Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Hammond-whiting Care Center during CMS and state inspections, most recent first.
Failure to address ROM loss in a resident with post-stroke hemiplegia: A resident with left-sided hemiplegia after a stroke was observed multiple times with the left hand held in a fist and minimal movement of the left arm, with no visible intervention noted. The record showed stroke-related care plan goals to prevent complications such as contractures, but a rehab screening did not include the hemiplegia or a ROM assessment, and the DON was unsure whether any hand interventions were in place. OT later found mild hypertonicity in the fingers and recommended therapy to trial a splint/palm guard.
Kitchen Sanitation and Food Storage Deficiencies: During a kitchen tour, the Head Cook observed food containers and boxes stored on the floor in the walk-in refrigerator and freezer, with no shelves in the freezer and 22 stacks of food boxes on the floor. A bag of biscuits was open to air and discolored, and the dishwasher had a heavy buildup of crumbs and debris. The Head Cook stated food should not be stored on the floor, the biscuits should be discarded, and the dishwasher needed cleaning.
Inaccurate MDS coding affected hospice, diet, and medication entries for multiple residents. One resident receiving hospice care had hospice services omitted from the MDS, another resident's MDS failed to reflect a therapeutic diet with multiple restrictions, and two residents had medication coding errors involving an anti-anxiety med and an opioid pain med. The MDS Coordinator acknowledged the inaccuracies.
Elopement Device Not Function-Checked and Hot Water Temperatures Exceeded Safe Levels: A resident at risk for elopement had a wander guard in place, but staff only visually checked placement and did not document regular function checks; the LPN did not know how to test it, and the DON stated there was no facility policy for checking function. On the North Unit, multiple resident room bathrooms had hot water temperatures above safe levels, with readings as high as 130 degrees Fahrenheit before later rechecks were lower.
Enteral feeding orders were not followed for several residents with PEG or gastrostomy tubes. A resident with dysphagia and multiple chronic conditions had tube feeding and water flush bags observed hanging without proper dating or labeling, another resident’s feeding was started later than ordered, and an LPN administering meds via PEG did not verify tube placement and used a syringe to plunge the final flush instead of gravity. Additional residents had outdated flush bags or did not receive ordered Glucerna when meal intake was below the threshold documented in the order.
Resident areas in the South and North units were not kept clean and in good repair. During an environmental tour with the Maintenance Director, surveyors observed missing toilet paper holders, dirty floor registers and vents, marred and gouged bathroom walls and door frames, a loose pedestal sink, a dusty bathroom ceiling vent, a dirty tube feeding pole with dried feeding on the base, and dried tube feeding spillage on the wall and floor behind the pump. The Maintenance Director stated the observed conditions were in need of cleaning and/or repair.
The facility failed to maintain resident dignity when a resident was observed wearing a hospital gown during the day without a documented preference for it. In addition, swallowing precaution signs and individualized swallowing instructions were posted in two residents’ rooms, including one resident who was cognitively intact for daily decision making. The DON stated the speech therapist likely posted the signs but was not aware they were present.
Failure to timely notify the physician of resident condition changes. One resident with diabetes, hyperlipidemia, and muscle weakness requested cough syrup, but the record did not show an assessment or physician notification until a later note documented cough complaints and a PRN Robitussin order. Another resident with CVA-related hemiplegia, dysphagia, and COPD had a significant respiratory decline with shallow breathing, low BP, and low O2 saturation; the record did not document physician notification when the change occurred, and the resident was later sent to the hospital.
A resident with type 2 DM, HF, bilateral BKA, and moderate cognitive deficits received PRN lorazepam for anxiety on multiple occasions. The behavior care plan called for calm conversation, redirection away from distress, assessment of needs, and documentation of attempted interventions, but no interventions were documented before the medication was administered. The DON confirmed the lack of documented interventions.
A resident with COPD, CHF, and atrial fibrillation, who was cognitively intact, was transferred to the hospital twice after calling 911 for breathing difficulty, pain, and SOB. The record showed no indication that the facility provided the bed-hold policy or State approved transfer form before or upon either transfer, and the DON stated there were no transfer or bed-hold policies provided.
Care plans failed to reflect the current needs and choices of two residents. One resident with hemiplegia, severe cognitive impairment, and dependence for ADLs was observed in a high bed position with legs hanging off the bed, but the care plan did not include the preference for keeping the bed high. Another resident with CHF and CKD had an indwelling urinary catheter, but the record lacked a catheter care plan; the DON confirmed one should have been in place.
Missed care plan conferences and outdated medication care plans. The facility did not consistently invite or hold care planning conferences for residents and/or family members, and several care plans were not updated to match current medication orders. A cognitively intact resident with CHF, CKD, and depression said she was not invited to a care conference, another cognitively intact resident with stroke, HF, anxiety, MDD, psychosis, and dementia did not recall attending one, and the resident’s care plan still listed opioid therapy after Hydrocodone was discontinued. A third resident with functional quadriplegia, cirrhosis, and vascular dementia had a care plan that still included diuretic therapy even though the diuretics had been stopped.
A resident who was cognitively intact and needed set-up help with oral care and partial/moderate assist with personal hygiene did not receive consistent assistance with brushing teeth or washing hair. The resident reported staff did not set her up for oral care and that her hair had not been washed recently, and her hair was observed to be unkempt. Review of records showed multiple bed baths, but hair washing occurred only once during the reviewed period, and a CNA confirmed she did not provide oral care assistance.
The facility failed to assess and monitor a resident’s persistent red, raised neck rash after the resident reported it had been present for about two months and was starting to itch; an RN later observed the area but had not been informed of it during report, and the chart showed no prior documentation of the rash or treatment orders until a later order for triamcinolone ointment. The facility also failed to follow BP parameters for another resident with CHF and CKD when metoprolol was given despite SBP readings below the hold parameter, and midodrine was given despite SBP readings above the hold parameter, with one dose given when no BP was documented.
Incomplete Documentation for Dialysis and Wound Treatments: The facility failed to keep accurate clinical records for a resident receiving dialysis and a resident with multiple wounds. For one resident, TARs showed bruit/thrill checks were documented as completed even though the resident had a perma catheter and said he had never had a fistula. For another resident with paraplegia and severe malnutrition, multiple wound treatments for several body areas were not signed out on the TAR, and the wound nurse said the treatments were done but not documented.
Infection control practices were not followed for two residents. A resident with an indwelling Foley catheter had the drainage bag observed on the floor during multiple checks, and a shared bathroom contained unlabeled wash basins on the floor and a urinal hanging on the grab bar. In addition, an LPN administered PEG tube medications to another resident without donning a gown, despite the DON stating a gown should be worn for PEG tube medication administration.
Nursing staff did not inform a resident with multiple diagnoses about the name or purpose of her prescribed medication during administration on two occasions. The resident struggled to take the medication due to its taste and became upset, but staff only encouraged her to finish it without providing education or explanation, contrary to facility policy and staff expectations.
A resident requiring assistance with ADLs, including bathing, did not receive a bath or shower for multiple consecutive days, as evidenced by observation of poor hygiene and a lack of documented care or refusals, despite a care plan indicating the need for such assistance.
A resident with multiple medical conditions did not receive ordered doses of vancomycin and alprazolam due to missing hospital discharge paperwork, lack of timely verification of medication orders, and absence of a prescription for the antianxiety medication. The MAR reflected several missed administrations, and staff were unable to provide explanations for these omissions.
Two residents with pressure-related skin conditions did not receive ordered care, including off-loading of heels and proper wound dressing. One resident was found with her heels resting on the bed despite an order to off-load, and another was observed without a dressing on a sacral wound and with heels not off-loaded. In both cases, staff did not follow physician orders for pressure ulcer prevention and care.
A resident with pressure ulcers had two active, conflicting physician orders for wound care—one for Aquacel alginate and another for Xerofoam—both of which were documented as completed on the TAR. During wound care, a nurse prepared to use the incorrect treatment before clarifying the current order, but both orders remained in the record, resulting in incomplete and inaccurate clinical documentation.
A wound nurse failed to wear a gown while providing wound care to a resident on Enhanced Barrier Precautions, despite CDC guidance requiring both gown and gloves for such high-contact care activities. The resident had multiple medical conditions and required significant assistance, and the facility's infection prevention nurse indicated their policy allowed discretion in applying EBP, which did not align with current CDC recommendations.
The facility's main kitchen was found to have unsanitary conditions, including dried food spillage on storage bins, improper placement of scoops directly on food, and a bag of thawed chicken in the refrigerator that was not dated. These issues were observed during a kitchen sanitation tour with the Dietary Food Manager.
The facility's kitchen was found to be unsanitary during inspections, with dirty floor tiles, dried food spillage, and dust accumulation on pipes. The Dietary Food Manager acknowledged the need for cleaning.
The facility failed to label and store medications properly, with unlabeled acetaminophen found in a medication cart and a medication room. Staff identified these as house medications, which were later confirmed by a nurse consultant to be inappropriate.
The facility did not follow the prescribed menu for residents on pureed diets. Instead of serving pureed beef tips with mushrooms over parsley noodles, residents were given pureed ham, peas, mashed potatoes and gravy, and bread. The Dietary Food Manager confirmed the error, noting that the cook usually prepared a special meal for these residents, leading to the menu deviation.
A resident with cognitive impairment and mobility issues had their call light consistently placed out of reach, contrary to their care plan. Observations confirmed the call light was clipped above the bed, making it inaccessible. Staff interviews and the Interim Administrator acknowledged the oversight.
The facility failed to hold care plan meetings and invite families for two residents. One resident, who was cognitively intact, was not informed about his care plan meetings, and his daughter was not contacted. Another resident, who was cognitively impaired, was also not invited to his care plan meetings. The Social Service Director confirmed there was no documentation of attempts to reach out to the residents or their families.
The facility failed to provide timely assistance with ADLs for two residents who required meal assistance, leaving them without help for over 10 minutes. Additionally, a resident with hemiplegia and visual impairment was not shaved regularly despite her request, as observed on multiple occasions. The Interim Administrator acknowledged these deficiencies.
A facility failed to provide a personalized activity program for a cognitively impaired resident in isolation. Observations showed the resident was often awake and restless, with her television off, despite her care plan indicating she benefited from activities and one-to-one visits. The Activity Director noted staffing shortages affected the frequency of visits, leading to a deficiency in meeting the resident's needs.
The facility failed to administer insulin as ordered for two residents, leading to deficiencies in medication management. A resident with dementia and diabetes did not receive her prescribed insulin on multiple occasions, and it was administered when her blood sugar levels were below specified parameters. Another resident on anticoagulant therapy was observed with a discoloration on the wrist, which was not assessed or monitored. Additionally, a resident reported late insulin administration, confirmed by the Medication Administration Record.
A resident with hemiplegia, dementia, and Stage 4 pressure ulcers did not receive necessary pressure ulcer care as prescribed. Observations showed her pressure-reducing heel boots were not used while in bed, and her feet rested directly on the mattress, contrary to physician's orders. The Treatment Administration Record inaccurately indicated that interventions were completed, and the Wound Nurse confirmed the care was not provided as documented.
A facility failed to administer oxygen at the prescribed flow rate for a resident with COPD and other health conditions. Observations showed the flow rate was below the required 3 liters per minute, despite documentation indicating it was given correctly. The Interim DON acknowledged the issue without further information.
A facility failed to complete a post-dialysis assessment for a resident requiring dialysis services. The resident, with conditions including kidney disease and hemiplegia, had a care plan that included monitoring the dialysis access site. However, post-dialysis communication forms were not consistently filled out, and vital signs were not documented as required by the facility's policy.
A resident in prolonged isolation due to Candida auris did not receive ongoing psychosocial visits, despite being at risk for mood changes due to anxiety. The resident, with multiple health conditions, expressed distress over the isolation. The facility's Social Service Director acknowledged the lack of regular psychosocial checks, contributing to the deficiency.
A facility failed to implement proper infection control guidelines, leading to improper PPE use and staff confusion about a resident's isolation status. The resident, with multiple health conditions including Candida auris, was incorrectly placed under droplet precautions. Additionally, an antiseptic bath ordered for the resident was not administered or documented on one occasion.
The facility failed to implement gradual dose reductions (GDR) for psychotropic medications for two residents. One resident continued to receive a higher dose of Seroquel despite a GDR order, and another resident continued to receive a higher dose of Ativan despite a GDR recommendation. There was no documentation of physician declination for the GDRs, and the Nurse Consultant confirmed the medications were not reduced as ordered.
The facility did not have an RN on duty for 8 consecutive hours on one day, as required. This was discovered during a review of staffing schedules, and the Interim Administrator confirmed the absence of RN coverage, which could have impacted all 67 residents.
Two residents with non-pressure related skin conditions were not properly assessed or monitored. One resident had a bruise on their hand while on anticoagulant therapy, with no documentation or monitoring orders. Another resident had multiple bruises and a scab, but no documentation or monitoring orders were in place. The DON was unaware or mistakenly believed monitoring orders were entered.
A resident with a history of stroke-related hemiplegia and cognitive impairment was observed multiple times with their bed not in a low position, despite being at risk for falls. The care plan required the bed to be kept low, but this was not adhered to, as confirmed by the DON, who noted the resident's preference against it.
Failure to Address ROM Loss in Resident With Post-Stroke Hemiplegia
Penalty
Summary
The facility failed to provide therapy or treatment for a resident with post-stroke hemiplegia, resulting in a loss of range of motion to the affected left hand. During multiple observations, the resident’s left hand remained in a fist position, the knuckles on the left hand appeared larger than on the right, and no visible intervention was observed for the left hand. During a care observation, the resident had minimal movement of the left arm, the left hand remained in a fist, and CNA 2 stated the resident did not really move the left hand or use the left arm. The resident’s record showed diagnoses including left-sided hemiplegia after a stroke and dementia, with the MDS indicating the resident was not cognitively intact and dependent in ADLs. The care plan identified stroke-related goals including being free from complications such as contractures and maintaining status within neurological limitations, with interventions to observe and report changes and to have PT and OT evaluate and treat as ordered. An OT evaluation noted the resident was totally dependent in ADLs and transfers, and a later rehabilitation screening stated the resident was not appropriate for skilled therapy at that time without including the hemiplegia or a ROM assessment. The DON stated she did not know if any interventions were in place for the resident’s hand, and OT later found mild hypertonicity in four fingers and recommended therapy to trial a splint/palm guard.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen during an initial kitchen tour with the Head Cook. In the portable walk-in refrigerator, two loose containers of beef broth were stored on the floor, along with a box of tortilla shells and two other food boxes placed on the floor. A bag of biscuits was open to air and discolored on the tops. In the portable walk-in freezer, there were no shelves and all food boxes were stacked in 22 stacks on the floor. The dishwasher also had a heavy buildup of crumbs and debris. During the interview, the Head Cook stated that food was not supposed to be stored on the floor, the biscuits should be thrown away, and the dishwasher needed cleaning.
Inaccurate MDS Coding for Hospice, Diet, and Medications
Penalty
Summary
The facility failed to ensure the comprehensive MDS assessments were accurate for 4 of 19 residents reviewed, with errors related to hospice services, diet, and medications. Resident 3 had diagnoses including dysphagia, Alzheimer's disease, heart failure, dementia, chronic kidney disease, stroke, a PEG tube for nutrition, and anxiety disorder. Records showed a physician order to admit the resident to hospice services and a hospice admission document confirming hospice admission, but the Significant Change MDS dated 12/8/25 did not check hospice services while the resident was receiving hospice care. The MDS Coordinator stated hospice services should have been checked. Resident 18 had diagnoses including heart failure, end stage renal disease, dialysis, heart disease, anemia, and anxiety. The Quarterly MDS dated 11/16/25 indicated the resident was cognitively intact and not on a therapeutic diet, but a physician readmission order dated 12/9/25 specified a regular diet with multiple restrictions, including no oranges, orange juice, bananas, potatoes, tomatoes, salt packets, or diet condiments. Resident 11's Annual MDS dated 1/23/26 indicated the resident received an anti-anxiety medication in the last seven days, even though a physician order dated 1/14/26 discontinued Buspirone 10 mg twice daily. Resident 2's Annual MDS dated 12/5/25 did not indicate opioid use despite a physician order for hydrocodone-acetaminophen 5/325 mg every eight hours for pain. The MDS Coordinator stated the anti-anxiety medication was coded inaccurately and that she would correct the discrepancies.
Elopement Device Not Function-Checked and Hot Water Temperatures Exceeded Safe Levels
Penalty
Summary
The facility failed to ensure a resident at risk for elopement had a wander guard pendant checked for function at least daily. Resident 9 had diagnoses including intracranial loss of consciousness, fracture of the occipital lobe, altered mental status, mental disorder, obsessive compulsive disorder, high blood pressure, major depressive disorder, and a history of falls. The physician’s order directed that the wander guard be placed on the right ankle for exit-seeking behaviors and checked for placement every shift, and the care plan identified the resident as at risk for elopement with a history of attempts to leave the facility unattended. Although the resident was observed with the wander guard in place, there was no documentation in the clinical record showing the device’s function was checked daily. Staff interviews showed the wander guard was only visually checked for placement by looking at the resident’s ankle, and the LPN did not use a device to verify function. The Maintenance Director stated he only checked the device before placement and did not check it once it was on the resident. The LPN later found the testing device in the medication cart with a dead battery, replaced the battery, and confirmed the wander guard lit up when tested. The DON stated the facility had no policy for checking function and later provided manufacturer guidelines indicating transmitters should be tested prior to use and on a regular basis. On the North Unit, hot water temperatures in resident room bathrooms were found above safe levels during observations. One room’s water was too hot to hold a hand under, and other rooms registered 130, 125, and 124 degrees Fahrenheit before later rechecks showed lower temperatures. The Maintenance Director stated the boiler had been set at 130 degrees Fahrenheit and that he planned to lower it to 120 degrees Fahrenheit after a recent circulating pump issue had made the water too cold. The bathrooms were shared by multiple residents in the affected rooms.
Enteral Feeding Orders Not Followed and PEG Tube Care Not Performed as Ordered
Penalty
Summary
Enteral feedings were not consistently administered as ordered for multiple residents with feeding tubes. Resident 3, who had dysphagia, Alzheimer’s disease, chronic kidney disease, stroke, and a PEG tube, was observed on several occasions with tube feeding infusing at 60 cc per hour, and a water flush bag hanging without a date or label. The physician’s order required Jevity 1.2 at 60 cc per hour for 20 hours with 125 cc water flushes every six hours, and the care plan identified the resident as dependent for tube feeding and water flushes. The DON stated the feeding should be infusing according to the physician’s order and that water bags should be changed every 24 hours and dated and labeled when hung. Resident 74, who had paraplegia, severe calorie protein malnutrition, dysphagia, and a PEG tube, was observed with enteral feeding infusing and a water flush bag that was not labeled or dated. The physician’s order required Glucerna 1.2 at 45 cc per hour for 24 hours via pump with 145 cc water flushes every four hours. The DON stated the water bag should be labeled and dated when hung and changed every 24 hours. Resident 76, who had muscular dystrophy, functional quadriplegia, and a gastrostomy tube, reported that the tube feeding ordered for 12 hours daily had not been started until 10:00 p.m. the previous night instead of the ordered 6:00 p.m. start time. During medication administration via PEG tube for Resident 76, an LPN crushed medications, diluted them with water, instilled an air bolus, did not verify tube placement by checking residual, and used a syringe to plunge the last of the water flush instead of giving it by gravity. The DON stated PEG placement should be verified before medications are administered and flushes should be given by gravity. Resident 15 also had a water flush bag hanging that was dated two days earlier, and Resident 33, who had hemiplegia following a stroke, dysphagia, severe cognitive impairment, and dependence in ADLs, did not receive ordered Glucerna tube feedings when meal intake was documented below 50% on multiple occasions. The nurse stated she had not given the tube feeding because she worked day shift and believed it was only to be given at 6:00 p.m., while the DON stated the resident should receive one can of Glucerna for each meal time when intake was less than 50%.
Resident Areas Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to keep resident areas clean and in good repair in the South and North units. During an environmental tour with the Maintenance Director, multiple rooms were observed with missing toilet paper holders in bathrooms, dirty floor registers and vents, marred bathroom walls, gouged bathroom door frames, dirty ceiling vents, and dirty tube feeding poles. In the South Unit, one room had a floor register with a dried substance and no toilet paper holder in the bathroom, another room had a floor vent with dried substance, another bathroom had no toilet paper holder, and another room had a dirty wall by the floor register, a dirty floor register, and marred bathroom walls. In the North Unit, one room had a dirty floor behind the bed, a baseboard pulling away from the wall, and a dusty bathroom ceiling vent; another room had a gouged bathroom door frame; another room had no toilet paper holder, a loose pedestal sink pulling away from the wall, marred bathroom walls, and a dirty tube feeding pole with dried feeding on the base and dried tube feeding spillage on the wall and floor behind the pump; and another room had gouged and marred bathroom walls and door frame. During interview, the Maintenance Director stated that all of the observed conditions were in need of cleaning and/or repair.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity by allowing Resident 15 to wear a hospital gown during the day. Resident 15 had diagnoses including left-sided hemiplegia after a stroke and dementia, and the End of PPS Part A Stay MDS dated 10/26/25 indicated the resident was not cognitively intact and was dependent in ADLs. During observations on 2/5/26, 2/9/26, and 2/9/26, the resident was seen wearing a hospital gown during daytime hours, and the care plan did not indicate a preference for wearing a hospital gown. When the DON was informed of the finding, no additional information was offered. The facility also posted swallowing-related signs in residents’ rooms. For Resident 33, a sign above the bed stated, “PATIENT IS A SILENT ASPIRATOR,” and the resident’s record showed diagnoses including hemiplegia following a stroke and a Quarterly MDS dated 1/22/26 indicating severe cognitive impairment and dependence in ADLs. For Resident 42, a sign stating she was a silent aspirator and a page of individualized swallowing instructions were posted on the wall next to the bed; the resident had dysphagia and the Quarterly MDS dated 12/17/25 indicated she was cognitively intact for daily decision making. The DON stated the speech therapist must have put up the signs in the residents’ rooms, but she was not aware they were there.
Failure to Timely Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to provide timely notification to the physician regarding a resident’s complaint of cough. Resident 63, who was cognitively intact and had diagnoses including diabetes mellitus, hyperlipidemia, and muscle weakness, requested cough syrup on 1/26/26. The note documented that the resident did not have an order for cough syrup and that the writer would contact the physician if the resident was having a cough or congestion, but there was no indication that the resident was assessed for a cough or that the physician was notified at that time. A later health status note on 2/9/26 documented that the resident complained of a cough, was assessed, the physician was notified, and an order for Robitussin as needed was received. The facility also failed to document physician notification for a change in respiratory status for Resident 15. The resident had diagnoses including left-sided hemiplegia after a stroke, dysphagia, and COPD, and was dependent in ADLs and not cognitively intact. A progress note on 12/13/25 documented that the resident was not responding to verbal stimuli, had shallow breathing, a blood pressure of 75/66, and oxygen saturation of 85%; oxygen was started at 5 lpm by nasal cannula and the resident was monitored, but the record lacked documentation that the physician was informed of the change in status. Later notes showed the resident remained unstable, and on 12/14/25 at 6:00 a.m. the resident was not responding to verbal or tactile stimuli, had oxygen saturation of 83% on 5 lpm oxygen, and an ambulance was called to send the resident to the hospital.
PRN Anti-Anxiety Medication Given Without Documented Interventions
Penalty
Summary
The facility failed to ensure interventions were attempted before administering PRN lorazepam for anxiety to one resident. The resident had diagnoses including type 2 diabetes, heart failure, and bilateral below-the-knee amputations, and the annual MDS indicated moderate cognitive deficits. A physician’s order dated 1/20/26 authorized lorazepam 0.5 mg every 12 hours as needed for anxiety for 14 days. The resident’s behavior care plan, revised on 7/29/25, identified behaviors of yelling, exit seeking, and aggression and listed interventions such as engaging calmly in conversation, guiding the resident away from the source of distress, assessing for needs, and documenting attempted interventions. The January 2026 MAR showed the resident received lorazepam on 1/22, 1/24, and 1/29/26, and no interventions were documented before the medication was given. During interview, the DON confirmed there were no documented interventions prior to administration.
Failure to Provide Bed-Hold and Transfer Documentation
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s responsible party were provided the facility’s bed-hold policy and the State approved transfer form before and upon transfer to the hospital for two hospital transfers on the same day. The resident had diagnoses including COPD, CHF, and atrial fibrillation, and the admission MDS dated 11/26/25 indicated the resident was cognitively intact. A health status note at 3:59 a.m. on 12/3/25 documented that the resident called 911 for difficulty breathing, EMS arrived, and the resident was transported to the hospital, then returned later that morning with no new orders. A second health status note at 3:45 p.m. on 12/3/25 documented that the resident again called 911 complaining of pain and shortness of breath, EMS arrived, and the resident was transported to the hospital and admitted. The record contained no indication that the bed-hold policy or State approved transfer form had been provided for either transfer, and the DON stated during interview that there were no transfer or bed-hold policies provided.
Care plans did not reflect resident bed-position preference or indwelling catheter care
Penalty
Summary
The facility failed to ensure the care plan reflected a resident’s current care needs and choices related to keeping the bed in a high position for a resident with hemiplegia following a stroke, severe cognitive impairment, and dependence in activities of daily living and transfers. During observation, the resident was found lying diagonally in bed with both legs hanging off the side and stated she was unable to move her legs back into the bed, while the bed was in a high position. Additional observations on multiple later dates showed the resident lying in bed with the bed still in a high position. The resident’s care plan addressed a prior fall risk and included interventions to anticipate and meet needs and keep the call light in reach, but it did not include the resident’s preference for keeping the bed in a high position. The DON stated the bed was kept high due to the resident’s preference, but there was no care plan for it. The facility also failed to develop a care plan for a resident with an indwelling urinary catheter. The resident had diagnoses including CHF and chronic kidney disease, and a progress note documented that an indwelling urinary catheter was inserted. During observation, a urine collection bag was hanging from the bedframe, and the resident stated he had an indwelling urinary catheter. The record lacked a care plan related to the catheter, and the DON acknowledged that a care plan should have been in place for the resident related to the indwelling urinary catheter.
Missed care plan conferences and outdated medication care plans
Penalty
Summary
The facility failed to invite and hold care planning conferences for residents and/or their family members, and it also failed to update care plans related to medications for 3 of 19 residents reviewed. Resident 6, who was cognitively intact for daily decision making and had diagnoses including heart failure, heart disease, chronic kidney disease, and depression, stated during interview that she had not been invited to a care conference. Her record showed only one psychosocial note indicating the IDT met with her for a quarterly care plan meeting, with no other care plan meetings documented in the clinical record. Resident 11, who was cognitively intact for daily decision making and had diagnoses including stroke, heart failure, anxiety, major depressive disorder, psychosis, and dementia without behaviors, did not recall attending a care plan meeting. Psychosocial progress notes showed quarterly care plan conferences on three dates, but there were no documented conferences between two of those meetings. The resident’s care plan, last revised on 11/10/25, still listed opioid pain therapy even though a physician order dated 1/14/26 discontinued Hydrocodone. Resident 13, with diagnoses including functional quadriplegia, cirrhosis of the liver, and vascular dementia, had a care plan dated 11/7/25 that still identified diuretic therapy even though the medication list no longer included any diuretics and RN 2 stated the physician had discontinued them.
Failure to Provide ADL Assistance for Oral Care and Hair Washing
Penalty
Summary
The facility failed to ensure a resident who needed assistance with ADLs received help with oral care and washing of hair. Resident 6 was cognitively intact and had diagnoses including heart failure, heart disease, chronic kidney disease, and depression. The resident’s MDS indicated she needed set up assistance with oral care and partial/moderate assistance with personal hygiene, and the care plan stated she needed assistance with ADLs and should be encouraged to participate as tolerated. During interviews, the resident stated staff did not set her up to brush her teeth, did not provide oral care, and her hair had not been washed recently; her hair was observed to be unkempt. Review of shower sheets showed the resident received multiple bed baths, but her hair was only washed once during the reviewed period. CNA 1 later stated she provided morning care but did not set the resident up to brush her teeth or assist with oral care.
Failure to Assess Skin Rash and Follow Blood Pressure Medication Orders
Penalty
Summary
The facility failed to ensure a skin rash was assessed and monitored for a resident with a red, raised area on the left side of the neck. The resident stated the area had been present for about two months, had been reported to nursing staff and dialysis nurses, and was starting to itch. When the area was observed, an RN noted the red and raised area, but she stated she had not been informed of the skin condition during report and was unaware of it. The resident’s record showed diagnoses including heart failure, end stage renal disease, dialysis, heart disease, anemia, and anxiety, and the weekly skin assessments documented intact skin with no notation of redness to the neck area. There were no physician orders for treatment to the neck area until an order was written for triamcinolone ointment after the condition was observed.
Incomplete Documentation for Dialysis and Wound Treatments
Penalty
Summary
The facility failed to ensure clinical records were complete and accurately documented for a resident receiving dialysis and for a resident with multiple pressure ulcers. For Resident 18, who had diagnoses including heart failure, end stage renal disease, dialysis, heart disease, anemia, and anxiety, the record showed physician orders to assess bruit/thrill after dialysis on Monday, Wednesday, and Friday evenings. The TARs for July through December 2025 and for January and February 2026 indicated those assessments were signed out as completed, yet during observation the resident had a perma catheter in the upper chest and stated he had never had a fistula and was going to have one later. RN 1 indicated she was unsure whether the resident had a fistula but knew he had a perma catheter, and the DON stated the dialysis orders were batch orders from the physician. For Resident 74, who had diagnoses including paraplegia, severe calorie protein malnutrition, and neuromuscular dysfunction of the bladder, the TAR for February 2026 showed multiple ordered wound treatments were not signed out as completed on 2/2/26 and 2/3/26. The missed documentation included treatments for bilateral heels and the lateral right big toe, the left heel and left pinky toe, the left outer ankle blister, the left thigh and leg, the right middle back, the right thigh, and the sacrum/coccyx. The wound physician assessed the resident on 2/3/26, and the wound nurse stated she completed the treatments on the days she worked, including Mondays, Wednesdays, Fridays, and Tuesdays when the wound physician made rounds, but she did not sign them out. The DON had no additional information to provide.
Infection Control Practices Not Followed
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented during observations involving Residents 74 and 76. Resident 74, who had diagnoses including paraplegia and neuromuscular dysfunction of the bladder, had an indwelling Foley catheter ordered for straight drainage with a 16 French catheter and 10 cc bulb. During three random observations, the resident’s Foley catheter bag was seen on the floor. The DON stated the Foley catheter bag should not have been on the floor, and the facility’s Indwelling Urinary Catheter Foley Management policy indicated the bag should not be rested on the floor. In a shared bathroom in room [ROOM NUMBER], two pink wash basins were observed on the floor and a urinal was hanging on the grab bar; none of the items were labeled or contained in a bag, and three residents shared the bathroom. During medication administration for Resident 76, an LPN prepared medications to be given via the resident’s PEG tube, washed hands, donned gloves, and administered the medications without donning a gown. The DON stated a gown should be worn when administering medications via a PEG tube, and the facility’s Keeping a Resident's Room in Order policy indicated bedpans and urinals must be covered with a plastic bag and marked with the resident’s name.
Failure to Inform Resident About Medication During Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed about her medication during administration. On two separate occasions, nursing staff prepared and administered the powdered medication Lokelma to a resident with diagnoses including high blood pressure, diabetes, and Bell's palsy. During both medication passes, the staff did not inform the resident about the name or purpose of the medication. The resident expressed difficulty consuming the medication due to its taste, gagged, and became visibly upset, but was only encouraged to finish the dose without any explanation or education provided. Record review showed that the resident was moderately impaired for daily decision making, and a physician's order was in place for daily Lokelma administration for high potassium. Interviews with staff confirmed that the expectation was for nurses and medication aides to inform residents about their medications prior to administration. The facility's medication administration policy also required staff to provide residents with information about the drugs they were receiving.
Failure to Provide Bathing Assistance for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including heart failure, kidney disease, anxiety, and diabetes, who was assessed as moderately impaired in daily decision-making and requiring assistance with activities of daily living (ADLs), did not receive proper assistance with bathing. Observation revealed the resident had greasy hair, and a review of shower records showed the resident had not received a bath or shower over a nine-day period, with no documented refusals for those dates. The care plan indicated the need for assistance with ADLs, but there was a lack of documentation and provision of bathing care as required.
Failure to Administer Antibiotic and Antianxiety Medications as Ordered
Penalty
Summary
A resident with diagnoses including paraplegia, osteomyelitis, anxiety, hypertension, muscle weakness, and ulcerative colitis was admitted to the facility and had physician orders for both an antibiotic (vancomycin) and an antianxiety medication (alprazolam). The Medication Administration Record (MAR) showed that vancomycin was not signed out as administered for four consecutive doses, and alprazolam was not signed out as given on multiple dates. The resident was cognitively intact and had reported to staff that she was supposed to be on antibiotics. The Assistant Director of Nursing (ADON) indicated that the facility did not receive the After Visit Summary (AVS) from the hospital at admission, which resulted in missing information about the vancomycin order. Despite attempts to obtain the AVS and follow up with the hospital, the facility did not verify the antibiotic order with the physician in a timely manner, leading to missed doses. Additionally, the pharmacy did not fill the alprazolam prescription because they never received a prescription, and nursing staff could not provide an explanation for the missed administration of the antianxiety medication.
Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents with pressure-related skin conditions. For one resident, observations revealed that her heels were not off-loaded as ordered while she was in bed, despite having wounds on her left foot. The wound nurse confirmed there was no current order for off-loading boots and stated she would contact the physician to obtain one. The resident's medical record indicated she was cognitively impaired, dependent for all activities of daily living, and at risk for developing pressure ulcers. A physician's order was in place to off-load heels while in bed and confirm every shift, but this was not followed. Another resident was observed without a dressing covering her sacral wound, which was open to air, and her heels were also not off-loaded as ordered. The wound nurse acknowledged the missing dressing and immediately applied one. During a subsequent wound treatment, the nurse failed to wear a gown despite the resident being on Enhanced Barrier Precautions, only realizing the omission after being prompted. The resident's record showed severe cognitive impairment, lower extremity impairment, and dependence on staff for care. Physician's orders required off-loading of heels and specific wound care, but these were not consistently implemented.
Conflicting Wound Care Orders and Incomplete Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with pressure ulcers, resulting in conflicting physician orders for wound treatment. During a wound care observation, a nurse prepared to apply Aquacel alginate to the wound bed, despite the current physician's order specifying the use of Xerofoam. The nurse stated she had confirmed with the physician that the Xerofoam order was correct and would remove the Aquacel order to prevent further confusion. However, both treatment orders remained active in the resident's record, and both were documented as completed on the Treatment Administration Record (TAR) on different dates. The resident involved had diagnoses including anemia, dysphagia, and high blood pressure, and was assessed as moderately impaired for daily decision-making, requiring dependent care for several activities of daily living. The care plan indicated the presence of pressure ulcers and directed staff to administer treatments as ordered. Despite this, the presence of two active, conflicting wound care orders led to inconsistent documentation and treatment practices, as evidenced by the TAR and direct observation.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a wound nurse failed to use the required personal protective equipment (PPE) while providing wound care to a resident who was under Enhanced Barrier Precautions (EBP). During the observed wound treatment, the nurse performed hand hygiene and donned gloves but did not wear a gown, despite an EBP sign being posted on the resident's door. The nurse acknowledged forgetting to put on the gown when questioned. The resident was in bed, covered with blankets, and was observed to be cold and crying at the time of care. The wound care involved opening the resident's brief, placing a new pad, and preparing a collagen dressing for application. The resident had significant medical conditions, including hemiplegia, dementia, and was at risk for pressure ulcers, requiring substantial assistance with daily activities and being dependent for toileting and lower body care. The facility's infection prevention nurse indicated that their policy allowed discretion regarding EBP, stating that if a wound could be covered and was not draining, EBP might not be necessary. However, current CDC guidance requires both gown and gloves for high-contact care activities, such as wound care, under EBP. The failure to follow these guidelines led to the cited deficiency.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as observed during a kitchen sanitation tour. There was an accumulation of dried food spillage on the outside and lids of the flour, sugar, and rice bins. Additionally, plastic scoops were found inside the flour and rice bins, positioned directly on the food, which is not in accordance with sanitary food handling practices. Furthermore, a bag of thawed chicken was found in a plastic bin in the walk-in refrigerator, which was twisted closed but not dated, indicating a lack of proper labeling and tracking of food items. These observations were made in the presence of the Dietary Food Manager, who acknowledged the issues.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen area in a functional and sanitary manner, as observed during two separate kitchen sanitation tours. On the first tour, the floor tile throughout the kitchen was found to have an accumulation of dirt and debris along the baseboards, with discolored and dirty grout. Additionally, there was dried spillage on top of and in front of the dishwasher, and an accumulation of dust on the metal pipes above it. During the second tour, dried liquid spillage was observed on the wall beneath the coffee and juice machines, and dried food spillage was found on the PVC pipes under the three-compartment sink. In both instances, the Dietary Food Manager acknowledged the need for cleaning.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store medications in accordance with accepted professional principles. During an observation of the north medication cart, two bottles of acetaminophen were found unlabeled in the top drawer. A Qualified Medication Aide (QMA) indicated these were house medications. Similarly, in the south medication room, a box of Benadryl and two bottles of acetaminophen were found without labels in the top left cabinets. A Licensed Practical Nurse (LPN) also identified these as house medications. The nurse consultant later confirmed that house medications should not be present and indicated that these medications had been removed.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets, which was identified through observation, record review, and interview. On October 3, 2024, it was observed that residents receiving a pureed diet were served pureed ham, peas, mashed potatoes and gravy, and bread, instead of the scheduled pureed beef tips with mushrooms over parsley noodles. This discrepancy was confirmed during an interview with the Dietary Food Manager, who acknowledged that the residents should have been served pureed beef tips as per the menu. The manager noted that the cook typically prepared a special meal for residents on pureed diets, which led to the deviation from the planned menu.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within reach, which is a deficiency in accommodating the needs of the resident. Observations on multiple occasions revealed that the call light was clipped to the cord above the head of the resident's bed, making it inaccessible. The resident, who was diagnosed with hemiplegia/hemiparesis following a stroke, dementia, and a history of falling, was cognitively impaired and required substantial to maximum assistance for mobility. Despite these needs, the call light was consistently out of reach, contrary to the care plan intervention that specified it should be within reach. Interviews with staff confirmed the oversight, and the Interim Administrator acknowledged that the call light should have been accessible to the resident.
Failure to Conduct and Communicate Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held and that families were invited to attend these meetings for two residents. Resident 35, who was cognitively intact, was not informed about his care plan meetings, and his daughter was not contacted by the staff as promised. Despite the resident's multiple diagnoses, including retention of urine, insomnia, chronic obstructive pulmonary disease, heart failure, gout, and type 2 diabetes mellitus, there was no documentation of any attempt to reach out to the resident or his family regarding the missed care plan meetings. Similarly, Resident 37, who was cognitively impaired, reported not being invited to his care plan meetings. The resident's diagnoses included psychotic disturbance, mood disturbance, anxiety, and atherosclerotic heart disease. The Social Service Director confirmed the lack of documentation showing any effort to contact the resident or his family about the care plan meetings. This oversight affected the facility's compliance with the requirement to develop and review care plans with the involvement of residents and their families.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for residents who were dependent on staff for meal assistance. Resident 28, diagnosed with dementia and diabetes, was observed seated in a broda chair with her lunch tray placed in front of her at 12:02 p.m., but she was not assisted with her meal until 12:15 p.m. Her care plan indicated she required supervision or touching assistance with eating due to cognitive impairment. Similarly, Resident 29, who had Alzheimer's, dementia, dysphagia, and severe protein calorie malnutrition, was left without assistance from 12:02 p.m. until 12:13 p.m. Her care plan required extensive assistance from staff for eating due to her cognitive impairment and dependency. Additionally, the facility did not adequately address the personal hygiene needs of Resident 27, who was observed with facial hair on her chin and above her lip on multiple occasions. Despite her expressed desire to be shaved, records indicated that her facial hair was not trimmed or shaved on scheduled bath days, and there was no shower sheet available for one of the dates. Resident 27 had multiple diagnoses, including hemiplegia, asthma, diabetes, and impaired visual function, which required assistance with personal hygiene. The Interim Administrator acknowledged that the resident should have been shaved at least weekly.
Failure to Provide Personalized Activity Program for Resident in Isolation
Penalty
Summary
The facility failed to provide a personalized activity program for a cognitively impaired and dependent resident, identified as Resident C, who was in isolation. Observations over several days revealed that Resident C was often awake and attempting to lift her head and feet off the mattress, with her television turned off. Despite her diagnoses, which included Alzheimer's disease, dementia with agitation, cognitive communication deficit, and delusional disorder, the resident's care plan indicated she benefited from small group activities and one-to-one visits. However, the September 2024 One to One Visit Log showed that her last one-to-one visit was on 9/20/24, consisting only of a hand massage. Interviews and record reviews indicated that the resident had expressed interest in listening to music and watching sports, such as baseball and football, but these preferences were not consistently met. The Activity Director acknowledged that the resident liked to watch television and should have had it turned on, but due to staffing shortages, one-to-one visits were not being completed as frequently as needed. This lack of personalized activity programming and stimulation for Resident C, especially while in isolation, contributed to the deficiency identified by the surveyors.
Insulin Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer insulin as ordered for two residents, leading to deficiencies in medication management. Resident 28, who has dementia and diabetes, did not receive her prescribed Lispro and Glargine insulin on multiple occasions in September 2024. The insulin was also administered when her blood sugar levels were below the specified parameters, contrary to the physician's orders. The Interim Administrator acknowledged that the insulin should have been administered as ordered. Resident 35, who is on anticoagulant therapy with Eliquis and Plavix, was observed with a discoloration on the right wrist, which was not assessed or monitored as required. Despite the care plan's directive to monitor for side effects of anticoagulant therapy, there was no documentation of a skin assessment for the discoloration. The MDS Coordinator confirmed the absence of a monitoring order for the discoloration. Resident 219, who has diabetes and uses insulin, reported that her insulin was administered late on several occasions. The Medication Administration Record confirmed that insulin was given late on 9/29/24, with delays of up to two hours. The Interim Administrator admitted that the insulin was not administered within the correct parameters, indicating a lapse in timely medication administration for this resident.
Failure to Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for a resident with a history of hemiplegia/hemiparesis following a stroke, dementia, and pressure ulcers on both heels. Observations on multiple occasions revealed that the resident's pressure-reducing heel boots were not in use while she was in bed, and her feet were resting directly on the mattress, contrary to the physician's orders for offloading and the use of Prevalon boots every shift. The resident was cognitively impaired and required substantial to maximum assistance for mobility, which further necessitated adherence to the prescribed interventions to prevent further deterioration of her condition. The resident's care plan and physician's orders clearly indicated the need for offloading her heels and using pressure-reducing boots to manage her Stage 4 pressure ulcers. However, the Treatment Administration Record for October 2024 inaccurately reflected that these interventions were completed, despite evidence to the contrary. During an interview, the Wound Nurse confirmed that the heel boots should have been applied, or at least the resident's heels should have been offloaded, and acknowledged that the documentation should not have been signed off if the care was not provided.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate as prescribed. Observations on multiple occasions revealed that the resident's oxygen flow rate was set below the prescribed 3 liters per minute. Specifically, on several dates, the flow rate was observed to be under 3 liters, including a specific instance where it was at 2.5 liters. The resident, who has a medical history including hemiplegia, COPD, and heart failure, requires continuous supplemental oxygen at 3 liters per minute as per the care plan and physician's order. Despite this, the Medication Administration Record indicated that oxygen was documented as being administered at the correct rate of 3 liters every shift, which was inconsistent with the observed flow rates. The Interim Director of Nursing acknowledged the concern but did not provide additional information.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident who required dialysis services. Resident 217, who had diagnoses including kidney disease, hemiplegia, hypertension, and anemia, was dependent on renal dialysis and had an arteriovenous fistula for dialysis access. The resident's care plan included interventions such as observing for bleeding at the dialysis access site and assessing the shunt site for bruit and thrill. However, the facility did not consistently fill out the post-dialysis communication forms on several occasions, specifically on 10/4/24, 9/30/24, and 9/25/24, and the form for 9/23/24 was missing. Interviews with LPN 1 revealed that vital signs and assessments of the bruit/thrill were supposed to be documented on the pre/post dialysis communication sheet. However, the Nurse Consultant confirmed that the post-dialysis communication sheet was not filled out consistently. The facility's policy required obtaining vital signs upon the resident's return from dialysis and completing the Pre/Post Dialysis Communication Form, which was not adhered to in this case.
Failure to Provide Psychosocial Support for Isolated Resident
Penalty
Summary
The facility failed to provide ongoing psychosocial visits for a resident who was in indefinite isolation. Resident 21, who was observed to be tearful and expressing distress about her prolonged isolation, was diagnosed with multiple conditions including hemiplegia, candidiasis, hyperlipidemia, anxiety, depression, heart failure, diabetes, and COPD. Her care plan indicated a risk for mood changes due to anxiety, and she had expressed preferences for leisure activities such as bingo, arts and crafts, listening to music, and going outside. Despite these needs, the facility did not ensure regular psychosocial support during her isolation period. The resident was placed in contact isolation due to a wound and Candida auris, with a physician's order for enhanced barrier precautions. Although there were some psychosocial notes indicating interactions with psych services and the interdisciplinary team, there was a lack of consistent psychosocial visits. The Social Service Director admitted to not conducting regular psychosocial checks for residents in prolonged isolation, which contributed to the deficiency in care for Resident 21.
Infection Control Deficiency Due to Improper PPE Use and Missed Antiseptic Bath
Penalty
Summary
The facility failed to implement proper infection control guidelines, as evidenced by the improper use of personal protective equipment (PPE) and a lack of staff awareness regarding the reasons for a resident's isolation. Observations revealed that staff and family members were using PPE inconsistently and without understanding the specific precautions required for the resident's condition. Interviews with various staff members, including an LPN, QMA, and CNAs, indicated confusion about the resident's isolation status, with some staff incorrectly attributing the droplet precautions to a condition the resident did not have. The MDS Coordinator clarified that the resident was only under contact and enhanced barrier precautions for Candida auris, not droplet precautions. Additionally, the facility failed to administer an antiseptic bath as ordered for the resident. The resident, who had multiple diagnoses including hemiplegia, candidiasis, and COPD, was supposed to receive a Chlorhexidine Gluconate body wash every evening shift for seven days as part of their care plan for Candida auris. However, the Medication Administration Record (MAR) indicated that the antiseptic soap was not signed out as given on one of the days. The Interim Administrator confirmed that the antiseptic soap was not administered or documented as given on that day, and no further information was provided to explain this lapse.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) of psychotropic medications for two residents, leading to a deficiency. Resident B, diagnosed with conditions including hemiplegia, dementia, Alzheimer's disease, and major depressive disorder, was prescribed Seroquel for restlessness. Despite a GDR being ordered to reduce the dosage from 25 mg to 12.5 mg, the resident continued to receive the higher dose from mid-September to early October. There was no documentation indicating that the GDR had been declined by the resident's physician, and the Nurse Consultant confirmed the medication had not been reduced as ordered. Similarly, Resident C, who had Alzheimer's disease, dementia with agitation, and delusional disorder, was prescribed Ativan for anxiety. A GDR was recommended to decrease the dosage from 0.5 mg to 0.25 mg, with the Interdisciplinary Team in agreement. However, the resident continued to receive the original dosage from mid-September to early October, with no documentation of a physician's declination of the GDR. The Nurse Consultant acknowledged that the medication had not been reduced as ordered. The facility's policy on psychotropic medication management requires GDR and non-pharmacologic interventions unless contraindicated, which was not adhered to in these cases.
Failure to Ensure Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours on one of the 14 days reviewed. This deficiency was identified during a review of staffing schedules for the period from September 16 to September 29, 2024. It was found that there was no RN coverage on September 29, 2024. During an interview, the Interim Administrator acknowledged the absence of an RN on that day and was aware of the requirement for daily RN coverage. This lapse had the potential to affect all 67 residents residing in the facility.
Failure to Monitor and Document Skin Conditions
Penalty
Summary
The facility failed to properly assess and monitor skin discoloration and scabbing for two residents with non-pressure related skin conditions. Resident D was observed with a reddish/purple discoloration on the top of their right hand on two separate occasions. Despite being on anticoagulant therapy, which requires monitoring for bruising, there was no documentation in the nursing progress notes regarding the discoloration, nor was there a physician's order to monitor the area. The Director of Nursing was unaware of the bruise on Resident D's hand. Resident E was observed with several reddish/purple bruises on their hands and arms, and a dressing on the left forearm covering a purple scab. Although a Skin Integrity Assessment noted skin tears on the resident's legs, there was no documentation or orders to monitor the discoloration on the hands and arms. The Director of Nursing was aware of the bruises but mistakenly believed that monitoring orders had been entered into the system. The facility's policy on skin integrity and wound management was not followed, as evidenced by the lack of proper documentation and monitoring.
Failure to Implement Fall Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to implement preventative fall measures for a resident at risk for falls. Resident B, who had a history of hemiplegia, hemiparesis following a stroke, seizures, and muscle weakness, was observed multiple times with their bed not in a low position, contrary to the care plan interventions. The resident had moderate cognitive impairment and was dependent on staff for bed mobility and transfers. The care plan, which was reviewed earlier, indicated that the resident was at risk for falls and had a history of putting themselves on the floor. Despite this, the bed was observed not in the low position on several occasions. The Director of Nursing acknowledged that the bed should have been in the low position and noted that the resident did not like the bed in that position, indicating a need for care plan updates.
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What surveyors actually found near you
We read the 1,702 citations issued within 25 miles in the last 12 months — including the 21 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
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Illustrative
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Nursing homes near Whiting
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of River Oaks | 4.7 mi | ★★★★★ | 15 | 0 |
| Harbor Health & Rehab | 4.9 mi | ★★★★★ | 38 | 0 |
| Aperion Care Dolton | 5.4 mi | ★★★★★ | 4 | 0 |
| Elevate Care Windsor Park | 5.7 mi | ★★★★★ | 31 | 0 |
| South Shore Rehabilitation | 6.3 mi | ★★★★★ | 11 | 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.