Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of The Willows during CMS and state inspections, most recent first.
A resident with dementia who required staff assistance for ADLs, including bathing, was scheduled to receive showers twice weekly, but facility records showed no bathing documented on multiple scheduled shower days, and no corresponding shower sheets were completed. The resident’s care plan and MDS indicated a need for partial to moderate staff assistance with toileting hygiene, dressing, personal hygiene, and bathing, yet the resident was mistakenly left off the shower schedule on at least one of the missed days and did not receive a shower as planned.
Water temperatures in resident rooms and shower rooms were not maintained at comfortable levels. A resident reported the sink water did not get hot, and Hospice staff said they had to heat basin water in a microwave for bed baths. Staff interviews indicated the issue had been known for some time but not fixed, and survey testing found room and shower water temperatures in the low 80s to mid-80s F, with maintenance logs showing only low-90s readings.
Improper glove use during meal prep was observed in the kitchen when a cook handled non-food items and then directly touched bread and cheese with the same gloves while making grilled cheese sandwiches and preparing soup. The DM stated cooks were not supposed to touch food items directly with gloved hands after touching non-food items.
A resident was observed being wheeled from his room to a shower room in a shower chair with a hospital gown open in the back, leaving his buttocks exposed and visible to others in the hallway. The CNA did not cover him with clothing or a blanket before transport, and both the CNA and ADON stated he should have been covered. The resident had anemia, HF, HTN, and severe cognitive impairment.
Failure to inform a resident and the resident's representative of a trazodone dose increase. The resident had insomnia and multiple chronic conditions, was moderately cognitively impaired, and had trazodone ordered for sleep after requesting a sleep aid. The record showed the dose was later increased, but there was no documentation that the resident or representative were informed, and the IP/Wound Nurse and DON could not confirm notification.
A resident with COPD, respiratory failure, and a history of laryngeal cancer had a tracheostomy stoma site and communicated with a whiteboard because he was unable to speak. Although an order directed daily and PRN stoma care with shift monitoring for infection, skin irritation, sputum discoloration, and respiratory status, the record contained no care plan related to the tracheostomy stoma site. The DON acknowledged the stoma site should have been included in the care plan.
Failure to obtain orders and document wound treatment changes for a resident with a right elbow surgical wound. The resident was cognitively intact, had COPD, respiratory failure, and a history of laryngeal cancer, and the wound had exposed hardware with 100% necrotic tissue. Although the wound care nurse said the resident received Hydrofera Blue and dressing changes 3 times weekly, the prior order had been discontinued and there were no active physician orders or TAR documentation for the wound during the reviewed period.
Failure to provide ordered ROM care occurred when a resident with dementia, left-sided hemiparesis, and a left-hand contracture was observed in bed with the left hand clenched in a fist and no palm protector in place on multiple observations. The care plan and MD order called for a left palm protector as tolerated with placement and skin checks every shift, but the MAR/TAR showed it as in place and there were no documented refusals.
Smoking safety and fall supervision failures were identified for three residents. One resident with dementia and prior smoking-related injury was observed smoking without the required smoking apron despite a care plan intervention and a smoking safety evaluation noting poor safety awareness. A second resident who was an active smoker had no smoking safety evaluation completed, and the DON stated the assessment had been missed. A third resident with severe cognitive impairment, hospice status, and repeated falls was left unattended in the dining room and was later found on the floor with a forehead laceration and bleeding.
A resident with a g-tube, dementia, and dysphagia was observed twice with the tube feeding not connected and the pump off, despite an order for Glucerna 1.5 at 50 cc per hour for 18 hours daily. The MDS showed the resident received most nutrition by tube feeding, the care plan directed nutrition and hydration via g-tube as ordered, and the MAR indicated the feeding had been administered as ordered, but the DON and Administrator were told the feeding had not been given as ordered.
Failure to Provide Ordered Oxygen Therapy: Two residents with physician-ordered continuous oxygen were observed not receiving oxygen as ordered. One resident with heart failure, dementia, and respiratory failure was seen multiple times without the nasal cannula in place despite an order for 4 L/min continuous oxygen, while another resident with COPD and severe cognitive impairment was observed on 2.5 L/min when the order called for 3 L/min continuous oxygen. The DON stated the family had been changing the concentrator settings.
The facility failed to monitor weights for a resident receiving diuretic therapy for heart failure, with multiple missed weight recordings despite an order for weights three times weekly. The facility also administered acetaminophen above the ordered 3-gram daily limit to a resident with heart disease and osteoarthritis, with MAR entries showing repeated excessive total daily doses. An LPN and the DON acknowledged the pain order needed clarification.
Failure to perform hand hygiene and change gloves during wound care. A Wound Nurse treated a resident with pressure ulcers on the foot and a coccyx wound, but did not change gloves or perform hand hygiene between wound sites and between glove changes. She later acknowledged that hand hygiene should have been performed with each glove change and gloves should have been changed between treatment of different wounds.
A resident with COPD was ordered azithromycin 250 mg by mouth every Monday, Wednesday, and Friday for COPD exacerbation prophylaxis, but the record contained no documentation of a true infection or criteria supporting antibiotic use. The IP/Wound Nurse stated the order did not meet McGeer criteria and could not provide documentation showing why the antibiotic was ordered.
Staff failed to follow infection control guidelines by not wearing masks when entering a resident's room marked for droplet and enhanced barrier precautions. Both a wound nurse and a CNA wore gowns and gloves but did not use masks, and staff were unclear about the resident's current isolation status despite signage and physician orders indicating the need for precautions.
Multiple areas of the facility, including three halls and the dining room, were found to have dirty and discolored vents, exposed electrical wiring, and a broken baseboard heating cover. The Maintenance Director was aware of the exposed wiring and noted that vent cleaning and repairs were still pending.
The facility did not ensure that CNAs consistently documented incontinence care every shift for three residents with cognitive impairment and incontinence, as required by facility policy. Record reviews showed multiple instances of missing documentation over a 30-day period, despite care plans and MDS assessments indicating the need for substantial assistance with toileting and hygiene.
The facility failed to maintain the privacy of residents' personal and medical records during a medication pass. An LPN was observed leaving the electronic medication record open and unlocked in the hallway while preparing medications for two residents, exposing their personal information. The LPN admitted to not knowing how to lock the screen, and the DON confirmed that screens should be locked when unattended.
A facility failed to implement care plans for a resident with severe cognitive impairment and multiple medication needs, including opioids. Despite being on hospice care and requiring maximal assistance for daily living activities, there were no care plans addressing pain management and opioid use. The DON confirmed the absence of these care plans.
A resident with a stage 4 pressure ulcer did not receive wound care as per the physician's orders. The prescribed treatment included specific steps and materials, but the observed care involved different products and procedures. The resident had significant cognitive impairment and required substantial assistance for bed mobility. The discrepancy was noted by the IP Nurse upon review.
A facility failed to provide a nutritional supplement and maintain accurate meal logs for a resident with a history of weight loss. The resident, who was at nutritional risk, did not receive the fortified soup indicated on her meal ticket, and meal consumption logs were incomplete. Staff interviews revealed a lack of awareness of the resident's dietary orders, and the Dietary Manager confirmed the importance of meal logs for assessing nutritional needs.
An LPN failed to perform proper hand hygiene during a medication pass for two residents. The LPN did not wash hands before preparing medications and only used hand sanitizer after pouring medications into a cup. The LPN misunderstood the hand hygiene protocol, believing it was only necessary to wash hands after every third resident. The facility's policy requires hand hygiene before and after resident contact and after touching objects in the resident's environment.
A facility failed to ensure timely follow-up on urine culture results for a resident with a UTI, leading to the administration of an ineffective antibiotic. The resident, who was cognitively intact and dependent on staff for toileting, was prescribed ciprofloxacin after returning from the hospital. Despite a request for hospital records, the facility did not receive the urine culture results until after the antibiotic course was completed, revealing resistance to ciprofloxacin. The delay resulted in continued symptoms for the resident.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dependent resident received bathing/showers at least twice weekly as required. Record review for Resident C, who had dementia and was cognitively impaired, showed a care plan updated on 1/7/26 indicating the resident required assistance with ADLs, including mobility and personal care. The Quarterly MDS dated 2/27/26 documented that the resident needed partial to moderate staff assistance with toileting hygiene, dressing, personal hygiene, and bathing. Facility Point of Care documentation from 2/4/26 through 3/24/26 indicated the resident was scheduled to receive showers on Thursdays and Sundays, but there was no bathing documented on 3/1/26, 3/12/26, and 3/19/26. Corresponding shower sheets for those dates were also missing. During interview, the ADON confirmed she could not locate completed shower sheets for those dates and stated the resident had been mistakenly left off the shower schedule on 3/12/26 and did not receive a shower on that date. This citation relates to Intake 2960382 and violations of 410 IAC 16.2-3.1-38(a)(3) and 410 IAC 16.2-3.1-38(b)(2).
Water Temperatures in Resident and Shower Areas Were Too Low
Penalty
Summary
The facility failed to maintain comfortable water temperatures in resident rooms and shower rooms. On 1/21/26, Resident 9 was observed sitting on the bed in her room and stated the sink water did not get hot in her room. Her roommate was on Hospice Services, and Hospice staff reportedly had to heat water in a basin in the microwave to provide a bed bath. When the sink water was turned on and allowed to run for about a minute, it was only slightly warm to the touch. During the survey, a Hospice CNA stated the facility water did not get hot and that she heated basin water in the microwave for bed baths, then stirred it with her hand to check that it was not too hot. Confidential staff interviews indicated the water in resident rooms and shower rooms did not get hot and that management had been informed about the issue previously, but it had not been fixed. On 1/27/26, an environmental tour with the Administrator found water temperatures of 86.1 F, 82.9 F, 84.7 F, 82.2 F, 80.2 F, and 82.7 F in resident rooms and a shower room. Maintenance logs reviewed during the survey showed temperatures in the low 90s on 1/22/26 and 1/26/26, and the Administrator and Maintenance Director stated the water company had called on 1/19/26 about a possible water leak, but no one had yet come out to check it. Staff also stated Assistant Maintenance 1 did not let them know the water temperatures were below 100 F.
Improper Glove Use During Meal Preparation
Penalty
Summary
The facility failed to serve food under sanitary conditions when a cook touched food directly with gloved hands after touching non-food items during lunch meal preparation in the main kitchen. During observation, the cook was seen placing items on plates, then using the same clean gloves to open a bag of bread, reach into the bag to remove a slice, place it on a pan, open a package of cheese, pick up cheese and place it on the bread, and then retrieve another slice of bread to complete a grilled cheese sandwich. The cook repeated these steps with the same gloved hands while also preparing another tray with soup and then another grilled cheese sandwich. The Dietary Manager stated that cooks were not supposed to touch food items directly with gloved hands after touching non-food items.
Resident Transported With Buttocks Exposed
Penalty
Summary
The facility failed to maintain a resident's dignity when Resident 24 was observed sitting in a shower chair in the doorway of his room with a hospital gown open in the back and his buttocks exposed and visible while being wheeled down the hallway to a shower room. CNA 1 transported the resident without covering him with additional clothing or a blanket, and other residents in the hallway could observe him. Resident 24's record showed diagnoses including anemia, heart failure, and hypertension, and his quarterly MDS dated 12/24/25 indicated he was severely cognitively impaired. During interviews, CNA 1 stated she should have covered the resident before transporting him, and the ADON agreed the resident should have been covered.
Failure to Inform Resident and Representative of Psychotropic Medication Increase
Penalty
Summary
The facility failed to ensure a resident and the resident's representative were informed of a change in treatment related to psychotropic medication for Resident 48. The resident had diagnoses including insomnia, anemia, heart failure, end stage renal disease, and respiratory failure, and the admission MDS dated 10/29/25 indicated the resident was moderately cognitively impaired and received an antidepressant medication. A Health Status Note dated 10/25/25 documented that the resident requested a sleep aid, the physician and resident representative were informed, and trazodone 50 mg nightly was ordered. The January 2026 Physician's Order Summary showed trazodone 50 mg, 2 tablets at bedtime for insomnia, but the record lacked documentation that the resident and resident representative were informed when the antidepressant medication was increased. During interviews, the Infection Preventionist/Wound Nurse was unaware whether they had been informed of the dosage increase, and the DON stated she could not provide documentation that they had been informed.
Missing Care Plan for Tracheostomy Stoma Care
Penalty
Summary
The facility failed to develop and implement a care plan related to a tracheostomy stoma site for one resident reviewed for respiratory care. The resident had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and a history of laryngeal cancer. The admission MDS dated 11/6/25 indicated the resident was cognitively intact and received tracheostomy care while a resident. A physician's order dated 10/31/25 directed tracheostomy stoma care to be completed by the resident daily and as needed, with monitoring every shift for signs and symptoms of infection or skin irritation and for discoloration of sputum along with respiratory status, with notification of the physician for significant changes. During interview and observation, the resident stated he was unable to speak, used a whiteboard to communicate, and performed his own stoma care daily; the stoma site appeared clean on observation. Review of the record showed there were no care plans related to the resident's tracheostomy stoma site, and the DON stated the stoma site should have been included in the care plan.
Failure to Obtain Orders and Document Wound Treatment Changes
Penalty
Summary
The facility failed to obtain physician orders and document treatment changes for a non-pressure skin condition for one resident with a surgical wound on the right elbow/right posterior upper arm. The resident was cognitively intact, had COPD, respiratory failure, a history of laryngeal cancer, and an impairment in range of motion of one upper extremity. He reported that screws were coming out of his right elbow and that he was awaiting surgery to correct it, and staff were changing the bandage for him. The care plan identified actual impairment to the right elbow with hardware showing from a surgical site and called for following facility protocols for treatment of the injury and weekly treatment documentation. The resident had physician orders for cleansing the surgical wound, applying Hydrofera Blue, and covering it with a foam dressing three times weekly, but that order was discontinued and a later order was not entered until after the period reviewed. Wound observation tools documented the right posterior upper arm surgical wound dehiscence with no drainage, measuring 1.5 cm by 1.2 cm by 0.2 cm, with 100% necrotic tissue and exposed hardware. Despite the wound care nurse stating the resident received wound care three times a week, there were no physician orders for treatment and no documented treatments on the TAR for the wound during the reviewed period.
Failure to Provide Ordered Palm Protector for Limited ROM
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason was not met when the facility failed to provide treatment for limited ROM related to a palm protector not being in place for Resident 4. The resident had diagnoses including type 2 diabetes mellitus, dementia with behavioral disturbance, and contracture of the left hand. The quarterly MDS indicated the resident was cognitively impaired and had impaired ROM to the upper and lower extremities on both sides. The care plan identified left-sided hemiparesis and risk for contractures, with an intervention for a left palm protector. The physician’s order directed that the left palm protector be used as tolerated and that placement and skin under the protector be checked every shift. However, on three separate observations, the resident was lying in bed with the left hand in a fist and no palm protector in place. The MAR and TAR indicated the palm protector had been in place as ordered, and there were no documented refusals.
Smoking Safety and Fall Supervision Failures
Penalty
Summary
The facility failed to ensure safety was maintained related to smoking safety interventions, a smoking assessment, and fall interventions for 3 residents reviewed for accidents. One resident with type 2 diabetes mellitus, vascular dementia, and major depressive disorder was observed smoking with staff supervision on two occasions without wearing the smoking apron that had been identified in the care plan after a prior smoking incident caused injury. The resident’s record showed cognitive impairment, a smoking incident on 10/20/25 in which a tissue paper pom pom caught fire while she was lighting a cigarette, and a smoking safety evaluation stating she exhibited poor safety awareness and needed interventions to promote smoking safety. A second resident, admitted with cognitive communication deficit and a personal history of mental and behavioral disorders, was observed smoking outside and had returned from smoking, but the record contained no Smoking Safety Evaluation. The admission MDS showed moderate cognitive impairment, and the DON stated the smoking assessment had not yet been completed because the resident was not currently going out to smoke due to cold weather, so he could not be assessed while outside smoking. The smoking policy had been discussed with the resident and signed, and the care plan identified him as at risk for respiratory illness related to being an active smoker. A third resident with non-traumatic brain dysfunction, senile degeneration of brain, stroke, and dementia was severely cognitively impaired, on hospice, dependent for multiple ADLs, and had a history of repeated falls. Her care plan identified her as a fall risk and included interventions for increased monitoring and assistance during high-risk times, but she was found on the floor in the dining room after staff left the area. The event note stated a CNA had walked out to answer a call light and returned to find the resident on the floor in front of her wheelchair with a forehead laceration and bleeding; 911 was called, and the DON later stated the resident was not supposed to be left unattended in the dining room.
Failure to Administer Ordered G-Tube Feeding
Penalty
Summary
The facility failed to ensure a resident with a gastrostomy tube received the ordered tube feeding. Resident 4 had diagnoses including type 2 diabetes mellitus, dementia with behavioral disturbance, and contracture of the left hand, and the quarterly MDS indicated the resident was cognitively impaired and received the majority of nutrition by tube feeding. The care plan stated the resident had dysphagia and a g-tube was in place to ensure adequate nutrition and hydration, with interventions for nutrition and hydration via g-tube as ordered. A physician's order directed Glucerna 1.5 at 50 cc per hour for 18 hours daily, but during two observations the tube feeding was not connected to the resident's g-tube and the pump was off. Although the MAR indicated the tube feeding had been administered as ordered, the DON and Administrator were informed that the tube feeding had not been administered as ordered.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure necessary respiratory care was provided for 2 residents who had physician-ordered oxygen therapy. Resident 51, whose diagnoses included heart failure, dementia, and respiratory failure, had a physician order dated 1/17/26 for oxygen at 4 liters per minute continuously via nasal cannula. During multiple observations, the resident was seen in bed with the nasal cannula sitting next to her head or with no nasal cannula in place, despite the oxygen concentrator being set at 4 liters per minute. The resident’s quarterly MDS dated 12/24/25 indicated she was cognitively intact. Resident 74, whose diagnoses included neurocognitive disorder with Lewy Bodies, schizophrenia, and COPD, had an admission MDS dated 1/21/26 indicating severe cognitive impairment and that he received oxygen. The current January 2026 physician order summary directed oxygen at 3 liters per minute continuously via nasal cannula, and the care plan included oxygen therapy for ineffective gas exchange. However, during observations, the resident was seen receiving oxygen via nasal cannula at 2.5 liters per minute instead of the ordered 3 liters per minute. During interview, the DON stated the family had been problematic with care and would change settings on the oxygen concentrator.
Unmonitored weights for heart failure and excessive acetaminophen dosing
Penalty
Summary
The facility failed to ensure weights were checked and monitored for a resident receiving medications for heart failure. Resident 48 had diagnoses including insomnia, anemia, heart failure, end stage renal disease, and respiratory failure, and the care plan directed staff to administer medications as ordered, observe and report sudden weight gain, and weigh the resident at the same time of day as ordered by the physician. The January 2026 orders included Lasix 20 mg daily, potassium chloride ER 10 mEq, and weights every Monday, Wednesday, and Friday with notification to the physician for a weight gain greater than 3 pounds. The MAR showed weights were not recorded on 1/8, 1/12, 1/14, 1/16, 1/19, and 1/21/26. The DON stated the resident was under isolation during some of the missing dates, but staff should have checked the resident's weight and did not. The facility also failed to ensure a pain medication was not administered in an excessive dose. Resident 75 had diagnoses including heart disease, fracture of the left ischium, hypertension, and osteoarthritis, and stated her pain was controlled as long as she received her scheduled pain medicine. The physician ordered acetaminophen 325 mg, 2 tablets by mouth every 4 hours for pain, not to exceed 3 grams in 24 hours. The MAR showed the resident received six doses on 1/16, 1/18, and 1/19/26 for a total of 3,900 mg, and five doses on 1/20 and 1/21/26 for a total of 3,250 mg, both exceeding the ordered daily limit. An LPN stated she would call the doctor to clarify the order, and the DON stated she would review the pain medication order with the nurse and have her contact the doctor for clarification.
Failure to Perform Hand Hygiene and Glove Changes During Wound Care
Penalty
Summary
Infection control practices were not followed during wound care for one resident with a pressure ulcer to the medial and lateral side of the left foot and a small open wound with slough on the coccyx. During observation, the Wound Nurse washed her hands, donned a gown and gloves, and removed the dressing from the lateral foot wound. After cleaning that area with saline and applying skin prep, she removed the old dressing from the medial foot without changing gloves or performing hand hygiene. She then removed her gloves and donned new gloves without hand hygiene before removing the coccyx dressing. After washing the coccyx wound with saline, she again removed her gloves and donned new gloves without performing hand hygiene before applying Santyl and a dry dressing. During interview, the Wound Nurse stated she should have performed hand hygiene with each glove change and changed gloves between treatment of different wounds.
Antibiotic Prophylaxis Ordered Without Infection Criteria
Penalty
Summary
The facility failed to promote antibiotic stewardship by ordering prophylactic antibiotic therapy for a resident with COPD without documentation that the resident met criteria for a true infection. Resident 5, who had diagnoses including atherosclerotic heart disease, an automatic implantable cardiac defibrillator, COPD, PVD, hypertension, diabetes mellitus type 2, and paroxysmal atrial fibrillation, was moderately cognitively impaired on the quarterly MDS dated 12/24/25. During interview, the resident stated he had been taking an antibiotic three times per week to keep his COPD from getting bad. The physician's order summary for 1/2026 showed Azithromycin 250 mg by mouth every Monday, Wednesday, and Friday for COPD exacerbation prophylaxis. The record contained no documentation that the resident met criteria for a true infection for antibiotic use, and the Infection Preventionist/Wound Nurse stated the order did not meet McGeer criteria and that she could not provide documentation showing why the medication use met criteria for a true infection or why the physician had ordered it.
Failure to Implement Proper PPE and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, specifically regarding the use of personal protective equipment (PPE) and staff awareness of isolation precautions. During observations, staff members, including a wound nurse and a CNA, entered a resident's room that was marked for enhanced barrier precautions (EBP) and droplet precautions without wearing masks, although they wore gowns and gloves. The wound nurse was unaware of the reason for the droplet precaution signage and believed the resident was only on contact isolation. The CNA did not question the signage, assuming the resident was no longer in isolation, and indicated she was unaware of any prior droplet isolation for the resident. The resident involved had multiple diagnoses, including neuromyelitis optica, paraplegia, pressure ulcer, neuromuscular dysfunction, dysphagia, and anemia, and was cognitively intact. Physician orders indicated EBP due to wounds and a Foley catheter, and there had been a previous order for contact and droplet precautions related to a COVID-19 infection. The care plan also indicated contact isolation for prophylactic antibiotic use for C. difficile. Despite these orders and signage, staff did not consistently implement appropriate PPE use or verify the current isolation status, leading to a failure in following infection control guidelines.
Environmental Cleanliness and Safety Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents, staff, and the public, as evidenced by multiple deficiencies observed during an environmental tour. Dirty and discolored ceiling vents were found throughout the East Hall, Center Hall, [NAME] Hall, and the dining room. In the Center Hall, exposed electrical wiring was observed both across from a resident room and hanging from a ceiling tile. Additionally, the dining room had a baseboard heating unit cover that was not attached. During an interview, the Maintenance Director acknowledged awareness of the exposed wiring and stated that the covers had been knocked off about a week prior and had not yet been replaced. The vents throughout the facility were also noted to be in need of power washing or replacement.
Failure to Maintain Complete Incontinence Care Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records regarding incontinence care for three residents who required assistance with activities of daily living (ADL). For each resident, the care plans and Minimum Data Set (MDS) assessments indicated varying levels of cognitive impairment and dependence on staff for toileting and hygiene, with frequent or occasional incontinence noted. Facility policy required Certified Nursing Assistants (CNAs) to document incontinence care at least every shift, three times daily, including whether the resident was continent or incontinent of bowel and bladder. Record reviews for the previous 30 days revealed multiple shifts where incontinence care documentation was missing for all three residents. Specific dates and shifts were identified for each resident where no documentation was present, despite the expectation for consistent charting. During interviews, the Regional Nurse Consultant confirmed that CNAs were required to document incontinence care every shift and was unable to provide further information regarding the missing documentation. The facility's policy on incontinence management also emphasized the need for documentation following care procedures.
Failure to Maintain Privacy of Electronic Medication Records
Penalty
Summary
The facility failed to maintain the privacy of residents' personal and medical records during a medication pass. On November 8, 2024, an LPN was observed preparing medications for two residents in the hallway using an electronic medication record on a computer. After preparing the medications for Resident 113, the LPN left the computer screen open and unlocked, exposing the resident's medications and personal information. The same incident occurred when the LPN prepared medications for Resident 6, again leaving the computer screen open and unlocked in the hallway. During an interview, the LPN admitted to not locking the screen, citing a lack of knowledge on how to unlock it. The Director of Nursing confirmed that computer screens should be locked when unattended and stated she would address the issue with the nurse.
Failure to Implement Care Plans for Pain and Opioid Use
Penalty
Summary
The facility failed to implement care plans for a resident, identified as Resident 9, who was severely cognitively impaired and required maximal to total dependence on staff for activities of daily living. The resident's diagnoses included senile degeneration of the brain and dementia, and she was receiving hospice care. According to the Quarterly Minimum Data Set (MDS) assessment, the resident was on multiple medications, including antipsychotic, anti-anxiety, antidepressant, and opioid medications. Specifically, the November 2024 Physician Order Summary indicated that the resident was prescribed morphine sulfate, an opioid pain medication, to be administered as needed every two hours, with a requirement for staff to observe for opioid side effects every shift. However, there were no care plans in place addressing pain management and opioid use for this resident. During an interview, the Director of Nursing confirmed the absence of these care plans in the resident's current care plan.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with a stage 4 pressure ulcer. On observation, the wound care provided to the resident did not align with the physician's orders. The resident, who had significant cognitive impairment and required substantial assistance for bed mobility, was observed receiving wound care that deviated from the prescribed treatment. The physician's order specified cleansing the coccyx with wound wash, applying skin prep to the periwound, a thin layer of germ shield to the wound bed, collagen, silver alginate, and a small foam dressing. However, the observed treatment involved the application of antimicrobial gel and calcium alginate, which was not in accordance with the physician's order. The IP Nurse acknowledged the discrepancy after reviewing the physician's orders.
Failure to Provide Nutritional Supplement and Maintain Meal Logs
Penalty
Summary
The facility failed to ensure that a nutritional supplement was offered during meal service and that food consumption logs were completed for a resident with a history of weight loss. On a specific date, Resident 5, who was seated in a wheelchair in the Assisted Dining Area, did not receive the fortified soup that was indicated on her meal ticket. The resident's meal tray included mashed potatoes, ground meatballs with gravy, vegetables, and ice cream, but lacked the fortified soup. The resident's care plan, which was revised earlier in the year, indicated that she was a nutritional risk and required supplements and a mechanically altered diet. The resident's physician's orders included fortified soup at lunch and supper, which was not provided during the observed meal. Additionally, the facility did not maintain accurate meal consumption logs for Resident 5, who had experienced significant weight loss over six months. The resident's weight had decreased from 136.2 lbs to 120.2 lbs, a loss of 11.75%. The Task Meal Consumption Logs lacked documentation for several meals over the past 30 days, including specific dates for breakfast and lunch. Interviews with staff revealed a lack of awareness regarding the resident's dietary orders, and the Dietary Manager confirmed that the meal consumption logs were important for assessing the need for adjustments in the resident's enteral feeding. The failure to provide the fortified soup and maintain accurate meal logs contributed to the deficiency identified by the surveyors.
Inadequate Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to implement proper infection control measures during a medication pass, as observed with two residents. On the morning of November 8, 2024, an LPN was seen administering medications to a resident without performing hand hygiene before preparing the medication. After giving the medications to the resident, the LPN returned to the medication cart and prepared medications for another resident, again without performing hand hygiene. The LPN used hand sanitizer only after the medications were poured into the medication cup. The LPN then delivered the medications to the second resident and returned to the medication cart without performing hand hygiene. During an interview, the LPN expressed a misunderstanding of the hand hygiene protocol, believing it was only necessary to wash hands after every third resident. The Director of Nursing confirmed that hand sanitizer should be used, and hands should be washed after every third resident unless something was touched. The facility's hand hygiene policy, dated July 15, 2022, requires hand hygiene before and after contact with residents and after contact with objects and surfaces in the resident's environment.
Failure in Timely Follow-Up on Urine Culture Results
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring timely follow-up on urine culture results for a resident with a history of urinary tract infections (UTIs). The resident, who was cognitively intact and dependent on staff for toileting assistance, was sent to the hospital for evaluation of vaginal bleeding and returned with an order for ciprofloxacin to treat a UTI. Despite a request for hospital records being faxed on October 16, 2024, the facility did not receive the urine culture and sensitivity results until October 22, 2024, which indicated resistance to ciprofloxacin and susceptibility to cefuroxime. The resident completed the ciprofloxacin course on October 21, 2024, but continued to experience symptoms, including pain and dark amber urine. The delay in receiving the urine culture results led to the resident being prescribed an ineffective antibiotic for the UTI. The Infection Prevention Nurse acknowledged the difficulty in obtaining timely test results from the hospital, as they had to rely on fax requests, which often required multiple attempts. The facility's antibiotic stewardship policy emphasizes the importance of appropriate antibiotic use to improve resident outcomes and reduce resistance, but this was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 636 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Valparaiso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valparaiso Care & Rehabilitation | 1 mi | ★★★★★ | 28 | 0 |
| Avalon Springs Health Campus | 1.2 mi | ★★★★★ | 14 | 0 |
| Brickyard Healthcare - Valparaiso Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Valparaiso | 1.9 mi | ★★★★★ | 15 | 0 |
| Ignite Medical Resort Chesterton | 7 mi | ★★★★★ | 27 | 0 |
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