Average — CMS composite of the measures below.
The next survey window likely opens 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 Spring Creek during CMS and state inspections, most recent first.
The facility failed to implement ordered nutritional interventions and double-portion meals for a resident with significant weight loss and for two additional residents. A resident identified as at risk for compromised nutritional status, with a goal to prevent further weight loss, was repeatedly not given the ordered double portions and had inconsistent meal intake documentation, with only a limited number of entries over a month and no recorded intake after a certain date. The resident was observed thin and frail, was not served lunch while sleeping in the dining room, and later received only a peanut butter and jelly sandwich. Serial weights showed substantial fluctuations and an additional 10.3% loss in one month, while the RD, aware of the history of significant weight loss and low BMI, continued existing supplements without new recommendations and relied on nursing staff for accurate weights and intake records.
Surveyors identified that housekeeping staff left an unsecured cleaning cart in a resident hallway containing mislabeled and improperly stored chemical products, while nursing staff failed to use required gait belts and appropriate assistance levels when transferring a resident with hemiplegia, repeated falls, and altered mental status. Two CNAs transferred a resident with hemiplegia and moderate cognitive impairment using a mechanical lift over fall mats that remained in place beside the bed, contrary to facility expectations. In addition, two high-fall-risk residents with multiple recent falls were repeatedly observed in specialized high-back chairs or wheelchairs without care-planned safety interventions, including non-slip seating material and appropriate leg or foot supports, and one was left in clearly unsafe, slouched, or cross-seat positions without staff repositioning despite posted communication about their high fall risk.
Surveyors found multiple open medications and biologicals on a medication cart without required open dates, including anticonvulsants, laxatives, and antacids, as well as an unlabeled, uncovered container of white powder identified as thickener. Facility leadership acknowledged that all opened medications should be dated and labeled per policy. In addition, a resident with COPD, dementia, and other conditions had nebulizer medication stored at the bedside and self-administered treatments without an order for self-administration or bedside storage. Another resident had an unidentified pill in a medication cup at bedside, and a different resident had prescribed nasal spray stored in an unlocked in-room refrigerator, contrary to the facility’s policy that medications be securely stored and accessible only to authorized staff.
Surveyors found multiple food safety and sanitation issues in the kitchen affecting all residents receiving dietary services. An open bag of dry beans, expired hard-boiled eggs, an open bucket of beef base, and a bucket of chicken base stored under a sink were observed, along with pans of cake placed within splashing distance of a sink. Red sanitizer buckets in use tested at 400 ppm, and serving utensils and mixing bowls stored for use were visibly soiled with dried food and residue. The Dietary Manager acknowledged that food should be sealed and dated, that outdated food should be discarded, that food should not be stored under or near sinks, and that dirty utensils can cause cross-contamination, and these practices were inconsistent with facility policies on sanitary food preparation, labeling, storage, and sanitizer use.
Staff failed to follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP) and hand hygiene, during care for several residents. An RN and an LPN provided g-tube care and enteral feedings to multiple residents who had EBP signage and care plans requiring gown and gloves for device care, but they wore only gloves. In a separate incident, a CNA provided incontinence care to a resident without performing hand hygiene, used the same towel and washcloth repeatedly on perineal and buttock areas, and touched room items and a roommate’s stuffed bear with soiled gloves before leaving the room. The DON confirmed that EBP, proper incontinence care, and hand hygiene are required by facility policy to prevent infection.
A resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses, known to have behaviors that intrude on others’ privacy, was observed sitting on the floor in a common area with pants down and genitalia exposed outside an incontinence brief. A social services director was seated at the nurses station with his back to the resident and was texting the DON while the resident remained undressed, and only after a CNA exited the elevator and alerted him was the resident assisted to stand, at which time genital exposure was still evident. Facility records and the MDS documented the resident’s behavioral symptoms, and the facility’s dignity policy required staff to promote and protect bodily privacy during care and treatment, which was not maintained in this incident.
A cognitively intact resident with multiple chronic conditions, including hemiplegia, morbid obesity, diabetes, major depressive disorder, and polyosteoarthritis, requested $40 from his personal funds account but did not receive the money for an extended period. The assistant administrator, who was the only person designated to access the bank, confirmed the resident had sufficient funds and had made the request weeks earlier but had not yet gone to the bank. This delay occurred despite a facility policy stating that the facility will hold, safeguard, and manage residents’ personal funds upon request.
A cognitively intact, continent resident with multiple medical conditions who uses a motorized wheelchair and requires assistance with toileting reported that a CNA refused to toilet her or change her menstrual pad after she requested toileting and a shower during her period, telling her to go in her pants. The resident reported this to the Administrator, and the DON stated she personally heard the CNA refuse to toilet the resident and later informed the Administrator. Documentation of the CNA’s discharge cited refusal to toilet a resident and other work issues. The Administrator, serving as abuse coordinator, did not report this allegation to the state agency and stated that refusing to toilet an alert, oriented, continent resident was not abuse, despite facility policy defining abuse to include deprivation of necessary goods and services and requiring timely investigative reporting.
Surveyors found that nursing staff failed to notify the NP/MD when a resident refused scheduled morning medications due to nausea and later received multiple ordered drugs, including gabapentin, outside the facility’s one-hour administration window without provider direction or documentation. Staff interviews, including with the NP, RN, LPN, and DON, confirmed that the expected practice was to administer antiemetic medication, reassess, and contact the provider if doses could not be given within the ordered time frame, but this did not occur. In a separate case, a resident independently managed a CGM device, reported glucose readings to staff, and received insulin and other interventions based solely on those readings, even though there was no physician order for CGM use, no assessment of the resident’s competency, no care plan interventions, and staff lacked instructions or knowledge of the device despite an existing facility CGM policy requiring an order and adherence to manufacturer guidelines.
A resident dependent on staff for care received g-tube feedings from unlabeled bags, including a clear bag connected to a water bag, while an open bottle of nutritional formula sat at the bedside. On repeated observations, the g-tube site had brown, thick, adherent drainage and no dressing, despite orders to clean the site with normal saline daily and as needed. A wound nurse stated nurses should assess and clean tube sites, and an RN acknowledged she could not identify the formula being infused because the bag was not labeled, even though the care plan required use of clinical standards, infusion as ordered, and regular checks of the tube site for drainage.
A resident with multiple chronic conditions did not receive several medications in accordance with physician orders or within the facility’s defined administration window, leading to a medication error rate above 5%. An RN delayed 9 AM doses due to nausea and administered Amantadine, Docusate, and Gabapentin together around early afternoon, outside the 8–10 AM window, and a daily multivitamin ordered for 9 AM was not actually given despite being signed off. Review of the POS, MAR audit, and interviews with an LPN, DON, and NP confirmed that medications were to be given within one hour of scheduled times and that prescriber clarification was required when doses were outside this window, which did not occur.
A resident with a history of respiratory complications and quadriplegia experienced severe shortness of breath and abnormal vital signs. Despite repeated requests from the resident and abnormal clinical findings, an LPN delayed calling 911 and instead sought routine ambulance transport, contrary to facility policy and staff expectations. When EMTs arrived, the resident was in significant distress and required immediate intervention.
A resident with a tunneled PICC line did not receive dressing and cap changes as ordered, with documentation showing missed or falsely recorded interventions. An LPN admitted to documenting dressing changes that were not performed and lacked training on central line care, while the DON confirmed only RNs should perform these tasks. The facility's policy for dressing changes and documentation was not followed.
A resident with quadriplegia and dependent on staff for eating was left unsupervised with a hot cup of coffee, resulting in 1st and 2nd degree burns. Despite recommendations against straw use and the need for supervision, the resident was allowed to drink from a straw, leading to the injury.
The facility failed to staff RNs for 8 consecutive hours daily, as required. On several occasions, no RNs were present for the required duration, confirmed by staff interviews and schedule reviews. The Administrator was unaware of these lapses, which could affect all residents.
The facility failed to obtain physician orders and conduct assessments for residents self-administering medications brought from home. Observations revealed medications at residents' bedsides without proper authorization or care plans, despite residents being cognitively intact. The DON confirmed no residents were assessed for self-administration, contrary to facility policy requiring assessments and orders for such practices.
Two residents with hemiplegia and contractures were not provided with necessary splints and palm protectors as prescribed. Despite physician orders and care plans, the required devices were not consistently applied, potentially worsening their conditions. Staff acknowledged the oversight and the need for proper documentation of any refusals.
The facility failed to prevent fall injuries and smoking hazards for several residents. A resident was pushed in a wheelchair without footrests, another was in a room with an exposed bed frame, and a third walked without skid-protection socks. Beds were left high without fall mats for residents at risk of falling. Additionally, a resident had smoking materials despite needing supervision, and her care plan was updated without a new assessment.
A resident with a G-tube was not properly managed, as staff failed to check tube placement and administer feeding at the correct rate. Despite orders for a 75 ml/hr rate, the feeding was consistently set at 70 ml/hr, and necessary residual checks were not performed. Staff interviews revealed outdated practices and non-adherence to facility policies, leading to a deficiency in care.
A medication error rate of 10% was identified when a nurse administered incorrect medications to a resident, failing to give Ezetimibe 10 mg as prescribed and incorrectly documenting it as given. The resident, with multiple diagnoses, was cognitively intact and had specific medication orders that were not followed.
The facility failed to ensure proper maintenance and monitoring of residents' personal refrigerators, leading to the presence of expired food items and lack of temperature control. Three residents were affected, with one having a refrigerator without a thermometer or temperature log, another with multiple expired food items, and a third with moldy fruit and expired dairy products. Housekeeping staff did not fulfill their responsibility to clean and monitor the refrigerators, posing a risk to residents' health.
A cognitively impaired resident suffered full thickness burns due to prolonged sun exposure, as the facility failed to provide adequate supervision. The resident, with a history of dementia and other medical conditions, was able to ambulate independently and frequently went outside. The facility did not have a system to monitor outdoor activities, and the patio door was left unlocked, allowing unsupervised access. Staff interviews confirmed the lack of supervision and absence of a policy for outdoor monitoring.
A resident with a history of knee prosthesis infection, hypertension, hypoglycemia, and hepatitis C was not provided access to $60 in their Trust Fund account after discharge. The Administrator confirmed the funds and promised a refund check, but the Director of Accounts Receivable verified that the money was still in the account and had not been sent.
The facility failed to protect residents from abuse, resulting in multiple altercations involving a resident with severe cognitive impairment who repeatedly entered other residents' rooms and took their belongings. This led to physical confrontations with two other residents, causing injuries and distress. Staff found it challenging to monitor the resident's behavior due to other caregiving responsibilities.
Failure to Implement Nutritional Interventions and Provide Ordered Double Portions
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow nutritional interventions for a resident with known significant weight loss, and failure to provide ordered double portions for multiple residents. One resident’s care plan, initiated on 11/03/2025, identified risk for compromised nutritional status with a goal of preventing further weight loss and an intervention to serve the ordered nutritional diet. Despite this, observations on 12/09/2025 showed the resident, who appeared thin and frail, was served only single portions of turkey, mashed potatoes, and mixed vegetables, even though the meal ticket specified double portions. The facility also failed to consistently document the resident’s meal intake, with the EMR showing only fifteen meal intake entries in the prior 30 days and the last recorded meal on 11/30/2025. On 12/10/2025, the same resident was observed sleeping in the dining room during lunch and was not served a meal during the meal service; staff stated they would later offer two peanut butter and jelly sandwiches and were unsure if the resident had eaten breakfast. The EMR confirmed no meal intake documentation after 11/30/2025. A standing weight obtained on 12/11/2025 was 131.8 lbs, compared with prior recorded weights of 159.2 lbs on 09/05/2025, 138.0 lbs on 10/14/2025, 147.0 lbs on 11/04/2025, and 145.7 lbs on 12/05/2025. The registered dietitian documented that the resident had a history of weight loss, significant weight loss over three and six months, and a BMI of 19.9, and noted that the resident was receiving a 240 ml nutritional supplement three times daily with no new recommendations. The dietitian later stated she suspected an error in the November weight, was aware of the family’s request for double portions, and was very concerned about the additional 10.3% weight loss in one month, indicating that closer monitoring of weights and intake might have prevented the significant weight loss. The facility also failed to serve ordered double portions for two additional residents reviewed for nutrition.
Failure to Control Environmental Hazards and Implement Safe Transfers and Fall-Prevention Measures
Penalty
Summary
The deficiency involves multiple failures to maintain a safe environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents. Housekeeping staff left an unsecured cleaning cart in a resident hallway containing an 8 oz bottle labeled as dermal wound cleanser but actually filled with glass cleaner, a generic spray bottle containing bleach, and a quart bottle of pine cleaner. The housekeeper reported that she had retrieved the wound cleanser bottle from the trash and refilled it with glass cleaner after her original bottle broke, and that the generic spray bottle contained bleach. The cart had no locked compartment, and the facility’s housekeeping policy did not provide direction on proper storage or use of hazardous cleaning products. Safety Data Sheets for the chemicals described risks such as skin irritation, serious eye damage, respiratory irritation, and harm if swallowed. The facility also failed to ensure safe transfer techniques were used for a resident with significant physical and cognitive impairments. A CNA was observed transferring this resident from bed to a high-back wheelchair by placing a hand under the resident’s arm, holding the waistband of the pants, and pulling the resident to stand and pivot without using a gait belt. Interviews with the restorative nurse, restorative CNA, and DON confirmed that staff were expected to use gait belts for transfers and not to pull residents by their waistbands. The resident’s diagnoses included hemiplegia and hemiparesis affecting the right dominant side, chronic pain, failure to thrive, repeated falls, and altered mental status. The MDS showed the resident required substantial assistance for sit-to-stand and chair-to-bed transfers, and the care plan documented a history of falls related to poor safety awareness and impulsive behavior, with interventions specifying extensive assist by two staff and use of a mechanical lift with two staff for certain transfers. Additional deficiencies were identified in the use of fall mats and implementation of fall-prevention interventions. Two CNAs transferred a resident with hemiplegia and moderate cognitive impairment from a wheelchair to bed using a mechanical lift while fall mats remained down on both sides of the bed; the lift was rolled over the fall mat to position the resident in bed. The restorative nurse and DON stated that fall mats should be moved prior to transferring residents back to bed because they interfere with proper positioning of the lift base under the bed and present a tripping hazard. For two other residents at high risk for falls, the facility did not implement care-planned positioning and seating interventions. One resident of shorter stature, with a history of four falls in front of his wheelchair, was repeatedly observed in a specialized high-back chair without leg rests or footrests, leaving his legs dangling and unsupported and in slouched or unsafe positions, including sitting across the seat with legs over the armrest while nursing staff did not assist with repositioning. Another resident, also with four recent falls in front of a specialized high-back chair, was observed multiple times in a high-back chair or wheelchair without the care-planned non-slip seating material and with feet dangling due to missing footrests. Staff acknowledged that these residents were frequent fallers and that specific fall interventions, including non-slip devices and safe positioning, were expected to be implemented based on posted communication sheets and updated care plans.
Improper Medication Labeling and Insecure Storage of Drugs and Biologicals
Penalty
Summary
Surveyors identified that multiple medications and biologicals on a medication cart were not labeled or stored according to facility policy and professional standards. During an inspection of medication cart #3 with the ADON, open bottles of antacid/anti-gas for one resident, Levetiracetam (Keppra) solution for another resident, Lactulose solution for a third resident, and Valproate Sodium oral solution for a fourth resident were found without open dates. Several stock medications and biologicals on the same cart, including Geri-Tussin DM, Polyethylene Glycol 3350, and Reguloid, were also open without open dates. Additionally, a container holding approximately 1/4 cup of an unlabeled white powder, identified by the ADON as liquid thickener, was missing its snap-on lid and had no label or date. The ADON acknowledged that she does not date all medications when opened and stated that the white substance should have been properly contained. The DON stated that all open medications are required to have an open date and that all containers should be labeled to identify their contents, consistent with the facility’s Medication Storage policy, which requires dating when the manufacturer’s seal is broken and sets a 30-day expiration unless otherwise specified. Physician orders confirmed that the undated open medications on the cart were active orders for the respective residents, including Valproate Sodium for agitation/anxiety, Keppra for epilepsy, Lactulose for toxic encephalopathy, and Maalox Max for indigestion. The facility’s written policies also required medications and biologics to be stored safely, securely, and properly. Surveyors also observed failures in secure storage and control of medications at the bedside and in resident rooms. One resident with diagnoses including COPD, cataract, myopia, dementia, major depressive disorder, anxiety, and polyarthritis had a nebulizer machine and two unopened vials of Albuterol Sulfate for inhalation on the bedside table and reported independently adding the medication to the machine and administering treatments daily without nursing supervision. The DON stated there were no residents authorized to self-administer medications and that no medications should be stored at the bedside without an order; the resident’s orders did not include bedside storage. Another resident had a medication cup at bedside containing a small white pill marked “AC 145,” which she believed might be for high blood pressure; her orders included Chlorthalidone 25 mg daily for hypertension. A separate resident’s unlocked in-room refrigerator contained Fluticasone Propionate nasal spray ordered for nightly use, despite the facility’s policy that medication supplies are accessible only to licensed nursing, pharmacy personnel, or staff lawfully authorized to administer medications.
Improper Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s dietary services affecting all 114 residents receiving dietary services, based on observations during a kitchen tour and staff interviews. In dry storage, surveyors observed a 25 lb bag of great northern beans left open to the air. In kitchen cooler #2, they found a facility container of hard-boiled eggs with an expiration date of 7/14/25 still present. A 30 lb bucket of beef base was observed open to air with the lid sitting loosely on top, and a 30 lb bucket of chicken base was being stored underneath the kitchen sink. Two silver facility pans containing yellow cake were placed on the counter within splashing distance of the kitchen sink. Two red sanitization buckets in use tested at 400 ppm, above the level later identified by the Dietary Manager as appropriate. Surveyors also observed that serving utensils stored in open bins were dirty with dried, crusted food, and two stacks of three silver mixing bowls under the food prep counter contained crumbs and a dried white substance. In a subsequent interview, the Dietary Manager stated that food should be sealed to prevent damage, contamination, and bacteria, and that dating food items is important to assure freshness, adding that outdated or misdated food needs to be discarded because it can cause sickness. The Dietary Manager acknowledged not knowing that food should not be stored under the sink or near the sink due to potential contamination from water, and stated that using dirty utensils will cause cross-contamination and sickness. The facility’s written policies required sanitary practices in food preparation, proper labeling and sealing of opened food items, appropriate storage of opened products in tightly covered containers, and following manufacturer recommendations for sanitizing solution concentration.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Device and Incontinence Care
Penalty
Summary
Surveyors identified that nursing staff did not follow the facility’s Enhanced Barrier Precautions (EBP) and PPE requirements when providing care to multiple residents with devices and wounds. One RN administered an enteral feeding via gastrostomy tube (g-tube) to a resident who had an EBP sign on the door and a care plan requiring EBP due to a g-tube, urinary catheter, and wound, but the RN wore only gloves. The same RN later assessed and flushed another resident’s g-tube, again with an EBP sign posted and a care plan requiring EBP for a g-tube and wound, while wearing only gloves. An LPN administered a bolus g-tube feeding to a third resident whose door displayed an EBP sign and whose care plan required EBP due to a g-tube, but the LPN also wore only gloves. The facility’s EBP policy required gown and gloves for high-contact resident care activities, including handling feeding tubes, and the DON stated staff were expected to adhere to EBP when rendering direct care. Surveyors also observed a CNA providing incontinence care to another resident without performing hand hygiene and while improperly using gloves and contaminated supplies. The CNA entered the room, closed the door, and donned gloves without hand hygiene, then removed a urine- and stool-soiled undergarment, turned off the call light with soiled gloves, and closed the privacy curtain, bumping the overbed table and knocking the roommate’s stuffed bear to the floor. The CNA picked up the bear with the same soiled gloves and then continued incontinence care, wiping under the resident’s reddened abdominal fold and vaginal area multiple times with the same towel, and wiping the buttocks and gluteal cleft multiple times with the same washcloth, before covering the resident, removing gloves, and leaving the room. The DON stated that not cleaning residents properly during incontinence care and touching environmental items with soiled gloves is an infection control concern and that staff should perform proper hand hygiene. Facility policies on incontinence care and hand hygiene required perineal/genital care to prevent infection and specified handwashing or alcohol-based hand rub use before and after glove use, after handling potentially contaminated items, and after direct resident care.
Failure to Maintain Resident Bodily Privacy in Common Area
Penalty
Summary
Surveyors identified a failure to maintain a resident's bodily privacy and dignity when a resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses was observed partially undressed in a common area. On 12/11/25 at 10:14 AM, the resident was sitting on the floor in a common area across from the nurses station, in front of the elevator, with pants pulled down to the knees and the penis not contained in the incontinence brief. The Social Services Director was seated at the nurses station with his back to the resident and was texting the DON while the resident remained on the floor undressed. At 10:16 AM, a CNA exited the elevator, observed the resident on the floor, and alerted the Social Services Director; together they assisted the resident to stand, at which time the resident’s penis was fully exposed outside of the incontinence brief. The resident’s admission record showed multiple diagnoses including encounter for surgical aftercare, autistic disorder, epilepsy, dementia, schizophrenia, impulse disorder, and intellectual disabilities. The MDS dated 10/05/25 documented severe cognitive impairment and behavioral symptoms that intruded on the privacy of others and disrupted care or living arrangements. Progress notes dated 12/11/25 at 10:53 AM described the resident as being in and out of other residents’ rooms, unable to be redirected, pushing past staff, and laying on the floor exposing self. The facility’s Dignity policy, revised 01/25, stated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that staff shall promote, maintain, and protect residents’ privacy, including bodily privacy during assistance with personal care and treatment procedures. Despite this policy and the known behavioral history, the resident was allowed to remain in a public common area with genital exposure until discovered by the CNA.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to manage his personal funds by not providing prompt access to requested money from his personal funds account. During observation, the resident, who was cognitively intact per an MDS dated 11/17/25 and had diagnoses including hemiplegia and hemiparesis, morbid obesity, diabetes, major depressive disorder, and polyosteoarthritis, reported that he had requested $40 from his personal funds account three weeks earlier from the Assistant Administrator/Human Resources and had never received it. In a subsequent interview, the Assistant Administrator/Human Resources confirmed that the resident had a $160 balance and had requested $40 approximately two weeks earlier, but she had not gone to the bank to obtain the funds and acknowledged that residents should not have to wait two weeks or more for requested money. The Assistant Administrator/Human Resources also stated she was the only person who could go to the bank to access residents’ funds. The facility’s Resident Personal Funds policy dated 05/14 stated that the facility manages residents’ personal funds when requested and that residents may choose to have the facility hold, safeguard, and manage their personal funds. Despite this policy and the resident’s request, the facility did not provide timely access to the resident’s personal funds, resulting in the deficiency.
Failure to Report Allegation of Abuse Involving Refusal of Toileting and Hygiene Care
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency after a cognitively intact resident reported that a CNA refused to provide necessary toileting and hygiene care. The resident, who has diagnoses including Arnold Chiari Syndrome, craniofacial dysostosis, monocular exotropia, seizures, scoliosis, and dysthymic disorder, is usually continent of bowel and bladder, has limited use of extremities, uses a motorized wheelchair, and requires assistance with toileting and toilet hygiene per her care plan. She stated that when she requested toileting assistance and a shower because her menstrual period had started, the CNA told her to go to the toilet in her pants and did not change her menstrual pad. The resident reported this incident directly to the Administrator and stated the CNA later told her she would not have said that if she knew the resident was "in her right mind." The Administrator, who is identified as the abuse coordinator, acknowledged that he did not submit a report to the Illinois Department of Public Health after being informed that the CNA did not provide the requested shower and refused to change the resident’s menstrual pad. The DON stated that she heard the CNA refusing to toilet the resident and that she informed the Administrator of this refusal, although she did not recall when. Documentation in the CNA’s corrective action notice listed discharge for refusal to do work, including refusing to toilet a resident during her shift, taking long breaks, and attitude issues. Despite this, the Administrator stated that refusing to toilet an alert, oriented, continent resident is not abuse and confirmed that no report was made, contrary to the facility’s Abuse Prevention Program policy, which defines abuse to include deprivation of goods and services necessary to maintain physical, mental, and psychosocial well-being and requires accurate and timely investigative reports.
Failure to Notify Provider of Missed Medications and Unassessed Use of Resident-Managed CGM
Penalty
Summary
The deficiency involves the facility’s failure to follow provider notification requirements and medication administration parameters when ordered medications were missed, and failure to assess and obtain orders for the use of a continuous glucose monitoring (CGM) device. For one resident with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness, the RN reported that the resident refused her scheduled morning medications due to nausea and that Zofran was given. The RN then administered multiple medications, including amantadine, docusate sodium, and gabapentin, at approximately 1:05 PM, well outside the facility’s stated one-hour medication administration window for a 9 AM dose, without contacting the NP or MD for direction. Review of the physician order sheet confirmed these medications were ordered on twice-daily and three-times-daily schedules, and the medication administration audit showed the 9 AM gabapentin dose was documented at 1:16 PM and the 1 PM dose at 1:19 PM. There were no progress notes indicating the RN had notified the NP or MD about the missed or delayed doses. Interviews with clinical staff and leadership confirmed that the nurse did not follow expected procedures for missed or delayed medications. The NP stated she was not contacted about any medications not administered to this resident and explained that if a resident was nauseous, she expected antinausea medication to be given and then, if the resident still could not take medications within the 8–10 AM window for a 9 AM dose, the nurse should call the provider to clarify which medications to administer, as it was not up to the nurse to decide due to differing medication half-lives and potential toxicity. Other nursing staff, including an RN and an LPN, stated that if a resident could not take medications at the scheduled time, they would notify the doctor to determine whether to skip or make up the dose, and the DON stated the nurse should contact the doctor if medications are held past the due time because it could result in an overdose if the next dose was due around the same time. The facility’s medication administration policy required medications to be administered within one hour of prescribed times, and the change in condition policy required physician or NP notification when deemed necessary or appropriate in the resident’s best interest. A second deficiency involved the facility’s failure to obtain a physician’s order, perform an assessment, and develop care plan interventions for a resident’s use of a CGM system, despite having a facility policy on continuous glucose monitoring. The resident reported that she independently managed her CGM, obtained her own blood glucose readings, and informed staff of the results, and that staff did not check her blood glucose with facility equipment. An LPN stated that insulin and other interventions were provided based on the readings the resident reported from her CGM, and these readings and related interventions were documented in the EMR. The DON confirmed that the resident had a CGM, that staff obtained and documented glucose readings from the device, that the resident maintained and connected it herself, and that no competency assessment of the resident’s use of the CGM had been completed. The DON also stated staff did not have instructions or knowledge of how the device worked, and the Administrator confirmed there were no facility policies guiding assessment or nursing actions based on resident-managed CGM devices. Record review showed there was no physician order for self-directed CGM use, no care plan interventions, and no documented assessment of the resident’s use of the CGM, despite a facility CGM policy requiring a physician’s order and adherence to manufacturer instructions.
Failure to Follow G-Tube Orders, Label Feedings, and Maintain Tube Site
Penalty
Summary
The deficiency involves the facility’s failure to follow gastrostomy tube (g-tube) feeding orders, properly label feeding bottles and bags, and maintain the g-tube site for one resident dependent on staff for care. On multiple observations, the resident was receiving g-tube feedings via a pump with hanging feeding bags that were not labeled with the type of formula being infused, and a clear bag was connected to a water bag without labeling. An open bottle of the ordered nutritional product was observed at the bedside. On one occasion, the feeding pump alarm was beeping to indicate inactivity, and the alarm continued for at least 15 minutes without resolution. When an RN assessed the infusion, she stated she was unsure of the type of feeding being administered because the bag was not labeled, and acknowledged that feeding bags should be accurately labeled to ensure the correct formula is infused. The resident’s g-tube site was repeatedly observed with brown, thick, adherent drainage and without a dressing, despite an order to clean the g-tube site with normal saline daily and as needed. The wound nurse stated that nurses should be assessing and cleaning tube sites to prevent complications. The resident’s care plan directed nursing staff to use clinical standards of practice in managing the tube, including infusing feeding as ordered and regularly checking the tube site for drainage. These observations and staff statements show that the facility did not implement the ordered care and care plan interventions for g-tube feeding administration, labeling, and site maintenance for this resident.
Medication Administration Outside Time Window Resulting in Elevated Error Rate
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and within the facility’s defined medication administration window, resulting in a medication error rate of 10.53% (4 errors out of 38 opportunities), exceeding the required rate of less than 5%. One cognitively intact resident with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness did not receive medications as ordered. On a specified date, an RN delayed the resident’s scheduled 9 AM medications because the resident was nauseous and subsequently prepared and administered them at 1:05 PM, outside the facility’s one-hour window around the prescribed time. The RN then documented the medications as administered in the electronic record between 1:15 PM and 1:19 PM. Medication reconciliation and record review showed that Amantadine HCl and Docusate Sodium, each ordered twice daily at 9 AM and 5 PM, and Gabapentin 300 mg, ordered three times daily at 9 AM, 1 PM, and 5 PM, were all administered at 1:05 PM instead of at the ordered 9 AM time. The 1 PM dose of Gabapentin was also signed out at 1:19 PM. A daily multivitamin ordered once a day at 9 AM was not administered as ordered, despite being signed off in the record. Interviews with an LPN, the DON, and an NP confirmed that the facility’s medication administration window for 9 AM medications was 8 AM to 10 AM, and that medications given outside this window required contacting the physician or NP for clarification, which was not documented for this resident. The facility’s policy required medications to be administered according to physician orders and within one hour of prescribed times, which was not followed in this instance.
Failure to Ensure Timely Emergency Response for Resident in Respiratory Distress
Penalty
Summary
The facility failed to ensure a timely ambulance transfer for a resident experiencing respiratory distress. On the day in question, the resident, who had a history of acute respiratory failure with hypoxia, sepsis, quadriplegia, and repeated hospitalizations for shortness of breath, repeatedly requested to go to the emergency room due to shortness of breath and not feeling well. Despite the resident's abnormal vital signs—including low blood pressure, elevated heart rate, and low oxygen saturation—the LPN on duty initially called for a routine ambulance instead of 911. The ambulance dispatcher advised the nurse to call 911 due to the resident's critical condition, but the nurse attempted to contact other ambulance companies instead, delaying emergency care. When the EMT arrived approximately 20 minutes later, the resident was found gasping for air with further deteriorated vital signs and required immediate intervention. The EMT noted that the resident was unable to call 911 herself due to her paraplegia. Interviews with other nursing staff, the DON, and the NP confirmed that the facility's policy and standard practice required calling 911 immediately for acute respiratory distress and significant changes in vital signs. The facility's care plan for the resident also specified prompt response to respiratory complications and emergency needs, which was not followed in this instance.
Failure to Provide Proper PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide proper care and maintenance for a resident's tunneled PICC (Peripherally Inserted Central Catheter) line. Upon admission to the hospital, the resident's PICC line dressing was found to be 22 days old, despite orders and facility policy requiring dressing changes every 7 days. Documentation in the resident's Medication Administration Record (MAR) indicated that dressing changes were performed on two dates, but the LPN who documented these changes later admitted that she did not actually perform the dressing changes and was unsure if an RN had done so. Additionally, there was no documentation of required PICC line cap changes in the MAR or Treatment Administration Record (TAR) for the month reviewed. Interviews with facility staff revealed a lack of clarity and training regarding central line care responsibilities and procedures. The LPN stated she had not received training on central line dressing changes and did not know the frequency for cap changes, believing these tasks were the responsibility of an RN. The DON confirmed that only RNs should perform central line dressing changes and acknowledged that staff needed reeducation on central line care. The facility's policy required dressing changes every 5-7 days and documentation of all interventions, which was not followed in this case.
Failure to Supervise Resident with Hot Liquids Results in Burns
Penalty
Summary
The facility failed to implement safety interventions and provide adequate supervision to prevent a resident from sustaining burns while drinking hot liquids. The resident, who has quadriplegia and is dependent on staff for eating, was left unsupervised with a hot cup of coffee that had no lid and was using a straw, despite recommendations against straw use due to aspiration risk. The resident suffered 1st and 2nd degree burns on her chest after the coffee spilled from the straw onto her chest. The incident occurred when a CNA warmed the resident's coffee in the microwave and returned it to her without a lid, allowing her to drink it unsupervised. The resident's care plan and previous swallow study explicitly advised against the use of straws and required supervision while drinking. The lack of adherence to these safety measures and the facility's policy on feeding and assisting residents led to the resident's injury.
Failure to Staff RNs for Required Hours
Penalty
Summary
The facility failed to staff Registered Nurses (RNs) for 8 consecutive hours, 7 days a week, as required. This deficiency was identified through a review of the facility's schedule and interviews with staff members. The schedule from September 28, 2024, through October 23, 2024, revealed that on several occasions, there were no RNs present in the facility for the required duration. Specifically, on September 29, October 13, and October 19, 2024, the facility did not have an RN on duty for 8 consecutive hours. The facility's policy mandates that an RN must be available for supervision for at least 8 consecutive hours daily, which was not adhered to on these dates. Interviews with staff, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and other RNs, confirmed that they did not work on the weekends unless necessary, and there was no documentation to show their presence on the specified dates. The Administrator acknowledged the requirement for RNs to be present for 8 hours daily but was unaware of the lapses in staffing. The facility's failure to meet the staffing requirement has the potential to affect all residents, as it compromises the supervision and care provided.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to obtain physician orders for medications brought from home and placed at the bedside, and did not complete self-administration of medication assessments for six residents. These residents were observed with various medications at their bedsides, including Lidocaine pain relief, antiacid tablets, nasal sprays, and eye drops, which they self-administered without proper assessment or orders. Despite being cognitively intact, as indicated by their BIMS scores, there were no documented assessments or care plans for self-administration of medications in their electronic medical records. The Director of Nursing (DON) acknowledged that medications brought from home should have orders and that residents need to be assessed for their ability to self-administer medications safely. However, the DON stated that no residents were currently assessed or authorized to self-administer medications. The facility's policy requires an assessment at admission or thereafter, with documentation and physician orders if self-administration is deemed appropriate. Additionally, medications kept at the bedside should be recorded on the medication record, and drug storage remains the responsibility of the nursing staff. One resident was found with a bisacodyl stimulant laxative at the bedside, which she took without informing her nurse, despite having no current order for it. The LPN confirmed that all medications should be administered by nursing staff, citing risks such as over-medicating and drug interactions. The facility's policy on medication storage emphasizes that medications should be stored safely and securely, accessible only by authorized personnel.
Failure to Apply Splints and Braces
Penalty
Summary
The facility failed to apply necessary splints and braces to two residents, R11 and R15, who required them to maintain or improve their range of motion. R11, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without the prescribed right resting hand splint. Despite having a physician's order and a care plan indicating the need for the splint to prevent further contracture, the splint was not applied during the observed times. The restorative nurse confirmed that the splint should have been on, as its absence could increase contraction. Similarly, R15, who had diagnoses including hemiplegia and contractures in both hands, was observed without the required palm protectors on several occasions. The physician's orders and care plan specified the need for bilateral palm protectors to manage muscle stiffness. The restorative nurse admitted that the palm protectors were not applied as required and noted that the night CNAs removed them without proper documentation or orders to do so. The Director of Nursing and other staff acknowledged that splints and protectors should be applied as ordered, and any refusal by residents should be documented.
Deficiencies in Fall Prevention and Smoking Supervision
Penalty
Summary
The facility failed to implement necessary interventions to prevent fall injuries and smoking hazards for several residents. One resident, who is blind and uses a wheelchair, was pushed by staff without footrests attached to his wheelchair, resulting in his feet hitting a raised section of concrete. Another resident with severe cognitive impairment was found in a room with an exposed metal bed frame, posing a potential injury risk. Additionally, a resident with severe cognitive impairment was observed walking without skid-protection socks, increasing her fall risk. The facility also failed to maintain appropriate bed heights and fall prevention measures for residents at risk of falling. One resident's bed was consistently left in a high position without fall mats, despite being at risk for falls and having a care plan that included fall mats as an intervention. Another resident, who preferred a high bed position, did not have fall mats in place as required by his care plan, and staff were unaware of the missing mats. Furthermore, the facility did not adequately assess and supervise a resident with smoking materials. A resident was found with a lighter and an aerosol spray can, despite a care plan indicating she required supervision when smoking. The facility's policy prohibits residents from keeping smoking materials if they are not safe to smoke independently, yet the resident's care plan was updated without a new smoking risk assessment.
Failure to Properly Administer G-tube Feeding
Penalty
Summary
The facility failed to properly manage the administration of G-tube feeding for a resident, identified as R15, who was admitted with conditions including hemiplegia, hemiparesis, dysphagia, and a gastrostomy. The Physician Order Sheet for R15 specified that the G-tube feeding should be administered at a rate of 75 ml/hr for 20 hours daily, with specific instructions to check tube placement and residuals before feeding. However, observations revealed that the feeding was consistently administered at an incorrect rate of 70 ml/hr, and the necessary checks for tube placement and residuals were not performed. On multiple occasions, staff members, including LPNs and the Assistant Director of Nursing, failed to adhere to the prescribed procedures for G-tube feeding. For instance, on one occasion, an LPN did not check the residual by aspirating the stomach contents before starting the feeding, and the feeding pump was set to an incorrect rate. Another LPN also failed to check the placement by checking for residual prior to flushing the G-tube with water. These actions were contrary to the facility's policy, which required checking for residuals to prevent potential complications such as regurgitation or aspiration. Interviews with staff, including the Director of Nursing, revealed a lack of adherence to the facility's policies and outdated practices being used, such as pushing air to check for tube placement. The Director of Nursing emphasized the importance of aspirating to check residuals and ensuring the feeding rate matched the physician's orders. The facility's policies clearly outlined the procedures for G-tube feeding and weight assessments, but these were not followed, leading to the deficiency in care for R15.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10%, which exceeds the acceptable threshold of 5%. During a medication pass observation, a registered nurse administered incorrect medications to a resident. Specifically, the nurse gave one tablet of Folic Acid 1000 mcg, one tablet of Torsemide 20 mg, and one tablet of Soaanz (Torsemide) 60 mg, but failed to administer Ezetimibe 10 mg as prescribed. The nurse incorrectly signed the Medication Administration Record (MAR) indicating that Ezetimibe was given, despite the medication not being available. The resident involved, who was cognitively intact, had multiple diagnoses including hypertension, hyperlipidemia, lymphedema, and atrial fibrillation. The resident's medication orders for October 2024 included Ezetimibe 10 mg, Folic Acid 400 mcg, and Torsemide 60 mg, with Torsemide 20 mg having been discontinued in September 2024. The Director of Nursing confirmed that medications should be administered as prescribed and that discontinued medications should not be present in the medication cart. The facility's policy emphasizes the importance of administering medications according to physician orders and documenting any deviations appropriately.
Deficiency in Refrigerator Maintenance and Food Safety
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in residents' personal refrigerators. Three residents were found to have expired food items and lacked temperature monitoring in their personal refrigerators. One resident had a refrigerator with no thermometer and no temperature log, and she reported that staff had never checked her refrigerator. Another resident had multiple expired food items, including milk and yogurt, and also lacked a thermometer and temperature log. The resident was unaware of the expired items until the surveyor pointed them out. A third resident's refrigerator contained old, moldy fruit and expired dairy products, and the refrigerator was cluttered and sticky. Despite the resident's inability to clean the refrigerator due to physical impairments, the housekeeping staff responsible for cleaning it had not done so. The Assistant Director of Nursing acknowledged the risk of illness from consuming expired food and confirmed that housekeeping was responsible for maintaining the cleanliness and safety of the refrigerators.
Lack of Supervision Leads to Resident's Sunburn
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired resident, resulting in prolonged sun exposure and subsequent full thickness burns to the resident's upper back and posterior neck. The resident, identified as having dementia, was able to ambulate independently and frequently went outside. However, the facility did not have a system in place to monitor or supervise the resident's outdoor activities, leading to the resident being exposed to the sun for an unknown duration. The resident's medical history included chronic obstructive pulmonary disease, Alzheimer's disease, fibromyalgia, basal cell carcinoma, chronic pain syndrome, and adjustment disorder with mixed anxiety and depressed mood. The resident was severely cognitively impaired and required assistance with activities of daily living. Despite these needs, the facility's care plan did not adequately address the supervision required to prevent the resident from wandering outside unsupervised. Interviews with facility staff revealed that the patio door was left unlocked, allowing residents to exit without staff knowledge. The Activity Assistant supervised the patio only during scheduled smoking breaks, and no staff were assigned to supervise the area at other times. The Director of Nursing confirmed that there was no investigation into the duration of the resident's sun exposure and no facility policy regarding outdoor supervision, contributing to the incident.
Failure to Provide Resident Access to Funds
Penalty
Summary
The facility failed to provide a resident access to their funds as requested. The resident, a male with a history of infection and inflammatory reaction due to an internal left knee prosthesis, hypertension, hypoglycemia, hepatitis C, and aftercare following joint replacement surgery, was admitted and later discharged from the facility. Approximately a month after discharge, the resident contacted the facility regarding his Trust Fund money. The Administrator confirmed that $60 remained in the resident's Trust Fund account and assured the resident that a refund check would be mailed. However, the Director of Accounts Receivable verified that the funds were still in the account and had not been sent to the resident. The resident's statement showed an ending balance of $60.04 on the date of discharge.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to keep residents safe from resident-to-resident abuse, resulting in multiple altercations involving residents R1, R2, and R3. On April 17, 2024, R1 was pushed by R2, causing R1 to fall and hit her head. R1 was sent to the emergency department and later released with no significant injuries. R1, who has moderate cognitive impairment and a history of repeated falls, reported feeling unsafe around R2 and preferred to stay in her bedroom to avoid further confrontations. R2, who has severe cognitive impairment and a history of wandering and taking other residents' belongings, was discharged for psychiatric care after the incident. Another incident occurred on February 26, 2024, when R2 struck R1 in the face and lip after a misunderstanding involving a stuffed animal. R1 did not require special treatment for the cut on her face. Staff members reported that R1 had previously threatened to give R2 a black eye if she entered her room, leading to an argument and subsequent physical altercation. R2's behavior of entering other residents' rooms and taking their belongings was noted by multiple staff members, who found it challenging to monitor her constantly due to other caregiving responsibilities. R2 was also involved in an incident with R3 on March 20, 2024, when R3 activated her call light and reported that R2 had slapped her on the right arm. Although no acute injury was noted, R3 experienced discomfort in the area. R3, who has moderate cognitive impairment and multiple medical diagnoses, remembered being hit by R2. Staff members confirmed that R2 was found in R3's bedroom but were unsure of her actions. These incidents highlight the facility's failure to protect residents from abuse and adequately monitor R2's behavior, leading to repeated altercations and a lack of safety for the affected residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 908 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Joliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny Hill Nursing Home Of Will County | 2.4 mi | ★★★★★ | 3 | 0 |
| Pearl Of Joliet, The | 3.7 mi | ★★★★★ | 3 | 0 |
| Parc Joliet | 4.1 mi | ★★★★★ | 29 | 0 |
| Avantara Joliet | 4.4 mi | ★★★★★ | 8 | 0 |
| Joliet Living & Rehab Center | 4.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.