Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Waterford Care Center, The during CMS and state inspections, most recent first.
Improper labeling and dating of food items was observed in the kitchen. An opened bottle of lemon juice, cottage cheese containers, and multiple spice bottles had dates that did not match or had passed the manufacturer’s expiration or best-by dates, and some opened dates were unreadable. The Dietary Manager acknowledged the items were expired or should have been discarded, and facility policy required food to be labeled and discarded according to manufacturer guidance.
Inaccurate PASRR Level I screens failed to identify known mental illness diagnoses for four residents, including Bipolar D/O, MDD, anxiety, psychosis, and dementia with behavioral disturbance. The records showed the facility relied on negative Level I screens even when the face sheets, MDSs, and medication orders documented psychiatric conditions, and the Social Service Director stated these diagnoses should have been included and triggered PASRR Level II review.
Medication storage and labeling failures were found in multiple med carts. Surveyors observed several inhalers that were opened without proper dating, an inhaler with an open date, and multiple insulin products that were either kept in med carts while unopened or left past their discard dates. An RN, LPN, and DON stated inhalers should be dated when opened and unopened insulin should be refrigerated, while facility guidance listed specific storage and discard instructions for the affected meds.
Failure to follow the pureed menu spreadsheet resulted in a cook preparing pureed bread but not serving it to five residents on a pureed diet. A resident was observed finishing the pureed meal and still seeking more food, while the Dietary Mgr and RD stated the menu items and recipes should be followed and that pureed bread should have been served.
Failure to Follow Ordered Diet and Thickened Liquid Consistencies: Multiple residents with dysphagia and other swallowing-related diagnoses did not receive liquids in the ordered thickness, and one resident on a pureed diet received diced peaches instead of a fully pureed consistency. Observations showed unthickened milk or juice served to residents ordered nectar- or honey-thick liquids, regular water kept at bedside for a resident on thickened liquids, and a resident on a pureed diet served diced fruit. Staff and dietary personnel stated the ordered consistencies were not consistently followed.
Call lights were not kept within reach for two residents with significant mobility limitations and high fall risk. One resident with COPD, respiratory failure, obesity, asthma, anxiety, and a history of falls was observed in bed unable to reach her call light, and she said she would have to yell for help. Another resident with paraplegia and vascular dementia was also observed with the call light out of reach and later asked an RN to retrieve it from the floor because he could not reach it. Staff stated the call light should be within reach so residents can call for assistance.
Inconsistent advance directive documentation: A resident’s chart contained conflicting CPR status entries, with the POLST showing CPR while the admission record, med review, and care plan documented DNR. The resident stated the facility educated them on advance directives and that they chose no CPR after discussing it with the MD. The SSD later said the POLST had been an error and the DON stated the resident’s wishes should have been consistent throughout the record.
A resident with multiple chronic conditions, dementia, and psychiatric diagnoses including bipolar disorder, major depressive disorder, and paranoid personality disorder did not have a current Level II PASARR evaluation/determination or annual resident review completed. The Social Services Director stated the resident's PASARR screening was dated decades earlier and that the newer psychiatric diagnoses represented a change in condition requiring another PASARR, but the facility did not provide additional information.
A resident with multiple chronic conditions, including bipolar disorder, chronic pain, morbid obesity, and a history of UTIs, was left in a wet brief and soiled bed for about 14 hours despite a care plan calling for incontinence checks every 2 hours and skin care after each episode. The resident reported staff ignored her call light and did not change her while trays were being passed. During observation, urine odor was present, the brief and gown were saturated, the sheet had a brown ring, and the mattress was wet. The CNA initially cleaned only part of the perineal area, then left after the resident said the front had not been cleaned properly.
Failure to Provide Timely Incontinence Care: A resident who was incontinent of urine and stool reported not being changed for about 14 hours and said her bed and brief were soaked. Staff observed a strong urine odor, a saturated brief, and a wet mattress with a brown ring on the sheet. An LPN, an agency CNA, and a CNA orientee were involved in the delayed care, and the resident stated the front was not cleaned properly during the attempted incontinence care.
Failure to properly monitor and label food in a resident’s personal refrigerator. Staff found the refrigerator warm, with a thermometer reading 60 degrees F, no temp log, ice buildup, and multiple food items that were expired, undated, or improperly stored, including opened dressing and raw salmon that appeared slimy and spoiled. Interviews showed staff were unclear about who was responsible for checking temps, labeling food, and discarding expired items; the resident was dependent on staff to place food in the refrigerator.
A CNA handled dirty meal trays, removed a resident’s tray without hand hygiene, and then fed a resident who was dependent for eating and had dementia, dysphagia, and multiple chronic conditions. The facility also failed to place a resident with an open right lower leg wound on EBP; there were no EBP orders, no signage posted, and staff stated the resident was not on EBP despite the care plan identifying the need for it.
A resident with cognitive impairment and multiple medical conditions was found by hospital staff to have bruising and bleeding in the vaginal and perineal area, in addition to other bruises. The ER nurse notified the facility nurse, but the information was not promptly reported to the abuse coordinator or state agency as required by facility policy. Facility staff interviews confirmed delays and lack of communication regarding the incident, resulting in a deficiency in abuse reporting procedures.
A resident with cognitive impairment and on anticoagulants was found by hospital staff to have unexplained bruising and bleeding in the vaginal and perineal areas, which was reported to a facility nurse. The facility failed to document, report, or investigate these findings as required by policy, and key leadership, including the DON and Administrator, were not notified. No investigation into the injury of unknown origin was initiated.
A resident with moderate cognitive impairment and multiple psychiatric diagnoses experienced a choking episode requiring the Heimlich maneuver and supplemental oxygen. Although the provider was notified, the state guardian was not informed of the incident or the change in condition, contrary to facility policy and guardianship requirements.
A resident in an LTC facility did not receive their prescribed Baclofen 10 mg due to a medication shortage. The nurse used a substitute Baclofen 5 mg card with a torn-off label, which is against professional standards. The DON was unaware of the shortage and confirmed that borrowing medications is not allowed. Facility policies require proper labeling and administration of medications.
A resident did not receive her prescribed Ambien medication for two days after returning from knee surgery due to unavailability in the facility. Despite a sufficient supply being dispensed, the medication was not administered as confirmed by the MAR. The DON and RN were aware of the issue, but the facility failed to adhere to its policy of administering medications as per prescriber orders.
The facility failed to follow proper sanitation and food storage practices, with uncovered and unlabeled food items found in the freezer and personal items on the clean dish rack. The Dietary Manager confirmed these practices were against facility policy, which requires food to be dated and personal items stored in designated areas.
The facility failed to conduct timely PASARR screenings for four residents, leading to a deficiency. These residents, with various mental health diagnoses, were not evaluated for Level I or Level II PASARR prior to or upon admission, as required. The Social Services Director acknowledged the oversight but could not provide a reason for the lapse.
The facility failed to set low air loss mattresses to the correct weight settings for four high-risk residents, compromising the effectiveness of these devices in preventing pressure ulcers. The Wound Care Nurse confirmed that the settings should match the residents' current weights, but observations showed discrepancies, such as a resident weighing 219 pounds with a mattress set to 290 pounds.
A survey found deficiencies in medication management at an LTC facility. An LPN left a medication cart unattended and unlocked on the first floor, while an RN found expired vitamin D tablets on the second floor. The DON confirmed the importance of securing medication carts and discarding expired medications, as per facility policy, to prevent unauthorized access and administration of expired drugs.
The facility failed to maintain proper infection control by not covering a linen cart, risking contamination, and a CNA did not wear a gown while caring for a resident on Enhanced Barrier Precautions. The resident had a history of MRSA and required specific precautions, which were not adhered to, as confirmed by the DON.
The facility failed to maintain the dignity of two residents. One resident, with a history of dementia, was repeatedly observed disrobed in bed with the privacy curtain open, exposing them to others. Despite the resident's preference to disrobe, staff acknowledged the need for privacy measures, which were not consistently applied. Another resident with a urinary catheter was seen with an uncovered drainage bag, despite expressing the need for a privacy bag with straps. These incidents highlight a failure to adhere to policies ensuring resident dignity and privacy.
A resident with respiratory failure and asthma was found with an incorrect oxygen flow rate of 2 LPM instead of the prescribed 3 LPM. The resident's oxygen cannula was also not in place, reportedly removed by a CNA. A nurse confirmed the error and corrected the flow rate. The DON highlighted the importance of following physician orders and ensuring proper oxygen administration.
Improper Labeling and Dating of Food Items
Penalty
Summary
Food items in the kitchen were not consistently labeled, dated, or discarded according to manufacturer guidance and facility policy. On 01/20/26 at 9:21 AM, the Dietary Manager stated that all prepared or opened containers should be labeled with an opened or prepared date and a use-by or expiration date, and that items are discarded after seven days or by the manufacturer’s date. During observation of the walk-in refrigerator, an opened bottle of lemon juice was labeled with a delivery date, opened date, and use-by date that did not match the manufacturer’s expiration date printed on the bottle, and an opened container of cottage cheese had a use-by date beyond the manufacturer’s best-by date. The Dietary Manager stated both items should be discarded. Additional observations in the milk cooler and cooking prep area showed unopened cottage cheese containers past the manufacturer’s best-by dates and multiple opened spice containers with delivery dates or unreadable opened dates while the manufacturer’s best-by dates had already passed. The Dietary Manager stated the kitchen should follow the manufacturer’s best-by dates and that the spices were expired and would be thrown out. The facility’s diet order list showed six residents receiving NPO status, and the facility policies on labeling and dating foods and refrigerated foods required items to be labeled with receipt, opened, and discard dates or discarded by the manufacturer’s expiration date when applicable.
Inaccurate PASRR Level I Screens and Missed Level II Referrals
Penalty
Summary
The facility failed to ensure accurate information was included in Level I PASRR screenings and failed to refer residents with known mental illness to the state-designated authority for a PASRR Level II evaluation and determination for four residents out of 28 reviewed. The report states that the facility relied on PASRR Level I screens that documented no mental health diagnosis was known or suspected and no PASRR condition was present, even though the residents’ records contained diagnoses including Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Unspecified Dementia with behavioral disturbance, Unspecified Psychosis, and Neurocognitive Disorder with Lewy Bodies. For one resident, the face sheet documented diagnoses including Dementia and Anxiety Disorder, and later records included Unspecified Psychosis, Psychiatric/Mood Disorder, and orders for Sertraline and Seroquel related to Adjustment Disorder and Unspecified Psychosis. Despite these diagnoses, the PASRR Level I screens stated the resident did not have a serious mental illness or intellectual/developmental disability and did not need more screening unless there was a significant change in treatment needs. The resident’s MDS also listed psychiatric/mood disorder diagnoses, including Anxiety Disorder and Psychotic Disorder. The Social Service Director reviewed the active diagnoses for three residents and stated they had mental illness diagnoses that should have been indicated in their PASRR Level I screenings. The Administrator stated PASRR is completed prior to admission to determine whether the facility is an appropriate fit and that the PASRR screening should be reviewed for accuracy and referred for Level II screening if needed. The facility policy stated PASRR documents should be reviewed as part of the assessment process and treatment suggestions or recommendations should be identified and addressed.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to properly label and store medications in three medication carts, affecting six residents. During inspection of the 3rd floor [NAME] medication cart, surveyors found that R25’s Spiriva Respimat multidose inhaler had an open date, while R48’s Incruse Ellipta multidose inhaler had no date. R102’s Stiolto Respimat multidose inhaler was also found opened with no date. The RN stated inhalers should be dated once they are opened. R25, R48, and R102 had diagnoses including COPD or asthma-related conditions, and their physician orders included the corresponding inhaled medications. On the 3rd floor Fargo med cart, surveyors found insulin storage and dating problems. R93’s Basaglar 100u/ml KwikPen multidose insulin was not opened but was kept inside the medication cart instead of the refrigerator, and another Basaglar pen had an open date. R117’s Lispro multidose insulin vial had an open date and discard date and was kept inside the medication cart. The RN stated insulin beyond the discard date should have been removed or discarded, and unopened insulin should be kept in the refrigerator. The DON stated nurses are expected to properly store and label medications, date medications once opened, and keep unopened insulin in the fridge. On the 1st floor [NAME] medication cart, surveyors found R132’s Lantus multidose insulin pen was not opened but was kept inside the medication cart. The LPN stated unopened insulin should be refrigerated. Facility policy and medication storage guidance stated refrigerated medications are to be stored in a secured refrigerator, discontinued or outdated drugs are to be returned or destroyed, inhalers are to be dated when opened, and insulin products have specific opened and unopened storage and discard instructions.
Failure to Follow Pureed Menu Spreadsheet
Penalty
Summary
The facility failed to follow the pureed menu spreadsheets for five residents on a pureed diet. During lunch observation, a cook prepared pureed food items, including pureed bread, and placed the bread on the tray line for service. However, when the lunch trays were observed going to the 2nd floor, pureed bread was not placed on any of the trays for the five residents identified as receiving a pureed diet. Those residents were documented as being on a pureed texture diet, and the spreadsheet for that meal indicated that pureed diets were to receive pureed bread. During the meal observation, one resident was seen eating his pureed lunch tray and stated he usually eats everything and would probably eat pureed bread if he received it. Later, that resident had consumed 100% of the pureed food served and was still bringing the spoon to his mouth even though there was no food left on the plate. The Dietary Manager stated all items listed on the spreadsheets should be served to residents, that pureed diet residents should receive the same items as the regular diet in pureed form, and that pureed bread should have been served. The Registered Dietitian stated the kitchen should follow the spreadsheets and recipes, and that residents on pureed bread should receive the pureed bread listed on the menu.
Failure to Follow Ordered Diet and Thickened Liquid Consistencies
Penalty
Summary
The facility failed to provide thickened liquids as ordered for multiple residents with swallowing disorders and failed to follow a mechanically altered diet order for one resident on a pureed diet. Resident R1 had diagnoses including chronic respiratory failure with hypoxia, dysphagia, cognitive communication deficit, dependence on supplemental oxygen, and dementia. His physician order specified a pureed diet with nectar-thick liquids, and his meal ticket reflected General Pureed, Nectar Thick Liquid. During lunch observation, R1 received a tray with pureed food, pudding, and a closed 8-ounce carton of milk that was not thickened. Resident R89 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, speech and language deficits, dysphagia, chronic respiratory failure with hypoxia, and cognitive communication deficit. Her physician order specified a pureed diet with honey-thick liquids, and her meal ticket reflected General Pureed, Honey Thick Liquid. During lunch observation, R89 received pureed food and applesauce, but no liquids were on the tray. A CNA later stated she obtained juice from the beverage cart and gave it to R89, and that the juice was not thickened. Staff also stated the kitchen normally sends thickened liquids on the tray, but that did not occur for R89. Resident R123 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, COPD, chronic respiratory failure, dysphagia, and cognitive communication deficit. His physician order specified a pureed diet with honey-thick liquids, and his meal ticket reflected General Pureed, Honey Thick Liquid, Pleasure Feeding. During lunch observation, R123 received pureed food, applesauce, and a closed 8-ounce carton of milk that was not thickened. Resident R87 had an order for mechanical soft consistency with nectar-thick liquids and was supposed to eat only with supervision, but he was observed eating lunch by himself with regular water at the bedside and no thickener present. Resident R81 had a physician order for pureed consistency texture, yet was observed with a cup of diced peaches on the tray. Staff and dietary personnel stated that thickened liquids were supposed to be provided on the tray, that regular milk should not have been sent, and that diced peaches were not appropriate for a pureed diet.
Call Lights Not Kept Within Reach for Two High-Fall-Risk Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents reviewed for reasonable accommodation of needs. R7 had diagnoses including COPD, acute and chronic respiratory failure with hypoxia, morbid obesity, asthma, dependence on supplemental oxygen, anxiety disorder, senile degeneration of the brain, and a history of falling. R7’s MDS documented intact cognition, functional limitations to both upper and lower extremities, and dependence for toileting hygiene, personal hygiene, dressing, bathing, and chair/bed transfers. Her care plan and fall risk evaluation identified her as high fall risk and directed staff to keep the call light within reach and encourage use of it for assistance. On observation, R7 was lying in bed with the call light out of reach, and she stated she could not reach it and would have to yell for staff if she needed help. A CNA later observed the call light out of reach and stated it should be clipped to the resident so she could reach it. R45 had diagnoses including paraplegia, lack of coordination, and vascular dementia. R45’s MDS documented intact cognition, functional limitations to both upper and lower extremities, and dependence for toileting hygiene, personal hygiene, dressing, bathing, and chair/bed transfers. His care plan and fall risk evaluation identified him as high fall risk and directed staff to keep the call light within reach and encourage use of it for assistance. On observation, R45 was lying in bed with the call light out of reach. Later, R45 asked the RN to get his call light off the floor because he could not reach it, and the RN picked it up. The RN stated the call light should have been within the resident’s reach so he could call staff for help, and the DON stated the call light should be located within reach and clipped to the pillowcase or side rail as needed.
Inconsistent advance directive documentation
Penalty
Summary
The facility failed to ensure that one resident’s advance directive wishes were consistent across the medical record and failed to redo the resident’s POLST form. R51’s record contained conflicting documentation: the POLST form documented Yes CPR, while the admission record and medication review report documented DNR, and the care plan report stated the resident had received education on advance directives and had selected DNR. The facility’s policy required advance directives to be respected and reviewed annually with the resident to ensure they remained the resident’s wishes, but R51’s last annual assessment had not included a review of the POLST form. During interview, R51 was oriented to person, place, time, and situation and stated the facility had educated the resident regarding advance directives. R51 recalled completing an advance directive and giving it to the social service director, and stated the resident elected no CPR after discussing it with the primary doctor. The social service director stated the resident elected DNR - No CPR and later said the POLST form had been an error, explaining that the wrong option had been selected. The director of nursing stated residents’ wishes should be consistent throughout the medical record and said the social service director should have reviewed the POLST and created a new form to reflect the resident’s wishes.
Failure to Complete PASARR Review After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a resident was referred to the appropriate state-designated authority for a Level II PASARR evaluation/determination and that an annual resident review was completed. The resident, R74, was admitted to the facility with a readmission date of 01/02/21 and had diagnoses including Chronic Kidney Disease, Stage 3, Paranoid Personality Disorder, Peripheral Vascular Disease, Chronic Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Major Depressive Disorder, Insomnia, and Dementia. R74's MDS BIMS indicated the resident was rarely or never understood. Record review showed R74's diagnoses information listed Bipolar Disorder, Major Depressive Disorder, Recurrent, and Paranoid Personality Disorder with an onset date of 12/28/23. The Social Services Director stated that the resident's PASARR screening for mental health determination was dated 04/25/95 and that if the psychiatric diagnoses were added after the initial screen, this would represent a change in condition requiring another PASARR. The director also stated that if PASARR was not completed, the resident may not be appropriate for living in the facility and would not be getting the appropriate services. The facility did not provide additional information for the resident's diagnosis or PASARR screening.
Delayed Incontinence Care and Incomplete Perineal Hygiene
Penalty
Summary
The facility failed to ensure a dependent resident received timely assistance with ADLs related to incontinence care. The resident had diagnoses including anxiety disorder, insomnia, major depressive disorder, bipolar disorder, morbid obesity, chronic pain, spinal stenosis, and a history of urinary tract infections. The resident’s BIMS score was 15, and the care plan directed staff to provide skin care after each incontinent episode, check the resident every two hours and as needed, wash and dry the perineum, and keep the skin clean and dry. On observation, the resident stated she had not been changed for 14 hours and reported that her bed was wet and that she had an active UTI. She said staff had been yelling and screaming and turning off her call light, and that they were not going to change her because they were passing trays. The LPN confirmed the resident said she had not been changed since the prior night and stated residents are changed when they ask. The LPN also apologized that the resident was not changed on the 11 p.m. to 7 a.m. shift. During the observation, the resident’s brief was saturated with urine, a strong urine odor was present, and the fitted sheet had a brown ring extending beyond the brief and underpad. The resident’s gown was also saturated with urine, and the mattress was wet. The CNA initially cleaned the resident’s buttocks and between the legs from behind, but the resident stated the front had not been cleaned and that the abdominal fold was where fungus was present. The CNA then stated she was agency and did not know, and left the room. Later, the CNA orientee stated the agency CNA had been rolling the sheet and drying the wet mattress with paper towels because she did not have wipes, and the DON stated incontinent care and checks are done every two hours and that leaving a resident in urine can compromise skin.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for a resident who was incontinent of urine and stool. The resident stated she had not been changed for about 14 hours, reported being sopping wet, and said her bed was wet. She also stated she had been yelling and screaming, but staff came in and turned off the call light. The resident reported that she had an active urinary tract infection and said she had wanted to be changed earlier in the morning. During interview, an LPN stated the resident told her she had not been changed since the prior night and that incontinent residents were changed when they asked. The LPN said she asked an agency CNA and a CNA orientee to change the resident after learning of the concern. The resident stated that staff had changed her roommate but did not offer to change her, and a strong odor of urine was noted at the bedside. The resident’s green brief was saturated with urine, the fitted sheet had a brown ring extending beyond the brief and underpad, and the mattress was wet. The agency CNA and CNA orientee were observed providing care, but the resident stated the front had not been cleaned properly and that the abdominal fold area was where the fungus was located. The agency CNA stated she had made rounds earlier, was told the resident wanted pain medication before being changed, and later was told by the LPN not to return to the room. The DON stated incontinent care and checks are done every 2 hours and that leaving a resident in urine can lead to skin breakdown and compromised skin. Facility documents stated incontinent care is provided to keep residents dry, comfortable, and odor free, and that peri care should be cleaned from front to back.
Failure to Properly Monitor and Label Food in Resident Refrigerator
Penalty
Summary
The facility failed to label and date food items stored in a resident’s personal refrigerator, failed to discard undated and expired foods, and failed to ensure the refrigerator was maintained in proper working order. During observation, the resident’s room contained a large amount of food, and the resident stated staff placed leftover food in his refrigerator because he could not walk. He also stated he was unsure whether anyone checked the refrigerator temperature or whether a thermometer was inside. When the refrigerator was opened, it felt warm and contained a thermometer reading 60 degrees F, with a large amount of ice buildup around the freezer compartment and no temperature log on or near the refrigerator. Inside were unopened packages of corned beef and smoked turkey with expiration dates of 01/06/26 and 01/03/26, an opened bottle of Thousand Island dressing without an open or use-by date, and an opened package of raw marinated salmon with one fillet missing. The salmon appeared slimy, milky brown, soft, and mushy, and part of it was stuck to a half-gallon container of milk placed on top of the opened salmon packaging. Staff interviews showed inconsistent understanding of responsibility for monitoring the refrigerator, labeling food, and discarding expired items. A CNA stated night CNAs were supposed to clean out resident refrigerators but were not responsible for checking temperatures. An RN stated staff should monitor expiration dates but did not know who checked temperatures. The DON, Activity Director, Dietary Manager, and Administrator each identified activity staff as responsible for daily temperature checks and documentation, while also stating that labeling and dating food was a shared responsibility or the responsibility of whoever handled the food. The resident’s diagnoses included paraplegia, lack of coordination, and vascular dementia, and the MDS documented intact cognition and dependence on staff for chair/bed to chair transfers.
Failure to Use Hand Hygiene During Feeding and to Place Resident With Open Wound on EBP
Penalty
Summary
The facility failed to ensure hand hygiene was performed during meal tray distribution and feeding for a resident who was dependent for eating and rarely or never understood. The resident had multiple diagnoses including dementia, dysphagia, protein-calorie malnutrition, chronic respiratory failure with hypoxia, diabetes, peripheral vascular disease, and other chronic conditions. The care plan identified the resident as having a nutritional problem related to a mechanical soft diet and cognitive impairment, with interventions to provide and serve the diet as ordered and monitor intake each meal. During observation, a CNA checked the food cart and handled several dirty meal trays before identifying the resident’s tray on the cart. The CNA removed the tray without performing hand hygiene, went to the resident’s room, and began feeding the resident. The LPN later stated the resident was a feeder and that the tray should not have been on the food cart with dirty trays, noting concern for cross contamination. The DON also stated the tray should not have been mixed with dirty trays and that the CNA should have washed her hands and called the kitchen for a new tray because of food contamination. The facility also failed to place a resident with an open wound on enhanced barrier precautions. The resident’s record showed an open wound to the right lower leg and wound care orders, and the care plan identified the resident as requiring enhanced barrier precautions related to blisters and a right leg wound. However, there were no EBP orders in the medication review report, no EBP signage posted on the resident’s door or living area, the resident’s name was not on the facility’s EBP list, and a nurse stated the resident was not on EBP. The DON stated anybody with an open wound should be on EBP and that the resident should have had an EBP sign on the bedroom door.
Failure to Timely Report Injury of Unknown Origin and Hospital Findings
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for a resident who was cognitively impaired and had multiple medical conditions, including long-term use of anticoagulants. The resident was re-admitted to the facility with documented bruising on her arms, legs, and thighs, but there was no documentation of bruising or bleeding in the vaginal or perineal area in the facility's records. During a subsequent hospitalization, an ER nurse identified bleeding and bruising in the resident's vaginal and perineal area, as well as additional bruising on the right thigh, and communicated these findings to the facility nurse. The facility nurse stated she was unaware of the bruising and bleeding in those areas and did not immediately report the information to the abuse coordinator or the state agency. Interviews with facility staff revealed that the wound care nurse had observed bruising on the resident's extremities and groin area upon re-admission and reported this at a morning meeting, but did not observe vaginal bleeding. The nurse in charge at the time of the resident's transfer to the hospital acknowledged being informed by the ER nurse about the bruising and bleeding but delayed notifying the Director of Nursing and did not report the incident to the abuse coordinator or state agency as required. The Director of Nursing and Administrator both confirmed they were not notified about the hospital's findings of vaginal bleeding and bruising, and facility policy requires immediate reporting of any suspected abuse, including injuries of unknown origin. Facility policies reviewed indicate that all incidents, allegations, or suspicions of abuse, neglect, or injuries of unknown source must be reported immediately to the administrator and appropriate authorities, with initial reporting to the state agency required within two hours if abuse or serious bodily injury is suspected. In this case, the failure to promptly report the injury of unknown origin and the findings communicated by the hospital staff constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of injury of unknown origin for one resident with significant medical history, including long-term anticoagulant use, cognitive impairment, and a colostomy. The resident was re-admitted to the facility with documented bruising on her arms and legs, but there was no documentation in the care plan or progress notes regarding bruising or bleeding in the vaginal, groin, or perineal areas. Hospital records and interviews with the emergency room nurse indicated that the resident was found with bleeding and bruising in these sensitive areas, which was communicated to the facility nurse at the time of hospitalization. Despite this notification, the facility staff did not document or report the new findings of vaginal and perineal bruising and bleeding. The nurse in charge at the time of the incident acknowledged being informed by the hospital but did not immediately notify the Director of Nursing or the Administrator, as required by facility policy. The Director of Nursing and Administrator both stated they were not made aware of the hospital's findings regarding the vaginal injuries, and no investigation was initiated into the injury of unknown origin. Facility policy requires immediate reporting and investigation of any alleged abuse or injury of unknown source, especially when the resident cannot explain the injury and the location is suspicious. In this case, the lack of timely reporting and investigation by staff resulted in a failure to respond appropriately to an allegation of potential abuse or injury of unknown origin, as required by both facility policy and regulatory standards.
Failure to Notify State Guardian After Resident Choking Incident
Penalty
Summary
The facility failed to notify a resident's state guardian following a significant change in the resident's condition. The resident, who has a history of dementia, schizoaffective disorder, and major depressive disorder, experienced a choking episode during dinner. The nurse on duty responded by performing the Heimlich maneuver, clearing the airway obstruction, and administering supplemental oxygen when the resident's oxygen saturation dropped to 89-90%. The resident's condition stabilized after intervention, and the provider was notified, but there was no documentation that the state guardian was informed of the incident or the change in oxygen saturation within 24 hours. Interview with the nurse involved revealed that he was unaware the resident had a state guardian and therefore did not notify the guardian after the incident. The Director of Nursing confirmed that facility policy requires notification of the resident's physician and representative or guardian in the event of a change in condition or incident. The resident's guardianship documentation also specifies that the public guardian must be notified immediately of incidents or changes in condition. Despite these requirements, the guardian was not informed as required.
Medication Mismanagement and Labeling Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of medication management, affecting a resident who was prescribed Baclofen 10 mg for musculoskeletal therapy. The issue arose when the resident's Baclofen medication was not available in the facility, and the nurse discovered that the medication had been lost. The pharmacy confirmed that a 30-day supply had been dispensed and signed for by a facility staff member, indicating that the medication should still have been available. In response to the shortage, a nurse used a substitute bingo card containing Baclofen 5 mg tablets, which had a torn-off label with another resident's name and the current resident's name handwritten on it. The Director of Nursing (DON) was unaware of the medication shortage until the day of the survey and confirmed that the practice of borrowing medications from one resident to administer to another is against professional standards. The facility's policy clearly states that medications ordered for a particular resident may not be administered to another resident, and any drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling. The DON also mentioned that she collects discontinued medication bingo cards in her office until the pharmacy picks them up, but she did not supply the Baclofen 5 mg card to the nurses. This incident highlights a breach in medication management protocols, as the facility failed to ensure proper labeling and administration of medications according to professional standards.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the resident's physician, resulting in a significant medication error for one resident. The resident, who had returned to the facility after knee surgery, did not receive her prescribed Ambien medication for two days. The Director of Nursing (DON) and a Registered Nurse (RN) were aware of the issue, as the medication was not available in the facility. Despite a 30-day supply of Ambien being dispensed to the facility and signed for by a staff member, the medication was not administered on the specified dates, as confirmed by the medication administration record (MAR). The General Manager of Pharmacy confirmed that there was a sufficient supply of Ambien, and there should not have been any lapses in administration. However, the DON was unsure if the medications were properly managed when the resident was readmitted, and did not verify if the medication was available in the emergency box. The facility's policy requires medications to be administered in accordance with prescriber orders, which was not adhered to in this case, leading to the deficiency.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed during a kitchen tour. Several food items, including turkey hot dogs, chicken patties, and chicken leg quarters, were found in the walk-in freezer uncovered and without open or discard dates. This lack of labeling and proper storage could potentially lead to foodborne illnesses, as dietary staff may not be aware of how long the food has been open. The Dietary Manager acknowledged that all food items should be dated once removed from their original packaging, in accordance with the facility's policy. Additionally, personal items such as cell phones and eyeglasses were found on the clean dish rack, which is against the facility's policy that prohibits storing personal belongings in the kitchen to prevent cross-contamination. The Dietary Manager confirmed that these items belonged to dietary employees and reiterated that personal items should be stored in designated areas like the locker room. The facility's policy on food storage and employee personal items, dated 2017, outlines these requirements to ensure safe food handling and storage practices.
Failure to Conduct Timely PASARR Screenings
Penalty
Summary
The facility failed to initiate a new Level I PASARR screening for four residents, which is a requirement for assessing mental disorders or intellectual disabilities. The deficiency was identified during a survey where it was found that residents R6, R7, R11, and R32 did not have the necessary PASARR screenings completed prior to or upon their admission to the facility. This oversight was discovered when the surveyor requested the PASARR screenings and found that they were only completed on 12/18/2024, despite the residents having been admitted earlier. Resident R11 was admitted with diagnoses including schizoaffective disorder and bipolar disorder, yet there was no documentation of a PASARR Level I or Level II evaluation prior to the survey date. Similarly, Resident R6, who has a history of schizoaffective disorder and other mental health conditions, was found to require a Level II evaluation, but this had not been conducted. Resident R7, with a history of bipolar disorder and self-harmful ideation, also required a Level II evaluation, which was not completed in a timely manner. Resident R32, who has a history of major depressive disorder and dementia, was similarly found to need a Level II evaluation. The Social Services Director acknowledged the responsibility for completing and submitting PASARR screenings but could not provide a reason for the failure to conduct these screenings. The facility's policy mandates that all new admissions undergo a Level I PASARR screening to determine the need for a Level II evaluation, which was not adhered to in these cases.
Incorrect Low Air Loss Mattress Settings for High-Risk Residents
Penalty
Summary
The facility failed to ensure that low air loss mattress devices were set to the correct weight settings for four residents who were at high risk of developing pressure ulcers. These residents were observed to have their mattress settings either too high or too low compared to their current weights, which could compromise the effectiveness of the mattresses in preventing pressure ulcers. For instance, one resident with a weight of 219 pounds had their mattress set to 290 pounds, while another resident weighing 86 pounds had their mattress set to 120 pounds. The facility's Wound Care Nurse confirmed that the low air loss mattresses should be set according to the current weight of the residents to effectively decrease pressure on bony areas and prevent pressure ulcers. The facility uses the BRADEN score to assess the risk of skin breakdown, and all four residents had scores indicating a high risk for developing pressure ulcers. The facility's policy requires that individuals at risk for pressure ulcers be placed on appropriate support surfaces, but the incorrect settings observed indicate a failure to adhere to this policy.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage and disposal, as observed during a survey. On the first floor, a medication cart was found unattended and unlocked, which was the responsibility of an LPN. This cart contained medications for residents on that floor, posing a risk of unauthorized access. Additionally, on the second floor, a medication cart inspection revealed a bottle of vitamin D tablets with an expiration date of the previous month. The RN acknowledged that expired medications should be discarded promptly to prevent administration to residents. The Director of Nursing confirmed the importance of securing medication carts when unattended to prevent access by residents or visitors. The facility's policy mandates that all drugs and biologicals be stored in locked compartments and that expired medications be returned to the pharmacy or destroyed. The survey findings indicated that these policies were not followed, potentially affecting the 86 residents residing in the facility.
Infection Control Deficiencies in Linen Storage and PPE Usage
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, specifically regarding the storage of facility linen and the use of Personal Protective Equipment (PPE) by staff. A linen cart was observed in the hallway without a side covering, containing towels, sheets, pillowcases, and gowns, which could lead to contamination. The Director of Nursing and the Maintenance Supervisor acknowledged that uncovered linen could become contaminated, and the linen cart with the missing flap needed replacement. Additionally, a Certified Nurse Assistant (CNA) was observed providing care to a resident on Enhanced Barrier Precautions without wearing a disposable gown, as required. The resident, who had a history of MRSA and was on long-term enteral feeding, required Enhanced Barrier Precautions. The Director of Nursing confirmed that staff should wear a mask, gloves, and a disposable gown when caring for such residents, but this protocol was not followed in this instance.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R6, by not ensuring their body was covered to prevent exposure to others. R6, who has a history of dementia and schizoaffective disorder, was observed multiple times lying in bed with only a diaper and socks on, with the privacy curtain open, allowing them to be viewed from the doorway. Despite R6's preference to disrobe, the facility staff, including the Director of Nursing and Social Services Director, acknowledged that the privacy curtain should be drawn to maintain dignity. However, the care plan addressing R6's behavior of disrobing was only updated after the surveyor's observation, indicating a lack of proactive measures to address the issue. Another deficiency was noted with a resident identified as R117, who was observed with a urinary catheter drainage bag hanging underneath their wheelchair without a privacy bag. R117, who has a neurogenic bladder and uses a suprapubic catheter, expressed the need for a privacy bag with straps, as the one provided by the facility was deemed useless. The Registered Nurse confirmed that the urinary drainage bag should be covered for dignity reasons, and the Director of Nursing reiterated that covers are supposed to be used. However, the lack of a proper privacy bag at the time of observation indicates a failure to uphold the resident's dignity. The facility's policies on Activities of Daily Living and Quality of Life-Dignity emphasize the importance of maintaining residents' dignity and privacy. These policies require that residents be treated with respect and that their privacy be protected, including covering urinary catheter bags. The observed deficiencies in maintaining resident dignity and privacy suggest a failure to adhere to these policies, as evidenced by the exposure of R6 and the uncovered urinary drainage bag of R117.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to a resident's care plan by not following the physician's order for the correct oxygen flow rate. The resident, who has acute and chronic respiratory failure with hypoxia and unspecified asthma, was observed with an oxygen flow rate set to 2 liters per minute (LPM) instead of the prescribed 3 LPM. This discrepancy was noted during an observation when the resident was found with the oxygen cannula tubing not in place, and the resident reported that a CNA might have removed it during care. The resident expressed the need for continuous oxygen use due to shortness of breath related to asthma and COPD. A registered nurse confirmed the incorrect oxygen flow rate and adjusted it after checking the physician's orders. The Director of Nursing emphasized the importance of following doctor's orders for oxygen administration to meet the individual needs of residents and stated that CNAs should not remove oxygen tubing but should inform nurses to ensure proper administration. The facility's policy on oxygen administration requires verification of physician orders and adherence to the care plan, which was not followed in this instance.
What surveyors are citing around you — mapped
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Plaza | 0.1 mi | ★★★★★ | 0 | 0 |
| Chalet Living & Rehab | 0.1 mi | ★★★★★ | 19 | 1 |
| Fargo Health Care Center | 0.2 mi | ★★★★★ | 21 | 0 |
| Lakefront Nursing & Rehab Ctr | 0.2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Lakeshore | 0.3 mi | ★★★★★ | 10 | 1 |
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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.