Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lincolnshire Health & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Notify Physician and RP of Change in Condition: The facility did not document timely notification to the physician and RP/POA for two residents with changes in condition. One resident with dementia, bipolar disorder, and violent behaviors had repeated aggression, a behavioral hospital referral, and later transfer, but the RP was not notified of the behaviors before the referral and was only notified by voicemail after acceptance; the same resident’s wrist swelling and x-ray order were also not documented as reported to the RP. Another resident with dementia and diabetes had a documented low blood sugar of 44, but there was no record that the physician or POA was notified as required by the order and facility hypoglycemia guidance.
Failure to Complete Ordered Lab Tests: Two residents did not receive ordered lab services. One resident with dementia and Alzheimer's disease had a UA with C&S ordered, but no urine sample was obtained and there was no documentation the test was completed; the DON said the physician was not notified. Another resident with diabetes mellitus and CKD had ordered CMP, CBC, and lipid panel monitoring that was not completed as ordered, and the DON stated the lab tests had not been done.
A resident with diabetes had low blood sugar episodes that were not accurately documented in the chart. The MAR did not show ordered hypoglycemia treatments such as glucagon or oral glucose gel/tablets being given, and the resident’s treatment and status were not recorded for one episode. Another episode involved a blood sugar of 44 with the resident unable to follow commands; EMS treated the hypoglycemia, but the MAR still did not reflect the treatments used.
A resident with hemiparesis, hemiplegia post-CVA, and COPD was discharged home without complete discharge documentation. Although the resident was notified of the last covered day and signed a discharge planning form, key sections addressing medications and follow-up visits were left blank. The SSD reported a home health referral, but this was not documented in the medical record, only referenced in an email. The DON indicated residents should receive a discharge summary, medication list, and equipment orders with a corresponding progress note, but these were not present, contrary to the facility’s discharge summary policy requiring a recapitulation of the stay and medication reconciliation.
A resident with Parkinson’s disease and dementia, documented as dependent for eating and requiring one-person physical assistance, was left with an uncovered breakfast tray for an extended period without timely feeding assistance. The resident, who had hand tremors and was unable to communicate the need for help, made no attempts to self-feed while food remained in front of her. A CNA later acknowledged the resident was a new admission needing assistance and attempted to feed her but did not obtain a fresh or reheated tray despite the delay. A family member later confirmed the resident was dependent for meal intake.
A resident with significant cognitive deficits, adult failure to thrive, and pressure ulcers on the coccyx and left heel did not consistently receive ordered wound care. Physician orders directed specific cleansing and dressing regimens for both wounds, including daily and scheduled treatments with normal saline, calcium alginate, and, at one point, triple antibiotic ointment. Treatment Administration Records for two consecutive months showed multiple dates on which these wound treatments were not signed out as completed. During interview, the wound nurse could not explain the missed treatments and noted some dates coincided with hospice visits, but hospice documentation was not available, contrary to facility policy requiring documentation of dressing changes.
Two residents with significant clinical needs did not receive timely nutritional assessments, resulting in incomplete medical records. One resident with diabetes had documented poor appetite and frequent meal refusals, and another resident with dementia had a deep tissue injury pressure ulcer along with difficulty chewing and swallowing some foods. In both cases, care plans identified nutritional concerns, but no corresponding nutritional assessments were documented. The RD reported being behind and lacking sufficient hours to complete assessments on time.
Unsafe Food Handling and Improper Food Storage: Dietary staff were observed touching food with bare hands, using gloves improperly while handling plates, utensils, and food, and a staff member with facial hair had a beard guard lowered around the neck. Surveyors also found dirty kitchen equipment, food spillage, ice buildup in the freezer, and unlabeled resident foods and beverages in the A Wing nourishment refrigerator.
Unsafe and Poorly Maintained Kitchen and Resident Areas: The kitchen had dried food spillage on dish room walls, dirty floor drains, discolored grout, adhered dirt along baseboards, food spillage on walls and ceiling, and a dusty, dirty, rusted ceiling vent. In resident areas, A02 had a basin on the bathroom floor, a hole and water damage in the wall, and an unsecured grab bar; B01 had a marred wall; and B08 had 3 uncontained basins on the bathroom floor and water-damaged wall near the toilet.
Failure to Treat and Monitor Skin Conditions: The facility did not complete an ordered treatment for a resident's surgical incision, and it did not adequately assess or monitor bruising, scabbing, dry scaly skin, or psoriasis for multiple residents. Observations and record review showed untreated or undocumented skin issues, missing or inaccurate skin assessments, and lack of documented interventions despite physician orders, care plans, and resident reports of discomfort or itching.
Loose pills were found in medication cart drawers, and insulin vials and pens were observed opened without proper dating. In addition, medications were left at the bedside for two residents who did not self-administer, including one resident with subarachnoid hemorrhage and psoriasis and another resident with COPD, diabetes, and a left BKA. An LPN and the DON acknowledged the storage issues, and the record showed no self-administration orders or assessments for either resident.
Failure to follow the pureed spinach recipe during meal prep. An dietary staff member blended cooked spinach and added unmeasured chicken broth, chicken stock, and Thick and Easy multiple times, even though the recipe called for spinach, margarine, and salt only. The Dietary Food Manager stated the cook should have followed the recipe.
A resident with aortocoronary bypass graft, atherosclerotic heart disease, type 2 DM, and moderate cognitive impairment was admitted with a peripheral IV line from the hospital. The admission nursing assessment did not document an IV present, and early nursing notes only described bruising related to IV insertion without stating whether the IV remained in place. A later MD note identified the hospital IV line, and the IV was not removed until after a physician order was entered.
Failure to Assess and Order Self-Administration of Medications: A cognitively intact resident with DM2, CHF, and HTN had nasal spray, eye drops, clotrimazole ointment, and Neosporin ointment observed at the bedside on multiple occasions. The chart showed an outdated self-administration assessment, a care plan referencing unsupervised self-administration without listing any meds, and a physician order allowing self-administration with facility setup assistance, but no orders for the ointments found. The DON stated the resident’s daughter sometimes brought medications in without notifying the facility.
A resident who was cognitively intact and able to use the call light was observed sitting in a wheelchair next to his bed while the call light pad was clipped to its cord on the wall on the opposite side of the bed. The resident had COPD, diabetes, and a left BKA, and the DON stated the call light should have been kept within his reach.
A resident with heart failure, pain, and vascular dementia was observed in bed with a blanket over his head and stated he could not see the TV because he was blind. Record review showed the quarterly MDS listed adequate vision, even though an IDT note linked vision impairment to a recent fall, a physician H&P stated the resident was blind, and staff confirmed the resident was legally blind.
Failure to provide nail care assistance: A resident with dementia, DM, and HTN was dependent on staff for ADL assistance, including personal hygiene and grooming. Staff care plans included keeping fingernails short, yet observations showed the resident lying in bed with jagged, uneven fingernails and dark debris underneath on multiple occasions. The DON was made aware of the condition during interview.
Failure to provide foot care and podiatry services for 3 residents was cited after staff observed long, thick toenails, dry scaly feet, and in one case a dried dark red substance under a great toenail. One resident with dementia and DM had no podiatry consult notes despite an order allowing podiatry, another resident with DM said he had requested podiatry multiple times after signing consent, and a third resident reported foot pain from overly long toenails while the record lacked documentation of foot care provided or refused.
A facility failed to provide ordered ROM-related treatment for three residents. One resident with left-sided hemiplegia was repeatedly observed with a clenched left hand and no ordered resting hand splint in place, another resident with Parkinson's, stroke, and epilepsy had contracted hands with no ordered palm protectors, and a third resident with a contracted right arm had a splint in place but no documentation of removal or skin checks. Records, observations, and staff interviews showed the ordered devices were not consistently in use or documented.
Fall precautions were not in place for a resident with a history of falls. The resident was cognitively intact, used a wheelchair, required supervision for bed mobility and transfers, and had multiple falls. Her care plan and chart identified interventions including non-skid strips by the bed, anti-tippers on the wheelchair, Dycem on the wheelchair cushion, and the bed in the lowest position, but observations showed these measures were missing while the resident was getting out of bed unassisted and using her wheelchair.
A resident with an indwelling urinary catheter, COPD, diabetes, and a left BKA was repeatedly observed with the urine collection bag hooked to the side of his wheelchair at about waist level while he sat in his wheelchair and moved through the hallways. The resident’s care plan directed staff to keep the catheter bag and tubing below the level of the bladder, and the DON stated the bag should be maintained lower than the bladder level.
A resident with Parkinson's disease, stroke, vascular dementia, epilepsy, and severe cognitive impairment was observed receiving a tube feeding while lying nearly flat in bed. The resident had a physician order and care plan directing HOB elevation during enteral feeding, but the facility failed to ensure the resident was positioned appropriately while the feeding was infusing.
Incorrect Oxygen Flow Rates for Two Residents: Two residents who were dependent on staff for all ADLs and ordered continuous O2 therapy were observed with their concentrators set at 3.5 L instead of the ordered flow rates. One resident’s order required 3 L continuously and 5 L when lying down, while the other resident’s order required 3 L continuously. The MAR/TAR showed oxygen signed out each shift, but there was no documentation of refusals or the prescribed flow rate.
Failure to monitor BP before giving ordered meds: two residents with HTN/hypotension had physician orders with BP parameters, but BP was not checked before administering Losartan and Midodrine on multiple occasions. The B Wing UM and DON acknowledged the BP should have been obtained before the meds were given.
A resident with diabetes and a skin condition was found lying on a soiled sheet covered in dry skin flakes and discoloration, reporting she had not received care since the previous night. CNAs confirmed that no care had been provided that morning, despite the resident's need for maximum assistance with hygiene and bed mobility.
A resident with diabetes mellitus and psoriasiform dermatitis was observed with scaly, shedding skin and dry skin flakes on bed linens. Although a physician's order for Tacrolimus cream was present, the care plan did not address the skin condition, and no interventions or monitoring were documented.
A dependent resident with diabetes and skin conditions did not receive timely incontinence care, as observed by surveyors who found her with a saturated brief and significant drainage on her incontinence pad. The resident, who required maximum assistance for ADLs and was frequently incontinent, reported not having received care since the previous night. Staff documentation and interviews confirmed a lapse in care, and facility policy required more frequent incontinence checks and assistance.
A resident with multiple pressure ulcers was found without required dressings in place, despite physician orders for scheduled and as-needed wound care. Staff were unaware that dressings were missing, and documentation showed that some treatments were not completed as ordered. The deficiency involved failure to ensure pressure ulcer treatments were provided as prescribed.
Three residents with diabetes did not receive blood sugar monitoring, insulin, or hypoglycemic medications as ordered by their physicians. Documentation showed multiple missed or undocumented blood sugar checks and medication administrations, with staff unable to verify completion of these tasks as required.
The facility failed to prepare pureed food correctly, affecting five residents on a pureed diet. A cook did not follow the recipe for pureed broccoli, resulting in a watery consistency despite adding thickening powder. The Dietary Manager confirmed the puree was not at the correct consistency, highlighting a need for staff training on proper preparation.
The facility failed to implement proper infection control measures, including the lack of clothing protectors for laundry aides, improper cleaning of a shared blood pressure cuff between residents, and incorrect signage for a resident on contact isolation. These deficiencies were observed during a survey, highlighting lapses in adherence to infection prevention protocols.
A facility failed to ensure a resident had the necessary physician's orders and assessments for self-administration of medication. A cognitively intact resident was observed with a fluticasone nasal spray on her bedside table, which she used independently without documented physician's orders, care plan, or self-administration assessments. The facility's policy requires an IDT evaluation and physician's order for self-administration, which were not documented.
A facility failed to notify a resident's family or representative about new medication orders, despite the resident being severely cognitively impaired. The resident had multiple diagnoses and received several new medications, but the facility did not inform the family as required by policy. Attempts to contact the resident's daughter were unsuccessful, yet the policy mandates such notification.
The facility failed to conduct quarterly care plan meetings and invite family representatives for three residents. One resident's POA was not invited due to possible address issues, while another resident, who was cognitively intact, was unfamiliar with care plan meetings. A third resident had no care plan meeting since admission, and the Social Service Director admitted to not holding the required meeting. The facility's policy to include residents and representatives in care planning was not followed.
The facility failed to provide adequate ADL care for three residents, as evidenced by a lack of documentation and observed deficiencies. A resident reported that staff never checked his brief, and records showed multiple instances of undocumented urinary continence care. Another resident experienced delays in incontinence care, with inconsistent documentation of her continence status. A third resident was observed with long, dirty fingernails and toenails, despite records indicating nail care was part of his routine. The DON confirmed the need for regular checks and documentation.
The facility failed to administer blood pressure medication within prescribed parameters for a resident with heart conditions, neglected to assess and document a bandage on a resident at risk for bleeding, and did not ensure a resident wore heel protectors as ordered. These deficiencies highlight lapses in medication administration, monitoring, and adherence to care plans.
A resident with impaired hearing was not provided necessary services, despite being observed to be hard of hearing and expressing a need for hearing aids. Facility staff were aware of the resident's hearing difficulties, but no care plans or audiology visits were documented, contrary to facility policy.
A resident with a contracted right hand was observed without the recommended splint over several days, despite an Occupational Therapy Discharge Summary advising its use. The facility lacked a current physician's order for the splint, and the recommendation was not communicated to nursing staff, leading to a failure in providing necessary treatment to prevent decreased range of motion.
A resident with dysphagia and severe cognitive impairment did not receive the prescribed adaptive equipment during meals. Despite the dietary care plan specifying no straws and the use of a 2 handled mug, the resident was observed with a Styrofoam cup with a straw and other inappropriate drinking vessels. The resident's medical conditions, including hemiplegia and hemiparesis, required the use of adaptive equipment to aid in self-feeding.
A resident with cognitive impairment and multiple diagnoses was observed with inconsistent oxygen administration, as the nasal cannula was often misplaced while the oxygen concentrator was running. Despite the use of oxygen, there were no physician orders or documentation in the resident's records. Interviews with staff confirmed the absence of current oxygen orders, contrary to the facility's policy requiring such orders.
A resident with hemiplegia and vascular dementia did not receive scheduled doses of hydrocodone-acetaminophen due to medication unavailability at the facility. Despite being cognitively intact and having a care plan for pain management, the resident missed multiple doses over June and July. Progress notes showed the facility was aware and had communicated with the pharmacy and doctor, but delays persisted due to the need for a new prescription.
The facility failed to ensure correct PPE was used by a CNA when providing care to a resident on Enhanced Barrier Precautions (EBP). The CNA was unaware of EBP requirements and initially only donned gloves without a gown. The resident had diagnoses including stroke and end-stage kidney disease with a dialysis port, necessitating EBP. The facility had conducted inservice training on EBP, but staff attendance was inconsistent.
The facility failed to provide timely incontinence care for two residents, both of whom were severely impaired and dependent on staff for toileting hygiene. Observations revealed that the residents were not checked or changed at least every two hours as required, leading to them being found in soiled briefs with bowel movements and urine. Documentation for incontinence care was also found to be inconsistent and lacking.
Failure to Notify Physician and Responsible Party of Changes in Condition
Penalty
Summary
The facility failed to ensure the physician and responsible party were notified of changes in condition for two residents. One resident with diagnoses including bipolar disorder, dementia, Alzheimer’s disease, and violent behavior had a severely impaired cognitive status and exhibited repeated verbal and physical aggression toward staff on multiple occasions. The record showed unsuccessful interventions, but there was no documentation that the responsible party was notified of the increase in behaviors before a referral was sent to a behavioral hospital. The resident was later accepted and transferred to the behavioral hospital, and the responsible party was notified by voicemail after acceptance. The same resident also had left wrist swelling with pain, the physician was notified, and an x-ray was ordered, but there was no documentation that the responsible party was notified of the swelling or the x-ray order. Another resident with dementia and diabetes mellitus had a physician order to notify the physician if blood sugar was less than 60 or above 400, and blood sugars were to be monitored before meals and at bedtime with Humalog given per sliding scale. A blood sugar result was documented as 44, but there was no documentation that the physician or POA was notified of the low blood sugar. Facility guidance received as current indicated the physician was to be notified for blood sugar below 60 unless otherwise ordered, and that notification was to be documented in the clinical record. The facility’s change in condition policy also stated that the physician and responsible party were to be notified when there was a significant change in condition or a decision to transfer the resident.
Failure to Complete Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure ordered laboratory services were completed for 2 residents. One resident with diagnoses including dementia and Alzheimer's disease had a physician order for a urinalysis with culture and sensitivity, but the resident was incontinent and a urine sample was not obtained; there was no documentation that the sample was later collected or that the UA with C&S was completed, and the DON stated the physician had not been notified that the test was not completed. Another resident with diagnoses including diabetes mellitus and chronic kidney disease had physician orders for monthly CMP and CBC testing and a lipid panel every 3 months, but the last CMP and CBC results in the record were from earlier in the year and the last lipid panel result was also not current; the DON stated the laboratory tests had not been completed as ordered and that the order was supposed to be changed to every 3 months but was not entered by the Unit Manager.
Incomplete Documentation of Hypoglycemia Treatment
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident with diabetes mellitus who had repeated episodes of low blood sugar. For one episode, the resident’s blood sugar was documented as 44, but the MAR did not show that ordered hypoglycemia treatments such as glucagon or Glutose gel were given, and the resident’s treatment and status were not documented in the medical record. A follow-up blood sugar was documented as 189 shortly afterward. During interviews, the Regional Nurse Consultant stated the 44 reading may have been a documentation error, and the DON stated the LPN who documented the blood sugar was no longer employed at the facility. The record also showed other hypoglycemia-related orders, including instructions to notify the physician for blood sugars below specified thresholds and to administer glucagon or oral glucose products as needed. Another episode showed a blood sugar of 44 with the resident awake but unable to follow commands; attempts to raise the blood sugar per physician orders were unsuccessful, the physician was notified, EMS was called, and EMS treated the hypoglycemia, with the blood sugar later documented as 166. However, the MAR for that month did not indicate that any of the hypoglycemia treatments had been used. An LPN stated the resident could not hold anything in his mouth and that glucose tablets brought in by the family were used, while the facility guideline stated that if the resident was unable to swallow, the physician should be notified and glucagon prepared from the emergency drug kit, with findings, interventions, and physician contact documented in the clinical record.
Failure to Provide Complete Discharge Information and Documentation
Penalty
Summary
The facility failed to provide required discharge information and documentation to a resident at the time of discharge. Resident G, who had diagnoses including hemiparesis and hemiplegia following a cerebrovascular accident and chronic obstructive pulmonary disease, was admitted on an unspecified date and discharged on 2/14/26. A psychosocial note dated 2/11/26 documented that the resident was notified their last covered day would be 2/13/26, but there were no additional notes regarding the resident actually being discharged or what discharge instructions were provided. A Discharge Planning Review dated 2/14/26 was signed by the resident, but only the first two sections were completed; the remaining sections, including medications and follow-up visits, were left blank. During interviews, the Social Service Director stated the resident was discharged home and that a home health referral had been made, but there was no documentation of this referral in the resident’s record, only an email related to the referral. The Director of Nursing stated that at discharge, residents should receive a discharge summary, a list of medications, any equipment orders, and there should be a progress note in the record, but such documentation was not present for this resident. The facility’s “Discharge summary” policy required that when discharge is anticipated, the resident must have a discharge summary including a recapitulation of the stay and reconciliation of pre-discharge and post-discharge medications, which was not fully completed or documented for Resident G.
Failure to Provide Timely Eating Assistance to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living, specifically eating, to a dependent resident. On the morning of 2/26/26, the resident was observed in bed with an uncovered breakfast tray containing scrambled eggs, hot cereal, a muffin, milk, and orange juice placed on a tray table. At 8:16 a.m., the tray was present and there were no attempts by the resident to feed herself. By 8:24 a.m., the tray remained in front of her; her left hand fingers were in the scrambled eggs, and she exhibited hand tremors when raising her fingers from the plate. She was unable to communicate whether she required help to eat, and there were still no attempts made by her to feed herself. At 8:45 a.m., the tray was still in place, the hand tremors continued, the scrambled eggs had been mixed into the hot cereal bowl, and there continued to be no attempts by the resident to feed herself. CNA 1 later indicated that the resident was a new admission who required assistance with meal intake and stated she would assist the resident. At 8:49 a.m., CNA 1 was observed at the bedside attempting to feed the resident and reported that the resident did not seem like she wanted to eat, though the resident did take a sip of orange juice. CNA 1 did not reheat the food or obtain a new breakfast tray despite the elapsed time. Later that day, a family member was observed assisting the resident with her lunch meal and stated the resident was dependent for meal intake. Record review showed the resident had diagnoses including Parkinson’s disease and dementia and had been admitted on 2/25/26. A Baseline Care Plan dated 2/25/26 documented that the resident required physical assistance of one person for eating, and a Functional Abilities and Goals assessment from the same date indicated the resident was dependent for eating.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatments for a resident with pressure ulcers on the coccyx and left heel who had adult failure to thrive, significant cognitive deficits, and required substantial to maximum assistance for bed mobility. A physician’s order dated 12/20/25 directed daily cleansing of the coccyx wound with normal saline, application of calcium alginate, and coverage with a dry dressing; however, the January 2026 Treatment Administration Record showed this treatment was not signed out as completed on 1/5 and 1/7. For the left heel wound, multiple physician’s orders were in place over time, including orders for cleansing with normal saline, application of calcium alginate, securing with Kerlix on specific days of the week, and later adding triple antibiotic ointment to the peri-wound area before applying calcium alginate and a dry dressing. These orders were revised and discontinued on several dates, with a final order for daily treatment starting 1/31/26. The January and February 2026 Treatment Administration Records indicated the left heel wound treatments were not signed out as completed on 1/5, 1/7, 1/25, 1/31, 2/9, 2/16, and 2/17. During interview, the Wound Nurse stated she did not know why the treatments were not completed on those dates and noted that some February dates corresponded with hospice visits, but hospice records requested were not received. The facility’s Wound Dressing Change policy required documentation of dressing changes on the treatment record.
Failure to Complete Timely Nutritional Assessments for Two Residents
Penalty
Summary
The facility failed to complete timely nutritional assessments for two residents, resulting in incomplete medical records that did not meet accepted professional standards. Resident B, who had diabetes mellitus, was admitted on 1/28/26 and discharged on 2/13/26; a care plan dated 2/10/26 documented poor appetite and frequent refusals of meals, yet there was no documentation in the record that a nutritional assessment had been completed to evaluate this resident’s nutritional needs. Resident C, who had dementia, was admitted on 1/19/26 and discharged on 2/5/26; an admission MDS dated 1/26/26 indicated a deep tissue injury pressure ulcer was present on admission, and a care plan dated 2/2/26 documented difficulty chewing and swallowing some foods with a moderate appetite, but there was likewise no documentation of a nutritional assessment to evaluate this resident’s nutritional needs. During an interview, the RD stated she was behind and did not have enough hours at the facility to ensure nutritional assessments were completed in a timely manner.
Unsafe Food Handling and Improper Food Storage
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions in the main kitchen and A Wing. During a kitchen sanitation tour, Dietary staff were observed handling food with improper glove use and bare hands: one Dietary staff member wore a glove on only one hand and used the bare hand to reach into a pan of cheese and cracker crumbs and place them on turkey noodle casserole. A Dietary aide standing nearby had facial hair and was wearing the beard guard lowered around his neck. The convection oven was dirty inside with dried food spillage, the walk-in cooler had dried milk spillage under the milk crates, the freezer floor had a large amount of ice buildup, and the steam table hood had grease, grime, and dirt. Another unused steam table contained food crumbs and debris in all four pans, and a non-functioning plate warmer was dirty with clean plates stacked on top of it. During the noon meal, the same Dietary staff member was observed serving residents while wearing gloves on both hands and handling plates, utensils, lids, and other items. She also used a gloved hand to move food on a plate after touching other items with those gloves. When a CNA requested a hot dog for a resident, she wore one glove and had the other hand bare, handled utensils and plates, then used the gloved hand to remove a hot dog bun from a plastic bag and assemble the hot dog for the resident. In the A Wing nourishment refrigerator, surveyors found an open bottle of iced tea, cake, strawberries, and a banana with no name or date on them. The Administrator had no additional information to provide, and the facility policy stated resident foods and beverages shall be labeled with the resident's name and dated.
Unsafe and Poorly Maintained Kitchen and Resident Areas
Penalty
Summary
The facility failed to keep the kitchen and resident environment clean and in good repair. During the kitchen sanitation tour, the dish room walls had dried food spillage, the floor drains under the dish machine were dirty with a large accumulation of dirt and debris, the floor tile grout near the steam tables was discolored, there was a moderate amount of adhered dirt and debris against the baseboard by the steam tables, there was a large amount of food spillage on random walls and areas on the ceiling, and the ceiling vent was dusty, dirty, and rusted over. During the environmental tour, Room A02 had a basin on the bathroom floor in the corner where a pipe was located, a hole in the wall with visible water damage to the adjacent wall area, and a grab bar next to the toilet that was not securely connected to the wall; one resident used the bathroom. Room B01 had a marred wall next to the resident's bed. Room B08 had 3 uncontained basins on the bathroom floor and visible water damage on the wall next to the toilet; one resident used the bathroom.
Failure to Treat and Monitor Skin Conditions
Penalty
Summary
The facility failed to ensure a surgical incision was treated as ordered for a resident with a history of aortocoronary bypass graft, atherosclerotic heart disease, and type 2 diabetes mellitus. The resident had a surgical wound on the chest, and the physician ordered the incision to be cleansed daily with antiseptic soap and water and left open to air unless drainage was present. Although the wound nurse assessed the incision and documented that it had no odor, no signs of infection, and no drainage, the August 2025 medication and treatment records did not list the treatment and it was not signed out as completed. The DON later stated the wound nurse said she completed the treatment but did not document it on the medication or treatment records. The facility also failed to assess and monitor bruising and scabbing for a resident with Parkinson's disease and anemia. The resident was observed with fading bruises on the right hand, and the bruising remained on a later observation. The record showed the resident was to have weekly skin assessments, but the skin assessment scheduled for 11/18/25 was coded as hospitalized even though the resident was not in the hospital. There was no current care plan related to the bruising, and the unit manager stated the bruising was most likely from a lab draw and should have been monitored. A similar failure occurred for another resident who was observed with a fading bruise on the left hand and a scabbed area on the right knee, and the resident could not state how the areas were obtained. The resident had a history of falling and was on anticoagulant therapy that had recently been changed to aspirin. The care plan called for daily skin inspections and reporting abnormalities, but the weekly skin assessment documented no new skin issues. In addition, the facility did not have interventions or treatments in place for dry, scaly skin on one resident's legs or for another resident's psoriasis, despite repeated observations of dry, flaky, patchy skin and the residents' reports of discomfort and itching.
Improper medication storage and bedside medications
Penalty
Summary
The facility failed to ensure proper medication storage when loose pills were observed in the medication drawers of the A Wing medication carts, and insulin products were found opened without proper dating. During observation, the C hall and B hall medication carts contained many loose pills in all drawers. The B hall cart also contained an opened multiuse vial of Humulin Regular insulin with no date and an opened multiuse vial of Lantus insulin with an open date of 10/8/25; an opened Lantus insulin pen was also present with a date opened. The LPN observed with the carts stated she was aware insulin vials and pens should be dated after opening, and the DON later stated they should have been dated after opening. The facility policy stated opened medications should follow manufacturer guidelines for expiration dates and that the date opened should be recorded when medications have a shortened expiration date once opened. The facility also failed to keep medications from being stored at the bedside for residents who did not self-administer. Resident G, who had diagnoses including subarachnoid hemorrhage and psoriasis, had a bottle of Debrox earwax remover and a bottle of nystatin powder on the nightstand during multiple observations. The record showed a current order for nystatin external powder but no current order for Debrox, and there were no orders or assessments for self-administration. An LPN stated the resident did not self-administer medications and that Debrox had been left in the room about a month earlier. Resident 71, who had diagnoses including COPD, diabetes, and a left below-the-knee amputation, had a bottle of nystatin powder on top of the refrigerator during multiple observations. The record showed a physician's order for nystatin external powder, but there were no orders or assessments for self-administration, and the LPN stated the resident did not self-administer medications.
Failure to Follow Pureed Spinach Recipe
Penalty
Summary
The facility failed to follow the recipe for pureed spinach during meal preparation for residents receiving a pureed diet. During observation, Dietary staff prepared pureed spinach by placing six scoops of cooked spinach into a blender, then adding an unmeasured amount of chicken broth and later additional unmeasured chicken stock. The staff member also added an unmeasured amount of Thick and Easy food thickening agent multiple times while blending and stirring the mixture. The pureed spinach was then poured into a pan and covered. During interview, the dietary staff member stated he had read the recipe before preparing the spinach, but the recipe for 5 servings called for one pound and 13 ounces of spinach, 3/4 ounce of margarine, and 1/8 teaspoon of salt, and did not include chicken broth or food thickener. The Dietary Food Manager stated the cook should have followed the recipe.
Failure to Assess and Remove a Hospital IV Line Promptly
Penalty
Summary
The facility failed to ensure an IV access site was assessed on admission and removed in a timely manner for one resident admitted with a peripheral IV line from the hospital. The resident had diagnoses including aortocoronary bypass graft, atherosclerotic heart disease, and type 2 diabetes mellitus, and the Medicare 5-day MDS indicated moderate cognitive impairment. The admission nursing assessment documented that the resident did not have an IV present, and the hospital after-visit summary also had no documentation related to an IV access site. However, nursing notes on the day of admission and the following day documented multiple small bruising areas related to IV insertion without stating whether the IV access was still present. A physician progress note later stated the resident had a peripheral IV line from the hospital that the hospital did not remove, and a physician order was entered several days later indicating it was okay to remove the peripheral IV site. Another nursing note documented the resident still had the peripheral IV line from the hospital, and the IV was removed after the order was obtained.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications and did not have physician orders for medications found at the bedside. On 11/17/25, 11/18/25, and 11/20/25, surveyors observed a bottle of nasal spray, refresh eye drops, clotrimazole ointment, and Neosporin ointment on the resident’s over-bed table and nightstand. The resident, identified as Resident 59, had diagnoses including type 2 diabetes mellitus, congestive heart failure, and hypertension, and the annual MDS dated 9/15/25 indicated the resident was cognitively intact. The record review showed a care plan updated 10/7/24 stating the resident had a physician’s order for unsupervised self-administration of medications, but no medications were listed. A self-administration assessment dated 7/16/24 indicated the resident would not be self-administering any medications, and there were no other self-administration assessments. A physician’s order dated 7/16/24 stated the resident could self-administer medications with facility assistance to set them up, but there were no physician’s orders for the clotrimazole ointment or Neosporin ointment. During interview, the DON stated the resident’s daughter sometimes brought medications in without informing the facility.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for Resident 71, who was able to use it. During multiple observations, the resident was sitting in his wheelchair next to his bed while the call light pad was clipped onto its cord on the wall on the opposite side of the bed. Resident 71’s record showed diagnoses of COPD, diabetes, and a left below-the-knee amputation. The Quarterly MDS dated 10/21/25 indicated the resident was cognitively intact for daily decision making and required moderate assistance with ADLs. The DON stated during interview that the resident was able to use the call light and that it should have been kept in his reach.
Inaccurate MDS Vision Assessment
Penalty
Summary
The facility failed to ensure the MDS comprehensive assessment was accurately completed for a resident with sensory/communication needs related to visual impairment. During observation, the resident was found in bed with a blanket over his head and stated he kept his head under the blanket because it was comfortable and he could not see the television because he was blind. Record review showed diagnoses including heart failure, pain, and vascular dementia, and the quarterly MDS dated 8/11/25 indicated severe cognitive impairment, dependence in ADLs, and adequate vision. However, an Interdisciplinary Team Note dated 6/9/25 identified vision impairment as a contributing factor to a recent fall, and a physician H&P dated 4/21/25 stated the resident was blind. Staff interviews confirmed the resident was legally blind, including an LPN and the DON, while the MDS Coordinator was informed of the finding and offered no further information.
Failure to Provide Nail Care Assistance
Penalty
Summary
The facility failed to ensure a dependent resident received assistance with ADLs related to nail care. Resident C, who had diagnoses including dementia, diabetes, and hypertension, was assessed as mildly cognitively impaired and dependent on staff for assistance with bathing and personal hygiene. The resident’s care plan indicated she required assistance with ADLs, including personal hygiene, dressing, and grooming as needed, and a later care plan noted scattered scabs to her skin with an intervention to keep fingernails short. During observations on 11/17/25 and 11/18/25, Resident C was lying in bed and her fingernails were noted to be jagged and uneven with dark debris underneath. The DON was informed of the condition of the resident’s fingernails during an interview on 11/21/25, and no further information was provided.
Failure to Provide Foot Care and Podiatry Services
Penalty
Summary
The facility failed to ensure residents received foot care and routine podiatry visits for 3 of 5 residents reviewed for ADLs. Resident C, who had diagnoses including dementia, diabetes, and hypertension and was dependent on staff for bathing and personal hygiene, was observed with long, thick toenails, dry scaly feet, and a dried dark red substance under the left great toenail on multiple observations. Although the physician's order summary allowed podiatry services, there were no podiatry consultation notes in the record, and the DON was unsure whether the resident had seen the podiatrist. The Social Service Director stated that a care plan meeting had just been held with the family and podiatry services were offered then, with consent to be signed by the family. Resident 33, who had diagnoses including type 2 diabetes mellitus, hypertension, and hypothyroidism and was cognitively intact, reported that his toenails were very long and thick and that he had requested multiple times to see the podiatrist after signing consent in September. His record also lacked podiatry consultation notes, and the Social Service Director stated she was unaware he wanted to see the podiatrist. Resident G was observed wearing shoes without socks and stated her feet hurt when her shoes were on because her toenails were too long; her toenails remained long on repeated observations. Her record lacked documentation of foot care provided or refused, and the Social Service Director stated she had not received podiatry services because they were private pay, though they could be obtained if the resident wanted to pay for them.
Failure to Provide Ordered Splints and Palm Protectors
Penalty
Summary
The facility failed to provide treatment for limited range of motion for 3 of 4 residents reviewed for ROM. One resident with diagnoses including CHF, COPD, atrial fibrillation, and left-sided hemiplegia was observed on multiple occasions with the left hand in a fist and no splint in place, despite a care plan and physician order directing that a left upper extremity resting hand splint be worn in the morning and evening as tolerated. The resident stated staff did not usually put anything on or in the hand, and the TAR showed the splint signed out as on daily with no refusals documented. The DON was informed that the splint had not been in place as ordered, and later stated the resident was physically able to remove it himself and would do so at times. A second resident with Parkinson's, stroke, and epilepsy, severe cognitive impairment, and dependence for ADLs and transfers was observed repeatedly with contracted hands, long fingernails, and no palm protectors in place, although a physician's order and care plan called for palm protectors to both hands. The record lacked documentation that the palm protectors were used or refused, and an LPN and the DON were unaware of the protectors. A third resident with heart failure, pain, and vascular dementia was observed with a contracted right arm and a splint in the right hand, but the record lacked documentation of splint removal and skin assessments underneath. The restorative care coordinator stated the resident was not receiving restorative care, and the DON stated splint application and removal were usually documented on the TAR.
Fall precautions not in place for resident with history of falls
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident with a history of falls. Resident 60 had diagnoses including type 2 diabetes mellitus, hypertension, and nontraumatic subarachnoid hemorrhage. The Quarterly MDS dated 10/30/25 indicated she was cognitively intact, required supervision with bed mobility and transfers, needed partial/moderate staff assistance with walking, used a wheelchair, and had two or more falls since the prior assessment. Her care plan, updated 8/22/25, identified her as high risk for falls and included interventions such as non-skid strips next to the bed, anti-tippers on the wheelchair, Dycem to the wheelchair cushion, and placing the bed in the lowest position. During observations on 11/17/25, 11/18/25, and 11/20/25, Resident 60 was seen getting out of bed unassisted, lying in bed with the bed not in the lowest position, and using a wheelchair without the identified fall interventions in place. Specifically, there were no non-skid strips by the bed, no Dycem on the wheelchair seat, and no anti-tippers on the wheelchair. The resident's chart also identified her as a fall risk due to transferring herself without assistance, and a Fall IDT note dated 9/24/25 documented an unwitnessed fall while she attempted to self-transfer from her wheelchair to her bed. During interview, the DON was made aware that the fall interventions were not in place.
Urinary catheter bag not maintained below bladder level
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter collection bag was maintained below the level of the bladder for 1 of 3 residents reviewed for urinary catheters. Resident 71 had diagnoses including COPD, diabetes, and a left below-the-knee amputation. The Quarterly MDS dated 10/21/25 indicated the resident was cognitively intact for daily decision making, required moderate assistance with ADLs, and had an indwelling urinary catheter. The care plan dated 5/4/24 identified the catheter and included an intervention to position the catheter bag and tubing below the level of the bladder. During multiple observations on 11/17/25, 11/19/25, 11/20/25, and 11/21/25, the resident was seen sitting in his wheelchair next to his bed or propelling himself in the hallway, and the urine collection bag was hooked on the side of the wheelchair near waist level. Multiple staff members walked by while the bag remained in that position. During interview on 11/21/25, the DON stated the urine collection bag should be maintained lower than the level of the bladder. The facility policy titled Urinary Catheter Care stated catheters shall be positioned to maintain a downhill flow of urine to prevent back flow into the bladder or tubing.
Improper positioning during tube feeding
Penalty
Summary
A resident with diagnoses including Parkinson's disease, stroke, vascular dementia, and epilepsy was found to be receiving a tube feeding while lying nearly flat in bed during a random observation. The resident's record showed severe cognitive impairment, dependence in ADLs and transfers, and a physician's order to keep the head of the bed elevated 30 to 45 degrees during tube feeding and for 1 hour after completion unless contraindicated. The care plan also identified the resident as at risk for complications related to dysphagia and directed that the head of the bed be elevated 45 degrees during and 30 minutes after tube feeding. The facility failed to ensure the resident was positioned with the head of the bed elevated while the feeding was infusing.
Incorrect Oxygen Flow Rates for Two Residents
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for 2 of 3 residents reviewed for oxygen administration. Resident 1 had diagnoses including CHF, COPD, and atrial fibrillation, was cognitively impaired, dependent on staff for all ADLs, and received oxygen therapy. The resident’s care plan and physician order required oxygen at 3 L via nasal cannula continuously and 5 L when lying down. However, on observation the resident was lying in bed with oxygen flowing and the concentrator set at 3.5 liters on two separate occasions. The MAR/TAR for 11/2025 showed oxygen signed out as administered every shift, but there was no documentation of refusals and no indication whether the flow rate was 3 L or 5 L. Resident 9 had diagnoses including CHF, type 2 diabetes mellitus, and vascular dementia, was cognitively impaired, dependent on staff for all ADLs, and received oxygen therapy. The resident’s care plan and physician order required oxygen at 3 L continuously. On two observations, the resident was lying in bed with a nasal cannula in place, oxygen flowing, and the concentrator set at 3.5 liters. The MAR/TAR for 11/2025 showed oxygen signed out as administered every shift. During interview, the DON was made aware that the oxygen was at the incorrect flow rate.
Failure to Monitor Blood Pressure Before Administering Ordered Medications
Penalty
Summary
The facility failed to ensure blood pressure monitoring was completed for residents receiving blood pressure medications with ordered parameters. One resident with diagnoses including Parkinson's disease and hypertension had a care plan noting risk for complications related to hypertension. The physician ordered Losartan Potassium 100 mg daily with instructions to hold if systolic blood pressure was less than 110 and notify the physician, but the resident's blood pressure was not obtained before the medication was administered on multiple occasions across August, September, October, and November 2025. During interview, the B Wing Unit Manager stated the resident's blood pressure should have been checked before the medication was given. A second resident with diagnoses including aortocoronary bypass graft, atherosclerotic heart disease, hypertension, and syncope and collapse had a care plan noting risk for complications related to hypotension. The physician ordered Midodrine HCl 5 mg three times daily for hypotension with instructions to hold if systolic blood pressure was above 130, but the resident's blood pressure was not obtained before the midday dose was given on four consecutive days in August 2025. During interview, the DON stated the resident's blood pressure should have been checked prior to giving the midday dose of Midodrine.
Resident Left on Soiled Bedding Without Timely Care
Penalty
Summary
A resident with diagnoses including diabetes mellitus and psoriasiform dermatitis was observed lying on a bed with a soiled bottom sheet containing dry skin flakes, dark specks, and discoloration spots. The resident reported needing to be changed and stated she had not received care since the previous night. Observations revealed her skin was scaly and shedding from her shoulders, arms, torso, and legs, with a significant amount of dried skin present on the sheet. Certified Nursing Assistants (CNAs) confirmed that care had not been provided to the resident prior to the observation that morning, despite the resident requiring maximum assistance for bathing, hygiene, and bed mobility as documented in her assessment. The electronic medical record indicated the last incontinence check was the previous evening, with no applicable care documented for the early morning hours.
Lack of Comprehensive Care Plan for Resident with Skin Condition
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident diagnosed with psoriasiform dermatitis. During observations, the resident was found lying in bed with scaly, shedding skin on her shoulders, arms, torso, and legs, and there were visible dry skin flakes and dark discoloration spots on the bed linens. The resident expressed a need to be changed and indicated discomfort. Certified Nursing Assistants confirmed the presence of a skin condition and provided care, but the resident's record review revealed no care plan addressing the skin condition. The resident's diagnoses included diabetes mellitus and psoriasiform dermatitis, and a physician's order was in place for the application of Tacrolimus cream to affected areas twice daily. Despite this, the care plan did not reflect interventions or monitoring related to the skin condition. The deficiency was confirmed when the Director of Nursing was notified, and no care plan had been provided by the end of the survey.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including diabetes mellitus and psoriasiform dermatitis did not receive timely assistance with activities of daily living, specifically incontinence care. On the morning of the survey, the resident was observed lying in bed, expressing discomfort and stating she had not received care since the previous night. Upon entering the room, two CNAs found the resident with a saturated incontinence brief and a large amount of dried, dark, and reddish/pink drainage on the incontinence pad. The resident exhibited pain during care and requested to be left alone. The CNAs reported the resident's pain and request to an LPN, who confirmed that routine pain medication had been administered earlier that morning. Further review of the resident's care plan indicated that incontinence care was to be provided after each episode and during routine rounds. The resident's assessment showed she required maximum assistance for bathing, hygiene, and bed mobility, and was dependent for toileting, with frequent incontinence. Documentation revealed the last recorded incontinence check was the previous evening, with no applicable entry for the early morning. The wound nurse later clarified that the drainage from the resident's pressure ulcer would not have been sufficient to account for the amount observed on the pad. Facility policy required routine assistance with incontinence care, including changing briefs, providing peri-care, and changing clothing and bed linens.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
A deficiency was identified when a resident with a history of diabetes mellitus and psoriasiform dermatitis was observed to have multiple pressure ulcers without the required dressings in place. During care, staff noted open areas on the left hip, lower back/sacrum, and right buttock, with the right buttock showing bloody drainage. Certified nursing assistants (CNAs) reported that they were not informed by the previous shift about missing dressings, and no dressings were found in the resident's brief or linens. The wound nurse stated that treatments had last been completed several days prior, and the physician's orders required dressings to be changed if soiled or dislodged, as well as on a scheduled basis. Record review revealed that physician's orders specified wound care regimens for the sacrum, right buttock, and left hip, including cleansing, drying, and application of hydrocolloid or foam dressings at specific intervals and as needed. Documentation showed that some scheduled treatments were not completed as ordered, and there was no record of as-needed treatments being performed when dressings were missing. The care plan indicated that wound care should be provided as ordered, but observations and interviews confirmed that the required treatments were not consistently in place, resulting in a failure to follow physician orders for pressure ulcer care.
Failure to Administer Diabetes Management as Ordered
Penalty
Summary
The facility failed to ensure that three residents with diabetes mellitus received blood sugar monitoring, insulin, and hypoglycemic medications as ordered by their physicians. For one resident, multiple instances were documented where blood sugar levels were not obtained at scheduled times, and insulin was either not administered or marked as refused without corresponding blood sugar results. In several cases, the Medication Administration Record (MAR) indicated that blood sugar monitoring was not completed or not documented, and insulin doses were coded as non-applicable or refused without supporting evidence. The Director of Nursing (DON) and Corporate RN Consultant confirmed that blood sugar results were not available for the dates in question, and the resident was later transferred to the hospital. Another resident's records showed that blood sugar monitoring was scheduled four times daily, but the MAR reflected that monitoring was marked as completed without actual results documented for numerous days. The Corporate RN Consultant acknowledged the lack of documentation for blood sugar results prior to a certain date. A third resident's records indicated missed blood sugar monitoring and missed administration of Metformin, a hypoglycemic medication, on several occasions. The DON was unable to verify that blood sugar testing or medication administration had been completed as ordered. These findings were confirmed through record review and staff interviews.
Failure to Prepare Pureed Food Correctly
Penalty
Summary
The facility failed to ensure that food was prepared in a form to meet individual needs, specifically concerning the preparation of pureed food. During an observation, a cook was seen preparing pureed broccoli for five residents on a pureed diet. The cook did not follow the recipe correctly, as she added an unknown amount of liquid and thickening powder to the broccoli, resulting in a watery consistency. Despite adding more thickener, the puree remained too thin. The Dietary Manager (DM) confirmed that the puree was not at the correct consistency and indicated that the cook should have added more thickening agent. The recipe for Pureed Broccoli specified the use of a certain amount of broccoli and margarine, with instructions to blend until smooth and add a thickening agent if necessary to achieve a pudding or soft mashed potato consistency. The facility's policy on pureed diets also emphasized the importance of achieving the correct texture by adding a measured amount of fluid or thickening agent. The DM acknowledged the error and mentioned plans to in-service the staff on proper preparation of pureed foods.
Infection Control Deficiencies in Laundry, Equipment Use, and Signage
Penalty
Summary
The facility failed to implement proper infection control measures in three distinct areas. Firstly, during an observation in the laundry room, it was noted that the Laundry Aide did not use any clothing protector while sorting soiled laundry, despite wearing gloves. The Laundry Aide mentioned she had never been instructed to use a clothing protector, and the facility's laundry policy did not address this issue. This lack of protective clothing could potentially expose staff to contaminants from the soiled laundry. Secondly, a Qualified Medication Aide (QMA) was observed using a shared blood pressure cuff on multiple residents without cleaning or disinfecting it between uses. The QMA acknowledged that she should have used a sani wipe to clean the cuff between residents, as per the facility's Infection Prevention and Control Program policy. Lastly, there was an issue with incorrect signage for a resident who was on contact isolation due to conjunctivitis. The signage did not clearly indicate the required personal protective equipment, and there was confusion about the resident's isolation status, as confirmed by interviews with staff members.
Failure to Ensure Proper Self-Administration of Medication Procedures
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician's orders and assessments for self-administration of medication. Specifically, a bottle of fluticasone nasal spray was observed on the bedside table of a resident who indicated she used it independently whenever she felt the need. Upon review of the resident's records, it was found that there were no physician's orders for the fluticasone spray, no care plan for its self-administration, and no self-administration of medication assessments completed. The resident involved was noted to be cognitively intact for daily decision-making, as indicated by the Quarterly MDS assessment. Despite this, the facility's policy on self-administration of medication requires an interdisciplinary team (IDT) to determine the safety of self-administration, completion of a Self-Administration of Medication Evaluation, and obtaining a physician's order. None of these steps were documented in the resident's care plan, indicating a lapse in following the facility's established procedures.
Failure to Notify Family of Medication Changes
Penalty
Summary
The facility failed to notify the family or representative of a resident regarding new medication orders, which is a requirement when there is a significant change in treatment. The resident in question, who was severely cognitively impaired, had multiple diagnoses including schizoaffective disorder, anxiety disorder, dementia with behavioral disturbance, and bipolar disorder. Despite the resident being aware of the new medication orders, the facility did not inform the family or legal representative as required by their policy. The resident's medical record showed several instances of new medication orders, including an antidepressant, a dementia treatment, and a smoking patch, as well as changes in dosage for anxiety medication. The Director of Nursing indicated that the resident was her own responsible party, and attempts to contact the resident's daughter had been unsuccessful. However, the facility's policy mandates notification of a family member or legal representative when there is a significant change in treatment, which was not adhered to in this case.
Failure to Conduct Care Plan Meetings and Invite Representatives
Penalty
Summary
The facility failed to ensure that quarterly care plan meetings were completed and that family representatives were invited for three residents. Resident D's Power of Attorney (POA) indicated that they had not been invited to a care plan meeting for a long time, and there was no documentation of a care plan meeting in 2024. The Social Service Director mentioned that invitations were sent out, but there might have been an issue with the address for the POA. Resident E, who was cognitively intact, stated he had not attended a care plan meeting and was unfamiliar with the process. The Social Service Director acknowledged that the resident was due for meetings in March and June, but they were not rescheduled after the resident's hospitalization. Resident B's record showed no documentation of a care plan meeting since admission, and there was no evidence of an invitation being sent to the resident or their representative. The Social Service Director admitted that no care plan meeting had been held with Resident B or their representative, despite the expectation to hold one within 72 hours of admission. The facility's policy emphasized the importance of including residents and their representatives in the care planning process, but this was not adhered to in these cases.
Deficiencies in ADL Care and Documentation
Penalty
Summary
The facility failed to provide adequate care for activities of daily living (ADLs) for three residents, as evidenced by a lack of documentation and observed deficiencies. Resident 10, who was cognitively intact and always incontinent of bladder, reported that staff never checked his brief for changes. The facility's records showed multiple instances where urinary continence care was not documented across various shifts. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that residents were supposed to be checked every two hours and documentation was required at least once per shift. Resident 4, also cognitively intact, reported delays in receiving incontinence care, with staff often turning off her call light and taking hours to return. Her records indicated she was always incontinent of bladder and frequently incontinent of bowel, requiring substantial assistance for personal hygiene. Documentation showed inconsistencies in marking her as incontinent, with some days only showing records twice per day, contrary to the expected frequency of every shift. The DON confirmed the expectation for CNAs to check and change residents every two hours and document accordingly. Resident C, who required total assistance with personal hygiene, was observed with long, dirty fingernails and toenails. He reported needing his nails trimmed and having to manually disimpact his stool, leading to dirty fingernails. Despite records indicating nail care was part of his routine, there was no documentation of toenail care. The DON acknowledged the need for staff to document nail care and confirmed that the resident required assistance for this task, although there was no record of him digging stool out or having constipation.
Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and treatment by administering a blood pressure medication, midodrine hcl, outside of the prescribed parameters. The medication was given to a resident with a history of atrial fibrillation, heart failure, hypertension, and orthostatic hypotension, despite the systolic blood pressure being above the threshold of 130 on multiple occasions. This oversight occurred repeatedly over a period of time, as documented in the Medication Administration Records for June and July 2024. Another deficiency involved a resident who had a bandage placed above her right wrist following a blood transfusion at the hospital. The facility did not have any documentation related to an assessment, monitoring, or physician's order for the bandage, nor was there a record of the reason for the bandage. The resident, who was on anticoagulant medication and at risk for abnormal bleeding, was observed with the bandage over several days without any intervention or removal by the facility staff. Additionally, the facility failed to ensure that a resident wore preventative heel protectors as ordered. The resident, who had hemiplegia, hemiparesis, and vascular dementia, was observed without heel protectors on multiple occasions, despite a physician's order for their use while in bed. The facility's records lacked documentation of whether the heel protectors were on, off, or refused, indicating a failure to monitor and adhere to the prescribed care plan for pressure relief and wound prevention.
Failure to Provide Necessary Hearing Services
Penalty
Summary
The facility failed to ensure that a resident with impaired hearing received the necessary services. Resident C, who was observed to be hard of hearing and reading lips during conversations, indicated a need for hearing aids. Despite this, there were no care plans related to hearing loss in the resident's records. The Annual Minimum Data Set (MDS) assessment had previously indicated that the resident was cognitively intact and had adequate hearing, which was inconsistent with the current observations and resident's statements. Interviews with facility staff, including the Social Service Director, Director of Nursing, LPN, and CNA, revealed that the resident's hearing impairment was known, yet no actions had been taken to address it. The Social Service Director was unaware of the resident's desire to see an audiologist, and the Director of Nursing acknowledged the resident's hearing difficulties but provided no further information. The CNA and LPN both noted the resident's reliance on lip-reading and difficulty hearing, yet no prior audiology visits were documented. The facility's policy required communication of hearing needs to the Director of Social Services, which was not followed in this case.
Failure to Implement Recommended Splint Use for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment to prevent decreased range of motion. This deficiency was identified when Resident D, who had a contracted right hand, was observed multiple times without the recommended hand splint in place. The observations occurred over several days, and the splint was noted to be hanging on the wall next to the resident's bed instead of being worn. The resident's medical history included hemiplegia, hemiparesis following a cerebral vascular accident, dysphagia, and a contracture of the right hand. The Occupational Therapy Discharge Summary from the previous year recommended that the resident wear a splint on the right hand with an established wearing schedule of four hours on and four hours off. However, there was no current or discontinued physician's order for the splint, and the recommendation was not communicated effectively to the nursing staff. The Therapy Director acknowledged that the recommendation was made by a PRN Occupational Therapist and was missed, indicating a lapse in communication and follow-up on the therapy recommendations.
Failure to Provide Adaptive Equipment for Resident with Dysphagia
Penalty
Summary
The facility failed to provide a resident with dysphagia the necessary adaptive equipment during meals, as ordered by the physician. On two separate occasions, the resident was observed without the prescribed 2 handled mug, which was intended to aid in self-feeding. Instead, the resident was provided with a Styrofoam cup with a straw, a cup of juice, and a cup of coffee, contrary to the dietary care plan that specified no straws and the use of a 2 handled mug. The resident's medical history included severe cognitive impairment, hemiplegia, hemiparesis following a cerebral vascular accident, dysphagia, and a contracture of the right hand, necessitating the use of adaptive equipment for safe and effective self-feeding. The oversight was noted despite clear instructions on the tray ticket and the dietary care plan.
Failure in Oxygen Administration for a Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically regarding oxygen administration. Observations over several days revealed inconsistencies in the use of the nasal cannula and oxygen concentrator. On multiple occasions, the nasal cannula was either not in place or improperly positioned, such as lying on the floor or hanging on a tube feeding pole, while the oxygen concentrator was running at 2 liters. These observations indicate a lack of adherence to proper oxygen administration protocols. The resident in question had diagnoses including atrial fibrillation, hypertension, and Parkinson's disease, and was noted to be cognitively impaired. Despite the use of oxygen, the resident's records, including the Physician's Order Summary and Medication Administration Record for July 2024, lacked any orders or documentation for oxygen administration. Interviews with the Director of Nursing and the Unit Manager confirmed that there were no current oxygen orders for the resident. The facility's policy on oxygen administration requires an order specifying the oxygen flow rate, delivery device, and indication for use, which was not followed in this case.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to ensure that pain medications were available and administered to a resident as per the physician's orders. Resident C, who was cognitively intact and diagnosed with hemiplegia, hemiparesis, and vascular dementia, reported missing scheduled doses of hydrocodone-acetaminophen due to the medication not being available at the facility. The resident's care plan included administering analgesia as per orders, but the June and July 2024 Medication Administration Records (MAR) showed multiple instances where the resident did not receive the prescribed medication. Progress notes indicated that the facility was aware of the medication unavailability and had communicated with the pharmacy and the doctor to obtain a new prescription. Despite these efforts, there were repeated delays in receiving the medication, as noted in several progress notes. The Director of Nursing confirmed that the delay was due to waiting for a new script from the doctor. This deficiency was related to a specific complaint, highlighting the facility's failure to provide timely pain management for the resident.
Failure to Use Correct PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member when providing care to a resident who was in Enhanced Barrier Precautions (EBP). During an observation, a sign indicating EBP was posted outside the resident's door, but no PPE was available either inside or outside the room. A Certified Nursing Assistant (CNA) entered the room, donned gloves, and began incontinence care without the required gown. Upon being stopped and reviewing the EBP sign, the CNA indicated she was unsure what EBP was and noted that PPE was usually available on a cart outside the door. The Administrator confirmed that more PPE containers had been ordered and that PPE was located at the end of the hallways. The Administrator also mentioned that inservice training on PPE/EBP had been completed and was mandatory, though attendance was inconsistent among staff. The CNA later donned a gown and gloves to complete the care after being informed of the requirements. Resident D, who was involved in the incident, had diagnoses including stroke and end-stage kidney disease with dependence on renal dialysis. A physician's order indicated that EBP was to be followed due to the resident having a dialysis port. The facility's EBP inservice, completed a few days prior, indicated that EBP required the use of gown and gloves during high-contact resident care activities. The facility's EBP guidelines, provided by the Administrator, also specified the use of gown and gloves during high-contact activities such as transfers, bathing assistance, and other close physical contact.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure dependent residents received timely assistance with activities of daily living (ADLs), specifically incontinence care, for two residents. During a random observation, a CNA was found to have neglected Resident B, who was severely impaired and dependent on staff for toileting hygiene. The resident was found with a large amount of bowel movement on the bed and his body, indicating he had not been checked or changed for several hours. The CNA admitted to not checking the resident at least every two hours as required. The resident's care plan indicated the need for assistance with toileting and routine care rounds at night, which was not adhered to, as evidenced by the lack of documentation on bladder elimination tasks for several days in the past month. Similarly, Resident C, who was also severely impaired and frequently incontinent, was found in a soiled brief with dark-colored urine and bowel movement. The CNA admitted to not checking the resident during the shift because she was sleeping. The resident's care plan required assistance with toileting and routine care rounds, which were not followed. Documentation for urinary incontinence was also found to be inconsistent and lacking for several days. Both the Nurse Consultant and the A wing Unit Manager confirmed that residents should be checked and/or changed at least every two hours, which was not done in these cases.
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 980 citations issued within 25 miles in the last 12 months — including the 6 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 Merrillville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Merrillville Care Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Spring Mill Health Campus | 0.6 mi | ★★★★★ | 21 | 0 |
| Colonial Nursing Home | 3.6 mi | ★★★★★ | 0 | 0 |
| Casa Of Hobart | 4.5 mi | ★★★★★ | 27 | 0 |
| Saint Anthony | 5.1 mi | ★★★★★ | 3 | 0 |
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