Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St James Wellness Rehab Villas during CMS and state inspections, most recent first.
A leaking ice machine in an unlocked nourishment room on the second floor was not repaired for a week, affecting seven residents with impaired cognition. CNAs reported the issue, but the Maintenance Director was only notified the day before. Residents were observed ambulating in the area, with one resident wandering near the ice machine.
The facility failed to provide timely incontinence care for three residents who required assistance with toileting and hygiene. One resident was found with heavily saturated bed sheets and incontinence products, while another was dependent on staff for toileting but was not changed in a timely manner. A third resident, with memory issues, was also not provided timely care. The staff did not adhere to care plans that required regular checks and changes every two hours.
A facility failed to follow physician orders for wound care for a resident with an unstageable sacral ulcer. The resident was found with a heavily saturated and detached dressing, exposing the ulcer. A CNA did not notify the nurse about the need for a dressing change due to being busy. The wound care physician stated that dressings should be changed daily and as needed when soiled, as per the physician order summary.
Two residents experienced medication administration deficiencies. One resident had a Symbicort inhaler at her bedside without a physician's order for self-administration. Another resident was fed unidentified substances mixed into her food, later revealed to be her medications, without proper administration procedures. These actions were not in compliance with the facility's medication administration policy.
The facility failed to follow physician's orders for catheter care for four residents with a history of UTIs. Observations included catheter bags touching the floor, improper cleaning methods, and missing documentation for urine output. The Director of Nursing confirmed these deficiencies, noting that improper care could lead to infections.
The facility failed to provide proper catheter care for four residents, leading to deficiencies in their care. A resident with a history of UTIs and kidney issues had a catheter bag touching the floor, and staff did not change the bag or tubing as ordered. Another resident with diabetes and kidney disease received inadequate catheter care, with improper cleaning and insufficient hand hygiene. A third resident with urinary retention did not receive proper catheter care, and there was a lack of documentation for urine output and missed medication doses. These deficiencies were confirmed by the DON, who noted a trend of residents developing UTIs and becoming septic.
The facility failed to provide enough clean linens, blankets, towels, and washcloths for its 69 residents, affecting their right to a safe and comfortable environment. Residents and staff reported shortages, with observations confirming insufficient supplies on linen carts and in the laundry area. The DON and other staff were aware of the issue, but no additional supplies were ordered, and the facility lacked a backup supply, impacting care delivery.
A resident with multiple diagnoses developed a DTI on the right heel, which was not documented or communicated to the physician or POA. The Wound Care Nurse noticed the injury but did not notify the doctor or apply treatments. The Nurse Practitioner was unaware of the DTI and the resident's elevated heart rate, indicating a failure in communication and documentation.
A facility failed to provide necessary wound care and manage abnormal vital signs for a resident with Covid-19 and other conditions. The resident's elevated heart rate was not documented or communicated to a physician, and a deep tissue injury on the resident's heel was not treated or reported. The facility's protocols for Covid-19 and skin assessments were not followed, leading to a lack of proper care and documentation.
The facility failed to maintain kitchen sanitation and proper food storage, affecting 80 residents. Observations included outdated and unlabeled food items, excessive sanitizer concentration, and cleanliness issues such as grease and dust. A turkey sandwich was served at an unsafe temperature, and an employee was observed with exposed hair, violating facility policies.
The facility failed to maintain the kitchen dishwasher and sink in good repair, affecting dietary services for 80 residents. The dishwasher was non-functional, and the sink was filled with dirty water, leading to the use of disposable plates. Observations revealed unsanitary conditions with dishware caked with food residue and bugs. The Maintenance Director noted ongoing drainage issues, and the Administrator lacked records of repair approvals. Facility policies on equipment maintenance and sanitation were not followed.
The facility failed to provide written notification to residents, their families, and the ombudsman regarding hospital transfers for six residents with various medical conditions. Despite verbal notifications, there was no documentation of written notices, violating the facility's Bed Hold and Readmission policy.
The facility failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers. This deficiency affected six residents, all of whom were transferred without receiving the required documentation. The facility's policy mandates informing residents or their representatives of the bed hold policy at the time of transfer, but this was not adhered to, as confirmed by the facility's Administrator and DON.
The facility failed to obtain physician orders for over-the-counter medications and improperly allowed medications to be stored in resident rooms. Six residents were affected, including those with glaucoma, dementia, and Parkinson's disease. Medications were found in rooms without proper authorization or physician orders, contrary to facility policy requiring secure storage and authorized access.
A long-term care facility was found to have multiple deficiencies in infection control practices, including improper hand hygiene and PPE usage. Staff failed to change gloves and sanitize hands during resident care, did not use required PPE for COVID-19 precautions, and improperly disposed of PPE. These actions violated the facility's policies and potentially exposed residents with serious health conditions to infection risks.
The facility failed to provide adequate ADL care for five residents dependent on staff assistance. Observations showed long, jagged fingernails, dry skin, and a lack of regular hygiene care, despite the facility's policy requiring such care. The DON confirmed that care should be provided as needed, and there was no record of residents refusing care.
The facility failed to implement fall interventions for four high-risk residents. One resident was found with non-skid socks and a wheelchair out of reach, while another lacked fall mats by the bed. Staff were unaware of fall interventions for a resident with multiple diagnoses, and a floor mat was misplaced for a cognitively impaired resident. The facility's policy requires interventions to minimize fall risks, which were not followed.
The facility failed to administer oxygen as ordered for two residents. One resident received less oxygen than prescribed, while another had a nasal cannula improperly placed, which was not corrected until a surveyor intervened. The DON confirmed the expectation for staff to ensure proper oxygen administration.
The facility failed to maintain a functioning call light system for two residents, one with dementia and high fall risk, and another with diabetes and limited mobility. Both residents were unable to use their call lights to request assistance, relying on others or physically moving to seek help. Staff acknowledged the issue, but the deficiency persisted.
The facility failed to position a resident's catheter bag correctly, causing backflow of urine, and did not provide timely incontinent care to several residents. A resident with a suprapubic catheter experienced backflow due to improper bag placement, while other residents were found with soiled briefs, indicating delays in care. CNAs cited being busy as a reason for not following the facility's protocol of providing care every two hours.
A resident experienced multiple episodes of vomiting and diarrhea, but the facility failed to notify the physician or document the condition change. The CNA informed a nurse, but the nurse did not recall notifying the doctor, and the resident's condition was not documented in the progress notes. This oversight violated the facility's guidelines for notifying physicians of significant changes in a resident's condition.
Leaking Ice Machine in Unlocked Nourishment Room
Penalty
Summary
The facility failed to repair a leaking ice machine in the nourishment room on the second floor, which affected seven residents who are ambulatory and have impaired cognition. On March 18, 2025, the nourishment room door was found wide open without a lock, and a puddle of water was observed on the floor due to the leaking ice machine. Certified Nursing Assistants reported the leak had been ongoing for a week. On March 19, 2025, the room remained unlocked, and wet bedsheets were used to absorb the leaking water. The Maintenance/Housekeeping Director acknowledged the leak but stated he was only notified the day before. Residents with impaired cognition were observed ambulating in the area, including one resident who was seen wandering in the hallway where the ice machine was located.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for residents who require assistance with toileting and hygiene. This deficiency was observed in three residents. The first resident, R1, was found in bed with heavily saturated bed sheets, incontinence brief, and pad, all stained with urine. R1 reported using the call light for assistance, but the staff turned it off without providing help. R1's care plan indicated a need for substantial assistance with toileting hygiene, yet the staff did not adhere to the plan's interventions, which included checking and changing every two hours. The second resident, R2, was also found heavily saturated with urine and had a bowel movement. R2 was dependent on staff for toileting and personal hygiene, but the staff failed to provide timely care. Similarly, R3 was found in a similar state, with urine saturation and a bowel movement. R3's care plan required regular checks and changes, but the staff waited for R3 to request assistance, despite R3's short-term memory problems. The facility's failure to follow care plans and provide timely incontinence care led to these deficiencies.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to follow physician orders for wound treatment and dressing changes for a resident with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia, and an unstageable pressure ulcer in the sacral region. On March 19, 2025, the resident was observed with a heavily saturated wound dressing that was dated the previous day and had become detached, exposing the unstageable sacral ulcer. The surrounding area was wet with exudates, and a leaking rectal tube was noted near the exposed wound. A CNA changed the resident's brief but did not notify the nurse about the need for a dressing change due to being busy with other assignments. The wound care physician confirmed that the dressing should be changed daily and as needed when soiled to prevent potential skin breakdown. The physician order summary indicated that the sacral area should be cleansed with normal saline, medihoney applied, and covered with a dry dressing every day and as needed if the dressing becomes loose or soiled. The facility's failure to adhere to these orders resulted in the deficiency.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper physician orders for self-administration of medication and accurate medication administration as prescribed. One resident, who has multiple medical diagnoses including chronic obstructive pulmonary disease and asthma, was found with a Symbicort inhaler at her bedside without a physician's order or an updated care plan authorizing self-administration. This indicates a lack of compliance with the facility's policy that requires specific authorization from the attending physician for residents to self-administer medication. Another resident, with diagnoses including type 2 diabetes mellitus and unspecified dementia, was observed being fed by a restorative aid with unidentified substances mixed into her pureed bread. The assistant director of nursing initially identified the substance as a sugar substitute, but it was later revealed by the primary nurse that the substances were actually the resident's medications, mixed into the food due to the resident's refusal to take them with applesauce. This practice was not in line with the facility's medication administration policy, which states that the person who prepares the dose must be the one to administer it, and highlights a failure to ensure medications are administered as prescribed.
Failure to Implement Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to implement physician's orders for four residents with a history of urinary tract infections (UTIs). For one resident, the catheter bag and tubing were observed touching the floor, and the urine was dark and cloudy. Despite the resident's complaints of pain, the nurse did not change the catheter bag or tubing as per the physician's order. Another nurse provided catheter care using only normal saline instead of soap and water, and there was leakage and a brown substance around the catheter. The nurse practitioner confirmed that the catheter should have been changed when clinically indicated, as per the physician's order. Another resident with multiple diagnoses, including diabetes and chronic kidney disease, received catheter care with only normal saline, contrary to the physician's order to use soap and water. The resident's electronic medication administration records (EMARs) showed missing documentation for urine output and failure to change the catheter securement device. The Director of Nursing verified these findings and acknowledged that improper catheter care could lead to UTIs. A third resident with a suprapubic catheter also received care with only normal saline, and the dressing was not changed as required. The EMARs revealed missing documentation for urine output and a missed dose of Bactrim, an antibiotic. The Director of Nursing noted that the failure to administer the medication could have contributed to the resident's UTI. A fourth resident, who was discharged to a hospital and later died, had missing documentation for urine output, and the Director of Nursing suggested that poor catheter care could have contributed to the UTIs and sepsis observed in the residents.
Inadequate Catheter Care Leads to Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide proper catheter care for four residents, leading to deficiencies in their care. Resident R3, who had a history of urinary tract infections, acute kidney failure, and other urinary issues, was observed with a catheter bag and tubing touching the floor, which was against the facility's catheter care policy. Despite R3's complaints of pain and the presence of dark, cloudy urine, the nursing staff did not change the catheter bag or tubing as per the physician's orders. Additionally, the nurse did not use soap and water for catheter care, which was required by the facility's policy, and there was a lack of documentation regarding R3's urine output. Resident R4, diagnosed with diabetes, chronic kidney disease, and urinary tract infections, also received inadequate catheter care. The nurse used only normal saline instead of soap and water to clean the catheter, and there was insufficient hand hygiene during the procedure. The facility's records showed a lack of documentation for urine output and failure to change the catheter securement device as ordered by the physician. These lapses in care were verified by the Director of Nursing, who acknowledged that such failures could lead to urinary tract infections. Resident R2, with a history of diabetes and urinary retention, received improper catheter care as well. The nurse did not use soap and water as required, and there was a failure to change the suprapubic dressing as per the physician's orders. Additionally, there was a lack of documentation for urine output and a missed dose of prescribed medication, Bactrim DS, which was crucial for treating R2's urinary tract infection. The Director of Nursing confirmed these deficiencies and noted a trend of residents developing UTIs and becoming septic, which could be attributed to the poor catheter care provided by the facility.
Linen Shortage in Facility Compromises Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of clean linens, blankets, towels, and washcloths for its 69 residents, compromising their right to a safe, clean, comfortable, and homelike environment. Multiple residents reported a shortage of essential items such as bed pads, wash rags, and Kleenex, with some stating that linens were not changed regularly. Observations confirmed the lack of sufficient linens on the facility's linen carts and in the laundry area, where only a minimal number of sheets, blankets, and other items were available. Staff interviews corroborated the residents' claims, with several CNAs and LPNs acknowledging the shortage and its impact on their ability to provide proper care, such as giving showers and changing bed linens. The Director of Nursing (DON) and other staff members, including the Maintenance Director and Housekeeping Director, were aware of the linen shortage but indicated that no additional supplies had been ordered or purchased. The facility's Laundry Services Policy mandates maintaining a sufficient inventory of clean linen to meet residents' needs, yet this was not adhered to. The DON expressed uncertainty about the availability of funds to address the issue, and staff reported that linens were sometimes disposed of due to being stained, though not intentionally discarded. The lack of a backup supply of linens, blankets, and towels was acknowledged by the facility's Administrator, highlighting a systemic issue in inventory management and resource allocation.
Failure to Notify POA and Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) and physician of changes in condition for a resident with multiple diagnoses, including vascular dementia and schizophrenia. The resident was admitted to the facility with a moderate cognitive impairment and later developed a Deep Tissue Injury (DTI) on the right heel, which was not documented or communicated to the physician or family. The Director of Nursing acknowledged the lack of documentation and notification, which could have led to further complications such as infection or sepsis. The Wound Care Nurse first noticed the DTI on the resident's right heel but did not notify the doctor or apply any protective treatments, only placing socks on the resident. The Nurse Practitioner was unaware of the DTI and the resident's elevated heart rate, which could indicate a progressing infection. The facility's records showed no wound care orders or notifications to the POA or provider regarding the skin alteration, indicating a failure in communication and documentation of the resident's condition changes.
Failure to Provide Wound Care and Manage Vital Signs for Resident with Covid-19
Penalty
Summary
The facility failed to provide necessary wound care treatment and manage abnormal vital signs for a resident diagnosed with Covid-19, vascular dementia, schizophrenia, and other conditions. The resident, who had moderate cognitive impairment, was admitted to the facility and later transferred to the hospital. The Director of Nursing acknowledged that the resident's elevated heart rate was not documented or communicated to a physician or nurse practitioner, which was a deviation from the expected protocol for residents with Covid-19. The Wound Care Nurse identified a deep tissue injury (DTI) on the resident's right heel but did not notify the physician or apply any protective treatments, as the area was not open. The nurse also failed to inform the resident's family or power of attorney about the DTI. The Licensed Practical Nurse who was responsible for the resident's care did not document the elevated heart rate or notify the physician, which could have led to further complications. The Infection Preventionist confirmed that the facility's Covid protocol required vital signs to be taken every four hours and documented every shift, but there was no standard form for Covid screening. The Nurse Practitioner was unaware of the resident's DTI and elevated heart rate, which could have indicated a progressing infection. The facility's protocols for acute condition changes and pressure/skin breakdown were not followed, as there was no documentation or reporting of the resident's condition changes or skin assessments.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 80 residents receiving dietary services. During a kitchen tour, it was observed that the dry storage contained a labeled powder with an outdated label. The walk-in cooler had several unlabeled and undated food items, including personal employee food items, which were not stored according to the facility's policy. The sanitizer solution in a red sanitizing bucket was tested at 400 ppm, exceeding the facility's policy requirement of 200 ppm. Additionally, the kitchen had visible cleanliness issues, such as grease and dust on the stove vents, greasy grime on the metal wall behind the stove, and yellow crusts and dead bugs on shelves containing dishware. Further observations revealed that a dietary aide served a turkey sandwich at 64.8 degrees Fahrenheit, which is above the facility's policy requirement of maintaining perishable foods at 41 degrees Fahrenheit or below. The Dietary Manager acknowledged that food items should be labeled with delivery, open, and use-by dates to prevent foodborne illness. It was also noted that employees' food stored in the kitchen refrigerator must adhere to the same labeling and storage standards. The Assistant Dietary Director was observed with exposed hair, contrary to the facility's policy requiring full hair coverage to prevent contamination.
Failure to Maintain Kitchen Equipment in Good Repair
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the dishwasher and sink, in good repair, affecting dietary services for 80 residents. On December 3, 2024, the Dietary Manager was unable to operate the dishwasher due to it not working, and the adjacent sink was filled with dirty water. The Assistant Dietary Manager confirmed that the dishwasher and sink had been malfunctioning since June, requiring the use of a shop vac to remove water from the sink. Dishes were either washed in a three-compartment sink or served on disposable plates. Observations revealed that shelves containing dishware, declared clean, were caked with yellow crusts, dried food, and small dead black bugs. The Maintenance Director, who had been with the facility for a month, stated that the dishwasher had been repaired, but the drainage problem persisted, preventing its use. The Administrator did not have records of repair quotes or work orders dating back to June but approved repairs for the floor to be dug up and pipes replaced on December 4, 2024. Previous work requests and service requests indicated ongoing issues with the dishwasher and drainage system, with some repairs pending approval or completion. The facility's policies on equipment maintenance and sanitation were not adhered to, as evidenced by the unsanitary conditions and malfunctioning equipment.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their families or Power of Attorney (POA), and the ombudsman regarding the reasons for hospital transfers. This deficiency was identified in six residents who were transferred to the hospital for various medical conditions, including sepsis, gastrointestinal bleeding, syncope, chest pain, worsening confusion, and urinary tract infections. Despite verbal notifications to some family members, there was no documentation of written notices provided to the residents, their POAs, or the ombudsman. For instance, one resident with severe cognitive impairment was transferred to the hospital for sepsis and a gastrointestinal bleed. Although the resident's daughter was verbally informed of the transfer, there was no written notice provided. Similarly, another resident with severe cognitive impairment was transferred for syncope, and while the family was verbally informed, no written documentation was provided. In another case, a resident experiencing chest pain was transferred to the hospital, and although the POA was notified by voicemail, there was no written notice documented. The facility's failure to provide written notifications is a violation of their Bed Hold and Readmission policy, which requires informing residents or their representatives of the policy at the time of admission and transfer. The policy also mandates written notification at the time of transfers, which was not adhered to in these cases. The facility's administration acknowledged the lack of written documentation and the omission of notifying the ombudsman.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the bed hold policy at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for six residents who were reviewed for discharge. The facility's policy requires that residents or their designated representatives be informed of the bed hold policy at the time of admission and at the time of transfer to a hospital or for therapeutic leave extending beyond 24 hours. However, the facility did not provide the required documentation to the residents or their Power of Attorney (POA) at the time of their hospital transfers. For instance, one resident with multiple diagnoses, including multiple sclerosis and dementia, was transferred to the hospital for evaluation due to a change in condition. Despite the transfer, there was no documentation of the bed hold policy being communicated to the resident or their POA. Similarly, another resident with severe cognitive impairment was transferred to the emergency room for evaluation, but again, no bed hold documentation was provided. This pattern was consistent across all six residents reviewed, indicating a systemic issue in the facility's adherence to its own policy. The facility's Bed Hold and Readmission Policy, dated November 2016, outlines the requirement for written notification of the bed hold policy to be provided at the time of transfer. However, interviews with the facility's Administrator and Director of Nursing revealed that they were not providing this written documentation to residents, families, or the ombudsman when residents were sent to the hospital. This lack of compliance with the policy resulted in the deficiency noted in the report.
Medication Storage and Physician Order Deficiencies
Penalty
Summary
The facility failed to obtain physician orders for over-the-counter medications and allowed medications to be stored in resident rooms without proper authorization. This deficiency was observed in six residents, each with varying medical conditions and cognitive statuses. For instance, one resident with glaucoma had a bottle of eye vitamin and mineral supplement in their room without a physician's order. Another resident with chronic obstructive pulmonary disease had Nystatin topical powder on their bedside table, despite having a physician's order for its use, there was no order permitting the medication to be stored in the room. In another case, a resident with dementia had two bottles of eye drops on their bedside dresser, which they used daily, but there was no physician's order for these specific eye drops, nor permission for them to be stored in the room. Additionally, a resident with Parkinson's disease had a nasal spray in their room, which they used, but again, there was no order allowing the medication to be stored in the room. Another resident with morbid obesity and major depressive disorder had Nystatin powder and Terconazole vaginal cream on their bedside table without an order for room storage. The facility's Director of Nursing stated that residents must be alert and oriented to have medications stored in their rooms, requiring an assessment and a physician's order. However, this protocol was not followed, as evidenced by a resident with dementia who had a nasal spray in their room without any orders for self-administration or storage. The facility's policy mandates that medications be stored securely and only accessible by authorized personnel, which was not adhered to in these instances.
Infection Control Deficiencies in PPE and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to standard infection control practices, as evidenced by multiple instances of improper hand hygiene and personal protective equipment (PPE) usage. A Certified Nurse's Assistant (CNA) was observed providing incontinence care to a resident without changing gloves or cleaning hands after handling soiled items, which is against the facility's hand hygiene policy. Similarly, a nurse failed to use the required PPE, such as a face shield or N95 mask, when entering rooms of residents under contact and droplet precautions for COVID-19. The nurse also improperly disposed of PPE in the hallway instead of in the resident's room, and continued to wear the same mask while attending to other residents. In another instance, a wound care nurse did not change gloves or perform hand hygiene between different stages of wound care, potentially leading to cross-contamination. This was observed during wound care for multiple residents, including those with COVID-19 and other serious health conditions. The nurse also placed clean wound care supplies on potentially contaminated surfaces without using a barrier, further violating infection control protocols. Additionally, there was a lack of proper disposal facilities for PPE in rooms, leading to improper disposal practices. The facility's policies on hand hygiene and transmission-based precautions were not followed, as evidenced by the lack of signage for Enhanced Barrier Precautions (EBP) and improper handling of PPE. Residents with serious health conditions, such as chronic wounds and COVID-19, were not adequately protected due to these lapses in infection control. The facility's failure to implement and adhere to its own policies contributed to the deficiencies observed during the survey.
Deficiency in Providing ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for five residents who were dependent on staff assistance. Observations revealed that several residents had long, jagged fingernails, dry flaking skin, and in some cases, a brown substance under their nails. These residents, including those with severely impaired cognition and those requiring moderate assistance, did not receive the necessary personal hygiene care. For instance, one resident was observed with long nails and dry skin, despite being dependent on staff for personal hygiene, and another resident had not received a shower or bed bath in over a month due to staffing issues. The Director of Nursing (DON) acknowledged that nail and skin care should be provided as needed, and there was no documentation of residents refusing care. The facility's policy on ADL care, which includes hygiene, bathing, dressing, grooming, and oral care, was not adhered to, leading to the observed deficiencies. The lack of proper care was attributed to insufficient staffing, as noted by a resident who expressed frustration over not receiving regular hygiene care.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for four residents identified as high risk for falls. One resident was observed standing next to his bed with his wheelchair out of reach and wearing only socks that were not non-skid, despite a care plan indicating the need for proper footwear. Another resident was found in bed without fall mats on the floor, contrary to the care plan that required mats to be in place when the resident is in bed. The Director of Nursing confirmed that these interventions should have been in place. Additionally, a resident with multiple diagnoses, including hemiplegia and cognitive deficits, was observed wearing regular socks without skid protection and without shoes, with staff unaware of the fall interventions in place for him. Another resident with severely impaired cognition had a floor mat placed four feet away from his bed, which was not repositioned after being moved by a CNA. The facility's policy requires staff to identify and implement relevant interventions to minimize the risk and consequences of falls, which was not adhered to in these cases.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R5 and R10, as per their physician's orders. R5 was observed on two occasions with oxygen administered at 2 liters per minute through a nasal cannula, despite the physician's order indicating a requirement for 4 liters per minute continuously with 100% humidity. This discrepancy was confirmed by the Director of Nursing (DON) upon reviewing R5's electronic health records. Similarly, R10 was found with his nasal cannula around his neck instead of in his nostrils, and it was not corrected until a state surveyor pointed it out. The staff member, V6, expressed uncertainty about how long R10 had been without oxygen, and the situation was later trivialized by V6 and a nurse, V9, who laughed about the oversight. R10's physician's order specified the use of a nasal cannula at 2 liters per minute as needed for shortness of breath every shift. The DON acknowledged the expectation for nurses to ensure the correct administration of oxygen, including verifying the rate and placement of the nasal cannula.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly for two residents, leading to a deficiency in resident care. One resident, who has diagnoses including metabolic encephalopathy, dementia, and is at high risk for falls, reported that her call light had not been working for some time. She relied on her roommate to call for assistance, as her own call light did not activate when tested by the surveyor. Despite informing staff about the issue, the call light remained non-functional, and the resident's care plan emphasized the need for a working call light due to her dependency on staff for personal care and hygiene. Another resident, with conditions such as diabetes mellitus and an acquired absence of the right leg below the knee, also lacked access to a functioning call light. His call light was found to be cut short and unavailable for use, forcing him to physically seek assistance by moving down the hallway. The staff, including a CNA and the DON, acknowledged the resident's need for a call light, but it remained unavailable during the survey period. This deficiency highlights the facility's failure to maintain an accessible and operational call light system for residents, compromising their ability to request assistance when needed.
Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to properly position a resident's indwelling catheter bag during a wound care dressing change. The catheter drainage bag was placed on the bed instead of below the bladder, leading to backflow of urine in the catheter tubing. The resident, who had a suprapubic indwelling catheter, was diagnosed with multiple conditions including spinal stenosis, pressure ulcers, quadriplegia, and a history of urinary tract infections (UTIs). The facility's policy requires the catheter drainage bag to be positioned lower than the bladder to prevent backflow and potential UTIs. Additionally, the facility did not provide timely incontinent care to several residents. One resident was observed with a heavily soiled brief and had been trying to get assistance since early morning. Despite turning on the call light, the resident did not receive timely care, and a CNA acknowledged the delay. The Director of Nursing confirmed that delayed incontinent care could lead to UTIs and skin infections. Other residents were also found with urine-soaked briefs, indicating a lack of timely incontinent care. CNAs admitted to being busy with other residents and not being able to provide care every two hours as required. The facility's protocol mandates scheduled toileting and incontinent care every two hours, but this was not consistently followed, leading to deficiencies in resident care.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a physician of a resident's change in condition, specifically for one resident who experienced vomiting and diarrhea. On the evening of August 30, 2024, the resident began vomiting and having diarrhea, which continued until the following morning. A CNA reported these episodes to a nurse, who did not recall notifying the resident's doctor. The nurse practitioner and physician were also unaware of the resident's condition, which would have prompted them to order lab tests and medication. The facility's guidelines require immediate notification of a physician when there is a significant change in a resident's condition. However, there was no documentation in the resident's progress notes indicating that the physician or nurse practitioner was informed. The Director of Nursing and the Administrator were also unaware of the resident's condition, which was not documented in the electronic health record beyond a large bowel movement. This lack of communication and documentation led to a failure in following the facility's notification procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Crete
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of Chicago Heights | 3.9 mi | ★★★★★ | 2 | 0 |
| Great Lakes Healthcare Center | 4.8 mi | ★★★★★ | 34 | 0 |
| Ignite Medical Resort Dyer Llc | 5 mi | ★★★★★ | 4 | 0 |
| Aperion Care Chicago Heights | 5.2 mi | ★★★★★ | 12 | 0 |
| Dyer Nursing And Rehabilitation Center | 5.5 mi | ★★★★★ | 8 | 0 |
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