having accidents while waiting. The DON acknowledged awareness of call light concerns and agreed that 30 minutes was too long for someone to be expected to hold their bladder, noting that staff call-offs increased during that time of year.
Failure to Arrange Transportation for Specialist Appointments
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received ordered specialist care when transportation was not arranged, resulting in missed pulmonology and neurology appointments. One resident with obstructive sleep apnea, congestive heart failure, and right lower lobe lung cancer had a scheduled pulmonology appointment documented on the facility’s calendar. Nursing progress notes show that on the day of the appointment the resident was prepared, a CNA had been arranged to accompany her, but no transportation arrived. Contracted transportation companies reported they did not have the resident scheduled for pickup, and the appointment had to be rescheduled. The LPN caring for the resident confirmed that the resident missed the pulmonology appointment solely due to transportation not being set up. Another resident, admitted with high fall risk related to confusion, deconditioning, gait/balance problems, poor safety awareness, and a history of falls, had a neurology referral ordered by the nurse practitioner due to confusion. Documentation shows the referral paperwork was faxed, the family was notified and agreed with the plan, and a neurology appointment was scheduled and entered on the facility’s calendar. The resident’s family later reported that the resident missed neurology appointments because the facility could not get him to the appointments and that he was charged no-show fees. Nursing notes and staff interviews confirm at least one missed neurology appointment due to transportation not being set up and that the consult order remained outstanding after several days. The nurse practitioner also confirmed there were transportation issues that caused the resident to miss a needed neurology appointment, and that during the stay the resident experienced signs and symptoms of stroke and went to the emergency room.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer resident call lights in a timely manner, as evidenced by multiple resident and visitor interviews, grievance log entries, and direct observations. Residents consistently reported waiting at least an hour, and sometimes up to an hour and a half, for staff to respond to activated call lights. Several residents stated that staff would turn off the call light and promise to return, but then failed to provide the requested assistance. Family members and visitors corroborated these accounts, noting that call lights often remained unanswered for extended periods and that they sometimes had to seek out staff multiple times to obtain help. The facility's own grievance log documented complaints about delayed call light responses, with conclusions indicating staff re-education or counseling, but residents reported no improvement over time. The facility's policy requires that call lights be accessible at each resident's bedside, toilet, and bathing area, and that all staff are responsible for responding to activated call lights. Despite this, interviews revealed that timely responses were not the norm, except during periods when state agency representatives were present in the facility. During these times, residents and visitors observed that call lights were answered much more quickly, with management and additional staff visibly assisting. The issue was described as ongoing by both residents and the facility ombudsman, who personally witnessed call lights remaining unanswered for over an hour.
Failure to Consistently Serve Meals According to Posted Menus
Penalty
Summary
The facility failed to consistently serve meals according to the posted menus, as required by regulations. Multiple residents reported that the meals served often did not match what was listed on the menu, with frequent substitutions and changes occurring without prior notice. Residents expressed frustration over the lack of variety, repeated substitutions, and the perception that cost-saving measures were prioritized over their dietary needs. Specific examples included changes such as substituting grilled cheese with deli meat sandwiches, replacing breakfast meats with eggs, and altering side dishes and desserts without explanation. Review of facility records confirmed numerous instances where the planned menu items were substituted with different foods across several weeks. These substitutions included changes to main entrees, side dishes, and desserts for multiple meals, often resulting in residents receiving meals that did not align with the posted or planned menus. The Dietary Manager's job summary indicated responsibility for planning menus with the dietitian, ensuring menus meet nutritional needs, and maintaining sufficient inventory, but the observed practices did not align with these responsibilities. Interviews with residents and facility staff further corroborated the inconsistency in meal service. Residents consistently reported dissatisfaction with the quality, quantity, and predictability of meals since a new company took over food service operations. The facility administrator acknowledged that dietary staff sometimes could not obtain the necessary food items and had to make substitutions, but did not perceive this as a frequent issue. The facility census indicated that all 76 residents were potentially affected by these deficiencies.
Failure to Update Care Plan for Resident with Physical Behaviors
Penalty
Summary
The facility failed to revise and update the care plan for a resident with a history of Parkinson's Disease and anxiety, who frequently exhibited physical behaviors resulting in self-harm and aggression towards staff. Despite the facility's policy requiring prompt assessment and care plan updates following changes in a resident's condition, the resident's care plan did not document her behavioral issues, known triggers, or interventions to reduce the risk of injury. Observations showed the resident was anxious, angry, and physically aggressive, including an incident where she sustained an open laceration and another where she struck a staff member while being assisted. Interviews with facility staff, including the nurse practitioner and the MDS coordinator, confirmed that the resident's mental state had declined and that the care plan had not been updated to reflect her current behaviors or needs. The lack of an updated care plan meant that staff were not provided with guidance on managing the resident's physical behaviors or preventing injury, despite multiple incidents and staff awareness of her triggers and risks.
Failure to Complete and Communicate Daily Weights for CHF Resident
Penalty
Summary
The facility failed to ensure that daily weights were completed as ordered for a resident with congestive heart failure (CHF), and did not identify or communicate significant weight increases to the physician. The resident, who had severe cognitive impairment and multiple comorbidities including CHF, COPD, and respiratory failure, was admitted with explicit hospital discharge instructions for daily weight monitoring and prompt reporting of weight gains. Despite these orders, daily weights were inconsistently documented, and significant weight changes were not communicated to the physician as required. Review of the electronic medical record and eMAR revealed multiple gaps in weight documentation, including days when weights were not recorded and periods when incorrect orders were entered, resulting in missed daily weights. On several occasions, the resident experienced notable weight gains that met the threshold for physician notification, but there was no evidence that the physician was informed. The care plan for CHF did not include specific interventions for daily weights or physician notification of weight changes, and the facility lacked a policy addressing CHF care or daily weight monitoring. Interviews with staff and the resident's physician confirmed concerns about the lack of consistent daily weight monitoring and communication. The physician reported receiving weight updates only once and expressed frustration with the lack of follow-through on orders. The DON acknowledged the importance of daily weights for CHF management and expected staff to complete them as ordered, but also confirmed the absence of a facility policy specific to CHF or daily weights. These failures resulted in the resident being transferred to the hospital multiple times for CHF exacerbations.
Failure to Provide Timely BiPAP Respiratory Support as Ordered
Penalty
Summary
The facility failed to provide a resident with a physician-ordered BiPAP machine for respiratory support, despite multiple hospital discharge orders specifying the need for BiPAP at specific settings. The resident, who had a history of acute diastolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypoxia, primary pulmonary hypertension, obstructive sleep apnea, and severe cognitive impairment, was admitted and readmitted to the facility several times. Each time, hospital discharge documentation included orders for BiPAP at night, but the facility's admission assessments and electronic medication and treatment administration records did not consistently reflect these orders, and the BiPAP was not made available to the resident in a timely manner. The resident's family provided a CPAP machine from home, but after a hospitalization, the discharge orders were changed to BiPAP, which was not immediately available upon the resident's return to the facility. There was a delay of several days before the BiPAP machine was delivered by the DME provider, during which time the resident did not have access to the prescribed respiratory support. Documentation showed inconsistent entries regarding the use of CPAP or BiPAP, and the care plan did not reflect BiPAP use until well after the resident's return from the hospital, despite clear orders from the hospital for its use. Interviews with the resident's power of attorney, physician, and the facility's Director of Nursing confirmed that there was confusion and a lack of clarity regarding the respiratory device orders, as well as delays in obtaining the correct equipment. The physician and DON acknowledged that the BiPAP should have been available from the initial admission based on the hospital orders, and that the orders should have been clarified and entered into the eMAR. The failure to provide the BiPAP as ordered resulted in the resident being hospitalized for respiratory failure due to not using the BiPAP machine.
Failure to Provide Sufficient Nursing Staff and Timely Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports of delayed response to call lights, missed or delayed care, and medication administration outside of scheduled times. Several residents with significant medical needs, including hemiplegia, diabetes, heart failure, cognitive impairment, and recent surgery, reported waiting 30 minutes to over an hour for assistance with toileting and other personal care. Some residents experienced incontinence while waiting for help, leading to feelings of humiliation and frustration. One resident resorted to emptying his own urinal due to lack of timely staff response, and another's spouse reported frequent delays resulting in accidents. Resident council meeting minutes over several months documented ongoing concerns about inadequate staffing, long call light wait times, missed showers, and staff turning off call lights before providing assistance. Residents consistently expressed that there were not enough CNAs to meet their care needs, and staff confirmed that frequent call-offs and reduced nurse staffing contributed to the inability to complete required tasks, such as providing showers and timely assistance. Staff also reported that high-acuity residents often required two-person assistance, further straining available resources. Medication administration was also affected by staffing shortages, with documentation showing that medications were given significantly outside of scheduled times. A physician noted poor communication and frequent staff turnover, stating that patients were not receiving appropriate care and that it was difficult to reach facility leadership. The DON acknowledged ongoing complaints about call light response times and attributed the issue to staffing cuts and changes in facility management structure. Facility policies required prompt response to call lights and timely medication administration, but these standards were not met.
Deficiency in Resident Council Meeting Protocols
Penalty
Summary
The facility failed to uphold the residents' rights to organize and participate in resident council meetings independently. The report highlights that non-residents, such as family members and facility staff, were present at these meetings without clear documentation of their invitation or purpose. Additionally, the facility did not record the names of residents attending the meetings, which is a crucial aspect of maintaining transparency and accountability. This lack of proper documentation and adherence to protocol undermines the independence of the resident council. Furthermore, the facility did not adequately address or resolve concerns raised during the resident council meetings. Specific grievances, such as issues with environmental services and maintenance, were noted in the minutes but lacked follow-up or resolution in subsequent meetings. The failure to document the names of residents with concerns and the absence of a clear plan to address these issues indicate a significant oversight in the facility's grievance handling process. This deficiency potentially affects all 62 residents in the facility, as their concerns are not being effectively managed or resolved.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during nursing care. On March 18, 2025, at noon, a resident was observed with their room door open while they were vomiting and complaining of stomach pain to an LPN. The resident's daughter was present in the hallway and noted that the door should have been closed to maintain privacy. When questioned, the LPN acknowledged that the door should have been closed to protect the resident's privacy.
Failure to Reweigh Resident After Significant Weight Change
Penalty
Summary
The facility failed to reweigh a resident after a significant weight change was recorded. The medical record for a resident documented a weight of 125.8 pounds on November 3, 2024, which then increased to 173 pounds on November 22, 2024, and remained the same on December 1, 2024. A progress note dated December 27, 2024, indicated that the Registered Dietician did not make any new dietary recommendations due to questioning the accuracy of the weight, suspecting it might have been taken with the resident in her wheelchair. The Director of Nursing acknowledged that the resident should have been reweighed after the significant weight gain recorded on November 22, 2024, despite the absence of a specific policy, as good nursing judgment should have prompted staff to verify the weight change.
Medication Administration Delays Due to Staffing Issues
Penalty
Summary
The facility failed to ensure timely administration of medications to five residents, resulting in significant delays. Each resident's medication administration record (MAR) indicated that medications scheduled for 8 AM were administered several hours late, with delays ranging from three to over four hours. Residents reported changes in their medication schedules, expressing concerns about the late administration. The medications involved included those for hypertension, neuropathy, chronic obstructive pulmonary disease, pain management, and anxiety, all of which were crucial for managing the residents' health conditions. The delay in medication administration was attributed to staffing issues on the morning of February 1, 2025. An agency nurse scheduled to work did not show up, leaving only two nurses to cover both the skilled and long-term care units. The Director of Nursing (DON) directed that one nurse from the skilled unit, which had fewer residents, assist in the long-term care unit. However, this transition did not occur until almost 11 AM, resulting in the late administration of medications. The facility's policy requires medications to be administered within an hour of the scheduled time, which was not adhered to in this instance.
Delayed Response to Call Lights Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that call lights were responded to in a timely manner for eight residents, as observed and reported during interviews and record reviews. The facility's Call Light Policy mandates prompt responses when the call system is activated, yet residents reported waiting times ranging from 5 minutes to over an hour. One resident specifically recounted an incident where they waited 1 hour and 55 minutes for assistance after an accident involving diarrhea. Another resident described a fall incident where help was delayed, requiring a roommate to yell down the hall for assistance. These delays were attributed to staffing issues following a change in facility ownership, which resulted in reduced staff numbers and increased stress among the remaining staff. Interviews with staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed that staffing cuts had occurred after the facility changed ownership, leading to increased workloads and longer response times to call lights. The Director of Nursing acknowledged that all staff are responsible for responding to call lights and that they should be answered promptly. The Monthly Resident Council Minutes also documented residents' concerns about call lights not being answered in a timely manner, further highlighting the ongoing issue of inadequate response times to residents' needs.
Failure to Ensure Safe Wheelchair Positioning Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe positioning in a wheelchair for a resident, resulting in the resident sliding out of the wheelchair and sustaining a fracture of her left leg. The resident, who had severe cognitive impairment and was dependent on staff for various activities of daily living, was being assisted by a CNA to change into a gown when the incident occurred. The CNA reported that the resident began sliding out of the wheelchair, and despite attempts to reposition her, the CNA had to lower the resident to the floor. The resident's medical history included severe cognitive impairment, dementia, and a history of falling, among other conditions. After the incident, the resident complained of pain in her left leg, which was initially not identified as an injury. Over the following days, the resident continued to experience significant pain, leading to the eventual discovery of a medial tibial plateau fracture through a portable x-ray. The family initially refused the x-ray due to concerns about the resident's stress levels but later consented to a portable x-ray after further discussions. Interviews with staff revealed inconsistencies in the handling of the incident and the assessment of the resident's condition. The CNA involved could not recall if the wheelchair was locked or if the footrests were in place, and there was a lack of clarity regarding the thoroughness of the initial assessment by the nurse. The facility's policies on safe lifting and positioning did not provide specific guidance on proper body mechanics in a wheelchair, contributing to the deficiency.
Medical Director's Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the Quality Assurance (QA) meetings, as required by their policy. The facility's QAPI (Quality Assurance Performance Improvement) program mandates monthly and quarterly meetings, with the Medical Director and Leadership team collaborating on day-to-day decisions. However, the QAPI sign-in sheets for a meeting held on 3/19/2024 did not include the signature of the Medical Director. This was confirmed by the Administrator during an interview on 05/22/24, who acknowledged that the Medical Director did not attend the QA meeting on 3/19/24 or review the QA information. This deficiency has the potential to affect all 72 residents in the facility.
Failure to Ensure Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), responsible for the Infection Prevention and Control Program (IPCP), was certified. The job description for the IP includes responsibilities such as attending Infection Control Committee meetings, completing infection surveillance reports, advising on isolation protocols, and participating in the Quality Assurance Committee. However, upon entrance to the facility, it was found that the current IP was not clearly designated, and the Care Plan Coordinator, who has the certification, did not oversee the IPCP. Instead, the Assistant Director of Nursing, who is halfway through the certification training, was acting as the IP without having completed the necessary certification. This deficiency has the potential to affect all 72 residents in the facility. The Administrator provided a list of key personnel that did not include the name of the current IP. The Care Plan Coordinator confirmed having the certification but stated they did not manage the IPCP. The Assistant Director of Nursing, who is currently acting as the IP, admitted to not having completed the certification. This lack of a certified IP overseeing the IPCP indicates a failure in the facility's compliance with infection control standards, potentially impacting the health and safety of all residents.
Failure to Implement Gradual Dose Reductions and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications for four residents. The facility did not attempt GDRs, identify target behaviors, or document behaviors justifying the use of psychotropic medications. This was confirmed through record reviews and interviews with the Director of Nursing (DON). For instance, one resident was on Olanzapine for dementia-related behaviors without any documented target behaviors or attempts at GDR. The nurse practitioner disagreed with the pharmacist's recommendation for a trial discontinuation, citing the resident's tolerance to the medication and lack of worsening behaviors. Another resident, diagnosed with unspecified depression, reported that their antidepressant was ineffective. Despite this, no GDR attempts were made for the Trazodone prescribed. The DON confirmed that assessments were not conducted due to management and pharmacy changes, and a Performance Improvement Plan (PIP) was in place to address this issue. Similarly, a third resident on Quetiapine for major depressive disorder had no identified target behaviors or personalized non-pharmacological interventions documented in their care plan. A fourth resident with multiple diagnoses, including bipolar disorder and schizoaffective disorder, was on several psychotropic medications without any documented GDR attempts or identified target behaviors. The pharmacist recommended a GDR for Citalopram, but the nurse practitioner disagreed, citing potential exacerbation of the resident's psychiatric condition. The DON confirmed the lack of documented GDRs and personalized care plan interventions for this resident as well.
Failure to Perform Proper Hand Hygiene
Penalty
Summary
The facility failed to perform proper hand hygiene during care for two residents. In the first instance, a Registered Nurse (RN) put on gloves before entering a resident's room, touched a computer and medication cart with gloved hands, and then administered an insulin injection without changing gloves or performing hand hygiene. In the second instance, a Certified Nurse Assistant (CNA) performed catheter care on a resident without changing gloves or performing hand hygiene before touching the resident's bedside table, redressing the resident, and adjusting the resident's position in bed. The CNA later acknowledged the failure to follow proper hand hygiene protocols.
Failure to Incorporate Hospital Discharge Instructions into Care Plan
Penalty
Summary
The facility failed to incorporate hospital discharge instructions for a cervical neck brace and skin care into the care plan and treatment plan for a resident (R65). The resident was admitted with diagnoses including a displaced fracture of the second cervical vertebra, a left pubis fracture, and multiple rib fractures. Despite the hospital's detailed instructions for collar and skin care, these were not included in the resident's care plan or Treatment Administration Record (TAR). Observations and interviews revealed that skin checks were not consistently documented or performed, leading to frustration from both the resident and their spouse. The hospital instructions specified that the cervical collar should be worn at all times, with skin checks and cleaning to be performed 2 to 3 times daily. However, the TAR showed multiple instances where skin checks were not documented. The resident and their spouse reported that skin checks were only performed twice since admission. The Director of Nursing acknowledged that the hospital instructions should have been incorporated into the resident's care plan and treatment plan, but this was not done, resulting in a failure to monitor and care for the resident's skin integrity as required.
Failure to Maintain Door Alarms
Penalty
Summary
The facility failed to ensure that all doors were alarmed at all times, as required by their Elopement Precautions Policy. This failure was highlighted by an incident involving a resident identified as R39, who was found outside the building on the sidewalk in the parking lot. The investigation revealed that R39, who was wearing an electronic monitoring bracelet, exited the building through the ambulance door without triggering the alarm. The security footage showed that R39 left his room in a wheelchair and exited the building without any delay or alarm sounding. Staff members did not react to any noise, indicating that the alarm did not go off as it should have. Further review of the facility's door monitoring logs for April and May 2024 showed that the ambulance door was not being checked regularly. The Director of Nursing (V2) confirmed that maintenance staff had stopped checking this door because they did not have the key to reset the alarm once it went off. This lapse in procedure was attributed to changes made during the COVID-19 pandemic. Despite the alarm working immediately after the incident and since then, the failure to check and maintain the alarm system on the ambulance door led to the deficiency and the potential risk for residents who wander.
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 173 citations issued within 25 miles in the last 12 months — including the 7 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 Silvis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenues At Quad Cities | 0.4 mi | ★★★★★ | 0 | 0 |
| Allure Of Moline | 1.6 mi | ★★★★★ | 5 | 1 |
| Celebrate Sr Living Of Moline | 1.6 mi | ★★★★★ | 1 | 0 |
| Hope Creek Nursing & Rehab | 1.9 mi | ★★★★★ | 6 | 0 |
| The Vistas At Bettendorf | 4.5 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.