Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Village during CMS and state inspections, most recent first.
A resident with dementia, acute kidney failure, DM2, and other chronic conditions was discharged despite abnormal labs showing elevated BUN, creatinine, and low eGFR consistent with dehydration. The DON could not verify the results were communicated to the MD, the MD said he was unaware of the abnormal labs and the resident’s hospital return, and the receiving HHA reported the resident was readmitted shortly after discharge with acute metabolic encephalopathy likely related to dementia, dehydration, and UTI.
A facility failed to notify the physician and resident representatives when new antibiotics were started for three residents, and failed to notify the physician of abnormal lab results for one resident. Progress notes lacked documentation that family or representatives were informed when ciprofloxacin or ertapenem was initiated, and the physician stated he was not aware of the abnormal BUN, creatinine, and eGFR results.
A resident who was alert, oriented, and able to communicate clearly had multiple personal checks written from his bank account to a CNA regularly assigned to his care, with the checks later found to have been mobile deposited into a personal account. After the resident’s death, his daughter discovered the suspicious checks while closing his bank estate and notified facility leadership, who confirmed through bank records that several checks labeled as “rent” in varying amounts had been issued to and deposited by the CNA. These events show that the facility failed to prevent misappropriation of the resident’s money in accordance with its abuse policy prohibiting exploitation and wrongful use of resident property.
The facility failed to ensure that two licensed nurses consistently completed and documented shift-to-shift controlled substance counts for medication carts containing narcotics for multiple residents. Review of controlled substance count forms for two medication carts showed missing "Nurse Off" initials at morning shift changes, despite staff statements that both incoming and outgoing nurses are required to count all narcotics together and initial the form, and that the DON should be notified of any missing initials or discrepancies. Facility policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, but this process was not consistently documented as completed.
Surveyors found that dietary staff failed to consistently label and date fresh produce and leftover foods, and did not discard items past their discard dates, including overripe bananas and unlabeled trays of fish and other foods in dry and cold storage. Multiple boxes of bananas lacked delivery-date labels, and some bananas had split peels with exposed flesh. During preparation of pureed sloppy joe sandwiches for residents on puree diets, a cook repeatedly washed hands for less than the required 20 seconds between tasks, despite facility policy and staff statements that 20-second handwashing is necessary to prevent cross-contamination. At the time, all but one resident were receiving oral diets, and the facility’s HACCP, dry storage, and hand hygiene policies required proper dating, discarding of expired foods, and thorough handwashing.
Staff failed to follow hand hygiene and respiratory etiquette requirements during direct care and dining. One CNA provided care to a resident without hand hygiene or gloves, carried a soiled napkin from that resident’s room into another resident’s room, placed it on the second resident’s dresser, then handled the shared ice machine without cleaning hands. Another CNA donned gloves and assisted with repositioning a resident without performing hand hygiene. During 1:1 feeding of a cognitively impaired resident on a mechanical soft diet, a CNA coughed into her scrub shirt and later sneezed into her elbow while seated next to the resident, did not perform hand hygiene, continued feeding, and used a bare hand to handle and feed a piece of the resident’s ice cream sandwich. These actions were inconsistent with the facility’s infection control, hand hygiene, and respiratory hygiene policies.
A resident requiring two-person assistance for transfers was improperly transferred by a single CNA, resulting in a leg laceration requiring 18 sutures. Despite clear documentation and staff awareness of the resident's needs, the CNA did not follow the care plan, leading to the injury.
A resident sustained a laceration requiring 18 sutures after being improperly transferred by a CNA, who did not follow the care plan requiring two-person assistance. The injury occurred when the resident's leg made contact with a loose bed frame that was not adjusted to match the mattress size. The facility lacked a system to ensure bed frames were properly secured, contributing to the safety hazard.
The facility failed to properly label, date, and store food items, risking foodborne illness for residents. Observations revealed uncovered beef patties, unlabeled pepperoni, and open tilapia fish, among other improperly stored items. The Dietary Manager acknowledged these practices were against facility policies, which require proper food handling to prevent cross-contamination.
The facility failed to ensure garbage dumpster lids were closed, as observed by a surveyor. A Dining Service Manager was seen closing the lids and acknowledged they should not be open, noting that CNAs also use the dumpsters. The Environment Service Director confirmed that lids should be closed. Facility policy requires garbage containers to be covered when not in use.
The facility staff failed to complete the controlled substance shift-to-shift count forms, leading to missing initials for several shifts in September. This deficiency was observed on both the second and first floors, affecting the accountability of controlled substances. Interviews revealed confusion among nurses about the procedure, which requires two nurses to count and verify the substances together. The DON highlighted the importance of this process to ensure all narcotics are accounted for.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, potentially affecting 27 residents. Staff were observed performing high-contact care without proper PPE. Interviews revealed confusion about EBP requirements, despite facility policy mandating EBP for residents with significant wounds. The resident's care plan indicated the need for EBP, but it was not followed, leading to a deficiency in infection control.
A resident's urinary catheter drainage bag was left uncovered, visible to passersby, compromising their dignity. The resident, with intact cognition and multiple diagnoses including bladder dysfunction, had their privacy breached as the facility's policy requiring covered catheter bags was not followed.
A resident with congestive heart failure and chronic kidney disease was observed consuming both ginger ale and water during a meal, contrary to their prescribed fluid restriction diet order. The dietician confirmed the error, noting that servers need to follow diet card instructions. The facility's policy requires adherence to prescribed dietary interventions, which was not followed in this instance.
The facility failed to maintain temperature logs and provide thermometers for personal refrigerators used by residents, leading to potential safety risks. Observations showed that these refrigerators lacked necessary monitoring tools, and interviews revealed confusion among staff about responsibility for temperature checks. The Director of Nursing indicated that families are responsible, but no specific policy exists for refrigerator maintenance.
A high fall risk resident with severe cognitive impairment and multiple medical conditions was left unsupervised, resulting in a fall and head injury. Despite requiring constant supervision and having a fall alert system, the resident was found on the bathroom floor with a laceration that required hospital treatment.
Discharge occurred despite abnormal labs and incomplete communication
Penalty
Summary
The facility failed to ensure an appropriate discharge for one resident by discharging her despite abnormal laboratory results that were indicative of dehydration. The resident was admitted with a history that included fracture of the left pubis, acute kidney failure, muscle wasting and atrophy, ataxic gait, type 2 diabetes mellitus, elevated white blood cell count, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hyperlipidemia, and essential hypertension. Her 2/16/2026 laboratory results showed abnormal BUN of 26 mg/dL, creatinine of 2.1 mg/dL, and eGFR of 21 mL/min. The DON presented documentation indicating the results were sent to the physician, but the physician stated he was not made aware of the abnormal laboratory results and could not verify that they were communicated by fax, telephone, or text. The physician also stated he was not aware the resident returned to the hospital after discharge and said that, given the abnormal results, he would have provided IV fluids, instructed increased fluid intake, and arranged follow-up monitoring before discharge. The receiving home health DON stated the resident started care the day after discharge and returned to the hospital within 24 hours with acute metabolic encephalopathy, most probably due to a combination of dementia, dehydration, and UTI, and that the abnormal laboratory results were not provided to the home health agency.
Failure to Notify Physician and Representatives of New Treatments and Abnormal Labs
Penalty
Summary
The facility failed to notify the physician and residents’ representatives when new treatments were initiated and failed to notify the physician of abnormal laboratory results for three residents reviewed for notification of changes. R1 was admitted with a history that included fracture of the left pubis, acute kidney failure, muscle wasting and atrophy, ataxic gait, type 2 diabetes mellitus, elevated white blood cell count, dementia, hyperlipidemia, and essential hypertension. R1’s physician order sheet showed an order for ciprofloxacin 500 mg by mouth twice daily for 7 days for UTI, but the progress notes did not document that the family member was informed antibiotics were started. R2’s physician order sheet showed an order for ciprofloxacin 500 mg by mouth twice daily for 7 days for UTI, and the progress notes did not document that the family member was informed antibiotics were started. R3’s physician order sheet showed an order for ertapenem 1 gram IV at bedtime for UTI for 7 days, and the progress notes did not document that the representative was informed that antibiotics were started. R1 also had abnormal laboratory results with a report date of 2/16/2026 showing BUN 26 mg/dL, creatinine 2.1 mg/dL, and eGFR 21 mL/min. The DON presented a copy of the lab results with a notation that they were sent to R1’s physician on 2/17/2026, but the physician stated he was not made aware of the abnormal results and could not verify that they were communicated by fax, telephone, or text. The physician also stated he was not aware that R1 ended up in the hospital after discharge from the facility and said he would have given IV fluids, instructed increased fluids, and arranged follow-up because the abnormal results could indicate dehydration. The facility policy titled Notification of Changes stated that the facility must inform the resident, consult with the physician, and notify the family member or legal representative when there is a change requiring such notification, including starting a new treatment.
Failure to Prevent Misappropriation of a Resident’s Funds by CNA
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy regarding misappropriation of resident property, resulting in an employee cashing multiple personal checks belonging to a resident without his knowledge or consent. The resident was admitted in late July 2025, arriving by wheelchair from another residential setting and documented as alert and oriented x3, able to communicate clearly and understand and be understood. In early September 2025, nursing notes documented that the resident was actively transitioning with hospice involvement and then became unresponsive and pulseless later that same day, with his daughter/POA present. After the resident’s death, his daughter discovered suspicious activity while closing her father’s bank estate, including several checks written from his account to a CNA employed at the facility. She contacted facility leadership to ask if this individual worked there and reported that several checks from her father’s account bore the CNA’s name and had been cashed. The facility’s own abuse report and interviews with the Assistant Executive Director, Executive Director/Administrator, and DON confirmed that the CNA had been regularly assigned to care for the resident and that the daughter provided copies of cancelled checks and bank statements showing multiple checks written to and deposited by the CNA. Record review showed a series of checks from the resident’s account, each listing the CNA as payee and referencing “rent,” with amounts ranging from $640.00 to $940.00 over multiple days in August and early September 2025. An Employee Action Form dated 10/6/25 documented that several checks were written to the CNA from the resident’s checking account and were subsequently mobile deposited into a personal account, and that the facility determined a violation of policy had occurred. The facility’s abuse policy defines misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the events described constitute such misappropriation for this resident.
Failure to Complete Shift-to-Shift Controlled Substance Counts by Two Licensed Nurses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that two licensed nurses conducted and documented a shift-to-shift physical inventory of controlled substances for all medication carts as required by facility policy. Surveyors reviewed the controlled substance shift-to-shift count forms for the second-floor and third-floor medication carts for September 2025 and found missing initials in the “Nurse Off” boxes at specific morning shift-change times. On the second-floor [NAME] medication cart, the “Nurse Off” initial box was left blank for a morning shift change on September 17, 2025. On the third-floor medication cart, the “Nurse Off” initial box was left blank for a morning shift change on September 23, 2025. These documentation gaps occurred for carts that contained controlled substances prescribed for 7 residents on the 3J cart and 5 residents on the 2J cart. During interviews, an LPN stated that every nurse is responsible for ensuring the narcotic count is correct and that two nurses are to count the controlled substances in the medication cart and sign the “on” and “off” spaces on the shift-to-shift count sheet, and that nurses are to notify the DON if initials are missing. An RN explained that the controlled substance shift-to-shift count sheets are used to document that the total number of narcotics in the cart is correct at the end of each shift, and that the incoming and outgoing nurses count all narcotics together and both initial the form once they agree the count is correct, notifying the DON if there is any discrepancy. The MDS Coordinator confirmed that nurses are responsible for completing these sheets to verify that all narcotics in the cart are accounted for and that the DON should be notified if the sheets are not initialed and completed for each shift. Review of the facility’s July 2025 policy on Controlled Substance Administration & Accountability documented that two licensed nurses must account for all controlled substances and access keys at the end of each shift, which was not consistently followed as evidenced by the missing “Nurse Off” initials.
Improper Food Labeling, Storage, and Hand Hygiene in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper food procurement, storage, labeling, dating, and hand hygiene practices in the kitchen. During an initial kitchen tour, the surveyor and the Dietary Director observed that dry storage food items were generally labeled with orange stickers indicating delivery dates, but multiple boxes of bananas had no delivery date labels. The bananas in two of these boxes were described as yellow with black spots and emitting a noticeable odor through the surveyor’s surgical mask. The Dietary Director confirmed that the boxes should have been dated and acknowledged that staff had not labeled them. In the walk-in cooler, the surveyor observed a tray of pre-cut salmon pieces under a clear plastic cover with no label or date, and two trays of cod (one plain and one with butter and dill) without any labels or dates. A deep stainless-steel pan of chicken in liquid and an opened package of sausage bratwurst were labeled with preparation and discard dates, but both were past their discard dates. On a follow-up kitchen tour, the surveyor again observed the same two boxes of ripe bananas with yellow peels and numerous black spots still on the dry storage shelves. The cook stated that one case would be discarded and the other used for smoothies in a chef demonstration and explained that staff determine how long food is good by referring to posted storage life guidelines. A third box of bananas, described as green/yellow, had arrived that morning but also lacked a delivery date label. When the Dietary Director opened one of the older banana boxes at the prep table, some bananas were found with split peels exposing the flesh and were discarded into the garbage; the Dietary Director again confirmed that the box had not been labeled or dated. The facility’s written policy on dry storage life of foods requires use of manufacturer expiration dates or, if absent, adding specified storage times to the date the food is received, and instructs that products be discarded when quality is unacceptable. The surveyor also observed multiple instances of improper hand hygiene by the cook during preparation of pureed sloppy joe sandwiches for residents on puree diets. The cook washed hands several times at the kitchen handwashing station, but each observed handwashing episode lasted less than 20 seconds, despite the cook’s verbal description of the correct procedure as including 20 seconds of lathering. The cook washed hands briefly, donned gloves, handled bread buns, ladled heated milk over the buns, touched the milk-soaked buns with gloved hands, removed gloves, and repeatedly moved between tasks such as checking milk on the stove, wiping the prep table with a sanitizing towel while gloved, and returning to food preparation, with each handwashing episode again documented as under 20 seconds. The facility’s handwashing policy requires staff to wash hands whenever they become soiled or contaminated, upon entering or returning to the kitchen, before food preparation, when switching between raw and ready-to-eat foods, during food preparation as often as necessary to prevent cross-contamination, and when changing gloves, and specifies that hands should be scrubbed following appropriate techniques. The Assistant Dietary Director later confirmed that kitchen staff are expected to wash hands every time they change tasks, after using the bathroom, or after touching door handles, and to wash for 20 seconds to remove germs, stating that washing for less than 20 seconds could allow germs to be carried to the next task. The Assistant Dietary Director also stated that fresh fruit items must be labeled with the date received and a discard date, and that all leftover prepared foods stored in the kitchen must be labeled with the date and time prepared, discard date and time, and staff initials. The Assistant Dietary Director explained that if ripened bananas with opening peels are kept past their discard date, bacteria can grow and the odor can attract fruit flies, and that leftover foods stored past their discard date cannot be served because bacteria and other contaminants can develop. At the time of the survey, facility records showed that 61 skilled residents were in the facility, with 60 receiving oral diets and one resident receiving tube feedings and nothing by mouth, and the cycle menu documented that pureed sloppy joe sandwiches were the planned hot lunch item for residents on puree diets.
Failure to Follow Hand Hygiene and Respiratory Etiquette During Resident Care and Dining
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program, specifically related to hand hygiene, handling of potentially contaminated items, and respiratory hygiene/cough etiquette. On one occasion, a CNA (V7) was observed providing direct care to a resident (R1) by repositioning and fixing an underpad without performing hand hygiene or donning gloves. During the same interaction, V7 removed a soiled napkin from R1’s bed and then exited the room. V7 then entered another resident’s (R5’s) room and placed the soiled napkin from R1’s room on R5’s dresser. Without performing hand hygiene, V7 donned gloves and assisted R5 to the restroom, then removed the gloves, picked up the same soiled napkin, and walked to the dining area. V7 placed the soiled napkin in a basket and then used the shared unit ice machine to place ice in a cup, again without performing hand hygiene. On another observation, a second CNA (V8) was seen donning gloves without performing hand hygiene before entering R1’s room to assist V7 in pulling R1 up in bed. V8 later acknowledged not sanitizing hands before putting on gloves and stated that hand hygiene should have been performed. V7 also acknowledged that she should have sanitized her hands and donned gloves before caring for R1, stating she was moving too fast and that she does not like to sanitize her hands before donning gloves because it makes her hands sticky. V7 further stated that she should sanitize her hands between residents but that it is very busy and she moves fast. The MDS Coordinator (V19) stated that hand hygiene is important to prevent the spread of infection, should be done before entering and leaving a resident’s room and between tasks, and that dirty linen should not be taken from one resident’s room to another. V19 also stated that the unit’s ice machine is for all residents and that if hand hygiene is not performed after resident care and then the ice machine is used, the ice machine is considered contaminated. A separate deficiency was observed during dining involving respiratory hygiene and hand hygiene while feeding a resident (R27). During a 1:1 feeding of an ice cream sandwich, V7 sat next to R27 and was observed coughing into her scrub shirt by turning her head and bringing the neck of the scrub shirt near her mouth with her right hand. V7 did not perform hand hygiene and began feeding R27 with a spoon. After feeding two bites, V7 sneezed into her right elbow while sitting next to R27 and again did not perform hand hygiene before continuing to feed three more bites. When a piece of the ice cream sandwich fell off the spoon onto the plate, V7 used her bare left hand to touch the ice cream sandwich piece and place it back onto the spoon, then fed it to R27. V19 later stated that staff should step away from residents if they have to cough or sneeze, perform cough etiquette, and then perform hand hygiene, and that staff feeding a resident 1:1 should not touch the resident’s food with bare hands. Facility policies on Infection Control, Hand Hygiene, and Respiratory Hygiene and Cough Etiquette require staff to perform hand hygiene before and after resident contact, after coughing or sneezing, and after contact with respiratory secretions, and to adhere to proper respiratory hygiene and cough etiquette to prevent the spread of infection.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper number of staff were used in transferring a resident, leading to an accident hazard. A resident, who required a two-person assist for transfers due to a history of hip surgery and other medical conditions, was transferred by a single CNA. This improper transfer resulted in the resident sustaining a laceration on the left lower leg, which required hospital treatment and 18 sutures. The resident's medical records indicated a dependency on staff for transfers, with a maximum of two-person assistance required. Despite this, the CNA involved in the incident did not adhere to the care plan, which was clearly documented and accessible to staff. The incident occurred during the evening shift, and the CNA admitted to transferring the resident alone, which was against the established protocol. The CNA's actions were inconsistent with the facility's job description and training provided to staff, which emphasized the need for two-person assistance for this resident. Interviews with various staff members, including the Director of Nursing, CNAs, and therapists, confirmed that the resident's care plan required two-person assistance for transfers. The staff were aware of the resident's needs, and the facility had systems in place, such as green and yellow cards in resident rooms and a 24-hour report, to communicate these needs. However, the failure to follow the care plan resulted in the resident's injury, highlighting a lapse in adherence to established safety protocols.
Resident Injury Due to Improper Bed Frame Adjustment
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer, resulting in a significant injury. The incident involved a resident who was being transferred from a wheelchair to a bed by a CNA, who did not follow the care plan that required two-person assistance. During the transfer, the resident's left lower leg made contact with a loose bed frame, causing a laceration that required 18 sutures. The resident was subsequently sent to the hospital for treatment. The investigation revealed that the bed frame was not properly adjusted to match the size of the mattress, which contributed to the injury. The bed frame was wider than the mattress, creating a safety hazard that led to the resident's leg making contact with the frame. The maintenance department was identified as responsible for ensuring that bed frames are properly secured, but it was found that there was no regular check in place to ensure the bed frames were locked or properly adjusted. Interviews with facility staff, including the Assistant Maintenance Manager and the Director of Nursing, confirmed that the bed frame was not properly secured at the time of the incident. The facility's policy on providing a safe environment was not adhered to, as there was no system in place to regularly monitor the safety of bed frames. The lack of documentation or work orders to address this issue further highlighted the deficiency in maintaining a safe environment for residents.
Improper Food Storage and Labeling in LTC Facility
Penalty
Summary
The facility failed to ensure that food items were properly labeled, dated, and stored to prevent the spread of foodborne illness to residents receiving oral nutrition. During an observation, a surveyor noted several food items in the facility's storage areas that were not covered, labeled, or dated. These included a container of uncovered beef patties, a roll of pepperoni without a received or discard date, and a bag of tilapia fish open to air. Additionally, tubs of chocolate and pecan ice cream were found with unsecured lids, and containers of bread battered cod and edamame dumplings were observed without lids and not dated. Interviews with the Dietary Manager confirmed that these practices were not in compliance with the facility's food safety policies, which require all food items to be covered and dated to prevent cross-contamination. The facility's policies, revised in March 2022 and March 2023, emphasize the importance of date marking and proper storage to ensure food safety. The failure to adhere to these policies has the potential to affect all residents receiving oral nutrition, as it increases the risk of foodborne illness due to improper food handling and storage practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the garbage dumpster lids were closed, as observed by a surveyor. On the specified date, the surveyor noted that a blue garbage dumpster had both lids open. The Dining Service Manager, identified as V4, was observed closing the lids and acknowledged that the lids should not be open, mentioning that CNAs also use the dumpsters. Additionally, the Environment Service Director, identified as V8, confirmed that the dumpster lids should be closed. The facility's policy on the disposal of garbage and refuse, implemented in February 2023, states that garbage and refuse containers must be covered when not in use, and containers and dumpsters should be kept covered when not being loaded. The job description for the EVS Director includes responsibilities for ensuring a safe and clean environment, adhering to regulatory requirements.
Failure to Complete Controlled Substance Count Sheets
Penalty
Summary
The facility staff failed to complete the controlled substance shift-to-shift count form, which is essential for ensuring accountability for controlled substances. This deficiency was observed during a review of the medication carts on both the second and first floors. Specifically, the forms for several shifts in September 2024 were found to have missing initials from the nurses responsible for counting and verifying the controlled substances. The missing initials were noted for the PM shift on September 8, the AM shift on September 9, and the PM shift on September 11 on the second floor, as well as the 6 PM shift on September 4 on the first floor. Interviews with the nursing staff, including two registered nurses and the Director of Nursing (DON), revealed that there was confusion among the nurses regarding the completion of the controlled substance count sheets. The process requires two nurses, one coming on shift and one going off shift, to count the controlled substances together and initial the count sheet to confirm accuracy. The DON emphasized the importance of this procedure to ensure all narcotics are accounted for and stated that nurses should notify her if the count sheets are not completed. The facility's policy, revised in August 2024, mandates that two licensed nurses verify the inventory of controlled substances at the end of each shift.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, identified as R21, which could potentially affect all 27 residents on the second floor. On observation, R21 was found in bed without an EBP sign or Personal Protective Equipment (PPE) bin in or near the room. Staff members, including a Registered Nurse (RN) and Certified Nursing Assistants (CNAs), were observed performing high-contact care activities such as wound care and hygiene assistance without wearing the appropriate PPE, specifically gowns. Interviews with staff revealed a lack of awareness and understanding regarding the necessity of EBP for residents with chronic wounds. The Wound Care Nurse, V9, acknowledged that residents with wounds require EBP but was unsure why R21 was not on EBP. The Infection Preventionist, V3, incorrectly stated that R21 did not require EBP because the wound was not chronic and lacked a history of Multidrug-Resistant Organism (MDRO). However, the Director of Nursing, V2, confirmed that residents with chronic wounds should be on EBP to prevent MDRO transmission. The facility's policy on EBP mandates the use of gowns and gloves during high-contact care activities for residents with significant wounds or indwelling medical devices, even if they are not known to be infected with MDRO. Despite this policy, R21's care plan and Physician Order Sheet indicated the need for EBP due to a chronic wound, yet these precautions were not implemented, leading to a deficiency in infection prevention and control practices.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag was covered with a privacy cover, which affected the resident's dignity. During an observation, the urinary catheter drainage bag was seen hanging off the lower bed frame of the resident's bed, visible to anyone passing by the open door. The bag contained yellow urine and was not covered with a privacy bag, contrary to the facility's policy. The resident involved had a diagnosis that included neuromuscular dysfunction of the bladder, retention of urine, difficulty in walking, and generalized muscle weakness. The resident's cognitive status was intact, as indicated by a BIMS score of 15. The facility's policy required that catheter drainage bags be covered at all times to maintain resident dignity, but this was not adhered to in this instance.
Failure to Adhere to Fluid Restriction Diet Order
Penalty
Summary
The facility failed to adhere to a resident's prescribed fluid restriction diet order, which was observed during a lunch meal. The resident, identified as R37, has a medical history that includes acute on chronic diastolic congestive heart failure, chronic kidney disease, and organ-limited amyloidosis. R37 also has some cognitive impairments, as indicated by a BIMS score of 10. During the observation, R37 consumed both a 7.5 oz can of ginger ale and a 6.0 oz cup of water, despite the dietary order specifying a fluid restriction of 6 oz of either water, coffee, juice, or soda, but not more than one option. The diet card and physician order sheet both documented a daily fluid restriction of 1500 mL, with specific allocations for dietary and nursing staff. The dietician, identified as V7, confirmed that R37 should not have been provided both beverages due to the fluid restriction. V7 acknowledged that the servers, who provide drinks before meals, need to read and adhere to the diet card instructions. The facility's policy on therapeutic diet orders emphasizes providing residents with foods and fluids in accordance with physician prescriptions and interdisciplinary team assessments. The failure to follow the fluid restriction order was identified as a deficiency during the survey, highlighting a lapse in the facility's adherence to prescribed dietary interventions for residents with specific medical needs.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain temperature logs and provide thermometers for personal refrigerators used by residents, specifically affecting two residents. Observations on multiple occasions revealed that the personal refrigerators of these residents lacked temperature logs and thermometers, which are necessary to ensure food safety. The facility's policy allows residents to have food brought in by family or visitors, but it requires that the food be handled safely. However, there was no clear responsibility assigned for monitoring the temperatures of these personal refrigerators, leading to potential safety risks. Interviews with staff, including a Certified Nursing Assistant, the Director of Nursing, a Registered Nurse, and the Environment Service Director, revealed confusion and lack of clarity regarding who is responsible for maintaining and monitoring the temperatures in residents' personal refrigerators. The Director of Nursing stated that the residents' families are responsible for the maintenance of these refrigerators, but acknowledged that the facility does not have a specific policy for their care and maintenance. This lack of oversight and clear policy could lead to food spoilage and potential health issues for the residents.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a confused resident (R1) who is a high fall risk. R1, who has a history of severe cognitive impairment and multiple medical conditions including a recent hip fracture and stroke, was found on the bathroom floor with a laceration to the back of the head. Despite being identified as a high fall risk and requiring constant supervision, R1 was left unsupervised, leading to the fall and subsequent injury that required hospital treatment and laceration repair with staples. R1's clinical records and care plan indicated that she had poor safety awareness and frequently attempted self-transfers and self-toileting without assistance. On the night of the incident, R1's family member had left the facility, and R1 was found by staff in the bathroom with significant bleeding from a head injury. The staff noted that R1 had a history of not using the call light and required close monitoring, which was not adequately provided at the time of the fall. Interviews with staff and family members revealed that R1 needed constant supervision due to her cognitive impairment and high fall risk. Despite having a fall alert system in place, the system failed to prevent the fall. The staff's failure to continuously monitor R1, especially after her family member left, directly contributed to the incident. The facility's policies on fall management were not effectively implemented, leading to R1's injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belhaven Nursing & Rehab Center | 0.1 mi | ★★★★★ | 33 | 0 |
| Avantara Evergreen Park | 1.9 mi | ★★★★★ | 4 | 0 |
| Morgan Park Healthcare | 2 mi | ★★★★★ | 22 | 1 |
| Mercy Circle | 2.6 mi | ★★★★★ | 3 | 0 |
| Landmark At 95th Rehabilitation And Nursing Center | 2.9 mi | ★★★★★ | 17 | 0 |
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