Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Rehabilitation Center At Hartsfield Village during CMS and state inspections, most recent first.
Posted swallowing-guideline sheets were observed in residents’ rooms and remained visible for multiple observations, including above beds and near a bathroom doorway, for residents with dx of Alzheimer’s disease, Parkinson’s disease, dementia, and dysphagia. The residents were cognitively impaired or severely impaired for daily decision making and received mechanically altered diets; none had a care plan related to posting personal care signs. During a noon meal observation, one resident received his tray last while other residents at the table and nearby tables were already eating, and a CNA then fed him.
Improper labeling and storage of insulin pens and a multi-dose vial were observed in the 1st Floor Medication Room and on three medication carts. An opened Tuberculin multi-dose vial was found in the refrigerator, and several insulin pens, including Lantus, Novolog, Humalog, and insulin lispro, were missing open dates or were only labeled with a room number. The DON was made aware of the concerns during interview, and facility policy required opened multi-dose vials and injectable medications to be labeled with the date opened and other required information.
A resident was observed keeping an AREDS tablet to take later instead of taking both tablets in the morning as ordered. The resident said staff kept giving both pills at once even though she had told them she took them at separate times at home. The chart showed diagnoses including CHF and acute respiratory failure, a nurse admission assessment noting the resident was cognitively intact but needed moderate ADL assistance, a physician order for PreserVision AREDS-2 twice daily in the morning with no self-administration order, and a self-administration assessment stating it was not appropriate for the resident to self-administer meds.
A resident wore a TLSO back brace for healing thoracic fractures, but the chart lacked a physician order for the brace, when it should be worn, or skin monitoring under the brace. Two other residents had bruising noted on assessment or observation, but the record lacked documentation and ongoing monitoring of the skin discolorations despite care plan directions and a physician order to document bruises.
Failure to Follow Swallowing Guidelines: Two residents with dysphagia were observed receiving meals and beverages in ways that did not follow posted swallowing guidelines. One resident with dementia and dysphagia was repeatedly eating in bed with straws in beverages despite instructions for assisted meals, small bites and sips, slow rate, and no straws. Another resident with Parkinson’s disease and dysphagia was observed with straws in multiple drinks, including Ensure and juice, despite a posted no-straw guideline and care plan directions for set-up and hands-on assistance.
Improper Foley Catheter Bag and Tubing Management: A resident with severe cognitive impairment, urinary retention, and an indwelling Foley catheter was repeatedly observed with the collection bag placed on the bed, under a blanket, under a wheelchair, and hooked on the bed frame, while the tubing was taut, stepped on, or pulled under the resident’s foot. The record lacked documentation of monitoring the tubing and urine collection bag, and staff were present during some of the observations.
Medication pass observations found a 16% error rate, with four errors in 25 opportunities involving two residents. An RN failed to ensure a resident rinsed after using a Breo Ellipta inhaler and gave an incorrect amount of Miralax after not determining the proper conversion for 17 grams. An LPN also failed to prime Lantus and Novolog insulin pens before administration, despite knowing priming was required.
A resident was found with a medication at her bedside without an assessment or physician's order for self-administration. The resident, who was cognitively intact and had multiple diagnoses, indicated the medication was given by a nurse. The ADON confirmed the lack of a self-medication assessment, contrary to the facility's policy.
A resident with a PICC line in the left upper arm did not have the dressing changed as ordered by the physician. The dressing was dated 8/26, and the facility's records lacked documentation of a required change on 9/2. An LPN confirmed the dressing had not been changed since the resident's admission, despite orders to change it weekly. The resident had significant cognitive impairment and required staff assistance.
An LPN failed to don a gown during a PICC dressing change for a resident under Enhanced Barrier Precautions, despite signage and available PPE. The resident had significant cognitive impairment and required staff assistance. The facility's policy required gloves and gowns for high-contact care activities.
The facility failed to conduct self-medication administration assessments for residents with medications at their bedside. Observations revealed that several residents had medications like inhalers, ointments, and glucose tablets in their rooms without proper assessments or physician orders for self-administration. The Assistant Director of Nursing confirmed that no residents were authorized to self-administer medications, highlighting a lapse in medication management procedures.
The facility failed to assess and monitor bruising and skin tears for four residents. A resident had a bruise on her hand that was not documented, despite weekly skin assessments. Another resident had a bruise from an IV insertion that was not recorded. A third resident had multiple bruises and a dressing on his arm without documentation. Lastly, a resident had a skin tear that was not documented, and staff were unaware of it during shift changes. These incidents indicate a lack of proper documentation and monitoring of skin conditions.
A resident's dignity was compromised when their foley catheter bag was left uncovered, allowing urine to be visible from the hallway on multiple occasions. Despite the facility's policy requiring catheter bags to be covered, this standard was not met, as confirmed by the ADON. The resident, who was cognitively intact and had several medical conditions, was observed with the uncovered catheter bag over several days.
Two residents with indwelling Foley catheters were observed with catheter bags and tubing improperly positioned on the floor, contrary to care plans and facility policy. One resident, with a history of sepsis and UTIs, was cognitively intact, while the other, with dementia, required assistance with toileting. Interviews confirmed the catheter care did not meet standards.
A facility failed to administer the correct oxygen flow rate for a resident with respiratory conditions. Despite a physician's order for 4 liters per minute, the resident's oxygen concentrator was consistently set at 3 1/2 liters. This discrepancy was observed over several days, indicating a failure to adhere to the prescribed oxygen therapy.
A resident with heart failure and high blood pressure received Verapamil outside of physician-ordered parameters, as the medication was administered despite systolic blood pressures being below the specified threshold. The MAR showed multiple instances of this non-compliance, and the Assistant DON acknowledged the nursing staff's failure to adhere to the physician's orders.
A facility failed to maintain accurate clinical records for a resident receiving dialysis. The resident's physician's order specified dialysis on certain days with specific times, but progress notes showed different days and times. This inconsistency was confirmed by the ADON, who noted the order had not been updated.
The facility failed to follow infection control practices during a blood sugar check for a resident, as an LPN did not sanitize hands between glove changes. Additionally, a Wound Nurse did not wear an isolation gown while treating a resident on contact precautions for C-Difficile. These actions were against the facility's policies, as confirmed by the ADON.
A facility failed to investigate and resolve grievances from a resident's family member. The resident's husband reported concerns about his wife's care, including being left in bed and missing activities. Despite filing a grievance, he received no written response. The facility's grievance policy requires written outcomes, but this was not followed. The administrator allowed staff to handle grievances without maintaining a log or tracking them, leading to the deficiency.
The facility failed to notify a resident's family of a significant change in condition and subsequent transfer to the hospital. The resident, who had multiple serious diagnoses, was found to be very lethargic and had labored breathing. Despite being assessed and sent to the emergency room, there was no documentation that the family was informed.
The facility failed to provide appropriate social services follow-up related to an outside allegation of exploitation and misappropriation for a resident. The APS representative indicated that they had contacted the assigned facility SW and left detailed voicemails, but received no further communication or documentation. The resident's record showed severe impairments and significant physical dependencies, but there was no social service documentation regarding the allegations or communication with APS. The SW formerly assigned to the resident no longer worked at the facility, and the DON was unaware of the situation.
Posted Swallowing Guidelines and Delayed Meal Service
Penalty
Summary
The facility failed to ensure personal care signs were not posted in residents’ rooms. A sheet of paper listing Resident 14’s swallowing guidelines was observed posted on the wall next to the bathroom doorway in the resident’s room and remained there on a later observation. Resident 14 had diagnoses including Alzheimer’s disease and dysphagia, was severely impaired for daily decision making, was dependent with eating, and received a mechanically altered diet. Resident 14 did not have a care plan related to posting personal care signs in the room. A similar swallowing-guideline sheet was observed posted above Resident 21’s bed and remained posted on a later observation. Resident 21 had Parkinson’s disease and dysphagia, was cognitively impaired for daily decision making, held food in the mouth or cheeks or had residual food after meals, and received a mechanically altered diet. Resident 21 also did not have a care plan related to posting personal care signs in the room. The same issue was observed for Resident 9, whose swallowing guidelines were posted above the bed during multiple observations over several days and remained in place. Resident 9 had dementia without behavior disturbance and dysphagia, was cognitively impaired for daily decision making, required set up or clean up assistance with eating, and received a mechanically altered therapeutic diet. Resident 9 did not have a care plan related to posting personal care signs in the room. In addition, during the noon meal observation, Resident 107 was seated in the dining room while other residents at the table and nearby tables ate before he received his tray. Resident 107 was the last resident to receive his tray and was then fed by a CNA. Resident 107 had dementia without behavior disturbance and dysphagia, was cognitively impaired for daily decision making, required substantial/maximum assistance with eating, held food in the mouth or cheeks or had residual food after meals, and received a mechanically altered therapeutic diet.
Improper Labeling and Storage of Insulin Pens and Multi-Dose Vials
Penalty
Summary
The facility failed to ensure proper medication storage and labeling for insulin pens and a multi-dose vial in the 1st Floor Medication Room and on three medication carts. In the 1st Floor Medication Room, an opened multi-dose vial of Tuberculin was observed in the refrigerator with an opened date recorded, and the vial label indicated it should be discarded after 30 days. On the D Wing 1st Floor medication cart, an insulin lispro pen and an insulin glargine pen were present with no open date. On the A Wing 1st Floor medication cart, a Novolog insulin pen, a Lantus insulin pen, and an insulin lispro pen were present with no open date, and the insulin lispro pen was only labeled with a room number. On the 2nd Floor D Wing medication cart, a Lantus insulin pen and an insulin lispro pen were observed with open dates recorded. During interview, the DON was made aware of the medication labeling and storage concerns. The facility policy for injectable medications stated that the date opened and initials of the first person to use the vial must be recorded on multi-dose vials, and the medication labels policy stated that injectable and liquid prescription medication labels should include required identifying information. The medication inserts for Lantus, Novolog, and Humalog indicated opened pens should be used within 28 days.
Self-Administration of Medication Not Supported by Order or Assessment
Penalty
Summary
The facility failed to ensure that a resident had both a physician's order and an assessment supporting self-administration of medications for one resident reviewed for this issue. During an observation, one AREDS tablet was seen in a medicine cup on the resident's overbed table, and the resident stated the nurse had given her two tablets but she was saving one to take later in the evening as she did at home. On a later observation, the resident was again found with an AREDS tablet wrapped in a tissue in the drawer of the overbed table, and she stated she had saved it from the morning medications so she could take it in the afternoon. The resident indicated she had told staff that she took the pills at separate times, but staff continued to bring both tablets in the morning. The resident's record showed diagnoses including congestive heart failure and acute respiratory failure. The nurse's admission assessment documented that the resident was cognitively intact for daily decision making and required moderate assistance with ADLs. A physician's order dated 8/9/25 directed PreserVision AREDS-2, 2 tablets once each morning, with no order for self-administration. The self-administration assessment dated 8/9/25 indicated it was not appropriate for the resident to self-administer any medications.
Missing Brace Order and Incomplete Bruise Monitoring
Penalty
Summary
The facility failed to ensure a Physician's Order was in place for a resident who was wearing a TLSO back brace for healing T2 and T3 wedge compression fractures. The resident was observed multiple times seated in her wheelchair with the black vest-like brace in place over her chest and back, and the hospital After Visit Summary indicated the brace was to be worn when out of bed. However, the Physician's Order Summary for 8/2025 lacked any order for the back brace, guidance on when it should be worn, or monitoring of the skin under the brace. The resident's care plan noted healing fractures and non-compliance with the brace, but did not include interventions related to the brace or when it was to be worn. The facility also failed to assess and monitor skin discolorations for two residents. One resident was observed with a large purple bruise next to a dressing on the right knee, and staff later stated they did not know whether the bruise was from surgery or a fall or how long it had been present; the record lacked monitoring of the bruise despite a care plan directing staff to observe the skin with each encounter for bruising due to anticoagulant therapy. Another resident was observed with bruises on the left cheek, right hand, and right arm after a motor vehicle accident and hospitalization, but the admission nurse assessment did not document the bruises and the record lacked monitoring of them despite a physician's order to complete a head-to-toe assessment and document and measure any bruises or skin tears noted.
Failure to Follow Swallowing Guidelines
Penalty
Summary
The facility failed to provide adequate supervision and follow the planned swallowing interventions for 2 residents with dysphagia. Resident 9, who had diagnoses including dementia without behavior disturbance and dysphagia, was observed eating meals in bed on multiple occasions, including breakfast and lunch, and straws were seen in beverages despite posted swallowing guidelines dated 6/23/25 stating to assist with meals, use small sips/bites, slow rate, and no straws. The resident’s record showed cognitive impairment for daily decision making, set up or clean up assistance with eating, a mechanically altered therapeutic diet, and a physician’s order for a no added salt mechanical soft diet with nectar thick liquids and high protein gelatin at lunch and dinner. Resident 21, who had diagnoses including Parkinson’s disease and dysphagia, also had swallowing guidelines posted above the bed stating no straws. During observations, straws were seen in the resident’s juice, water, and an outside beverage in the room, and later in Ensure and juice during breakfast in the dining room. The resident’s record showed cognitive impairment for daily decision making, that she would hold food in her mouth or cheeks or have residual food after meals, and that she received a mechanically altered diet. Her care plan stated she could feed herself with set up assistance and that staff would provide hands on assistance as needed to ensure adequate intake, while the August 2025 physician’s order summary listed a regular diet with Ensure at breakfast and dinner.
Improper Foley Catheter Bag and Tubing Management
Penalty
Summary
The facility failed to ensure proper care of an indwelling urinary catheter for Resident 119, who had diagnoses including left femur fracture, urinary retention, and dementia. The resident’s 6/29/25 MDS indicated severe cognitive impairment, substantial assistance needed for chair-to-bed transfers, and use of an indwelling catheter for urination. The care plan dated 7/7/25 identified the need for catheter management and included positioning the collection bag below the level of the bladder, with the short-term goal that the catheter would be managed appropriately without signs of infection or urethral trauma. During multiple observations, the Foley collection bag was found on the bed under a blanket, lying under the wheelchair, hooked under the wheelchair next to the bed, and later hooked on the bed frame with the tubing pulled taut. The resident was also observed stepping on the tubing with hard-soled shoes and having the catheter tubing coming out of the bottom of a narrow pant leg and under his foot. The record lacked documentation of monitoring the tubing and urine collection bag. RN 1 and CNA 1 were present during some of the observations, and the Administrator and DON later stated they would re-educate staff and the resident on monitoring and maintaining Foley catheter tubing and bags.
Medication pass errors exceeded the acceptable rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% for 2 of 7 residents observed during medication pass. Surveyors observed four errors during 25 opportunities for error, resulting in a 16% medication error rate. The deficiency involved Resident 28 and Resident 116 during medication administration observations. For Resident 28, an RN prepared Breo Ellipta inhaler 200-25 mcg and Miralax 17 grams. The RN handed the inhaler to the resident, who inhaled it herself, but the resident did not rinse her mouth afterward and the RN did not instruct her to do so. The RN then prepared Miralax by adding 5 cc to a cup with 4 ounces of water and left it on the resident’s over-bed table; after the resident drank it, the RN stated she gave 5 cc because the marking inside the manufacturer lid was no longer there and she was not aware of how much 17 grams equaled. The ADON stated she should have determined the correct amount before administering it. For Resident 116, an LPN prepared Lantus insulin 10 units and Novolog insulin 5 units using insulin pens but did not prime the pens before administration, despite stating she knew priming was required. The insulin inserts indicated a safety test/priming should be performed before each injection.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications, as evidenced by a medication being left at the bedside. Resident D was observed with a pill in a medication cup on her overbed table, which she identified as Imodium given to her by a nurse. The resident's record showed no assessment for self-administration of medications or a physician's order permitting it. The resident, who was cognitively intact according to a recent mental status assessment, had been admitted with diagnoses including endocarditis, diabetes mellitus, and anemia. The Assistant Director of Nursing confirmed that the resident did not have a self-medication assessment and should not have had any pills in her room. The facility's current pharmaceutical services policy requires that residents with orders for self-administration have medications delivered by a licensed nurse or QMA.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure the timely change of a PICC line dressing for a resident, identified as Resident B, who was admitted with a PICC line in his left upper arm. The dressing was observed to be dated 8/26/24, and the resident's record indicated a physician's order to change the dressing every seven days. However, the September 2024 Treatment Administration Record lacked documentation of a dressing change on 9/2/24, as required. During an interview, LPN 1 confirmed that the dressing had not been changed since the resident's admission on 8/28/24, despite the order and facility protocol requiring a change on admission and weekly thereafter. Resident B had significant cognitive impairment and was dependent on staff for assistance, with diagnoses including osteomyelitis, Parkinson's disease, anemia, and weakness.
Infection Control Breach During PICC Dressing Change
Penalty
Summary
The facility failed to ensure proper infection control measures were implemented during a dressing change for a resident receiving intravenous care. On the specified date, an LPN was observed changing the PICC dressing on a resident's left upper arm while wearing a face mask and gloves but not a gown, despite the requirement for Enhanced Barrier Precautions. A sign on the resident's door indicated that all staff performing direct care were to wear gloves and a gown, and a PPE bin with gowns and masks was available outside the room. The LPN mistakenly believed the sign was for the resident's roommate and acknowledged the error during an interview, subsequently donning a gown. The resident involved had been admitted with diagnoses including osteomyelitis of the vertebrae, Parkinson's disease, anemia, and weakness, and was noted to have significant cognitive impairment, requiring staff assistance for toileting and transfers. A physician's order required the PICC line dressing to be changed every seven days. The facility's policy on the prevention and management of multi-drug resistant organisms specified the use of gloves and gowns for high-contact care activities, such as device care. This incident was related to a complaint investigation.
Failure to Conduct Self-Medication Assessments
Penalty
Summary
The facility failed to ensure that a self-medication administration assessment was completed for residents who had medications at their bedside. This deficiency was observed in four residents during random checks. Resident 6 was found with a Breo inhaler, antibiotic ointment cream, and healing ointment cream on her window sill, but there were no physician orders for these medications or for self-administration. Similarly, Resident 73 had a bottle of Nystatin powder on his nightstand without a self-administration assessment or physician's order to keep the medication at the bedside. Both residents were cognitively intact according to their Minimum Data Set (MDS) assessments. Resident 88, who was not cognitively intact, also had a bottle of Nystatin powder on her dresser without the necessary assessments or orders. Additionally, Resident 82 had glucose tablets and Systane eye drops in her room without a self-medication assessment or physician's order for self-administration. The Assistant Director of Nursing confirmed that no residents on the unit were authorized to self-administer medications, indicating a systemic oversight in medication management and assessment procedures.
Failure to Document and Monitor Skin Conditions
Penalty
Summary
The facility failed to properly assess and monitor areas of bruising and skin tears for four residents. Resident 26 was observed with a reddish-purple discoloration on her right hand, which was not documented in the nursing progress notes or the Medication Administration Record (MAR). Despite weekly skin assessments being signed off, there was no documentation related to the bruising. The Assistant Director of Nursing (ADON) acknowledged that bruises should have been documented when observed. Resident 60 was seen with a light purple discoloration on her right hand, which was also not documented in the nursing progress notes or MAR. The ADON confirmed that bruises should have been documented. Similarly, Resident 168 had multiple areas of discoloration on his arms, with no documentation in the nursing progress notes or MAR. The resident's care plan indicated a risk for complications due to aspirin and antiplatelet therapy, yet there was no order to monitor the bruising or for the dressing on the left upper arm. Resident 6 was observed with a bandaid on her left forearm, which later revealed a skin tear. There was no documentation regarding the skin tear in the nursing progress notes. The ADON was unaware of the skin tear, and the Hospice Nurse mentioned a previous scab on the arm. The RN caring for the resident was not informed of the skin tear during the shift change. These incidents highlight a lack of proper documentation and monitoring of skin conditions, leading to deficiencies in care.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not covering the resident's foley catheter bag, allowing urine to be visible from the hallway. This deficiency was observed multiple times over several days, with the resident's catheter bag being uncovered and visible on 5/28/24, 5/29/24, and 5/30/24. The resident, who was cognitively intact and had an indwelling foley catheter due to urinary retention, was observed in bed with the catheter bag hanging on the side of the bed without a dignity cover. The facility's policy, as of 1/1/24, required that drainage bags be covered with a dignity bag, a standard that was not adhered to in this case. The Assistant Director of Nursing confirmed during an interview that the catheter bag should have been covered. The resident's medical history included conditions such as sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia, chronic kidney disease, acute cystitis, and a urinary tract infection, which necessitated the use of a foley catheter.
Improper Foley Catheter Care for Two Residents
Penalty
Summary
The facility failed to ensure proper care for residents with indwelling Foley catheters, as observed in two residents. Resident 73 was repeatedly seen with his Foley catheter bag and tubing in contact with the floor, both while in a wheelchair and in bed. Despite having a care plan that required the catheter bag and tubing to be maintained below bladder level, these observations were made over several days. Resident 73's medical history included sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia, chronic kidney disease, acute cystitis, and a urinary tract infection. The resident was cognitively intact and had a physician's order for a Foley catheter due to urinary retention. Similarly, Resident 93 was observed multiple times with his Foley catheter tubing on the floor while sitting in a wheelchair. This resident had a history of anemia, hypertension, urinary retention, arthritis, dementia, anxiety, and depression, and was dependent on assistance for toileting hygiene. The care plan for Resident 93 also noted the potential for complications related to the urinary catheter. Interviews with the Assistant Directors of Nursing confirmed that the catheter bags and tubing should not have been on the floor, and the facility's policy required securement of the catheter and proper positioning of the collection bag to prevent urine reflux.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate as prescribed by the physician. Resident 60, who has diagnoses including pneumonia, emphysema, and congestive heart failure, was observed multiple times with an oxygen concentrator set at 3 1/2 liters per minute, despite a physician's order specifying 4 liters per minute. This discrepancy was noted over several days, with observations on 5/28/24, 5/29/24, and 5/30/24, indicating a consistent failure to adhere to the prescribed oxygen therapy. The resident's care plan required oxygen therapy due to multiple respiratory conditions, yet the facility did not comply with the physician's order for the correct oxygen flow rate.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering blood pressure medication to a resident diagnosed with heart failure, high blood pressure, and anxiety disorder. The resident, who was not cognitively intact for daily decision-making, had a physician's order for Verapamil, a medication used to treat chest pain and lower blood pressure, to be administered at 60 mg twice a day, with instructions to hold the medication if the systolic blood pressure was under 140. However, the Medication Administration Record (MAR) for April and May 2024 showed multiple instances where the medication was administered despite the resident's systolic blood pressure being below the specified threshold. The MAR indicated that Verapamil was given on numerous occasions with systolic blood pressures ranging from 113 to 139, all below the ordered parameter of 140. This occurred on various dates in April and May, demonstrating a pattern of non-compliance with the physician's orders. During an interview, the Assistant Director of Nursing acknowledged that the nursing staff should have followed the physician's orders for administering Verapamil, indicating a lapse in adherence to prescribed medication protocols.
Inaccurate Dialysis Scheduling for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident undergoing dialysis. The resident, who had diagnoses including end-stage renal disease and dependence on renal dialysis, was admitted with a physician's order for hemodialysis at a specific dialysis center on Monday, Wednesday, and Friday, with a pick-up time of 3:00 p.m. and a chair time of 4:00 p.m. However, a progress note indicated that the resident received dialysis on Tuesday, Thursday, and Saturday, with a pick-up time of 12:00 p.m. and a chair time of 1:00 p.m. This discrepancy was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the dialysis order had not been updated.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices during a blood sugar check for Resident 53. An LPN did not sanitize her hands before donning gloves, between glove changes, or after removing gloves while using a glucometer. Although she sanitized her hands before leaving the resident's room, the facility's hand hygiene policy requires hand sanitization after glove removal and before medication administration. This lapse in protocol was confirmed by the Assistant Director of Nursing during an interview. In another incident, the Wound Nurse did not adhere to contact precautions for Resident 73, who was on enteric/contact isolation due to a positive C-Difficile toxin test. The nurse performed a skin treatment without wearing an isolation gown, despite signs indicating the need for such precautions. The resident's medical history included sepsis, high blood pressure, and a urinary tract infection, among other conditions. The Assistant Director of Nursing confirmed that the Wound Nurse should have donned an isolation gown before the treatment, as per the facility's policy on managing multi-drug resistant organisms.
Failure to Investigate and Resolve Grievances
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances in writing from a resident's family member. Resident B's husband expressed concerns about his wife's care, specifically that she was left in bed for extended periods and missed activities. Despite filing a grievance with the administrator, he did not receive any written response or follow-up regarding his complaint. The facility's grievance policy requires the administrator or a designee to oversee the grievance process and provide written outcomes, but this was not adhered to in this case. Resident B, who was cognitively intact, had multiple diagnoses including hemiplegia, hemiparesis, and other conditions following a cerebral infarction. Her husband repeatedly voiced concerns about her care, including issues with her being left in bed and not receiving showers as requested. Despite these grievances being communicated to the staff and the administrator, there was no documentation of an investigation or resolution provided to the resident or her representative. The administrator indicated that she allowed staff to handle grievances autonomously and did not maintain a grievance log or track grievances. This lack of formal documentation and follow-up is contrary to the facility's grievance policy, which mandates tracking grievances and providing written outcomes. The absence of a formal grievance form and the failure to provide written follow-up contributed to the deficiency identified in the report.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure the resident's family was notified of a change in condition for Resident H. Resident H had multiple diagnoses, including sepsis, chronic respiratory failure, and heart failure. On 2/26/24, the resident was noted to be very lethargic and had increased confusion and labored breathing. The Nurse Practitioner (NP) was notified and assessed the resident, who was later found to have a hemoglobin level of 6.9. The resident was subsequently sent to the emergency room for altered mental status and acute kidney injury. However, there was no documentation that the resident's family was notified of these changes or the transfer to the hospital. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the nursing staff were supposed to notify the resident's family at the time of the change in status, but this did not occur. The deficiency was identified during a review of the resident's records and was related to Complaint IN00429419.
Failure to Follow Up on Allegations of Exploitation and Misappropriation
Penalty
Summary
The facility failed to provide appropriate social services follow-up related to an outside allegation of exploitation and misappropriation for a resident by family and facility staff. The Adult Protective Services (APS) representative indicated that they had contacted the assigned facility Social Worker (SW) regarding the resident and left detailed voicemails, but received no further communication or documentation from the SW after an initial call. The APS representative had recommended a psychiatric evaluation and requested documentation for the current healthcare POA, but these were not followed up on by the facility. The record for the resident showed severe impairments in daily decision-making and significant physical dependencies, but there was no social service documentation regarding the allegations or communication with APS in the resident's chart. The SW formerly assigned to the resident no longer worked at the facility, and the Director of Nursing was unaware of the situation. During interviews, the Administrator indicated there were no grievances for the last three months and that unit managers were empowered to handle concerns as they arose. The Social Service Director (SSD) confirmed the lack of documentation regarding the allegations and communication with APS. The deficiency was identified during a complaint investigation and related to the facility's failure to provide medically-related social services to help the resident achieve the highest possible quality of life.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Munster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Munster Med-inn | 1.1 mi | — | 44 | 2 |
| Dyer Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 8 | 0 |
| Tri-state Village Nrsg & Rhb | 3.4 mi | ★★★★★ | 5 | 0 |
| Ignite Medical Resort Dyer Llc | 3.5 mi | ★★★★★ | 4 | 0 |
| Thryve Of South Holland | 4.1 mi | ★★★★★ | 15 | 0 |
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