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 Whitehall Of Deerfield during CMS and state inspections, most recent first.
Fall interventions were not consistently in place for a resident at high risk for falls. The resident had impaired cognition, needed substantial to maximal assistance with transfers and walking, and had recently been found on the floor in her room. Although the care plan called for high floor mats on both sides of the bed, staff observed the mats missing or not positioned by the bed, and a CNA said he was unsure whether the resident was supposed to have them.
Staff failed to follow infection prevention and control practices for residents on contact/droplet isolation for COVID-19. A CNA and a PTA were observed placing N95 respirators over surgical masks instead of using a properly fitted N95 alone, and the PTA moved between COVID-19 isolation rooms without removing masks or performing hand hygiene. Facility leadership and policies specified that residents with COVID-19 require gown, gloves, eye protection, and a fit-tested N95, with all PPE changed and hand hygiene performed between residents, and posted signs instructed staff to clean hands before entering and when leaving rooms and to remove the N95 after exiting, but these requirements were not followed in the observed care.
Dietary staff did not follow facility recipes or portion sizes, resulting in residents receiving less than the required amount of three bean salad and mandarin oranges. Additionally, pureed soup was not prepared according to the recipe, with residents receiving strained broth instead of a pureed mixture, leading to complaints from a resident.
Surveyors observed dietary staff failing to follow safe food handling procedures, including using the same gloves for dirty and clean dishes, not washing hands properly, and leaving serving utensils uncovered or improperly stored. The Food Service Director confirmed these actions were not consistent with facility policy, potentially affecting all residents receiving food from the kitchen.
Surveyors found that insulin pens and Tuberculin PPD vials were not labeled with open or expiration dates and were not always stored securely. Insulin pens were left unsecured on top of a medication cart, and open, undated Tuberculin vials were found in the medication room refrigerator. Staff confirmed these medications were in use for residents, and facility policy requires proper labeling and secure storage, which was not followed.
Several residents with indwelling medical devices or wounds did not have required enhanced barrier precautions (EBP) signage or PPE carts outside their rooms, despite documentation indicating the need for EBP. Staff were observed not changing gloves or performing hand hygiene between dirty and clean care tasks. Documentation inconsistencies and lack of adherence to infection control protocols were noted for multiple residents.
A resident requiring assistance with personal care and feeding was observed being fed by an Activity Coordinator who stood over him rather than sitting at eye level, contrary to facility policy and expectations for maintaining resident dignity.
Two residents did not receive care as ordered: one with significant weight loss and multiple medical conditions was not weighed weekly as prescribed, and another with a history of blood clots did not have compression stockings applied according to physician orders. Staff were unaware of or did not follow the orders, and the DON confirmed that all physician orders are expected to be followed.
Three residents at high risk for pressure injuries did not consistently receive required pressure-relieving interventions, such as heel offloading devices or protective boots, as outlined in their care plans and physician orders. Staff observations and interviews confirmed that these interventions were not always in place, and documentation of refusals was lacking.
A resident with a history of hemiplegia and a contracted hand was repeatedly observed without the required rolled washcloth in place to prevent further injury, despite facility policy and staff acknowledgment that this intervention was necessary.
A resident was found with prescribed mycophenolate tablets left at their bedside to take later, despite not having orders to self-administer medications. Facility policy and the DON confirmed that medications should not be left with residents unless self-administration is authorized.
A resident who had previously received a PCV13 vaccine did not receive the required follow-up PPSV23 dose, and there was no documentation of refusal in the medical record. The facility's policy, consistent with CDC guidelines, required this second dose, but it was missed and confirmed by the ADON.
A resident with severe cognitive impairment and dependency on staff was found with a bruised and swollen left big toe, later diagnosed as a fracture. The injury was first noticed by a weekend caregiver but was not reported to facility staff until the next day by another caregiver. The facility's policy requires immediate reporting of such injuries, which was not adhered to by the caregiver.
A resident, who was nonverbal and severely cognitively impaired, sustained a fracture to the left great toe due to improper mechanical lift transfer. The CNA admitted to transferring the resident alone, contrary to the facility's policy requiring two staff members. The resident's physician noted a history of osteomyelitis, suggesting increased fracture susceptibility, but attributed the injury to blunt force trauma.
A facility failed to inform a resident's representative, who is also the Power of Attorney, about a care plan meeting. The resident, diagnosed with developmental and autistic disorders, had no documentation indicating that their representative was informed of the care plan meeting. The facility's staff stated that notifications are given verbally, but no policy was provided to support this practice.
The facility was cited for deficiencies in food handling, including improper glove use and inadequate sanitization of food thermometers. A dietary aide used the same gloves for handling both dirty and clean dishes, while a cook failed to properly sanitize a thermometer between food items, contrary to facility policies.
The facility failed to enforce smoking safety protocols for two residents, leading to non-compliance with smoking contracts. One resident was observed smoking without a protective apron, and another smoked unsupervised without a designated schedule. Despite the facility's policy requiring protective measures, staff did not enforce these rules, compromising resident safety.
A resident with an indwelling urinary catheter was observed with the catheter tubing dragging on the floor, compromising infection control practices. The DON confirmed the tubing should not be on the floor due to infection risks. The resident had multiple medical conditions, and the care plan lacked specific catheter-related interventions. The facility's catheter policy did not address preventing tubing from dragging on the floor.
A resident with moderate cognitive impairment and multiple health conditions was found with an unconsumed Telmisartan pill, indicating a failure in medication administration. The RN confirmed the pill was left from a previous shift, contrary to the facility's policy requiring supervision during medication pass.
A resident with dysphagia was served thin soup instead of the prescribed nectar thick consistency, due to staff's lack of awareness and failure to update the care plan. The resident's medical history includes neurocognitive disorder and Parkinson's disease, necessitating a specific diet to prevent aspiration.
A resident with a left hip prosthetic experienced a dislocation due to the facility's failure to consistently apply hip precautions. Despite orders for a knee immobilizer and abduction pillow, the resident's leg was found shortened and internally rotated, indicating a dislocation. The abduction pillow was missing, and the resident was sent to the hospital for further evaluation.
Fall interventions not in place for a resident at high risk for falls
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident identified as high risk for falls. R3’s Fall Risk Evaluation dated 4/29/26 showed she was at high risk for falls, and her MDS assessment showed impaired cognition and that she required substantial to maximal assistance to sit to stand, transfer, and walk. R3’s Incident Report dated 4/29/26 stated that she was found on the floor during the early morning hours, with her head toward the foot of the bed, and she was unable to give a description of what happened. R3’s Fall Care Plan included an intervention initiated on 5/6/26 to keep high floor mats in place on both sides of the bed, with a date initiated of 4/29/2026. On 5/6/26, R3 was observed in bed without fall mats next to her bed or in her room, and later the mats were present but not positioned in place: one mat was on the floor but not parallel to the bed, and the other was propped against the wall and not near the bed. A CNA stated he was not sure whether R3 was supposed to have fall mats and said he had not seen them in place earlier that day. The care plan coordinator stated that after R3’s fall, fall mats were to be applied to the sides of her bed and kept down at all times when she was in bed. The facility’s Fall Occurrence Policy stated that residents identified as high risk for falls would be provided fall interventions.
Improper Hand Hygiene and PPE Use for COVID-19 Isolation Residents
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to hand hygiene and proper use of PPE for residents with COVID-19. The facility census was 151 residents, and at least three residents were documented as COVID-19 positive and on contact/droplet isolation with N95 precautions. Isolation tracking records showed that these residents had tested positive for COVID-19 on specific dates and were placed on isolation the same day. Their room doors were posted with signs requiring N95 plus eye protection and contact precautions. Despite these requirements, a CNA was observed going to COVID-19 isolation rooms wearing a surgical mask, then placing an N95 mask over the surgical mask along with other PPE before entering, contrary to the facility’s stated requirement that a fit-tested N95 be worn appropriately without a surgical mask underneath. A PTA was observed exiting a COVID-19 positive resident’s room wearing a surgical mask over an N95 mask, not removing either mask or performing hand hygiene upon leaving the room, and then proceeding directly to another COVID-19 positive resident’s room wearing the same masks. The PTA stated he performs in-room therapy with COVID-19 positive residents and relies on door signs to identify isolation status, and also stated he believed he could go to multiple COVID-19 rooms wearing the same N95 mask. The Infection Prevention Nurse and Director of Rehab both stated that residents with COVID-19 are on contact/droplet isolation requiring gown, gloves, eye protection, and an N95 mask, and that all PPE, including the N95, must be changed and hand hygiene performed between residents. The Regional Nurse reported that staff are educated on donning and doffing PPE using the isolation poster. Facility policies and posted signage required hand hygiene before entering and after leaving rooms and removal of the N95 after exiting, which was not followed in the observed instances.
Failure to Follow Dietary Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure that dietary staff followed facility recipes and portion sizes as required. On the observed date, dietary staff were seen using a 4oz slotted spoodle to serve three bean salad and mandarin oranges, but the actual portions provided were less than 4oz, with the mandarin oranges being approximately 2oz and the three bean salad approximately 3oz. The posted kitchen menu did not indicate portion sizes, and staff would need to consult the recipe binder for correct measurements. The facility's diet spreadsheet specified that a #8 scoop, which provides 4oz, should be used for both items, but this was not followed. Additionally, the process for preparing pureed beef barley soup did not follow the facility's recipe. Instead of pureeing the entire soup (including solids and liquid) to a smooth consistency, kitchen staff strained the solids and served only the liquid portion to residents requiring pureed diets. This resulted in at least one resident receiving a thin, broth-like liquid instead of pureed soup, leading to dissatisfaction and complaints. The recipe for pureed beef barley soup was found to have been altered with white-out to indicate straining for broth, but the unaltered recipe required blending the entire soup to a smooth consistency.
Deficient Food Handling and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe food handling procedures were practiced in the kitchen, as observed during multiple instances involving dietary staff. One dietary aide was seen wearing the same gloves while handling both dirty and clean dishes, including moving between the dirty and sanitized sides of the dish machine and rinsing gloved hands without soap. The Food Service Director confirmed that staff should remove gloves and wash hands after handling soiled items and before handling clean items, in accordance with facility policy. Additionally, there were no soap dispensers available at the sink where the aide rinsed their gloved hands. Further observations revealed that kitchen staff did not properly cover or clean serving utensils between uses. A cook's helper repeatedly placed uncovered scoops back onto the warmer or into clean pans after use, and a cook stored portion cups inside soup base containers, returning them after use. The Food Service Director acknowledged that these practices were not in line with facility food handling policies, which require food to be stored, prepared, handled, and served to minimize the risk of foodborne illness. These deficiencies had the potential to affect all residents receiving food from the kitchen.
Failure to Label and Secure Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and secure storage of medications, specifically insulin pens and Tuberculin PPD solution vials, for several residents. During inspection of medication carts, two open insulin pens were found without open or expiration dates, and one insulin pen was found to be expired. These pens belonged to two residents and were not immediately removed from the cart as required. Additionally, a nurse was seen leaving insulin pens unsecured on top of a medication cart while attending to other tasks. Medication Administration Records confirmed that the insulin pens were actively being used for residents with orders for insulin administration. Further inspection of the medication room refrigerator revealed two open Tuberculin PPD vials that were not labeled with open dates. Staff acknowledged that these vials should be dated and that they are used for new admissions requiring TB skin tests. Records showed that three recently admitted residents received doses from these vials. Facility policies require all opened medication vials to be labeled with the date opened and expiration date, and all medications to be stored securely, but these procedures were not followed as observed during the survey.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices, specifically regarding enhanced barrier precautions (EBP) and hand hygiene, for several residents with indwelling medical devices or wounds. Multiple residents who required EBP due to the presence of devices such as indwelling catheters, gastrostomy tubes, or interventional radiology drains did not have appropriate EBP signage or personal protective equipment (PPE) carts outside their rooms as required by facility policy. In several cases, the residents' care plans or risk evaluation forms indicated the need for EBP, but there were no corresponding physician orders or visible precautions in place at the time of observation. Direct observations revealed that staff did not consistently follow proper glove use and hand hygiene protocols during resident care. For example, a CNA was observed providing incontinence care to a resident without changing gloves or performing hand hygiene between handling soiled and clean items, which is contrary to infection control standards. The Director of Nursing confirmed that hand hygiene and glove changes should occur after contact with dirty items and before touching clean items, but this was not observed in practice. Documentation reviews further showed inconsistencies between residents' medical records, care plans, and the actual implementation of EBP. Some residents with documented indwelling devices did not have EBP orders or visible precautions, while others had discrepancies between risk evaluation forms and progress notes regarding the presence of such devices. These lapses in infection control practices and documentation were observed for multiple residents, indicating a systemic failure to ensure adherence to established infection prevention protocols.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, pneumonitis, difficulty walking, need for assistance with personal care, dysphagia, depression, and anxiety disorder was observed during a lunch meal sitting in a high back recliner. The Activity Coordinator was standing in front of the resident while spooning thickened liquids and pureed food into his mouth, rather than sitting at eye level. The facility's policy requires staff to respect residents' privacy and dignity at all times, and the Administrator confirmed that staff are expected to sit while feeding residents to facilitate engagement.
Failure to Monitor Weights and Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to monitor weights as ordered for a resident with significant weight loss and multiple complex medical conditions. The resident, an eighty-three-year-old female with diagnoses including Parkinson's disease, acute post hemorrhagic anemia, stage 3 sacral pressure ulcer, dysphagia, mild protein-calorie malnutrition, and pancreatic cancer, was readmitted from the hospital with a physician's order for weekly weights. Despite this order, only two weights were documented in the medical record over a period of more than a month, and the clinical nutrition manager confirmed that regular weight monitoring is necessary to identify and address weight loss. Additionally, the facility failed to apply compression stockings as ordered for a resident with a history of blood clots. The resident, who had a right lower extremity deep vein thrombosis and an inferior vena cava filter, had a physician's order for bilateral knee-high stockings to be applied in the morning and removed at bedtime. Observations on multiple occasions showed the resident was not wearing the stockings, and an LPN was unsure if the resident was supposed to wear them. The director of nursing confirmed that the expectation is to follow all physician orders, including those for compression stockings.
Failure to Implement Pressure-Relieving Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate pressure-relieving interventions for residents identified as being at high risk for pressure injuries. For one resident with a history of diabetes, peripheral vascular disease, and an unstageable sacral pressure ulcer, staff did not consistently offload the resident's heels as required by the care plan, despite the resident being at high risk for pressure injuries. Observations showed the resident's legs and heels were directly on the mattress without protective devices, and the resident reported that staff had not recently offered to place anything under his legs. The resident's family was not informed of any refusals, and staff interviews confirmed that offloading should be reattempted if initially refused. Another resident, who had an order for heel suspension boots to be worn in bed or in a wheelchair every shift, was observed with only one boot in place and no documentation of refusal. Staff confirmed the boots were necessary to prevent new wounds, especially given the resident's tendency to cross her legs, which impairs circulation. A third resident, at high risk for pressure injuries due to Parkinson's disease and decreased mobility, was observed multiple times with his heels and feet directly on the footrest of a recliner without any protective devices, contrary to the care plan and facility policy. The facility's own wound care guidelines require offloading of heels, but this was not consistently implemented for these residents.
Failure to Implement Contracture Prevention Measures
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, dysphagia, and a sacral pressure injury was observed multiple times with a contracted left hand bent up on his chest, without any device in place to address the contracture. The resident's record and a facility-obtained picture indicated that a rolled washcloth should be used in the contracted hand to prevent further injury. However, during several observations, no such device was present. The DON confirmed that the rolled washcloth was intended to be in place as an intervention for the contracture. The facility's Restorative Nursing Program policy requires appropriate nursing and restorative services, including contracture prevention and management, but these were not consistently implemented for this resident.
Medication Administration Not in Accordance with Professional Standards
Penalty
Summary
A deficiency occurred when a resident was found with a cup containing two pills, identified as mycophenolate, on their bedside table. The resident stated that they were holding the medication to take later on an empty stomach, as they had not yet eaten breakfast. Review of the resident's medical orders confirmed a prescription for mycophenolate but did not include authorization for self-administration of medications. The Director of Nursing confirmed that facility procedure requires nurses to remove medications if a resident chooses not to take them at the time of administration and that no residents were currently authorized to self-administer medications. Facility policy also mandates adherence to all federal and state regulations regarding medication pass procedures.
Missed Pneumococcal Vaccination Dose
Penalty
Summary
The facility failed to administer a pneumococcal vaccine as required to one of five residents reviewed for immunizations. The resident was admitted to the facility and had documentation of receiving a Pneumococcal Conjugate Vaccine 13 (PCV13) on 10/20/18, but there was no record of a subsequent Pneumococcal Polysaccharide Vaccine 23 (PPSV23) or any documented refusal in the resident's electronic medical record. According to the facility's policy, which aligns with CDC recommendations, a PPSV23 should have been administered one year after the PCV13 for individuals over age 65. The Assistant Director of Nursing confirmed that the second dose was missed and not documented.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that a resident's caregiver immediately reported a new injury of unknown origin. The resident, who was nonverbal, severely cognitively impaired, and completely dependent on staff for all care, was found to have a bruise and swelling on her left big toe. The injury was first noticed by a weekend caregiver but was not reported to the facility staff until the following day by another caregiver. An X-ray later revealed an acute intra-articular corner fracture at the lateral margin of the left great toe. The facility's policy requires that all injuries of unknown origin be reported immediately to a nurse. However, the weekend caregiver did not report the injury to the facility staff or her staffing agency on the day it was discovered. The facility's administrator and director of nursing confirmed that caregivers hired by families are expected to follow the same reporting guidelines as facility staff. The failure to report the injury promptly was acknowledged by the caregiver and her agency supervisor.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide care to a resident in a manner that prevented injury, specifically during a mechanical lift transfer. The resident, who was nonverbal, severely cognitively impaired, and completely dependent on staff for all care, sustained an acute intra-articular corner fracture at the lateral margin of the left great toe. The injury was discovered by an agency caregiver who noticed the resident's left great toe was bruised and swollen. The resident's care plan indicated that all mechanical lift transfers should be conducted with two staff members present to ensure safety. However, a Certified Nursing Assistant (CNA) admitted to using the mechanical lift alone to transfer the resident, citing a lack of available assistance. The CNA stated that the resident's feet did not hit anything during the transfer, and no injuries were observed during incontinence care. The Director of Nursing confirmed that the facility's policy required two staff members for mechanical lift transfers. The resident's physician noted a history of osteomyelitis, which could make the foot more susceptible to fractures, but indicated the injury was likely caused by blunt force trauma.
Failure to Inform Resident's Representative of Care Plan Meeting
Penalty
Summary
The facility failed to inform or invite a resident's representative to a care plan meeting, which is a requirement for comprehensive care planning. The resident in question, identified as R1, was admitted to the facility with diagnoses of lack of expected normal physiological development in childhood and autistic disorder. R1's mother, who is also his guardian and Power of Attorney, reported that she was not informed of any care plan meetings or the care planning process. This was confirmed during an interview on December 2, 2024. Further investigation revealed that the Director of Social Services and the Director of Nursing both stated that residents and their representatives are verbally informed of care plan meetings. However, there was no documentation in R1's electronic medical record to indicate that his mother was informed of such meetings. A progress note from November 7, 2024, indicated that the initial plan of care was reviewed with R1 and his mother, but the Baseline Care Plan Conference/Care Plan Summary document dated November 25, 2024, did not have her signature. The facility was unable to provide a policy regarding care plan meetings.
Deficiencies in Food Handling and Sanitization Practices
Penalty
Summary
The facility was found to have deficiencies in food handling practices, specifically related to the use of gloves and the sanitization of food thermometers. During an observation, a dietary aide was seen wearing the same gloves while loading dirty dishes into the dishwasher and then using those same gloves to handle clean items, such as dipping a test strip into the 3-compartment sink. This practice was contrary to the facility's policy, which requires staff to change gloves or wash hands when moving from handling dirty to clean dishes to prevent contamination. Additionally, the facility failed to properly sanitize food thermometers between uses. A cook was observed using a metal-type thermometer to check the temperature of various food items without adequately sanitizing it between uses. The thermometer was only wiped with a brown paper towel or rinsed with water, which does not meet the facility's policy that requires thermometers to be sanitized according to the manufacturer's instructions, such as using an alcohol swab or the three-sink method. These practices were not in line with professional standards for food safety and could lead to cross-contamination.
Failure to Enforce Smoking Safety Protocols
Penalty
Summary
The facility failed to ensure that residents adhered to smoking contracts, compromising safety and supervision protocols. Resident R27 was observed smoking without a protective apron, despite the facility's policy requiring it. The Life Enrichment Director, V4, was present but did not enforce the use of the apron. R27's smoking schedule was noted on her wheelchair, and she confirmed that her cigarettes were kept in her room while the nurse held her lighter. The facility's smoking policy mandates that residents who require supervision must have their smoking materials held by nursing staff and wear a protective apron. However, there was no documentation of non-compliance in R27's progress notes, despite the observed breach of the smoking contract. Resident R24, who has a history of dementia and recent hospitalization for a shoulder fracture, was also found to be non-compliant with the smoking contract. R24 reported smoking alone without a designated schedule and without wearing a smoking apron, contrary to the facility's requirements. The Registered Nurse, V9, confirmed that smoking aprons were not provided to R24, although the facility administrator stated that aprons were available. R24's care plan indicated a need for fall precautions and frequent reorientation, yet the smoking assessment deemed her a safe smoker without the need for staff supervision. This inconsistency highlights a failure to enforce the smoking policy and ensure resident safety.
Deficiency in Catheter Management and Infection Control
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter for a resident, leading to a deficiency in infection control practices. On May 28, 2024, a resident with an indwelling urinary catheter was observed sitting in a high back wheelchair in the dining room area, with the catheter tubing dragging on the floor as the resident propelled the wheelchair back and forth. A registered nurse was also observed pushing the resident to the dining room table while the catheter tubing continued to drag on the floor. This observation was confirmed by the Director of Nursing, who acknowledged that the catheter tubing should not be on the floor due to infection control concerns and the risk of the tubing being pulled out. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease, atherosclerosis, and dementia with behavioral disturbances, among others. The resident's care plan indicated the use of enhanced barrier precautions due to the presence of the indwelling urinary catheter, but it did not address specific concerns or interventions related to the catheter. Additionally, the facility's indwelling catheter policy did not include procedures to prevent catheter tubing from dragging or laying on the floor, contributing to the deficiency observed.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as R79, took her prescribed medications as required. R79, who has moderate cognitive impairment and multiple diagnoses including hypertension and dementia, was observed with a medication cup containing a white pill and powdery fragments. She expressed confusion about whether she had taken the correct medication and requested assistance from a nurse. The Registered Nurse, V10, confirmed that the remaining pill was Telmisartan 40 mg, a medication scheduled to be taken twice daily for hypertension. The Director of Nursing, V2, stated that it is expected for nurses to supervise residents during medication administration to ensure all medications are taken. However, V10 indicated that the pill might have been left by the night shift nurse, as she personally ensures residents take their medications one by one. The facility's policy, revised in July 2023, mandates adherence to federal and state regulations during medication pass procedures, which was not followed in this instance, leading to the deficiency.
Failure to Provide Nectar Thick Liquids as Prescribed
Penalty
Summary
The facility failed to ensure that a resident's soup was prepared in a nectar thick consistency as required for their dietary needs. During an observation, a CNA served the resident a garden vegetable soup that appeared to be a thin liquid, contrary to the nectar thick requirement. Upon checking, it was found that the thickener was not properly mixed into the soup, and even after stirring, it did not achieve the necessary consistency. The CNA was unaware of the reason for the resident's nectar thick liquid requirement, and the resident himself was not aware of any swallowing issues. The resident in question has a medical history that includes neurocognitive disorder with Lewy bodies, Parkinson's disease, and dysphagia, among other conditions. The resident's care plan and physician orders indicated a need for a mechanical soft diet with nectar thick liquids to prevent aspiration due to swallowing difficulties. However, the care plan was not updated to reflect the current dietary requirements, and the staff failed to adhere to the facility's policy on managing dysphagia and aspiration risks, which requires proper documentation and communication regarding dietary changes.
Failure to Maintain Hip Precautions for Resident with Hip Prosthetic
Penalty
Summary
The facility failed to ensure that hip precautions and interventions were consistently applied for a resident with a left hip prosthetic, leading to a dislocation. The resident, who had a history of hip dislocation and was diagnosed with conditions including Periprosthetic Fracture around Internal Prosthetic Left Hip Joint, Difficulty in Walking, Chronic Obstructive Pulmonary Disease, Parkinson's Disease, and Dementia, was admitted to the facility. On a particular day, the resident complained of severe pain in the left hip, and an X-ray confirmed a dislocation. The resident was sent to the ER for further evaluation and returned to the facility with orders for a knee immobilizer and strict posterior hip precautions, including the use of an abduction pillow at all times. Despite these orders, the resident experienced another hip dislocation. On the morning of the incident, the physical therapist found the resident's left leg shortened and internally rotated, indicating a dislocation. The therapist noted that the abduction pillow, which was supposed to be in place, was missing. The CNA also reported that the resident was restless and often threw the pillow out of bed. The resident was subsequently sent to the hospital for surgery, but the procedure was put on hold as the family considered other options, including hospice care.
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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 Deerfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northbrook Health And Rehab | 1.4 mi | ★★★★★ | 0 | 0 |
| Grove Of Northbrook,the | 2.2 mi | ★★★★★ | 1 | 0 |
| Elevate Care Northbrook | 2.2 mi | ★★★★★ | 15 | 1 |
| Aliya Of Highwood | 3 mi | ★★★★★ | 11 | 0 |
| Brandel Health And Rehab | 3.1 mi | ★★★★★ | 1 | 0 |
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