Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Winning Wheels during CMS and state inspections, most recent first.
A resident with hemiplegia, left-side neglect from CVA, dysphagia, and a history of spillage required substantial assistance with ADLs and had documented difficulty managing cups and lids. During breakfast, the resident attempted to reposition the lid on a short metal insulated coffee cup using only one functional arm, fumbled the cup, and hot coffee spilled onto the inner left knee, causing a partial-thickness burn with blistering and pain. Staff interviews revealed that coffee temperatures were not routinely checked before service, CNAs were not instructed to check temperatures, and hot liquid temperature monitoring was done only randomly and infrequently without clear documentation, despite a facility policy requiring dietary staff to check hot liquid temperatures prior to distribution and to provide individualized supervision and assistive devices for residents with difficulties handling hot liquids.
The facility failed to implement its pest control policy and maintain an effective pest control program, as evidenced by two residents reporting mouse droppings in their room and on a bed, and repeated pest contractor reports identifying an unrepaired gap at an exit door. The Environmental Services Director stated he had not received recent pest control reports and did not round with the pest contractor, while the pest specialist reported he provided recommendations to administration and expected they would be relayed to maintenance. The Administrator believed another supervisor was responsible for notifying the Environmental Services Director of needed repairs. Multiple pest control reports documented the same door gap and need for a door sweep replacement, and surveyor observation confirmed a sizable ground-level gap at the exit door, despite a facility policy requiring an effective pest control program and a reporting system for pest issues.
A resident with chronic pain had a physician’s order for a Fentanyl transdermal patch and for patch placement checks every shift, with documentation on the MAR. On one day, the MAR showed that both day and night shift checks were completed, but an incident report later documented that the patch was missing during a night shift check. An LPN admitted she became distracted, did not actually see the patch during her shift, yet documented it as in place, and only later discovered with another LPN that the patch was missing. Staff interviews showed inconsistent practices regarding whether oncoming and outgoing nurses checked the patch together, despite the DON and facility policy requiring verification of the patch site and date every shift with proper MAR documentation.
An LPN was observed on video diverting controlled medications, including narcotics, from six residents by removing extra doses, failing to document administration, and ingesting or pocketing the drugs. Medication reconciliation records and staff interviews confirmed that the medications were not given as ordered, and proper documentation was not maintained, resulting in misappropriation of resident medications.
Staff failed to promptly report and investigate suspected misappropriation of medications involving multiple residents. An LPN was observed sleeping during her shift, handling medications inappropriately, and possibly diverting narcotics. Concerns about her behavior were not immediately escalated, and the incident was not reported to authorities within the required timeframe, resulting in a delay in addressing the suspected abuse.
An LPN failed to administer and document scheduled medications for multiple residents during a night shift, resulting in missing records for a variety of prescribed drugs. The DON confirmed that standard procedures to verify administration, such as checking medication cards, were not followed, and the facility's policy requiring immediate documentation was not adhered to.
Staff were observed serving food without proper hand hygiene after coughing and sneezing, and using hands instead of utensils, contrary to facility policy. Additionally, two residents had room refrigerators storing perishable food without thermometers or documented temperature checks, despite facility requirements for proper food storage and monitoring.
Four residents on pureed diets were served pureed barbecue without the required cornbread, as the cook omitted cornbread during preparation and only included it after the initial batch ran out. The dietary manager confirmed that staff should follow the menu and recipes, in accordance with facility policy.
Four residents on pureed diets were served meals that were thick, dry, and not of a smooth consistency, contrary to facility policy and dietary requirements. The pureed foods, including fish and barbecue pork, were prepared and served in a form that did not meet the prescribed texture for individuals requiring pureed diets.
A resident was prescribed Diazepam, a psychotropic medication, on an as-needed basis without a specified end date, contrary to facility policy requiring a defined duration for such medications. Staff confirmed that PRN psychotropic medications should be limited to 14 days, but this was not followed in the resident's case.
A resident with a new diagnosis of schizoaffective disorder did not receive a required PASARR Level 2 assessment, as indicated by record review and administrator interview, despite facility policy requiring prompt referral for such evaluations when a serious mental disorder is newly identified.
A resident with a stage 4 pressure injury did not have a required dressing in place for several hours after it came off during a shower. Staff did not replace the dressing, instead waiting for the wound care doctor, and documentation showed missed dressing changes on two days. Facility policy required dressings to be replaced if they came off, but this was not followed.
A CNA was observed pulling a resident's arm above head level to assist with a transfer from a recliner, rather than using a gait belt as required by facility policy. The resident had quadriplegia, a history of falls, and required assistance with transfers. The DON confirmed that this method was not safe and could cause injury.
A resident receiving tube feeding for multiple medical conditions was observed with a bag of liquid nutrition that was not labeled with the resident's name, date, or time of initiation. The bag remained in use for several hours, and the DON confirmed that proper labeling was required by facility policy.
A resident with multiple psychiatric and medical diagnoses did not receive an increased dose of trazodone as ordered by the physician, resulting in a delay of two days before the new dose was administered. The DON was unable to explain the delay, and facility records confirmed the medication was not given as ordered.
A multidose Lispro insulin pen was found in the medication cart with an open date but no documented discard date, and it was administered to a resident multiple times beyond the recommended 28-day period. An LPN confirmed that insulin pens should be labeled with both open and discard dates, in accordance with facility policy and manufacturer guidelines.
A resident with cognitive impairment and significant dental issues had not received dental care since their last documented appointment several years prior. Staff were unaware of the lapse, and no documentation was available to show that the facility assisted the resident in obtaining required dental services, despite the facility's policy.
A CNA did not change gloves or perform hand hygiene after removing a soiled brief and before handling clean equipment and showering a resident with multiple medical conditions who was on enhanced barrier precautions. This action was not in accordance with the facility's infection control policy requiring hand hygiene after contact with contaminated surfaces and before moving to clean tasks.
Two residents with significant physical disabilities were observed with multiple flies landing on them in their shared room, with no pest control measures in place. The pest control contractor was not notified of the issue, and the Safety Director was also unaware, despite facility policy requiring prompt reporting and management of pest problems.
Three residents experienced falls during transfers and personal care due to lack of proper safety measures, including failure to use a gait belt, not securing a shower chair seatbelt, and absence of non-slip surfaces in the shower. One resident sustained a fractured humerus, while others had minor or no injuries. Staff interviews and documentation confirmed that required safety protocols were not followed at the time of the incidents.
A resident with a history of recurrent UTIs and other complex medical conditions experienced a delay of nearly 48 hours in receiving appropriate treatment for a symptomatic UTI. Despite positive urine culture results and ongoing symptoms, no new antibiotics were started, and care was not escalated in a timely manner. The resident ultimately required hospital admission for the untreated UTI.
The facility failed to sign off controlled medications in the electronic narcotic inventory system at the time of administration for several residents. During a medication pass, an LPN did not immediately update the system, leading to discrepancies between the electronic counts and physical medication cards. The DON confirmed that the facility's protocol requires immediate sign-off to ensure accurate tracking and prevent medication diversion.
A resident with type 2 diabetes experienced improper placement of a glucose monitoring sensor by an RN, leading to its removal and reliance on finger pricks for blood sugar monitoring. The facility failed to adhere to physician orders and insurance limitations delayed the replacement sensor. The DON was initially unaware of the issue.
Two residents in the facility did not receive adequate assistance with activities of daily living. A resident with multiple health issues was left without her pendant call light in a dining room, leading to a delay in receiving help. Another resident, dependent on staff for oral hygiene due to limited movement, reported that his teeth were not brushed before breakfast as per his preference, a recurring issue despite informing staff. The facility's policy requires daily personal care, which was not followed.
The facility failed to document and execute treatment orders for two residents. One resident with a PICC line lacked dressing change orders for over a month, contrary to policy requiring weekly changes. Another resident with a surgical wound and skin tear had no treatment orders documented for nine days. The Wound Care Nurse noted the absence of standing orders and the need for nurses to seek physician orders, which were not timely documented.
The facility failed to maintain a clean and sanitary kitchen environment, with black oil in the deep fryer and food debris on the floor. Dietary staff did not sanitize thermometers between uses, risking cross-contamination. The cleaning schedule was not followed, and the kitchen floor was not mopped every shift as required.
The facility failed to ensure staff wore appropriate PPE for residents on enhanced barrier precautions (EBP). A resident with a history of MDRO was not provided with proper PPE during care, despite signage indicating the need for gowns and gloves. Another resident's EBP order was delayed, and staff did not wear gowns during dressing changes. Similar issues were observed with two other residents, indicating a pattern of non-compliance with infection control policies.
A resident with quadriplegia and neurogenic bladder was left exposed for 36 minutes during a bathing session by CNAs, compromising their dignity. Staff interviews confirmed this was against the facility's policy on maintaining resident privacy and dignity.
The facility failed to protect residents from abuse, involving incidents where a resident was physically assaulted by a roommate, another was smacked and grabbed by a peer, and a third was kicked by the same aggressive peer. Despite reports and documentation of these incidents, the facility's staff expressed uncertainty about classifying them as abuse, indicating a need for clearer guidelines.
The facility failed to investigate allegations of abuse involving three residents. One resident reported being hit by her roommate, but the facility's administrator did not speak to the involved residents until three days later, violating the facility's abuse policy. Additionally, two other resident-to-resident altercations were not investigated, despite being documented in reports to the Illinois Department of Public Health.
The facility failed to obtain Level 2 PASRRs for two residents with mental health diagnoses of schizophrenia, depression, and bipolar disorder. Despite their diagnoses, the PASRR Level 1 Screen Outcomes indicated no need for Level II PASRRs. The administrator acknowledged the oversight but was unsure why the assessments were not completed. The facility lacked a policy on PASRRs.
A resident with cerebral palsy and dysphagia did not receive necessary feeding assistance for dinner, despite being dependent on staff for eating. The resident reported that a tray was delivered but staff did not return to assist, leaving them unable to eat. The care plan required assistance to prevent aspiration and weight loss, yet the meal intake record showed no intake for that meal. Staff interviews confirmed that assistance should be provided immediately upon tray delivery.
A resident with quadriplegia and other medical conditions had a scab on his buttocks that went unnoticed by staff despite daily skin checks. The scab, measuring 3.0 cm by 2.5 cm, was only identified after a surveyor's inquiry. Facility policy required reporting and documenting skin changes, but the scab was not detected in prior assessments, highlighting a lapse in the facility's skin care protocol.
Two residents in an LTC facility developed pressure injuries due to improper care. One resident suffered a medical device-related pressure injury on the penis due to incorrect catheter placement, resulting in permanent disfigurement. Another resident developed a Stage 3 sacral pressure ulcer, which was not identified promptly. During wound care, the nurse failed to clean stool from the resident's buttocks before applying a clean dressing, violating care protocols.
The facility failed to apply prescribed splints for two residents with limited range of motion, leading to non-compliance with care plans. One resident with severe cognitive impairment and hemiplegia was observed without a splint on two occasions, while another resident at risk of contractures due to hemiplegia reported inconsistent application of his splint. Staffing issues were cited as a reason for these deficiencies.
A hospice resident with multiple health issues was transferred without a gait belt, contrary to facility policy. The resident required substantial assistance, and the transfer was performed by a CNA without the necessary safety equipment, increasing the risk of accidents. The facility's policy mandates gait belt use for all assisted transfers, which was not followed in this instance.
A resident with a complex medical history, including neuromuscular dysfunction of the bladder and a history of UTIs, was found with his catheter drainage bag improperly handled, leading to increased infection risk. The drainage bag was observed in contact with the floor and not in a dignity bag, contrary to facility policy. The infection preventionist confirmed that such practices could lead to infections, and the resident was recently diagnosed with a UTI involving methicillin-resistant Staphylococcus aureus.
A resident with a history of exit-seeking behaviors and hallucinations eloped from the facility, reaching a heavily traveled highway. Despite being assessed as high risk for elopement, the resident was able to cut off her wander guard bracelet and exit unsupervised. Staff attempts to redirect the resident were unsuccessful until a passerby intervened. The facility's failure to implement effective supervision and security measures led to this incident.
The facility failed to protect a resident from sexual abuse by another resident. R5, who has moderate cognitive impairment, touched R4's breast while they were on the front patio. R4 reported the incident immediately, and staff confirmed R5's history of making sexually inappropriate comments.
A resident with a history of cognitive issues alleged sexual abuse by another resident. Despite being informed by a forensic nurse, the facility's DON and Administrator did not report or investigate the claim, assuming it occurred at the hospital and attributing it to the resident's history of hallucinations.
The facility failed to investigate an abuse allegation involving a cognitively intact resident who reported being sexually abused by another resident. Despite receiving a report from a forensic nurse, the facility staff did not initiate an investigation, assuming the abuse occurred at the hospital and attributing the allegations to the resident's history of hallucinations.
Failure to Safely Serve Hot Liquids Resulting in Resident Burn
Penalty
Summary
The deficiency involves the facility’s failure to ensure hot liquids were safely served and to have an effective process in place for hot liquids, resulting in a resident sustaining burns from spilled coffee. The resident had multiple diagnoses including acute and chronic respiratory failure with hypoxia, atherosclerotic heart disease, dysphagia, epilepsy, hemiplegia/hemiparesis, and mononeuropathy of the left lower limb. Facility assessments and care plans documented that the resident had no cognitive impairment but required substantial to maximum assistance for most cares, had hemiplegia and left-side neglect from a prior CVA, limited strength and mobility on the left side due to a chronic left rotator cuff tear and shoulder masses, and a swallowing problem with loss of food/liquids from the mouth. The care plan also noted that the resident had moderate spillage of food and fluids, would fall asleep or become distracted during meals, and would remove lids from cups causing liquids to spill. On the morning of the incident, nursing documentation showed that the resident spilled hot coffee on the left knee during breakfast, resulting in a red area measuring approximately 5 inches by 3 inches on the inner left knee and reported pain level of 5, for which PRN Tylenol was given. A skin check the same day documented a new in-house acquired burn to the front left knee measuring 12.5 cm by 7.5 cm. Subsequent observation of the wound revealed triangular and oval open areas on the inner left knee where fluid-filled blisters had burst. The resident reported that he had been trying to turn his short metal insulated coffee cup with a plastic lid so the drinking hole was in position, fumbled the cup, and the coffee poured out of the small hole onto his leg. Staff interviews indicated that the resident could not turn the lid himself due to only having use of his right arm and might have placed the cup between his knees while attempting to turn the lid. The facility’s hot liquid safety policy required that hot liquid temperatures be checked in the dietary department prior to distribution and that residents with difficulties receive appropriate supervision and assistive devices, with individualized interventions on the care plan. However, the dietary aide stated that they did not perform temperature checks on coffee, and a CNA reported never being asked to check coffee temperatures before serving. The dietary manager stated that typically coffee was poured, lidded, and placed on the cart without routinely checking temperatures, and that any temperature checks were random and infrequent, with no clear documentation process. During observation, the dietary manager measured coffee at 164°F, then diluted it to 147°F before sending it to the unit, and acknowledged that hot liquids posed burn risks, especially for residents with neurological impairments who might not be able to hold cups. These actions and inactions demonstrate that the facility did not consistently implement its hot liquid safety policy or ensure safe serving practices for hot beverages for this resident.
Failure to Implement Pest Control Program and Address Rodent Entry Points
Penalty
Summary
The facility failed to implement its pest control policy and maintain an effective pest control program to prevent and address mice and other pests. The facility census showed 74 residents resided in the facility. One resident reported finding mouse droppings in her dresser in October 2025 and provided a photograph showing small mouse droppings and what appeared to be crystallized urine in the dresser, which she described as disgusting and a disease problem. Another resident reported having mouse droppings on the bed, with the most recent occurrence reported as having happened the previous week. The Environmental Services Director stated that a third-party pest elimination contractor is employed and that the contractor generates reports identifying trouble areas and entry points for pests. However, he reported he had not seen a pest control report since September and was unaware of the contractor’s recent recommendations, including those in the 1/13/26 report, because administration only forwards reports if there are issues they believe need to be resolved. The contracted pest specialist stated he provides recommendations to administration and expects they are passed on to maintenance. The Administrator stated she believed the Safety Supervisor was notifying the Environmental Services Director of pest recommendations. Pest elimination reports from multiple months documented a gap at the B wing exit door and a needed door sweep replacement, and observation showed a 1 inch by 0.5 inch ground-level gap at the B hall exit door open to the outside. The facility’s Pest Control Program policy states it will maintain an effective pest control program and a report system for issues arising between scheduled pest service visits.
Failure to Verify and Accurately Document Fentanyl Patch Placement Each Shift
Penalty
Summary
The deficiency involves the facility’s failure to verify and accurately document the placement of a prescribed narcotic pain patch as ordered for one resident. The resident was admitted with multiple diagnoses including chronic and unspecified pain and had a physician’s order for a Fentanyl 25 mcg/hour transdermal patch to be applied every 72 hours with rotation of the site. The Medication Administration Record (MAR) also contained an order for Fentanyl patch placement checks every shift, with documentation required on the MAR. On the date in question, the MAR showed that both day and night shift placement checks were documented as completed. However, the facility’s incident report documented that during the night shift placement check, the Fentanyl patch was found to be missing, despite earlier documentation indicating it was in place. Interviews with nursing staff revealed inconsistent practices and a failure to follow the facility’s policy and the physician’s order for verification of patch placement. One LPN stated that Fentanyl patches are checked every shift with the outgoing nurse present, and that the patch’s presence, date, and initials are documented on the MAR. Another RN reported that the nurse on duty checks the patch alone, without the outgoing nurse. A different LPN acknowledged that on the morning in question she intended to verify the patch but became distracted by other residents and events in the hallway, did not actually see the patch, yet documented on the MAR that it was in place; she later discovered with another LPN at the end of her shift that the patch was missing and stated she should have documented “No” for patch placement. The DON confirmed that both oncoming and outgoing nurses are supposed to check patch placement together each shift, and the facility’s narcotic pain patch policy requires verification of the patch site and date every shift with documentation in the MAR, which did not occur as required for this resident.
Failure to Prevent Misappropriation of Controlled Medications by LPN
Penalty
Summary
The facility failed to protect six residents from misappropriation of medications by a Licensed Practical Nurse (LPN), as evidenced by video surveillance, medication reconciliation records, and staff interviews. Over the course of a night shift, the LPN was observed on camera removing medications, including controlled substances such as oxycodone, pregabalin, lorazepam, morphine, diazepam, and Norco, from medication drawers and narcotic boxes. The LPN was seen dispensing medications into her bare hands, placing them into cups, and at times putting items into her mouth or her clothing. At no point was the LPN observed referencing the Electronic Medication Administration Record (EMAR) while handling these medications. Record reviews revealed that the LPN removed additional doses of medications for six residents without documenting administration in the residents' MARs or the narcotic reconciliation system. In several cases, the medications were not administered to the residents as ordered, and there was no documentation to support that the residents received their prescribed doses. One resident reported not receiving pain medication, despite the MAR indicating it had been signed out, and accepted alternative pain relief. Staff interviews confirmed that the only way to verify medication administration is through proper documentation, and discrepancies were identified when reviewing the narcotic reconciliation system and MARs. The facility's investigation, supported by video evidence and staff statements, established that the LPN diverted medications intended for residents, including controlled substances, and failed to follow required documentation and administration protocols. The facility's policies require that the dose noted in the usage form or automated dispensing system must match the dose recorded in the MAR and other records, which was not adhered to in these instances. The misappropriation was reported to local authorities for further investigation.
Failure to Timely Report and Investigate Suspected Misappropriation of Medications
Penalty
Summary
The facility failed to report alleged violations of misappropriation involving six residents to the Illinois Department of Public Health (IDPH) within the required 24-hour timeframe and did not implement policies and procedures for reporting the possible crime to law enforcement. Video evidence showed an LPN sleeping in the medication room during her shift, dispensing medications from cards into her bare hands, and placing items in her mouth and pocket without referencing the Electronic Medication Administration Record (EMAR). Medication discrepancies were later discovered, and concerns about the LPN's behavior were reported by another nurse to the previous Director of Nursing (DON) the following morning. However, the initial concerns were not escalated immediately, and the facility did not recognize the misappropriation until a resident reported not receiving medications. The misappropriation was ultimately reported to IDPH and local police nine days after the facility began its investigation, rather than within the required reporting window. The facility's policy requires immediate notification of the Administrator and DON regarding any complaints, observations, or suspicions of resident abuse, mistreatment, or neglect, but this protocol was not followed. The delay in reporting and failure to implement established procedures resulted in a deficiency related to timely reporting and investigation of suspected abuse and misappropriation.
Failure to Administer and Document Scheduled Medications
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for four residents. On the night in question, the agency night nurse, an LPN, reportedly slept through most of her shift and did not complete wound treatments or document medication administration in the Electronic Medication Administration Record (EMAR). As a result, there was no documentation that several residents received their scheduled early morning medications, including a range of drugs such as Amantadine, fluoxetine, lactulose, omeprazole, baclofen, buspirone, diazepam, levetiracetam, Norco, fluticasone, omeprazole, aspirin, finasteride, furosemide, lidocaine patch, trelegy inhalation, venlafaxine, doxycycline, Eliquis, metformin, metoprolol, oxybutynin, gabapentin, baclofen, escitalopram, scopolamine patch, tizanidine, Colace, famotidine suspension, Lyrica, trihexyphenidyl, and propranolol. The lack of documentation made it unclear whether the medications were administered as ordered. The Director of Nursing confirmed that if there is no documentation in the MAR, the facility would typically check medication cards to determine if medications were given, but this was not done in this instance. The medication cards for the relevant period were not available for review, and the charting system's shift changeover may have prevented the next nurse from noticing missed doses. The facility's policy requires immediate documentation after medication administration, which was not followed in these cases.
Failure to Maintain Sanitary Food Service and Monitor Resident Refrigerator Temperatures
Penalty
Summary
A deficiency was identified when a cook was observed serving food from the steam table while wearing gloves and using her hands instead of utensils to plate fish sticks and cornbread. During the meal service, the cook coughed onto her right wrist, sneezed into her left elbow, and wiped her nose with her left wrist, but did not remove her gloves or perform hand hygiene before continuing to serve food. The facility's own handwashing guidelines require dietary employees to clean their hands and exposed portions of their arms after coughing, sneezing, or blowing their nose, and to use utensils when serving food. The dietary manager confirmed that staff are expected to follow these procedures. Additionally, the facility failed to ensure that resident room refrigerators were equipped with thermometers and that their temperatures were monitored. Two cognitively intact female residents were found to have refrigerators in their rooms without thermometers, containing perishable food items such as yogurt, lunchmeat, cheese, ice cream, and leftovers. Both residents reported that they did not recall staff checking the refrigerators or the presence of thermometers. The safety director acknowledged that while room checks are performed, there is no documentation for monitoring resident refrigerator temperatures, and confirmed that thermometers should be present. The facility's policy requires proper handling, serving, and storage of food items brought into the facility.
Failure to Follow Pureed Diet Menu and Recipe
Penalty
Summary
The facility failed to follow the prescribed pureed diet menu for four residents who required pureed diets. According to the facility's records, these residents were supposed to receive pureed barbecue on cornbread, pureed green beans, and pureed canned fruit for a specific meal. However, during meal preparation, the cook pureed only the barbecue pork with milk, omitting the required cornbread from the mixture. The pureed barbecue was served to the residents without the cornbread component as specified in the menu and recipe. Only after running out of the initial batch did the cook add cornbread to the subsequent preparation. The dietary manager confirmed that staff are expected to follow the menu and recipes, and the facility's policy requires adherence to individual recipes for pureed food preparation.
Failure to Provide Properly Prepared Pureed Diets
Penalty
Summary
The facility failed to provide meals in the appropriate form for four residents who were prescribed pureed diets. According to the facility's records, these residents were to receive pureed foods with a smooth, pudding-like consistency, as outlined in the facility's Puree Food Preparation Policy. However, during meal preparation, the cook pureed breaded fish sticks and barbecue pork, adding warm milk, but the resulting mixtures were observed to be very thick and not smooth. When served, the pureed foods were found to be thick, dry, and lacking the required smooth consistency, which did not meet the dietary needs of the residents on pureed diets. The dietary manager confirmed that the pureed foods should have been smooth and homogenous, without lumps or chunks.
Failure to Specify Duration for PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that psychotropic medications were prescribed for a defined duration for one resident reviewed for unnecessary medications. Specifically, a resident had an active order for Diazepam, a psychotropic medication, to be administered as needed, with a start date but no end date documented. According to the facility's policy and staff interview, psychotropic medications ordered as needed should only be prescribed for a duration of 14 days, after which a new order must be obtained. The lack of an end date on the order did not comply with these requirements, as confirmed by the MDS Coordinator and a review of the facility's policy.
Failure to Complete PASARR Level 2 Assessment After New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 assessment for a resident who was diagnosed with schizoaffective disorder. Record review showed that the resident, a sixty-year-old male, was originally admitted to the facility and later received a diagnosis of schizoaffective disorder, with the onset documented in the physician's summary. Despite this new diagnosis, there was no evidence in the electronic record that a PASARR Level 2 screening was completed as required by the facility's policy, which mandates prompt referral for a Level 2 review when a resident exhibits a newly evident or possible serious mental disorder. The administrator confirmed that a Level 2 PASARR assessment is needed for residents with new mental disorder diagnoses.
Failure to Maintain Dressing on Stage 4 Pressure Injury
Penalty
Summary
A resident with a history of spina bifida, urinary tract infections, wheelchair dependence, malnutrition, and a stage 4 pressure injury to the left buttock was admitted to the facility with physician orders for daily application of calcium alginate dressing to the wound. On the day of the survey, the resident's dressing came off during a shower, and the Certified Nursing Assistant (CNA) did not replace it, instead waiting for the wound care doctor to arrive. The resident was left in bed without a dressing on the pressure injury for several hours, despite the wound care doctor being present in the building but not yet having visited the resident. The resident reported that no staff had replaced the dressing and that he remained in bed waiting for the wound doctor, although he preferred to be in his wheelchair. Record review showed that the dressing was not documented as completed on two separate days, including the day of the observation. The wound evaluation confirmed the presence of a stage 4 pressure injury with specific measurements and a treatment plan requiring daily and as-needed dressing changes if the dressing became saturated, soiled, or dislodged. Facility policy required the use of protective dressings for at-risk individuals and replacement of dressings if they came off. The Director of Nursing confirmed that dressings should be replaced if they come off, indicating that the facility failed to ensure appropriate pressure ulcer care by not maintaining a dressing on the resident's wound as ordered.
Unsafe Transfer Technique Used During Resident Assistance
Penalty
Summary
A certified nursing assistant (CNA) was observed pulling a resident's left arm to assist him out of a recliner, raising the arm above the level of the resident's head. The resident had a history of traumatic brain injury, quadriplegia, repeated falls, limited mobility, decreased strength, and decreased sitting and standing balance, and required assistance with ambulation and transfers. The Director of Nursing (DON) confirmed that a gait belt should be used for such transfers and that pulling a resident's arm could cause injury. The facility's policy requires safe handling during transfers to prevent or minimize injury, but this was not followed in the observed incident.
Failure to Label Tube Feeding Nutrition as Required
Penalty
Summary
The facility failed to properly label a bag of liquid nutrition being administered via feeding tube for a resident with multiple diagnoses, including intracranial injury, dysphagia, contractures, aphasia, and epilepsy. Observation revealed that the bag of liquid nutrition hanging next to the resident's bed did not have the resident's name, date, or time it was initiated, and this unlabeled bag remained in use for several hours. Interview with the DON confirmed that the bag should have been labeled with the date, time, type of nutrition, and resident's name, as required by the facility's tube feeding policy. Record review showed that the policy mandates labeling the feeding with specific identification information to ensure safe administration.
Failure to Timely Administer Physician-Ordered Medication Increase
Penalty
Summary
A resident with a history of myocardial infarction, congestive heart failure, generalized anxiety disorder, major depressive disorder, pain, post-traumatic stress disorder, alcohol use, and bipolar disorder was admitted to the facility and had a physician order to increase trazodone to 100mg at bedtime due to worsening and unstable major depressive disorder. The order was written on July 10, 2025, and entered to start on July 11, 2025. However, the resident did not receive the increased dose of trazodone as ordered and continued to receive the previous 75mg dose until July 13, 2025. The resident reported delays in starting new medication orders and specifically noted not receiving the increased trazodone dose when it was ordered to help with sleep. Review of the Medication Administration Record confirmed the delay in administering the increased trazodone dose. The Psychotropic Informed Consent form for the increased dose was signed by the resident on July 13, 2025, the same day the new dose was first administered. The Director of Nursing was unable to provide an explanation for the delay in administering the medication as ordered. Facility policy requires medications to be administered only upon the written order of an authorized prescriber.
Failure to Discard Insulin Pen After 28 Days
Penalty
Summary
A multidose Lispro insulin pen for one resident was found in the medication cart with an open date of 6/15/25 but without a documented discard date, despite facility policy and manufacturer guidelines requiring disposal 28 days after opening. Observation confirmed the pen was still present and in use beyond the recommended timeframe, and review of the resident's medication administration record showed the insulin pen had been administered multiple times after the 28-day period had elapsed. An LPN confirmed that insulin pens should be labeled with both the open date and a discard date, and the facility's policy aligns with the manufacturer's instructions for timely disposal.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for a resident with moderate cognitive impairment, hemiplegia/hemiparesis, and intracranial injury. Observation revealed the resident had several broken teeth on the upper jaw and dark-colored tooth fragments or roots along the lower jaw. Record review showed the last documented dental consent and appointment occurred in 2020, with no evidence of dental care provided since then. Staff interviews confirmed the resident had ongoing dental issues and that social services were unaware of the lapse in dental care. The facility's dental policy required assistance in obtaining routine and emergency dental care, but no documentation was available to show compliance with this policy for the resident in question.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control procedures during incontinence care for a resident with multiple diagnoses, including intracranial injury, dysphagia, atopic dermatitis, and neuromuscular bladder dysfunction. The resident, who was on enhanced barrier precautions and required proper hand hygiene, was observed receiving incontinence care where a CNA removed a soiled brief, then touched clean items such as a mechanical lift sling and its controls, and proceeded to shower the resident without changing gloves. The facility's policy requires hand hygiene after contact with contaminated surfaces and before moving from a soiled to a clean body site, which was not followed during this care event.
Failure to Maintain Pest-Free Resident Rooms
Penalty
Summary
The facility failed to ensure that resident rooms were free from pests, specifically flies, for two residents who were roommates on the B-wing. One resident, a male with a tracheostomy, traumatic brain injury, and left-sided hemiplegia, was observed lying in bed with 4-6 flies flying around and landing on him. He had difficulty waving the flies away and indicated that they were bothering him. No pest reduction methods were present in the room at the time, and more than a dozen flies were observed in the room. The second resident, a male with intracranial injury, quadriplegia, and dysphagia, was seen resting in a reclined wheelchair with several flies landing on his face and crawling across his nose and cheek. Due to quadriplegia, he was unable to scare the flies away himself. The pest control specialist stated that while treatments for flies exist, they cannot be used in resident rooms and that their main intervention is a chemical spray in open areas. The specialist also reported not being notified of any pest issues in specific resident rooms. The Safety Director confirmed that staff are expected to report pest issues so they can be addressed, but he was not informed about the fly problem affecting these two residents. The facility's pest control policy requires maintaining an effective program to control common pests, including flies.
Failure to Implement Safety Measures During Resident Transfers and Cares
Penalty
Summary
The facility failed to implement adequate safety measures and supervision during resident care and transfers, resulting in falls for three residents. One resident with a history of hemiplegia, muscle weakness, and prior falls was being assisted off the toilet by a CNA without the use of a gait belt. During the transfer, the resident lost balance and fell, sustaining a fractured left humerus. The CNA reported not being trained to use a gait belt with this resident and instead sometimes used the waistband of the resident's pants for support. The restorative nurse confirmed that gait belts were not previously required for this resident, despite variable strength due to medical conditions. Another resident with muscular dystrophy, poor trunk control, and high fall risk slid out of a shower chair while being pushed by a CNA. The seatbelt on the shower chair was not properly secured, as the CNA believed it was fastened but it had not clicked into place. The resident did not sustain injuries, but the incident was attributed to the unsecured seatbelt, as confirmed by documentation and staff interviews. A third resident with a traumatic brain injury, gait abnormalities, and dementia fell in the shower area while staff were assisting with dressing. The resident lost balance and slipped on a wet floor, which lacked anti-skid mats or strips. The CNA assisting the resident did not place a towel or any non-slip surface on the floor prior to the resident standing, and the resident was not wearing socks or shoes at the time of the fall. The resident sustained a superficial abrasion as a result.
Delay in UTI Treatment and Failure to Escalate Care
Penalty
Summary
A resident with a history of partial paralysis following a stroke, ESBL, recurrent urinary tract infections, morbid obesity, and congestive heart failure was not provided timely treatment for a urinary tract infection (UTI). The resident's urine culture and sensitivity results, indicating a UTI, were received and the physician, nurse practitioner, and DON were notified. Despite the resident exhibiting symptoms such as urinary frequency, burning, severe pain, and dark, concentrated urine, no new antibiotics were initiated, and there was a delay in escalating care. The infectious disease doctor declined to prescribe antibiotics due to not having seen the resident recently, and the nurse practitioner communicated that if the resident could not be treated in-house, she should be sent out for treatment. Over the course of nearly 48 hours after the positive UTI test results, the resident continued to experience symptoms without appropriate intervention. The resident eventually requested to be evaluated in the emergency room and was subsequently admitted with a UTI. Facility documentation and staff interviews confirmed that prompt treatment was not provided, and the resident was not sent out for evaluation in a timely manner despite clear indications and provider recommendations.
Failure to Sign Off Controlled Medications in Electronic System
Penalty
Summary
The facility failed to ensure that controlled medications were signed off in the electronic narcotic inventory system at the time they were administered to seven out of ten residents in the sample. During a medication pass observation, it was noted that the Licensed Practical Nurse (LPN) did not sign off the controlled medications in the electronic system immediately after administration. This discrepancy was identified during a narcotics count, where the counts in the electronic system did not match the physical medication cards for several residents. The residents involved were receiving various controlled substances for conditions such as pain, anxiety, and seizures. For instance, one resident's Tramadol and Pregabalin counts were off by one tablet each, while another resident's Morphine and Klonopin counts also showed discrepancies. The Director of Nursing (DON) confirmed that the facility's protocol requires nurses to sign off controlled medications in conjunction with the residents' Medication Administration Records (MARs) to ensure accurate tracking and prevent medication diversion. The facility's policy, dated January 2001, mandates that controlled substances be subject to special ordering, receipt, and record-keeping requirements in accordance with federal and state laws. The electronic narcotic inventory system is used as the special dose administration record required by federal guidelines. However, the failure to adhere to this policy resulted in inaccurate medication counts and potential risks associated with medication administration errors.
Failure to Properly Utilize Glucose Monitoring Sensor
Penalty
Summary
The facility failed to utilize a glucose monitoring sensor per physician orders for a resident with type 2 diabetes. The resident expressed dissatisfaction with a registered nurse who incorrectly placed the glucose monitoring sensor, resulting in the needle bending and necessitating its removal. Consequently, the resident had to undergo finger pricks to monitor blood sugar levels. The resident was informed that a new sensor could not be used immediately because the insurance only covers two sensors per month, leaving her without a sensor for 14 days. A licensed practical nurse confirmed the incident and mentioned that the director of nursing had not been notified at the time. The director of nursing later applied a new sensor, which was available in the facility, but was unaware of the situation until then. The resident's physician orders specified that the glucose monitoring sensor should be changed every 14 days and applied to the back of the arms only. The facility's medication administration policy requires accurate procedures for acquiring, receiving, dispensing, and administering medications to meet residents' needs, which was not adhered to in this case.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for two residents, R1 and R2, as observed during the survey. R1, who has multiple diagnoses including cerebral palsy and chronic respiratory failure, was left without her pendant call light while in a reclining wheelchair in the dining room. She reported that staff often do not attach her pendant unless she requests it, leading to an incident where she was left in the dining room and had to call out for help. Staff members V6 and V8 were mentioned in relation to this incident, with V6 acknowledging that R1 had complained about staff not assisting her and not having time for her needs. R2, who is dependent on staff for oral hygiene due to left hemiparesis, reported that his teeth were not brushed before breakfast, which is his preference. He expressed frustration that this was a recurring issue and had previously informed the nurses. V3, a CNA, confirmed that R2's teeth had not been brushed due to an emergency, while V5, an LPN, acknowledged R2's complaints and had assisted with his oral hygiene the previous week. The facility's policy mandates daily personal care, including oral hygiene, which was not adhered to in R2's case.
Failure to Document and Execute Treatment Orders for Residents
Penalty
Summary
The facility failed to ensure proper orders and documentation for the care of residents with specific medical needs. One resident, who returned from a wound care appointment with a PICC line, did not have the necessary dressing change orders documented in their Medication Administration Record (MAR) and Treatment Administration Record (TAR) until over a month after the PICC line was inserted. The facility's policy required weekly dressing changes to prevent infection, but the first documented change occurred weeks after the insertion, indicating a lapse in following protocol. The Director of Nursing confirmed the absence of documented dressing changes and orders prior to the noted date. Another resident, who returned from the hospital and was placed in hospice care, had a surgical wound and a skin tear that were not documented with treatment orders in the MAR and TAR. The first order for treating the resident's abdominal wound was entered nine days after the wounds were identified, and the initial order was incorrectly documented. The Wound Care Nurse stated that there were no standing orders for skin tears and that floor nurses should have sought orders from her or the physician. The facility's policy required the Wound Care Coordinator to document and transcribe new physician orders, but this was not done in a timely manner for the resident's wounds.
Unsanitary Kitchen Conditions and Food Safety Lapses
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the kitchen, which has the potential to affect all residents. Observations revealed that the oil in the deep fryer was black with visible dark food crumbs around the edges, indicating it had not been changed or cleaned regularly. The Dietary Manager admitted that the deep fryer had been used daily for almost a week without the oil being changed, and the cleaning schedule was not followed as the fryer cleaning had not been marked off since May 21, 2024. Additionally, the kitchen floor was observed to be dirty and sticky with food debris in multiple areas, including under prep tables, serving tables, and the 3-compartment sink area. Mop heads were found under the ice machine, and the floor was not being mopped every shift as required. The Dietary Manager acknowledged that the cleaning schedule was not being adhered to, as multiple days lacked initials to confirm tasks were completed. The facility's staff also failed to follow proper food safety protocols. Dietary Cooks were observed using a digital thermometer to check food temperatures without sanitizing it between uses, risking cross-contamination. The Dietary Manager confirmed the importance of sanitizing the thermometer to prevent cross-contamination but acknowledged that it was not being done. The facility's policies for cleaning fryers and general kitchen sanitation were not being followed, contributing to the unsanitary conditions.
Inadequate Use of PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the correct personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP). For Resident 32, staff members were observed changing the resident's incontinent brief and linens without wearing isolation gowns or masks, despite the presence of an EBP sign on the door indicating the need for gloves and gowns. The resident had a history of multi-drug resistant organisms (MDRO) in the urine and was on EBP due to this condition. The facility's policy required the use of gowns and gloves during high-contact activities, but this was not adhered to by the staff. Resident 23 also experienced a deficiency in infection control practices. The resident had an order for EBP due to a history of MDRO with indwelling devices, but the order was not implemented until a day after it was issued. Additionally, there was no signage on the resident's door to indicate the need for EBP, and the staff member performing a dressing change did not wear a gown as required. The resident had open wounds, an indwelling catheter, and a feeding tube, all of which necessitated the use of EBP. Similar issues were observed with Residents 31 and 67. Resident 31 had an order for EBP due to a history of MDRO with indwelling devices, but there was no sign on the door to inform staff of the necessary PPE. Resident 67 had a sign indicating EBP, but a staff member was observed emptying the urinary catheter bag with only gloves on, without wearing a gown. The Director of Nursing acknowledged the oversight in Resident 67's chart regarding the EBP order, which had been in place since March 2024. These deficiencies highlight a pattern of non-compliance with the facility's infection control policies regarding the use of PPE for residents on EBP.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to provide personal care in a manner that promoted dignity for a resident with multiple medical conditions, including quadriplegia and neurogenic bladder. The resident required extensive assistance for various activities, including dressing, bed mobility, and bathing. During a bathing session, three CNAs were involved in washing the resident, and one CNA left the room to get supplies, leaving the resident's body exposed. The resident remained uncovered for a total of 36 minutes while care was being provided, which was against the facility's policy on promoting resident dignity. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed that leaving a resident exposed during care is unacceptable and does not maintain the resident's privacy and dignity. The facility's policy, revised in March 2017, emphasized the importance of maintaining or enhancing each resident's dignity and respect. The incident highlighted a failure to adhere to this policy, as the resident was left uncovered for an extended period, compromising their dignity.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving three residents. One resident, who was cognitively intact, reported being physically assaulted by her roommate. The incident was reported to a registered nurse, who informed the facility administrator. However, the administrator did not classify the incident as abuse, citing a lack of willful intent. The resident expressed feeling surprised, scared, and outraged by the incident, which she considered abusive. Another resident with mild cognitive impairment was involved in an altercation where a peer, who had a history of aggressive behavior, smacked him in the face and grabbed his shirt. This incident was documented in the resident's care plan, highlighting the peer's ongoing behavioral issues. The peer had been monitored for aggressive behaviors, which occurred frequently over the past month. A third resident, with no cognitive impairment, was kicked by the same aggressive peer after a verbal confrontation. A licensed practical nurse acknowledged the intentional nature of the kick and considered it resident-to-resident abuse. Despite the peer's known behavioral issues, the facility's staff expressed uncertainty about classifying such incidents as abuse, indicating a need for clearer guidelines on identifying and addressing resident-to-resident abuse.
Failure to Investigate Allegations of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving three residents. One incident involved a resident who reported being hit in the back of the head by her roommate during Memorial weekend. Despite the resident reporting the incident to a registered nurse immediately, the facility's administrator did not speak to the involved residents until three days later. The facility's abuse policy requires immediate investigation and interviews with involved parties, which were not conducted in a timely manner. The facility's documentation showed that the incident was reported to the state agency as a resident-to-resident altercation, not suspected abuse, and lacked a thorough investigation as per the facility's policy. Additionally, two other incidents involving resident-to-resident altercations were not investigated. In one case, a resident was struck on the cheek by another resident, and in another, a resident was kicked in the leg by a resident in a power wheelchair. Both incidents were documented in reports to the Illinois Department of Public Health, but no investigations were performed to determine if these were cases of abuse. The facility's failure to investigate these incidents is a violation of their abuse program policy, which mandates thorough investigations to ensure resident safety.
Failure to Obtain Level 2 PASRR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to obtain a Level 2 PASRR (Pre-Admission Screening and Resident Review) for two residents who were reviewed for PASRR screening. Resident 61's electronic face sheet indicated diagnoses of schizophrenia and depression, yet the PASRR Level 1 Screen Outcome document stated that the resident did not require a Level II PASRR and had no mental health diagnosis. Similarly, Resident 67's electronic face sheet showed diagnoses of schizophrenia and bipolar disorder, but the PASRR Level 1 Screen Outcome also indicated no need for a Level II PASRR and no mental health diagnosis. The facility administrator acknowledged that PASRRs are conducted prior to admission and should be updated if there are changes, but was unsure why Level 2 PASRRs were not completed for these residents. The facility did not have a policy regarding PASRRs available for review.
Failure to Provide Feeding Assistance
Penalty
Summary
The facility failed to provide necessary feeding assistance to a resident diagnosed with cerebral palsy, dysphagia, major depressive disorder, diaphragmatic hernia, and gastroesophageal reflux disease. The resident, who is dependent on staff for eating and requires a mechanically altered diet, reported not receiving assistance with dinner on a particular night. The resident stated that a tray was brought to their room, but staff did not return to assist with feeding, leaving the resident unable to eat due to their inability to move their arms. The facility's grievance form confirmed the resident's report, noting that the resident had previously mentioned similar incidents. The care plan for the resident indicated a need for assistance with all meals to prevent aspiration and weight loss. Despite this, the meal intake record showed no intake for the evening meal on the date in question. Interviews with staff, including a CNA and the Director of Nursing, revealed that meal assistance should be provided immediately upon tray delivery, and there was no justification for a resident missing a meal due to lack of assistance.
Failure to Identify and Treat Resident's Skin Concern
Penalty
Summary
The facility failed to identify, assess, and initiate treatment for a skin concern on a resident, referred to as R49, who was at risk of developing pressure ulcers due to his medical conditions, including quadriplegia and neuromuscular dysfunction. Despite having an active order for daily skin checks, the staff did not detect a scab on R49's right buttocks until a surveyor inquired about it during a personal care session. The scab, measuring 3.0 cm by 2.5 cm, was not documented in the facility's wound reports or evaluations prior to the surveyor's observation. The facility's policy required nurse aides to report any skin changes to the nurse on duty, who would then notify the Director of Nursing and obtain treatment orders. However, the scab on R49's buttocks was not identified during the daily skin checks conducted from 6/7/24 to 6/10/24, which only noted venous wounds on his lower extremities. The wound nurse, V3, confirmed that the scab was due to shearing and not pressure, and expressed that it should have been identified earlier. The Director of Nursing also stated that staff should have detected the skin concern before it developed into a scab of that size.
Failure to Prevent and Identify Pressure Ulcers
Penalty
Summary
The facility failed to prevent a medical device-related pressure injury and did not identify an area of pressure before it developed into a Stage 3 ulcer for two residents. One resident, a male with spina bifida and other complex medical conditions, developed a pressure injury on his penis due to improper catheter placement. The catheter tubing was not secured correctly, leading to a disfiguring split on the penile shaft. Despite the use of a stat lock to prevent further damage, the injury resulted in permanent disfigurement. The resident's care plan required extensive assistance for toileting and bed mobility, and the facility's urinary catheter care policy emphasized securing the catheter to prevent tension and checking the skin for irritation. Another resident, with a history of traumatic brain injury and hemiplegia, developed a Stage 3 pressure ulcer on the sacrum. The wound was initially unstageable due to necrotic tissue and was identified by staff during a weekend. The resident was dependent on staff for bathing and transfers and was always incontinent of bowels. During a wound care session, the wound nurse failed to clean stool from the resident's buttocks before applying a clean dressing to the sacral wound, which was a deviation from proper wound care protocol.
Failure to Apply Splints for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that two residents, identified as R19 and R30, received appropriate care to maintain their range of motion by not applying their prescribed splints. R19, who has severe cognitive impairment and requires a wrist, hand, and finger orthosis (WHO) for contraction management, was observed on two occasions without the splint on his left hand. The Certified Nursing Assistant (CNA) was unable to locate the splint, and it was noted that staffing issues contributed to the failure to apply the splint. R19's physician's orders indicated the splint should be worn for up to 4 hours as tolerated, but this was not adhered to. Similarly, R30, who has no cognitive impairment but is at risk of contractures due to hemiplegia, was observed without his left hand splint on two separate occasions. R30 reported that staff only sometimes applied the splint, and on the day of observation, it had not been offered or applied. The Restorative Director acknowledged that the hand brace should be applied daily for 4 hours and attributed the oversight to staffing issues, as restorative staff were pulled to other duties. The facility's policy emphasizes the importance of restorative nursing services, including splint or brace assistance, but this was not consistently implemented for these residents.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to safely transfer a hospice resident, identified as R76, using a gait belt, which is a required safety measure. R76 had multiple diagnoses, including cerebral infarction, chronic obstructive pulmonary disease, and polyneuropathy, and required substantial assistance with transfers. During an observed transfer, a CNA wrapped her arms around R76 and lifted her from a wheelchair to a bed without using a gait belt, contrary to the facility's policy. R76 did not assist with the transfer, and her feet were not flat on the floor, increasing the risk of an accident. The facility's policy mandates the use of a gait belt for all assisted resident transfers, except in cases of bed mobility or medical contraindications. The Director of Nursing confirmed that a gait belt should have been used. The care plan for R76 indicated she required maximum assistance for stand-pivot transfers, and the facility's staff acknowledged that two staff members should assist with such transfers using a gait belt. The failure to adhere to these protocols resulted in a deficiency in providing a safe environment for resident transfers.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to maintain proper catheter care for a resident, leading to a deficiency in infection control practices. The resident, a male with a complex medical history including intracranial injury, neuromuscular dysfunction of the bladder, and a history of urinary tract infections, was observed with his catheter drainage bag and tubing in contact with the floor and not placed in a dignity bag. This improper handling of the catheter drainage system was noted on two separate occasions, with the drainage bag being lifted over the resident's body and placed on the bed, which is against the facility's policy to keep the bag below the level of the bladder at all times. The facility's infection preventionist acknowledged that the improper positioning of the urinary drainage bag could lead to infections, as it allows for potential contamination and backflow of urine into the bladder. The resident's medical records indicated a recent episode where he was unresponsive and diagnosed with a urinary tract infection, with a urine culture showing a significant presence of methicillin-resistant Staphylococcus aureus. This incident highlights the facility's failure to adhere to its own urinary catheter care policy, thereby increasing the risk of infection for the resident.
Failure to Supervise Resident with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to supervise a resident with exit-seeking behaviors, resulting in the resident eloping from the building and reaching a heavily traveled highway. The resident, who had diagnoses including hypoxic ischemic encephalopathy, major depression disorder with psychotic features, anxiety, dementia, and cardiomyopathy, was assessed to be at high risk for elopement. Despite this, the resident was able to cut off her wander guard bracelet and exit the facility unsupervised. The incident report shows that the resident was found in the back parking lot, where she became physically aggressive with staff and attempted to hit them with a piece of wood. The resident's care plan indicated a risk for elopement and aggressive behavior due to auditory hallucinations, but these interventions were not effectively implemented to prevent the elopement. On the day of the incident, multiple staff members observed the resident outside the facility and attempted to redirect her back inside. However, the resident was uncooperative and continued to walk towards the road. The Director of Nursing and other staff members were involved in trying to manage the situation, but the resident's aggressive behavior and hallucinations made it difficult to control her. The resident was eventually redirected back towards the facility after a passerby activated their car's flashers, which caught the resident's attention. The facility's video footage showed the resident climbing over a fence and falling on the other side, indicating a lapse in supervision and security measures. The resident had a history of exit-seeking behaviors and hallucinations, as documented in nursing progress notes. In the days leading up to the elopement, the resident exhibited multiple instances of trying to leave the facility, expressing delusional thoughts about her family being in danger. Despite these clear signs of distress and risk, the facility did not take adequate measures to ensure the resident's safety. The facility's policy on safety and supervision emphasized the need for increased supervision in response to changes in a resident's condition, but this was not effectively applied in the case of this resident, leading to the elopement incident.
Removal Plan
- Social Services will review all care plans of residents at high risk for elopement.
- IDT will ensure elopement interventions are implemented following findings of high-risk residents and report to MDS Coordinator. MDS Coordinator will complete audits weekly, then monthly, then quarterly. Audits will be reported to QAPI monthly and then quarterly.
- Any residents that are actively exit seeking, will be placed on line of sight supervision while in courtyard, Code alert checks will be increased and Code alert will be double banded.
- BeSpoke Hotline will be utilized with new onset of hallucinations.
- Medical Director will be contacted for support and/or any orders to assist in new onset of hallucinations.
- Upon R1 return she will be placed on line of sight supervision while in courtyard, Code alert check, and Code alert bracelet will be double banded.
- Upon admission, admitting nurse will complete Elopement Risk Assessments. Social Services or designee will now complete monthly reassessments for high risk residents and continue Elopement Risk Assessments on all other residents quarterly.
- Maintenance staff to place cameras in front courtyard. A monitor will be placed in the front office to have visuals of courtyard.
- Maintenance will immediately complete daily checks on all door alarms/maglocks, and Code Alert wandering systems.
- Front outside door to courtyard will be locked at night by nursing staff or designee and unlocked in the morning by maintenance staff or designee.
- Administrator will audit Social Services immediate care plan review to ensure that Elopement Reassessments are complete on high risk elopement residents.
- Administrator will audit Social Service or designee monthly Elopement Risk Assessments on high risk residents once a month and results will be reported to QAPI.
- When resident is determined to be at high risk for elopement and has attempted a prior elopement at this facility, resident will be placed on line of sight supervision while in courtyard by nursing administration and/or Administrator.
- Safety Coordinator or designee will place a Code Alert bracelet on residents that are not high risk with exit seeking behaviors followed by 15 minute checks until IDT evaluates.
- Following an elopement, all exit door codes will be changed by Safety Director or designee.
- All new hires complete Elopement Training upon hire by Safety Director and all current staff currently complete Elopement Training annually via Company Training. However due to incident, all staff will now be required to complete immediate and quarterly training on Preventing and Responding to Elopement via Company Training.
- Safety Coordinator or designee will make all staff aware of high-risk residents for elopement on PCC communications. Safety Coordinator or designee will now place a note at time clock for staff notifying them of any changes to Residents at High Risk for Elopement and to check PCC communications.
- IT will do weekly maintenance on cameras to ensure they are working properly.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident (R4) was free from sexual abuse by another resident (R5). On 4/27/24, R5 touched R4's breast while they were sitting outside on the front patio. R4, who has no cognitive impairment and uses a manual wheelchair, reported the incident to an LPN immediately after it occurred. R5, who has moderate cognitive impairment and uses a motorized wheelchair, refused to answer questions about the incident but was able to recall other details and interact with the surveyor. R5's care plan had previously noted a potential for making sexually inappropriate comments to females. Staff interviews revealed that R4 reported the incident to the LPN, who then informed the Administrator. The LPN noted that R5 had made sexual comments in the past but had never grabbed anyone. The CNA who assisted R5 on the day of the incident stated that R5 could not move his wheelchair independently and needed staff assistance. The Director of Nurses confirmed that both residents were alert and oriented, and reiterated that any unwanted physical touching constitutes sexual abuse. The facility's Abuse Program policy defines sexual abuse as including unwanted touching and mandates the ongoing safety of residents.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident (R1) who was cognitively intact and had a history of hypoxic ischemic encephalopathy, major depression disorder with psychotic features, anxiety, dementia, and cardiomyopathy. R1 was taken to the hospital after eloping from the facility and becoming aggressive. The next morning, the facility was contacted by a forensic nurse who reported that R1 had alleged sexual abuse by another resident (R2). Despite this, the Director of Nursing (V2) and the Administrator (V1) did not initiate an abuse investigation or report the allegation, assuming the abuse occurred at the hospital and attributing the claim to R1's history of hallucinations and past abuse allegations. The forensic nurse's report indicated that R1 had refused a rape kit but named R2 as the perpetrator, initially stating the abuse occurred at the hospital but later specifying it was the resident she sat with at meals in the facility. The facility's policy mandates that all allegations of abuse, regardless of their perceived truthfulness, must be reported to the administrator and appropriate agencies. However, this protocol was not followed, leading to a failure in addressing and investigating the abuse allegation properly.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident (R1) who was cognitively intact and had a history of hypoxic ischemic encephalopathy, major depression disorder with psychotic features, anxiety, dementia, and cardiomyopathy. R1 was taken to the hospital after eloping from the facility and becoming aggressive with the staff. The next morning, the facility was contacted by a forensic nurse from the hospital, who reported that R1 had alleged sexual abuse by another resident (R2). Despite this report, the Director of Nursing (V2) and the Administrator (V1) did not initiate an abuse investigation, assuming the abuse occurred at the hospital and attributing the allegations to R1's history of hallucinations and past abuse claims. The facility's policy mandates a thorough investigation of all abuse allegations, which was not followed in this case. The forensic nurse's report indicated that R1 had refused a rape kit but named R2 as the perpetrator, stating that the abuse occurred in her room at the facility. The hospital report also noted that R1 initially claimed the abuse happened at the hospital but later identified R2, a resident she sits with at meals, as the assailant. Despite these details, the facility staff did not conduct an investigation or report the incident, failing to adhere to their policy on abuse investigation and reporting. This oversight highlights a significant deficiency in the facility's response to abuse allegations, compromising resident safety and failing to protect R1 as required by their own protocols.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 89 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Prophetstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Prophetstown | 1 mi | ★★★★★ | 16 | 0 |
| Resthave Home-whiteside County | 9.3 mi | ★★★★★ | 8 | 0 |
| La Bella Of Morrison | 9.9 mi | ★★★★★ | 24 | 0 |
| Allure Of Sterling | 14.8 mi | ★★★★★ | 15 | 1 |
| Rock Falls Rehab & Hlth Care C | 15.1 mi | — | 0 | 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.