Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thryve Of Crestwood during CMS and state inspections, most recent first.
Medication administration was not properly documented for two residents. One resident with intact cognition reported potassium had been missed earlier but received that morning, yet the MAR had blank entries for multiple scheduled meds and no nursing note documented whether they were given or not. Another resident’s MAR showed eye drops marked with a code meaning 'see Nurses note,' but no progress note explained whether the meds were administered or omitted, and the DON/Administrator could not confirm what occurred.
A facility failed to provide ADL assistance for several residents who were dependent for transfers and, for one resident, failed to provide eating assistance. One resident reported not being taken out of bed for weeks because a wheelchair was missing, another said staff did not get the resident up in time for lunch, and a third was observed in bed with lunch out of reach and no staff present to assist. Interviews and record review showed the residents were dependent for transfers, and staff acknowledged the lack of documentation for refusals or attempts to get residents up.
Infection control failures involved a resident on contact precautions for C. diff and another resident who should have been on EBP for a G-tube and wounds. An RN entered the C. diff resident’s room without gown, gloves, or hand hygiene, then continued medication pass without hand hygiene. Housekeeping used non-sporicidal products for C. diff rooms, no C. diff-killing cleaner was initially identified, and soiled linen was found unsecured in the laundry chute and receiving bin. A second resident had no precaution sign or PPE setup despite an EBP order.
Failure to Post Required Complaint Posting: The facility did not post the State Survey Agency's name, address, phone number, or the required statement telling residents they may file complaints about suspected abuse, neglect, exploitation, or misappropriation of property. A cognitively intact resident stated the number was not posted anywhere, and a tour of resident areas, elevators, bulletin boards, and the main entrance did not find the required information. The Administrator and Social Services Director both acknowledged the posting should be available to residents.
Food storage and kitchen sanitation deficiencies were identified when surveyors observed expired and undated food items, dirty scoops, and improperly labeled dry goods in storage. The kitchen and dry storage areas had heavy grease, dirt, food debris, stained ceilings, dirty equipment surfaces, damaged walls and flooring, and a suspected mold-like substance. The Dietary Manager and Cook confirmed many of the unsanitary conditions, and the exhaust hood was reported to be functioning poorly.
Improper Garbage Storage and Smoking Area Housekeeping: The facility failed to keep garbage and refuse contained in dumpsters and failed to maintain the garbage storage area in a sanitary condition. Observations with the Housekeeping/Laundry Manager found food wrappers, soiled gloves, rotting cardboard, cigarette butts, broken medical equipment, wood, fabric, siding, PVC piping, and other refuse scattered in and around the garbage area. The smoking area receptacle was completely full, cigarette butts were littered around the area, and a pail with cigarette butts and paper products had no sand in it.
Facility assessment failed to accurately reflect resident capacity, cultural and religious factors, in-house dialysis services, staffing plan, and the recruitment/retention plan for direct care staff. The assessment listed capacity as 182 residents despite a census of 200 and leadership stating the facility could care for over 250 residents. Leadership also confirmed the assessment omitted resident ethnic and religious needs, the dialysis unit, and the facility’s actual licensed nurse and CNA staffing levels, even though the facility had a recruitment and retention program in place.
Unsafe maintenance conditions were observed in the kitchen, dry storage area, and 2nd-floor shower rooms. Broken and uncovered light fixtures, a bowed ceiling tile with exposed insulation, peeling drywall and damaged wall surfaces, and a leaking rusted pipe above a shower chair were confirmed by the Maintenance Director and DON. The shower room also had a nonworking exhaust fan and no privacy curtains or barriers, and the Administrator and Maintenance Director could not produce maintenance work orders or documentation for the disrepair.
Kitchen and second-floor shower room ventilation was not functioning properly. Surveyors observed heavy grease and dirt buildup on the kitchen ceiling, oven window, and oven dials, and the dietary manager confirmed the exhaust hood was not on. In the shower room, the area felt warm and humid, the exhaust fan did not work, and both fan covers were coated with dust. The DON and maintenance director confirmed the issue, and no work orders or documentation were produced.
A facility failed to align its resident smoking policy with state smoking requirements and did not address resident vape use. A resident was observed smoking too close to the entrance of the smoking area, and the supervising aide confirmed the resident was within the restricted distance. The employee handbook addressed smoke- and vape-free expectations for staff, but the resident policy did not include the same entrance-distance restriction or e-cigarette guidance.
Call Lights Not Within Reach or Functioning for Dependent Residents: The facility failed to keep call lights within reach and functioning for several residents with mobility or cognitive impairments. A resident with multiple diagnoses was found with the call light behind the bed, another resident with hemiplegia had the call light on a dresser and unplugged, a resident with severe cognitive impairment had the call light dangling below the mattress, and another resident with cerebral infarction had the call light on the floor and not plugged in. Staff confirmed the call lights were not within reach or connected.
The facility failed to keep several resident rooms adequately lit and left a damaged bathroom faucet with sharp, frayed metal edges in place. Residents and a CNA reported that overhead lights had not worked for some time, rooms were too dark, and staff knew about the problem, while the MDS and BIMS showed affected residents had dementia or cognitive impairment. The surveyor also observed oatmeal on a resident room floor, and an LPN identified it as oatmeal or cereal.
Failure to supervise a high-fall-risk resident and control safety hazards. A resident with dementia and severe cognitive impairment repeatedly tried to transfer without help and was found on the floor after an unwitnessed fall that caused a head laceration requiring sutures. Surveyors also observed unattended razors, a loose curtain rod, and residents with cigarettes in their possession despite facility policies restricting contraband and requiring supervision for residents who could not safely follow smoking rules.
Respiratory equipment was not maintained or stored as required for multiple residents. The facility had no respiratory equipment policy, and staff observed a CPAP mask, nebulizer masks, and a BiPAP mask left uncontained when not in use. An LPN and the DON stated respiratory items should be changed weekly and stored in a bag, but resident observations and interviews showed this was not consistently happening.
Controlled substances were not signed out immediately before administration, and counts did not match the controlled drug record for several residents. An RN admitted the meds were not documented until hours later and did not count with the ADON at shift change. Surveyors also found an unmarked storage room with mixed medications, including controlled meds for a current resident and several discharged residents, without the required controlled substance records or tracking log.
Medication storage and security were not maintained for multiple residents. An intact resident had Milk of Magnesia left on a bedside table, another resident had a pill on a windowsill, and the same resident also had a Symbicort inhaler left at bedside even though it was not ordered to be kept there. Surveyors also found an unsecured supply room with mixed current and discontinued meds, injectable meds, and controlled substances without required double-lock protection or tracking, and unlicensed staff had access to the room.
Personal refrigerator food safety lapses were identified when multiple residents’ room refrigerators lacked thermometers, contained undated outside food, were dirty, and had expired items left inside. Residents with diagnoses including impaired mobility, paraplegia, COPD, depression, and other conditions had food items such as take-out containers, bread, milk, and mayonnaise stored without proper dating or removal, and a CNA stated refrigerators were only cleaned if residents asked. The IP/Unit Manager stated thermometers should be present and outside food should be dated.
Medication Administration Errors: An LPN administered Tylenol to a resident without a physician order, and an RN was observed measuring polyethylene glycol powder for another resident using a medicine cup marked by hand rather than the provided cap. The DON stated staff are expected to follow the five rights of medication administration and ensure medications are given according to physician orders.
Medication administration errors exceeded the 5% threshold, with 2 errors in 31 opportunities for a 6.45% rate. An LPN gave a resident 2 Tylenol tablets without a physician order, and an RN measured a MiraLAX dose by marking a medicine cup and pouring powder into it rather than using an accurate measuring device. The facility’s policy required an order for all medications and proper dose verification.
Failure to Obtain Ordered Dental Consultation: A resident with a trach, aphonia, and dysphagia, and who was cognitively intact, reported not seeing a dentist in the past 4 months. Although a physician ordered a dental consult, the resident was not added to the monthly dental list and was not seen during the contracted dental visit; the DON stated social services handled adding residents after nursing notification.
Missing and Nonfunctioning Call Light System: Two residents, both cognitively intact and requiring assistance with ADLs/toileting, were found without a working call light or alternate call device in reach. Surveyors observed the wall jack hanging and not in working condition, with no cords plugged in, and both residents said they would have to rely on their roommate to call for help. The Maintenance Director acknowledged the call lights had been missing for at least two weeks, and a repair quote for the 3rd floor and shower room had not yet been approved or scheduled.
Failure to implement the abuse policy and QAPI process, and failure to post the required notice for covered individuals. A cognitively intact resident reported poor care, fear among residents, and not knowing where to find the State Survey Agency complaint number; another cognitively intact resident who was dependent for ADLs reported rough handling by a CNA and fear of retaliation. Surveyors did not find the required posting in conspicuous locations during the tour, and the administrator and HR director confirmed it was not properly posted. QAPI records also did not document review of abuse-related data, incident reports, or allegations as required by policy.
A cognitively impaired, non-ambulatory resident who required a mechanical lift for transfers was found on a floor mat after an unwitnessed fall and complained of right hip pain. An LPN assessed the resident, administered pain medication, and obtained a provider order for a STAT right hip X-ray expected to be completed and resulted within several hours, but the X-ray was never performed. The following day, the resident continued to exhibit pain, including facial grimacing and guarding of the right leg, and another LPN arranged transfer to the hospital due to unresolved right leg pain and the uncompleted STAT X-ray. At the emergency room, imaging showed a displaced comminuted intertrochanteric right femoral fracture, and the report notes that a reasonable person in this situation would have experienced psychosocial harm related to pain.
Multiple rooms and the dialysis area were recorded at temperatures above 81°F, with several residents reporting discomfort and using fans or makeshift methods to cool themselves. Staff confirmed that AC units were not functioning for several days, and temperature checks were not conducted overnight. Dialysis staff noted increased resident fatigue and fluctuating vital signs during treatments in the overheated room. Most residents were not proactively offered fans, and some were unaware they were available.
A resident with multiple health conditions, including neurogenic bladder and a sacral pressure ulcer, experienced four recurrent UTIs while having an indwelling urinary catheter. Despite ongoing complaints of discomfort and repeated infections, staff did not timely assess or consider removal of the catheter, and there was no documented outreach to the physician for reassessment. Facility policy requiring ongoing review and adjustment of care for residents with catheters and recurrent infections was not followed.
A resident with multiple complex medical conditions was admitted without a completed admission assessment, baseline care plan, or reconciliation of medications. Nursing staff did not administer medications or initiate G-tube feeding due to missing information and lack of follow-up with available resources, resulting in the resident not receiving necessary care until a code blue was called.
A facility failed to notify the attending physician about delays in urgent lab tests for a resident, resulting in a nine-hour delay. The resident, who had decreased food and fluid intake, was later hospitalized with dehydration, pneumonia, and a UTI. Incomplete documentation and lack of timely communication with the primary NP and physician contributed to the resident's deteriorating condition.
A resident with complex medical conditions, including end-stage renal disease, refused dialysis and was not properly monitored for fluid overload. The facility failed to notify the nephrologist of the refusal and abnormal X-ray results. The resident complained of shortness of breath and was later found unresponsive, leading to their death. Staff communication and adherence to policies were inadequate.
The facility failed to maintain adequate hot water temperatures in all shower rooms, affecting residents' ability to shower. The issue began when the Maintenance Director noticed dropping water temperatures, and a plumbing contractor was called. Despite efforts, the problem persisted, and residents had to use wipes or microwaved water for hygiene. Residents were not informed about repair progress, and documentation revealed inconsistencies in recording water temperatures. The deficiency highlights the facility's failure to provide a safe and comfortable environment.
The facility failed to maintain its hot water system, resulting in suboptimal water temperatures in shower rooms on multiple floors. The issue was identified on January 3rd, but delays in communication and approval processes, along with inadequate documentation and maintenance, prolonged the deficiency. A resident with spinal stenosis, fibromyalgia, and lumbar disc degeneration was affected.
A resident with a history of dialysis and low potassium levels experienced an acute change in condition, including lethargy and low oxygen saturation. Despite these symptoms, there was a delay in transporting the resident to the hospital. The nurse practitioner initially stabilized the resident with oxygen, but the condition worsened, leading to a diagnosis of severe sepsis upon hospital admission. The delay in response and transport contributed to the deficiency identified in the facility's care.
Two residents were involved in a physical altercation in an elevator, where one resident, diagnosed with schizophrenia, struck another resident with a cell phone, causing injury. The incident occurred when the second resident attempted to enter the elevator, leading to a confrontation. Staff intervened, but the facility failed to prevent the abuse, resulting in physical harm.
The facility failed to follow its abuse prevention policy, resulting in a resident-to-resident physical assault. A resident with severely impaired cognitive skills was assaulted by another resident, causing significant injuries. Staff failed to adhere to protocols requiring constant supervision and immediate reporting of abuse incidents.
A facility failed to supervise a resident with physical aggression and dementia, leading to the resident assaulting a peer. The injured resident sustained severe injuries, including multiple lacerations and a nasal bone fracture, requiring hospital treatment. The incident occurred in a locked unit left unattended by staff despite clear signage requiring constant supervision.
A resident developed an unstageable, necrotic pressure ulcer due to the facility's failure to identify, assess, and treat a change in skin condition. Despite being at risk for pressure ulcers, the resident's sacral wound was not addressed until it showed signs of infection, leading to hospitalization. Staff interviews highlighted the importance of early identification and documentation of skin changes to prevent such deterioration.
Two residents experienced verbal abuse from a CNA who used profanity and loud behavior during an interaction. Both residents, who have no cognitive impairments, confirmed the incident. The facility's investigation corroborated the residents' accounts, and the CNA admitted to the inappropriate conduct.
A resident's medications, specifically Adderall XR and Adderall, were not administered as ordered due to availability issues and documentation gaps. The resident was discharged to the hospital multiple times, and the nurse indicated that the facility's locked medication dispensing system required supervisor access, which hindered timely administration. The facility's policy for handling unavailable medications was not effectively followed.
Medication Administration Not Documented for Two Residents
Penalty
Summary
The facility failed to follow its medication administration policy by not ensuring that medication administration was documented and by not documenting when medications were received or not received in the Nurses' notes for two residents reviewed. One resident had a BIMS score of 15, indicating cognition intact, and stated that potassium had been missed a few days earlier because of the pharmacy but was received that morning. However, the June 2026 MAR showed scheduled 9:00 a.m. medications including Potassium Chloride, Cyanocobalamin, Ferrous Sulfate, Vitamin C, Carvedilol, Docusate Sodium, Famotidine, and Lactulose with blank entries on 6/3/26 at 9:00 a.m. The DON stated that if the MAR was blank, staff did not sign it out or indicate whether the resident did not receive it, and later stated the assigned RN said all scheduled medications were given that day and the resident said she received all her meds. Another resident had a BIMS score of 15 and denied concerns with medication administration when interviewed, but the June 2026 MAR showed Prednisolone Acetate Ophthalmic suspension scheduled for 6:00 a.m. and Ketorolac Tromethamine Ophthalmic solution scheduled for 9:00 a.m. On 6/2/26, both medications were marked with a 9 on the MAR, which the Administrator said meant 'Other, see Nurses note,' yet there was nothing documented in the Nurses' progress notes about administration or non-administration of either eye drop. When asked whether the resident received the eye drops as ordered, the Administrator said she would have to contact the nurse to determine what occurred and why staff documented 9.
Failure to Assist Residents With Transfers and Eating
Penalty
Summary
The facility failed to provide assistance with activities of daily living for residents who were dependent for transfers and, in one case, failed to provide supervision or touching assistance with eating. The report states that four of 42 residents reviewed for ADL care were affected: R6, R14, R37, and R131. The deficiencies were identified through observation, interview, and record review, and the report notes that these failures resulted in R131’s reported discomfort and feelings of uselessness and R37’s reported frustration. R37’s record showed a BIMS of 15 and dependence for chair or bed-to-chair transfers. R37 also had diagnoses including cardiomegaly, cauda equina syndrome, paraplegia, chronic kidney disease, history of pressure ulcer, peripheral vascular disease, major depressive disorder, bilateral primary osteoarthritis, reduced mobility, obesity, diabetes, neuromuscular dysfunction, and polyneuropathy. R37 stated that the wheelchair was missing, that the resident had not been out of bed for about three weeks, and that the resident wanted to get out of bed. Staff interviews reflected that R37 should have been getting up with assistance, but documentation of attempts or refusals was not found in the EHR. The resident’s roommate stated this was the first time R37 had been out of bed in two weeks, and the resident later stated feeling better out of bed but that the wheelchair provided was too large and the seat cushion was still missing. R131’s record showed a BIMS of 15 and dependence for chair or bed-to-chair transfers, with diagnoses including heart failure, muscle wasting and atrophy, peripheral vascular disease, and history of acute embolism and thrombosis. R131 stated that the resident wanted to get up the prior day but was not taken out of bed because staff said they were busy with dialysis patients, and the resident reported leg soreness from lying in bed. When later observed in a wheelchair, R131 stated feeling better up and said that when staff did not get the resident up, the resident felt useless and dissatisfied. R6’s record showed cognitive intactness and dependence for transfers, and R6 stated staff did not let the resident get up for lunch and that lunch was missed because the resident was not assisted out of bed in time. R14’s record showed severe cognitive impairment, dependence for eating supervision or touching assistance, and substantial/maximal assistance for lying to sitting. When observed, R14 was in bed with lunch placed on a nearby table, not within reach, with no staff present to cue or feed the resident; the meal was barely touched, and the resident stated no assistance had been provided. The facility policy required assistance for residents unable to feed themselves, including positioning the resident properly and cutting food into small pieces, but those actions were not provided during the observation.
Infection Control Failures With PPE, Cleaning, Linen Handling, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow infection prevention and control policies and procedures for residents on transmission-based precautions and enhanced barrier precautions. One resident admitted with diagnoses including gastrointestinal hemorrhage, ulcerative colitis, colostomy, and enterocolitis due to C. diff had a BIMS score of 6 and was documented as continuing on oral vancomycin for C. diff. The resident was observed on contact precautions with signage on the room door for both contact precautions and enhanced barrier precautions related to a Foley catheter. A unit manager stated the double signage could be confusing. A registered nurse was observed entering the resident’s room, pushing the medication cart to the door, not performing hand hygiene, assembling medications, entering the room without gown or gloves, administering medication, exiting without hand hygiene, and then proceeding to the next room and assembling medications without hand hygiene. The nurse stated that PPE should have been used. The resident’s room was also discussed with housekeeping staff, who stated that the room was cleaned with Neutral Cleaner 15 and Hospital Use Disinfectant-Cleaner 11, the same products used for all rooms, including rooms for residents with C. diff. The disinfectant label reviewed did not list C. diff, and a sales representative stated the product could not claim to kill C. diff because it had not been tested for that organism. Housekeeping staff also described an automated mixing system for cleaning solutions, and no sporicidal solutions were initially identified in the housekeeping closet during observation. Later, a micro-kill bleach product was mentioned by the housekeeping/laundry manager, but the housekeeper stated he had never seen those bottles and did not have them on his cart. In the laundry room, surveyors observed two opened bags of soiled linen in the laundry chute and one soiled blanket with a yellow stain in the dirty laundry receiving bin not placed in a plastic bag. The housekeeping/laundry manager stated the opened bags should have been tied shut to prevent spreading germs. Another resident with a G-tube, PICC line, active bacteremia treated with IV cefazolin, pressure ulcers, and an order for enhanced barrier precautions due to wounds and a G-tube was observed without any precaution sign or PPE setup at the room, and the infection prevention nurse stated the resident should have been on enhanced barrier precautions.
Failure to Post Required State Survey Agency Complaint Information
Penalty
Summary
The facility failed to post the names, addresses, and telephone numbers of the State Survey Agency and other pertinent state agencies and advocacy groups, and failed to post a statement informing residents that they may file a complaint with the State Survey Agency regarding suspected violations of state or federal nursing facility regulations, including resident abuse, neglect, exploitation, and misappropriation of resident property. The deficiency affected all 200 residents in the facility. Facility census documentation dated 5/4/2026 showed 200 residents residing in the building. R202 was a cognitively intact resident with diagnoses including displaced fracture of the 3rd metatarsal bone of the right foot, type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, wedge compression fracture of the 4th vertebrae, unspecified muscle wasting and atrophy, and a personal history of transient ischemic and dysphagia. During interview, R202 stated the care was not good, that complaints did not change anything, and that the resident did not know where the number to notify the State Survey Agency was because it had not been seen posted anywhere. The Administrator stated the agency contact information was posted in elevators and on bulletin boards, but a facility tour of floors, resident units, nurse's stations, bulletin boards, elevators, reception areas, and the main entrance did not find the required posting or complaint statement. The elevator bulletin boards were covered in glass casing accessible only to staff, and the Administrator confirmed the information was not posted for residents. The Social Services Director stated residents have the right to complain to the State Survey Agency and that the agency's contact information should be posted with other required postings, while facility policy required such postings to be in a form and manner accessible and understandable to residents and resident representatives.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, label, prepare, and serve food in accordance with professional standards and failed to maintain a clean and sanitary kitchen, food preparation, and food storage environment. On the initial tour of the kitchen and food service areas, surveyors observed Worcestershire sauce in the cooler with a use-by date of 3/6/2026, a tray of chicken salad covered in plastic wrap with no date, and two visibly dirty scoops covered in a yellowish orange powder in a plastic bag on a dry storage shelf with no date on the bag. The Dietary Manager confirmed the expired sauce, the undated chicken salad, and the dirty scoops, and removed the sauce and scoops from the area. Surveyors also observed a black dirt-like substance caked across approximately 25% of the dry storage room floor tiles. The Dietary Manager confirmed the observation and stated the floor did not look clean. In the kitchen food preparation area, surveyors observed black and reddish-brown stains covering over 75% of the ceiling near the oven, range, and food prep areas, old grease covering approximately 75% of the oven window, dark brown grease and food particulate covering approximately 25% of the oven dials, tan food particulate splattered across approximately 25% of the stainless-steel food storage area, black and tan dried food debris on the ceiling above the food prep area, and crumbs and dirt throughout the floor. A Cook and the Dietary Manager confirmed these conditions and identified the stains as grease and dirt. Surveyors further observed plastic food bins of dried mashed potato flakes and powdered thickener with lids covered in gray and black dirt-like substance and bits of dried shredded orange cheese. The mashed potato flake bin had a sticker indicating a date of 2/2 and a use-by date of 60 days, and the Dietary Manager stated the date was wrong and that the product was good for a year. In the dry storage room, surveyors observed brown and streaked drywall and paint, an area of missing paint exposing the wall base, broken or absent corner tiles exposing black adhesive or underlayment, and a black spotted substance on the tiles that the Dietary Manager stated looked like black mold. The report also notes the exhaust hood was not functioning properly and that a vendor believed the ventilation system was not pulling enough air.
Improper Garbage Storage and Smoking Area Housekeeping
Penalty
Summary
The facility failed to contain garbage and refuse within dumpsters and failed to maintain garbage storage areas in a sanitary condition. On 5/4/2026, the garbage area and staff smoking area were observed with the Housekeeping/Laundry Manager. Outside the dumpsters were food wrappers, loose medical waste including soiled gloves, flattened rotting cardboard, and cigarette butts. In the garbage area were more than 6 palettes of wood, rotting pieces of wood stacked against the fence, used milk crates, food wrappers and waste, broken medical equipment and beds, large spools of light blue fabric, large pieces of fabric in piles on the ground, soiled plastic garbage bags, piles of used siding, piles of used PVC piping, rotting cardboard pieces and boxes, used plastic bags, and other unidentifiable garbage. The Housekeeping/Laundry Manager confirmed the observations and stated that some of the garbage had been there since the prior week and some had been there for years. The manager stated that all of it needed to be cleaned out and that a dumpster had been suggested a few weeks earlier, but it had not happened yet. In the smoking area, the receptacle attached to the building was completely full of cigarettes, cigarette butts were littered in the back parking lot and staff smoking area, and a pail containing cigarette butts and discarded paper products had no sand in it. The manager confirmed these observations and stated it was their responsibility to remove the cigarette butts and that placing used cigarettes in the pail with paper products could create a fire hazard. Facility policy required garbage and refuse to be disposed of properly and in a timely manner, with waste contained in dumpsters or compactors with lids and garbage storage areas maintained in a sanitary condition.
Facility Assessment Did Not Accurately Reflect Resident Needs, Staffing, or Services
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that accurately identified the resources needed to care for residents competently during day-to-day operations and emergencies. Based on interview and record review, the assessment did not accurately identify the facility’s resident capacity, listing capacity as 182 residents even though the census showed 200 residents in the facility and the administrator stated the facility could care for over 250 residents. The assessment also did not identify ethnic, cultural, or religious factors that could affect care, despite the administrator and COO stating the facility had residents of Latin descent, African American residents, Christian residents, and Polish residents, and that services such as Cinco de Mayo parties and in-house church services were provided. The facility assessment also omitted the facility’s in-house dialysis unit services. In addition, the staffing plan documented in the assessment was inaccurate. The administrator and COO both reviewed the assessment and confirmed the staffing information was incorrect, including the licensed nurse and nurse aide ratios and the number of staff assigned per shift. The COO stated the facility’s actual licensed nurse staffing should be 1:20, with specific staffing levels on the 2nd, 3rd, and 4th floors across AM, PM, and night shifts, and stated there should be 15 CNAs per shift. The assessment further failed to include a recruitment and retention plan for direct care staff, even though the COO stated the facility had such a program in place, including a corporate recruiter, job board postings, outreach to schools, and a monthly allowance to build staff culture. The facility assessment policy required the assessment to address resident population, ethnic, cultural, and religious factors, services provided, staffing needs, and a plan to maximize recruitment and retention of direct care staff. The deficiency affected all 200 residents in the facility.
Unsafe Maintenance and Shower Room Disrepair
Penalty
Summary
The facility failed to follow its preventative maintenance policy and failed to maintain the environment in a safe, functional, sanitary, and comfortable condition for residents, staff, and the public. On observation, three broken kitchen light fixtures had no lightbulbs, three light covers were cracked, and three other lights had no cover, leaving exposed lightbulbs. The Maintenance Director confirmed the observations and stated the covers were intended to protect the bulbs and staff because the bulbs could explode. In the kitchen and storage areas, the ceiling above the clean dishware/pots/pans was discolored and bowed downward, exposing insulation above the tile. In the dry storage area, drywall was peeling, paint chips and debris were on the floor, and a section of wall lacked paint and left the base exposed. Broken or missing tiles in the corner of the dry storage area exposed black adhesive/underlayment. The Maintenance Director stated a prior pipe leak had caused water damage, that a plumber had repaired the pipe, and that the other damaged areas had not yet been repaired. The second-floor shower rooms were observed to be warm and humid, with linen on the floor, water pooled under the shower chair, and a missing ceiling tile above the shower area exposing a rusted pipe that was wet and leaking about one drop every 8 to 10 seconds onto the shower chair. The exhaust fan did not work, and there were no curtains or other privacy barriers in the shower area. The DON and Maintenance Director confirmed these conditions. When asked for maintenance orders or documentation related to the disrepair items, the Maintenance Director and Administrator could not produce any records, and no documentation was provided before the survey exit.
Kitchen and Shower Room Ventilation Not Functioning
Penalty
Summary
The facility failed to ensure adequate ventilation was in good working condition in the kitchen and the second-floor shower room. On 05/04/2026, surveyors observed black and reddish-brown stains covering over 75% of the kitchen ceiling near the oven, range, and food prep areas. Old grease covered approximately 75% of the oven window, and dark brown grease and food particulate covered about 25% of the oven dials. The dietary manager stated the stains were from grease and dirt, said the ceiling had been like that since before they started in the role over a year earlier, and confirmed the exhaust hood was not on when observed. The maintenance director also confirmed the exhaust hood was not functioning properly and stated a vendor had assessed it and believed the ventilation system was not pulling enough air. Surveyors also observed the second-floor shower rooms on 05/04/2026 and found them warm and humid. Linen was on the floor from a resident who had just taken a shower, and a puddle of water was observed under the shower chair. When the surveyor flipped the light switch next to the unused shower stall, nothing happened, and the maintenance director stated it controlled the exhaust fan and that it did not work. Both exhaust fan covers were covered in a thick layer of dust, which the maintenance director confirmed. The administrator and maintenance director could not produce any work orders or documentation related to the ventilation problems, and the administrator stated a vendor had assessed the exhaust fan and that the ventilation system needed to be replaced.
Smoking Policy Missing Required Restrictions and E-Cigarette Guidance
Penalty
Summary
The facility failed to develop a smoking policy that met the requirements of the Smoke Free Illinois Act, failed to include resident e-cigarette use in the resident smoking policy, and failed to follow the staff smoking policy in the employee handbook. The facility census documented 200 residents, and the smoking list documented 45 residents who smoke in the facility. The resident smoking policy, revised in November 2013, addressed designated smoking areas, smoking contracts, supervision, and restrictions on smoking materials inside the building, but it did not address smoking within 15 feet of an entrance or resident use of e-cigarettes or vapes. The surveyor observed a resident smoking less than 15 feet from the entrance to the smoking area near the handicap door access button. The activity aide who was supervising the smoking area confirmed the resident was smoking too close to the door and directed the resident to move farther into the smoking area. The distance from the threshold of the door to where the resident was smoking was measured at 91 inches, or approximately 7.8 feet. The social services director and administrator both affirmed that residents should be smoking at least 15 feet away from the facility, and the administrator also affirmed that residents do use electronic cigarettes. Additional observations showed poor control of smoking-related waste and conditions in the smoking areas. The garbage area contained food wrappers, loose medical waste including soiled gloves, flattened rotting cardboard, and cigarette butts. The smoking receptacle attached to the building was completely full of cigarettes, cigarette butts were littered in the back parking lot and staff smoking area, and a pail in the staff smoking area contained cigarette butts mixed with paper products and no sand. The housekeeping/laundry manager confirmed these observations and stated that placing used cigarettes with paper products could create a fire hazard. The employee handbook’s smoke free policy stated that smoking and vaping were only permitted outside in designated areas where smokers would not interfere with those entering and leaving the facility, but the resident smoking policy did not include those requirements.
Call Lights Not Within Reach or Functioning for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach and functioning for four dependent residents, despite care plans and assessments indicating they needed assistance and should have access to a call bell. R27, who had diagnoses including acquired absence of the right ankle, type 2 diabetes, necrotizing fasciitis, pneumonia, and renal dialysis, was observed lying in bed with the call light behind the bed and not within reach. V11 confirmed the call light was behind the bed and not within reach, and the DON stated the facility expectation was that call lights should be within reach so staff could address residents’ needs. R11, who had hemiplegia and hemiparesis and required partial/moderate assistance with transfers, was observed sitting on the bed with the call light on the dresser out of reach and unplugged; V14 confirmed it was not plugged in. R14, who had lack of coordination, a history of falling, repeated falls, and severe cognitive impairment, was observed with the call light dangling below the mattress and out of reach, and V13 left the room after checking the urinary catheter without placing the call light within reach. R84, who had cerebral infarction and cognitive communication deficit and required partial/moderate assistance with transfers, was observed with the call light on the floor and not plugged into the wall; V15 stated there was nothing plugged in and that the cord on the floor appeared to be the call light.
Unsafe lighting, damaged faucet, and housekeeping concerns
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents by not ensuring adequate lighting and by leaving broken equipment and housekeeping concerns unaddressed. During observation, several resident rooms lacked working overhead lighting, including rooms occupied by residents with dementia, cognitive impairment, diabetes, depression, COPD, and other diagnoses. One CNA stated that the lights behind three residents’ beds had not worked for some time, and residents reported that the rooms were too dark, that the lighting had been out for days, and that staff knew about the problem but had not fixed it. A maintenance director later confirmed that the lights were not working and said replacement lights had been ordered but were on back order. The surveyor also observed a damaged metal faucet with frayed, sharp edges in a shared bathroom used by three residents. The surveyor experienced discomfort while attempting to turn the faucet handle because of the exposed sharp metal edges. One resident stated that the bathroom faucet was not surprising in its condition and that staff did not live that way. During the facility tour, the maintenance director acknowledged the faucet was bad, said he had not been aware of it, and stated that someone could cut themselves. The report also noted oatmeal splattered across the floor in one resident’s room, and an LPN identified the substance as oatmeal or cereal on the floor. Record review showed the facility’s preventative maintenance policy required a safe, functional, sanitary, and comfortable environment and assigned the Maintenance Director responsibility for maintaining buildings, grounds, and equipment in a safe and operable manner. The Maintenance Director job description also required repair of resident property and coordination with vendors when repairs could not be completed. The resident rights pamphlet stated residents must be treated in a safe, clean, comfortable, and homelike environment and receive services and items included in the plan of care. The observations and interviews showed that these conditions were not consistently met for the residents identified in the sample.
Failure to Supervise High-Risk Resident and Control Safety Hazards
Penalty
Summary
The facility failed to follow its fall prevention and safety procedures for a resident with dementia and severe cognitive impairment who had a documented history of being a high fall risk and repeatedly trying to get up without help. The resident had diagnoses including dementia, seizures, hypertension, anemia, and protein calorie malnutrition, and his BIMS score was 6 out of 15. Staff interviews confirmed he needed assistance with transfers, often tried to get up on his own, and sometimes did not know how to use the call light. On the day of the unwitnessed fall, he was found on the floor next to his bed after attempting to self-transfer alone and unattended, and he sustained a closed head injury and a laceration above the left eye requiring five sutures. Record review showed the resident’s care plan identified him as high risk for falls and included interventions such as keeping the call light within reach, educating him to use it, and keeping him in visible view of staff as allowed. However, staff statements indicated these interventions were not effectively implemented. One CNA stated the resident tried to get up without help, and another CNA said he often tried to put himself back to bed and that staff had to keep redirecting him. The RN described that the resident was trying to get into his wheelchair early in the morning when his aide was in another room helping another resident, and that he fell while attempting to get up by himself. The facility also failed to identify and control other safety hazards observed during the survey. Three razors were found unattended on one resident’s bathroom sink even though staff stated residents were not allowed to have razors in their possession. A curtain rod in another resident’s room was bent, falling down, and completely off its hook, with staff stating it would fall if opened. In addition, a resident with dementia and a smoking contract was observed with a cigarette behind his ear, and another resident had a pack of cigarettes in his hoodie pocket despite facility policy stating smoking materials are prohibited inside the building and must be given to designated staff. These observations were made in the context of policies requiring hazard control, contraband containment, and supervision for residents at risk.
Respiratory equipment was not maintained or stored as required
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents by not having a policy or procedure for maintaining respiratory equipment, not ensuring respiratory equipment was discarded weekly, and not keeping respiratory equipment in a bag when not in use. The report identified residents R1, R108, R135, and R190 as affected in the sample reviewed for respiratory care. During record review and interviews, the Administrator stated there was no respiratory equipment policy, while the DON stated staff protocol was to change nebulizer masks or mouthpieces weekly and store equipment in a bag when not in use. The oxygen safety/use policy reviewed in January 2026 stated oxygen tubing would be changed weekly and stored appropriately to prevent contamination when not in use. R108, who had diagnoses including COPD with acute exacerbation, chronic respiratory failure, and type 2 diabetes, was observed with a CPAP mask placed directly on top of the CPAP machine without being contained, and later stated that staff usually leave the respiratory mask uncontained unless surveyors are present. R190’s nebulizer mask was observed uncontained on a dresser with tubing dated 3/16/26, and the resident stated staff change the tubing only "once in a while." R1’s nebulizer mask was observed uncontained on a windowsill with a date of 4/3, and R135’s BiPAP mask was observed uncontained on a dresser. Staff interviews confirmed the equipment was not being stored in bags as expected, and one LPN stated the nebulizer mask was not in a bag while another said it should be in a bag.
Controlled substances were not signed out promptly and were left unaccounted for in storage
Penalty
Summary
The facility failed to immediately sign out controlled substances before administration and failed to maintain documented accountability for controlled substances that were not in use. During a medication cart review with the ADON, discrepancies were found for three residents on the controlled drug receipt/record/disposition forms: Tramadol 25 mg for one resident had 19 tablets available when 20 were expected, Pregabalin 75 mg for another resident had 2 capsules available when 3 were expected, and Clonazepam 1 mg for a third resident had 3 tablets available when 4 were expected. The ADON confirmed that controlled medications should be signed out immediately when removed from the cart to maintain an accurate count. The day shift RN stated the medications should have been signed out at the time they were given but were not documented before shift change, and the RN did not count with the ADON before handing off the medication cart keys. The RN reported administering Clonazepam and Pregabalin during the morning med pass and could not recall administering Tramadol to the resident. The MAR showed Tramadol was administered later in the day, while the other two medications were documented as given in the morning. The facility policy stated controlled substances are to be counted each shift or whenever keys are exchanged, with both nurses verifying the package and count sheet and signing the shift controlled substance count sheet. Surveyors also found an unmarked storage room containing a large quantity of medications mixed with general supplies, including resident-specific medications, injectable medications, and controlled substances. Controlled medications found there included Lorazepam injection vials for a current resident and multiple controlled medications for discharged residents, including Buprenorphine-Naloxone films, Lorazepam liquid, Fentanyl patches, Midazolam nasal spray, Dronabinol capsules, and Lacosamide tablets. There were no controlled drug receipt/record/disposition forms or tracking log for the medications in the room. The DON stated there should be no controlled medications in the room and that discontinued controlled medications should have been destroyed, while other medications were to be returned to the pharmacy.
Medication Storage and Security Failures
Penalty
Summary
Drugs and biologicals were not stored securely or in accordance with facility policy for two residents in the main sample and seven residents in the supplemental sample. On 5/4/26, a medication cup containing a white liquid was observed on a cognitively intact resident’s bedside table, and the resident identified it as Milk of Magnesia that had been there since the day before. Later that day, a white pill was observed on another resident’s windowsill and was identified by staff as likely a calcium pill. The same resident also had a Symbicort inhaler on the bedside table, even though the physician order stated it was to be given every 12 hours and was not marked as a medication that could be kept at bedside. Staff, including an LPN and the DON, stated that medications were not allowed to be left at bedside. On 5/6/26, surveyors inspected an unmarked supply overstock room and found a large quantity of medications scattered among general supplies, including current and previous pharmacy medication cards, patient-specific medication packs, and injectable medications. Controlled and non-controlled medications were mixed together, there were no Controlled Drug Receipt/Record/Disposition forms or tracking log for the controlled medications, and controlled medications were not secured by a second lock within the room. The room was accessible by a numeric keypad, and unlicensed personnel were able to access it. The unit manager stated the medications were from the previous pharmacy, discontinued, or left after residents had been hospitalized, while the DON stated discontinued controlled medications should have been destroyed and that the unlicensed staff member should not have access to medications.
Personal Refrigerator Food Safety Lapses
Penalty
Summary
Failure to follow the facility’s policy for personal food storage was identified in multiple residents’ room refrigerators. Observation, interview, and record review showed that several personal refrigerators did not have thermometers, outside food items were left undated, refrigerators were dirty, and expired food was not removed. The facility policy stated that housekeeping was responsible for cleaning personal refrigerators, monitoring refrigerator temperatures, and disposing of spoiled items, and that all refrigerator units should have an internal thermometer. The report also noted that residents’ rights materials stated the facility must be safe, clean, comfortable, and homelike. R4, who had diagnoses including history of falling, need for assistance with personal care, disorder of muscle, and reduced mobility, had undated partially eaten take-out food in the personal refrigerator and said the items had been there for a few days. R163, who had central cord syndrome, spine fusion, fall, and paraplegia, had no thermometer in the personal refrigerator and said there had not been one for a while. R8, who had COPD, depression, and acquired absence of the right leg, had undated take-out food and wrapped bread in the refrigerator. R91 also had no thermometer in the personal refrigerator. R3’s personal refrigerator was described as very dirty and contained a gallon of milk dated 4/25/2026 and a mayonnaise bottle dated 6/11/2024. A CNA stated staff only cleaned the refrigerator if residents asked them to, and the Infection Preventionist/Unit Manager stated thermometers should be in personal refrigerators and outside food should be dated.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure staff followed its medication administration policy by administering Tylenol to a resident without a physician order. The resident was 69 years old and had diagnoses including acute posthemorrhagic anemia, melena, reduced mobility, major depressive disorder, type 2 diabetes, and end stage renal disease. During an observed medication pass, an LPN gave the resident 2 tablets of Tylenol, but review of the medication reconciliation, active physician orders, and the May MAR showed no order for Tylenol and no documentation that the dose was signed for on the MAR. When asked later, the LPN stated she did not see an order and thought the resident had one. The facility also failed to ensure the correct dose of polyethylene glycol powder was administered to another resident. That resident was 54 years old and had diagnoses including multiple sclerosis, abnormal posture, urinary tract infection, elevated white blood cell count, and neuromuscular dysfunction. The physician order specified MiraLAX 17 grams by mouth daily for constipation. During observation, an RN measured the powder by drawing a line on a medicine cup between the 15 mL and 20 mL marks and poured the powder into the cup, stating it was approximately 17. Later, the ADON demonstrated measuring the dose using the bottle cap and stated the medication cups do not provide an accurate measurement of 17 grams, which is why the provided cap should be used to measure the exact dose.
Medication Administration Errors Exceeded the Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate at 5% or below, with 2 medication errors out of 31 medication opportunities for a 6.45% error rate. One error involved a nurse administering 2 tablets of Tylenol to a resident who did not have a physician order for Tylenol. The resident was 69 years old, had resided at the facility since 3/1/2026, and had diagnoses including acute posthemorrhagic anemia, melena, reduced mobility, major depressive disorder, type 2 diabetes, and end stage renal disease. The resident’s MDS documented a BIMS score of 15 and need for assistance with ADLs. Review of the active physician orders and the May MAR showed no Tylenol order and no documentation that the medication was signed as given. The second error involved a resident with diagnoses including multiple sclerosis, abnormal posture, urinary tract infection, elevated white blood cell count, and neuromuscular dysfunction. The resident’s MDS documented a BIMS score of 15 and need for substantial to partial/moderate assistance with ADLs. During observation, an RN prepared polyethylene glycol powder for the resident’s ordered MiraLAX dose of 17 grams by placing a medicine cup on the cart, marking a line between the 15 mL and 20 mL marks, and pouring powder directly into the cup. The RN stated the amount was approximately 17 and appeared level at the 17 mL mark. Later, the ADON demonstrated measuring the dose using the medication bottle cap and stated the medication cups do not provide an accurate measurement of 17 grams, which is why the provided cap should be used. The facility’s medication administration policy required an order for all medications and directed staff to verify the proper dose and use an appropriate measuring device.
Failure to Obtain Ordered Dental Consultation
Penalty
Summary
The facility failed to obtain routine dental services for one resident with a physician order for a dental consultation. The resident had diagnoses including malignant neoplasm of laryngeal cartilage, acquired absence of larynx, tracheostomy care, aphonia, and dysphagia, and had a BIMS score of 13, indicating cognitive intactness. During interview, the resident communicated by whispering short answers and nonverbal gestures and indicated not having seen a dentist in the past 4 months. The resident’s record showed a dental consultation order dated 04/02/2026, but the resident was not placed on the monthly dental evaluation list and was not seen during the contracted dental visit on 04/30/2026. Social services stated they were responsible for adding residents to the dental list after nursing notification, and the DON stated this was the facility process for dental consultations. The resident’s care plan identified risk for oral/dental problems and included coordination for dental care and transportation as needed or ordered.
Missing and Nonfunctioning Call Light System
Penalty
Summary
The facility failed to provide a working call light system in the bathroom and bathing area and failed to ensure the call light was in good repair for two residents, R179 and R197. On 5/4/2026 at 10:40 AM, surveyors observed that no call light was available for either resident to call for staff assistance. The call light jack near their beds was hanging with a left tilt, was not flush with the wall, and was not in working condition. No call light cords were plugged into the jack, and no bell or alternate call device was within the residents’ reach. Both residents were in bed and confirmed they did not have a call light and would have to get their roommate across the room to call for assistance. Record review showed R179’s MDS dated 3/31/2026 documented a brief interview of mental status summary score of 15, indicating cognitive intactness, along with diagnoses including cancer, malnutrition, inguinal hernia, disturbances of salivary secretion, opioid use, and other post-procedural pain; R179 required supervision/touching assistance with ADLs. R197’s MDS dated 2/28/2026 documented a brief interview of mental status summary score of 15, indicating cognitive intactness, and diagnoses including pathological fracture of the right humerus, cancer, anemia, hypertension, orthostatic hypotension, diabetes mellitus, hyperlipidemia, hip fracture, chronic pain syndrome, muscle wasting and atrophy, and unsteadiness on feet; R197 had impairment on one side of the upper and lower body, required partial/moderate assistance for toileting, supervision/touching assistance for bed mobility, was dependent on staff for bed-to-chair transfers and toileting assistance, and used a wheelchair. On 5/5/2026, the Maintenance Director acknowledged there was no call light available for the two residents and stated the call lights had been missing for at least two weeks. A written quote dated 4/22/2026 for replacing call lights in third-floor resident rooms and the shower room was provided, but no work had begun and no schedule for repairs was documented.
Failure to Implement Abuse Policy, QAPI Review, and Required Posting
Penalty
Summary
The facility failed to implement its abuse policy, failed to coordinate abuse-related information with the QAPI program as required by that policy, and failed to post the required notice informing covered individuals of their rights, including the right to file a complaint with the State Survey Agency. The report states the facility census was 200 residents. The abuse policy required a posted notice stating employees’ and covered persons’ obligation to report a suspected crime and how to file such a report without retaliation, and it required the Quality Management committee to review concern identification reports, accident reports, incident reports, missing item reports, and safety committee reports at least quarterly to assess possible patterns or trends related to abuse, neglect, mistreatment, or misappropriation of property. R202’s record showed diagnoses including displaced fracture of the 3rd metatarsal bone of the right foot, type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, wedge compression fracture of the 4th vertebrae, unspecified muscle wasting and atrophy, and a history of transient ischemic attack and dysphagia. R202’s BIMS score was 15, indicating cognitive intactness. During interview, R202 stated the care was not good, that complaints did not change anything, that people seemed afraid to speak up, and that R202 did not know where the number to notify the State Survey Agency was because it was not seen posted anywhere. R6’s record showed diagnoses including end stage renal disease, muscle wasting and atrophy, urinary tract infection, quadriplegia, metabolic encephalopathy, anemia, and dysarthria following cerebrovascular disease. R6’s BIMS score was 15, and R6 was dependent on staff for activities of daily living. R6 reported being handled roughly by staff during turning and repositioning on evening shifts and said fear of retaliation prevented disclosure of the staff member at first. R6 later identified a CNA as the staff member. The administrator confirmed the posting for covered individuals’ rights was supposed to be posted in the elevator and on the units, but a facility tour of resident units, nurse’s stations, bulletin boards, elevators, reception areas, the main entrance, employee break rooms, and employee time clock areas did not find a notice meeting the regulatory requirements. The elevator bulletin boards were behind glass and accessible only to staff, and the administrator and HR director confirmed the required posting was not in place. A receptionist later stated staff placed the signs the night before after the surveyors observed typed 8.5x11 signs taped to the front desk. Review of QAPI records showed abuse data, including accident reports, incident reports, missing item reports, safety committee reports, and allegations of abuse, had last been collected and reviewed by the QAPI committee on 1/30/2026. The 4/30/2026 meeting minutes and agenda did not show review of the required abuse-related data, and the administrator confirmed there was no documentation to verify that the QAPI committee discussed abuse allegations or other required information as stated in the abuse policy. The administrator stated there were approximately two reportable abuse allegations per month during the quarter, but no documentation was provided showing the required data was collected or reviewed before the survey exit.
Failure to Carry Out STAT Hip X-Ray Order After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement a physician’s STAT order for a right hip X-ray after an unwitnessed fall involving a cognitively impaired, non-ambulatory male resident who required a mechanical lift for transfers and was dependent for all ADLs. Following the fall, the resident was found on a floor mat next to a low bed by a CNA, who summoned the nurse. The LPN in charge performed a head-to-toe assessment, during which the resident complained of right hip pain. The LPN medicated the resident for pain and obtained a provider order for a STAT right hip X-ray, with an expectation that results would be available within 4–6 hours. The resident’s record later documented ongoing right hip pain, facial grimacing, and guarding of the right leg the following morning. Despite the STAT order and the provider’s and DON’s stated expectations that such X-rays be completed and resulted within hours, the ordered X-ray was never performed. The LPN who later transferred the resident to the hospital reported that the transfer occurred because the resident continued to complain of right leg pain and the previously ordered STAT X-ray had not been done. The resident was ultimately sent to a local emergency room approximately eighteen hours after the unwitnessed fall, where imaging revealed a superior laterally displaced comminuted intertrochanteric right femoral fracture. The report states that a reasonable person in the resident’s position would have experienced psychosocial harm related to pain, including facial grimacing and guarding of the right leg, as a result of the failure to carry out the STAT X-ray order.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable room temperatures for residents, with multiple resident rooms and the dialysis room recorded at temperatures ranging from 82 to 85 degrees Fahrenheit, exceeding the recommended maximum of 81 degrees. Observations revealed that residents expressed discomfort due to the heat, with some using fans or fanning themselves with paper, and others requesting additional fans. Staff interviews confirmed that the air conditioning units were not functioning properly, and parts had to be ordered and replaced, resulting in several days of elevated indoor temperatures. The maintenance director reported that temperature checks were conducted hourly during the day but not overnight, and that fans were provided only upon request. Some residents were unaware that fans were available. Dialysis staff reported that residents undergoing treatment in the dialysis room, which was also affected by the heat, appeared more fatigued and had more fluctuating vital signs than usual. Staff provided cold water, popsicles, and monitored for signs of heat-related illness, but did not check on residents during dialysis sessions. The facility's temperature logs confirmed that room temperatures remained above 81 degrees for extended periods. The deficiency affected 53 out of 54 sampled residents, with both residents and staff acknowledging the uncomfortable and potentially unsafe conditions caused by the inadequate temperature control.
Failure to Prevent Recurrent UTIs and Timely Reassess Catheter Use
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident, who had multiple diagnoses including neurogenic bladder, sacral pressure ulcer, and chronic kidney disease, was admitted with a urinary catheter and experienced ongoing discomfort and recurrent UTIs. Despite repeated complaints of pain and discomfort related to the catheter, as well as multiple documented UTIs treated with antibiotics, there was no timely or appropriate assessment for the removal of the catheter. Observations and interviews revealed that the resident repeatedly expressed discomfort and requested removal of the catheter, but staff did not act on these requests until much later. The infectious disease nurse practitioner and infection prevention nurse both indicated that there was no documented outreach to the physician to consider discontinuing the catheter, and the attending physician confirmed that there had not been any prior attempt to reassess or remove the catheter before it was eventually dislodged and removed. The resident had been treated for UTIs on several occasions, with the same bacteria recurring, and the infectious disease nurse practitioner noted that improper cleaning and contamination from a sacral wound may have contributed to the infections. Facility policies required ongoing assessment and review of residents with indwelling catheters, especially in cases of recurrent infection, but these procedures were not followed. The lack of timely reassessment and failure to consider catheter removal contributed to the resident experiencing four UTIs during her stay, with ongoing discomfort and repeated antibiotic use.
Failure to Provide Necessary Services Upon Admission
Penalty
Summary
The facility failed to provide necessary services upon admission for a resident with multiple complex medical diagnoses, including diabetes, hypertension, chronic kidney disease, and obesity. Upon admission, there was no face sheet, initial admission assessment, or baseline care plan in the resident's medical record. Nursing staff documented that the resident was non-verbal, responsive only to painful stimuli, and on 7 liters of oxygen via trach collar. Although a head-to-toe assessment and vital signs were recorded, there was no documentation of height, weight, or blood sugar. The nurse who received the resident did not reconcile medications or obtain any orders, and the subsequent nurse did not administer any medications or initiate G-tube feeding, citing lack of information and inability to reach the physician for orders. Multiple staff interviews revealed that the feeding rate for the G-tube was not obtained from the hospital report, and the nurse did not connect the feeding or administer medications, waiting for a physician's response. The nurse did not seek assistance from the supervisor, and the supervisor was unaware that the resident had not received medications or feeding. The DON stated that urgent medications could be accessed from the facility's medication system and that the feeding rate was present in the admission papers. The nurse practitioner confirmed that alternative contacts and the dietician should have been involved if the physician was unavailable. The resident did not receive necessary medications or nutrition from admission until a code blue was called later that evening.
Failure to Timely Notify Physician of Urgent Lab Delays
Penalty
Summary
The facility failed to adhere to its policy for notifying the attending physician or nurse practitioner about urgent laboratory tests not being completed within the required 4-6 hour timeframe. This oversight affected a resident who was subsequently sent to the hospital and diagnosed with dehydration, pneumonia, and a urinary tract infection. The delay in obtaining laboratory results was over nine hours, which contributed to the resident's deteriorating condition. Interviews and record reviews revealed that the resident had a history of decreased food and fluid intake, which was documented by the certified nurse aide. The resident's condition worsened, showing signs of weakness, fatigue, and dehydration. Despite the urgent need for laboratory tests, there was a lack of timely communication with the primary nurse practitioner and physician, which hindered the management of the resident's care. The facility's documentation was incomplete, with missing records of the resident's fluid intake and bladder continence episodes. The resident's medical records did not show any urinalysis conducted before hospitalization, and the medication administration record lacked documentation of an administered inhaler. These documentation gaps, along with the delay in laboratory testing, contributed to the resident's hospitalization for dehydration, pneumonia, and a urinary tract infection.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, resulting in a critical incident. The resident, who had a complex medical history including chronic respiratory failure, morbid obesity, congestive heart failure, and end-stage renal disease, refused dialysis treatment and was not adequately monitored for fluid volume overload. Despite the resident's refusal to go to the hospital as ordered by the nephrologist, the facility staff did not notify the nephrologist of the refusal or the abnormal chest X-ray results, which showed signs of fluid overload. The resident complained of shortness of breath and requested to go to the hospital, but the facility staff only provided education on breathing techniques and did not perform a thorough assessment or take further vital signs. The resident was found unresponsive later that day and expired in the facility. Interviews with staff revealed a lack of communication and follow-up on the resident's condition, with several staff members unaware of the resident's complaints or the significance of the missed dialysis treatments. The facility's policies on refusal of treatment and notification of change were not followed, as the attending physician and nephrologist were not properly informed of the resident's condition and refusal of care. The facility also failed to ensure timely completion and review of the STAT chest X-ray, which was not performed within the expected timeframe, and the results were not communicated to the physician in a timely manner. This series of inactions and communication failures contributed to the resident's deterioration and eventual death.
Removal Plan
- All current dialysis residents were assessed for potential fluid overload, intervention in place as appropriate.
- Licensed nurses were educated by the Director of Nursing on the need to assess and implement interventions related to fluid volume overload when residents miss dialysis treatments.
- Dialysis assessment orders were updated per their physician. Their assessment order reads: Monitor for signs and symptoms of fluid volume overload, edema, bloating, headache, weight gain, shortness of breath, elevated blood pressure, JVD, lung sounds with crackles or wheezing, abdominal distention, or tachycardia. This assessment will be completed every shift and PRN.
- Licensed nurses were educated by the Director of Nursing on the importance of notifying the Attending physician and if unable to reach him/her notifying the resident's Nephrologist.
- Licensed nurses were educated by the Director of Nursing if STAT radiology orders are not able to be completed within the recommended timeframe the provider will be notified for additional instructions.
- Licensed Nurses will not work until they have been educated.
- Radiology company (All-Stat) has been notified of the expectation of timely notification of abnormal radiology results.
- Licensed nurses were educated to review their electronic health records to check and communicate the results of the radiology report.
- An additional email notification system has been implemented with the radiology company. This ensures all nursing managers receive results as they are uploaded into the electronic health record.
- All nursing managers were educated on the additional notification system.
- The Director of Nursing will audit all residents who refused dialysis to ensure they have been assessed, appropriate interventions are implemented, and that the physician was made aware.
- The Director of Nursing will complete audits to ensure any STAT radiology orders were completed within the recommended timeframe, and if the physician was notified.
Facility Fails to Maintain Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain adequate hot water temperatures in all six shower rooms, affecting five residents. The issue began when the Maintenance Director noticed dropping water temperatures on January 3rd, 2025, and a plumbing contractor was called immediately. Despite the contractor's efforts, the problem persisted, and residents were unable to take showers due to the cold water. The Maintenance Director reported that the water temperatures were below the desired range of 100-110 degrees Fahrenheit, and staff were instructed not to use the showers until further notice. Residents expressed dissatisfaction with the situation, as they were unable to take showers and had to resort to using wipes or microwaved warm water for personal hygiene. Several residents reported not being informed about the progress of the repairs or when the hot water would be restored. The Assistant Administrator was notified of the issue on January 4th, 2025, and the Site Manager was informed on January 6th, 2025. The plumbing company identified a malfunctioning heat exchanger as the cause of the problem, and a new part was ordered, but the repairs were delayed due to approval and cost issues. The facility's documentation revealed inconsistencies in recording water temperatures, with no records of the temperatures during the period when they were below the acceptable range. The Loss of Hot Water Guideline outlined procedures for managing such situations, but there was a lack of communication and timely action to resolve the issue. The deficiency highlights the facility's failure to provide a safe and comfortable environment for residents, as required by regulations.
Failure to Maintain Hot Water System
Penalty
Summary
The facility failed to maintain its hot water system, resulting in suboptimal water temperatures in the shower rooms on the second, third, and fourth floors. The issue was first noticed by the Maintenance Director on January 3rd, when the water temperatures began to drop. A plumbing contractor was called immediately, and it was identified that the heat exchanger was malfunctioning. Despite efforts to address the issue, including cleaning the heat exchanger and replacing copper piping, the water temperatures remained below the required range for several days. The Assistant Administrator was informed of the hot water issue on January 4th, and the Site Manager was notified on January 6th. However, there was a delay in communication and approval processes, which contributed to the prolonged period of inadequate water temperatures. The Site Manager expressed concern about not being informed sooner and emphasized the need for timely communication to approve necessary repairs. The plumbing company was unable to complete the repairs promptly due to the facility's not-to-exceed limit on service costs, which required further approval. Throughout this period, water temperatures were inconsistently documented, and the Maintenance Director was unable to provide maintenance logs for the water heater system. The lack of scheduled maintenance and documentation, combined with delayed communication and approval processes, led to the deficiency in maintaining adequate hot water temperatures for the residents, including a resident with spinal stenosis, fibromyalgia, and lumbar disc degeneration.
Delayed Transport of Resident with Acute Medical Condition
Penalty
Summary
The facility failed to immediately transport a resident experiencing an acute change in medical condition, which was identified during a review of the resident's care. The resident, who had a history of dialysis and was noted to have low potassium levels, exhibited symptoms of lethargy, shortness of breath, and low oxygen saturation. Despite these symptoms, there was a delay in transporting the resident to the hospital. The nurse practitioner initially assessed the resident and applied oxygen, which temporarily stabilized the resident's condition, but the resident's oxygen levels later deteriorated. The nurse practitioner was not initially aware of the resident's critically low potassium levels from previous laboratory results. On the day of the incident, the resident's condition worsened, with symptoms including hypoxia and tachycardia. The nurse practitioner ordered urgent laboratory tests and administered antibiotics intramuscularly. However, the resident's oxygen saturation continued to decline, necessitating the use of a non-rebreather mask and eventually leading to the decision to transport the resident to the hospital. The documentation revealed that there was a lack of timely communication and action regarding the resident's abnormal laboratory results and acute symptoms. The resident was eventually transported to the hospital with a diagnosis of severe sepsis, but there was a significant delay from the time the resident's condition was identified as critical to the time of transport. This delay in response and transport contributed to the deficiency identified in the facility's care of the resident.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical abuse involving two residents. Resident R4, diagnosed with schizophrenia and peripheral vascular disease, displayed erratic behavior by striking Resident R5, who has a diagnosis of malignant neoplasm of the lung, chronic obstructive pulmonary disease, and Parkinsonism. The altercation occurred when R5 attempted to enter an elevator already occupied by R4, leading to R4 striking R5 in the face and hand with a cell phone, causing a laceration and pain. The incident was documented in nursing notes, a police report, and a facility incident report. Staff interviews revealed that R5 asked R4 to move forward to make room for both wheelchairs on the elevator. When R5's wheelchair accidentally bumped R4's, R4 became physically aggressive, hitting R5 with a closed fist and a cell phone. Staff intervened to separate the residents, and R5 sustained a scratch on the face and pain in the finger. The facility's care plans and assessments for both residents indicated that R4 was at risk for inappropriate responses due to schizophrenia, and R5 was at risk for abuse due to residing in a skilled facility. Despite these assessments, the facility's failure to prevent the altercation resulted in physical harm to R5, which was classified as physical abuse according to the facility's abuse prevention policy.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in a resident-to-resident physical assault. Resident R4 entered R1's room and physically assaulted R1, causing significant injuries including multiple lacerations, swelling, and a nasal bone fracture. R1, who has severely impaired cognitive decision-making skills, was transported to the hospital for treatment. The incident occurred despite signage in the men's village indicating that staff must be present at all times, and staff failed to adhere to this requirement. On the day of the incident, V4 CNA was working in the men's village and encountered combative behavior from R4. V4 attempted to redirect R4 but eventually left the men's village unattended to seek assistance from V3 LPN, who did not immediately respond. During this time, R4 entered R1's room and assaulted him. V4 and V3 only responded after hearing screams from the men's village, by which time R1 had already sustained injuries. V4 was unaware of the requirement to report the incident to the abuse coordinator. The facility's abuse prevention policy mandates staff training on assessing, preventing, and managing aggressive residents, and requires immediate reporting of any abuse incidents. However, the staff failed to follow these protocols. Additionally, R4's care plans related to his psychiatric diagnoses were not documented until after the incident, despite his history of visual delusions and hallucinations. This lack of adherence to the facility's policies and procedures contributed to the failure to prevent the assault on R1.
Failure to Supervise Aggressive Resident Results in Severe Injury
Penalty
Summary
The facility failed to effectively supervise and monitor a resident with a diagnosis of physical aggression and dementia, resulting in the resident physically assaulting a peer. This incident affected two residents, with one resident sustaining severe injuries including multiple lacerations, a swollen eye, ear redness and swelling, and a nasal bone fracture. The injured resident required hospital treatment and sutures to repair facial lacerations. The incident occurred in a locked unit known as the men's village, which was left unattended by staff for a period of time despite clear signage indicating that staff must be present at all times. On the morning of the incident, a CNA reported that a resident was being combative and attempted to redirect him. The CNA left the unit to get supplies, leaving the residents unattended. The CNA informed an LPN at the nurses' station about the combative resident, but the LPN did not immediately respond. Approximately ten minutes later, the CNA and LPN heard screaming and found the injured resident bleeding in his room. The injured resident and his roommate both reported that the aggressive resident had attacked him. The facility's Director of Nursing and Administrator were unaware that the men's village had been left unattended until after the incident occurred. The aggressive resident had a history of physical aggression and hallucinations, and his care plan included interventions to report all instances of alleged abuse. However, these measures were not effectively implemented, leading to the severe injury of a resident.
Failure to Identify and Treat Pressure Ulcer Timely
Penalty
Summary
The facility failed to identify, assess, and treat a change in skin condition for a resident, leading to the development of an unstageable, necrotic pressure ulcer. The resident, who was dependent on staff for toileting hygiene and required maximal assistance for movement, was admitted to the facility without any pressure ulcers. However, the resident was at risk for developing pressure ulcers as indicated by a Braden skin risk assessment. Despite this, the resident developed an unstageable pressure ulcer on the sacrum, which was first identified by the wound physician on November 22, 2023. The wound was initially documented as having moderate exudate, 20% slough, and 80% eschar, with no signs of infection. However, by December 6, 2023, the wound had declined, showing 100% eschar and signs of infection, including odor, necessitating hospitalization for further evaluation and treatment. Interviews with facility staff revealed that the certified nursing assistants (CNAs) are expected to report any skin changes to the floor nurse, who would then assess the resident's skin and notify the wound care nurses. However, the wound care nurse/coordinator acknowledged that the wound should have been identified before becoming necrotic. The wound care physician confirmed that the worsening of the sacral wound, with 100% eschar and possible infection, required surgical debridement and further evaluation. The registered nurse and CNA emphasized the importance of early identification and documentation of skin changes to prevent the progression to pressure ulcers. The failure to identify and address the skin condition in a timely manner resulted in the resident's wound deteriorating and requiring hospitalization.
Verbal Abuse Incident Involving Two Residents
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a staff member. On a specific date, a resident reported that a CNA entered their room and used profanity when the resident requested a specific size diaper. The resident's roommate confirmed the incident, stating that the CNA responded aggressively when asked to stop. Both residents involved were assessed to have no cognitive impairments, indicating they were aware of the situation and its impact. The facility conducted an investigation following the incident, which confirmed the CNA's use of profanity and loud behavior. The CNA admitted to using inappropriate language and acknowledged being too loud. The facility's abuse prevention policy defines verbal abuse as the use of disparaging and derogatory language, which aligns with the behavior exhibited by the CNA. The investigation was documented, and the CNA was no longer employed at the facility following the incident.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, specifically concerning the administration of Adderall XR and Adderall. The Medication Administration Record for the resident showed multiple instances where the medication was ordered and then discontinued within a short period. The resident was discharged to the hospital on three separate occasions during this time frame. On two occasions, the medication administration was marked with a '9', indicating a need to refer to the nurse's notes. However, there was no corresponding nurse's note for one of these instances, leaving a gap in documentation. The nurse involved, identified as V6, stated that if a medication is not available, they follow up with the pharmacy. The facility has a locked medication dispensing system, but the nurse indicated they were unable to access it without a supervisor. The resident had complained about not receiving their Adderall, but the nurse explained that if the medication was not available, it could not be administered. The facility's Medication Administration Policy outlines steps to be taken if a medication cannot be located, including contacting the pharmacy or using the night box/emergency kit, but it appears these steps were not effectively followed in this case.
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 1,907 citations issued within 25 miles in the last 12 months — including the 20 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 Crestwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya Of Crestwood | 1.1 mi | ★★★★★ | 33 | 0 |
| Crestwood Terrace | 1.7 mi | ★★★★★ | 3 | 0 |
| Elevate Care Palos Heights | 2.2 mi | ★★★★★ | 3 | 0 |
| Aperion Care Midlothian | 2.8 mi | ★★★★★ | 4 | 0 |
| Belhaven Nursing & Rehab Center | 3.7 mi | ★★★★★ | 29 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Thryve Of Crestwood.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.