Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 South Shore Rehabilitation during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene between resident contacts during meal service, and the facility did not consistently display Enhanced Barrier Precaution (EBP) signage or provide PPE for residents with wounds, surgical incisions, or indwelling devices. Additionally, clean linens and personal laundry were found on the floor in the laundry area, contrary to infection control policy. These deficiencies affected multiple residents with complex medical needs.
Surveyors found that the facility did not follow its policy for cleaning lint traps in the laundry area, as a dryer was observed with a large amount of lint and the cleaning log was not completed for the day. This failure to adhere to scheduled lint removal and documentation requirements had the potential to affect all residents.
Multiple residents were found to be living in rooms with unrepaired damage, including holes in doors and walls, missing crown molding, and paint chipping. The Maintenance Director was aware of these issues but cited supply limitations, and the Administrator confirmed that maintenance is responsible for repairs and conducts daily rounds to identify such problems.
A resident with severe cognitive impairment and multiple comorbidities was repeatedly observed with their bed in a high position, contrary to the care plan requiring the bed to be in the lowest position, and did not receive quarterly fall risk assessments as required. Additionally, two oxygen tanks were found unsecured in another resident's room, not stored in holders as per facility policy, with staff confirming the correct procedures were not followed.
Surveyors found that several residents with respiratory conditions had their nebulizer masks left uncovered on surfaces instead of being stored in labeled bags as required by facility policy. Staff interviews confirmed awareness of the infection control policy, but the practice was not consistently followed, affecting residents with conditions such as COPD, heart failure, and pneumonia.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not complete required PASARR screenings and referrals for two residents with mental health diagnoses, including one with a new diagnosis of schizophrenia and another with delusional disorders. Staff confirmed that necessary assessments were not performed or documented, and that some residents lacked proper PASARR Level 1 screenings due to inconsistent implementation of the electronic submission process.
A resident with a PICC line and cognitive intactness did not receive a scheduled IV Vancomycin dose, despite an LPN documenting its administration on the MAR. The LPN admitted to signing out the medication without giving it, contrary to facility policy, resulting in inaccurate medication records and a failure to meet professional standards.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not provide evidence that the decline was clinically unavoidable, as required.
Two residents with physical limitations, including one with severe cognitive impairment, were not provided necessary assistance with shaving facial hair. Despite facility policies and care plans requiring staff to help with personal hygiene, both residents were observed with noticeable facial hair and reported that staff had not offered or provided shaving assistance, even after requests. Staff interviews revealed inconsistent practices and a lack of adherence to established procedures, resulting in unmet ADL needs and compromised dignity.
A resident with significant mobility and cognitive impairments was found lying on a low air mattress set to a weight far exceeding their actual weight, contrary to manufacturer guidelines and facility policy. Nursing staff were unaware of the correct protocol, and there was no physician order for the mattress. The improper setting was verified by multiple staff, including a wound care technician and coordinator, who acknowledged that incorrect settings can contribute to pressure ulcer development.
A resident with multiple complex medical conditions became unresponsive and exhibited labored breathing, but staff failed to promptly assess, monitor, and notify the physician as required. Despite several staff observing the resident's deteriorating condition, appropriate interventions and timely physician notification did not occur, resulting in delayed care and the resident's subsequent death.
The facility did not update care plans to include isolation needs for four residents who had active physician orders for contact or contact and droplet isolation precautions. Despite these orders, the care plans lacked documentation or planning for isolation, as confirmed by the DON and in accordance with facility policy.
Staff were unable to access required PPE such as gloves and gowns for residents on enhanced barrier and contact precautions, with multiple instances of empty isolation bins and missing hand sanitizer. The DON confirmed PPE containers had been removed for refilling, leaving staff without necessary supplies. Additionally, a linen cart was found uncovered, contrary to facility policy, and was only covered after being pointed out by an LPN.
Several residents at risk for pressure ulcers were observed without pressure-relieving cushions in their wheelchairs, despite care plans indicating the necessity of such devices. Staff acknowledged the absence of these cushions, which are essential to prevent skin breakdown. Records confirmed the residents' risk for pressure ulcers, highlighting a lapse in adhering to preventative measures.
A resident with severe cognitive impairment and multiple medical conditions sustained a knee fracture due to improper transfer by a CNA who failed to use the required mechanical lift and two-person assistance. The CNA, aware of the policy, transferred the resident alone, leading to the injury. The facility's policy mandates mechanical lifting devices for residents needing two-person assistance to ensure safety.
A resident with dementia and hemiparesis, at moderate fall risk, was improperly placed in a shower chair instead of a shower bed, leading to a fall and fracture. Staff interviews confirmed the resident's inability to sit upright, yet the care plan lacked appropriate interventions until after the incident. The CNA left the resident unattended, resulting in the fall.
The facility did not have a policy for providing required beneficiary notifications, such as NOMNC and ABN, to its residents. Interviews and record reviews revealed that these notices were not given to Medicare residents, and the Social Service Director was unaware of the ABN requirements. The facility's administrator acknowledged the lack of a process for these notifications, affecting 182 residents under Medicare/Medicaid coverage.
The facility's kitchen failed to adhere to food safety and sanitation practices, including a dietary aide not wearing a beard protector, improper labeling and storage of food items, and inadequate refrigerator cleanliness. These deficiencies could impact all residents receiving food from the kitchen.
The facility failed to update its infection prevention and control policies annually, with some dating back to 2006, potentially affecting all residents. Additionally, an LPN did not sanitize a shared blood pressure device between uses on multiple residents, despite having the necessary wipes available. The DON confirmed that sanitization is required to prevent infection spread.
The facility failed to maintain effective pest control, with flying insects observed in resident rooms and common areas. Staff acknowledged the presence of gnats and flies, particularly in summer, and the Maintenance Director noted delays in pest control measures. Pest control reports indicated recurring issues with flies, gnats, and roaches over several months.
The facility failed to provide physician-ordered double portions to several residents, compromising their nutritional care. Observations and interviews revealed that residents prescribed double portions were often served single portions, despite their specific medical and nutritional needs. Staff acknowledged the inconsistency, attributing it to miscommunication, which could lead to inadequate nourishment and potential health issues.
The facility failed to follow medication management policies, including leaving medications at a resident's bedside without authorization, not locking medication carts, and not dating opened medications. Expired medications were also found in storage areas, indicating systemic issues with medication labeling and storage.
An LPN failed to lock the computer screen on the medication cart, leaving three residents' personal medication information visible to passersby in the hallway. The DON confirmed that this action violated the facility's policy on maintaining privacy and confidentiality of residents' medical records.
The facility failed to ensure call lights were within reach for two residents, leading to unmet needs and potential delays in care. One resident, unable to get out of bed without assistance, had their call light on the floor, while another resident with mobility issues had their call light placed out of reach. Staff acknowledged the oversight and repositioned the call lights as per facility policy.
A facility failed to obtain a physician order for a resident's code status, despite the resident being identified as DNR on the POLST form. The Social Service Director and Director of Nursing acknowledged the need for a physician's order, but the physician order sheet lacked this documentation. The resident's care plan indicated a DNR status, but the facility did not follow its policy to secure the necessary physician orders.
A facility failed to complete a Quarterly MDS assessment for a resident with multiple diagnoses, including diabetes and schizophrenia, within the required timeframe. The last assessment was completed in early February, and the next was due in early May but was not done on time. Staff acknowledged the delay, which could potentially affect care and reimbursement. The facility's policy requires assessments to be completed within specific timelines, which were not followed in this instance.
The facility failed to transmit MDS records to the CMS system within the required timeframes for three residents, affecting their care plans and reimbursement. Despite following RAI guidelines, the MDS assessments were submitted late, violating the facility's policy on timely completion and transmission.
A facility failed to conduct a PASRR for a resident diagnosed with bipolar disorder, as required by their Pre-Admission Assessment Policy. The resident's MDS assessment did not indicate a serious mental illness, despite the admission record showing a diagnosis of bipolar disorder. The facility provided an outdated PASRR from another facility and did not have a current PASRR for the resident's recent admission. The Admissions Director noted that the previous director should have completed the PASRR prior to the resident's transfer.
A resident with multiple chronic conditions, including paraplegia, was left in a soiled state for several hours despite requesting assistance. The CNA was unable to provide timely incontinence care due to other duties, resulting in the resident's brief being heavily soiled and leaking onto the bedsheet. The facility's policy requires incontinence care every two hours, which was not followed.
The facility failed to provide proper respiratory care by not storing oxygen and nebulizer masks in bags, not following oxygen flow rate orders, and not using humidifier bottles with oxygen concentrators. A resident's nasal cannula was found on the floor, and another resident's nebulizer tubing was overdue for replacement. The Director of Nursing confirmed the importance of following physician orders and infection control protocols.
A resident with a history of strokes did not receive a timely speech therapy evaluation despite a physician's order. The facility's Director of Rehabilitation Services initially claimed a screening was done, but later admitted evaluations are not conducted for residents on a regular diet. The resident's presentation indicated a need for evaluation, which was delayed until much later, contrary to facility policy.
The facility did not follow its policy for timely education and administration of the pneumococcal vaccine for two residents. The Infection Prevention Nurse failed to document education, consent, or declination for one resident, and another resident who consented did not receive the vaccine. The facility's process involves periodic vaccine clinics, but staff must administer vaccines for new admissions, leading to a lapse in vaccination.
The facility failed to ensure shower room safety by not maintaining non-skid tape on floor tiles, posing a risk to residents. Observations revealed missing or peeling non-skid tape in multiple shower rooms, with the Maintenance Director unaware of the issue due to a lack of supplies and incomplete reporting processes. The DON confirmed the necessity of non-skid surfaces to prevent slips, but no work orders for repairs were available.
The facility failed to maintain the privacy and dignity of two residents by not covering their urine collection bags, which were visible from the hallway. Observations revealed that the bags were not placed inside privacy bags as required by the facility's policy. Both the Case Manager and an LPN acknowledged the oversight, and the DON confirmed the necessity of covering the bags to promote dignity.
The facility failed to ensure proper labeling, physician ordering, and secure storage of inhaler medications for two residents. An LPN found an unlabeled inhaler and Latanoprost tubes on a resident's over-bed table without a physician's order. Similarly, another resident had an unlabeled inhaler with no order found. The facility's policy requires medications to be stored securely and labeled properly, accessible only to authorized personnel.
A resident reported sexual abuse by a CNA during incontinence care, but the facility failed to immediately report the allegation and remove the CNA, leading to further trauma for the resident. The resident had previously expressed discomfort with the CNA, but this was not escalated. The CNA continued to work until the police intervened, highlighting lapses in the facility's abuse reporting and prevention procedures.
Failure to Follow Infection Control Protocols and Maintain Precaution Signage
Penalty
Summary
The facility failed to follow established infection prevention and control protocols in several key areas, as observed through direct staff actions and environmental conditions. Staff did not consistently perform hand hygiene between resident contacts during meal service. For example, an activity aide and a CNA were observed setting up food trays and assisting residents without sanitizing their hands between tasks, despite facility policy and staff acknowledgment that hand hygiene is required after contact with residents or their wheelchairs. This lapse was noted during meal service for multiple residents with severe cognitive impairment and complex medical conditions, such as hemiplegia, epilepsy, and malnutrition. The facility also failed to properly implement and display Enhanced Barrier Precaution (EBP) signage and provide necessary personal protective equipment (PPE) for residents requiring these precautions. Several residents with wounds, surgical incisions, or indwelling medical devices did not have EBP signs posted on their doors, and PPE bins were not always available as required. In some cases, EBP orders were delayed or not in place upon admission, and signage was missing or removed without immediate replacement. Staff interviews confirmed that the expectation is for clear signage and PPE availability to inform staff of required precautions, but these measures were not consistently followed. Additionally, the facility did not maintain sanitary conditions in the laundry area. Clean linens and personal laundry were observed on the floor, and staff acknowledged that this practice is not permitted due to the risk of cross-contamination. Facility policies require that all linens and personal laundry be handled, stored, and transported in a manner that prevents the spread of infection, but these procedures were not adhered to during the survey. These failures affected multiple residents with complex medical needs and placed all residents at risk for the spread of infection.
Failure to Maintain Lint Trap Cleaning in Laundry Area
Penalty
Summary
Surveyors observed that the facility failed to empty the lint compartment and lint filter in one of the dryers in the laundry area. During a tour with the Housekeeping Director, a large amount of lint was found in dryer number 1's lint compartment, which had not been emptied as required. The Housekeeping Director confirmed that laundry staff are expected to check and empty lint traps every two hours, and that this process should be documented in a logbook. However, on the day of the survey, the lint trap cleaning logbook showed no staff signatures or completion for that date. Facility policy requires that lint removal and cleaning schedules for laundry equipment be documented, posted, and adhered to, with monthly quality assurance audits conducted by the Environmental Services Director. The job description for Laundry Aides also specifies strict adherence to health and safety rules. Despite these policies, the lack of documentation and observed accumulation of lint indicated that the required procedures were not followed, potentially affecting all 198 residents in the facility.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Physical Damage
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple instances of physical damage and disrepair in resident rooms. Specifically, one resident's bathroom door had a hole in the middle and another hole covered with a white substance, while two other residents' walls behind the head of their beds were missing crown molding and had paint chippings. Additionally, another resident's wall had a large hole. These deficiencies were directly observed by surveyors during their inspection. Interviews with facility staff revealed that the Maintenance Director was aware of the needed repairs but was limited by the availability of supplies, as the facility had discontinued its contract with a previous supplier and now relied on purchasing supplies from a retail store. The Administrator confirmed that staff are expected to submit work orders for repairs and that maintenance is responsible for addressing these issues, conducting daily rounds to identify problems. Facility policies and job descriptions reviewed by surveyors indicated that maintenance is responsible for timely repairs and coordination with outside vendors if necessary.
Failure to Implement Fall Precautions and Proper Oxygen Tank Storage
Penalty
Summary
The facility failed to implement a care planned fall precaution intervention for a resident with multiple comorbidities, including dementia, reduced mobility, and severe cognitive impairment. The resident was observed on multiple occasions lying in bed with the bed height visibly elevated, approximately 2.5 feet from the floor, despite the care plan specifying that the bed should be in the lowest position when the resident is lying in bed. The bed controller was consistently out of the resident's reach, and staff incorrectly stated that the resident was care planned for a high bed, which was not documented in the care plan. Additionally, the facility failed to perform the resident's fall risk assessment on a quarterly basis as required, with the most recent assessments not aligning with the expected schedule. The facility's own policy requires fall risk evaluations upon admission, quarterly, annually, and with significant changes in condition, and mandates individualized fall precautions for residents at risk. The policy also emphasizes the importance of maintaining an environment free from hazards and providing appropriate supervision. Interviews with staff confirmed that the bed should be kept in the lowest position to minimize injury in the event of a fall, and that regular fall risk assessments are necessary to identify changes in residents' needs. In a separate incident, the facility failed to secure a resident's oxygen tanks in a proper holder. Two oxygen cylinders were observed leaning against the wall in a resident's room, not placed in a holder as required by facility policy. Staff confirmed that oxygen tanks should not be free-standing and must be stored in a holder or on a designated rack to prevent accidents. The improper storage of oxygen tanks was acknowledged by multiple staff members, including the DON, who stated that the purpose of using a holder is to ensure resident safety.
Failure to Contain Nebulizer Masks per Infection Control Policy
Penalty
Summary
The facility failed to properly contain nebulizer masks for four residents who required respiratory care, as observed during a survey. The facility's policy requires that nebulizer masks be placed in a labeled bag when not in use to prevent contamination. However, surveyors observed that the nebulizer masks for several residents were left uncovered on nightstands or other surfaces, rather than being stored in bags as required by policy. Residents affected by this deficiency had significant medical histories, including chronic pulmonary embolism, asthma, chronic obstructive pulmonary disease (COPD), heart failure, and pneumonia. For example, one resident with asthma and pulmonary embolism had their nebulizer mask left on the nightstand without a bag. Another resident with COPD, pleural effusion, and heart failure also had their nebulizer mask left uncovered. Staff interviews confirmed that the masks should have been contained in bags for infection control, and staff acknowledged awareness of the policy but did not consistently follow it. Additional observations included a resident with pneumonia and moderate cognitive impairment whose nebulizer mask was left on a bedside table, and another resident with COPD and a heart assist device whose mask was placed on top of their LVAD, not in a bag. Staff, including nurses and the Director of Nursing, confirmed that the masks should be stored in plastic bags to prevent contamination, but this was not done for the residents observed.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals within the facility.
Failure to Complete Required PASARR Screenings and Referrals for Residents with Mental Disorders
Penalty
Summary
The facility failed to refer two residents for appropriate PASARR (Preadmission Screening and Annual Resident Review) evaluations and did not perform additional screening for one resident diagnosed with a new mental disorder. For one resident, the initial OBRA screening did not indicate any mental illness or developmental delay at admission, but subsequent medical records showed a diagnosis of schizophrenia and the use of antipsychotic medication. Despite this new diagnosis, the facility did not have a PASARR Level 2 evaluation in the resident's chart, and staff interviews confirmed that a referral for further assessment should have been made but was not completed. Another resident's admission record included multiple diagnoses, such as dementia and delusional disorders, but the only available documentation was an older interagency certification that did not specify the resident's physical or mental condition or required level of services. Staff confirmed that this document was not equivalent to a PASARR Level 1 screening and that no such screening had been completed for this resident. The facility's admissions and social services staff acknowledged that every resident should have a PASARR Level 1 screening and that the process for electronic submission had only recently been implemented, leaving some residents without proper screening. Facility policy required preadmission screening and resident review prior to admission and updates as needed, with responsibility assigned to the admissions director and administrator. However, interviews and documentation revealed that these procedures were not consistently followed, resulting in the lack of required PASARR screenings and referrals for residents with mental health diagnoses or changes in condition.
Failure to Accurately Document and Administer IV Medication
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) signed out an intravenous (IV) medication, Vancomycin HCL, as administered to a resident, but did not actually give the medication. The resident, who had a peripherally inserted central catheter (PICC) and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported not receiving the IV medication at the time it was documented as given. The Medication Administration Record (MAR) and Medication Administration Audit Record (MAAR) both indicated that the medication was administered at 10:01 am, but the resident stated at 1:00 pm that the medication had not been received. The LPN confirmed during an interview that the medication was signed out but not administered, and acknowledged that medications should only be signed out after they are given to prevent errors. The Director of Nursing (DON) also stated that facility policy requires medications to be signed out immediately after administration, and not before. The facility's policies and job descriptions for both LPNs and RNs specify that medications must be administered and recorded in accordance with physician orders and regulatory requirements. The failure to follow these procedures resulted in inaccurate documentation and a failure to meet professional standards of quality for medication administration.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their ADL abilities unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through observations and record reviews that did not show appropriate justification for the decline in residents' functional abilities.
Failure to Assist with Personal Hygiene and Shaving
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically personal hygiene related to shaving facial hair, for two residents. One resident with severe cognitive impairment and physical limitations was observed with medium-length chin hair and stated she was aware of the hair but could not remove it herself, and no staff had offered to assist her despite her desire to have it removed. Staff interviews indicated that shaving is supposed to be offered during showers or when facial hair is noticed, but this was not done in this case. Facility procedures and care plans documented the need for staff to provide total assistance with shaving for this resident. Another resident, who was cognitively intact but had physical limitations, was observed with a moderate amount of facial hair and reported repeatedly asking staff for assistance with shaving, but staff had not provided the service. Staff interviews revealed inconsistent practices, with some staff stating that shaving is done as needed or when time allows, and that a wound care technician sometimes performs shaving but is rarely available. Facility policies and job descriptions require staff to assist residents with personal hygiene, including shaving, but these were not followed, resulting in unmet care needs and a lack of dignity for the affected residents.
Failure to Maintain Correct Air Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified when a resident was observed lying on a low air mattress with the pump set to a weight setting significantly higher than the resident's actual weight. The air mattress pump was set past 360 pounds on the 'Firm' setting, while the resident's documented weight was 150.8 pounds. Nursing staff, including an RN, verified the incorrect setting and stated they were unaware of the facility's protocol for air mattress settings. The wound care technician confirmed that only specific staff members are authorized to change the air mattress settings and acknowledged that an incorrect setting could contribute to the development of pressure ulcers. The wound care coordinator further explained that low air mattresses are intended to promote wound healing and that improper settings can lead to wound decline. The resident in question had multiple diagnoses, including cerebral infarction, hemiplegia, mild neurocognitive disorder, and dysphagia, and was dependent on staff for all activities of daily living. The care plan identified a risk for skin integrity issues due to self-care deficits, impaired mobility, and comorbidities, and included interventions such as the use of a pressure redistribution mattress and frequent repositioning. Despite these interventions, there was no physician order for the low air mattress, and facility policy specified that such mattresses are to be used for residents with certain types of pressure ulcers. The manufacturer's manual indicated that the mattress should be set according to the resident's weight, which was not followed in this case.
Failure to Promptly Assess and Intervene for Resident's Change in Condition
Penalty
Summary
The facility failed to promptly assess, monitor, identify, and intervene for a resident who experienced a significant change in condition, transitioning from being responsive and communicative to unresponsive. The resident had multiple complex diagnoses, including heart failure, paroxysmal atrial fibrillation, hyperlipidemia, hemiplegia, shortness of breath, acute embolism and thrombosis of deep veins, type 2 diabetes, schizophrenia, and epilepsy. Despite these risk factors, staff did not take immediate and appropriate action when the resident became unresponsive and exhibited labored breathing. Multiple staff members observed and reported the resident's deteriorating condition throughout the day. A CNA was instructed by an LPN to sit with the resident and repeatedly call their name to keep them awake, despite the resident's labored breathing and unresponsiveness. The LPN noticed the resident was sweating and reported a change in condition to the wound care coordinator, who advised monitoring the resident but did not assess the resident in person or notify the physician. Another nurse observed the resident as lethargic and unresponsive, communicated this to the wound care coordinator, and was told to obtain vital signs and inform the physician, but there was no evidence that the physician was notified at that time. Documentation shows that the resident's physician was not notified of the change in condition until much later, and there was no record of timely assessment or intervention prior to the resident's transfer to the hospital. When paramedics arrived, the resident was in cardiac arrest and subsequently expired. The facility's own policies required prompt assessment and physician notification for acute changes in condition, but these protocols were not followed, resulting in a delay in care for the resident.
Failure to Update Care Plans for Residents on Isolation Precautions
Penalty
Summary
The facility failed to update and document care plans to accurately reflect the isolation needs of four residents who had active physician orders for contact or contact and droplet isolation precautions. Record reviews showed that, despite these orders, the care plans for each of these residents did not include information or planning related to their isolation requirements during their stay. The Director of Nursing confirmed that care plans should be updated to reflect isolation status when applicable. Facility policy also requires that care plans be revised as changes in a resident's condition dictate, including the need for isolation precautions.
Failure to Ensure PPE Availability and Proper Linen Handling
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was readily available for staff use when providing care to residents requiring enhanced barrier precautions and transmission-based precautions. Observations revealed that enhanced barrier precaution signs were posted on several residents' doors, but no PPE was accessible outside these rooms. Staff confirmed the absence of PPE, stating they would be unable to provide care without it. In multiple instances, isolation bins for residents on contact precautions were found to be missing gloves and hand sanitizer, with staff having to search for or relocate the last available box of gloves from other locations, leaving other areas without necessary supplies. The Director of Nursing acknowledged that PPE containers had been removed for refilling, resulting in their unavailability at the point of care. Additionally, the facility failed to maintain proper linen handling practices, as a linen cart was observed uncovered on the first floor. A nurse confirmed that the cart should always be covered to keep linens clean and reduce exposure to germs, and subsequently covered the cart upon observation. Review of facility policies confirmed requirements for PPE use and linen handling but did not specify procedures to ensure PPE availability at the point of care.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions as outlined in the care plans for residents at risk for pressure ulcers. During observations, several residents were found sitting in wheelchairs without the required pressure-relieving cushions, which are essential to prevent skin breakdown and pressure ulcers. Specifically, residents R2, R3, R4, R5, R6, and R7 were observed without these cushions, despite their care plans indicating the necessity of such devices due to their risk of developing pressure ulcers. Staff members, including a CNA, a Unit Manager, a Wound Care Technician, and a Wound Care Nurse, acknowledged the absence of the cushions and the need for them to prevent pressure ulcers. The records for each resident confirmed their risk for pressure ulcers, with assessments and care plans explicitly stating the need for pressure-reducing devices in their wheelchairs. The facility's policy on pressure ulcer prevention also mandates regular audits of care plans and the implementation of preventative measures based on residents' clinical conditions. However, the failure to provide the necessary cushions as per the care plans and policy indicates a lapse in adhering to these preventative measures, potentially affecting the residents' skin integrity and increasing their risk for pressure ulcers.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to its policy regarding the safe transfer of residents, resulting in a significant injury to a resident. The incident involved a resident who was severely cognitively impaired and dependent on assistance for activities of daily living, including transfers. The resident, who had multiple medical conditions including osteitis deformans and chronic kidney disease, required a mechanical lift device with two-person assistance for transfers. However, a newly hired CNA improperly transferred the resident alone, without using the mechanical lift device, leading to a fracture of the resident's right knee. The Director of Nursing (DON) was informed of the incident after the resident complained of knee pain, and an x-ray confirmed a fracture. The investigation revealed that the CNA, aware of the requirement for a mechanical lift and two-person assistance, chose to pivot the resident into a chair without assistance. This action was against the facility's policy, which mandates the use of mechanical lifting devices for residents needing two-person assistance to ensure safety and prevent injuries. The CNA involved in the incident did not return to the facility after being informed of the investigation and was unreachable for further statements. The facility's policy on safe lifting and movement of residents clearly states that mechanical lifting devices must be used for any resident needing a two-person assist, except in emergencies. The failure to follow this policy directly resulted in the resident's injury, highlighting a critical lapse in adherence to established safety protocols.
Inadequate Supervision and Equipment Use Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and use appropriate shower equipment for a resident, resulting in a fall and injury. The resident, who had medical diagnoses including dementia, seizures, cerebral infarction, hemiplegia, and hemiparesis affecting the right side, was at moderate risk for falls. Despite this, the resident was placed in a shower chair, which was inappropriate given their poor trunk control and inability to sit upright. This led to the resident falling out of the shower chair and sustaining a closed nondisplaced fracture of the greater trochanter of the right femur. Interviews with staff revealed that the resident's baseline status required the use of a shower bed rather than a shower chair due to their inability to sit up independently. On the day of the incident, a CNA left the resident unattended in the shower chair while retrieving linens, during which time the resident fell. The facility's care plan did not include the necessary intervention of using a shower bed until after the fall occurred. The facility's failure to adhere to appropriate care protocols and provide necessary supervision directly contributed to the resident's fall and subsequent injury.
Failure to Provide Required Beneficiary Notifications
Penalty
Summary
The facility failed to implement a policy and procedure for providing beneficiary notifications, specifically the Notice of Medicare Non-Coverage (NOMNC) and the Advanced Beneficiary Notice (ABN), to its residents. This deficiency was identified during interviews and record reviews, revealing that the facility did not provide these notices to Medicare residents, as required. The Social Service Director (SSD) admitted that NOMNCs were only given to managed care or insurance residents and was unaware of the ABN requirements. The Social Service Consultant confirmed that there was no established process for issuing these notifications. The review of records showed that no NOMNC or ABN had been provided to residents discharged from Medicare-covered Part A stays in the past six months. The facility's administrator acknowledged the absence of a process for beneficiary notifications and stated that the facility would adhere to CMS guidelines in the future. The facility's census indicated 182 residents under Medicare/Medicaid coverage, with 16 residents discharged without receiving the necessary notifications. The facility was unable to provide a policy or procedure for these notifications, highlighting a significant oversight in compliance with Medicare requirements.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in its kitchen, as observed during a survey. A dietary aide was seen in the kitchen without a beard protector, despite having facial hair, which is against the facility's policy requiring all kitchen staff with facial hair to wear beard coverings to prevent food contamination. The dietary manager confirmed the availability of beard guards and acknowledged the requirement for their use. Additionally, the facility did not adhere to proper labeling and storage protocols for food items. Several opened food items, including balsamic vinaigrette dressing and barbeque sauce, were found without opened or use-by dates, making it difficult to track their freshness and safety. Spices in the kitchen were also improperly labeled, with some containers missing use-by dates and others showing signs of age and wear, indicating they were past their recommended usage period. The facility's kitchen was also found to be inadequately maintained, with cleanliness issues noted in the refrigerator. A thermometer inside the refrigerator was covered in black spotted material, and the fan cover had visible black spots, suggesting a lack of regular cleaning. An opened bag of pureed bread mix was improperly stored, and a container of lemon juice was left unrefrigerated despite manufacturer instructions to refrigerate after opening. These lapses in food safety and sanitation practices have the potential to affect all residents receiving food from the facility's kitchen.
Infection Control Policy and Equipment Sanitization Deficiencies
Penalty
Summary
The facility failed to update its infection prevention and control policies annually, with some policies dating back to as far as 2006. This oversight was identified during a review of the facility's infection control policies, which included outdated protocols for various procedures such as blood and body fluid exposure, cleaning spills, and standard precautions. The Infection Prevention Nurse acknowledged that the policies were sent by a corporate consultant, and the Director of Nursing confirmed that policy reviews are conducted at the corporate level. This failure to update policies has the potential to affect all residents at the facility. Additionally, the facility did not ensure that shared medical equipment was sanitized between uses during medication administration. An LPN was observed using a manual blood pressure device on multiple residents without sanitizing it between uses. The LPN admitted to forgetting to sanitize the device, despite having the necessary wipes available. The Director of Nursing stated that nurses are required to sanitize all shared medical equipment before and after each use to prevent the spread of infections. This lapse in protocol was observed with three residents during the survey.
Pest Control Deficiency Due to Inadequate Measures
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by the presence of flying insects in resident rooms and common areas. Observations were made of flying insects in various locations, including a conference room, a ground floor hallway, and on a resident's bed linen. Staff interviews revealed that the presence of gnats and flies was a known issue, particularly during the summer months. A Licensed Practical Nurse mentioned efforts to quickly remove food trays to prevent fruit flies, while a Certified Nurses Aide and a Housekeeping staff member acknowledged seeing flies and gnats. The Maintenance Director confirmed that an outside pest control vendor visits every two weeks, but noted delays in addressing the issue. The pest control reports from the outside agency indicated recurring issues with flies, gnats, and occasionally roaches in different areas of the facility. These reports documented sightings of fruit flies and gnats in resident rooms, dining rooms, and the kitchen over several months. Despite the facility's pest control guidelines, the ongoing presence of pests suggests that the measures in place were insufficient to effectively manage the problem. The Director of Housekeeping acknowledged the issue and mentioned recent discussions to address it, but no immediate corrective actions were noted in the report.
Failure to Provide Physician-Ordered Double Portions
Penalty
Summary
The facility failed to provide physician-generated diet orders for several residents, leading to deficiencies in nutritional care. Observations revealed that residents who were prescribed double portions as part of their diet orders were not consistently receiving them. For instance, Resident 110, who was observed eating lunch, received only single portions despite a meal ticket indicating double portions. Similar discrepancies were noted for Residents 75, 15, 7, and 152, all of whom were supposed to receive double portions but did not. Interviews with staff, including a Dietary Aide and the Dietary Manager, confirmed the inconsistency in serving double portions. The Dietary Aide acknowledged that trays meant for double portions contained only single portions. The Dietary Manager stated that a double portion diet should include double servings of meat, vegetables, and starch, but this was not being followed due to miscommunication. The Registered Dietitian emphasized the importance of adhering to diet orders, noting that failure to provide double portions could lead to inadequate nourishment and potential health issues for the residents. The report highlights specific medical conditions and nutritional needs of the affected residents, such as Resident 110's vascular wound requiring increased calorie and protein intake for healing, and Resident 15's need for weight gain due to a low BMI and history of weight loss. Despite these documented needs and physician orders, the facility's failure to provide the prescribed double portions compromised the residents' nutritional care.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards and facility policies regarding medication management. During an inspection, it was observed that medications were left at the bedside of a resident without a care plan or provider order for self-administration. Additionally, a Licensed Practical Nurse (LPN) left a medication cart unlocked multiple times while administering medications, which was against the facility's policy that requires medication carts to be locked when not attended. The inspection also revealed that several opened multi-dose medications, including insulin vials and eye drops, were not properly dated, which is necessary to ensure they are discarded after the recommended period. This was observed across multiple medication carts and storage rooms, indicating a systemic issue with labeling and dating medications upon opening. Furthermore, expired medications were found in the medication storage areas, which should have been removed and destroyed according to the facility's policy. The Director of Nursing acknowledged the importance of dating medications once opened to prevent the use of expired medications, which could lead to adverse reactions in residents. The facility's policies clearly state that medications should be stored securely and administered only by authorized personnel, and that opened medications should be labeled with a new expiration date. However, these policies were not followed, leading to the deficiencies noted during the survey.
Failure to Protect Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy and confidentiality of residents' personal medication administration records for three residents. During a medication administration observation, a Licensed Practical Nurse (LPN) left the computer screen on the medication cart unlocked and displaying personal medication information for three residents at different times. The screen was visible to anyone passing by in the hallway. The LPN acknowledged forgetting to lock the computer screen, which is necessary to protect residents' personal information. The Director of Nursing confirmed that the computer screen should always be locked to maintain resident privacy and confidentiality, as per the facility's policy on dignity and resident rights.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach, affecting two residents out of a sample of 36. One resident, identified as R171, was observed lying in bed with the call light on the floor, making it inaccessible. R171, who is cognitively intact with a BIMS score of 13, expressed that they cannot get out of bed without assistance and sometimes have to scream for help when the call light is unreachable. A Certified Nursing Assistant (CNA) confirmed the call light should not be on the floor and acknowledged the potential problem of unmet needs. The Director of Nursing (DON) also stated that it is expected for staff to ensure the call light is within reach to prevent delays in care. Another resident, R43, who has a medical history of difficulty walking, repeated falls, and reduced mobility, was found sitting in a wheelchair with the call light out of reach. The call light cord was placed on a chair on the opposite side of the bed, making it inaccessible. R43, who has a care plan focusing on fall prevention and assistance with ambulation, was unable to call for help and requested the surveyor to refill their water pitcher. A CNA acknowledged the call light should be within reach and repositioned it accordingly. The facility's policy, last revised in 2008, states that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Obtain Physician Order for Resident's Code Status
Penalty
Summary
The facility failed to obtain a physician order for the code status of a resident, identified as R109, who was reviewed for advance directives. The resident was admitted with multiple diagnoses, including spinal stenosis, chronic obstructive pulmonary disease, and paraplegia, among others. During an interview, the Social Service Director (V3) acknowledged that they were assisting the resident and family with advance directives, including code status, which requires a physician's order. However, upon reviewing the physician order sheet with V3, it was found that there was no code status order for R109, despite the resident being identified as DNR (Do Not Resuscitate) on the POLST form. The Director of Nursing (V2) confirmed that a resident's code status, whether full code or DNR, should have a physician's order and be maintained in the resident's health record. The care plan dated shortly after admission documented that R109 had a DNR advance directive. However, the physician order sheet reviewed on a later date still showed no order for code status. The facility's policy on advance directives indicated that any changes or revisions should involve contacting the resident's attending physician to secure appropriate orders, which was not done in this case.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessment for a resident, identified as R124, within the regulatory timeframe. R124 was admitted with multiple diagnoses, including Type 2 diabetes mellitus, major depressive disorder, anemia, schizophrenia, bipolar disorder, and dysphagia. The last quarterly assessment for R124 was completed on February 4, 2024, and the next assessment was due approximately 92 days later, around the first week of May 2024. However, the assessment was not completed on time, and the facility acknowledged that the quarterly assessment was late. Interviews with the MDS Director and the Reimbursement Specialist revealed that the MDS assessments are crucial for developing care plans and for reimbursement purposes. They follow the Resident Assessment Instrument (RAI) guidelines, which require the assessment to be completed within 14 days from the Assessment Reference Date (ARD) and transmitted within another 14 days. The failure to complete the assessment on time could potentially delay care and payment, as noted by the staff. The facility's policy, dated October 2023, outlines the required timeline for completing the quarterly assessments, which was not adhered to in this case.
Failure to Timely Transmit MDS Records
Penalty
Summary
The facility failed to electronically transmit Minimum Data Set (MDS) records to the CMS system within the required timeframes for three residents. The residents involved were admitted with various medical conditions, including diabetes, dementia, and heart failure. The MDS assessments, which are crucial for developing care plans and ensuring proper reimbursement, were not transmitted within the 14-day period following their completion. This delay in transmission was identified for a quarterly assessment, an annual assessment, and an admission assessment for the respective residents. The MDS Director and Reimbursement Specialist acknowledged the importance of timely MDS assessments and transmissions, as they are essential for care planning and payment purposes. Despite following the Resident Assessment Instrument (RAI) guidelines, the facility did not meet the regulatory timeframes, resulting in late submissions. The facility's policy outlined specific deadlines for MDS completion and transmission, which were not adhered to in these cases, leading to the identified deficiency.
Failure to Conduct PASRR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to conduct a Preadmission Screening and Resident Review (PASRR) for a resident, identified as R101, who was part of a sample of 36 residents reviewed for PASRR compliance. The deficiency was identified through interviews and record reviews. R101's Admission Minimum Data Set (MDS) assessment, dated August 10, 2023, indicated that the resident was not considered to have a serious mental illness. However, the resident's Admission Record documented a medical diagnosis of bipolar disorder with an onset date of July 28, 2023. Despite multiple requests from the surveyor on July 23 and 24, 2024, the facility failed to provide a PASRR related to R101's admission on July 28, 2023. Instead, the facility provided an outdated pre-admission screening from January 10, 2021, which was directed to another facility. The Admissions Director, who started at the facility in October 2023, stated that R101 was a transfer from another long-term care facility and that the previous Admission Director should have completed the PASRR prior to the transfer or admission. The facility's Pre-Admission Assessment Policy from March 2016 requires a PASRR to be conducted prior to admission to determine the appropriate level of service.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R109, who required assistance with toileting. R109, who was admitted with multiple diagnoses including paraplegia and chronic conditions, was observed to be alert and oriented but expressed dissatisfaction with the care received. On the morning of the observation, R109 reported being left in a soiled state since 3 AM and had requested assistance after breakfast around 8 AM. Despite activating the call light, the resident remained unchanged for approximately two hours until a Certified Nursing Assistant (CNA) and a Medical Records staff member attended to him. Upon observation, the resident's incontinence brief was heavily soiled, and the soiling had leaked onto the bedsheet. The CNA, identified as V14, acknowledged that incontinence care should be performed at least every two hours and as needed to prevent skin breakdown. However, she was unable to attend to R109 promptly due to other duties, such as picking up breakfast trays and assisting another resident. This was the first incontinence care provided to R109 during V14's shift, which began at 6 AM. The Director of Nursing confirmed that staff are expected to conduct regular rounds and provide incontinence care at least every two hours. The facility's policy on perineal care emphasizes the importance of cleanliness, comfort, and skin condition observation, which was not adhered to in this instance.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure proper respiratory care for residents, as evidenced by several observations and interviews. One resident was observed with an oxygen mask on the bedside table, not stored in a plastic bag as required by facility policy. A Certified Nurses Aide confirmed that unused oxygen masks and cannulas should be wrapped in a plastic bag. Additionally, the same resident's nasal cannula was found on the floor with the oxygen machine running, and a Licensed Practical Nurse noted the need to replace the cannula and check the resident's oxygen saturation, which was at ninety-one percent. Another resident's nebulizer mask was found uncovered on a side table after a treatment, contrary to the facility's policy that requires such equipment to be stored in a bag to prevent contamination. An Agency LPN admitted to not placing the mask in a bag after use. The Director of Nursing confirmed that it is the nurse's responsibility to ensure the mask and tubing are bagged for infection control. Furthermore, the nebulizer tubing was overdue for replacement, having been dated nine days prior, while the policy mandates weekly changes. A third resident was observed receiving oxygen at a higher flow rate than ordered, without a humidifier bottle attached to the concentrator. The LPN was unaware of the correct order and confirmed the discrepancy upon checking. The Director of Nursing emphasized the importance of following physician orders and using a humidifier bottle to prevent dry air. The resident's care plan specified oxygen therapy related to congestive heart failure, with orders to maintain oxygen saturation at ninety-two percent or greater.
Failure to Provide Timely Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide a speech therapy evaluation for a resident, identified as R176, despite having a physician's order for such services. The order for speech therapy to evaluate and treat was written on May 22, 2024, and signed by the physician on June 19, 2024. However, by July 23, 2024, the resident had not received the speech therapy evaluation. The Director of Rehabilitation Services initially stated that a speech therapy screening was performed and an evaluation was not indicated, but later admitted that the facility does not conduct evaluations for residents on a regular diet, which was the case for R176. The resident, R176, who had a history of multiple strokes, expressed uncertainty about receiving speech therapy, although they had attended physical therapy sessions. The Director of Rehabilitation Services mentioned that speech therapy screenings are not documented in the electronic health record but are kept in paper format. Upon further review, it was revealed that the speech therapy screening tool recommended an evaluation based on the resident's presentation, which included deficits in attention, speech, and language. Despite this, the evaluation was delayed until July 25, 2024. The facility's policy on rehabilitation screens indicates that screenings should be performed at admission based on clinical need. However, the facility's approach to speech therapy evaluations was inconsistent with this policy, as the decision not to evaluate R176 was based on their regular diet status rather than their clinical presentation. This inconsistency and failure to follow through with the physician's order led to a significant delay in providing necessary speech therapy services to the resident.
Failure to Administer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to adhere to its policy and professional standards regarding the timely education and administration of the pneumococcal vaccine for two residents. The Infection Prevention Nurse (V4) acknowledged that the documentation of resident education, consent, or declination for the pneumococcal vaccine was missing for one resident, and although another resident had consented, the vaccine was not administered. The facility's policy requires that each resident be educated about the benefits and potential side effects of the vaccines, and their decision to accept or refuse must be documented in their clinical record. During the survey, it was found that the electronic health records of the residents did not contain the necessary documentation for the pneumococcal vaccine. The Infection Prevention Nurse admitted to not being aware of the need for vaccination for one resident due to a lack of consent documentation. Additionally, the facility's process involves a clinic that administers vaccines periodically, but for residents admitted after the last clinic visit, the facility staff is responsible for administering the vaccines. This lapse in the process led to the failure in providing the pneumococcal vaccine to the residents in question.
Deficiency in Shower Room Safety Measures
Penalty
Summary
The facility failed to maintain a safe and functional environment by not ensuring that the shower room floor tiles had non-skid tape attached, which is essential to prevent accidental hazards. This deficiency was observed in multiple areas, including the 3rd floor shower room where six floor tiles were missing non-skid grip tapes, and some were rolled up. The Maintenance Director, who was present during the observation, acknowledged the absence of non-skid tape and admitted to running out of supplies. Additionally, the 2nd floor shower room had a water puddle under the wash sink, and two shower stalls were missing non-skid tapes. On the 1st floor, the shower stall was observed to have peeling non-skid tape, and the Maintenance Director was unaware of these issues until they were pointed out by the surveyor. The Director of Nursing confirmed that the shower room floors should have non-skid surfaces to prevent slipping. Despite the facility's policy requiring staff to report maintenance issues via a log at the nurse's station, there was no work order available for the repair of the non-skid tapes as of the survey date. The Maintenance Director mentioned a transition from a maintenance book log to a computer form for tracking repairs, but this change had not yet been fully implemented. The facility's job description for the Director of Maintenance emphasizes the responsibility to maintain a safe and comfortable environment, including ensuring the availability of necessary supplies.
Failure to Ensure Privacy of Urine Collection Bags
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents by not covering their urine collection bags, which were visible from the hallway. On the specified date, one resident was observed in bed with a urine bag collection visibly noted from the hallway. When this was pointed out to the Case Manager, it was confirmed that the facility's policy required urine bags to be inside a privacy bag. Similarly, another resident was observed with a urine collection bag visible from the hallway, and the LPN acknowledged that it should have been covered with a dignity bag. The Director of Nursing also confirmed that urine collection bags should be covered to promote dignity. The facility's policy on dignity emphasizes treating residents with respect and ensuring their quality of life, which includes keeping urinary catheter bags covered.
Improper Medication Storage and Labeling for Two Residents
Penalty
Summary
The facility failed to ensure proper labeling, physician ordering, and secure storage of inhaler medications for two residents, R4 and R5. During an observation, R5 was found with an inhaler and Latanoprost tubes on the over-bed table, neither labeled nor ordered by a physician. The LPN acknowledged that medications should not be left at the bedside unless ordered and labeled with the patient's name and administration directions. Upon checking R5's physician order and MAR, there was no order for the inhaler or permission to leave it at the bedside. Similarly, R4 was observed with an unlabeled Symbicort inhaler on the over-bed table, with no physician order found in the electronic medical record. The RN case manager suggested that the family might have brought the medication, indicating a lack of awareness of residents' belongings. The facility's policy mandates that medications be stored securely and labeled properly, accessible only to authorized personnel. The DON confirmed that medications should be stored properly and locked away, aligning with the facility's policy on medication storage.
Failure to Report and Act on Allegation of Sexual Abuse
Penalty
Summary
The facility failed to follow their abuse policy by not ensuring the immediate reporting of an allegation of sexual abuse made by a resident regarding a certified nursing assistant (CNA). The resident, who has a history of major depressive disorder, PTSD, and heart failure, reported that the CNA penetrated her vagina with his fingers during incontinence care. Despite the resident's immediate distress and reporting of the incident to another CNA, the allegation was not promptly reported to the administrator or the nurse on duty, leaving the resident vulnerable to further trauma as the alleged perpetrator remained in the facility and re-entered her room shortly after the incident. The resident had previously expressed discomfort with the same CNA, reporting that he had rubbed her face and called her beautiful, but this concern was not escalated to the administration. On the night of the incident, the resident's husband called the facility to report the abuse, prompting the nurse manager to assess the resident and notify the police. The resident was sent to the emergency room for evaluation, where hospital records indicated mild bleeding and a urinary tract infection. The facility's investigation concluded that the allegation was unfounded, attributing the resident's perception to the CNA's cleaning process. Interviews with staff revealed that the CNA continued to work in the facility after the initial report, contrary to the facility's abuse prevention policy, which mandates the immediate removal of the alleged perpetrator. The night supervisor and other staff members failed to follow protocol, resulting in the CNA's arrest by the police only after the resident's husband intervened. The facility's failure to act promptly and protect the resident from further harm highlights significant lapses in their abuse reporting and prevention procedures.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,808 citations issued within 25 miles in the last 12 months — including the 23 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Windsor Park | 0.6 mi | ★★★★★ | 31 | 0 |
| Landmark Of Hyde Park Rehabilitation And Nursing C | 1.8 mi | ★★★★★ | 14 | 0 |
| Montgomery Place | 2 mi | ★★★★★ | 20 | 0 |
| Pavilion Of South Shore | 2 mi | ★★★★★ | 1 | 0 |
| Wentworth Rehab & Hcc | 3.3 mi | ★★★★★ | 6 | 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.