Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Smith Crossing during CMS and state inspections, most recent first.
An LPN without required IV certification administered ordered IV Vancomycin to a resident with multiple complex conditions, including UTI, sepsis, CHF, kidney failure, vascular dementia, and type 2 DM with circulatory complications. The resident’s EMR and MAR showed IV Vancomycin doses given, and the MAR contained the LPN’s initials for one of the administrations. The LPN acknowledged not being certified to give IV antibiotics but confirmed having administered them, and the ADON verified that IV certification is required for LPNs to infuse IV antibiotics and that this LPN was not on the facility’s list of IV-certified LPNs.
The facility did not follow its policy for documenting complete pressure ulcer assessments for three residents with pressure injuries. For each, required admission and weekly wound assessments—including measurements and detailed descriptions—were missing from the EMR, as confirmed by the wound care nurse and DON. The facility's policy specified comprehensive documentation, but this was not consistently performed.
A cognitively impaired resident with a contracted, non-weight bearing arm suffered a comminuted and impacted humeral fracture after agency aides pulled on her arm while turning her in bed, contrary to her care plan. The resident expressed pain during and after the incident, and the injury was later confirmed by diagnostic imaging. Staff interviews revealed inadequate communication and improper handling techniques, leading to the injury.
Three high-risk residents experienced repeated falls, including incidents resulting in serious injuries such as a cervical neck fracture and head laceration, due to the facility's failure to consistently implement and monitor individualized fall prevention interventions. Staff did not always follow care plans, failed to ensure required equipment like floor mats and VST monitors were in place, and did not provide adequate supervision, leading to preventable accidents.
A resident with dementia and a history of left arm fracture was found with a new arm injury after two agency aides were observed handling her roughly during care, resulting in pain and a fracture. Despite a family member reporting the incident and showing video evidence to nursing leadership, the event was not recognized or reported as suspected abuse according to facility policy, and the administrator was not promptly informed.
The facility failed to ensure proper hand hygiene and hair restraint practices in the kitchen, affecting 74 residents. A dishwasher handled clean dishes without washing hands after loading dirty items, and several kitchen staff did not restrain their hair properly. The facility lacked beard covers, violating its dress code policy.
The facility failed to maintain privacy during personal care for several residents. Instances included a CNA and nurse leaving a resident exposed with open blinds and door, a nurse discussing a resident's health loudly in a public area, and another nurse administering care with open blinds and door. These actions violated the facility's policies on resident privacy and dignity.
A survey found that a LTC facility failed to store medications safely, with a nurse's cart containing an improperly handled controlled drug and a medication room refrigerator lacking temperature monitoring. The facility's policies on medication storage were not followed, leading to potential contamination and compromised drug integrity.
A long-term care facility failed to follow proper infection control protocols, including neglecting hand hygiene and PPE use during resident care. Staff did not adhere to isolation precautions for residents with infections like C. Diff. and ESBL, and soiled linen was improperly handled, increasing the risk of cross-contamination.
A facility failed to assess a resident's ability to self-administer medications. A Ventolin inhaler was found on the resident's bedside table, but there was no order for self-administration or assessment confirming the resident's ability to do so safely. Interviews revealed that the facility's policy requires an assessment and doctor's approval for self-administration, which was not followed in this case.
A facility failed to provide a written bed hold policy to a resident and their representative before a hospital transfer. The resident, with multiple medical conditions, was transferred due to a medical emergency. Despite the facility's policy to remind residents of the bed hold policy, there was no documentation that this was done. Staff interviews confirmed the policy was not followed, as no evidence was found that the policy was provided or discussed during the transfer.
A resident with chronic venous hypertension and ulcers did not receive wound dressing changes as per physician's orders, leading to soaked and soiled dressings. The wound nurse and DON acknowledged the failure to adhere to the dressing change schedule and inadequate documentation of the wound's condition.
The facility failed to properly store oxygen cylinders, creating a potential explosion hazard, and did not use a gait belt during a resident transfer, increasing fall risk. Observations showed unsecured oxygen cylinders and improper transfer techniques, contrary to facility policies.
A resident with chronic respiratory conditions did not receive oxygen therapy as prescribed due to improper nasal cannula positioning and staff inaction. The CNA did not understand the device's warning message, and the RN failed to check oxygen saturation or correct the cannula position, leading to an elevated respiratory rate.
Uncertified LPN Administered IV Antibiotic
Penalty
Summary
The facility failed to ensure that an LPN who administered an IV antibiotic to a resident had the required IV training/certification. The resident had multiple diagnoses, including urinary tract infection, sepsis, difficulty walking, unspecified skin changes, chronic congestive heart failure, kidney failure, unspecified organism, vascular dementia, and type 2 diabetes mellitus with circulatory complications, and had a physician’s order for Vancomycin 750 mg IV every 18 hours over several days in February 2026. The resident’s EMR and MAR showed that the ordered Vancomycin IV piggyback was administered, and the MAR for one of those days contained the initials of an LPN who later stated she was not certified to give IV antibiotics, although she acknowledged she had administered some to this resident about a month prior and planned to obtain training in the future. The Assistant Director of Nursing confirmed that LPNs at the facility are required to have specific certification to infuse IV antibiotics, verified that the initials on the MAR identify the person who administered the medication, and stated that this LPN’s name did not appear on the facility’s list of LPNs certified to administer IV medications. Thus, the IV Vancomycin was infused by an LPN who lacked the required IV certification, contrary to facility expectations and practice as described by nursing leadership.
Failure to Document Complete Pressure Ulcer Assessments
Penalty
Summary
The facility failed to follow its own policy regarding the documentation of complete pressure ulcer assessments for three residents with pressure ulcers. For one resident admitted with multiple diagnoses including orthostatic hypotension, muscle wasting, pulmonary embolism, dementia, and a stage 3 sacral pressure ulcer, the care plan required weekly wound assessments with measurements and descriptions. However, there was no documentation of a complete admission wound assessment or weekly assessments after a certain date, as confirmed by both the wound care nurse and the DON. Another resident, admitted with a fractured leg, muscle wasting, heart failure, and dementia, had a care plan addressing a deep tissue injury (DTI) to the left heel. The wound care nurse stated that she did not document wound assessments in the EMR, and the DON confirmed that neither an admission nor weekly wound assessments were completed or documented for this resident's DTI. A third resident, with diagnoses including urinary tract infection, muscle wasting, and dementia, developed a stage 4 sacral pressure injury. The care plan required monitoring and documentation of the wound's location, size, and treatment. However, there was no documentation of a weekly wound assessment, including measurements and description, for a specific week when the resident was not seen by the wound doctor. The facility's policy required complete wound assessments on admission and weekly, including specific wound characteristics, but these were not consistently documented for the affected residents.
Failure to Provide Proper Care Results in Arm Fracture for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of left humerus fracture, dementia, and severe functional limitations was dependent on staff for all activities of daily living, including dressing, bathing, and transfers. The resident's care plan specified that her left upper extremity was non-weight bearing due to a previous humerus fracture, and that a sling should be worn at all times. The resident also had a contracture in her left arm, which was to be handled with care during all care activities. On the morning in question, two agency aides assisted the resident with showering and dressing. According to interviews and a review of video footage by a family member, the aides were observed pulling on the resident's contracted left arm and thigh to turn her in bed, despite her care plan indicating that her arm should not be used for such maneuvers. The resident was heard yelling out in pain during this process and continued to complain of arm pain after being dressed and transferred to her chair. Staff and family members noted that the resident's arm appeared more limp than usual, and a bruise was observed. The incident was not immediately reported to management, and the aides involved were not fully aware of the resident's specific limitations. Subsequent assessment and diagnostic imaging revealed that the resident had sustained a comminuted and impacted fracture of the left humeral head. The injury was discovered after the resident continued to express pain and was sent to the hospital for evaluation. Interviews with staff indicated a lack of communication regarding the resident's care needs and improper handling techniques, which directly contributed to the injury. The facility's investigation confirmed that staff failed to provide care in accordance with professional standards and the resident's care plan.
Failure to Implement and Maintain Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain effective fall prevention interventions for multiple residents identified as high risk for falls. For one resident with a history of falls, head injury, dementia, and significant physical limitations, the care plan included interventions such as floor mats, bed/chair alarms, and keeping personal items within reach. Despite these interventions, the resident experienced multiple falls, including incidents where she was found on the floor after attempting to access the phone or bathroom without assistance. After one such fall, the resident sustained a cervical neck fracture and facial abrasions, requiring emergency hospital transfer. Interviews with staff revealed that after repeated falls, no new interventions were added to the care plan, and only minor adjustments were made to existing interventions. Another resident with severe cognitive impairment, a history of falls, and physical limitations also experienced repeated falls, including one resulting in a head laceration that required staples. The care plan for this resident included frequent monitoring, use of floor mats, and virtual sense technology (VST) for alerting staff to movement. However, during one incident, the assigned CNA did not have the required alert tablet with her, leaving the resident unsupervised and resulting in a fall with significant injury. Staff interviews confirmed that the expected supervision and monitoring protocols were not consistently followed, and the resident was able to move unsupervised from a common area to her room, where the fall occurred. A third resident, also at high risk for falls due to dementia, weakness, and a history of fractures, was observed without all required fall prevention interventions in place. The resident was found sleeping in a bed that was not in the lowest position, with only one floor mat in place instead of the required mats on both sides. Additionally, the VST monitor intended to alert staff to movement was not present in the room, and the assigned CNA was unaware of its location. Staff interviews indicated that frequent checks were not documented, and the required interventions were not consistently implemented or monitored. These failures resulted in repeated falls and inadequate supervision for residents at high risk.
Failure to Recognize and Report Suspected Abuse Following Resident Injury
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin as a suspected allegation of abuse for a resident with a complex medical history, including dementia, a prior left humerus fracture, and other chronic conditions. On the morning in question, a certified nursing assistant observed the resident guarding her left arm and expressing pain when touched, with a noticeable green bruise and abnormal arm movement. There was no prior report of a fall, and the incident was not communicated during shift change. Pain medication was administered, and an x-ray was ordered, but the resident was ultimately sent to the emergency room, where a comminuted and impacted fracture of the left humeral head was diagnosed. Interviews revealed that a family member had observed two agency aides handling the resident roughly during morning care via a room camera, specifically pulling on the resident's contracted left arm and thigh to turn her, which caused the resident to cry out in pain. The family member reported this observation to an LPN, who did not escalate the concern to management, believing the action was not malicious. The family member also showed video evidence of the incident to the DON, ADON, and other staff, who acknowledged that the aides' handling was inappropriate and contrary to proper transfer techniques for the resident's condition. Despite these observations and reports, the incident was not initially treated as a suspected abuse case or reported to the administrator as required by facility policy. The administrator was not informed until after the fact, and the incident was not viewed as abuse by some members of the leadership team. Facility policies require that injuries of unknown origin and allegations of abuse be reported and investigated according to established procedures, but these protocols were not followed in this case.
Deficiencies in Hand Hygiene and Hair Restraint in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene and hair restraint practices in the kitchen, affecting 74 of 75 residents who consume food prepared there. During an observation, a dishwasher staff member handled clean dishes and utensils without washing hands or changing gloves after loading dirty items into the dishwasher. This staff member also used a cloth towel to dry gloved hands after cleaning a transport cart, which is against the facility's hand hygiene policy. The policy mandates that all staff perform proper hand hygiene to prevent infection spread. Additionally, several kitchen staff members did not properly restrain their hair while preparing food. A sous chef and a cook were observed with unrestrained hair, and two staff members had large, uncovered beards. The facility's uniform dress code policy requires all food service associates to wear approved hair restraints and beard nets. However, the facility did not have beard covers available at the time of the survey, as confirmed by the Food Service Director.
Privacy Breaches During Resident Care
Penalty
Summary
The facility failed to ensure privacy during personal care for several residents, as observed by surveyors. In one instance, a CNA and a nurse provided wound and incontinence care to a resident with the blinds open, exposing the resident to view from the patio area. The nurse left the room with the door open, leaving the resident exposed to anyone passing by in the hallway. Another incident involved a nurse loudly discussing a resident's frequent urinary tract infections in a public dining area, compromising the resident's privacy. Additionally, a nurse administered medication and G-tube feeding to a resident with the door, privacy curtains, and window blinds open, while the resident was partially exposed. Further observations revealed that a CNA provided incontinence care to a resident with the window blinds open, exposing the resident to view from outside. The facility's policies on perineal care and promoting resident dignity emphasize the importance of maintaining privacy by closing doors and blinds during personal care. However, these policies were not adhered to, resulting in multiple instances where residents' privacy and dignity were compromised.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to appropriately store medications and biologicals safely for several residents, as observed during a survey. A nurse's medication cart was found with a controlled drug, alprazolam 0.5mg, that was opened and retaped, which should have been discarded due to potential contamination. The nurse was unaware of when the medication was last administered, and there was no physician's order for the 0.5mg dosage, indicating a discrepancy in medication management for the resident with an anxiety disorder. Additionally, the facility's medication room refrigerator lacked a thermometer and a temperature log, which are essential for ensuring medications are stored at the correct temperature. The refrigerator contained various medications, including vaccines and emergency kits, as well as medications for multiple residents. The absence of temperature monitoring raises concerns about the integrity of these medications, as they may have been exposed to improper temperature conditions. The Director of Nursing acknowledged the issues, stating that medications should be discarded if there is any chance of contamination or if the temperature control is compromised. The facility's policies require medications to be stored under proper temperature controls and in locked compartments to prevent contamination, diversion, or accidental exposure. However, these policies were not adhered to, leading to the deficiencies observed during the survey.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of staff not following isolation precautions and neglecting hand hygiene. For instance, a CNA entered a resident's room under Enhanced Barrier Precautions (EBP) without wearing a gown and handled the resident's urinary catheter bag improperly. The CNA also failed to perform hand hygiene after removing gloves, which is critical in preventing cross-contamination. Additionally, the resident was later confirmed to have Clostridium Difficile (C. Diff.), necessitating contact isolation, yet staff continued to enter the room without appropriate personal protective equipment (PPE). Another deficiency was observed with a resident on contact precautions for ESBL (Extended Spectrum Beta-Lactamases) in the urine. Despite the contact precautions, the resident was allowed to eat in the dining room with other residents, and staff interacted with the resident without wearing the required PPE. Housekeeping staff also failed to sanitize equipment after cleaning the resident's room, potentially spreading contaminants throughout the facility. The Infection Preventionist incorrectly believed that the infection was contained, allowing the resident to leave their room, which contradicted the facility's policy. Further deficiencies were noted in the handling of soiled linen and during incontinence and wound care. Staff were observed not changing gloves or performing hand hygiene when transitioning from dirty to clean tasks, such as after providing peri care or wound care. This lack of adherence to infection control protocols was consistent across multiple staff members and residents, indicating a systemic issue within the facility's infection control practices. Additionally, soiled linen was improperly placed on the floor, further contributing to the risk of infection spread.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess whether a resident was able to self-administer medications independently. During an initial tour, a Ventolin inhaler was found on the bedside table of a resident, who stated she took two puffs a day. The resident's Physician Order Sheet indicated an order for Ventolin to be administered every six hours, but there was no order for self-administration. Additionally, the facility could not provide a self-administration assessment or progress notes confirming the resident's ability to self-administer medications safely. Interviews with the RN and the Director of Nursing revealed that residents are allowed to self-administer medications if approved by a doctor and after an assessment is conducted. However, the RN was unaware of any residents approved for self-administration, and the Director of Nursing confirmed that an order and assessment should be documented in the Electronic Medical Record. The facility's policy states that residents have the right to self-administer medications if deemed clinically appropriate by the interdisciplinary team, but this process was not followed for the resident in question.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a written copy of its bed hold and bed payment policy to a resident and their representative before transferring the resident to a hospital. This deficiency was identified during a review of a case involving a male resident who was transferred to a local community hospital due to a medical emergency. The resident, who had multiple diagnoses including urinary tract infection, metabolic encephalopathy, congestive heart failure, hypothyroidism, and hypertension, was transferred after being found only briefly arousable. Despite the presence of the resident's wife at the bedside, there was no documentation indicating that the bed hold policy was provided to either the resident or his representative at the time of transfer. Interviews with facility staff, including the Director of Nursing and the Social Service Director, revealed that while it is the facility's policy to remind residents of the bed hold policy during transfers, there was no evidence that this was done in this case. The facility's policy requires providing notice of transfer and the bed hold policy, but it does not specify that a hard copy must be given. The staff acknowledged that the policy was not followed, as there was no documentation to confirm that the resident or his representative received the bed hold policy or were reminded of it during the transfer process.
Failure to Adhere to Wound Dressing Change Orders
Penalty
Summary
The facility failed to provide wound dressing changes as per the physician's order for a resident with multiple diagnoses, including cerebral infarction, cellulitis, and chronic venous hypertension with ulcers on the lower extremities. The resident's care plan required dressing changes every other day and as needed, with specific instructions for cleansing and dressing application. However, during an observation, it was noted that the resident's dressings were not changed according to the schedule, resulting in soaked and soiled dressings with significant drainage. The wound nurse admitted that the dressing change should have been done earlier due to the amount of drainage, and there was a lack of proper documentation regarding the wound's condition. The Director of Nursing (DON) and the wound nurse acknowledged that the dressing changes were not performed as required, and the wound nurse failed to document the wound's status and drainage adequately. The facility's policy stated that dressing changes should be done according to the physician's orders and could be adjusted if the dressing was soiled or wet. However, the lack of adherence to these protocols and insufficient documentation contributed to the deficiency in care for the resident's wound management.
Improper Oxygen Storage and Transfer Procedures
Penalty
Summary
The facility failed to store oxygen cylinders properly, creating a potential explosion hazard. Observations revealed that a portable oxygen cylinder in a resident's room was not secured in a stand or tethered, posing a risk to nearby residents if it were to tip over. Staff interviews indicated a lack of awareness and adherence to the facility's policy on oxygen storage, which mandates that cylinders be secured to prevent accidents. Despite the policy, the oxygen cylinder remained unsecured, and staff members acknowledged the potential danger of an explosion or injury if the cylinder were to fall. Additionally, the facility failed to use a gait belt during the transfer of a resident, increasing the risk of falls and injury. A CNA was observed transferring a resident by pulling on the waistband of the resident's pants instead of using a gait belt, contrary to the facility's Safe Resident Handling policy. The resident, who was a high fall risk and required two-person assistance, was not transferred safely, as confirmed by staff interviews. The facility's policy mandates the use of gait belts for transfers, yet this was not followed, compromising the resident's safety.
Improper Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure a resident received oxygen therapy consistent with physician orders, as observed during a survey. A resident, identified as R15, was seen in the dining room with a nasal cannula improperly positioned, with one prong in the right nostril and the other on the cheek. The portable oxygen delivery device connected to the cannula was flashing a warning message indicating 'no breathing detected, please check cannula.' Despite this, the CNA present did not understand the message and continued feeding the resident without notifying the nurse. The resident's respiratory rate was elevated at 32 breaths per minute, indicating potential respiratory distress. When the surveyor informed the RN about the issue, the RN switched the resident's oxygen source to a portable tank but did not check the oxygen saturation level or ensure the nasal cannula was correctly positioned. The resident's medical history includes chronic obstructive pulmonary disease, respiratory failure, and cognitive communication deficit, requiring continuous oxygen therapy. The facility's policy mandates that oxygen therapy be administered per physician orders and that staff should address any issues with oxygen delivery immediately. The Director of Nursing confirmed that the staff should have assessed and corrected the nasal cannula positioning to ensure proper oxygen delivery.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,299 citations issued within 25 miles in the last 12 months — including the 17 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 Orland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Estates Of Orland Park | 2.7 mi | ★★★★★ | 7 | 1 |
| Frankfort Terrace | 4.8 mi | ★★★★★ | 0 | 0 |
| Warren Barr Orland Park | 4.9 mi | ★★★★★ | 3 | 0 |
| Victorian Village Hlth & Well | 5.6 mi | ★★★★★ | 1 | 0 |
| Elevate Care Country Club Hill | 7.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Smith Crossing.
100% money-back within 48 hours.
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.