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 Orland Park during CMS and state inspections, most recent first.
Surveyors found that staff failed to ensure correct low air loss mattress (LALM) settings for two high-risk residents with actual or recently healed wounds. One resident with paraplegia and a history of a stage 3 sacral ulcer was observed on a LALM set to a much higher weight than the resident’s actual weight and in static mode, which the manufacturer describes as providing a firm surface, while the RN present was unaware of the significance of the static setting. Another resident with diabetes, cellulitis, a below-knee amputation, and a right leg wound was observed on a LALM set far above the resident’s recorded weight. The wound care coordinator later stated that both residents’ LALM weight settings should have been closer to their actual body weights and that the first resident’s mattress should have been on an intermittent, not static, mode.
Two residents experienced undignified and non–preference-consistent dining care. One resident with Parkinson’s disease, dysphagia, and moderate cognitive impairment had an active order for a puree diet but was repeatedly served non-pureed food, including whole fish fillet, bun, and vegetables, despite a meal ticket marked for puree and the resident’s statements that he needed pureed or cut-up food. The same resident reported asking daily to be transferred to a chair for meals so he could feed himself, but staff left him in bed, limiting his ability to self-feed, while a care card in his closet listed him as an independent feeder. Another resident with significant cardiac and renal conditions was observed being fed in bed by a CNA who stood over him, and both CNAs reported they stand when feeding, contrary to the DON’s expectation that staff sit at the resident’s level. These actions and inactions failed to respect resident dignity, self-determination, and reasonable accommodation of needs and preferences during dining.
A resident with glaucoma and multiple comorbidities did not consistently receive ordered dorzolamide 2% eye drops three times daily, as documented by multiple early morning doses marked as "sleeping" on the MAR without subsequent administration. The resident reported frequent missed doses, especially at night and early morning, and stated she had previously self-administered the drops reliably when they were kept at bedside. The physician order allowed the drops to be kept at bedside for self-administration, and the DON confirmed that the resident was permitted to self-administer and that medications marked as "sleeping" should be given upon awakening, but these practices were not consistently followed, resulting in failure to provide treatment as ordered.
A resident with severe mobility impairments and morbid obesity, who required extensive assistance for bed mobility, was being turned in bed by a CNA working alone. During the process, the resident's leg slid off the bed and she rolled onto the floor, resulting in a right femur fracture. Staff interviews confirmed that proper procedures, such as rolling the resident toward the caregiver and ensuring support on both sides of the bed, were not followed.
A resident with severe cognitive impairment had their debit card taken by a newly assigned CNA, who attempted to use it at a gas station. The incident was confirmed through video evidence and the CNA's admission, revealing a failure to safeguard the resident's personal property and finances.
Surveyors identified multiple deficiencies in food storage, sanitation, and documentation, including a leaking coffee station drainpipe, unclean equipment, expired and unlabeled food items, missing temperature and cleaning logs for refrigerators and ice machines, and improperly stored dry goods. The Dietary Director and other staff confirmed lapses in maintenance, cleaning, and adherence to facility policies.
The facility did not have documentation showing that staff were educated about or offered the COVID-19 vaccine, nor did it maintain records of staff vaccination status. The Infection Control Nurse and Administrator were unable to provide evidence of education, offers, or a vaccination tracker, despite facility policy requiring promotion and documentation of COVID-19 vaccination.
Multiple residents with impaired mobility and cognitive conditions did not receive necessary assistance with ADLs, including hair washing, shaving, and nail care. Residents were observed with greasy hair, long and dirty fingernails, and foul odors, and some reported that staff did not fulfill requests for personal hygiene. Family members sometimes performed nail care themselves due to staff inaction. Staff and policy confirmed that regular hygiene and grooming should be provided, but these standards were not met.
The facility did not obtain or document required pacemaker information, such as make, model, and serial number, in the medical records of several residents with cardiac pacemakers. Additionally, physician orders for pacemaker checks were missing or incomplete, and care plans lacked details on when the devices were last assessed, contrary to facility policy.
Expired food items, including yogurt, gelatin, cheese, and beverages, were found in the personal refrigerators of four cognitively intact residents with complex medical conditions. Facility staff, including housekeeping and nursing, had inconsistent understanding of their responsibilities for removing expired food, and there was no documentation to show that regular checks were performed, despite facility policy requiring timely removal of such items.
Staff failed to follow infection prevention protocols by not performing hand hygiene between resident contacts, using the same gloves for dirty and clean tasks, and not wearing required PPE when caring for residents on isolation or enhanced barrier precautions. These lapses occurred during feeding, toileting, incontinence care, and when entering COVID-19 isolation rooms, affecting multiple residents with complex medical needs.
Two residents identified as high fall risk were found with their beds and over bed tables left in elevated positions, contrary to their care plans and facility policy. One resident, with a history of cerebral infarction and muscle wasting, reported the bed was dangerous, and a PTA confirmed the risk. Another resident with a femur fracture, diabetes, and dementia was also left in a high bed position by a CNA, despite being at risk for falls.
Surveyors found that medications and biologicals were not securely stored, as several residents were observed keeping items such as pain-relieving gels and vitamin supplements at their bedside or in their rooms without physician orders or proper assessment for self-administration. Nursing staff confirmed that facility policy prohibits residents from keeping medications at bedside, and that all medications should be secured in locked storage areas.
A facility failed to follow a physician's order to collect a urinalysis for a resident with multiple diagnoses, including dementia and altered mental status. Despite an order on 06/16/24, the urine was not collected until 06/18/24, with no documentation explaining the delay. The DON admitted to not documenting a conversation with the resident's daughter, who had requested the test due to symptoms. The facility's policy required prompt action for signs of infection, which was not adhered to.
The facility failed to provide adequate ADL care to four residents, as observed and documented by surveyors. Residents were found with unshaved facial hair and dirty fingernails, despite needing assistance with personal hygiene. Staff confirmed that shaving and nail care are typically done on shower days, but these tasks were not adequately performed, leading to the noted deficiencies.
The facility failed to provide food services in a manner that prevents foodborne illness, affecting all 166 residents. Observations included improperly labeled and dated food items, open and exposed food products, expired food items, poor sanitization practices, and undated or moldy food in the 2nd floor pantry and servery refrigerator. Additionally, staff demonstrated inadequate hand hygiene and improper use of sanitization buckets.
The facility failed to assess residents for self-administration of medications and did not obtain physician orders for residents to self-administer medications or store them in their rooms. Multiple residents were found with various medications at their bedside without proper authorization or assessment, contrary to the facility's policy.
The facility failed to ensure call lights were accessible to dependent residents, affecting four residents with varying degrees of cognitive impairment and physical dependency. Observations revealed that call lights were often out of reach, preventing residents from calling for assistance when needed.
The facility failed to maintain proper temperature logs, thermometers, and cleanliness for residents' personal refrigerators. Several residents' refrigerators lacked thermometers and contained expired or unlabeled food items. Interviews with staff revealed inconsistencies in responsibility for maintaining these refrigerators, and the facility's policies on refrigerator maintenance and food brought from outside were not followed.
The facility failed to ensure that two residents were free from physical restraints. One resident with severe cognitive impairment was observed with full-length side rails up, and another cognitively intact resident was observed with a position change alarm on her bed and chair. Both instances lacked proper assessments, care plans, or physician's orders, violating the facility's policies on restraints.
A resident did not receive her evening medications, including antibiotics and blood thinners, until nearly midnight, despite multiple requests to the staff. The medications were scheduled for 5 PM and 9 PM but were administered six and two hours late, respectively. The resident's doctor was not notified about the delay.
A facility failed to adjust a resident's bed frame, leaving exposed metal parts that posed a hazard. Despite the resident's cognitive impairment and dependency on staff, the issue was not addressed until pointed out by a surveyor. The facility's policy to ensure safety was not followed, leading to the deficiency.
A resident experienced significant weight loss due to the facility's failure to maintain nutritional status and monitor weights as ordered. The resident, dependent on enteral feeding, did not receive the prescribed amount of feeding consistently, and weights were not obtained as required. Staff were unaware of the missing weights and incomplete feedings, contributing to the resident's weight loss.
The facility failed to evaluate for gradual dose reductions (GDR) for a resident receiving psychotropic medications. Despite being prescribed Prozac and trazadone hydrochloride, no GDR had been conducted since the resident's admission. The DON acknowledged the resident was overdue for a GDR, and the Nurse Practitioner confirmed that the primary care physician was responsible for the GDR, which should be completed every six months. Additionally, the nursing staff had not been documenting the resident's behaviors, essential for evaluating the medication's effectiveness.
The facility failed to administer medications as ordered, resulting in a 10.34% error rate. An LPN gave Norco to a resident without verifying the order or last administration time, and another LPN crushed extended-release medications before administering them, contrary to facility policy.
The facility failed to apply PPE and perform proper hand hygiene for a resident on contact isolation for C. Diff. Staff members, including a CNA, Director of Housekeeping, and Wound Care Technicians, were observed not following infection control protocols. Another resident with respiratory failure was left without oxygen during care, and the nasal cannula was placed back on without ensuring cleanliness.
Improper Low Air Loss Mattress Settings for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure correct use and settings of low air loss mattresses (LALMs) for residents at high risk for skin breakdown and with actual or recently healed pressure injuries. One resident with multiple sclerosis, paraplegia, a history of a stage 3 sacral pressure ulcer, impaired mobility, incontinence, and high risk for skin integrity impairment was care planned for a low air loss mattress for pressure reduction. Physician orders and a wound assessment specified use of an alternating air/low air loss mattress with settings maintained at an appropriate level based on the resident’s needs and body habitus. During observation, this resident was found lying on a LALM set at 260 lbs and in static mode, even though the resident reported weighing about 150 lbs and the most recent recorded weight was 146 lbs. The RN present was unaware of the significance of the static mode and indicated the mattress was supposed to be in static mode while the resident was lying in bed, despite manufacturer guidance that static mode provides a firm surface. The wound care coordinator later stated that this resident’s LALM weight setting should be around 140–150 lbs and that the mode should be intermittent, not static, and acknowledged that a weight setting that is too high could increase pressure under the patient. A second resident with type II diabetes mellitus, cellulitis of the right lower limb, absence of the left leg below the knee, and a high risk for skin integrity impairment was also observed lying on a LALM with the weight setting at 350 lbs, although the resident reported weighing 242 lbs and the most recent recorded weight was 238.2 lbs. This resident had an actual skin integrity impairment to the right lower leg, and the resident reported a wound on the right medial calf that was nearly healed. The RN confirmed the LALM weight setting at 350 lbs. The wound care coordinator later stated that this resident’s LALM settings should be somewhere between 230 and 250 lbs, depending on the specific mattress unit. Facility policy required residents with stage III or IV pressure injuries to be placed on specialized air mattresses such as LALMs, and manufacturer guidelines indicated that static mode is used to provide a firm surface. The observations and interviews showed that staff were not consistently aware of or using appropriate LALM weight and mode settings while the mattresses were in use for these high-risk residents.
Failure to Provide Dignified, Preference-Consistent Dining Care
Penalty
Summary
The deficiency involves the facility’s failure to provide a dignified dining environment and to honor resident preferences and diet orders for two residents. One resident with multiple diagnoses including Parkinson’s disease, dysphagia (oral phase), repeated falls, spinal stenosis, orthostatic hypotension, and moderate cognitive impairment (BIMS score 12) had an active order for a regular diet with puree texture and thin liquids. Despite this order, the resident reported receiving only one pureed meal since the diet change and, on observation, was served a regular breaded fish fillet with cheese, a whole hamburger bun, and green beans. The meal ticket showed the regular diet scratched out with “puree” handwritten, but the food provided was not pureed or cut up as the resident stated was needed and as he reported was documented in his chart. On a subsequent day, the same resident was observed in bed at mealtime, with a CNA assisting to sit him up in bed and then leaving the room. The resident stated he had requested to be placed in a chair instead of eating in bed, explaining that sitting in bed restricted his ability to feed himself and caused him to spill food because his movement was restricted. He reported that staff did not listen to his request, that he asked to be put in a chair every day so he could feed himself, and that staff told him it was not their job. During another observation, while a different CNA was feeding him, the resident again stated he could feed himself if seated in a chair but could not do so in bed. A care card posted in his closet documented him as an “independent feeder,” indicating a discrepancy between posted care information and the assistance and positioning actually provided. Another resident with multiple cardiac and renal diagnoses was observed being fed lunch in bed by the same CNA, who was standing over the resident while feeding. The CNA stated that this resident was “not a feeder” but that she was helping because he was having trouble, and also stated she always stands when feeding residents. Another CNA confirmed that when feeding a resident, she stands up. The DON stated that when feeding a resident, staff are supposed to sit so they are at the same level as the resident and not hovering over them, and that if a resident asks to sit in a chair, they should be gotten up to the chair unless there is a reason they cannot. Facility policies and CNA job descriptions require that residents be treated with dignity, respect, and reasonable accommodation of needs and preferences, including during feeding and dining, but the observed practices and resident reports showed that these standards were not followed for these residents.
Failure to Administer Glaucoma Eye Drops as Ordered and Honor Self-Administration Order
Penalty
Summary
The deficiency involves the facility’s failure to administer glaucoma eye drops as ordered by the physician and in accordance with the resident’s preferences and goals. The resident, who has multiple diagnoses including glaucoma, hemiplegia/hemiparesis, COPD, atrial fibrillation, type 2 diabetes, hypertension, and mild cognitive impairment (BIMS score 11), reported that she is supposed to receive dorzolamide 2% eye drops three times daily but has frequently missed doses, particularly at night and early morning. She stated that when she previously kept the eye drops at her bedside and self-administered them at approximately 5:00 a.m., 1:00 p.m., and 9:00 p.m., she did not miss doses, but the drops were taken away and she no longer knows why. She consistently expressed that she is capable of self-administering the drops and that not receiving them as ordered is her primary concern. Record review showed a physician order and MAR entry for dorzolamide 2% eye drops, one drop in both eyes three times a day for glaucoma, with a notation that the resident may keep the eye drops at bedside for self-administration per NP. The March MAR documented the early morning dose as “S” (sleeping) on 11 of 21 days, and the DON confirmed that “S” indicates the resident was sleeping and that the medication should be administered when the resident wakes up. The DON also stated that if a resident has an order to keep medication at bedside, it should be at bedside, and that this resident is allowed to have the eye drops at bedside and self-administer if she prefers. The attending physician stated he should have been notified that the resident was not receiving the medication as ordered and confirmed that the eye drops are intended to reduce intraocular pressure and should be given three times per day; if the resident is sleeping at the scheduled time, the drops should be administered as soon as she awakens rather than omitted. These interviews and records demonstrate that the ordered three-times-daily dosing and bedside self-administration option were not consistently implemented.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to safely turn a resident in bed, resulting in the resident rolling off the bed and sustaining a right femur fracture. The resident had significant medical conditions, including functional quadriplegia, morbid obesity (BMI 50-59.9), reduced mobility, muscle wasting, and was non-ambulatory. Care plans indicated the resident required extensive assistance from two staff for mobility and transfers, and was dependent on staff for bed mobility and toileting. However, interventions related to bed mobility and transfers had not been updated in over two years, and documentation showed the resident was dependent on staff for these activities. On the day of the incident, a CNA was providing care to the resident alone and attempted to turn the resident in bed. The resident reported that her leg slid off the bed while being turned, and she subsequently rolled off the bed onto the floor. The CNA stated that the resident turned herself and that she did not touch the resident, but also confirmed she was alone during the care. Interviews with facility staff, including the Therapy Director and Assistant Director of Nursing, confirmed that staff should not roll residents away from themselves and that, given the resident's weight and immobility, there was a risk of the resident's leg sliding off the bed if not properly supported. The investigation revealed that no staff member was present on the opposite side of the bed to prevent the resident from falling, and the resident was not rolled toward the staff member as recommended. The facility's policy required care to be provided to meet residents' physical needs, including adequate assistance with activities of daily living. The failure to follow these procedures and provide adequate supervision directly led to the resident's fall and injury.
Failure to Protect Resident from Financial Exploitation by Staff
Penalty
Summary
A resident with severe cognitive impairment and multiple medical conditions, including cerebral infarction, abnormal gait, and sepsis, was admitted to the facility. The resident's son reported that his father's debit card was missing and that an attempt had been made to use the card, which was declined. The son had brought the resident's wallet to the facility, and the notification of the attempted use was received shortly after. An internal investigation and collaboration with the city police department confirmed that a newly assigned Certified Nursing Assistant (CNA), who was still in orientation and on her first day on the floor, took the resident's debit card and attempted to use it at a gas station. Video footage from the gas station corroborated the CNA's involvement, and the CNA admitted to taking the card but stated that none of the transactions were successful. The facility's records and interviews revealed that the CNA initially denied the theft when questioned by the administrator but later admitted to the attempted use of the card after being informed of the video evidence. The CNA refused to answer further questions and ended the interview abruptly. The facility's abuse and neglect policy defines financial abuse as the misappropriation or exploitation of a resident's money or property, which was substantiated in this incident. The event demonstrated a failure to protect the resident from the wrongful use of personal belongings and money.
Deficient Food Storage, Sanitation, and Documentation in Dietary Services
Penalty
Summary
The facility failed to maintain the kitchen and food service areas in a manner that would prevent foodborne illness for all 162 residents receiving dietary services. Surveyors observed a leaking coffee station drainpipe wrapped in black tape, dripping into a container with brown liquid containing a gray furry film and white unidentifiable chunks. The stand mixer was found covered in plastic but had white and yellow crusted drips, and the vents over the stove had a visible layer of dust. The Dietary Director confirmed that the vents are cleaned quarterly by an outside company and that the mixer should have been cleaned after use. The leaking drainpipe had not been previously reported to maintenance. The ice machine lacked a cleaning log, and neither the Dietary Director nor the Administrator were aware of a cleaning schedule or policy for the ice machine. The Executive Director stated that an outside company cleans the ice machines but could not provide documentation of these services. In the walk-in cooler, several food items were found past their use-by dates, including prune juice and cottage cheese, and some items were not labeled with open or use-by dates. A container of cottage cheese was found with a bubbled lid and seal, and the Dietary Director acknowledged that food should be labeled and not used past the manufacturer’s date. Unit refrigerators on all three floors lacked temperature logs, and some logs that were provided showed temperatures above the required 41 degrees Fahrenheit with no documented corrective action. In dry storage, open bags of baking cocoa and food thickener were exposed to air, and dented cans of food were present. The Dietary Director stated that dented cans should be discarded and food items should be sealed to prevent contamination. Facility policies require proper maintenance, labeling, and storage of food, but these were not consistently followed.
Lack of Documentation for COVID-19 Vaccine Education and Offer to Staff
Penalty
Summary
The facility failed to maintain documentation that staff were educated about and offered the COVID-19 vaccine, as well as to record the vaccination status of staff members. During the survey, the Infection Control Nurse (RN) stated that there was no documentation available to show that staff had been offered the COVID-19 vaccine or educated on its benefits and potential side effects. The RN indicated that vaccines might be offered through an outside company and that she had not personally offered them to staff. No logbook or documentation was provided to the surveyor to confirm that staff had been offered the vaccine or educated about it. Additionally, the infection control binders lacked any records indicating staff education, acceptance, or receipt of the COVID-19 vaccine, and there was no documentation of staff vaccination status. Although the Administrator stated that the Director of Nursing enters employee COVID-19 data into a tracker, no such tracker was provided to the surveyor. The facility's policy indicated a commitment to promoting and providing COVID-19 vaccination in accordance with CMS, CDC, and state guidance, but the required documentation to demonstrate compliance was not available.
Failure to Provide Adequate ADL and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, to multiple residents who required such care. Observations and interviews revealed that several residents were left with unwashed, greasy hair, long and dirty fingernails, and unaddressed grooming needs. In several cases, residents and their family members reported that requests for assistance with hair washing, shaving, and nail care were not fulfilled by staff, with some residents stating that CNAs cited lack of time as a reason for not providing care. Family members of one resident reported having to perform nail care themselves due to staff inaction, expressing concern about the risk of infection from long, dirty nails. Documentation review showed that the affected residents had care plans indicating the need for assistance with ADLs, including grooming, nail care, and personal hygiene, due to various medical conditions such as impaired mobility, cognitive impairment, depression, and risk for skin integrity issues. Despite these documented needs, staff failed to provide regular and necessary care, as evidenced by residents' unkempt appearance and persistent hygiene issues over multiple days. Staff interviews confirmed that nail care and hygiene should be provided regularly, especially on shower or bath days, and that failure to do so could lead to skin breakdown and infection. Additionally, one resident was observed to have been transferred using a soiled mechanical lift sling and placed in a wheelchair with a foul odor, indicating a lack of attention to cleanliness and infection control. Staff acknowledged that slings and wheelchair cushions should be cleaned regularly and replaced when soiled. Facility policies reviewed by surveyors confirmed the expectation for daily ADL care and regular nail care to maintain cleanliness and prevent infection, but these standards were not met for the residents reviewed.
Failure to Document and Maintain Pacemaker Information in Medical Records
Penalty
Summary
The facility failed to obtain and document essential information regarding residents' pacemakers, including the make, model, and serial number, as well as ensuring that this information was readily available in the residents' medical records. For five residents with pacemakers, medical records, progress notes, admission assessments, and care plans did not include the required pacemaker details. In several cases, it was also unknown when the pacemaker was last assessed, and physician orders for pacemaker checks were either missing or incomplete. The facility's own policy requires documentation of the pacemaker's make, model, serial number, date and place of insertion, and specific orders for monitoring, but these requirements were not met for the affected residents. Interviews with facility staff, including the DON, confirmed that obtaining pacemaker information is challenging, with difficulties in acquiring details from residents, families, and cardiology offices. Despite these challenges, the admission nurse and DON are responsible for attempting to gather this information, but the records reviewed showed consistent omissions. The lack of documentation and clear orders for pacemaker monitoring was observed across all five residents reviewed for this issue.
Failure to Remove Expired Food from Resident Refrigerators
Penalty
Summary
The facility failed to remove expired food items from the personal refrigerators of four residents, as observed during a survey. Expired yogurts, gelatin, pepperoni, cheese, orange juice, and flavored water were found in the refrigerators of residents who were all cognitively intact and had various medical conditions, including dysphagia, prediabetes, malnutrition, diabetes, and muscle wasting. The residents were unaware that the food items were expired and expressed willingness to have them discarded when informed. Interviews with facility staff, including the DON, CNA, and housekeeping leadership, revealed inconsistent understanding and implementation of responsibilities for checking and discarding expired food. Housekeeping staff were identified as responsible for cleaning and removing expired items weekly, but there were no logs or documentation to confirm that these tasks were being performed. The facility's policy required discarding food after a set number of days and removing undated items, but this was not followed in practice, resulting in expired food remaining in resident refrigerators.
Failure to Follow Infection Control and PPE Protocols
Penalty
Summary
Multiple instances of staff failing to follow infection prevention and control protocols were observed during direct resident care. One staff member provided feeding assistance to two residents, moving between them and handling their food, utensils, and personal items without performing hand hygiene between contacts, despite facility policy and expectations requiring hand hygiene to prevent cross-contamination. Another staff member was observed assisting a resident with toileting and incontinence care, using the same gloves to handle soiled items, clean the resident, retrieve clean clothing, and assist with dressing, without changing gloves or performing hand hygiene between dirty and clean tasks. This same staff member, along with another, also failed to change gloves or perform hand hygiene when moving from soiled to clean areas during incontinence care for a different resident. Additional deficiencies were noted in the use of personal protective equipment (PPE) for residents on isolation or enhanced barrier precautions. Staff and a vendor entered a resident's COVID-19 isolation room without wearing the required N95 mask, face shield, or gown, and failed to perform hand hygiene upon exiting the room. The isolation room door was left open on multiple occasions, contrary to facility policy and staff training. Staff also failed to educate a vendor on proper PPE use before allowing entry into the isolation room. In another case, staff provided care to a resident on enhanced barrier precautions wearing only gloves, omitting the required gown and mask during high-contact activities such as incontinence care, dressing, and transferring. Facility policies reviewed indicated clear requirements for hand hygiene before and after resident contact, after handling soiled items, and when moving between dirty and clean tasks. Policies also specified the use of full PPE, including N95 masks, gowns, gloves, and face shields for COVID-19 isolation, and gowns and gloves for enhanced barrier precautions during high-contact care. Despite these policies and staff knowledge of the requirements, the observed failures to adhere to infection control protocols involved multiple staff members and affected several residents, including those with significant medical needs such as hemiplegia, cellulitis, and indwelling medical devices.
Failure to Maintain Safe Bed Heights for High Fall Risk Residents
Penalty
Summary
The facility failed to ensure that resident beds were maintained at a safe height, resulting in accident hazards for two residents identified as high risk for falls. In one instance, a resident with a history of cerebral infarction, hypertension, and muscle wasting was found with both the bed and over bed table in a very high elevated position. The resident expressed concern about the bed's safety, and the Physical Therapy Assistant confirmed the bed should not have been left in that position, noting the increased risk of injury if a fall occurred. The resident's care plan indicated a risk for falls and included interventions to provide a safe environment. In another case, a resident with a displaced femur fracture, diabetes, vertebral fracture, and dementia was also found with the bed and over bed table in a high position. A CNA acknowledged leaving the bed elevated, despite the resident being identified as a high fall risk with a care plan intervention to provide a safe environment. The facility's policy required fall interventions for those at high risk, but these were not followed in these instances.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors observed that medications and biologicals were not securely stored as required by facility policy and federal regulations. In three separate cases, residents were found with medications at their bedside or in their rooms without physician orders permitting self-administration or bedside storage. One resident, admitted with multiple musculoskeletal diagnoses, had a Biofreeze Roll On Pain Relieving Gel on her bedside table on two separate occasions, and stated she used it independently for knee pain. The resident's physician order sheet did not include an order for this medication. A registered nurse confirmed that residents were not allowed to keep medications at bedside and would remove any found. Another resident, diagnosed with multiple sclerosis and severe malnutrition, had both Biofreeze and Vitamin C gummies on her dresser, which she stated she brought from home and kept in her room. There were no physician orders for these items. A third resident was found with a tube of diclofenac sodium gel, prescribed for sciatic nerve pain, on her overbed table and later in her wash basin. The LPN assigned to this resident confirmed that no residents were assessed or permitted to keep medications at bedside, and that the diclofenac was not scheduled for administration during his shift. Facility policy requires all medications to be secured in a locked storage area.
Failure to Timely Collect Urinalysis as Ordered
Penalty
Summary
The facility failed to follow the physician's orders for obtaining a urinalysis in a timely manner for a resident diagnosed with metabolic encephalopathy, unspecified fracture of the right pubis, muscle weakness, dementia, depression, scoliosis, and altered mental status. The resident was cognitively impaired and dependent on staff for toileting. On 06/16/24, a physician's order was written to collect urine for a urinalysis and culture & sensitivity, but the urine was not collected until 06/18/24. There was no documentation explaining the delay in the progress notes. The Director of Nursing acknowledged that the urinalysis should have been collected as ordered and admitted to not documenting a conversation with the resident's daughter, who had requested the test due to the resident's symptoms of tiredness and headache. The Medical Doctor confirmed that the order was expected to be followed promptly. The facility's Infection Prevention and Control Policy required notification of the Director of Nursing or designee if a resident developed signs or symptoms of infection, but this protocol was not followed in this case.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care to four residents, as observed and documented by surveyors. Resident 8, who has intact cognition and requires partial to moderate assistance with hygiene, was found with a beard he did not like and stated that staff had not assisted him with shaving. Resident 9, with moderately impaired cognition and needing partial to moderate assistance with personal hygiene, had several white hairs on her chin that she wanted removed, but staff had not recently attended to this. The next day, the facial hair was still present. Resident 14, with severely impaired cognition and requiring substantial to maximal assistance with personal hygiene, was observed with dirty fingernails on two consecutive days. Resident 19, who has intact cognition and needs partial to moderate assistance with personal hygiene, had several white hairs on her upper lip and chin that she did not like, and staff had not assisted in removing them. Certified Nurse Aide V16 confirmed that CNAs are responsible for shaving and nail care, which is typically done on residents' shower days. The facility's policies on Nail Care and Shower and Hygiene, both revised in 2023, state that nursing staff should regularly check and maintain residents' nail care and provide necessary hygienic care. However, the observations and resident statements indicate that these policies were not being adequately followed, leading to the deficiencies noted in the report.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to provide food services in a manner that prevents foodborne illness, affecting all 166 residents receiving food services. During a kitchen tour, several deficiencies were observed, including improperly labeled and dated food items, open and exposed food products, and expired food items. For instance, a storage bin containing oatmeal was not labeled with contents or expiration dates, and an open box of instant food thickener was exposed to air. Additionally, various food items in the walk-in freezer and cooler were found to be open to air, covered in frost, or freezer burned, such as unbaked chocolate chip cookies, mostaccioli, barbeque ribs, and hamburger patties. The walk-in cooler contained improperly stored and expired food items, including shredded mozzarella cheese with a red substance, hot dogs with white specks, and pureed mandarin oranges past their expiration date. Furthermore, personal food items were found in the facility kitchen, which could lead to cross-contamination and foodborne illness. The facility also demonstrated poor sanitization practices. The microwave was found with food splatters and grease smears, and the sanitization buckets were not properly measured, with one bucket testing at 500 ppm instead of the required 200 ppm. The disinfectant dispenser on the wall was not operational, leading staff to pour disinfectant without measuring it. Additionally, a dietary aide was observed entering the kitchen and food preparation line without washing hands, and another dietary aide touched her hair without wearing a hair net while preparing food trays. The sanitization level for the three-compartment sink was found to be 0 ppm, and an oven mitt that fell on the floor was used to remove a pan from the oven without being washed. The 2nd floor pantry and servery refrigerator also had several issues. There was no thermometer or temperature log, and the freezer section was filled with ice buildup. Various food items were found undated, expired, or improperly stored, including a bag labeled chicken soup with a dried yellow substance, a container with apple pie, and a takeout container with multiple food items. The servery refrigerator contained moldy and undated food items, such as broccoli, green beans, bacon, and partially eaten chicken parts. The facility did not provide temperature logs for the 2nd floor unit refrigerators or product concentration information for their quat sanitizer or directions for their testing strips.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration of medications and did not obtain physician orders for residents to self-administer medications or to store medications in their rooms. This deficiency was observed in five residents who had various medications at their bedside without proper authorization or assessment. For instance, one resident had Tums Calcium Carbonate on their bedside dresser without a physician's order or care plan for self-administration. Another resident had multiple antifungal medications and Clotrimazole cream at their bedside, also without the necessary orders or assessments. Additionally, a resident had Nystatin Powder, lubricant eye drops, and Chloraseptic sore throat spray in their room without proper documentation or orders for self-administration. The facility's policy requires an interdisciplinary team to evaluate a resident's ability to self-administer medications and obtain a physician's order for storing medications at the bedside, which was not followed in these cases. In another instance, a resident with major depressive disorder and generalized anxiety disorder had Fluticasone Propionate Nasal Spray at their bedside, which was brought by a family member. The resident's medical records did not contain a physician's order for the medication to be stored at the bedside or an assessment for self-administration. The Director of Nursing confirmed that the facility only had one resident authorized to self-administer medications, and it was not this resident. The facility's policy mandates that medications brought from home should be shown to the nurse and stored in the medication cart unless there is a physician's order and a completed self-administration assessment form. Another resident with a wedge compression fracture and other chronic conditions had an inhaler on their bedside table. The resident stated that the staff did not bring the medication to them, so they kept it at their bedside. The Director of Nursing later confirmed that the assessment and physician's order for self-administration were obtained only after the issue was brought to their attention. The facility's policy requires an assessment and physician's order before allowing residents to self-administer medications and store them at the bedside, which was not adhered to in this case as well.
Failure to Ensure Call Lights Were Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to dependent residents, affecting four residents (R8, R21, R77, and R147). For instance, R21, who has diagnoses including respiratory failure and moderate cognitive impairment, did not have her call light within reach while receiving care. This resulted in her being unable to call for assistance when she experienced shortness of breath. Similarly, R8, who has moderate cognitive impairment and requires assistance for various activities of daily living, was observed multiple times without the call light within reach, despite his care plan indicating it should be accessible. R8 expressed that staff often did not provide him with the call light, and he was unable to locate it himself. R77, who has severe cognitive impairment and is dependent on staff for all activities of daily living, also did not have her call light within reach during care. She mentioned that if the call light was out of reach, she was unable to call for help. Additionally, R147, who has moderate cognitive impairment and requires substantial assistance for personal care, was found with the call light on the ground and out of reach. The facility's Call Light Policy states that call lights should be within reach of residents at all times, but this was not adhered to in these cases, leading to the deficiency.
Failure to Maintain Proper Temperature Logs and Cleanliness for Residents' Personal Refrigerators
Penalty
Summary
The facility failed to maintain proper temperature logs, thermometers, and cleanliness for residents' personal refrigerators. During the initial tour, it was observed that several residents' refrigerators lacked thermometers and contained expired or unlabeled food items. For instance, R62's fridge had no thermometer and contained undated sandwiches and stained surfaces. Similarly, R53's fridge had moldy bread and no thermometer, and R94's fridge contained unlabeled food items and no temperature log. Interviews with staff, including the Director of Nursing (DON), Administrator, and Housekeeping Director, revealed inconsistencies in the responsibility for maintaining these refrigerators, with each department assuming the other was responsible for temperature logs and cleanliness. The Housekeeping Director admitted to not having completed the March temperature logs for some residents' refrigerators, further highlighting the lapse in protocol adherence. The facility's policies on refrigerator maintenance and food brought from outside were not followed. The policies require that refrigerators in residents' rooms be kept clean, have thermometers, and maintain temperatures between 32 and 41 degrees Fahrenheit. Additionally, food items should be properly labeled and dated, with expired items removed. However, these procedures were not adhered to, as evidenced by the presence of expired and unlabeled food items in multiple residents' refrigerators. The lack of proper monitoring and maintenance of these refrigerators poses a risk to the residents' health and safety.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from physical restraints. Resident R77, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed with full-length side rails up on multiple occasions. The CNA and LPN confirmed that the side rails were kept up to prevent falls, but the Director of Nursing acknowledged that having both full-length side rails up constituted a restraint, which could pose a risk of the resident trying to climb over and falling from a greater height. No proper assessment or care plan was documented for the use of these side rails as restraints. Resident R386, who was cognitively intact and independent with ambulation and transfers, was observed with a position change alarm on her bed and chair. Despite the resident expressing that the alarm was aggravating and unnecessary, staff insisted it was mandatory. The resident had no documented assessment, care plan, or physician's order for the use of the mobility alarms. The Director of Nursing confirmed that the alarms were put in place without proper assessment and acknowledged that such alarms could be considered restraints if they prevented the resident from moving. The facility's policies on side rails and restraints were reviewed, showing that any device that restricts freedom of movement should be assessed and evaluated to determine if it is a restraint. The policies also required a physician's order and a detailed care plan for the use of any restraint. The facility failed to comply with these policies, resulting in the inappropriate use of physical restraints for both residents without proper assessments or documentation.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer medications timely as per the physician's orders for one resident. The resident, who had intact cognition, was on strict contact isolation precautions due to an active infection (ESBL urine) and required antibiotic therapy. On one occasion, the resident did not receive her evening medications, including antibiotics, blood thinners, and other critical medications, until nearly midnight, despite multiple requests to the staff. The medications were scheduled for 5 PM and 9 PM but were administered six and two hours late, respectively. The resident's doctor was not notified about the delay in medication administration. The Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time and that giving medications late can cause significant issues. The facility's policy on medication pass, last reviewed in July 2023, states that the facility adheres to all federal and state regulations regarding medication pass procedures. However, the resident's Medication Administration Audit Report and Progress Notes indicated a clear deviation from this policy, as the medications were administered significantly late without notifying the physician.
Failure to Adjust Bed Frame, Creating Hazard
Penalty
Summary
The facility failed to adjust the mattress and bed frame, resulting in an exposed metal frame that posed a hazard. This deficiency was observed in a resident who was cognitively impaired and dependent on staff for transfers and repositioning. The resident's care plan included interventions to keep the environment uncluttered and free of potentially harmful items. However, on multiple occasions, the metal bed frame was observed to be exposed and not covered by the mattress, creating a potential risk for injury. Despite the facility's policy to ensure safety and remove hazardous items, the exposed metal frame was not addressed until a surveyor pointed it out. The Director of Maintenance confirmed that the bed frame could be adjusted by anyone and that maintenance could be contacted for assistance if needed. The Director of Nursing acknowledged that the exposed metal parts were a potential hazard that could cause skin tears. The facility's failure to promptly address this issue led to the deficiency being cited.
Failure to Maintain Nutritional Status and Monitor Weights
Penalty
Summary
The facility failed to maintain a resident's nutritional status and monitor weights as ordered, resulting in significant weight loss for one resident. The resident, who was dependent on enteral feeding due to malnutrition and weight loss, experienced a 10% weight loss over several months. The facility's records showed multiple dates where the resident's weight was not obtained as ordered. Additionally, the resident's tube feeding orders were not consistently followed, with observations noting that the tube feeding pump often did not have formula hanging and the feeding was not administered for the full prescribed duration. The dietitian and Director of Nursing were unaware of the missing weights and the incomplete feedings, which contributed to the resident's weight loss. The resident's medical history included severe cognitive impairment and dependency on staff for most activities of daily living. The resident's progress notes indicated an episode of vomiting that led to a hospital admission, but no other vomiting episodes were documented. Despite the dietitian's adjustments to the tube feeding regimen to address weight loss, the resident continued to lose weight due to the inconsistent administration of the feedings. Interviews with staff revealed a lack of awareness and adherence to the prescribed feeding schedule and weight monitoring orders, further exacerbating the resident's nutritional decline.
Failure to Evaluate Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to evaluate for gradual dose reductions (GDR) for a resident receiving psychotropic medications. The resident, who was admitted with diagnoses including dementia and depression, was not being followed by a psychiatrist. Despite being prescribed Prozac and trazadone hydrochloride, no GDR had been conducted since the resident's admission. The Director of Nursing (DON) acknowledged that the resident was overdue for a GDR and that there were no specific notes written by a psychiatrist. The Nurse Practitioner confirmed that the primary care physician was responsible for the GDR, which should be completed every six months. Additionally, the nursing staff had not been documenting the resident's behaviors, which is essential for evaluating the effectiveness of the medication and determining the need for dosage adjustments or additional medications. The facility's policy requires GDR within the first year of initiating the medication and annually thereafter, unless contraindicated with documented rationale from a psychiatrist. The report highlights that the facility did not adhere to its own policy regarding GDR for psychotropic medications. The lack of documentation and evaluation for GDR, as well as the absence of psychiatric oversight, contributed to the deficiency. The facility's failure to monitor and document the resident's behaviors further compounded the issue, making it difficult for medical staff to assess the necessity and effectiveness of the prescribed medications. This oversight could potentially impact the resident's overall well-being and treatment outcomes.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 10.34%. One incident involved an LPN administering Norco 5/325 mg to a resident at 9:15 AM without verifying the doctor's order or the last administration time. The resident's Medication Administration Record (MAR) indicated scheduled doses at 6 AM, 2 PM, and 10 PM, with no dose scheduled for 9:15 AM. Additionally, the PRN order for Norco was specifically for administration prior to wound care, which was not performed on the day in question. The LPN did not document the administration of the 9:15 AM dose on the MAR, and the wound care coordinator confirmed that no wound care was done that day for the resident, whose wound had already healed by 3/18/24. Another incident involved an LPN crushing extended-release medications, Metoprolol 50 mg ER and Potassium Chloride 20 meq ER, and mixing them with applesauce before administering them to a resident. The facility's policy and the ISMP Do Not Crush List explicitly state that extended-release medications should not be crushed. The Director of Nursing (DON) and other nursing staff confirmed that crushing extended-release medications can interfere with their absorption and effectiveness. The facility's policy on medication pass procedures also emphasizes the importance of checking before crushing medications to ensure they are appropriate for crushing.
Failure to Apply PPE and Perform Hand Hygiene for Residents on Contact Isolation
Penalty
Summary
The facility failed to apply PPE and perform proper hand hygiene for a resident on contact isolation for C. Diff. A CNA was observed exiting the resident's room without performing hand hygiene and provided incontinence care without changing gloves or washing hands. The Director of Housekeeping, two Wound Care Technicians, and a Wound Care LPN were also observed in the resident's room without wearing the required PPE and failed to perform proper hand hygiene. The Director of Nursing confirmed that staff should wear a gown, gloves, and mask in the resident's room and perform hand hygiene before and after resident care. Another resident with respiratory failure and continuous oxygen orders was left without oxygen during a bed bath. The CNA left the room to get water, leaving the resident's nasal cannula on the floor and the call light out of reach. The resident appeared short of breath and requested help from the surveyor. A Restorative Aide later placed the nasal cannula back on the resident without ensuring it was clean. The Administrator confirmed that the nasal cannula should be kept in a bag to prevent infection.
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What surveyors actually found near you
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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 Orland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Estates Of Orland Park | 2.2 mi | ★★★★★ | 7 | 1 |
| Victorian Village Hlth & Well | 3.8 mi | ★★★★★ | 1 | 0 |
| Harmony Palos | 4 mi | ★★★★★ | 9 | 0 |
| Avantara Palos Heights | 4 mi | ★★★★★ | 29 | 0 |
| Aliya Of Palos Park | 4.3 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.