Above 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 Thrive Of Fox Valley during CMS and state inspections, most recent first.
Failure to Maintain Clean Resident Rooms: Housekeeping staff and the EVS Director stated resident rooms should be cleaned daily, but staff reported short staffing and missed rooms when discharges and other duties took priority. Three residents reported their rooms were not cleaned every day, and surveyors observed crumbs, debris, trash, a puddle of water, wet wipes on the floor, and a dirty bathroom sink with visible stains. The facility policy stated resident rooms are cleaned daily.
A resident with new-onset cardiomyopathy requiring a LifeVest cardiac monitor was readmitted and later discharged without physician orders or care plan focus for device management, and without documented discharge teaching on cardiac monitoring, device care, complications, or cardiology follow-up. Nursing staff acknowledged forgetting to enter cardiac monitoring orders, assuming other staff changed the battery and that the resident knew how to manage the device. The discharge form only noted that the resident left with the cardiac vest, while facility policies and its cardiopulmonary program description required documented education, equipment management instructions, and discharge teaching for such devices.
A resident with cellulitis, chronic lymphedema, and a documented risk for skin impairment did not receive ordered skin assessments and treatments. Despite an active order for Nystatin powder to treat a fungal rash under the breast and a care plan directing staff to evaluate and treat skin conditions, ETAR review showed multiple missed Nystatin administrations, and the resident had already filed a medication concern about not receiving this treatment. The resident also reported that an RN did not assess or treat a newly developed open wound on the left thigh, which was later identified by the WCN as a facility-acquired abrasion with serosanguinous drainage. The WCN stated that nurses were expected to assess new skin issues, notify the physician, and follow treatment orders in line with the facility’s wound management policy.
A resident with chronic renal failure, high fall risk, and dependence for transfers was being transported in a wheelchair by a CNA after hemodialysis when the CNA suddenly stopped, causing the resident to fall forward out of the wheelchair. A RN witness and the resident reported that the wheelchair had no footrests in place, despite therapy recommendations and facility policy requiring footrests and safe, controlled transport. The resident sustained multiple lacerations and abrasions and was sent to the hospital for evaluation.
A resident with chronic pain syndrome and acute leg pain from cellulitis had an active PRN order for Norco and a care plan requiring staff to anticipate and promptly respond to pain complaints, yet her request for pain medication around the evening meal was not fulfilled for several hours. Call light records and CNA statements showed the resident repeatedly called for assistance and the CNA repeatedly notified an RN, but the medication was not administered until late that evening after another nurse reportedly lacked access to the drug. The EMAR confirmed the delayed administration time, and the DON stated that nurses were expected to provide pain medications as ordered upon request in accordance with the facility’s pain management policy.
Two residents did not receive appropriate care: one with a cholecystostomy drain was not assessed or monitored by staff, and the dressing from the hospital was left unchanged and undated. Another resident did not receive timely assistance with wet bed linens and incontinence care, despite multiple requests and use of the call light system. Staff failed to follow facility policies for wound care and call light response, and documentation did not accurately reflect the residents' needs or interventions provided.
A resident with a history of pulmonary embolism and TIA experienced an unwitnessed fall while on a blood thinner. The facility's policy required regular neuro-checks after such incidents, but records showed only one check was completed after the initial evaluation. The on-call physician noted that checks should have been conducted throughout the night to monitor for head injuries, indicating a failure to adhere to the facility's protocol.
The facility failed to resolve grievances about extended call light response times, as reported by residents during multiple meetings. Despite training sessions for staff, residents continued to experience delays, particularly during night and weekend shifts. Three residents reported significant wait times, impacting their care and comfort. The facility's grievance policy was not effectively implemented, as evidenced by ongoing complaints and inadequate documentation of resolutions.
Two residents in an LTC facility experienced delays in medication administration, contrary to facility policy. One resident, with multiple diagnoses, had medications administered late on consecutive days without prescriber notification. Another resident reported concerns about late pain medication, which was administered over four hours late without prescriber contact. The DON confirmed the expectation for nurses to notify prescribers of such delays.
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition. Expired and unlabeled items were found, and the Dietary Manager admitted to lacking a food storage policy, contributing to the oversight.
The facility failed to accommodate the needs of two residents by not providing a functioning over bed light and an adaptive call/light button. A resident with paralysis and macular degeneration was unable to use the standard call light, and another resident experienced issues with a broken over bed light that could not be turned off. Staff did not follow procedures to ensure call lights were within reach or report maintenance issues promptly.
A resident with multiple health issues, including a fractured arm and malnutrition, did not receive timely incontinence care, resulting in saturated clothing and bedding. The resident, who requires substantial assistance with daily activities, reported not receiving care since the previous night. The facility's policy mandates care every two hours, which was not followed, as confirmed by the DON.
The facility failed to administer medications as prescribed for two residents. One resident did not receive her Trospium for urinary incontinence for eight days, despite it being listed on her hospital discharge documents. The pharmacy sent an alternative medication, which the resident refused. Another resident did not receive his glaucoma eye drops for two days, requiring his wife to bring the medication from home. The DON acknowledged these as medication errors, and the facility's policy lacked a process for timely medication availability.
The facility failed to provide safe respiratory care for three residents. A resident with COPD and asthma had a CPAP mask not stored properly, while another with asthma had a nebulization mask left uncovered. A third resident with COPD and CHF also had improperly stored respiratory equipment. The DON confirmed that equipment should be rinsed, air-dried, and stored in a designated bag, as per facility policy.
Two residents in the facility did not receive their prescribed intravenous antibiotics as ordered, resulting in significant medication errors. One resident, treated for MRSA bacteremia, did not receive the correct vancomycin IV dosage and frequency, while another resident missed several doses of cefazolin IV for a hand infection. The facility's policies on medication administration were not adhered to, leading to these deficiencies.
A resident with an ileostomy experienced frequent leaks from the ostomy appliance, leading to skin irritation and burning sensations. Despite staff awareness of the issue, the wound nurse was not consistently notified, and there were no specific ostomy care orders documented. The facility's standard of care, which includes regular evaluation and documentation of skin conditions, was not followed, resulting in a deficiency.
Failure to Maintain Clean Resident Rooms
Penalty
Summary
The facility failed to maintain a clean environment for residents in 3 of 5 sampled residents, including R1, R2, and R3. Multiple housekeepers and the Environmental Services Director stated that resident rooms should be cleaned daily, but staff also reported being short-staffed, with only two housekeepers on the floor at times, one laundry staff member, and missed rooms when discharges and other responsibilities took priority. Staff stated they did not have time to clean every room, and resident council minutes documented a resident complaint that housekeeping did not come every day. R1, who was admitted with diagnoses including pneumonia, acute respiratory failure with hypoxia, COPD with acute exacerbation, anemia in CKD, type 2 DM, and a history of TIA/CVA without residual deficits, stated his room had not been cleaned since Friday and was not cleaned every day. Surveyors observed crumbs and debris around his bed, a full garbage can, a band-aid wrapper and white plastic tab on the floor, and another piece of plastic in the walkway between his bed and R2's bed. Later in the day, the same debris remained in the room and R1 again stated no one had come to clean it. R2, who was cognitively intact and admitted with diagnoses including cerebral infarction, weakness, ataxia, dysphagia, dysarthria/anarthria, need for personal care assistance, and type 2 DM, stated housekeeping did not clean his room every day. Surveyors observed crumbs and debris by his bed, a white cap on the floor, a puddle of water under and beside his wheelchair after medication was given, a bag of wet wipes on the floor, and a wet wipe under the wheelchair. R3, who had moderately impaired cognition and diagnoses including COPD with acute exacerbation, repeated falls, epilepsy, muscle weakness, osteoarthritis, interstitial pulmonary disease, and chronic respiratory failure, stated his room was not cleaned daily and had not been cleaned over the weekend. Surveyors observed extensive crumbs and debris on the floor, a brown streak on the floor, pieces of plastic, and a dirty bathroom sink with white chalky substance and brown stains around the bowl and on the top of the sink. The facility policy stated resident rooms are cleaned daily.
Failure to Provide Discharge Education and Orders for Cardiac Vest Monitor
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary discharge education and related documentation for a resident using a cardiac vest monitor. The resident was admitted with multiple diagnoses, including new onset cardiomyopathy requiring a LifeVest wearable cardioverter-defibrillator, and was cognitively intact and able to follow instructions. During the resident’s readmission, the RN who routinely cared for him acknowledged she forgot to enter cardiac monitoring orders, even though such orders were needed to ensure the monitor was checked every shift and its battery changed daily. The EMR and order summary for the readmission did not contain orders for cardiac vest care, and the comprehensive care plan, while addressing discharge planning, did not include a focus problem for the new cardiac condition or management of the cardiac vest. The ADON later confirmed that the EMR did not identify which cardiologist was managing the device and that there were no nursing management orders for the device, despite the resident being admitted to the facility’s Cardiopulmonary Program. At discharge, the RN who discharged the resident stated that the resident left with the cardiac vest in place, along with the charger and extra battery, but there were no active orders for device management, and she assumed the overnight nurse had changed the battery and that the resident knew how to care for the monitor. She did not provide specific instructions on cardiac monitoring, device care, cardiac complications, cardiology follow-up, or who to contact for device issues, and the Transition Home discharge form only noted that the resident was discharged with a cardiac vest monitor without documenting any specific discharge nursing instructions. The facility’s own Specialized Cardiopulmonary Program description stated that it would provide education and resources to help patients manage their disease and determine equipment needs and education at discharge, and its Wearable Cardioverter-Defibrillator and Discharges policies required documentation, specific care instructions, and teaching on special tasks at discharge. The resident was later seen in the ER with bilateral lower extremity edema and reported that the LifeVest was not working due to battery complications, and the ER documentation indicated he was educated there on contacting the device company and monitoring for cardiac complications.
Failure to Assess and Treat Resident Skin Conditions as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to assess and treat a cognitively intact resident’s skin conditions as ordered and as care planned. The resident had a care plan identifying actual skin impairment and risk for further skin breakdown related to left lower leg cellulitis and chronic lymphedema, with interventions directing nursing staff to evaluate and treat her skin as ordered. The EMR showed an active order for Nystatin powder to be applied under the breast twice daily and wound consults as needed. The resident reported that on the evening of 3/26/2026 she requested an RN to assess a new open wound on her left anterior thigh, but the RN did not assess or treat the wound, leaving it untreated and uncovered. She also reported that her ordered antifungal powder for a rash under her left breast was routinely not administered. Record review and staff interviews confirmed multiple omissions in the administration of Nystatin powder on several dates, despite the resident’s Medication Concern form documenting her complaint about not receiving this treatment. When the wound care nurse later assessed the resident, she identified a new open wound on the left thigh measuring 3 x 0.4 x 0.1 cm with serosanguinous drainage, and confirmed that the fungal rash under the left breast still required ongoing treatment as ordered. The wound was documented as a facility-acquired trauma wound (abrasion) with 100% bright pink/red tissue and serosanguinous drainage. The wound care nurse stated that nurses were expected to assess new skin alterations, notify the physician to obtain and initiate treatments, and review ETARs to ensure treatments were administered as ordered, consistent with the facility’s wound management policy that emphasizes comprehensive wound care and staff accountability.
Failure to Use Wheelchair Footrests and Safe Transport Techniques Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to safely transport a high fall-risk resident in a wheelchair, resulting in a fall with multiple lacerations. The resident had chronic renal failure requiring hemodialysis, unsteadiness on his feet, reduced mobility, need for assistance with personal care, and glaucoma, and was assessed as cognitively intact but dependent for transfers and lower body care. A fall risk evaluation identified him as high risk for falls. On the day of the incident, after returning from dialysis, a CNA was wheeling the resident down the hallway when she suddenly stopped, causing the resident to fall forward out of the wheelchair. The resident reported that there were no footrests on the wheelchair at the time, and he sustained abrasions and lacerations to his knees, elbows, and scalp and was transferred to the hospital for evaluation. Witness accounts and documentation confirmed that the wheelchair was not used in accordance with facility safety expectations. A RN who observed the event stated that the CNA abruptly stopped while transporting the resident, that the resident then fell forward onto his left side, and that there were no footrests present, which she said should have been used for proper positioning and safe transport. A physical therapist assistant stated that the resident required a wheelchair due to generalized fatigue, needed staff assistance for wheelchair mobility, and required the use of footrests, noting that he had not shown poor safety noncompliance with wheelchair use. The facility’s policies on fall prevention and transfers required that residents receive adequate supervision and assistive devices to prevent accidents, that transfer ability be determined per evaluation or therapy recommendations, and that footrests be used for transport or, if not, that transport be done slowly. The incident occurred when these measures were not followed, leading to the resident’s fall.
Failure to Timely Administer PRN Opioid for Resident’s Reported Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide timely PRN pain medication to a resident with chronic pain syndrome and acute leg pain from cellulitis. The resident’s care plan identified a potential for pain and included interventions such as administering opioid medication as ordered, anticipating her need for pain relief, and responding immediately to any complaint of pain. The resident’s MDS indicated she was cognitively intact, and her EMR showed an active order for Norco 10-325 mg, one tablet every six hours as needed for pain. On the evening in question, the resident reported that she requested Norco at around 6 PM but did not receive it until approximately 9:30 PM. She stated that a CNA responded to her call light multiple times, each time reporting that the RN had been notified, while the resident continued to experience chronic and acute pain. The call light log documented six calls between 6:06 PM and 9:13 PM. The CNA confirmed that the resident requested pain medication around 6 PM and that she repeatedly notified the RN of the ongoing requests. The RN reported that another nurse had attempted to administer the medication but did not have access to it, and she was unsure when she was first notified of the resident’s request. The EMAR showed the PRN Norco was administered at 9:26 PM, and the DON stated that nurses were expected to administer pain medications as ordered upon request, consistent with the facility’s pain management policy.
Failure to Monitor Cholecystostomy Drain and Provide Timely Resident Assistance
Penalty
Summary
The facility failed to properly assess, monitor, document, and care plan for a resident with a cholecystostomy drain. The resident was observed with a cholecystostomy drainage bag and an incision site covered by a hospital-applied dressing that had not been changed or assessed by facility staff since admission. The dressing was undated and showed a dried area of drainage. The resident and her son confirmed that the dressing had not been changed since the hospital, and the LPN on duty was unaware of any dressing change orders or requirements to monitor the insertion site. The resident's admission assessment and progress notes incorrectly documented that she did not have a surgical drain, and her care plan lacked interventions for monitoring or caring for the cholecystostomy drain. Physician orders were unclear regarding site care, and the nurse consultant was uncertain about the specifics of the order, indicating a lack of clarity and follow-through in care planning and execution. Another deficiency involved the facility's failure to provide timely assistance to a resident requiring staff help with activities of daily living and incontinence care. The resident reported that after spilling water on her bed, she used her call light for assistance, but staff did not change her wet linens for several hours despite multiple requests. The call light was turned off without the resident's needs being met, and assistance was only provided after the resident's son intervened. The resident also requested that her roommate, who had an incontinence episode, receive help first, indicating a broader issue with staff responsiveness. The facility's policies require staff to assess wounds, monitor for infection, and respond to call lights promptly, but these were not followed in the cases reviewed. The DON confirmed that staff are expected to answer call lights within 10-15 minutes and not to turn them off until the resident's needs are met. However, documentation and interviews revealed that these expectations were not met for the residents involved, resulting in unmet care needs and lack of appropriate monitoring and documentation.
Failure to Conduct Regular Neuro-Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that a resident's neurological evaluations were completed and monitored following an unwitnessed fall. The resident, who had a history of pulmonary embolism and transient ischemic attack, experienced an unwitnessed fall while on a blood thinner. The facility's policy required neuro-checks to be conducted regularly after such incidents, but the resident's records showed that only one neuro-check was completed after the initial evaluation. The on-call physician stated that neuro-checks should have been conducted throughout the night at specific intervals to monitor for potential head injuries. However, the facility's records indicated that the neuro-checks were not performed as required by the facility's protocol, which could have helped identify signs of a head injury, such as brain bleeding or intracranial pressure. This deficiency was identified during a review of the resident's care, highlighting a lack of adherence to the facility's neurological assessment policy.
Failure to Resolve Call Light Response Time Grievances
Penalty
Summary
The facility failed to address and resolve grievances related to extended wait times for call light responses, as voiced by residents during multiple Resident Council meetings. Despite the concerns being communicated to the Director of Nursing and Administration, and a training session being conducted for nursing staff, residents continued to report dissatisfaction with the response times. The grievances were documented in Resident Council Meeting Minutes over several months, indicating a persistent issue that was not adequately resolved. Three residents, identified as R1, R2, and R4, expressed specific concerns about the timeliness of call light responses, particularly during night and weekend shifts. R1 reported waiting at least 30 minutes, resulting in an incident where she urinated on herself due to the delay. R2 mentioned waiting for an hour for assistance during the night shift, and R4 described a similar experience while needing medication for a migraine. These residents had various medical conditions requiring assistance with activities of daily living (ADLs), making timely responses critical. The facility's grievance log showed that R1's daughter filed a grievance about the call light issue, but the documentation lacked a timely resolution. The facility's policy on grievances emphasized prompt resolution and tracking of grievances for quality improvement, yet the ongoing complaints and lack of documented resolutions suggest a failure to adhere to this policy. The facility's inaction in effectively addressing the grievances led to continued dissatisfaction among residents regarding call light response times.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications timely in accordance with its policy, affecting two residents. Resident R4, who was admitted with multiple diagnoses including Guillain-Barre Syndrome and West Nile virus, was cognitively intact and dependent on staff for activities of daily living. The Medication Administration Audit report showed that R4's medications scheduled for 9:00 AM on two consecutive days were administered significantly late, with no notification to the prescriber about the delays. R4's wife expressed concern about the late administration of medications. Resident R2, who was cognitively intact and had multiple diagnoses including spinal stenosis and diabetes, also experienced late medication administration. R2 reported concerns about the timeliness of her pain medication. The Medication Administration Audit report indicated that R2's scheduled 9:00 AM medication was administered over four hours late, with no documentation of prescriber notification or guidance on the next dose. The Director of Nursing confirmed that it is expected for nurses to contact the prescriber when medications are administered late.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition from the facility. During a kitchen tour, several expired food items were found, including feta cheese, cheese ravioli, chopped spinach, Eggo frozen waffles, various types of bread, pepperoni, pizza sausage, Boston cream pie, frozen cranberries, white corn grits, chicken and herb stuffing, and [NAME] crumbs. These items were either past their expiration dates or lacked proper labeling, such as received or expiry dates. The Dietary Manager, identified as V9, acknowledged that expired items should be discarded to prevent potential harm to residents. However, V9 admitted to not having a policy on food storage, which contributed to the oversight. The facility's census was 57 residents, with no residents on NPO status, indicating that all residents were potentially affected by the improper food storage practices.
Failure to Accommodate Resident Needs and Address Maintenance Issues
Penalty
Summary
The facility failed to accommodate the needs of two residents, R26 and R31, by not providing a functioning over bed light and an adaptive call/light button. R26, who has a range of medical conditions including paralysis of the hands and macular degeneration, was unable to use the standard call light due to her physical limitations. Despite her cognitive intactness, as indicated by a BIMS score of 15, R26 reported that her call light was often out of reach and that she had waited up to three hours for assistance. Her family member confirmed her inability to activate the call light due to neuropathy and macular degeneration. The facility had alternative call devices available, but they were not provided to R26, indicating a lack of awareness or assessment of her specific needs by the staff. R31, another resident, experienced issues with a broken over bed light that could not be turned off, which affected her ability to rest. The light fixture had been broken since shortly after her admission, and staff had placed a sheet over it as a temporary solution, which posed a potential fire hazard. The RN responsible was unaware of the issue, and no repair requisition was made until it was reported to the Director of Environmental Services, who stated that the repair would have been quick if notified. The facility's policies require staff to ensure call lights are within reach and to report maintenance issues promptly, but these procedures were not followed, leading to the deficiencies observed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R26, who was admitted with multiple diagnoses including a displaced comminuted fracture of the right arm, moderate protein calorie malnutrition, and intrahepatic bile duct carcinoma. On the morning of July 23, 2024, R26 reported that she required assistance with all activities of daily living but felt that the staff was not fully aware of her care needs. She stated that she had not received incontinence care since the previous night, and the first staff member she saw was at 10:40 AM. Upon the surveyor's request, incontinence care was provided at 11:56 AM, revealing that R26's gown, disposable undergarment, absorbent bed pad, transfer sheet, and bottom sheet were saturated with urine. Additionally, R26 exhibited pink blanchable skin on several areas and a non-blanchable area on her left buttock. The facility's Director of Nursing confirmed that incontinence care should be provided every two hours and as needed to prevent skin breakdown and urinary tract infections. The last incontinence care provided to R26 was at 7:15 AM, indicating a significant lapse in care. R26's Minimum Data Set (MDS) showed she was cognitively intact and required substantial assistance with toileting due to impaired mobility and weakness. Her care plan specified the need for assistance with toileting and cleaning the peri area with each incontinent episode. The facility's policy stated that care should be provided according to the resident's individualized care plan, which was not adhered to in this instance.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications according to physician's orders and resident preferences for two residents. One resident, who had been admitted to the facility about eight days prior, did not receive her prescribed Trospium 20 mg for urinary incontinence. Despite the medication being listed on her discharge documents from the hospital, the facility did not have the medication available, and the pharmacy sent an alternative medication, Oxybutynin, which the resident refused. The facility's records showed multiple instances where the medication was noted as 'not available,' and the resident continued to go without her prescribed medication. Another resident did not receive his prescribed eye drops for glaucoma for two days. His wife had to bring the medication from home for the facility to use. The facility's records indicated that the eye drops were not available, and the resident's MAR showed the medication was not administered on a specific date. The DON acknowledged that the failure to provide the medication was a mistake on the part of the nurse and classified it as a medication error. The facility's policy on medication administration did not include a process for ensuring medications are available to residents on time.
Failure to Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents, as observed during a survey. Resident 15, who has diagnoses including Chronic Obstructive Pulmonary Disease and Asthma, was found with a CPAP mask and tubing not in use and not contained in a bag on two separate occasions. The physician's orders required the CPAP/BiPAP to be used at bedtime and for the mask to be cleansed and air-dried after removal. Similarly, Resident 20, diagnosed with asthma and anxiety, had a nebulization mask and medication container left uncovered on the bedside table, contrary to the physician's orders for inhalation treatment every four hours as needed. Resident 265, with Chronic Obstructive Pulmonary Disease and Congestive Heart Failure, was also observed with a CPAP mask and tubing not in use and not contained in a bag, and a nebulization mask and medication container left uncovered on the nightstand. The physician's orders for this resident included CPAP/BiPAP use at bedtime and cleansing of the mask, as well as inhalation treatment every eight hours as needed. The Director of Nursing confirmed that the equipment should be rinsed, air-dried, and stored in a designated bag to prevent contamination, as per facility policy.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to administer ordered intravenous antibiotics for two residents, leading to significant medication errors. Resident R3, who was being treated for MRSA bacteremia, did not receive the correct dosage and frequency of vancomycin IV as ordered. The pharmacist, responsible for dosing the medication, noted that R3's therapeutic blood levels were not within the target range, indicating nontherapeutic treatment. Despite recommendations to adjust the dosage, the facility did not implement these changes, resulting in R3 not receiving the appropriate treatment for his infection. Similarly, Resident R44, who was being treated for an acute osteomyelitis infection of the right hand, missed several scheduled doses of cefazolin IV. The EMAR showed omissions on specific dates, indicating a failure to administer the medication as ordered. The facility's policies on medication administration and physician's orders emphasize the importance of administering medications as prescribed, yet these were not followed, leading to the deficiencies observed.
Failure to Provide Adequate Ostomy Care
Penalty
Summary
The facility failed to provide appropriate ostomy care for a resident, leading to skin irritation around the stoma site. The resident, a male with multiple diagnoses including end-stage renal failure and ileostomy status, experienced frequent leaks from his ostomy appliance. Staff members, including RNs, LPNs, and CNAs, reported that the appliance would often leak two to three times per shift, causing stool to come into contact with the resident's skin, resulting in burning sensations and raw skin. Despite these issues, the wound nurse was not consistently notified, and there were no specific ostomy care orders documented for the resident. The facility's standard of care requires documentation of skin conditions around the stoma and notification of the wound nurse in case of skin breakdown. However, these protocols were not followed, as evidenced by the lack of ostomy care orders and the failure to report ongoing skin irritation to the wound nurse. The resident's physician noted problems with the ostomy leaking and recommended adjustments to minimize skin exposure, but these recommendations were not reflected in the resident's care plan or treatment orders. The facility's policy on ostomy care, which includes regular evaluation and documentation of skin conditions, was not adhered to, contributing to the deficiency.
What surveyors are citing around you — mapped
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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 964 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Patrick's Residence | 2.4 mi | ★★★★★ | 4 | 1 |
| Meadowbrook Manor - Naperville | 2.5 mi | ★★★★★ | 8 | 0 |
| Tabor Hills Health Care Fac | 2.9 mi | ★★★★★ | 0 | 0 |
| Alden Of Waterford | 3 mi | ★★★★★ | 5 | 0 |
| Alden Courts Of Waterford | 3.1 mi | ★★★★★ | 12 | 1 |
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