Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa At Parkridge during CMS and state inspections, most recent first.
Unresolved Resident Council Grievances About Call Light Response Times: Residents reported ongoing slow call light response times discussed at monthly council meetings for months without improvement. Residents described waits of more than an hour on night shift and said staff responded with comments about being busy or short staffed. Meeting minutes showed repeated complaints over multiple months, with the facility documenting only staff re-education. Residents also reported they did not know where to find or how to complete a grievance form or how the grievance process worked.
Failure to inform residents of the grievance process and ongoing call light delays. During a confidential Resident Council meeting, 8 residents reported repeated slow call light response times, including waits of more than 1 hour on the night shift, and said staff responses were dismissive and made them feel like a bother. The residents stated the issue had been discussed for months without improvement, and none of the 8 residents knew where to find a grievance form or how to complete the grievance process.
A facility failed to provide enough nursing staff to meet resident needs and ensure timely response to call lights. Residents reported waits of more than an hour, including one resident who said he had waited up to 3 hours, while observations showed two nurses sitting at the nurses' station as multiple call lights were active. A resident with paraplegia, neurogenic bowel, and sarcoidosis, another resident needing bathroom assistance, and a resident with a painful brief all reported unmet needs, and a CNA reported being assigned 17 residents with no break.
Failure to Maintain Resident Dignity and Privacy: A resident with paraplegia, neurogenic bowel, and intact cognition reported that staff were rude, did not explain care, and left him exposed during wound care and pericare, including not pulling the privacy curtain and exposing his genitals while his roommate was present. An LPN was also observed entering the room without properly knocking, and the DON stated staff are expected to knock, introduce themselves, wait for an answer, and pull privacy curtains during care.
A resident with stroke-related apraxia, dysarthria, and right-sided weakness was unable to use a standard push-button call light, which was observed clipped out of reach on his affected side. Staff were unsure how he communicated needs, a communication board was not in his room, and the DON stated a soft-touch or pancake call light would be more fitting. The resident was also observed thirsty, warm, unbathed, and in an unkempt condition.
Damaged Bathroom in Resident Room: A resident on reverse isolation was found in a room with a dark, visibly damaged bathroom, including a large hole at the wall-ceiling junction in the shower, exposed pipes, a covered tub reported as unusable, and visible debris and staining on the tub and mirror. The resident stated the condition had been present for an extended period, and maintenance staff acknowledged awareness of the repair issue after a prior pipe leak.
A resident with type 2 diabetes and a left calf wound did not receive ordered wound care even though the TAR showed it as completed by multiple LPNs. The resident reported the dressing had not been changed for several days, and surveyors observed the same dated dressing still in place. Staff interviews showed the LPNs could not confirm the care was done, and the DON stated the nurses did not follow the physician's orders.
Misappropriation of resident property: A resident with intact cognition and diagnoses including difficulty walking and partial intestinal obstruction reported that a CNA entered his room while he was asleep, removed his phone from its charger, and plugged in the CNA’s personal iPhone at his bedside. A UM stated staff should not charge personal cellphones in resident rooms using residents’ property.
Incomplete Care Planning and Failure to Implement Ordered Monitoring and Treatments: The facility did not document required monitoring for a resident on antidepressant therapy and with mood-related diagnoses, did not document mood observations in the EMR, and failed to provide or re-order ordered BIPAP support for another resident after hospital returns. A third resident with stroke-related impairments was observed unbathed, thirsty, unable to reach the call light, and needing assistance with drinking and hygiene, while the care plan did not reflect implemented monitoring or support.
Ineffective Communication and Inaccessible Call Light: A resident with post-stroke apraxia, dysarthria, and right-sided weakness was rarely or never understood, yet staff stated they had no effective way to communicate with him and often guessed his needs. He could answer yes/no questions by nodding, indicated he was thirsty and had not been bathed, and showed he could not use the push-button call light because of limited arm function. The communication board was not in the room, and the call light was observed out of reach or on his affected side.
Failure to provide ADL care including bathing and grooming: A resident with stroke-related apraxia, dysarthria, and right-sided weakness was observed unbathed, unkempt, with dry lips, overgrown toenails, and a call light out of reach. The resident indicated he had not been receiving showers and wanted a shower, shaving, and a haircut. Records showed he was dependent for bathing, showers were scheduled, but only bed baths were documented over the past 30 days with no refusals noted.
A resident with post-stroke apraxia, dysarthria, and right-sided weakness was dependent on staff for food and fluids, but was found thirsty with dry lips, limited bedside water, and no reliable way to summon help. Staff stated he could not use the call light, the communication board was not in his room, and the EMR showed no consistent fluid intake documentation or monitoring. The resident indicated he had not been receiving showers and could not give himself drinks of water.
Failure to Provide Ordered BiPAP Therapy: A resident with COPD, OSA, chronic respiratory failure, and recent hypercapnic respiratory failure returned from the hospital with discharge instructions to use BiPAP when sleeping and napping, but the facility did not re-order it and there was no evidence it was used for about two months. The resident reported staff had not assisted with the BiPAP and the machine was found in her closet; the ADON confirmed the order was not re-entered after the hospital return.
A resident with type 2 diabetes and intact cognition had ordered wound care for a left calf wound, but the dressing remained dated and unchanged while the TAR was signed off as completed by multiple LPNs. Interviews showed the nurses could not confirm the care was actually provided, the DON stated the orders were not followed, and prior discipline for falsified documentation was found in the staff files.
A resident with stroke-related apraxia, dysarthria, and right-sided weakness was found in a very warm room with dry lips, poor hygiene, an out-of-reach call light, and limited water access. Surveyors observed duct tape sealing the window shut so it could not be opened or cracked, and maintenance said it had been taped because it was drafty when temperatures were low; no related work order was found.
A resident experienced a fall resulting in a hip fracture that was not immediately assessed or reported to the physician or responsible party. An LPN and CNA assisted the resident back to bed without documenting the fall or conducting a full assessment, including range of motion or neuro checks. The incident was only discovered after the resident reported pain to therapy and the guardian was informed by the roommate, leading to delayed hospital transfer and diagnosis.
The facility did not adequately address repeated concerns from the Resident Council about food palatability, call light response times, and provision of evening snacks. Residents reported long waits for call light responses, particularly during afternoon and night shifts, and noted that staff sometimes consumed snacks meant for residents. Additionally, grievances and concerns raised by the Resident Council were not satisfactorily resolved.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in medical records. A resident did not receive a pneumococcal vaccination despite consent, and another had incorrect documentation regarding a Gradual Dose Reduction. Weight loss data was inaccurately recorded for a resident, and the use of bed bolsters as potential restraints was not properly assessed for two residents. The facility's staff provided conflicting information about restraint use, indicating a lack of proper assessment and documentation.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in care. A resident with bullous pemphigoid had an unplugged pressure mattress, another on dialysis lacked proper monitoring and care plan updates, a resident with psychiatric conditions had missing behavioral interventions, and a resident with a history of falls had an inaccessible call light. These issues highlight a lack of proper care plan implementation and monitoring.
The facility failed to provide adequate staffing, resulting in delayed response times to call lights, particularly during afternoon and night shifts. Residents reported waiting 45 to 60 minutes for assistance, with some experiencing incontinence due to the delays. Staff were observed turning off call lights without providing care, and residents' concerns about staffing were not addressed.
The facility failed to provide palatable and safe food, affecting 125 residents. Several residents expressed dissatisfaction with the quality and temperature of the food, leading some to store personal food items unsafely. Food trays were transported in non-insulated carts, contributing to improper food temperatures. The facility's meal distribution policy did not ensure proper temperature maintenance, as evidenced by surveyor observations and resident complaints.
A resident reported missing clothing items that were not returned from the laundry, despite being labeled. The facility staff failed to follow the grievance process, as no grievance form was completed, and the Nursing Home Administrator confirmed no grievances were documented. The resident was cognitively intact and had diagnoses including adjustment disorder and Alzheimer's Disease.
The facility failed to assess bed bolsters as potential restraints for two residents, leading to a deficiency. One resident with schizoaffective disorder and dementia had bolsters that restricted their ability to get out of bed, and another resident with a history of falls had a positioning wedge and bolster that prevented them from getting out of bed. The medical records lacked restraint assessments, and staff confirmed the use of bolsters for fall prevention without proper evaluation.
A facility failed to timely complete a Significant Change MDS assessment for a resident with dementia who had recently ended hospice services. The assessment, required within 14 days of a significant change, was completed late, as confirmed by the MDS Coordinator.
The facility failed to provide necessary care and assistance with ADLs for two residents, resulting in unmet personal care preferences and lack of engagement in activities. One resident, with multiple medical conditions, was not assisted in participating in activities like bingo, while another resident, with severe cognitive impairment, did not receive showers as preferred due to a broken shower bench. The staff's inaction and lack of proper documentation contributed to the deficiency.
A resident in a long-term care facility, who was cognitively intact and dependent on all care, was not provided with meaningful and individualized activities, leading to potential feelings of depression and boredom. Despite expressing a desire to participate in activities like Bingo, the resident was not assisted in getting out of bed in time to attend. Staff interviews revealed a lack of coordination and communication, and records showed no documented participation in activities over the past 30 days.
The facility failed to manage the nutritional care and weight of two residents effectively. One resident, who was cognitively intact and had a gastrostomy, experienced significant weight gain without adjustments to their tube feeding regimen, despite their preference for weight loss. Another resident, with severe cognitive impairment, suffered significant weight loss, and the facility did not update their care plan with new interventions. The facility did not adequately address the nutritional needs and preferences of these residents.
A facility failed to ensure proper dialysis care for a resident with end-stage renal disease. The resident reported that their dialysis access site was not routinely monitored, and there was no active physician's order for their fluid restriction. The Kardex did not reflect the resident's dialysis status or care considerations. Interviews with staff revealed inconsistencies in understanding the resident's care needs, and the Director of Nursing acknowledged that necessary orders were not reimplemented after a hospital visit.
A resident with a cerebral infarction was not provided with necessary personal items and expressed dissatisfaction with having a legal guardian and being unable to leave the facility. Despite being cognitively intact, the resident's requests for basic supplies and communication with the guardian were not adequately addressed by social services or nursing staff. The resident's condition worsened to suicidal ideation, highlighting the facility's failure to provide timely and appropriate social services.
A resident did not receive their prescribed morning dose of Lithium Carbonate due to a medication administration error. An RN pre-filled a medication cup and stored it in the medication cart, but failed to include the Lithium capsule. The Director of Nursing confirmed that medications should be administered directly from the bubble pack at the time they are due.
A resident with celiac disease was not provided meals that adhered to her gluten-free diet, as the facility frequently substituted her meals with hot dogs and hamburgers. Despite having a diet order for a gluten-free diet with extra protein, the resident reported a lack of dietician visits and a downward trend in her weight. Staff interviews confirmed the resident's complaints, indicating a failure to meet her dietary needs.
A facility failed to ensure proper collaboration and communication with a hospice provider for a resident receiving hospice services. Despite a scheduled hospice visit calendar, documentation was lacking in both the Hospice Binder and the electronic medical record. Interviews revealed that hospice visit notes were expected to be available but were not, and a request for the hospice communication log was not fulfilled before the survey exit.
A resident with severely impaired cognitive skills did not receive a pneumococcal immunization despite consent from their DPOA. The ADON/IP confirmed the consent but was unsure why the immunization was not administered.
The facility failed to update care plans for two residents, one experiencing significant weight loss and another with unadjusted tube feeding despite oral intake. The care plans did not reflect current needs and preferences, leading to deficiencies in care.
A resident suffered second-degree burns after a CNA failed to check the temperature of reheated noodles, which were then spilled. The facility did not follow proper procedures for reheating food or providing immediate burn care. Staff were inadequately trained on these protocols, contributing to the incident.
A resident suffered burns from hot noodles due to inadequate temperature checks and delayed physician notification. The facility failed to provide immediate and appropriate burn treatment, and staff were not adequately trained in reheating food or responding to burn injuries.
A resident suffered second-degree burns after spilling hot noodles on himself due to inadequate food temperature checks and lack of immediate burn care. The facility failed to report the incident promptly and lacked proper training and policies for reheating food and treating burns, contributing to the resident's injuries.
A resident with multiple health issues and a BIMS score indicating cognitive intactness was not informed of the resolutions to grievances they submitted regarding facility concerns. Despite documentation of actions taken, the facility's computerized system did not track whether the resident was notified, and the Nursing Home Administrator could not confirm that the resident was informed or satisfied with the outcomes.
Unresolved Resident Council Grievances About Call Light Response Times
Penalty
Summary
The facility failed to address and resolve grievances raised in Resident Council meetings regarding slow call light response times and resident treatment during care requests. During a confidential Resident Council meeting, 8 of 8 participating residents reported an ongoing issue with call lights not being answered in a timely manner, with concerns discussed at every monthly meeting for months without improvement. Residents described call light response times of more than one hour on night shift and reported that when staff arrived, they were told staff were busy and short staffed, and one resident stated, "That is not our problem" when asking for help with basic care such as using the bathroom. Review of Resident Council meeting minutes from 9/23/25 through 3/8/26 showed resident complaints about long call light response times in 5 of 6 months. The facility responses documented in the minutes were that staff were re-educated on call light answering, but the same concerns continued to be raised. During the confidential meeting, 8 of 8 residents also reported they were not aware of where to locate or how to complete a grievance form or how the grievance process worked.
Failure to Inform Residents of Grievance Process and Ongoing Call Light Delays
Penalty
Summary
The facility failed to notify residents of where to find grievance forms and how to file a grievance, as discussed during a confidential Resident Council meeting with 12 residents present and 8 actively participating. During the meeting, all 8 participating residents reported ongoing slow response to call lights, stating the issue had been discussed at every Resident Council meeting for months without improvement. Residents described call light response times of more than one hour on the night shift and reported that when staff arrived, they were told, "I am busy, we are short staffed, what do you need," which made them feel like a bother to staff. Another resident reported being told the facility was short staffed after waiting for a call light to be answered, and stated, "That is not our problem when we have to ask for assistance with basic care like going to the bathroom." Eight of 8 confidential residents were not aware of where to locate or how to complete a grievance form or how the grievance process worked.
Delayed Response to Call Lights and Inadequate Nursing Coverage
Penalty
Summary
The facility failed to provide adequate nursing staff every day to meet resident needs and to ensure a licensed nurse was in charge on each shift. Review of observations, interviews, and records showed repeated delays in answering call lights and unmet resident care needs for residents including R7, R41, and R64, as well as eight residents identified in confidential group interviews. R7, who was admitted with paraplegia, neurogenic bowel, and sarcoidosis and had intact cognition on MDS assessment, reported waiting as long as 3 hours for his call light to be answered and said his roommate often had to go to the nurses' station because staff were sitting there talking and response times routinely exceeded an hour. During a confidential Resident Council Meeting, 8 of 8 participating residents reported ongoing slow response to call lights, with examples of waits greater than one hour on night shift and staff responding with comments about being short staffed. Residents also reported they were not aware of where to locate or how to complete a grievance form. On observation, multiple call lights were activated while two nurses remained seated at the nurses' station chatting. R41 was heard repeatedly calling for a nurse and later stated she had been waiting over an hour to use the bathroom, while a confidential CNA reported having 17 residents assigned and no break. R64 reported his call light had been on since after lunch because his brief was digging into his skin and causing pain. The DON stated that all staff are responsible for answering call lights and that ignoring them is not acceptable.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat a resident with dignity by not consistently providing privacy and courtesy during care. The resident was admitted with diagnoses including paraplegia, neurogenic bowel, and sarcoidosis, and had intact cognition with a BIMS score of 15/15. During an interview, the resident stated that staff were rude, did not explain what they were doing before providing care, and often left him exposed during wound care and pericare. He specifically reported that during recent wound care his privacy curtain was not pulled, he was not covered, he could see his roommate ambulating in the room, and his genitals were exposed. He also stated that staff routinely did not pull the privacy curtain while providing care and that he wanted basic common courtesy. During observation, an LPN entered the resident's room without knocking and only knocked after opening the door and seeing that an interview was in progress. The LPN stated she sort of knocked, had her phone in her hand, and was looking for the bladder scanner. The resident reported that staff rarely knock before entering his closed door. During an interview with the DON, it was stated that staff are expected to knock, introduce themselves, and wait for an answer before entering resident rooms, and that staff should always pull privacy curtains when performing resident care.
Call Light Not Adapted to Resident’s Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with apraxia following cerebral infarction, dysarthria, and right-sided weakness/paralysis had a call system adapted to his physical limitations. The resident’s MDS reflected that he was rarely or never understood. During observation, he was seen lying in bed with his push-button call light clipped out of reach on his curtain or mattress on his affected right side. When asked to demonstrate use of the call light, he was unable to do so and indicated he could only raise and lower his left arm, with his fingers fixed in a fanned-out position. The resident also communicated that he could not use the push-button call light, and the DON stated that a soft touch or pancake call light would be more fitting for him. Interviews showed staff were unsure how the resident communicated his needs and one CNA stated she was not sure if he could use his call light, while another CNA stated he could not use it. The UM stated the resident communicated by nodding yes or no or using a communication board, but the communication board was not in his room. The resident was observed without the adapted communication support in place, and his call light remained positioned where he could not reach or use it. During the same observations, he was also noted to be very warm, thirsty, unbathed, and in an unkempt condition, with dry, chapped lips, overgrown toenails, and water left on the bedside table without a straw.
Damaged Bathroom in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident who was on reverse isolation precautions. The resident was admitted with pancytopenia, immunodeficiency due to drugs, asthma, paraplegia, depression, and anxiety, and had a BIMS score of 15/15 indicating intact cognition. A sign was posted to see staff before entering the room, and the resident was confirmed to be in reverse isolation due to immunosuppressive long-term linezolid use. When the room was observed, the resident was lying in bed while the bathroom area was dark and visibly damaged. The bathroom door was open, and a large hole measuring about 6 inches by 6 inches was seen where the wall and ceiling met in the shower, with dark rust-colored debris and two exposed pipes. The ceiling had a replacement piece covering apparent damage, the tub was covered with a board and was reported as unusable, and there was a brown splatter-like substance on the tub exterior near the floor and a white streaking substance on the mirror. The resident stated the wall and shower area had been in that condition for an extended period and had been worse in the past. Maintenance staff acknowledged awareness of the bathroom repair issue and stated the original problem began with a pipe leak in mid-November 2025.
Wound care documented as completed but not performed
Penalty
Summary
The facility failed to protect one resident, R135, from neglect when ordered wound care for a left posterior calf wound was not completed as prescribed, even though the treatment administration record (TAR) showed it as completed. R135 was admitted with type 2 diabetes and was cognitively intact with a BIMS score of 15 out of 15. The physician ordered the wound to be cleansed with normal saline, treated with Medihoney, and covered with a foam dressing every other evening shift, but the resident reported that the dressing had not been changed since 3/2/26 or 3/3/26. When observed on 3/8/26 and again on 3/9/26, the same dressing dated 3/3/26 remained in place, and the resident stated the wound care still had not been done. The TAR reflected wound care as completed on 3/4/26, 3/6/26, and 3/8/26 by three different LPNs, but interviews showed the staff could not confirm the care was actually provided. One LPN stated she changed a dressing on another resident and did not perform wound care on the back of a calf, another said she was not sure whether she completed the treatment, and a third could not recall if she completed the wound care. The DON stated the nurses did not follow the physician's orders and that there was no reason for the wound care to be signed out as completed but not done. The resident's dressing was finally changed during the survey observation, and the removed dressing showed drainage and an open wound bed.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to prevent misappropriation of resident property for one resident. The resident was admitted with diagnoses including difficulty in walking and partial intestinal obstruction, and the MDS assessment showed intact cognition with a BIMS score of 15/15. During observation, the resident was sitting at the edge of the bed eating lunch and reported that a staff member entered his room while he was asleep, said she needed to use his phone charger, removed the resident's phone from the charger, and plugged in her own phone at his bedside. A pink iPhone was observed plugged in and charging at the resident's bedside. The resident described the staff member, and it was determined that the phone belonged to a CNA. A UM stated that staff should not have cellphones in resident rooms or charge personal cellphones in resident rooms using residents' personal property.
Incomplete Care Planning and Failure to Implement Ordered Monitoring and Treatments
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents. For one resident with diagnoses including bipolar disorder, depression, generalized anxiety disorder, post-traumatic disorder, vascular dementia with anxiety, and major depressive disorder, the care plan included interventions to monitor and document adverse reactions to antidepressant therapy and to monitor and record mood changes, depression, anxiety, sadness, and related symptoms. However, the medical record contained no documentation that these monitoring interventions were completed, and the DON confirmed that no such documentation could be found in the EMR. For another resident with apraxia following cerebral infarction, dysarthria, and right-sided weakness/paralysis after a stroke, the resident was observed in bed wearing only an adult brief, lying flat on his back with heels not elevated, in a very warm room, with an unpleasant body odor, unkempt appearance, dry and chapped lips, and overgrown toenails. A Styrofoam cup on the bedside table contained only a small amount of water. The resident was unable to verbally respond but could answer simple questions by nodding or shaking his head, indicated that he was thirsty, stated he had not been receiving showers, and said he needed assistance with eating and drinking. He also indicated that he did not have a communication board and could not hold a cup to drink independently. For a third resident with recent admissions related to acute on chronic respiratory failure with hypoxia and hypercapnia, CO2 narcosis, sleep apnea, morbid obesity, COPD, respiratory failure with hypoxia dependent on oxygen, anxiety, and depression, the resident reported that staff had not assisted with use of the ordered BIPAP machine since returning from the hospital. The machine was found in the closet. The care plan identified a potential for difficulty breathing related to CHF, COPD, chronic respiratory failure, and OSA and included BIPAP per MD order, but the ADON verified that after the hospital readmissions the BIPAP was not re-ordered even though the resident remained on the care plan and staff were expected to follow it.
Ineffective Communication and Inaccessible Call Light
Penalty
Summary
The facility failed to ensure an effective and consistent means of communication for a resident with apraxia, dysarthria, and right-sided weakness/paralysis following a stroke. The resident’s MDS reflected that he was rarely or never understood. During observation and interview, he was unable to verbally respond, but he could answer simple questions by nodding yes or no and appeared to understand conversation. He indicated that he was thirsty, had not been receiving showers, wanted a shower, wanted his face shaved and a haircut, and required assistance with eating and drinking. He also indicated that he could not hold a cup or give himself drinks of water and could not explain how he requested help from staff. A psychiatric note also reflected that he was able to shake his head to answer simple questions. Despite this, staff members stated they did not have a way to effectively communicate with the resident and that they did their best to guess his needs. The resident’s call light was observed clipped out of reach or positioned on his affected side, and he demonstrated that he could not use the push-button call light because of his limited left arm function. A unit manager stated the resident communicated by nodding yes or no or by using a communication board, but the board was not in the room. The resident was also observed lying in bed in an unkempt condition, with dry and chapped lips, overgrown toenails, body odor, and water left at the bedside that he indicated he had not drunk.
Failure to Provide ADL Care Including Bathing and Grooming
Penalty
Summary
The facility failed to ensure activities of daily living were completed for one resident who was unable to perform them independently. The resident had diagnoses including apraxia following cerebral infarction, dysarthria, and weakness/paralysis affecting the right dominant side following a stroke. The MDS reflected the resident was rarely or never understood and was dependent for bathing. On observation, the resident was found in his room wearing only an adult brief, lying flat on his back with heels not elevated, with an unpleasant body odor, very dry and chapped lips, overgrown toenails, and a call light clipped out of reach. The resident indicated he had not been receiving showers, wanted a shower, wanted his face shaved and a haircut, and was thirsty. Record review showed the care plan identified bathing as requiring physical assistance, and the task list scheduled showers for Wednesdays and Saturdays. However, the past 30 days reflected only bed baths and zero showers, with no refusals documented. The resident was able to answer simple questions by nodding or shaking his head, and a psychiatric note documented that he could shake his head to answer simple questions. The DON reviewed the documentation and was unable to find any refusals or any preference for bed baths versus showers in the care plan.
Failure to Maintain Hydration Monitoring and Bedside Fluids
Penalty
Summary
The facility failed to ensure consistent availability of water at the bedside, failed to ensure hydration was offered, and failed to document fluid intake for one resident who was dependent on staff for bringing food or liquid to his mouth. The resident had a history of apraxia following cerebral infarction, dysarthria, and right-sided weakness/paralysis after a stroke. The MDS reflected that he was rarely or never understood and that he was dependent on staff for bringing food or liquid to his mouth. During observation, the resident was found lying flat in bed in a very warm room, wearing only an adult brief, with an unkempt appearance, unpleasant body odor, dry and chapped lips, and overgrown toenails. A Styrofoam cup on the bedside table contained only about one-quarter of water and was dated several days earlier. The resident indicated that he was thirsty, that he could not hold a cup or give himself drinks of water, and that he required assistance with eating and drinking. He also indicated that he had not been receiving showers and wanted a shower, a shave, and a haircut. The resident’s call light was observed clipped out of reach or positioned on his chest, and staff stated that he could not use it. The unit manager stated that the resident communicated by nodding yes or no or by using a communication board, but the communication board was not in his room. The electronic medical record showed no consistent documentation or monitoring of fluid intake. The DON stated that staff should be offering fluids to dependent residents every two hours and documenting fluid intake in the medical record.
Failure to Provide Ordered BiPAP Therapy
Penalty
Summary
The facility failed to ensure a resident received ordered respiratory care when BiPAP use was not provided after the resident returned from the hospital. The resident was a cognitively intact female with diagnoses including acute on chronic respiratory failure with hypoxia and hypercapnia, CO2 narcosis, sleep apnea, morbid obesity, COPD, respiratory failure with hypoxia dependent on oxygen, anxiety, and depression. Her history and physical reflected recent hospital transfer for pneumonia and obesity hypoventilation syndrome, and the hospital discharge summary stated that BiPAP was needed when sleeping and napping because the altered mental status was related to hypercapnia that resolved with BiPAP. The record showed physician orders for BiPAP at bedtime before the hospital transfer, but after the resident returned to the facility there was no evidence of a BiPAP order from the return through the survey date. The MAR and TAR also showed no evidence that BiPAP was used for about two months. During interview, the resident stated staff had not assisted her with the BiPAP since January and that the machine was in her closet. The ADON confirmed the resident had a history of COPD and BiPAP use, acknowledged the BiPAP order was not re-entered after the hospital return, and verified the equipment was located in the closet and was being set up at the time of interview.
Falsified Wound Care Documentation
Penalty
Summary
The facility failed to ensure medical records were accurate and not falsified for one resident with type 2 diabetes and a cognitively intact BIMS score of 15 out of 15. The resident had a physician’s order for wound care to the left posterior leg every other day on the evening shift, but on observation the dressing on the left calf was still dated 3/3/26 on 3/8/26 and again on 3/9/26, and the resident reported the dressing had not been changed since 3/2/26 or 3/3/26. The resident also reported the facility had removed his own wound care supplies from his room when he was admitted. The TAR showed the wound care was checked off and signed as completed on 3/4/26 by one LPN, on 3/6/26 by another LPN, and on 3/8/26 by a third LPN, but interviews showed the nurses could not confirm the care was actually done and one LPN stated she had changed a dressing on another resident’s heel, not this resident’s calf. The DON stated the nurses did not follow the physician’s orders and there was no reason for the wound care to be signed out as completed when it was not done. The resident’s progress notes contained no explanation for why the wound care was not completed on those dates, and the personnel files showed prior discipline for falsified or inaccurate documentation by the same nurses.
Window Sealed Shut in Resident Room
Penalty
Summary
The facility failed to provide a functional window for one resident with significant communication and mobility impairments. The resident was admitted and readmitted with diagnoses including apraxia following cerebral infarction, dysarthria, and weakness/paralysis affecting the right dominant side following a stroke. The MDS dated 1/16/26 reflected that the resident was rarely or never understood. During observation on 03/08/2026, the resident was found lying flat in his room wearing only an adult brief, with his heels not elevated, his room very warm, a Styrofoam cup of water on the bedside table, dry and chapped lips, an unkempt appearance, unpleasant body odor, and overgrown toenails. His call light was clipped to the curtain on his right side and out of reach. The resident communicated by nodding yes or no and indicated that he was warm, thirsty, had not been receiving showers, and wanted a shower, shave, haircut, and assistance with drinking water. On 03/10/2026, the resident was again observed lying flat with his heels not floated, and an LPN stated the room was hot. A full room-temperature cup of water was on the bedside table with no straw. On 03/08/2026, duct tape was observed around the perimeter of the window, preventing it from being opened or cracked and effectively sealing it shut. The room continued to feel very warm. Review of eight months of work order requests for the resident's room showed no work order related to the window. Maintenance stated the duct tape had been applied because the window was drafty when temperatures were low and said the facility intended to get window repair personnel out to repair the windows.
Failure to Notify Physician and Responsible Party After Resident Fall With Major Injury
Penalty
Summary
The facility failed to immediately assess and notify the physician and responsible party following a fall with major injury for one resident. The resident was found sitting next to his bed and was unable to articulate what happened. The LPN and CNA assisted the resident back to bed, and the LPN documented that there were no injuries or pain and that a body assessment was conducted. However, there was no documentation of a fall on the date of the incident, and no evidence that the physician or responsible party was notified at that time. Additionally, there was no documentation of range of motion assessment or neuro checks following the incident. The resident later complained of right hip pain to occupational therapy, who then notified nursing. The resident's guardian learned of the fall from the resident's roommate and requested immediate hospital transfer, where a right hip fracture requiring surgical repair was discovered. Interviews with staff revealed that the LPN who found the resident did not notify the physician or responsible party and did not perform a range of motion assessment. The DON confirmed that the facility's expectation was for the physician and responsible party to be notified after any incident once the resident was assessed and safe.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and respond to repeated concerns raised by the Resident Council regarding food palatability, call light response times, provision of evening snacks, and satisfactory resolutions to grievances. Review of the Resident Council Minutes from February to December 2024 indicated ongoing issues with the taste of food and delayed call light responses, particularly during the afternoon and night shifts. During a confidential resident group meeting, the majority of residents reported that their concerns about food taste and staffing had been discussed without any corrective actions being taken. Residents experienced long waits for call light responses, ranging from 45 to 60 minutes, and one resident noted that staff were often heard chatting at the nurse's station while call lights were on. Additionally, some residents reported that snacks were not offered, and staff would sometimes consume the snacks meant for residents. Several residents also expressed dissatisfaction with the resolution of grievances and concerns raised by the Resident Council.
Inaccurate MDS Assessments and Restraint Mismanagement
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their medical records. For Resident #48, the MDS indicated that the pneumococcal vaccination was offered and declined, despite the Durable Power of Attorney for Healthcare having consented to the vaccination. The resident did not receive the vaccination, and the MDS Coordinator admitted to not reviewing consents when completing assessments. Resident #103's MDS assessments were inaccurately coded regarding a Gradual Dose Reduction (GDR) for medications. The MDS indicated that a GDR was attempted and documented as clinically contraindicated, which was incorrect as no GDR was attempted. The MDS Coordinator acknowledged the coding errors in the assessments. For Resident #374, the MDS inaccurately reflected weight loss data, failing to indicate a significant weight loss that occurred. The Registered Dietician and MDS Nurse both confirmed the inaccuracy. Additionally, Residents #63 and #25 had issues with the use of bed bolsters, which were not properly assessed as potential restraints. The facility's Director of Nursing and MDS Coordinator provided conflicting information about the use of bolsters, indicating a lack of proper assessment and documentation regarding restraint use.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Resident #48, who was admitted with bullous pemphigoid and had severely impaired cognitive skills, was observed multiple times with an alternating pressure mattress that was not functioning. Despite a physician's order to monitor the mattress, it was found unplugged, and staff had to troubleshoot the issue. This indicates a lack of proper monitoring and implementation of the care plan for skin integrity. Resident #75, who was cognitively intact and dependent on renal dialysis, reported that their dialysis access site was not routinely monitored by nursing staff. The resident's care plan and Kardex did not reflect their dialysis status or the location of the access site, which is crucial for their care. Additionally, the Nutrition Care Plan was not initiated until six months after admission, showing a significant delay in addressing the resident's nutritional needs. Resident #109, with a history of psychiatric conditions, had a care plan that did not include behavioral interventions known to be effective, such as changing conversation topics to reduce agitation. This omission was acknowledged by the Director of Nursing. Similarly, Resident #25, who had a history of falls and anoxic brain damage, was observed with a call light out of reach, contrary to the care plan intervention to ensure it was accessible. This oversight could prevent the resident from communicating needs effectively, highlighting a failure to implement the care plan for fall prevention.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels to meet the needs of residents, particularly during the afternoon and night shifts. This deficiency was highlighted by ongoing concerns documented in the Resident Council Minutes, which reported long call light response times ranging from 45 to 60 minutes. During a confidential resident group meeting, the majority of residents expressed that their concerns about staffing had not been addressed, with reports of staff being inattentive and spending extended periods at the nurse's station without responding to call lights. Specific incidents involved three residents who experienced significant delays in receiving care. One resident reported that staff would turn off the call light without providing the requested service, leading to prolonged waits for assistance. Another resident, who required two-person assistance, reported that it took hours for staff to respond to their call light at night. A third resident experienced delays of 30 to 45 minutes, particularly around meal times and shift changes, resulting in instances of incontinence due to the wait for assistance.
Facility Fails to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide palatable and safe food products, affecting 125 residents, which increased the likelihood of decreased resident food acceptance and nutritional decline. Multiple residents expressed dissatisfaction with the quality and temperature of the food. Resident #94 mentioned that the food could be better and expressed a preference for more than just hamburgers and hot dogs. Resident #105 reported a desire for specific nutritious vegetables and noted that the facility's green beans were often inedible, the rice was tough, and the beans were sour. Resident #103 complained about the poor taste and temperature of the food, particularly breakfast items, and resorted to storing personal food items in their room due to dissatisfaction with the facility's offerings. The surveyor observed that Resident #103 stored personal food items on a windowsill, using the open window for limited refrigeration, which is not a safe practice. The facility's policy on safe storage and handling of outside food was not adhered to, as the resident's food was not properly labeled or stored in a designated refrigerator. Additionally, Resident #65 criticized the facility's grilled cheese sandwiches and reported that the food was often cold and of poor quality, describing the meat as rubbery. During the survey, food trays were observed being transported in non-insulated carts, which likely contributed to the improper food temperatures recorded. The pork loin and green beans served to Resident #65 were below the required temperature, while the pineapple tidbits, lemonade, and yogurt were above the safe temperature for cold foods. The facility's meal distribution policy was not effectively ensuring proper temperature maintenance, as evidenced by the surveyor's palatability tests, which found some food items to be bland, cold, or of poor quality.
Failure to Resolve Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to promptly resolve grievances for a resident, identified as R88, who was admitted with diagnoses including adjustment disorder with depressed mood and Alzheimer's Disease. R88, who was cognitively intact as per the Brief Interview for Mental Status, reported missing several clothing items, including sweatshirts, pants, t-shirts, and a green plaid jacket. Despite the items being labeled with R88's name, they were not returned from the laundry. R88 expressed uncertainty about whether a grievance form was filled out on their behalf. Interviews with facility staff revealed that the grievance process was not properly followed. Certified Nursing Assistant X acknowledged being informed by R88 about the missing items and verbally communicated this to the laundry staff but did not complete a grievance form. The Environmental Services Director indicated that all missing clothing items should be processed through the grievance system but was unsure if a follow-up was conducted with R88. The Nursing Home Administrator confirmed that no grievances related to the missing items were documented for R88, highlighting a failure in the facility's grievance handling process.
Failure to Assess Bed Bolsters as Potential Restraints
Penalty
Summary
The facility failed to assess the use of bed bolsters as potential restraints for two residents, leading to a deficiency in ensuring residents are free from physical restraints unless needed for medical treatment. Resident #63, who has schizoaffective disorder and unspecified dementia, was observed with bed bolsters that restricted their ability to get out of bed independently. The medical record did not reflect an assessment of the bolsters as restraints, and staff interviews indicated that the bolsters were used to prevent the resident from rolling out of bed, despite the resident's cognitive deficits preventing consistent removal of the bolsters. Similarly, Resident #25, with a history of falling, anoxic brain damage, and dementia, was observed with a positioning wedge and bolster that prevented them from getting out of bed. The resident's call light was out of reach, and the medical record lacked documentation of a restraint assessment. Staff confirmed that the bolsters and wedge were used to prevent falls, but the facility did not evaluate these as potential restraints. Interviews with the Director of Nursing and other staff revealed a lack of restraint assessments in the medical records for both residents. The facility's failure to assess the use of bed bolsters as potential restraints resulted in a deficiency, as the bolsters restricted the residents' freedom of movement without proper evaluation or documentation.
Delayed Completion of Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment in a timely manner for one resident out of 25 reviewed. The resident, who was admitted with a diagnosis of dementia, began hospice services on November 1, 2024, and ended these services on January 21, 2025. A Significant Change MDS assessment was initiated with an Assessment Reference Date of January 27, 2025, but was still in progress as of February 10, 2025, and was not completed until February 11, 2025. During an interview, the MDS Coordinator confirmed that the assessment was completed late, acknowledging that such assessments must be completed within 14 days of determining a significant change in the resident's condition, as per the Resident Assessment Instrument (RAI) Manual.
Deficiency in Providing Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents, resulting in a deficiency. Resident #29, who has multiple medical conditions including acute and chronic respiratory failure, type 2 diabetes, and chronic obstructive pulmonary disease, was not assisted in participating in activities such as bingo, which she expressed a desire to attend. Despite being cognitively intact and dependent on all care, the staff did not facilitate her participation in activities, leaving her in bed during scheduled events. The care plan indicated that she should be reminded and assisted to attend activities, but there was no documentation of her participation in any activities over the last 30 days. Resident #49, who has severe cognitive impairment and multiple health issues such as cerebral infarction and end-stage renal disease, did not receive showers as preferred, instead receiving bed baths without hair washing. The resident expressed a desire for showers, but due to a broken shower bench, she was not provided with this option. The facility's records showed that she had not received a shower in the last 30 days, and oral care was documented at inappropriate times, such as during the middle of the night while she was sleeping. Additionally, there were discrepancies in the documentation of her ability to wheel herself in a manual wheelchair, which contradicted her assessed dependency on all care. The facility's failure to provide adequate care and assistance with ADLs for these residents resulted in a lack of engagement in activities and unmet personal care preferences. The staff's inaction and lack of proper documentation contributed to the residents not receiving the care needed to maintain their highest practicable well-being, leading to potential embarrassment and humiliation.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide meaningful and individualized activities for a resident, resulting in the potential for depression, boredom, and feelings of lack of self-worth. The resident, who was cognitively intact and dependent on all care, expressed a desire to participate in activities such as Bingo but was not assisted in getting out of bed in time to attend. Despite having a care plan that included reminders and assistance to attend activities, the resident was observed still in bed during a scheduled Bingo activity, and no staff member was seen assisting her to participate. Interviews with staff revealed a lack of communication and coordination in ensuring the resident's participation in activities. A CNA, unfamiliar with the resident's preferences, did not assist her in getting up for activities. The Activity Director acknowledged the resident's interest in participating but cited logistical challenges in getting her ready due to her need for a two-person mechanical lift. A review of the resident's records showed no documented participation in activities over the past 30 days, with staff only noting that the resident watched TV daily.
Failure in Nutritional Care and Weight Management
Penalty
Summary
The facility failed to honor dietary preferences and manage weight effectively for two residents, leading to deficiencies in nutritional care. Resident #79, who was cognitively intact and had a gastrostomy for nutritional support, experienced significant weight gain over several months. Despite the resident's preference for weight loss and maintenance, the facility did not adjust the tube feeding regimen or consult the physician about the weight gain. The Registered Dietitian noted the resident's overweight status and the presence of a stage four pressure ulcer, but the medical record lacked documentation of discussions with the resident or their responsible party about the risks and benefits of the current diet orders. Resident #374, who had severe cognitive impairment and was at risk for malnutrition, experienced a significant weight loss of 11.7% over one month. The resident's care plan was not updated with new interventions after this weight loss, and the facility failed to implement the recommendations from the nutritional progress notes. The resident's weight continued to decline, and the medical record did not reflect any new or additional preventive measures to address the ongoing weight loss. The Registered Dietitian at the time of the survey was unfamiliar with the resident's case and could not explain why the previous dietitian's recommendations were not fully implemented. The deficiencies highlight the facility's failure to provide adequate nutritional care and weight management for the residents, as evidenced by the lack of appropriate adjustments to dietary plans and insufficient communication with residents and their responsible parties. The facility did not take necessary actions to prevent weight gain in one resident and weight loss in another, resulting in unmet nutritional needs and preferences.
Failure to Monitor Dialysis Access Site and Update Care Plans
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for Resident #75, who required such services due to end-stage renal disease and dependence on renal dialysis. The resident reported that the nursing staff were not routinely monitoring their dialysis access site, which was located in their left arm. The resident also mentioned that they were on a fluid restriction, but there was no active physician's order for this in their medical record. The Kardex, which guides Certified Nurse Aides (CNAs) in providing care, did not reflect the resident's dialysis status, the location of their access site, or any related care considerations. Additionally, the resident's Medication Administration Record (MAR) for February 2025 did not include orders for monitoring or assessing the dialysis access site. Interviews with facility staff revealed inconsistencies and a lack of clarity regarding the resident's care needs. A CNA, who did not frequently work on the resident's floor, was unsure about the location of the dialysis access site and relied on the Care Plan and Kardex for guidance. The Registered Dietitian reported that the resident was not on a fluid restriction, contradicting the information provided by the Registered Nurse (RN) and the Director of Nursing (DON). The RN was unable to locate orders for monitoring the dialysis access site, and the DON acknowledged that the orders were discontinued after the resident's hospital visit and not reimplemented upon their return. The DON also stated that the expectation was for daily monitoring of the dialysis access site, which was not being documented as required.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R375, who was admitted with a diagnosis of cerebral infarction. Despite being cognitively intact and able to communicate his needs and frustrations, R375 was not provided with necessary personal items such as clothing, shoes, and cigarettes, which were left at a previous facility. R375 expressed extreme dissatisfaction with his current situation, including having a legal guardian he did not want and being unable to leave the facility. The resident's requests for basic supplies and communication with his guardian were not adequately addressed by the facility's social services or nursing staff. R375's medical record indicated that he refused meals, showers, therapy, and medications, expressing a desire to be discharged from the facility. The social services notes revealed that the resident's guardian was aware of his behaviors and was in the process of finding another placement for him. However, the facility did not take steps to reassess the need for guardianship, despite R375's mental capacity to make his own decisions. The social workers were aware of the resident's dissatisfaction but did not take effective action to resolve his concerns or advocate for his needs. Interviews with social workers indicated a lack of initiative in addressing R375's situation, as they relied on the guardian to provide the requested items and did not pursue a competency evaluation to reassess the guardianship. The resident's condition worsened to the point of expressing suicidal ideation, yet the facility's response remained inadequate. The guardian eventually agreed to bring the resident's items and meet him at the hospital, but the facility's failure to provide timely and appropriate social services contributed to the resident's distress and unmet needs.
Medication Administration Error Due to Improper Storage
Penalty
Summary
The facility failed to ensure the safe storage and administration of medications for one resident, resulting in a medication error. During a medication administration observation, a Registered Nurse (RN) was seen removing a pre-filled medication cup from the top drawer of her medication cart, which she had filled earlier with the resident's 8:00 AM medications. The RN did not include the resident's prescribed Lithium Carbonate Oral Capsule 150mg in the medication cup, leading to the resident missing their morning dose. This incident was confirmed during an interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNA), where the DON stated that the expectation is for medications to be pulled from the bubble pack and administered directly at the time they are due.
Failure to Honor Gluten-Free Diet for Resident
Penalty
Summary
The facility failed to honor the food preferences and dietary needs of a resident diagnosed with celiac disease, which requires a gluten-free diet. The resident, who was cognitively intact, expressed frustration with the meals provided, stating that the kitchen frequently substituted her meals with hot dogs and hamburgers, sometimes including a bun, which is not gluten-free. Despite having a diet order for a gluten-free diet with extra protein due to pressure ulcers, the resident reported that the dietician had not visited her since her admission, and her weight was trending down. Interviews with facility staff confirmed the resident's complaints. A Certified Nursing Assistant (CNA) acknowledged that the resident was often sent hot dogs or hamburgers and was growing tired of them. The Registered Dietician (RD) stated that meat should not be substituted for residents with a gluten-free diet, indicating a failure to adhere to the dietary requirements. The deficiency was identified through observation, interviews, and record reviews, highlighting the facility's failure to provide meals that accommodate the resident's dietary needs and preferences.
Failure in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure proper collaboration and communication with the hospice provider for a resident receiving hospice services. The resident, who had been diagnosed with neuromyelitis optica and cerebral infarction, was admitted and readmitted to the facility and was receiving hospice care. Despite having a hospice visit calendar that scheduled 14 visits from hospice staff, the Hospice Staff Collaboration Log only noted four visits, and there were no progress notes pertaining to hospice visits in the Hospice Binder. Additionally, the resident's electronic medical record lacked documentation of hospice service visits, and their care plan did not reflect the hospice disciplines involved in their care. Interviews with facility staff revealed that hospice visit notes should have been available in the Hospice Binder and scanned into the electronic medical record, but this was not done. The Social Services Director reported coordinating hospice services, and the Director of Nursing confirmed that hospice visit notes were expected to be accessible to staff. An email request for the hospice visit calendar and communication log was made to the Nursing Home Administrator, but the hospice communication log was not provided before the survey exit.
Failure to Administer Pneumococcal Immunization
Penalty
Summary
The facility failed to administer a pneumococcal immunization to a resident, identified as R48, despite having received consent from the resident's Durable Power of Attorney (DPOA) for Healthcare. R48 was admitted to the facility with severely impaired cognitive skills for daily decision-making, as noted in the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/25. The medical record indicated that the pneumococcal immunization was not up to date, and although it was offered, it was initially declined. However, the Vaccine Consent and Administration Form showed that the DPOA consented to the immunization on 4/17/24. Despite this consent, the immunization was not administered. During an interview, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) acknowledged the consent but was unsure why the immunization had not been given.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. Resident #374 experienced a significant weight loss of 11.7% in one month, which was not reflected in their care plan. Despite being at risk for malnutrition due to their medical condition, no updates or additional interventions were made to the care plan after the weight loss and hospitalization. The Registered Dietician, who was new to the facility, was unable to provide an explanation for the lack of updates to the care plan. Resident #79's care plan did not reflect their preference to consume breakfast by mouth, despite receiving the majority of their nutrition through tube feeding. The resident reported gaining 20 pounds and consuming meals by mouth, but their tube feeding regimen had not been adjusted accordingly. The Director of Nursing acknowledged that the resident's meals should have been care planned, indicating a failure to update the care plan to reflect the resident's current nutritional preferences and needs.
Resident Burned Due to Unsafe Food Temperature
Penalty
Summary
The facility failed to ensure that hot food was served at a safe temperature, resulting in a resident suffering second-degree burns. The resident, a cognitively intact male with multiple health conditions including diabetes and chronic kidney disease, requested a CNA to heat a cup of noodles. The CNA heated the noodles in the microwave for 3-4 minutes and returned them to the resident without checking the temperature. The resident accidentally spilled the hot noodles on himself, causing burns to his abdomen, groin, and right thigh. The incident was not immediately reported to the necessary parties, including the physician, DON, and NHA. The initial response to the burn was inadequate, as the RN who assessed the resident did not apply appropriate first aid measures such as cooling the burn with water. Instead, petroleum jelly was applied, which is not recommended for acute burns. The incident was not documented in a timely manner, and the facility's policy on reheating food was not followed. Interviews with staff revealed a lack of training and awareness regarding the facility's policies on reheating food and immediate burn treatment. Several staff members, including CNAs and LPNs, were unaware of the correct procedures for checking food temperatures and providing first aid for burns. The facility's microwaves were not equipped with thermometers, and staff were not trained to use them prior to the incident. This lack of training and policy enforcement contributed to the resident's injury and the facility's failure to prevent the accident.
Delayed Physician Notification and Inadequate Burn Treatment
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, resulting in a delay in treatment of a burn and increased risk for pain and infection. The resident, a cognitively intact male with multiple medical conditions including diabetes and heart failure, accidentally spilled hot noodles on himself while eating in bed. The incident occurred when a CNA heated the noodles in a microwave for 3-4 minutes and returned them to the resident without checking the temperature. The resident suffered burns to his abdomen, groin, and right thigh. The incident was not reported to the physician, Director of Nursing, Nursing Home Administrator, or family member until over 15 hours later. Initial first aid was inadequate, as the RN who assessed the resident did not apply cool compresses or notify the physician immediately. The resident reported significant pain at the time of the incident, but this was not documented or addressed promptly. The facility lacked a clear policy for immediate burn treatment, and staff were not adequately trained in reheating food or responding to burn injuries. Interviews with staff revealed a lack of awareness and training regarding the facility's reheating policy and immediate response to burns. The microwaves were removed from resident floors after the incident, and staff were instructed to use a microwave in the staff breakroom. However, there was confusion about the appropriate temperature for serving food and the facility's policy on reheating. The facility's failure to provide timely and appropriate care for the resident's burns highlights deficiencies in staff training and communication protocols.
Failure to Provide Adequate Burn Care and Food Safety
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practical physical well-being of a resident, resulting in second-degree burns. The resident, a cognitively intact male with multiple health conditions including diabetes and hemiplegia, requested a CNA to heat a cup of noodles. The CNA heated the noodles in the microwave for 3-4 minutes and returned them to the resident, who was in bed. The resident accidentally spilled the hot noodles on himself, causing burns to his abdomen, groin, and right thigh. The incident was not immediately reported to the necessary parties, including the physician, Director of Nursing, and Nursing Home Administrator, until over 15 hours later. Initial first aid provided by the RN was inadequate, as it did not include cooling the burn areas with normal saline or cool cloths. The facility lacked a clear policy or training for immediate burn treatment, and staff were not educated on the proper procedures for heating and reheating food prior to the incident. Interviews with staff revealed a lack of awareness and training regarding the facility's reheating policy and immediate burn care. The CNA involved did not check the food temperature before serving it to the resident, and there was no thermometer available for staff use at the time. The facility's failure to follow its reheating policy and provide immediate and appropriate burn care contributed to the severity of the resident's injuries.
Failure to Notify Resident of Grievance Resolutions
Penalty
Summary
The facility failed to notify a resident of the investigation and resolution of grievances they had submitted. The resident, who was admitted with multiple diagnoses including cirrhosis of the liver, anxiety, and depression, was cognitively intact as indicated by a BIMS score of 15 out of 15. The resident expressed frustration during an interview, stating that they had submitted two concern forms regarding issues such as bathroom cleanliness, dietary requests, and roommate disturbances, but had not been informed of any resolutions. The grievance forms, dated in early July, documented that various managers had been notified and discussions had taken place to address the concerns. However, the forms did not indicate that the resident had been informed of these resolutions. The Nursing Home Administrator acknowledged that the computerized grievance system did not track whether residents were notified of the outcomes, and could not provide evidence that the resident had been informed or satisfied with the resolutions. The facility's grievance policy required a response to the resident, which was not demonstrated in this case.
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 667 citations issued within 25 miles in the last 12 months — including the 2 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 Ypsilanti
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gilbert Residence | 0.6 mi | ★★★★★ | 10 | 0 |
| Villa At Willow Place | 2.6 mi | ★★★★★ | 19 | 0 |
| Optalis Health And Rehabilitation Of Ann Arbor | 3.9 mi | ★★★★★ | 2 | 0 |
| Glacier Hills | 5.3 mi | ★★★★★ | 0 | 0 |
| Regency At Canton | 6.3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.