Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Byron Health Center during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow facility policies for food labeling, storage, and sanitation, affecting all residents receiving meals. Multiple food items in freezers, refrigerators, dry storage, and on countertops were left open to air, lacked lids, and were not labeled with open or expiration dates, including frozen items, bread products, cereals, and seasonings that had been removed from original packaging. In addition, a set of keys was left on the steam table serving area, the handwashing sink contained visible debris, and the grill and grill foil had significant black buildup despite documentation that these surfaces had recently been cleaned. The Dietary Manager confirmed that these conditions did not comply with the facility’s standards for labeling, covering, and cleaning food and food-contact surfaces.
The facility failed to maintain proper kitchen sanitation and food labeling for all residents receiving meals, with surveyors observing multiple open and undated food items, including frozen products, dry goods, and bread, as well as seasoning stored without a lid. Similar issues had been cited previously under F812 for sanitation, open food items, and lack of labeling and dating. The ED reported that she and an assistant conducted undocumented kitchen observations and that a committee had been working on food temperatures, labeling, dating, and cleanliness, but no related policy was provided at survey exit.
Two residents with neurological impairments and contractures did not consistently receive prescribed cervical collars and a mechanical back/cervical splint during bedrest and meals. One resident, ordered to wear a soft cervical collar in bed and for all meals for neck contracture management, was repeatedly observed without the collar, which was found on the bedside stand, and her care plan and CNA Kardex lacked instructions for its use or refusal despite documentation that she preferred wearing it. Staff gave conflicting accounts about whether the collar was still in use, and there was no documentation of refusals as required by facility policy. Another resident, ordered to wear a cervical brace during all meals, was repeatedly observed with her head leaning to one side, without the brace, and not eating, while CNAs reported the brace’s Velcro failed and her head slipped out despite repeated attempts to reposition and reapply it. Therapy and restorative staff acknowledged ongoing issues with the brace, missed reassessment, and lack of reported concerns, contrary to facility policy requiring regular assessment and reporting of problems with assistive devices.
The facility failed to complete post-fall neurological assessments as described by staff practice for three residents with conditions including dementia, epilepsy, abnormal posture, and diabetes. After unwitnessed and other falls, required neuros at specified intervals and every shift for 72 hours were repeatedly missing across multiple days and shifts, despite care plan directives to follow the fall protocol. The DON and an LPN described a detailed neuro check schedule after falls, but record reviews showed numerous omitted assessments and entire periods with no documented neuros, even though the written falls protocol required assessment and documentation of neurological status.
A resident with Alzheimer’s disease, anxiety, depression, and significant cognitive impairment expressed suicidal ideation to a volunteer, stating she had nothing to live for and wanted to kill herself. The resident’s care plan required immediate supervisor notification and redirection for suicidal comments, and facility policy required immediate reporting to the nurse supervisor, continuous supervision, completion of a suicide risk assessment, provider notification, and documentation. The volunteer documented the statement on a 1:1 visit log and verbally reported it to staff on an adjacent unit, but nursing staff on the resident’s unit were unaware of the incident, the Life Enrichment Specialist read the log days later and did not report it, and no further assessment, provider notification, or documentation of follow-up occurred.
A resident with altered mental status and diabetes had a portable urinal repeatedly observed over several days hanging, still containing urine, from a trash bin that also held other discarded items, and later placed on a table with personal items. The CNA acknowledged this as an infection control concern and reported uncertainty about where to store the urinal, while also noting the resident’s preference to keep it close due to frequent bathroom use. The DON stated that urinals were expected to be cleaned after use and stored on the back of the toilet, and that any preference to keep a urinal at bedside should be reflected in the care plan, but this was not documented for this resident despite a facility policy outlining proper bedside urinal management and care plan notation.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised, traveling several miles and crossing busy streets before being returned by police. The resident's care plan did not address her risk for elopement or include interventions for wandering, and staff were unaware of her absence until notified by an external party. No elopement risk assessments were completed despite documented wandering behaviors.
Surveyors observed multiple failures in kitchen sanitation and food handling, including unlabeled and undated opened food items, expired and uncovered food, improper storage of scoops in dry goods, and inadequate cleaning of kitchen surfaces and equipment. Baking pans were stacked while still wet, and food items were left open to air exposure. These deficiencies affected nearly all residents served by the kitchen.
A resident with diabetes and dementia received a subcutaneous injection of Trulicity from an LPN in a common dining area while eating breakfast, requiring the resident to expose his abdomen in front of others. Staff interviews and facility policy confirmed that medication administration in public areas during meals is not permitted due to dignity and privacy concerns.
A resident's personal and medical information, including medication list and vital signs, was left visible on an unattended computer screen and paper worksheet on a medicine cart in a hallway. The information was accessible to staff and residents passing by, and the RN later acknowledged not securing the records as required by facility policy.
Two residents with significant medical conditions were transferred to the hospital without documentation that the facility's bed hold policy was explained to them or their families. The DON confirmed that this notification should have been documented in the progress notes, in accordance with facility policy.
The facility did not ensure accurate assessment and documentation for two residents with complex medical needs. One resident with chronic neurological issues had repeated documentation of normal pupil response despite observed unequal pupils, and the care plan did not address this known condition. Another resident with acute respiratory conditions did not receive required shift-by-shift respiratory assessments as ordered, with several shifts missing documentation of breath sounds. Staff interviews confirmed gaps in awareness and adherence to assessment protocols.
A resident with chronic respiratory failure and cognitive impairment was found on two occasions with unbagged oxygen tubing left out and the oxygen concentrator running while not in use. The resident was also observed in bed with labored breathing, poorly positioned, and unable to access her oxygen, with staff confirming she could not have moved the tubing herself. Facility policy requiring proper oxygen application and storage was not followed.
A resident at high risk for falls was left unattended in a shower chair by a CNA, leading to an unwitnessed fall. The resident, with a history of traumatic brain injury and quadriplegia, began foaming at the mouth, prompting the CNA to leave the room to seek help. Upon return, the resident was found on the floor. The facility's policy lacked specific interventions for high fall risk residents.
Improper Food Labeling, Storage, and Kitchen Sanitation in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food labeling, storage, and protection from contamination affecting all 103 residents who received food from the facility’s kitchen. During an initial kitchen observation, multiple food items in the walk-in freezer, refrigerator, dry storage, countertop, and reach-in freezer were found open to air, without lids, and lacking open or expiration dates. These included a bag of frozen chips, a box of cinnamon rolls, an open container of beef base without a lid, elbow macaroni removed from original packaging and placed in an unlabeled plastic container, multiple bags of sliced bread and buns in various locations, and an open box of frozen hamburgers. On the spice rack, an open container of dill weed seasoning without a lid was observed, and on the back cabinets, Raisin Bran and Trix cereals had been removed from their original packaging and placed into plastic containers without open dates. The Dietary Manager stated that facility practice was to label and date all items when opened and to follow manufacturer expiration dates when items remained in original packaging, and confirmed that the observed items were not labeled or dated and that food should not be left open to air. Surveyors also observed sanitation and cleanliness issues in the kitchen environment. A set of keys was found sitting on the steam table serving area, the handwashing sink contained brown chunks and white debris, and the grill had black buildup between and underneath the grates, with a large accumulation of black residue on the grill foil. A review of the facility’s weekly cleaning list showed that the grill foil, grill grates, shelving, grill, and stovetop had been documented as cleaned on the two days prior to the observation. The Dietary Manager attributed the black buildup on the grill to cooking breakfast and suggested that staff may have had food on their hands when using the handwashing sink, and also acknowledged that keys should not have been left on the kitchen serving area. These conditions were inconsistent with the facility’s written policies requiring all foods stored in refrigerators, freezers, and dry storage bins to be covered, labeled, and dated, and requiring food service equipment and food-contact surfaces to be cleaned and sanitized at a frequency that prevents contamination.
Repeat Failure to Maintain Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to effectively implement interventions to maintain kitchen sanitation for all 103 residents who consumed food prepared in the kitchen. During a kitchen observation, surveyors found multiple food items improperly stored and not dated, including a bag of frozen chips and cinnamon rolls in the freezer open to air with no open dates, beef base without an open date, and elbow macaroni in a clear bin without a date. Additional undated bread products included white bread, whole wheat bread, hamburger buns, and sub buns, and dill weed seasoning was observed without a lid and open to air. These sanitation and food labeling issues were similar to those cited under F812 in a prior recertification survey, which had identified problems with maintaining sanitation, open food items, labeling of food, and dating of opened food. In an interview, the Executive Director reported that she and the Assistant Executive Director conducted various observations of the main kitchen and neighborhood kitchenettes but had no documentation of these observations. The Executive Director stated that the committee had been working on food temperatures, labeling, dating, and cleanliness since the previous April and noted there had been turnover among dietary aides, which she believed had corrected the problem until the most recent annual survey results. No policy related to these issues was provided at the time of survey exit.
Failure to Provide and Maintain Prescribed Cervical Collars and Splints for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and maintain prescribed cervical collars and a mechanical back/cervical splint for two residents with significant neurological and musculoskeletal impairments. For one resident with a history of cerebral infarction, right middle cerebral artery occlusion, and left-sided hemiplegia/hemiparesis, surveyors repeatedly observed her in bed without the ordered soft cervical collar in place, despite a physician’s order that she wear the collar while in bed and for all meals for neck contracture management. The collar was seen on the bedside stand during one observation, and the resident’s care plan and CNA Kardex contained no instructions regarding use or refusal of the collar. The NP’s earlier progress note documented that the resident liked wearing the collar and wanted to wear it more frequently than ordered, and there were no subsequent notes documenting refusal or discontinuation. Staff interviews further showed inconsistent understanding and implementation of the collar order for this resident. A CNA reported believing the collar had been discontinued after a trial for meals only, stating it was unsuccessful and that she understood it was no longer in use. The DON stated the collar had been used when the resident was eating meals consistently, but that it was not being used because the resident was now being offered food for pleasure only and was expected to receive a feeding tube. The DON also stated the collar was in the laundry because it was dirty and acknowledged that refusals should have been documented and that frequent refusals should have triggered re-evaluation of the device. The Director of Therapy confirmed the collar had been implemented for a right-sided neck contracture and that the resident initially wanted to wear it more often, and indicated that documentation of refusals was the responsibility of nursing. The facility’s policy on braces and assistive devices required documentation of refusals, follow-up actions, and care plan updates addressing device type, application instructions, monitoring guidelines, and specific risks, which were not reflected in the record. For a second resident with diagnoses including unspecified intracranial injury, left-sided hemiplegia, and traumatic subarachnoid hemorrhage, surveyors repeatedly observed her during meals with her head leaning to the left, without the prescribed mechanical back/cervical splint in place, and with full or covered meal trays that she was not eating. Her care plan identified an ADL self-performance deficit and included an intervention for application of a cervical/back splint during meals and removal afterward. Physician orders directed that she wear a cervical brace during all meals, angled approximately 30 degrees in extension with a towel under the brace. However, the most recent MDS did not indicate use of splints or braces, and staff interviews revealed ongoing problems with the brace’s fit and function that were not effectively addressed. CNAs reported that the resident should have had the brace on but that her head repeatedly slipped out of it, even after attempts to reposition her and reapply the brace, and one CNA stated she was unsure whether the NP or therapy had been notified. Another CNA described the Velcro on the brace releasing and the resident sliding in her seat so that the brace could not support her head, and indicated she had not been instructed on alternative interventions if the brace was ineffective and was unaware of any notification to NP or therapy. The Director of Therapy stated that therapy was initially responsible for the brace and that, after discharge, restorative nursing managed issues, with therapy performing screenings every three months; she acknowledged awareness that the Velcro continued to come undone but did not describe additional actions to ensure the brace was safe and properly fitting. The restorative nurse reported that Velcro had been replaced earlier in the month and that staff had not reported ongoing issues. The DOT later stated that the resident had been missed for a scheduled reassessment that should have occurred approximately three months after the last assessment and that she was on a list for reevaluation while therapy awaited an order. The facility’s policy required assessment of braces and assistive devices on admission, with changes in condition, and periodically as part of the care plan process, with nursing staff reporting changes in mobility or tolerance and reassessment quarterly with MDS review, which was not consistently carried out for this resident.
Failure to Complete Post-Fall Neurological Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete neurological assessments after falls in accordance with its described practice for multiple residents. For unwitnessed falls, an LPN and the DON both stated that staff were to assess the resident for injuries, determine the cause of the fall, initiate neurological checks every 15 minutes for the first hour, then hourly for four hours, and then every shift for 72 hours, along with provider and family notification, skin and post-fall assessments, dehydration assessment, and documentation. Record review for a resident with epilepsy, dementia, and diabetes showed missing neurological assessments following an unwitnessed fall on specific dates and times, including incomplete checks on the night and subsequent shifts. Another resident, also with epilepsy, dementia, and diabetes and care planned as being at risk for falls with an intervention to follow the facility fall protocol, had multiple missing neurological assessments after falls. These included missing second-shift neuros on several consecutive days, missing neuros at multiple specified times on another date, and absent first- and second-shift neuros on a subsequent date, as well as missing neuros at designated early-morning times and no documented every-shift neuros for 72 hours on three days. A third resident with dementia, abnormal posture, and diabetes had no neurological assessments located by the DON for multiple falls over several days, and neuros were also missing for three days following a fall later in the year. The facility’s written Falls Clinical Protocol required assessment and documentation of neurological status and related factors after falls but did not specify the frequency of neurological assessments.
Failure to Investigate and Respond to Resident’s Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond to a resident’s verbalization of suicidal ideation as required by the resident’s care plan and facility policy. The resident had diagnoses of Alzheimer’s disease, anxiety, and depression, and a current MDS showed significant cognitive impairment with a BIMS score of 4. The resident’s care plan for depression with a history of suicidal ideation directed staff to immediately notify a supervisor and redirect the resident when suicidal comments were made. On 3/9/2026, a progress note documented that the resident told a volunteer she had nothing to live for and wanted to kill herself, and a 1:1 visit log from that same encounter recorded the same statement. However, there were no additional progress notes or documentation showing that the suicidal ideation was further assessed, that the care plan interventions were implemented, or that the provider was notified. Interviews revealed multiple communication and follow-through failures. The DON stated that any resident verbalizing suicidal ideation should be asked if they had a plan to harm themselves, the care plan should be reviewed and followed, and the resident might be sent for inpatient psychiatric care if appropriate. A QMA who regularly worked on the resident’s unit reported she was not aware of the suicidal statement made on 3/9/2026, although she recalled the resident had made suicidal remarks upon admission months earlier. The Life Enrichment Specialist stated that volunteers complete visit logs and that she entered the 3/9/2026 log into the computer on 3/18/2026, at which time she read the suicidal statement but did not report it as she should have. The volunteer reported that after hearing the suicidal statement, he offered supportive words and then reported it to staff on an adjacent unit when he could not immediately find the unit nurse. The facility’s “Suicide Threats” policy required immediate reporting of any suicide threats to the Nurse Supervisor, continuous supervision of the resident, completion of a Columbia Suicide Severity Rating Scale, reporting findings to the provider, following any provider orders, and documenting the situation, but these steps were not carried out for this resident’s suicidal verbalization.
Improper Storage and Handling of Bedside Urinal
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to improper storage and handling of a portable urinal for one resident. On multiple observations over three consecutive days, the resident was seen sitting in a recliner with a portable urinal containing yellow liquid hanging by its handle on a trash bin in the room. On one of those days, the trash bin also contained a glove, a plastic drinking cup, a piece of folded paper, and three paper towels, while the urinal remained hanging from the bin. In a later observation the same day, the urinal was seen sitting on top of the resident’s table alongside three remote controls and a piece of folded paper. The urinal had been dated several days earlier, and there was no indication it had been emptied and cleaned between observations. Record review showed the resident had diagnoses including altered mental status and diabetes mellitus. The resident’s current care plan did not indicate that a urinal was to be kept at the bedside or within immediate reach while seated in a recliner. During interview, the CNA caring for the resident acknowledged that hanging the urinal on the trash can was an infection control concern and stated she was unsure where to place the urinal because the resident’s table had items on it, while also noting the resident liked to have the urinal close by due to frequent bathroom use. The DON stated that staff were expected to clean the urinal after use and store it on the back of the toilet when not in use, and that clean urinals should be stored there. The DON also stated that the care plan should reflect if a resident preferred to keep a urinal close by, but this preference was not documented for this resident. The facility’s policy indicated that if a resident keeps a urinal at bedside, it should be checked frequently, emptied and cleaned as necessary, documented on the care plan, and stored on a paper towel on the bedside stand with a cover when not in use.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with a history of severe cognitive impairment and high risk for wandering was able to leave the facility unsupervised and travel approximately three miles, crossing heavily trafficked streets, before being returned by local police. The resident, who had a BIMS score of 3/15 indicating severely impaired cognition and diagnoses including an unspecified mental disorder and chronic obstructive pulmonary disease, resided on an unsecured unit and had a documented history of wandering within the facility. Despite these risk factors, the resident's care plan did not address her ability to exit the facility alone, did not include interventions for wandering, and did not specify how often her whereabouts should be checked. On the day of the incident, the resident was observed by the facility's CFO exiting and re-entering the building multiple times in the morning, with the final exit occurring at 10:03 AM. No staff member was aware that the resident had left the facility, and her absence went unnoticed until the CFO received a call from the resident's friend at 12:49 PM, informing her that the resident was at her former apartment and that the police were returning her to the facility. Interviews with staff revealed that the last known sighting of the resident was around 9 AM, and staff did not realize she was missing until notified by an external party. The resident did not sign out or have a family member or friend accompany her, as required for a leave of absence. Review of the resident's records showed that while she was assessed as high risk for wandering, no elopement risk assessments were completed, and her care plan lacked specific interventions for her wandering behavior. Nursing notes prior to the incident documented episodes of the resident being lost within the facility and expressing intentions to leave, but these behaviors were not addressed with targeted interventions. The facility's policy required assessment and interventions to prevent elopement, but these were not implemented for this resident prior to the incident.
Deficient Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food handling practices, as evidenced by multiple observations during a survey. Opened food items, such as a container of ice cream and chef salads, were found in the kitchen without being labeled or dated. Several food items in the freezer, including hamburger patties, chicken strips, and French fries, were left open to air exposure and not dated when opened. An open box of popsicles was observed past its expiration date, and a cart containing expired fruit and cake was not disposed of as required. Additionally, scoops for flour and sugar were stored inside the bins, contrary to policy, and the fruit and cake on the cart were not individually covered and appeared dry. Sanitation issues were also noted, including a shelf next to the fryer with a large amount of oily liquid and debris, and multicolored streaks and splatters on the freezer doors. Baking pans were found stacked while still wet, with clear liquid dripping from them, indicating they were not thoroughly air dried before storage. The Dietary Manager confirmed that these practices did not align with facility policies, which require all food to be covered, labeled, and dated, and all equipment to be sanitized and properly air dried. These deficiencies affected 95 of 96 residents who were served food prepared in the kitchen.
Medication Administration in Common Area Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a nurse administered medications, including a subcutaneous injection of Trulicity, to a resident in a common dining area while the resident was eating breakfast. The resident, who had diagnoses of type 2 diabetes, chronic gingivitis, and unspecified dementia, was observed pulling up his shirt to expose his abdomen for the injection in the presence of others. The resident's care plan did not indicate any preference for receiving medications in common areas. Interviews with staff confirmed that it was not permitted to administer medications in the common area during meals due to concerns about resident dignity and the expectation that residents should enjoy their meals without interruption. Facility policy also required staff to maintain resident privacy and dignity during treatment procedures, including protecting bodily privacy. The administration of the injection in a public setting was not consistent with these policies.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
A deficiency occurred when a computer screen displaying a resident's name, picture, medication list, and other personal health information was left open and visible on top of a medicine cart in a hallway. Additionally, a paper worksheet containing vital signs and other health information for multiple residents was left on top of the cart. Both the computer screen and worksheet were accessible in an area where staff and residents were passing by, making the information visible to unauthorized individuals. The incident was observed during routine activities, including medication administration and meal assistance. The resident involved had diagnoses including cerebral palsy, abnormal weight loss, dysphagia, and altered mental status, with a BIMS score indicating cognitive impairment. During interviews, the RN acknowledged forgetting to lock the computer screen and failing to turn over the worksheet to protect resident information. The DON confirmed that facility policy requires computer screens to be locked and paper records to be secured when unattended, in order to maintain confidentiality of resident information.
Failure to Provide Bed Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide required documentation or notification regarding the bed hold policy to two residents prior to their discharge to the hospital. Resident 35, who had diagnoses including kidney failure, respiratory failure, and pneumonitis due to inhalation of food and vomit, was sent to the hospital without any documentation in the medical record indicating that the bed hold policy had been explained to her or her family. Similarly, Resident 47, with diagnoses of respiratory failure, dysphagia, and altered mental status, was also transferred to the hospital without evidence that the bed hold policy was communicated to him or his family. The Director of Nursing confirmed that the bed hold policy should have been documented in the progress notes and that residents or their representatives should always be informed of the policy prior to leaving the facility. The facility's current policy requires informing residents upon admission and prior to transfer for hospitalization or therapeutic leave about the bed hold policy, but there was no documentation to show this occurred for the two residents.
Failure to Accurately Assess and Document Neurological and Respiratory Status
Penalty
Summary
The facility failed to ensure accurate assessments and documentation for two residents with significant medical conditions. For one resident with a history of 6th abducent nerve palsy, 3rd oculomotor nerve palsy, and blepharoconjunctivitis, observations revealed unequal pupils—one dilated and nonreactive, the other normal—yet skilled charting repeatedly documented the pupils as equal, round, and reactive to light over several months. The resident's care plan addressed issues such as impaired vision and droopy eyelids but did not include interventions or monitoring for the known unequal pupils, despite this being a longstanding condition. Staff interviews confirmed a lack of awareness and proper documentation regarding the resident's pupil irregularities. For another resident with acute respiratory failure, pneumonitis, and dysphagia, physician orders required shift-by-shift documentation of breath sounds and related respiratory assessments following episodes of pneumonia and chest tube removal. However, multiple shifts lacked documentation of breath sounds as ordered, with specific dates noted where assessments were not completed. The DON acknowledged that the required assessments were missed. Facility policies required comprehensive neurological and respiratory assessments, but these were not consistently followed for the residents reviewed.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and hypoxia. On two separate occasions, oxygen tubing was observed lying unbagged and not in use, with the oxygen concentrator left on and releasing oxygen while the resident was not present or not wearing the nasal cannula. Staff interviews confirmed that oxygen should be turned off when not in use and tubing should be bagged, but a bag was not available in the resident's room. The facility's policy required oxygen to be turned on only at the time of application and placed on the resident, but this was not followed. Additionally, the resident was found in bed with labored breathing, poorly positioned with her chin tucked to her chest, and without access to her oxygen tubing, which was out of her reach. The resident was cognitively impaired, required assistance with personal care, and had no documented refusal of care. Staff confirmed the resident could not have moved the tubing herself or accessed her wheelchair, indicating a lack of appropriate monitoring and intervention to ensure her respiratory needs were met.
Failure to Follow Fall Prevention Protocols for High-Risk Resident
Penalty
Summary
The facility failed to ensure fall prevention interventions were followed for a resident identified as being at high risk for falls. On the evening of the incident, a Certified Nurse Aide (CNA) assisted the resident in the shower. During the shower, the resident began to foam at the mouth and turned blue. The CNA left the resident alone in the shower chair to seek help, and upon returning with a Qualified Medication Aide (QMA), they found the resident on the floor of the shower. The incident was unwitnessed, and the resident was left unattended, which is against the facility's protocol for high fall risk residents. Interviews with staff members, including the Director of Nursing (DON), confirmed that the resident should not have been left alone in the shower chair. The facility's policy on falls did not specify interventions for high fall risk residents, which contributed to the deficiency. The resident's medical history included a traumatic brain injury, muscle weakness, and quadriplegia, and a recent fall assessment had indicated a high risk for falls. The care plan required assistance with transfers and showers, which was not adequately provided during the incident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Park | 0.3 mi | ★★★★★ | 7 | 0 |
| Saint Anne Home | 0.5 mi | ★★★★★ | 4 | 0 |
| Celebrate Senior Living Of Fort Wayne | 0.6 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of Fort Wayne | 1.7 mi | ★★★★★ | 9 | 0 |
| Waters Of Fort Wayne Skilled Nursing Facility, The | 1.8 mi | ★★★★★ | 5 | 0 |
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