Average — CMS composite of the measures below.
The next survey window likely opens around May 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 Warren Barr North Shore during CMS and state inspections, most recent first.
Missed Dialysis Treatments Not Reported to Physician: A resident with ESRD on HD three times weekly missed two HD treatments after becoming tired following an MRI, and the dialysis nurse was notified and the treatments were rescheduled, but there was no documentation that the physician was notified. The resident later signed off early from HD and was hospitalized with chest pain, junctional bradycardia, and hyperkalemia requiring ICU care and emergent HD.
The facility failed to provide bed hold notices to two residents who were transferred to the hospital. One resident was sent out for a scheduled procedure and later hospitalized for surgery, but staff documented no attempt to issue a bed hold notice to the resident or POA. Another resident was transferred for oxygen desaturation, and the record showed the bed hold policy was not given to the resident or representative before transfer, despite staff stating the facility relied on the Change in Condition Form and did not provide another paper copy.
A resident with schizophrenia, dementia, bipolar disorder, and metabolic encephalopathy was mainly bedbound and was observed in bed with the TV on and no other activities available in her room. She stated she did nothing all day, did not like coloring, and wanted more meaningful activities such as assembly-line tasks, pet therapy, latch hook, and tissue-paper crafts. An activity assistant described pop-in visits and casual conversation, but there was no documentation of these visits in the activities record.
The facility failed to provide appropriate nail care for a resident with CKD, ESRD on dialysis, DM2, and hemiplegia/hemiparesis, whose fingernails were overgrown, thickened, discolored, and reportedly not addressed despite the resident asking staff for help. The facility also failed to ensure daily weights were properly performed and documented for a resident with CHF; the resident said weights were only taken on dialysis days, the record showed missing numerical weights, and the DON confirmed the daily weight order was not recorded correctly.
A resident with multiple comorbidities had a painful left heel pressure injury with black/necrotic areas, but weekly wound assessments were not completed and the heel was observed without a protective dressing; the wound record also reflected changing descriptions of the injury, including a suspected DTI, stage 2 pressure injury, and later DTI with no further assessment documented. Another resident at high risk for skin breakdown had an order and care plan for a low air loss mattress, but was observed on a standard mattress instead of the ordered pressure-relief surface.
A resident with a CVA history, severe cognitive impairment, and right-sided contractures was observed with his right hand clenched in a tight fist and no splint or padding in place, despite the care plan calling for the affected extremity to be well padded. Staff later stated the resident should have a towel roll or splint to prevent skin breakdown and manage the contracture, and the restorative nurse confirmed the need for one.
A resident at risk for altered nutritional status did not receive an ordered fortified pudding supplement with lunch. The meal tray did not include the supplement, and the resident confirmed it was not received, even though the MAR was documented as given by an RN who stated the supplement should have come from the kitchen on the tray.
Medication administration was not carried out as prescribed for two residents. One resident had five pills left on the bedside table after meds were left there, and another resident’s Potassium Chloride ER tablet was crushed and mixed with applesauce even though the medication card said, Do not crush. The DON stated staff should not leave medications at the bedside, and the LPN said she always crushes the potassium because the resident is anxious and wants meds when she wants them.
Failure to Use PPE and Implement EBP: A resident on EBP with a tracheostomy received device care from an RN who wore gloves but no gown, despite the care plan and posted sign requiring gloves and gowns for high-contact care. Another resident with a nephrostomy tube had no EBP signage or PPE cart at the room, and staff and a family member reported EBP was not being used even though the care plan required gloves and a gown for tube care.
A resident was not documented as being offered the pneumococcal vaccine upon admission. The immunization record showed no evidence the vaccine was offered, and the EMR had no history of prior pneumonia vaccines. The Infection Prevention Nurse said she is the only staff member who offers vaccines and that timing depends on workload, while the DON stated new admissions should be offered immunizations when they arrive. The facility policy stated pneumococcal vaccination will be offered upon admission if recommended by ACIP.
Failure to offer the COVID-19 vaccine on admission for one resident reviewed for immunizations. The IPN stated she is the only staff member who offers vaccines and that timing depends on how backed up she is, with some short-stay residents leaving before vaccines are offered. The DON stated new admissions should be offered immunizations when they arrive, and the facility policy required recommended vaccines to be provided in a timely manner before the peak of the fall respiratory season.
Survey Binder Not Accessible to Residents: The facility failed to keep the state agency survey binder with past survey results readily accessible. No residents knew where it was located, and the binder was found on a lobby table blocked by furniture and only reachable from one end, making it inaccessible to residents in wheelchairs without staff assistance. The Administrator stated residents could ask staff for help if they could not reach it.
A CNA paused a resident's enteral feeding pump during cares and again when returning with another staff member to provide care. The resident had a G-tube for enteral feedings as the primary source of nutrition, and the DON stated CNAs are not allowed to operate enteral feeding pumps because they are not licensed or trained to do so.
A facility failed to provide timely incontinence care and feeding assistance to dependent residents. Two residents were found with soiled briefs containing urine and stool, with stool leakage and red buttocks/groin, while a third resident with metabolic encephalopathy and ESRD was observed eating in bed without proper positioning or feeding setup, with food scattered around the bed and coughing during the meal despite needing 1:1 feeding assistance and upright positioning.
Failure to provide ordered wound care and pressure relief interventions for residents with pressure injuries and pressure injury risk. A resident with a Stage 4 sacral wound was found with stool in the wound, a soiled dressing, and no condom catheter in place. Another resident with a heel pressure injury did not have the ordered dressing in place and was on a low air loss mattress set for the wrong weight. A third resident at high risk for pressure injuries was also on a low air loss mattress set incorrectly, with heels resting directly on the mattress instead of being offloaded.
The facility failed to keep an indwelling catheter bag below the bladder for one resident and failed to apply an ordered condom catheter for another resident. One resident’s catheter bag was observed in bed at hip level with urine backflow noted during incontinence care, despite the care plan and facility policy requiring the bag and tubing to be positioned below the bladder. Another resident with dementia, urinary incontinence, and a stage 4 sacral PI was found with a urine-soaked brief, stool contamination of the wound and dressing, and no condom catheter in place, even though a physician order and care plan required it.
Failure to provide ordered colostomy care: A cognitively intact resident with a colostomy was supposed to have the bag changed every 3 days, but the treatment record showed inconsistent documentation and the LPN denied performing a documented bag change. During observation, the resident said the bag had not been changed since returning from the hospital and reported itching and irritation around the site; she also stated she had never refused care.
Enteral feeding order not fully administered. A resident with Alzheimer’s disease, malnutrition, and a G-tube as her sole source of nutrition had ongoing weight loss while the RD increased Jevity 1.5 from 560 ml to 630 ml at 35 ml/hr. The POS and MAR still showed both the old and new orders as active, and staff signed off both orders as given. Surveyors observed the feeding running at 35 ml/hr with only 560 ml total volume hanging, and the DON confirmed the amount infused matched the old order rather than the current order.
Medication Supervision Failure: A resident had a medication cup with multiple unknown meds left on the bedside table while sleeping. The resident said staff leave meds on the table, and the LPN stated she had not yet passed meds to the resident and did not know where the meds came from. The resident’s care plan and active orders did not indicate self-administration.
A resident with a history of falls, lack of coordination, and abnormal gait did not have floor mats at the bedside as required by their care plan. Despite a recent unwitnessed fall, observations confirmed the absence of this intervention, and staff acknowledged that care plan interventions should be in place.
A resident with a history of hip replacement and infection suffered an intertrochanteric fracture after a CNA reportedly handled her roughly during a diaper change, despite her refusal. The incident was corroborated by the resident's roommate and medical records, which highlighted the need for gentle handling due to the resident's impaired mobility and pain. Previous concerns about CNA roughness during night shifts were noted in the facility's resident council minutes.
The facility failed to store liquid lorazepam according to the manufacturer's guidelines, as it was found in medication carts instead of being refrigerated. This affected four residents, with LPNs and an RN acknowledging the oversight. The facility's policy requires medications to be stored per manufacturer's instructions, which was not followed in this case.
The facility failed to provide comfortable medical equipment for two residents. One resident's wheelchair was uncomfortable, and despite complaints, no action was taken due to a lack of communication among staff. Another resident's bed was malfunctioning, causing discomfort, but the issue was not reported to maintenance. Both cases highlight a breakdown in communication and reporting processes within the facility.
A resident requiring ongoing eye injections did not have an ophthalmologist appointment scheduled in a timely manner, despite a physician's order. The resident expressed frustration over the lack of follow-through, and the facility's ward clerk admitted the task was delayed. The ophthalmologist's office confirmed no contact from the facility, and the assistant administrator acknowledged the expectation for prompt scheduling was not met.
A resident with right-sided paralysis and chronic renal disease was unsafely transferred by two CNAs using a gait belt and manual lifting, contrary to the care plan that required a mechanical aid. The resident was unable to bear weight or pivot, highlighting a failure to ensure safe transfer practices.
A resident with a history of weight loss and multiple diagnoses, including moderate protein calorie malnutrition, did not receive the ordered fortified pudding with her meals. Despite a significant weight loss over several months, the resident's lunch tray lacked the prescribed supplement. The dietitian noted the resident's tendency to sleep during meals, which may have contributed to her weight loss, and the facility's policy did not address insidious weight loss.
A resident with a history of multiple health issues, including rheumatoid arthritis and dementia, experienced significant pain during incontinence care. Despite expressing severe pain, the nursing staff failed to conduct a comprehensive pain assessment before administering pain medication. The facility's policy requires thorough pain evaluations, which were not followed in this case.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peritoneal dialysis catheter upon admission. The resident was not identified for EBP, and staff were observed providing care without appropriate PPE. Interviews revealed that the Infection Control Preventionist and a Registered Nurse acknowledged the oversight, as the facility's policy requires EBP for residents with indwelling medical devices.
A resident with a suspected stress fracture did not receive ongoing assessments, leading to a delay in medical intervention. Despite an x-ray indicating a possible fracture, the resident's condition was not documented or assessed from 7/4 to 7/7, resulting in hospitalization for a femoral neck fracture and deep venous thrombosis. Staff interviews revealed a lack of communication and adherence to facility policies regarding changes in resident condition.
Missed Dialysis Treatments Not Reported to Physician
Penalty
Summary
The facility failed to ensure dialysis treatments were provided for a resident who required hemodialysis three times a week. The resident had diagnoses including chronic kidney disease, end stage renal disease, dependence on renal dialysis, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarct, and hypertension. The physician orders required hemodialysis every Tuesday, Thursday, and Saturday. During an interview, the resident stated he missed dialysis after an MRI because he was tired and later had trouble breathing and was sent to the hospital. Nursing staff stated that when a resident misses dialysis, the dialysis nurse is usually notified and the treatment is rescheduled, and the physician is notified if a second treatment is missed. Record review showed the resident refused hemodialysis on 2/26/26 and again on 2/27/26, with documentation that the dialysis nurse was notified and the treatment was rescheduled, but there was no documentation that the physician was notified of either missed treatment. The resident then received dialysis on 2/28/26 but signed off early, and was later sent to the hospital with a change of condition. The nurse practitioner note documented that the resident had been admitted with chest pain and was found to have junctional bradycardia and hyperkalemia with a potassium level of 8.3 due to missed dialysis sessions, requiring ICU admission and emergent hemodialysis. The DON confirmed there was no documentation that nursing notified the physician of the missed dialysis treatments.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to two residents who were transferred to the hospital. For one resident, progress notes showed the resident was sent to a local hospital for a scheduled procedure and then remained hospitalized for surgery, but there was no documentation that the facility attempted to issue a bed hold notice to the resident or the resident’s power of attorney after learning of the hospitalization. The Administrator stated the facility did not attempt to give the resident a bed hold notice, and the Executive Director stated the facility never issued one. For another resident, the electronic record showed the resident was sent to the hospital for oxygen desaturation, and the Change in Condition Form stated that prior to transfer, the facility’s bed hold policy was not given to the resident and/or representative. The Administrator stated uncertainty about what was sent with the resident, while the DON stated the facility sent the Change in Condition Form to the hospital, gave the bed hold policy on admission, and did not provide another paper copy at transfer. The facility’s bed hold policy stated that the resident or family members being transferred must be informed in writing of the duration of bed hold.
Failure to Provide Meaningful In-Room Activities
Penalty
Summary
The facility failed to offer a bedbound resident meaningful activity to support her mental health. The resident, who had diagnoses including schizophrenia, dementia, bipolar disorder, and metabolic encephalopathy, was described in the care plan as having limited mobility and mainly staying in bed. During observations, she was found in bed with the television on, and at one point she was not willing to engage with the surveyor. On another observation, she was lying in bed with the television on but did not appear to be watching it, and she did not have any other activities available to her while in her room. When the resident was later interviewed, she stated that she did nothing in her room all day and said she did not really like coloring, although staff had brought it in. She expressed that she liked to feel productive and wanted activities such as assembly-line style tasks, pet therapy with puppies and kittens, latch hook, and making flowers out of colored tissue paper. An activity assistant stated that staff did pop-in visits, chatted with the resident, organized her room or snacks, and talked about the TV, weather, or staff care, but also said the resident had never asked for in-room activities and that documentation of visits may not have been completed. No documentation of pop-in visits was provided in the activities section of the resident’s electronic record.
Failure to Provide Nail Care and Daily Weight Monitoring
Penalty
Summary
The facility failed to provide appropriate nail care and services for a resident with chronic kidney disease, end stage renal disease, dependence on renal dialysis, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarct affecting the right dominant side, and hypertension. The resident’s left fingernails were observed to be overgrown, curved, hardened, and significantly thickened with a white chalky buildup under the nailbed and yellowish/brownish discoloration. The resident stated he had asked staff to cut his nails, but they said they could not, and he reported that the podiatrist told him he could only cut toenails. The resident also said he believed he had fungus on his nails because he had it in the past. An RN said he was not sure what was going on with the resident’s nails and that they had been like that since the resident started at the facility about two months earlier. The DON said she was not aware of the nail condition and staff should have notified the physician to obtain treatment orders. The resident’s physician order sheets for June 2026 showed no treatment orders or appointments for nail care, and the care plan showed he required extensive assistance with activities of daily living including personal hygiene care. The facility also failed to ensure daily weights were performed and documented for a resident with CHF. The resident’s orders included daily weights for 2 weeks, then weekly unless otherwise indicated by the cardiologist, and another order to monitor weight daily and notify the doctor for a 2-pound gain in one day or 5-pound gain in one week. The resident stated she was not being weighed daily and was only weighed when she went to dialysis on Monday, Wednesday, and Friday. The weight record for May 2026 contained only two recorded weights, and the MAR showed daily weights were to be done but only check marks were entered with no numerical values. The DON confirmed the daily weights were not recorded and said the order had been entered incorrectly. An RN stated that for a resident with heart failure, weights are done to monitor fluid status. The care plan identified the resident as at risk for fluctuating weights and directed monitoring as ordered.
Failure to Complete Wound Assessments and Use Ordered Pressure-Relief Support Surfaces
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for 2 residents. For R22, who had diagnoses including end stage renal disease, type 2 diabetes with diabetic neuropathy, major depressive disorder, and cerebral infarction, surveyors observed a painful left heel wound with black/necrotic areas while she was sitting in her wheelchair. The wound nurse and wound nurse practitioner identified two separate pressure areas on the left heel, including a deep tissue injury with eschar, but the report states weekly wound assessments were not performed and there was no protective dressing in place at the time of observation. The wound had been identified on admission, and the record showed changing descriptions of the left heel wound, including a suspected deep tissue injury, a stage 2 pressure injury, and later a deep tissue injury measuring 3.5 cm x 3.5 cm, with no further assessments documented for the deep tissue injury. For R153, the care plan identified a history of MASD to the buttocks, high risk for skin breakdown and pressure injuries due to incontinence and obesity, extensive assistance needs for repositioning and ADL care, and a requirement for a low air loss mattress. A physician order also directed use of a low air loss mattress. However, surveyors observed R153 on a standard facility mattress rather than the ordered low air loss mattress, and staff confirmed that residents with pressure injuries or at risk for skin breakdown should have low air loss mattresses and that nursing was responsible for ensuring the correct mattress was in place.
Failure to Provide Padding or Splint for Contracted Hand
Penalty
Summary
The facility failed to ensure a resident with limited ROM wore a hand splint or padding for treatment of a contracted hand. R133 had a history of CVA with contractures to the right arm and leg, was severely cognitively impaired, and was dependent on staff for all cares. His care plan stated that his right hand and wrist were contracted and that his affected extremity should be well padded, with restorative services identified for his contractures. During observations, R133 was found in bed with his right hand contracted into a tight fist, and his fingernails appeared to be pressing into the palm of his right hand. No splint or padding was noted on multiple observations. The restorative aide stated the resident should have padding or a towel roll in place to prevent skin breakdown and to keep the contracture from worsening, and the restorative nurse later stated the resident needed a splint or towel roll to the hand. The facility policy stated contracture prevention and management may include PROM, AROM, and splint/orthotic management.
Missed Dietary Supplement at Lunch
Penalty
Summary
The facility failed to ensure a resident received a dietary supplement as ordered for one of 33 residents reviewed for nutrition. The resident’s care plan identified the resident as at risk for alteration in nutritional status and directed staff to provide diet and supplements as ordered. The order summary showed an order for a house supplement of magic cup with dinner and fortified pudding with lunch, with substitution allowed with a house supplement. The meal ticket for lunch indicated the resident was to receive fortified pudding, but during observation the resident was eating lunch in the room and did not have pudding or a magic cup on the tray. The resident confirmed not receiving the fortified pudding. Although the MAR was checked to show the supplement was given, the RN who documented it stated fortified pudding was provided by the kitchen and should have been on the meal tray, and she confirmed documenting the supplement as received without knowing it was not on the tray. A dietary note also indicated the resident was to receive fortified pudding with lunch.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as prescribed for 2 of 33 residents reviewed for pharmacy services. One resident was observed in bed with a medication cup containing five pills left on the bedside table, and the resident stated that nursing just leaves them there. The resident’s June 2026 MAR showed 9:00 AM orders for Amiodarone 200 mg 0.5 mg daily for abnormal heart rate, Clopidogrel 75 mg daily for blood clots, Metformin 500 mg daily for diabetes, Cyanocobalamin 500 mcg daily, and Losartan Potassium 100 mg daily for hypertension. Another resident had an order for Potassium Chloride ER 20 MEQ daily, but an LPN dispensed the pill, crushed it, mixed it with applesauce, and administered it despite the medication card sticker stating, Do not crush. When the surveyor pointed this out, the LPN stated that she always crushes the potassium because the resident is anxious and wants her meds when she wants them.
Failure to Use PPE and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff wore the required PPE for a resident on enhanced barrier precautions and failed to implement enhanced barrier precautions for another resident. R154’s care plan, initiated on 10/21/25, showed the resident was on enhanced barrier precautions and required gloves and gowns during high-contact care; the same plan noted a tracheostomy. On 06/01/2026 at 10:05 AM, an enhanced barrier precaution sign was posted near R154’s room, and the resident was in bed receiving oxygen via a tracheostomy collar. The oxygen tubing had disconnected from the collar, and V7, a RN, entered the room, put on gloves, reconnected the tubing, and adjusted the tracheostomy collar, but did not wear a gown. On 06/02/2026, V7 stated that for a resident on enhanced barrier precautions, staff should wear gloves and a gown when providing direct care or device care. R80’s admission/current care plan showed the resident required enhanced barrier precautions due to a nephrostomy tube, with staff to wear a protective gown and gloves when handling or providing care to the tube. On 6/1/26 at 10:00 AM, R80 was in bed with a family member present, and the nephrostomy drainage bag was lying in bed next to the resident with a scant amount of urine in it. No enhanced barrier precaution or isolation signage was noted on or around the room door, and no PPE cart was noted in the hallway. The family member stated she visited daily and had never seen staff wear a gown when handling or providing care to the nephrostomy tube. On 6/2/26 at 9:25 AM, the same lack of signage and PPE cart was observed, and at 11:10 AM an LPN stated R80 was not currently on enhanced barrier precautions but should be because of the nephrostomy tube and should have an enhanced barrier precaution sign on the door. The facility’s policy dated 9/16/25 stated enhanced barrier precautions would be implemented for residents with open wounds, indwelling medical devices including urinary catheters, and residents colonized or infected with multidrug-resistant organisms.
Failure to Offer Pneumococcal Vaccine on Admission
Penalty
Summary
The facility failed to offer the pneumococcal vaccine upon admission for one resident reviewed for immunizations. The resident’s facesheet showed admission to the facility on [DATE], and the immunization report dated 6/1/26 showed no information that the pneumococcal vaccine had been offered. The resident’s electronic medical record contained no documentation of historical pneumonia vaccines, although the pneumonia vaccine consent form showed the resident was provided education and verbally refused the vaccine on 11/10/2025. During interview, the Infection Prevention Nurse stated she asks residents or their representatives if they want immunizations, including the pneumococcal vaccine, and that she is the only staff member offering vaccinations at this time; she also stated the timing depends on how backed up she is and that short-term stay residents may discharge before vaccines are offered. The DON stated new admissions should be offered immunizations when they come in, and if admitted in July, they would be expected to have been offered vaccinations prior to November. The facility’s pneumococcal vaccination policy stated the vaccine will be offered upon admission if recommended by ACIP.
Failure to Offer COVID-19 Vaccine on Admission
Penalty
Summary
The facility failed to offer the COVID-19 vaccine upon admission for 1 of 7 residents reviewed for immunizations, R18. R18’s facesheet showed admission to the facility on [DATE]. R18’s immunization report dated 6/1/26 showed that R18 refused the COVID-19 vaccine, and the COVID-19 vaccine consent form showed R18 was provided education and verbally refused the vaccine on 11/10/2025. During interview on 6/1/26, the Infection Prevention Nurse stated that upon admission she asks the resident or representative if they would like immunizations, including the COVID-19 vaccine, and that she is the only staff member currently offering vaccinations and obtaining signed consents or declinations. She also stated that the timing of offering vaccines depends on how backed up she is, and that short-term stay residents sometimes admit and discharge too quickly to be offered vaccinations. The Director of Nursing stated on 6/3/26 that new admissions should be offered immunizations when they come in and that if a resident admitted in July, she would expect vaccinations to have been offered prior to November. The facility policy dated 2/27/26 stated that recommended vaccines should be provided in a timely manner, before the peak of the fall respiratory season, to residents and health care personnel.
Survey Binder Not Accessible to Residents
Penalty
Summary
The facility failed to ensure the state agency survey binder with past survey results was accessible without residents having to ask for assistance. The facility had 159 residents, and on 6/2/26 at 10:15 AM, no residents were aware of where the survey binder was located. Later that day at 11:08 AM, the surveyor found the binder on a table in the corner of the lobby sitting area. The table was against the wall on two sides and was partially blocked by a sofa, a chair, and a coffee table, leaving only about two and a half feet between the back of the chair and the wall. This placement prevented residents in a wheelchair from accessing the binder without assistance. On 6/3/26, the Administrator stated residents could ask staff for help if they could not reach the binder in its current location, and later said the binder should ideally be on a table in the lobby with nothing impeding residents from grabbing it to view.
Unqualified staff operated enteral feeding pump
Penalty
Summary
The facility failed to ensure a qualified staff member operated a resident's enteral feeding pump for one resident reviewed for qualified persons/staff. The resident was admitted with diagnoses of respiratory failure and dementia and had a gastrostomy tube in place for enteral feedings. The resident's current care plan showed enteral feedings were the primary source of nutrition. During observation, a CNA entered the resident's room while the enteral feeding was infusing via a pump at the bedside and paused the pump while repositioning the resident. The CNA later returned with additional staff and paused the pump again so cares could be provided. The DON stated CNAs are not allowed to operate a resident's enteral feeding pump because they are not licensed and have not been trained to do so.
Failure to Provide ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide feeding assistance and incontinence care to residents who were dependent on staff for these activities of daily living. R4, admitted with respiratory failure and dementia and with a tracheostomy and gastrostomy in place, was documented as completely dependent on staff for all cares, including toileting and incontinence care. On 8/18/25, R4 was found in bed with an odor of stool in the room, and when CNA V8 and the wound nurse entered the room, R4’s brief was saturated with urine and contained a large amount of mushy stool that had leaked onto the bed. Stool was noted under the sacral dressing and in the wound, and R4’s groin and buttocks were red. V8 stated she had not yet provided incontinence care that morning and that R4 had last been changed on nights. R6 was also dependent on staff for toileting and incontinence care and was incontinent of bowel and bladder. On 8/18/25, CNA V6 stated he had not yet provided incontinence care that morning, and when R6’s brief was checked, liquid stool leaked out and the brief contained a large amount of urine and liquid stool; dried stool was also noted on the buttocks, which appeared bright red. R61, a Spanish-speaking resident with metabolic encephalopathy and end stage renal disease, was observed in bed eating a mechanical soft meal with her hands while food was all over the bed and items were on the floor. She was coughing, was not positioned upright, and her tray was not set up appropriately until staff were found and assisted her. Her care plan and dietary note indicated she required 1:1 feeding assistance or set-up, orientation to the plate due to blindness, and upright positioning during meals, but at the time of observation she was eating without that assistance.
Failure to Provide Ordered Wound Care and Pressure Relief
Penalty
Summary
The facility failed to provide wound treatments and pressure-relieving interventions for residents with pressure injuries and for a resident at high risk for pressure injuries. One resident was admitted with respiratory failure and dementia, had a tracheostomy and gastrostomy, and was documented with a Stage 4 sacral pressure injury on admission. The resident was incontinent of bowel and bladder, had an order for a urinary condom catheter, and the care plan directed wound treatment as ordered and keeping wounds clean and dry. During observation, the resident remained in bed with an odor of stool in the room, had not yet received morning incontinence care, and was later found with a brief saturated with urine and stool, stool under the dressing, stool in the sacral wound, red and excoriated skin around the wound, and bleeding from the surrounding skin. No condom catheter was in place at that time. A second resident had a Stage 2 pressure injury to the left heel with an order for a bordered foam adhesive dressing to remain in place at all times and a low air loss mattress ordered as a pressure treatment intervention. The resident was observed lying on a low air loss mattress that was set for a resident weighing 200 lbs instead of the resident's recorded weight of 168.2 lbs. No dressing was present on the left heel during observation, and later only a small band-aid was noted on the heel. The wound nurse stated the mattress should be programmed to the resident's accurate weight and that the heel wound should have an adhesive dressing covering it at all times, not a band-aid. A third resident was assessed as high risk for pressure injuries and had care plan interventions for a low air loss mattress and heel offloading with a pillow or heel boots. The resident was observed on a low air loss mattress set for 250 lbs instead of the resident's recorded weight of 196 lbs, and the heels were resting directly on the mattress with no pillow under them. Heel boots were present in the room but were not being used. The facility policy stated residents with Stage III and IV pressure injuries would be placed on specialized air mattresses like a low air loss mattress, and routine daily wound care treatment or dressing changes were to be administered by the wound care nurse or designee daily.
Improper Catheter Positioning and Failure to Apply Ordered Condom Catheter
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter bag was maintained below the level of the bladder for one resident. During observation, the resident was in bed while staff provided incontinence care, and the catheter bag was unhooked and placed in the bed beside the resident at hip level, higher than the bladder, while the bag was half full of urine and urine backflow was noted. The wound NP and wound nurse were present in the room during the care, and the wound nurse later stated the catheter bag should be placed below the level of the bladder for gravity and to prevent UTI. The resident’s care plan and the facility’s indwelling catheter policy both directed that the catheter bag and tubing be positioned below the bladder region. The facility also failed to apply a condom catheter as ordered for another resident who was admitted with respiratory failure and dementia and was completely dependent on staff for all cares. The resident had a physician order for a urinary condom catheter and a care plan noting urinary incontinence and a stage 4 sacral pressure injury. During observation, the resident’s brief was saturated with urine and contained a large amount of mushy stool that had leaked onto the bed; the groin and buttocks were red, the dressing over the sacral wound was partially unsecured, stool was under the dressing and in the wound, and the surrounding skin was red, excoriated, and bleeding. No condom catheter was observed on the resident or in the brief, and a CNA later stated the resident did not have a condom catheter on. The wound nurse stated the resident had an order to wear a condom catheter to keep him dry and help his wound heal.
Failure to Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care to a resident as ordered and as per the resident’s preference. The resident was admitted with a colostomy in place, was cognitively intact, and had a care plan directing staff to perform ostomy care daily and as needed per physician’s order. A physician order directed that the colostomy bag be changed by staff every 3 days, and the resident’s treatment record documented a bag change on 8/9/25 and a refusal on 8/15/25. During observation on 8/18/25, the resident was seated in her room with the colostomy bag intact and stated that her bag had not been changed since returning from the hospital on 8/9/25. She reported that the skin around the site was starting to itch and become irritated, and said the bag and appliance should be changed every 3 or 4 days. She also stated that she had never refused to allow staff to change her colostomy bag. On 8/19/25, the LPN stated he never changed the resident’s colostomy bag on 8/12/25, despite the treatment record documenting that he did.
Enteral feeding order not fully administered
Penalty
Summary
The facility failed to ensure the required volume of enteral feeding was administered for a resident with insidious weight loss. R10’s record showed diagnoses including Alzheimer’s disease, moderate protein-calorie malnutrition, and gastrostomy placement, and her enteral feeding care plan stated that she required tube feedings via gastrostomy tube as her sole source of nutrition. Her weight record showed a decline from 121 lbs on 4/3/25 to 119.8 lbs on 5/4/25, 117.6 lbs on 6/5/25, and 115.8 lbs on 7/7/25. A dietary note by the RD documented that R10 had weight loss after a desired weight gain and increased Jevity 1.5 from 560 ml to 630 ml at 35 ml/hr until the total volume infused. However, the POS and MAR continued to show both the old 560 ml order and the updated 630 ml order as active, and the MARs from April through August 2025 showed both orders being signed off as given. During observation on 8/20/25, the tube feeding was infusing at 35 ml/hr with 430 ml infused and 130 ml remaining, and the bag had been hung the prior evening; the DON verified that this totaled 560 ml. The DON stated that when the new order was received, the old order should have been discontinued and only the current 630 ml order followed.
Medication Supervision Failure
Penalty
Summary
The facility failed to ensure medications were supervised during administration for one resident, R26. During observation on 8/18/2025 at 9:37 AM, R26 had a medication cup on her bedside table in front of her containing multiple unknown medications, and R26 stated that staff leave medications on her table when she is sleeping. At 9:39 AM, the LPN identified as R26’s nurse stated nurses stay with residents every time to make sure the resident takes the medication and for safety reasons like choking, and said none of her residents can self-administer medications. The LPN also stated she had not yet passed medications to R26 and did not know where the medications in the cup came from, adding they could have been left by night shift. R26’s care plan dated 7/29/2025 and the active order summary as of 8/18/2025 did not list R26 as being able to self-administer medications.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident, who was at high risk for falls due to lack of coordination and abnormal gait, did not have required fall prevention interventions in place. The resident's care plan, last reviewed on 5/19/25, specified that floor mats should be provided at the bedside as a fall intervention. However, during observations on 6/11/25, no floor mats were present in the resident's room while the resident was in bed. The resident had previously experienced an unwitnessed fall on 5/29/25, as documented in the progress notes and incident report. Staff interviews confirmed that fall interventions are determined after an incident and should be implemented as listed in the care plan, but the required intervention was not in place at the time of observation.
Resident Injury Due to Rough Handling by CNA
Penalty
Summary
The facility failed to ensure a resident was repositioned safely, resulting in a significant injury. A resident, who had a history of hip replacement and was recovering from a hip joint infection, reported that a Certified Nursing Assistant (CNA) was rough while attempting to change her, despite her refusal. The resident heard a pop in her hip and subsequently experienced pain, which led to a diagnosis of an intertrochanteric fracture requiring surgery. The resident's roommate corroborated the account, stating that the resident was upset and in pain after being moved by the CNA. The resident's medical records indicated she was dependent on staff for all activities of daily living and was incontinent, requiring maximum staff assistance. The facility's care plan for the resident emphasized the need for gentle handling due to her impaired mobility and pain. Despite this, the CNA reportedly attempted to change the resident multiple times against her wishes, leading to the injury. The facility's resident council minutes also noted previous concerns about the roughness of CNAs during the night shift, suggesting a pattern of behavior that may have contributed to the incident.
Improper Storage of Lorazepam
Penalty
Summary
The facility failed to store medications according to the manufacturer's guidelines for four residents. During an inspection, it was observed that liquid lorazepam, which requires refrigeration, was stored in the locked narcotic boxes of medication carts on both the first and second floors. Specifically, for residents R9, R12, R123, and R132, the lorazepam was not refrigerated as required. The medication for these residents was found either unopened or partially used, with dates indicating they had been stored improperly for several weeks. Licensed Practical Nurses (LPNs) V10 and V11, as well as Registered Nurse (RN) V15, confirmed that the lorazepam should have been refrigerated but had been stored in the medication carts instead. The facility's policy on medication storage, which mandates adherence to the manufacturer's recommendations, was not followed. The manufacturer's guide for lorazepam clearly states that it should be stored at a cold temperature, between 36 to 46 degrees Fahrenheit, which was not adhered to in these instances.
Failure to Provide Comfortable Medical Equipment for Residents
Penalty
Summary
The facility failed to provide comfortable medical equipment for two residents, R99 and R24, as observed during the survey. R99 expressed discomfort with her wheelchair, stating that her feet did not touch the ground, making it uncomfortable to sit. Despite her complaints to the nurses and aides, no action was taken to replace the wheelchair. The staff, including the Registered Nurse, Central Supply, and Restorative Director, were unaware of R99's issue, indicating a lack of communication and follow-up on the resident's needs. R99's Minimum Data Set confirmed her cognitive intactness and dependency on staff for transfers, emphasizing the importance of having suitable equipment. R24's bed was malfunctioning, with the foot of the bed stuck in an elevated position, causing her to lay crooked. This issue was observed over multiple days by different CNAs, yet it was not reported to the Maintenance Director, who stated that any staff could report equipment issues. The Maintenance Director was unaware of the problem, highlighting a breakdown in the reporting process for maintenance issues. R24's medical history includes chronic obstructive pulmonary disease, malnutrition, dementia, Alzheimer's disease, rheumatoid arthritis, anxiety disorder, and major depressive disorder, which necessitates proper equipment to ensure her comfort and safety.
Failure to Schedule Ophthalmologist Appointment for Resident
Penalty
Summary
The facility failed to schedule a necessary ophthalmologist appointment for a resident, identified as R107, who was reviewed for quality of care. R107 had been hospitalized multiple times and required ongoing eye injections as part of her treatment. Despite a physician's order dated 9/23/24 to schedule an ophthalmologist appointment as soon as possible, the appointment had not been scheduled by 10/09/24. The resident expressed frustration over the lack of follow-through by the facility, stating that she often had to remind staff or call herself to ensure appointments were made. The physician's progress note from 9/23/24 indicated that R107 was inquiring about her appointments, highlighting the importance of these follow-ups for her ongoing care. The ward clerk/scheduler admitted that scheduling the appointment was still on her to-do list, 16 days after the order was given. The ophthalmologist's office confirmed that no appointment had been scheduled and that they had not been contacted by the facility. The assistant administrator stated that the expectation was for appointments to be scheduled within a few days of the order, which was not met in this case.
Unsafe Transfer of Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, identified as R95, who was reviewed for safety. R95 has a medical history that includes right-sided paralysis due to a stroke and chronic end-stage renal disease requiring hemodialysis. On October 7, 2024, at 10:15 AM, R95 was observed being transferred from a reclined chair to his bed by two Certified Nursing Assistants (CNAs), V13 and V14, after dialysis treatment. The CNAs used a gait belt to pull R95 into a standing position, despite R95 being unable to hold himself up and leaning towards his right side. The CNAs then placed their hands under R95's armpits to lift him to his bed, even though R95 was unable to bear weight or pivot during the transfer. R95's care plan, initiated on January 26, 2024, indicated that a mechanical aid (sling) should be used for transfers due to his high risk for falls and impaired mobility. A physical therapist, V16, confirmed that all residents should be transferred correctly for their safety.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident with a history of weight loss the ordered nutritional supplements, specifically fortified pudding, as part of her dietary regimen. The resident, who was admitted with diagnoses including moderate protein calorie malnutrition, Alzheimer's disease, anemia, and major depressive disorder, had an order for fortified pudding twice daily with lunch and dinner. However, during an observation on October 8, 2024, the resident's lunch tray did not include the fortified pudding, which was part of her prescribed dietary plan. The resident's weight records indicated a significant weight loss over several months, with a decrease from 160.4 lbs in April 2024 to 145 lbs by October 2024. The dietitian confirmed that the resident was supposed to receive fortified pudding and ensure plus daily, but noted that the resident often slept during meal times, which could contribute to her weight loss. The facility's policy on weights did not address insidious weight loss, which may have contributed to the oversight in providing the necessary nutritional supplements to the resident.
Failure to Conduct Comprehensive Pain Assessment
Penalty
Summary
The facility failed to perform a comprehensive pain assessment for a resident, identified as R24, who complained of significant pain. R24, who has a medical history including chronic obstructive pulmonary disease, malnutrition, dementia, Alzheimer's disease, rheumatoid arthritis, anxiety disorder, and major depressive disorder, was admitted to the facility with a care plan indicating a risk for pain related to her conditions. On two separate occasions, R24 expressed severe pain during incontinence care, rating her pain as high as 7/8 on a scale of 0-10. Despite these complaints, the nursing staff did not conduct a thorough pain assessment, including evaluating the pain's characteristics, performing a skin assessment, or assessing range of motion, before administering pain medication. On the first occasion, a CNA reported R24's pain to an RN, who administered Norco without further assessment. On the second occasion, R24 continued to express pain during care, and a Tylenol was administered by an LPN without a comprehensive assessment. The Director of Nursing later confirmed that the facility's policy requires a nurse to assess the resident's pain and perform necessary evaluations, which were not done in these instances. The facility's pain policy mandates that all residents be assessed for pain in situations where pain is likely, which was not adhered to in R24's case.
Failure to Implement Enhanced Barrier Precautions for Resident with Medical Device
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an implanted medical device, specifically a peritoneal dialysis catheter, upon admission. The resident, identified as R339, was admitted with diagnoses including dependence on renal dialysis and a complete traumatic amputation of toes. Despite the presence of a peritoneal dialysis catheter and a surgical dressing on the left lower foot, there was no EBP sign or Personal Protective Equipment (PPE) cart outside the resident's room. A Certified Nursing Assistant (CNA) was observed preparing to provide care without wearing a PPE gown, indicating a lapse in infection control measures. Interviews with facility staff revealed a lack of adherence to the facility's Infection Prevention and Control Policy, which mandates the use of gloves and gowns during high-contact care activities for residents with indwelling medical devices. The Infection Control Preventionist (ICP) acknowledged that the resident should have been placed on EBP upon admission. Additionally, a Registered Nurse confirmed that residents with implanted medical devices should be isolated upon admission, and staff should wear gowns and gloves during care. However, there was no physician order for EBP for the resident, further highlighting the oversight in implementing necessary infection control precautions.
Failure to Provide Ongoing Assessments for Resident with Injury
Penalty
Summary
The facility failed to provide ongoing assessments for a resident who had an injury of unknown origin, resulting in a significant delay in appropriate medical intervention. On 7/3/24, the resident was noted to be wincing when being changed, prompting a nurse practitioner to order an x-ray, which revealed a suspicious stress fracture in the left femur. Despite this finding, there were no documented assessments of the resident's condition from 7/4/24 to 7/7/24, and the resident remained in pain and bedbound during this period. The lack of assessments and documentation continued until 7/8/24, when the resident was finally sent to the emergency room due to abnormal behavior and inability to walk. At the hospital, the resident was diagnosed with a mildly impacted and angulated left femoral neck fracture and deep venous thrombosis, conditions that had developed while the resident was under the facility's care. Interviews with staff revealed that although the resident's pain and immobility were noted, there was a failure to conduct thorough assessments or communicate changes in the resident's condition effectively. The facility's policies required notification of significant changes in a resident's condition and ongoing assessments, but these were not adhered to in this case. The Director of Nursing acknowledged the absence of assessments and documentation, which could have identified the resident's deteriorating condition earlier. The failure to perform regular assessments and document findings contributed to the delay in addressing the resident's medical needs, ultimately leading to hospitalization and surgery.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,273 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Highland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya Of Highwood | 1.3 mi | ★★★★★ | 12 | 0 |
| Whitehall Of Deerfield | 3.4 mi | ★★★★★ | 2 | 0 |
| Northbrook Health And Rehab | 4 mi | ★★★★★ | 0 | 0 |
| Lake Forest Place | 4.1 mi | ★★★★★ | 3 | 0 |
| Grove Of Northbrook,the | 4.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.