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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at George Ade Memorial Health Care Center during CMS and state inspections, most recent first.
A resident with an indwelling catheter had a urine bag left uncovered and visible from the hallway on repeated observations, despite a facility policy requiring catheter covers or dignity bags to preserve privacy. In a separate incident, a cognitively intact resident who needed assistance with bathing reported that an LPN forced her into the shower room and told her she could not refuse a shower when she did not want to use the available chair, and the facility’s investigation substantiated that her rights were violated.
A resident with dementia and Parkinson's disease had an MDS quarterly assessment that coded the alarm item as not used, even though the physician had ordered a Wanderguard on the resident's wrist with instructions for ongoing monitoring. The MDS Coordinator stated she thought the device had been discontinued, and the RAI Manual identifies wander/elopement alarms as devices that must be considered in alarm coding.
A resident with stroke and anxiety was assessed as cognitively intact and dependent on staff for transfers, but her care plans only noted assistance with transfers and did not document that she required a Hoyer lift or 2-person assist. The resident stated she needed a Hoyer lift to get out of bed, an LPN confirmed this, and the DON stated the care plans should have reflected the Hoyer lift transfer status.
Failure to provide activities for a cognitively impaired resident. A resident with Alzheimer’s disease, MDD, and psychotic disorder was repeatedly observed lying in bed staring at the ceiling, picking at her hair, and smacking her teeth while no TV, music, or room activity was present, even when group activities were occurring elsewhere. Her MDS showed severe impairment in daily decision making, and her care plan included music, church services, special events, and one-on-one contact, but observations documented limited engagement in the room.
The facility failed to notify the physician when a resident had repeated diarrhea despite PRN loperamide use, and failed to follow a physician order for another resident's catheter tubing securement. One resident was cognitively intact, dependent for toileting, and had ongoing diarrhea episodes with no documentation that the MD was notified. Another resident with an indwelling catheter reported the adhesive securement device ripped her skin open, even though the order directed staff not to use a catheter securement device and to keep tubing off the skin using abdominal pads.
Failure to follow an ordered fluid restriction for a resident with heart failure. The resident was cognitively intact and had a care plan for fluid restriction, but the chart showed fluid intake documented by both intake records and MAR entries that did not clearly align with the physician's order for 1,200 ml/day. The DON stated the order was not specific about how much fluid nursing and dietary were each to provide.
A resident with emphysema and asthma was observed on PRN O2, but the MAR/TAR lacked documentation that the O2 was administered or titrated as ordered. Another resident with severe cognitive impairment developed cough and congestion, but the record lacked documentation of COVID/flu testing when symptoms began, and the planned Robitussin was not implemented in the order summary.
Failure to apply ordered ROM devices: two residents were observed without a left-hand splint or palm protector in place despite care plans and physician orders directing their use. One resident with hemiplegia and impaired ROM said he was unsure when to wear the splint, and the DON stated there was no clear schedule. Another resident with Alzheimer's disease and severe cognitive impairment was repeatedly observed in bed without the ordered palm protector on the left hand.
A resident who was cognitively impaired and dependent on staff for bathing fell in the shower room when a non-reclining shower chair tipped as a CNA tried to move it. The resident had previously used a bariatric lay-down shower chair, but the facility had stopped renting it and used a regular shower chair instead. The resident reported being dumped from the chair and said she was afraid to use that type of chair again.
A resident with dementia and a high risk for falls, who was care planned for two-person assistance with ADLs, was assisted by a single CNA during a shower. The resident attempted to stand from the shower chair, fell, and sustained a laceration requiring sutures, an abrasion, and later was diagnosed with a right hip fracture. Documentation and interviews confirmed the CNA did not follow the care plan, leading to the resident's injuries and decline.
A resident with cognitive impairment and a history of falls experienced a shower fall resulting in pain and decreased mobility. Despite ongoing complaints of right leg pain and worsening ambulation, nursing staff did not perform or document timely assessments of the affected limb. The lack of thorough evaluation led to a delay in diagnosing a right hip fracture, which was only identified after significant physical changes were observed.
A resident with a history of cognitive impairment and other medical conditions was admitted with a deep tissue injury (DTI) on the left foot. The facility failed to provide timely treatment for the DTI, as documented treatment did not begin until several days after admission, despite a physician's order for daily skin prep. The Director of Nursing acknowledged that treatment should have been initiated immediately, highlighting a deficiency in adhering to the facility's policy on pressure ulcer care.
A resident with a history of falls and cognitive impairment was observed multiple times without anti-rollback bars on her wheelchair, despite a care plan intervention requiring them. The resident had previously fallen and sustained injuries, and the facility's policy emphasized the need for safety interventions. The DON confirmed the bars should have been in place, indicating a failure to provide a safe environment.
A facility failed to provide proper oxygen therapy for a resident with chronic respiratory failure and heart failure. The resident was observed multiple times without oxygen, despite having a physician's order for 2-4 liters per nasal cannula every shift. The MAR indicated oxygen was signed off as administered, but the rate was not documented, and there were no documented refusals. The facility's policy required documentation of liter flow and response, which was not consistently followed.
A facility failed to assess the necessity for bed rails for a resident with cognitive impairment and receiving hospice services. The resident was observed with half-length side rails without any documented evaluation or assessment, and the Physician's Order Summary lacked orders for side rails. The DON acknowledged the absence of an assessment and was unsure if other interventions were attempted. A Side Rail Assessment was later provided, indicating the use of side rails for assistance with transfers and bed mobility.
The facility failed to maintain the dignity of two residents by not covering their urinary drainage bags, as required by policy. One resident with cerebral palsy and intellectual disabilities was observed with an uncovered bag multiple times. Another resident with dementia and urinary retention had an uncovered bag until after morning care. The facility's policy mandates the use of covers to preserve dignity.
The facility failed to provide necessary assistance with ADLs for two residents, specifically in oral care and eyeglass placement. A resident with Alzheimer's did not receive oral care as required by her care plan, and another resident with dementia did not receive oral care or have his eyeglasses placed, despite facility policies mandating these actions.
A resident with a urinary catheter did not receive proper care, as observed when a CNA placed the drainage bag and tubing on the floor multiple times during morning care. The outlet tube was not disinfected after emptying, and the catheter was not washed. The resident had a history of urinary tract infections, and the care plan required the drainage system to be kept off the floor and catheter care to be completed regularly, which was not adhered to.
The facility failed to ensure staff used PPE for residents on Enhanced Barrier Precautions (EBP). Two CNAs were observed entering residents' rooms without PPE, despite signs indicating EBP. The residents had conditions requiring EBP, and care plans specified PPE use. The facility's policy required gowns and gloves to be available near the rooms.
Failure to Preserve Resident Dignity and Honor Bathing Choice
Penalty
Summary
The facility failed to maintain a resident’s dignity when a urinary catheter bag was observed hanging from the side of the bed with visible urine in the bag and no cover over it, making the bag visible from the hallway on multiple observations. Resident G had diagnoses including obstructive and reflux uropathy, urine retention, and neuromuscular dysfunction of the bladder, and the care plan indicated the resident had impaired urinary elimination and an indwelling catheter. The facility policy stated catheter covers or dignity bags are used to preserve dignity and privacy when out of the room or per resident request, and nursing staff are responsible for applying and securing them. The facility also failed to honor a resident’s choice regarding bathing. Resident 57, who was cognitively intact and required substantial to maximal assistance with showering, stated she was supposed to receive showers three times a week. She reported that staff took her to the shower room, but when her usual shower chair was not there, she began backing out because she did not want to use a different chair. She stated that an LPN pushed her wheelchair back into the shower room and told her she was going to take a shower and was not going to refuse, which the resident felt was forced. The resident’s care plan indicated she needed assistance with bathing on Tuesday, Friday, and Sunday evening shifts. The facility-reported incident and investigation documents stated the resident reported the LPN pushed her back into the shower room forcefully and told her she could not refuse the shower. Multiple staff statements described the resident saying she did not want the shower until later or did not want to use the chair that hurt her, while the LPN insisted she would take the shower now and assisted in moving her back into the shower area. The investigation summary stated the incident was substantiated because the resident’s rights were violated.
Inaccurate MDS Coding for Wanderguard Alarm
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed for a resident with a history of wandering. Resident 37 had diagnoses including dementia and Parkinson's disease, and the quarterly MDS dated 1/26/26 indicated moderate cognitive impairment and need for partial to moderate assistance with showering, personal hygiene, and putting on and taking off footwear. On the MDS, the alarm item was coded as 0, meaning not used. The resident's physician order dated 12/15/25 indicated a Wanderguard to the right wrist with instructions to monitor proper placement every shift and functioning daily. During interview, the MDS Coordinator stated she thought the Wanderguard had been discontinued. The CMS RAI Manual guidance cited in the report states that wander/elopement alarms include devices worn by or attached to the resident that activate an alarm when the resident nears or exits a specific area or building.
Care Plan Did Not Reflect Hoyer Lift Transfer Status
Penalty
Summary
The facility failed to update Resident 16’s care plans to reflect the resident’s transfer status. Resident 16, who had diagnoses including stroke and anxiety, was assessed as cognitively intact on the annual MDS dated 12/2/25 and was dependent on staff for transfers. On 3/2/26, the resident was observed lying in bed and stated that she required a Hoyer lift for staff to transfer her out of bed, and she reported that when the facility was short staffed, staff would not always have 2 people available to transfer her. The care plans for self-care deficit related to impaired mobility and for fall risk due to impaired mobility and weakness both included interventions for staff to assist with transfers, but neither care plan documented that the resident required a Hoyer lift or a 2-person assist for transfers. An LPN confirmed the resident required a Hoyer lift, and the DON stated the care plans should have been updated to indicate the resident was a 2-person assist with a Hoyer lift for transfers.
Failure to Provide Activities for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide activities to support the psychosocial well-being of a cognitively impaired, dependent resident. Resident H had diagnoses including Alzheimer's disease, major depressive disorder, and psychotic disorder with delusions. The annual MDS dated 1/5/26 indicated the resident was severely impaired for daily decision making, and the activity preference assessment showed preferences for showers, family or significant other involvement in care discussions, reading, listening to music, being around animals, and participating in religious activities or practices. The care plan, revised on 2/8/26, noted the resident showed little awareness of programs, could complete few or no simple tasks, and was on palliative care, with interventions including assistance to programs, target, sing a long, church services, special events, music programs, and one-on-one staff contact during activities. During multiple observations, Resident H was repeatedly found lying flat in bed with eyes open staring at the ceiling, with the curtain pulled and positioned so she could not see into the hall. At several times there was no television, music, or activity occurring in her room, while activities were occurring in the dining room. The resident was also observed repeatedly picking at her hair, smacking her teeth together, and pulling at her hair while lying in bed. Although the activity director stated staff provided daily room visits that included talking, reading, and/or massage, and that staff were supposed to turn on music in the resident's room, the observations documented periods when no activities were occurring in the room and the resident remained in bed without engagement.
Failure to Notify Physician for Recurrent Diarrhea and Follow Catheter Securement Order
Penalty
Summary
The facility failed to ensure a resident received necessary treatment and services when staff did not notify the physician after the resident had multiple episodes of diarrhea. The resident had diagnoses including stroke and anxiety, was cognitively intact, and was dependent on staff for transfers and toileting hygiene with bowel and bladder incontinence. The resident had an order for loperamide as needed after unformed stools, and the MAR showed the medication was given on multiple occasions for diarrhea, including an episode where the resident had three episodes of diarrhea and the medication was not effective. There was no documentation that the physician was notified after the repeated diarrhea episodes. The facility also failed to follow a physician's order related to catheter securement for another resident with neuromuscular dysfunction of the bladder and urinary retention. The resident had an indwelling catheter and was cognitively intact. A physician's order directed staff to place clean abdominal pads to the bilateral inner upper thighs to keep catheter tubing off the skin and not use a catheter securement device because the resident's skin would blister. However, the resident was observed with catheter tubing secured to the right leg using an adhesive catheter securement device, and the resident stated the adhesive rips her skin open. The DON stated the hospital had applied the adhesive and staff should have noticed and removed it, and that the adhesive had caused problems to the resident's skin previously.
Failure to Follow Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure physician's orders were followed for a fluid restriction for one resident with heart failure. The resident's quarterly MDS dated 12/2/25 indicated the resident was cognitively intact, and the care plan revised on 3/3/26 identified that the resident was on a fluid restriction with interventions to follow ordered fluid restrictions and monitor and record intake. A physician's order dated 3/2/26 specified a regular diet with a 1,200 ml per day fluid restriction, and another order dated 3/1/26 directed staff to document fluid intake with medication every shift. However, the Intake: Fluids documentation showed 1,030 ml on 3/1/26, 1,080 ml on 3/2/26, and 900 ml on 3/3/26, while the March 2026 MAR showed the resident received 510 ml, 540 ml, and 360 ml of fluid with medication pass on those same days. During interview, the DON stated the order needed to be clear about how much fluid each department was to give the resident because it was not specific to reflect 600 ml for nursing and 600 ml for dietary.
Failure to Document PRN Oxygen Use and Respiratory Testing/Orders
Penalty
Summary
Safe and appropriate respiratory care was not provided for Resident 32 and Resident 12. Resident 32, who had diagnoses including emphysema and asthma, was observed multiple times with oxygen in place via nasal cannula and the portable tank set at 2 liters. The physician’s order dated 3/1/26 directed oxygen at 2-4 liters as needed to keep oxygen saturation above 90%, but the March 2026 Medication and Treatment Administration Records did not contain documentation that the PRN oxygen had been administered or titrated. The facility’s oxygen therapy policy required recording oxygen therapy on the treatment or special record and nursing notes if PRN, including the type of catheter, liter flow, and response to treatment. Resident 12, who was severely cognitively impaired, had a documented cough, poor appetite, pale skin, and a temperature of 99.4 degrees Fahrenheit on 2/17/26, followed by a physician note on 2/18/26 indicating cough, congestion, no fever, no respiratory distress, and a viral upper respiratory infection with a plan for Robitussin. Subsequent progress notes documented a moist congested cough with expiratory crackles in the upper left lobe and later a dry, non-productive cough with diminished lung sounds. The record lacked documentation of COVID/flu testing when the cough began, and the February 2026 Physician Order Summary did not include an order for Robitussin. The DON stated she could not find documentation of a COVID/flu test for 2/18/26 and that there were no orders implemented for Robitussin.
Failure to Apply Ordered Splints and Palm Protector
Penalty
Summary
The facility failed to provide treatment for limited ROM when splints were not in place for 2 of 3 residents reviewed for ROM. Resident G had diagnoses including hemiplegia of the left non-dominant side, and the MDS indicated impaired ROM to the upper and lower extremities on one side. His care plan required use of a splint for contracture of the left hand, and a physician order dated 3/1/26 directed a left hand splint for 2 to 4 hours daily or as tolerated to help prevent future contractures. However, during multiple observations on 3/2/26 and 3/3/26, Resident G was seen without the splint in place on his left hand, with the splint found on his bed or wheelchair. He stated he had a splint he would wear on his left hand sometimes, was unable to put it on himself, and was unsure when he was supposed to wear it. The DON stated there had been no clear schedule for when the splint was to be worn and that the orders were updated to be put on at night. Resident H had diagnoses including Alzheimer's disease and adult failure to thrive, and the annual MDS indicated severe impairment in daily decision making and a limitation in ROM to one upper extremity. A physician order dated 3/1/26 directed a palm protector to the left hand on in the morning and off at night. During observations on 3/2/26 and 3/4/26, Resident H was repeatedly seen lying in bed without the palm protector in place to the left hand. The March 2026 MAR/TAR indicated the palm protector was applied as ordered daily from 3/1/26 through 3/4/26, but the DON had no further information to provide during interview.
Inadequate Shower Equipment Led to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was provided with adequate equipment to prevent a fall during showering. Resident D’s quarterly MDS, dated 12/16/25, indicated the resident was moderately cognitively impaired and dependent on staff for showering/bathing. On 3/3/26, an Event: Safety Events - Fall documented that the resident fell in the shower room while receiving a shower, with no injuries. A progress note stated the shower chair tipped in the shower and the CNA lowered the resident to the floor; the resident did not hit her head and there were no injuries. During interview, the CNA stated the resident usually used a larger bariatric lay-down shower chair that the facility no longer rented, so a regular shower chair that did not recline was used instead. She reported the resident’s size and weight distribution made positioning difficult, and when she attempted to move the chair, it tipped forward and the resident had to be safely lowered to the ground. The resident stated she was “dumped” from the shower chair and was afraid to use that type of chair again. The DON and Social Service Designee stated the facility had been renting a bariatric lay-down shower chair, purchased a new chair that did not have the reclining feature, and later planned to resume renting the bariatric chair.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided shower assistance to a resident who was care planned for two-person assistance with activities of daily living (ADLs), including bathing and transfers. The resident had a history of Alzheimer's disease, dementia, moderate intellectual disabilities, and was identified as high risk for falls. The care plan specifically required care in pairs due to the resident's cognitive impairment, fall risk, and behavioral concerns, including threatening harm to staff. Despite these documented interventions, the CNA assisted the resident alone in the shower. During the shower, the resident attempted to stand from the shower chair without adequate support, resulting in a fall. The resident sustained a laceration above the right eye requiring four sutures, an abrasion to the right knee, and was transferred to the emergency room for evaluation. Initial assessments and imaging did not reveal a hip fracture, but the resident subsequently experienced a decline in mobility, increased pain, and difficulty ambulating. Over the following days, the resident's right leg became painful, discolored, and showed signs of injury, eventually leading to the diagnosis of a right femoral neck fracture eight days after the fall. Interviews and documentation confirmed that the CNA was aware of the care plan requirement for two-person assistance but proceeded alone. The Director of Nursing and the attending physician both indicated that the hip fracture was likely caused by the fall during the unsupervised shower. The facility's failure to follow the care plan and provide adequate supervision and assistance directly resulted in the resident's injuries and subsequent decline in function.
Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice following a fall, specifically by not conducting timely and thorough assessments after changes in the resident's condition. The resident, who had diagnoses including right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities, experienced a fall in the shower resulting in a laceration above the right eye and an abrasion to the right knee. After returning from the emergency room, the resident began to complain of right knee and leg pain and was placed in a wheelchair for safety. Despite these complaints and a recommendation for the physician to evaluate the leg, documentation shows that nursing staff did not perform or document comprehensive assessments of the right leg on multiple occasions over several days as the resident's pain and functional status worsened. Throughout the days following the fall, the resident exhibited increasing pain, difficulty with ambulation, and changes in mobility, including refusal to walk, reliance on a wheelchair, and eventually inability to stand without assistance. Nursing notes repeatedly failed to document assessments of the right leg even when pain was reported by the resident or observed by staff. It was not until several days after the initial fall, when the resident's right leg appeared shorter, discolored, and rotated, that an x-ray was ordered, revealing a right femoral neck fracture. Prior to this, only a right knee x-ray had been obtained, which was negative for injury, and the resident continued to experience significant pain and decreased mobility. Interviews with facility staff, including the PT and DON, confirmed that the resident's pain and functional decline were not adequately assessed or addressed in a timely manner. The DON acknowledged that no further assessments were completed by nurses when the resident's right leg pain increased and his functional status changed, until the significant physical changes were observed. This lack of timely and thorough assessment delayed the diagnosis and treatment of the resident's fractured right hip.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment for a resident with a pressure ulcer, leading to a deficiency in care. The resident, who was cognitively impaired and had a history of hypertension, cerebral infarction, and Alzheimer's disease, was admitted to the facility with a deep tissue injury (DTI) on the left foot. Upon admission, the DTI was noted to be a dark brownish purple area measuring 0.8 cm x 3 cm. Despite the presence of the DTI, the Treatment Administration Record (TAR) showed no documented treatment for the left lateral foot from the time of admission on November 22, 2024, until November 26, 2024, when a physician's order for daily skin prep was received. The deficiency was further highlighted during an interview with the Director of Nursing (DON), who acknowledged that a treatment plan should have been implemented immediately upon identifying the DTI. The facility's policy on Skin Condition and Pressure Ulcer Assessment mandates that at the earliest sign of a pressure ulcer, the resident, legal representative, and attending physician should be notified, and the condition should be documented in the nursing notes. However, the lack of timely treatment and documentation for the resident's DTI indicates a failure to adhere to this policy, resulting in inadequate care for the resident.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident with a history of falls. Resident 52, who was cognitively impaired and had a history of falls, was observed multiple times without anti-rollback bars on her wheelchair, despite a care plan intervention indicating their necessity. The resident's diagnoses included dementia with behavioral disturbance, anxiety disorder, and hypertension, and she required partial to moderate staff assistance with bed mobility. The resident had previously fallen and sustained injuries, prompting the interdisciplinary team to decide on the application of anti-rollback bars for her wheelchair. Observations on three separate occasions revealed that the anti-rollback bars were not present on the resident's wheelchair, contrary to the care plan's directives. The Director of Nursing confirmed that the anti-rollback bars should have been in place. The facility's Fall Prevention policy emphasized the need for safety interventions based on initial assessments, yet the required intervention for this resident was not implemented, leading to a deficiency in providing a safe environment for the resident.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure proper treatment and care related to oxygen administration for a resident with chronic respiratory conditions. Resident 4, who has diagnoses including congestive heart failure, chronic respiratory failure, and type 2 diabetes mellitus, was observed multiple times without oxygen in place, despite having a physician's order for oxygen administration of 2-4 liters per nasal cannula every shift. The resident's care plan indicated the need for oxygen therapy due to heart failure and chronic respiratory failure, with interventions to administer oxygen as ordered and as needed. The Medication Administration Record (MAR) for January 2025 showed that oxygen was signed off as administered every shift, but there was no documentation of the rate of oxygen administered or any refusals by the resident. Progress notes indicated that the resident sometimes refused oxygen during the day and was oxygen-dependent at night. However, there were no documented refusals in the MAR. The Director of Nursing later indicated that the physician had been updated, and the oxygen orders were changed to PRN. The facility's policy on oxygen therapy required documentation of the liter flow and response to treatment, which was not consistently followed.
Failure to Assess Necessity for Bed Rails
Penalty
Summary
The facility failed to attempt alternative measures and assess the necessity for bed rails for a resident reviewed for bed rails. The resident, who was cognitively impaired and receiving hospice services, was observed on two occasions with half-length side rails on both sides of the bed. The resident's record indicated diagnoses of dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment noted that the resident required partial to moderate staff assistance with bed mobility and that bed rails were not used as a physical restraint. However, there was no documented evaluation or assessment for the use of side rails, and the Physician's Order Summary lacked any orders for side rails. During an interview, the Director of Nursing (DON) acknowledged the absence of an assessment for the side rails and was unsure if any other interventions had been attempted prior to their use. A Side Rail Assessment was later provided, indicating the use of bilateral top half side rails for assistance with transfers and bed mobility. The facility's policy on side rails stated that an assessment should be performed to determine the need for full-length side rails to treat medical symptoms, and the use of full side rails requires a Physician's Order. The policy also mentioned that a half side rail should be used in accordance with assessed need and resident desires.
Failure to Cover Urinary Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of residents by not covering urinary drainage bags, as observed in two residents. Resident C was seen multiple times with an uncovered urinary drainage bag attached to the side of the bed, visible from the door. Resident C's medical history includes cerebral palsy and moderate intellectual disabilities, with a moderately impaired cognitive status and dependency on activities of daily living, as noted in a recent MDS assessment. Similarly, Resident D was observed with an uncovered urinary drainage bag while asleep and later when awake. Despite being assisted by a CNA, the urinary drainage bag remained uncovered until after morning care. Resident D's medical history includes dementia, a history of urinary tract infections, and urinary retention, with a moderately impaired cognitive status requiring supervision for hygiene. The facility's urinary catheter care policy mandates the use of catheter covers to preserve residents' dignity, which was not adhered to in these instances.
Failure to Provide Oral Care and Eyeglass Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, specifically in the areas of oral care and the placement of eyeglasses. Resident B, who has Alzheimer's disease and is dependent on staff for hygiene, was observed being transferred from bed to a Broda Chair without receiving oral care, despite her care plan indicating the need for assistance with oral hygiene twice daily. Similarly, Resident D, with a history of dementia and urinary issues, was observed receiving morning care without oral care being completed or eyeglasses being placed, even though his care plan required assistance with oral hygiene for his upper denture and lower natural teeth twice a day. The facility's policies, as confirmed by the Director of Nursing, require oral hygiene to be part of morning and evening care, and eyeglasses to be cleaned and placed on residents. However, these policies were not followed for Residents B and D. Interviews with staff revealed that oral care was expected to be provided daily, and while Resident D sometimes refused to wear glasses, there was no indication that this was the case during the observed deficiency. The failure to adhere to these care plans and policies resulted in the cited deficiencies.
Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide proper care for a resident with a urinary catheter, leading to a deficiency in catheter management and infection prevention. During an observation, a CNA was seen placing the urinary drainage bag on the floor multiple times while assisting the resident with morning care. The catheter tubing was also on the floor, and the resident was observed rolling the tubing with his foot. After draining the urine from the bag, the CNA did not disinfect the outlet tube before clamping it and returning it to the holder. The urinary catheter was not washed during the care process, and the drainage bag was placed under the wheelchair seat with the tubing still on the floor. The resident involved had a history of urinary tract infections and urinary retention, with a care plan indicating a risk for infections due to the indwelling catheter. The care plan specified that the urinary drainage bag should be stored in a protective bag, the drainage system should not touch the floor, and catheter care should be completed every shift and as needed. The facility's urinary catheter care policy also required that the drainage bags and tubing be positioned to prevent contact with the floor and that outlet tubes be disinfected after emptying. However, these protocols were not followed, as observed during the survey.
Failure to Use PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to residents under Enhanced Barrier Precautions (EBP). During an observation, CNA 1 entered a resident's room without wearing any PPE, despite a sign above the bed indicating the need for EBP. The resident had a history of dementia, urinary tract infections, and urinary retention, and required moderate assistance for daily activities. The care plan and physician's order specified the use of PPE, including gowns and gloves, during care. Similarly, CNA 6 was observed preparing to provide care to another resident without PPE. This resident had cerebral palsy and moderate intellectual disabilities, and was dependent on assistance for all activities of daily living. The care plan and physician's order also required EBP, with PPE to be used during care. The Director of Nursing noted that EBP signs had been moved to above the residents' beds for confidentiality, but the facility's policy required gowns and gloves to be available near or outside the resident's room.
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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 Brook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rensselaer Care Center | 10.8 mi | ★★★★★ | 30 | 0 |
| Arcadia Care Watseka | 21.7 mi | — | 11 | 0 |
| Iroquois Resident Home, The | 22.5 mi | ★★★★★ | 0 | 0 |
| Aperion Care Demotte | 22.9 mi | ★★★★★ | 2 | 0 |
| Oak Grove Christian Retirement Village | 24.2 mi | ★★★★★ | 18 | 0 |
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