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 Warren Barr Gold Coast during CMS and state inspections, most recent first.
A resident with bilateral knee osteoarthritis and intact cognition reported receiving only a few PT sessions over more than a month despite a physician order and PT plan of care for 2–3 sessions per week. The resident stated that a therapist came once and did not return that week and that staff told her she was not on the therapy schedule when she asked to get up for therapy. Record review confirmed only three PT encounters during the ordered treatment period, while the Therapy Director acknowledged that the ordered PT frequency was not met, contrary to the facility’s policy requiring therapists to follow physician-approved plans of care and ordered frequency and duration.
A resident with a history of traumatic subarachnoid hemorrhage, stroke with hemiplegia, falls, and syncope reported that a CNA hit or bumped her head on the bed and also punched her face during incontinence care. Nursing staff, including an RN and the DON, assessed the resident’s head and skin and completed incident, risk management, and pain assessment forms, finding no visible injury or pain on palpation. However, despite the resident’s clear report of a head impact and the facility’s policy and leadership statements that any suspected or reported head injury requires neurological checks for 72 hours, no neuro assessment or neuro checks were initiated or documented in the resident’s records, resulting in a failure to provide appropriate treatment and care after a reported head injury.
The facility assigned only one LPN per floor to two LTC units, each with 35 to 38 residents, resulting in delayed medication administration and inadequate attention to resident needs. Both LPNs reported being overwhelmed, and the staffing coordinator confirmed the reduced nurse staffing was directed by the DON, despite ongoing complaints from nursing staff. The DON acknowledged implementing the change and recognized that the assignments were overwhelming.
Due to recent staffing changes that reduced the number of nurses per floor, multiple residents did not receive their prescribed medications within the required time window. Both LPNs assigned to the third and fourth floors reported difficulty completing the morning med pass on time, and the eMAR system showed numerous overdue medications. Facility policy requires medications to be administered within one hour before or after the scheduled time, but this was not achieved for a significant number of residents.
A resident's legal representative was not provided timely access to the resident's medical records despite submitting a valid surrogate decision form, as required by facility policy. The records were withheld due to miscommunication and failure to properly review the submitted documentation, resulting in a significant delay before the records were released.
A resident with intact skin and multiple medical conditions was admitted to a facility and developed pressure ulcers due to inadequate repositioning and skin checks. Despite being non-ambulatory and requiring assistance, the facility failed to consistently implement a turning schedule, leading to the worsening of the resident's condition and subsequent hospitalization.
Staff used incorrect serving utensils for portioning grits, oatmeal, and pureed toast, resulting in residents not receiving the full food portions specified on the menu and meal tickets. The cook and Dietary Director confirmed that the correct utensils were not used, and the facility's portion control guides and policies were not followed.
Two residents, both cognitively intact and able to express their needs, were not notified or invited to participate in daily activities despite their interest and care plan goals. Staff interviews and observations confirmed that activity sessions occurred without these residents being informed or encouraged to attend, in violation of facility policy requiring daily engagement based on resident interests.
The facility failed to follow proper sanitation and food storage practices, with unlabeled food items found in storage areas and a malfunctioning dishwasher that did not reach the required sanitization temperature. Additionally, improper sanitization practices were observed in the kitchen's three-compartment sink, contributing to inadequate hygiene standards.
The facility failed to complete and transmit a resident's discharge assessment to CMS within the required 14-day period. The MDS/Clinical Coordinator acknowledged the oversight, noting the assessment was overdue by 122 days. Facility documentation confirmed the assessment should have been completed within 14 days.
A resident with schizoaffective disorder, anxiety, and depression was not referred for a PASARR Level II assessment due to incorrect documentation from the hospital and oversight by the facility's admission staff. The facility's DON acknowledged the need for evaluation to monitor the resident's behavior and medications, highlighting a deficiency in the assessment process.
The facility failed to properly use low air loss mattresses for three residents, with incorrect weight settings and excessive layers between the residents and mattresses. Staff provided conflicting information on the appropriate number of layers, potentially compromising pressure ulcer prevention and care.
The facility failed to maintain accurate records of controlled substances, leading to discrepancies in medication counts for several residents. An agency nurse found an unaccounted Hydromorphone tablet in a medication cart, and another nurse admitted to not signing the narcotic book, contributing to the discrepancies. The DON confirmed that all narcotics should be documented on a controlled substance sheet.
The facility failed to maintain a medication error rate below 5%, resulting in a 6.67% error rate. Two residents were affected: one received Vancomycin at an incorrect infusion rate, and another received an incorrect dosage of Vitamin D. The errors were due to staff not following prescribed medication administration procedures.
The facility failed to ensure that residents had access to functioning call lights, which are essential for requesting assistance. One resident's call light was not within reach, another's was non-functional, and a third's was found on the floor. These oversights occurred despite facility policies requiring call lights to be accessible and operational at all times.
A resident with hemiplegia and hemiparesis experienced significant tooth pain and anxiety due to the facility's failure to include dental care in her care plan. Despite a dentist's recommendation for tooth extraction, the care plan was not updated for over a month, affecting the resident's ability to eat and contributing to her depression. The facility did not adhere to its policy of updating care plans within seven days of assessment.
The facility failed to implement fall precautions for two residents at high risk for falls. One resident's bed alarm pad was incorrectly placed, and the assigned CNA was on a break without proper monitoring. Another resident's bed alarm was not plugged in, and the CNA was unaware of the requirement. Both residents had care plans indicating fall risks, but interventions were not properly executed.
A resident with end-stage renal disease did not receive prescribed Midodrine before dialysis sessions, despite physician orders and reminders to nursing staff. The nurse responsible did not administer the medication, citing high blood pressure, and failed to document the administration or reason for not administering it. The facility did not adhere to its medication pass and hemodialysis care policies.
Failure to Provide Ordered Physical Therapy Services as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services, specifically physical therapy, as ordered by a physician for one cognitively intact resident with bilateral primary osteoarthritis of the knees. The resident reported that for over a month she had received very little rehabilitation therapy despite being told by her physician that she would be referred to therapy. She stated that one therapist came once and did not return that week, and that since March she had only two or three therapy sessions. On the day of interview, she asked a CNA if she was scheduled to get up for therapy, as she required assistance to get out of bed, and was told she was not on the therapy schedule. The resident expressed that she believed therapy would help with her arthritis and knee pain. Record review showed that the resident had a physician order and PT plan of care for physical therapy 2–3 times per week for 41 days beginning in mid-March, based on an evaluation documenting balance deficits, decreased functional capacity, pain, strength impairments, and a need for skilled PT to improve mobility and safety. PT encounter notes showed only three visits (evaluation and two treatment sessions) over this period. The Therapy Director confirmed that the resident was evaluated in mid-March and seen for treatment on two subsequent dates, and acknowledged that, based on the visits provided, the physician’s order for 2–3 sessions per week was not followed. The facility’s own policy required therapists to follow physician-approved plans of care and deliver services per the ordered frequency and duration, but this did not occur for this resident.
Failure to Perform Neuro Checks After Reported Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to complete neurological monitoring after a resident reported a head injury. The resident had diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness (subsequent encounter), history of falling, syncope and collapse, asthma, hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side, atherosclerotic heart disease, and type 2 diabetes mellitus. The resident was cognitively intact with a BIMS score of 14 and required one-person assistance with ADLs, was incontinent of bowel and bladder, and had right-sided weakness. On the early morning in question, the resident reported that a CNA hit or bumped her head on the bed/headboard during incontinence care and also alleged being punched in the face. Following the allegation, the CNA immediately reported the incident to the RN and the RN supervisor. The RN assessed the resident’s head and reported no bruising, swelling, bleeding, obvious injuries, or pain on palpation. The RN documented that the resident stated her head was hit on the bed and the right side of her face and that she was punched in the face, and the RN completed a risk assessment report, a physical injury incident report, and a pain assessment report. The DON later assessed the resident’s head and reported no bumps or discoloration. Multiple internal incident and risk management forms were completed, including a Post Altercation/Alleged Abuse assessment, an Accident/Incident Report, and Risk Management documentation. Despite the resident’s report of her head being hit and the facility’s own expectations and policy, no neurological assessment or ongoing neurological checks were performed or documented. The RN acknowledged that neurological monitoring should be conducted anytime there is a report of a head injury or suspected head injury, and the DON stated that any witnessed or unwitnessed head injury requires neurological status monitoring with neuro checks for 72 hours. The facility’s Neurocheck policy states that the nurse will inform the physician of the incident and follow physician orders, including a neurocheck on the resident. Review of the Post Altercation/Alleged Abuse assessment, Accident/Incident Report, Risk Management form, and progress notes from the date of the incident through several days afterward showed no neurological checks documented or performed, demonstrating the failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Insufficient Nurse Staffing on Two LTC Facility Floors
Penalty
Summary
The facility failed to provide sufficient nursing staff, specifically Registered Nurses and Licensed Practical Nurses, to the third and fourth floors, which had the potential to affect 71 residents. On multiple occasions, only one nurse was assigned to each of these floors, with each nurse responsible for 35 to 38 residents per shift. Both nurses assigned to these floors reported feeling overwhelmed and unable to provide timely medication administration or adequate attention to all residents' needs. The nurses stated that while there were enough Certified Nursing Assistants (CNAs) present, the CNAs could not perform nursing duties, and the nurses were left to manage all clinical responsibilities alone. The staffing coordinator confirmed that the third and fourth floors were staffed with only one nurse per 12-hour shift, following instructions from the Director of Nursing (DON). The coordinator also reported that nurses had complained about the workload being too heavy for one nurse, but she was unable to make staffing changes herself. The DON acknowledged that the change to one nurse per floor was a recent decision and that nurses had previously expressed concerns about the workload, especially during the morning shift when medication passes and other activities were at their peak. The DON admitted to implementing the reduced nurse staffing schedule and recognized that the assignments were overwhelming for the nurses. She stated that she had previously tried the assignment herself and was able to complete the work, but acknowledged that the nurses' complaints indicated residents were not receiving the proper care. Review of staffing schedules and facility policy confirmed the reduction in nurse staffing and the facility's stated requirement to provide adequate staff to meet residents' needs.
Delayed Medication Administration Due to Staffing Changes
Penalty
Summary
The facility failed to administer prescribed medications to residents in a timely manner according to physician orders, affecting 29 out of 35 sampled residents. On the day of the survey, only one nurse was assigned to each of the third and fourth floors, whereas previously two nurses had been assigned per floor. Both nurses reported that the new staffing schedule made it difficult to complete the morning medication pass within the required time frame. The eMAR system showed multiple residents with overdue medications, indicated by a red color, and both nurses confirmed that some medications were late. Observations by the surveyor confirmed that numerous residents' eMARs were marked as late, and a medication audit report documented that scheduled medications for these residents were administered outside the facility's policy window of one hour before or after the scheduled time. Facility policies require medications to be administered according to prescriber orders and within the specified time window, but these requirements were not met due to the staffing changes and resulting delays.
Failure to Provide Timely Access to Medical Records for Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records as required by policy. The resident in question had a history of multiple medical conditions, including cerebral infarction, congestive heart failure, type 2 diabetes, and atherosclerotic heart disease. After the resident was discharged, the resident's daughter, acting as a surrogate decision maker, requested access to the medical records. She provided a surrogate decision form, which the facility accepts as valid documentation for releasing records. However, the Medical Records Director did not release the records, citing the absence of a power of attorney (POA) document, and referred the matter to the corporate office for review. Despite the surrogate decision form being provided and accepted by facility policy, the records were not released in a timely manner. The Medical Records Director assumed the corporate office had reviewed the attached surrogate form, but it appears only the first page was reviewed, and the form was overlooked. The legal representative did not receive the requested records until months later, after further review during the survey process. The delay was due to miscommunication and failure to properly review and act on the provided surrogate documentation.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure ulcers in a resident, identified as R2, who was admitted with intact skin. R2 had multiple medical diagnoses, including neuromuscular dysfunction of the bladder and impaired mobility, which increased the risk for skin breakdown. Despite being non-ambulatory and requiring assistance for repositioning, the facility did not consistently implement a turning and repositioning schedule as outlined in R2's care plan. This lack of regular repositioning and skin checks contributed to the development of two pressure ulcers on R2's right buttock and left heel. R2's care plan indicated a high risk for skin integrity impairment, necessitating skin checks every shift and repositioning every two hours. However, interviews with R2 and staff revealed that R2 was not regularly repositioned or checked on by the nursing staff, even after the development of the wounds. R2 expressed that he was unable to reposition himself and relied on staff assistance, which was not consistently provided. The wounds worsened, leading to hospitalization for infection and surgical intervention. The facility's wound care guidelines emphasized the importance of individualized care plans and regular skin inspections to prevent pressure injuries. Despite these guidelines, the facility did not promptly implement interventions such as an air mattress and heel protectors until after the wounds had worsened. The delay in appropriate interventions and failure to adhere to the care plan contributed to the deterioration of R2's condition, highlighting a significant deficiency in the facility's care practices.
Failure to Serve Adequate Food Portions as Specified on Menu
Penalty
Summary
The facility failed to serve adequate food portions as specified on the menu and meal tickets, affecting all residents receiving food from the kitchen. During a survey, it was observed that a 4-ounce ladle was used to portion grits and oatmeal for all diet types, and a number 12-scoop was used for pureed toast, which did not match the portion sizes indicated on the meal tickets and menu guides. The cook responsible for setting up the tray line confirmed that the meal tickets only listed portion measurements and not the specific utensils to use, and admitted to using incorrect utensils due to the absence of a previously posted diagram that matched utensils to portion sizes. Further review with the Dietary Director revealed that staff are expected to reference a Diet Manual Spreadsheet, which details the correct serving utensils, but this was not followed. The facility's own policy and menu documentation require that menus be served as written and that portion sizes be adhered to, with specific utensils designated for each food item and consistency. The incorrect use of serving utensils resulted in residents not receiving the full portions as planned and approved by the Registered Dietitian, as confirmed by both the cook and the Dietary Director.
Failure to Notify and Engage Residents in Meaningful Activities
Penalty
Summary
The facility failed to ensure that residents were properly notified, invited, and engaged in meaningful activities that matched their interests, as required by facility policy. Two residents, both cognitively intact and able to verbalize their needs, reported not being informed about daily activities. One resident, who is blind and dependent on staff for mobility, expressed a desire to participate in activities such as bingo and gospel hour but stated that staff had not provided information or invitations regarding these events. The resident also noted that activity sheets, previously distributed, had not been received for some time. The other resident, present in the facility for three months, similarly reported never being told about available activities and expressed interest in participating if informed. Observations confirmed that activity sessions were being conducted, but neither of the two residents attended, and staff interviews revealed that they had not been personally invited that day. The Activity Aide and Activity Director both acknowledged that they had not notified or invited these residents to the day's activities, despite the facility's policy and the residents' care plans indicating the need for daily engagement and encouragement. Documentation showed that one resident had a care plan goal to participate in at least one activity per week to address depression and isolation, yet there was no evidence of consistent efforts to inform or involve the resident in activities.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed during a survey. In the walk-in cooler, several food items were found without proper labeling, including beverage dispensers and pitchers filled with juice, a container of margarine spreads past its use-by date, an opened box of chocolate chips, and a package of hard-boiled eggs. In the walk-in freezer, items such as a box of fish fillets, a box of bread, and plates covered with aluminum foil were also found without appropriate labeling. Additionally, a 25-pound bag of instant nonfat dry milk was improperly stored in the dry storage area. The facility's dishwasher was found to be malfunctioning, as it did not reach the required temperature of 160 degrees Fahrenheit during the wash/rinse cycle, as evidenced by testing strips that failed to change color. This issue persisted despite attempts to repair the dishwasher, indicating that dishware was not being sanitized properly. The facility's only dishwasher was unable to sanitize dishware effectively, posing a risk of foodborne illness to residents. Furthermore, improper sanitization practices were observed in the kitchen's three-compartment sink. A cook was seen submerging a pan in the sanitizing solution for only 8 seconds, contrary to the required 30 seconds or manufacturer recommendations. This inadequate sanitization process further contributed to the facility's failure to maintain proper hygiene standards in food preparation and storage areas.
Failure to Complete and Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a resident's assessment data to the CMS system within the required timeframe. Specifically, the discharge assessment for a resident, identified as R151, was not completed within 14 days after the resident was discharged from the facility. During an interview, the MDS/Clinical Coordinator, V34, acknowledged familiarity with the resident and explained the process for completing assessments when residents are admitted or sent to the hospital. However, upon review, it was found that R151's discharge assessment was overdue by 122 days. The facility's documentation indicated that the discharge assessment should have been completed within 14 calendar days, but this was not adhered to in the case of R151.
Failure to Conduct PASARR Level II Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to refer a resident with serious mental disorders for a Preadmission Screening and Resident Review (PASARR) Level II assessment. The resident, identified as R143, is a [AGE] year-old individual with medical diagnoses including schizoaffective disorder, anxiety disorder, and depression. Despite these diagnoses, the resident's PASRR Level I Screening incorrectly documented that there was no suspected or known mental diagnosis. This oversight was discovered during a survey, revealing that the resident's mental health needs might not be properly addressed due to the lack of a PASARR Level II assessment. The Director of Nursing acknowledged that the resident should have been evaluated for PASARR Level II to monitor behavior and medications related to behavioral health. The facility's administrator stated that they rely on hospitals to provide accurate information regarding PASARR assessments, and in this case, the hospital failed to document the resident's mental health diagnoses. Additionally, the facility's admission office staff, who is not a nurse, did not review the resident's diagnoses to determine the need for a PASARR Level II screening. This lack of proper assessment and coordination led to the deficiency identified by the surveyors.
Improper Use of Low Air Loss Mattresses for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer preventative measures for three residents using low air loss mattresses. Observations revealed that the mattress settings for two residents were not adjusted according to their weights, with one resident's mattress set at 310-318 pounds despite their weight being 227 pounds, and another resident's mattress set at 90 pounds despite their weight being 148.4 pounds. Additionally, the facility staff, including a Registered Nurse and a Certified Nursing Assistant, confirmed that there were multiple layers between the residents and the mattresses, which could impede the effectiveness of the mattresses in preventing pressure ulcers. The facility's staff provided conflicting information regarding the appropriate number of layers allowed on the low air loss mattresses. While some staff members stated that only one layer should be used, others mentioned that up to three layers, including a brief, chuck, and sheet, were permissible. The facility's Director of Nursing and Wound Care Coordinator acknowledged the importance of setting the mattress according to the resident's weight and the role of the mattress in preventing and aiding in the healing of pressure ulcers. However, the discrepancies in mattress settings and layering practices indicate a failure to adhere to the intended use of the low air loss mattresses, potentially compromising the residents' care.
Controlled Substance Recordkeeping Deficiency
Penalty
Summary
The facility failed to maintain accurate records of controlled substances, specifically Hydromorphone, Hydrocodone, Pregabalin, and Clonazepam, leading to discrepancies in medication counts. An agency nurse discovered a Hydromorphone tablet in a medication cart without a resident name or controlled substance record form. The nurse was informed by a colleague that it was an extra medication, but acknowledged that it should not have been unaccounted for in the cart. Additionally, another agency nurse admitted to not signing the narcotic book after medication pass, which contributed to the discrepancies in narcotic counts for three residents. The discrepancies included missing tablets for Hydrocodone, Pregabalin, and Clonazepam, with the actual count being less than the recorded count. The Director of Nursing later stated that the unaccounted Hydromorphone was used for a resident whose supply had not yet arrived, but confirmed that all narcotics should be documented on a controlled substance sheet. The facility's policy requires an accurate count of Schedule II controlled medications, with nurses signing off on the controlled medication sheet after removing medication from its packaging.
Medication Administration Errors Lead to 6.67% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.67% error rate during a survey of 35 residents. Two residents were directly affected by this deficiency. One resident, identified as R427, received Vancomycin at an incorrect infusion rate. The Registered Nurse (RN) set the IV pump to 166ml/hr instead of the prescribed 120ml/hr, causing the medication to be administered over 55 minutes instead of the ordered 75 minutes. The RN was unsure if the rate could be adjusted manually on the pump and stated that the usual procedure was to input the dose, allowing the pump to determine the rate. The Medical Director confirmed that the medication was administered faster than prescribed but noted no adverse reactions at the IV site. Another resident, identified as R89, received an incorrect dosage of Vitamin D. The Licensed Practical Nurse (LPN) administered one tablet of 1000 IU instead of the prescribed two tablets. The facility's policy, dated 8/16/2024, mandates adherence to all Federal and State regulations regarding medication pass procedures, which was not followed in these instances. These errors contributed to the facility's failure to maintain the required medication error rate.
Failure to Ensure Functioning Call Lights for Residents
Penalty
Summary
The facility failed to ensure that residents had access to functioning call lights, which is crucial for their ability to request assistance. In the case of one resident, the call light was not within reach as it was wrapped around the bed frame. Although the resident was cognitively intact and able to use the call light, the CNA on duty acknowledged that she should have ensured the call light was accessible during her rounds. The resident's care plan emphasized the importance of having the call light within reach due to her dependency on assistance for activities of daily living. Another resident experienced a non-functional call light, which prevented her from calling for help. This resident, who had severe cognitive impairment and required assistance with various activities, was observed trying to use the call light without success. The CNA confirmed the call light was not working and highlighted the risk of the resident attempting to reach for items without assistance, potentially leading to injury. The facility's policy mandates regular checks of call lights to ensure they are operational, but this was not adhered to in this instance. A third resident's call light was found on the floor, out of reach, which prevented her from calling for assistance. The LPN and CNA responsible for her care acknowledged the oversight, with the CNA noting she had not yet conducted her rounds. The resident was alert and oriented, capable of using the call light, and required significant assistance. The facility's policy clearly states that call lights should be within reach at all times, but this was not followed, leading to the deficiency.
Failure to Address Resident's Dental Care Needs
Penalty
Summary
The facility failed to provide adequate planning of care related to oral and dental care for a resident diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident, who is cognitively intact, reported tooth pain that began in early September, which was initially noted by a medical doctor on 9/11/2024. Despite being seen by a dentist on 9/12/2024, who recommended a tooth extraction, the resident's care plan did not include any interventions for the dental issue until 10/16/2024. The delay in addressing the dental problem resulted in the resident experiencing significant pain and anxiety, affecting her ability to eat and contributing to her depression. The resident's care plan was not updated to include the dental issue until over a month after the problem was first identified. The Director of Nursing acknowledged that the care plan was not comprehensive enough to address all issues related to the resident's tooth problem, including pain management and dietary changes. The facility's policy requires that care plans be developed and implemented within seven days of a comprehensive assessment, but this was not adhered to in this case. The deficiency was identified during a review of the resident's care plan and interviews with facility staff, highlighting a failure to meet federal regulations for comprehensive, person-centered care planning.
Failure to Implement Fall Precautions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall precaution interventions for two residents identified as a fall risk. The first resident, R2, was observed lying in bed with a bed alarm pad hanging on the rails at the top of the bed instead of being placed underneath the resident's body. The registered nurse, V5, acknowledged that the bed alarm pad was incorrectly placed and that R2 required 1:1 care with a CNA present at all times. However, the assigned CNA, V6, was on a break and had instructed another CNA to monitor R2, but the bed alarm pad was still not correctly positioned. R2's care plan indicated a risk for falls with interventions including a mobility alarm, and a nursing progress note documented a previous incident where R2 was stuck between the bed and side rail. The second resident, R4, was found with a bed alarm pad in place but not plugged in, rendering it ineffective. The CNA, V7, who started her shift late, was unaware of the bed alarm requirement and only plugged it in after being prompted. The LPN, V8, confirmed that R4's fall precaution interventions included a bed alarm, and acknowledged that an unplugged alarm would not alert staff if R4 fell. R4's care plan and fall risk assessment indicated a high risk for falls, with a history of falls in the facility. The facility's policy required that residents at high risk for falls be provided with interventions, which were not properly implemented in these cases.
Failure to Administer Medication Per Physician Parameters Before Hemodialysis
Penalty
Summary
The facility failed to administer medication per physician parameters prior to hemodialysis for one resident (R2). R2, who has a diagnosis of end-stage renal disease and other significant health conditions, reported that they are supposed to receive Midodrine before leaving for dialysis sessions on Tuesdays, Thursdays, and Saturdays. Despite reminding the nurses, R2 did not receive the medication as prescribed. The resident's records confirmed the physician's order to administer Midodrine if the systolic blood pressure (SBP) was less than 100 before dialysis. However, the medication was not administered on at least one occasion when R2's blood pressure was recorded as 93/54 before dialysis, and there was no documentation of the medication being given in the Medication Administration Record (MAR) for that date. Interviews with the nursing staff revealed that the nurse responsible for R2's care during the night shift did not administer the Midodrine, citing that R2's blood pressure was usually too high before dialysis. The nurse admitted to not administering the medication and not documenting it in the MAR. The Director of Nursing (DON) confirmed that nurses are expected to follow physician orders and document medication administration immediately in the electronic medication administration record (EMAR). The facility's policies on medication pass and hemodialysis care were not adhered to, as the nurse failed to administer the medication as ordered and did not document the administration or the reason for not administering it. The facility's failure to follow physician orders and document medication administration properly resulted in R2 not receiving the prescribed Midodrine before dialysis. This deficiency highlights a lapse in the facility's adherence to its medication pass procedures and hemodialysis care policies, as well as a failure to ensure that nursing staff follow physician orders and document care accurately. The DON emphasized the importance of checking order summary reports and following medication parameters, which were not met in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terraces At The Clare | 0.3 mi | ★★★★★ | 1 | 0 |
| Warren Barr Lincoln Park | 2.2 mi | ★★★★★ | 10 | 0 |
| Little Sisters Of The Poor | 2.2 mi | ★★★★★ | 0 | 0 |
| Avantara Lincoln Park | 2.4 mi | ★★★★★ | 9 | 0 |
| Landmark Of Lincoln Park Rehabilitation And Nursin | 2.4 mi | ★★★★★ | 4 | 0 |
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