Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Addison Heights Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failed Pest Control Program Allowed Ant Infestation: The facility failed to maintain an effective pest control program when a resident with multiple chronic conditions and cognitive impairment was found covered in ants during a hospice RN visit. Staff statements and interviews described ants on the resident after spilled ice cream was left uncleaned, and other ants were noted in the facility, including on an overbed table and in the Administrator’s office. The pest control vendor confirmed routine services for ants and other pests had been suspended because of an overdue balance, and routine pest control had not occurred for weeks.
Resident Found Covered in Ants: A hospice resident with multiple chronic conditions, cognitive impairment, dependence for toileting and bed mobility, and unhealed pressure ulcers was found with ants crawling all over her body, including her groin and perineal area. Staff and hospice RN confirmed the resident had been left with spilled ice cream and was covered in ants when discovered, and the facility had no documentation of the event in the medical record. The resident’s right to dignity and respect was not maintained.
The facility failed to protect residents’ personal belongings by not maintaining accurate, complete, and updated inventories and by not ensuring clothing was labeled before being sent to laundry. Several residents with both impaired and intact cognition reported missing clothing such as underwear, pajamas, pants, shoes, and sentimental items, and stated they had notified staff without receiving follow-up. Surveyors found undated and unsigned inventory forms that listed only general categories of items without quantities, while room checks revealed many more, often unlabeled, clothing items than documented. Laundry staff and the Laundry Account Manager reported that most inventory sheets were incomplete, clothing was routinely sent to laundry in unlabeled bags, and the process for tracking missing items was not functioning, as no missing item forms had been received for months. Observations showed large amounts of unlabeled clothing in the laundry room and on racks in the social worker’s office, including items matching residents’ descriptions of missing garments, while the DON, ADON, CNAs, and receptionist gave inconsistent accounts of who was responsible for inventorying and labeling, and the Resident Council President reported ongoing problems with clothing not being returned from laundry.
A resident with severe cognitive impairment and multiple comorbidities developed left arm swelling, leading to a STAT x-ray that revealed a non-displaced distal radial fracture. Nursing staff notified the NP and implemented orders for imaging and ice, and later a splint was ordered for the affected extremity. However, there was no documentation that the resident’s representative was promptly informed of the fracture when it was first identified, and the family was ultimately notified days later by a hospice nurse rather than facility staff, contrary to facility policy requiring prompt notification of changes in condition.
A resident with multiple serious diagnoses and intact cognition became agitated, searched through belongings, and loudly claimed that personal accounts were hacked and all money was stolen while staff and a hospice nurse attempted to calm the situation. The resident tried to leave the building, police and EMS were called, and the resident was combative with officers and arrested. Despite the clear allegation that the resident’s account was hacked and money was gone, the facility did not submit a self-reported incident to the state agency or initiate an investigation, contrary to its abuse, neglect, exploitation, and misappropriation policy, and there were conflicting staff reports about whether leadership had been informed of the allegation.
A resident with paraplegia, stage 4 pressure ulcers, an indwelling urinary catheter, and an ostomy had physician orders and a care plan requiring enhanced barrier precautions (EBPs), including gown and glove use for high-contact care such as hygiene, bed mobility, linen changes, and device care. Despite EBP signage on the door and PPE supplies available outside the room, a CNA provided oral care, adjusted bed linens, repositioned the resident, and emptied the urinary catheter drainage bag while wearing only gloves and no gown. The CNA reported being unaware the resident was on EBPs, stated staff were not in the habit of wearing gowns, and indicated she had not received EBP training, while the DON confirmed staff should wear PPE for residents on EBPs during high-contact care, as required by facility policy.
A resident with cancer, COPD, liver malignancy, low back pain, intact cognition, and frequent pain had multiple Oxycodone orders, including a change from 30 mg PRN to 20 mg scheduled and PRN, but the facility failed to maintain accurate controlled substance records. MARs showed numerous Oxycodone doses given, yet corresponding controlled substance monitoring records were missing for several days, and discontinued 30 mg tablets were removed from the card without documentation of administration, waste, or disposal. On another occasion, Oxycodone 20 mg was charted as administered without a matching removal on the control record, and destruction records for 30 mg tablets contained conflicting counts and altered entries. The resident reported not receiving pain medication when requested, and interviews with the DON, ADON, and other staff confirmed missing control records, improper combining of scheduled and PRN orders on one card, incomplete shift-change inventory documentation, and failure to follow required documentation and review procedures for controlled substances.
During a COVID-19 outbreak, staff failed to consistently use required PPE such as N95 masks, gowns, gloves, and face shields when caring for residents in isolation or under droplet precautions. Several staff members entered rooms of COVID-19 positive residents or provided care in affected areas without following posted PPE requirements, and some reported confusion or lack of education regarding proper protocols. The facility's own policy mandated specific PPE for suspected or confirmed COVID-19 cases, but these measures were not reliably implemented, affecting both infected and non-infected residents.
A resident with impaired mobility and multiple medical conditions did not have the required bilateral bed rails in place as ordered and care planned, due to the absence of a grab bar on one side of the bed. The Maintenance Director confirmed the missing grab bar and stated that no assessment or adjustment of the bedframe or mattress had been performed to ensure proper fit and compliance with the resident's needs.
A resident with severe cognitive impairment and total dependence on staff was found in a wheelchair in a common area with another cognitively impaired resident kneeling beside her and making inappropriate contact inside her brief. The incident occurred when the area was unsupervised, as staff were occupied elsewhere. A CNA witnessed the event and reported it, but the written account was less detailed than the verbal description provided later. The facility's lack of supervision in the lounge area led to this incident of sexual abuse.
A resident with severe cognitive impairment and multiple diagnoses was found with another resident's hand in her brief. Although staff intervened immediately, the Administrator did not report the alleged sexual abuse to the State Agency within the required timeframe, citing a belief that no abuse had occurred. This failure to report was not in accordance with facility policy.
Two residents did not receive multiple doses of their prescribed medications, including antibiotics, antipsychotics, muscle relaxers, and pain medications, because the medications were not available at the facility. Documentation and interviews confirmed that these medications were missed as they were either awaiting delivery or a new prescription, resulting in deviations from physician orders.
Staff did not label opened thickened liquid cartons with open dates and were unaware that these products were only safe for seven days after opening, resulting in improper storage and monitoring of beverages for a resident with impaired cognition and special dietary needs.
A resident with multiple medical conditions was found to have a low air loss mattress that overhung the bed frame by about five inches, preventing the installation of a grab bar on one side. The Maintenance Director confirmed the mattress was too large for the frame and not fully supported.
A resident with complex medical and psychological needs was subjected to repeated removal of a comfort item by an LPN, resulting in distress. Although staff reported the incident internally, the facility did not notify the State Survey Agency of the abuse allegation within the required timeframe, as confirmed by staff interviews and review of facility records.
Medication storage and labeling were deficient in several areas. A resident had an Ozempic syringe on the cart that was partially used but not labeled with the date opened or expiration date. In the med storage room, the refrigerator freezer was encased in ice and the refrigerator temperature was 52 F instead of the required range for refrigerated meds. Two opened PPD vials were also missing open dates, and expired syringes and needles were found in the memory care med storage room.
Insufficient dietary staffing delayed meal service for all residents. Only the Dietary Manager was observed working in the kitchen while scheduled cook and dietary aide coverage was not present, and lunch was not served until well after noon. A resident was seen asking where lunch was because she was hungry, and multiple residents reported that lunch was very late. An MRC was later transferred to the kitchen to help with meal service.
Improper food storage and expired food were observed in the kitchen. Expired pears, jelly, and another dated container were found in the walk-in refrigerator, ground beef was sitting on a tray with no dates, frozen chicken patties were left open to air in the freezer, and a bin of bread crumbs in dry storage had a loose lid and was open to air. The Dietary Mgr verified the items were not stored per facility policy.
Water Management Program Not Effectively Implemented: The facility failed to implement and monitor an effective water management program to minimize the risk for Legionella growth. The Legionella Infection Control Protocol only addressed flushing toilets and running sinks in resident rooms daily and did not include flushing in other areas or a way to track and monitor flushed areas. An LPN reported random Legionella testing and yearly sample testing, but could not verify tracking sheets or yearly test results, and a Monthly Flushing and Faucet Inspection showed checks only for recent months.
The facility failed to ensure an RN was on duty for 8 consecutive hours when census exceeded 60 residents. Staffing records showed the DON was the only RN listed, and the Scheduling Coordinator confirmed no additional RN was scheduled when the census reached 61 residents on multiple days. This deficiency affected all residents in the facility.
The facility failed to maintain a safe, clean, comfortable, and homelike environment. An LPN reported there was often not enough linen available to complete incontinence care or change bedding, and observations found no flat sheets in the linen rooms when a resident needed a linen change. Two broken wheeled shower chairs were found in the 100-hall shower room, with one having broken wheels and the other a broken handle. Room observations also showed cobwebs, chipped paint, crumbs, stains, food in a bed, bent blinds that did not provide privacy, an uncovered baseboard heater with exposed metal fins, and unfinished drywall repairs.
Failure to Provide Scheduled Hygiene and Grooming Assistance: Multiple residents who needed staff help with ADLs were observed with unkept hair, matted hair, and beard growth, and shower records showed missed or incomplete bathing opportunities. Care plans called for assistance with bathing and grooming, but documentation and staff interviews confirmed that scheduled showers and hygiene care were not consistently provided, including for residents with cognitive impairment and residents dependent on staff for personal care.
A facility failed to maintain effective pest control after black flying insects and gnats were observed throughout resident rooms, meal areas, and common spaces. Residents reported insects landing on food, beverages, trays, curtains, and personal items, and several said the insects bothered them while eating or in their rooms. The administrator and DON confirmed the presence of insects, while pest control records showed treatments only in employee areas and laundry, not resident areas. A resident’s window screen also had an approximate one-inch gap that allowed insects to enter the room.
A resident’s MDS was inaccurate for vision. Although the MDS showed adequate vision and no need for corrective lenses, the record included notes that he had been losing his vision before admission, had dense cataracts, and was referred for cataract surgery. The resident reported no vision in one eye and low vision in the other, and the MDS Coordinator and an LPN/SW staff member acknowledged the vision assessment was not completed as directed.
Baseline Care Plan Not Individualized for Cognitive and ADL Needs: A resident admitted with multiple diagnoses, including Alzheimer’s disease, AMS, and protein-calorie malnutrition, had a BIMS score indicating severe cognitive impairment and required substantial to maximal assistance with all ADLs. Review of the care plan found no interventions addressing the resident’s Alzheimer’s disease or ADL needs, and the DON verified the omission.
Failure to implement ordered fall prevention measures for two residents was cited. One resident with severe cognitive impairment, epilepsy, and repeated falls was observed barefoot and without an ordered soft helmet while moving about the facility, and the record did not document what fall interventions were in place during the falls. Another resident with mobility impairment and a history of multiple falls had care plan interventions for appropriate footwear, grippy socks, nonskid strips, and siderail/grab bar use, yet was repeatedly found without slip-resistant footwear and without accessible siderails/grab bars, and the chart did not document fall interventions in place at the time of the unwitnessed falls.
Failure to Provide Ordered Tracheostomy Care: A resident with a trach, chronic respiratory failure with hypoxia, and multiple comorbidities did not receive trach care as ordered every shift. Staff observed a tattered dressing, moderate green drainage, and mucus buildup in the inner cannula; one LPN said the prior shift did not change the dressing or cannula, another RN said trach care did not populate on the TAR, and an LPN documented care as completed after only observing the stoma and stated they were unfamiliar with the policy.
A resident with chronic venous insufficiency, lower-extremity ulcers, and skin breakdown did not receive ordered prevention measures. Staff observed a low air loss mattress that was not functioning, no compression stockings in place, and no off-loading boots on the resident’s lower extremities. The resident said he had requested the mattress and stockings, and a CNA and LPN confirmed the missing or incorrect interventions.
Failure to Provide Ordered Pressure Ulcer Care: Two residents with pressure ulcers did not receive ordered wound treatment and dressing care. One resident with a stage IV sacral ulcer had a dressing come off during incontinence care and it was not replaced despite repeated requests, while an LPN said she was unaware because there was no report or EMR documentation. Another resident with a stage III gluteal pressure ulcer was observed with the wound open to air and no dressing in place, despite orders for cleansing, zinc oxide, bordered dressing, and offloading.
Surveyors found that multiple rooms and restrooms had significant maintenance and cleanliness issues, including damaged walls, peeling paint, broken fixtures, missing hygiene supplies, and non-functional lighting. Staff interviews confirmed these conditions, and only one of three showers in the memory care unit was operational. These deficiencies affected at least ten residents and did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with multiple complex diagnoses and cognitive impairment had only one care conference during their admission, despite requiring regular care conferences at admission, quarterly, and with significant changes in condition. Staff interviews and facility policy review confirmed that the required schedule for care conferences was not followed.
A resident with significant risk factors for skin breakdown, including impaired mobility and incontinence, was not provided with physician-ordered pressure-relieving devices such as a wheelchair cushion and offloading boots. Observations and staff interviews confirmed that these devices were not in use or available, and care instructions for CNAs did not include their application, despite the resident's recent history of a healed stage III pressure ulcer.
Surveyors found that several residents were exposed to uncomfortably cold temperatures, requiring them to wear heavy coats and blankets, while multiple rooms had significant maintenance issues such as damaged walls, peeling paint, unsecured toilets, and broken window sills. Staff confirmed these conditions, which did not meet the facility's own standards for a safe and homelike environment.
Staff left open canisters of hazardous Sani-Cloth wipes on a linen cart accessible to residents, including several who were cognitively impaired and independently mobile. An LPN confirmed these chemicals should have been locked away according to facility policy, but they were left unsecured in a resident area, contrary to safety protocols.
The facility failed to maintain a homelike environment due to pervasive foul odors throughout the facility, excluding the secured memory care unit. Observations and interviews with staff and visitors confirmed the presence of strong, unpleasant odors, particularly near the nurses' station and certain resident rooms. The facility's policy on minimizing institutional odors was not followed, leading to this deficiency.
A facility failed to notify a physician in a timely manner about a resident's abnormal lab results, which included an elevated sodium level. The resident had multiple health conditions, and the facility's policy required prompt notification of the physician for significant changes in medical treatment. Interviews revealed uncertainty and lack of documentation regarding the notification timeline.
A facility failed to ensure timely follow-up by a physician for a resident with elevated sodium levels. The resident, with multiple health issues, had a lab report showing abnormal sodium levels, which the MD reviewed but did not act upon until days later. Interviews revealed a lack of awareness and follow-up, despite facility policy requiring timely medical assessments.
The facility failed to maintain air temperatures at a comfortable level, affecting 18 residents. Observations revealed that the memory care unit's ambient air temperatures were below the required 71 degrees Fahrenheit, with readings ranging from 65.3 to 70.1 degrees Fahrenheit. CNAs confirmed the cool temperatures during resident bathing, and the Maintenance Director was unaware of the issue despite weekly checks. The facility's policy requires maintaining temperatures between 71 to 81 degrees Fahrenheit.
A resident with multiple health conditions did not receive ordered weekly lab work for CBC and BMP, as confirmed by the DON. The facility's records lacked evidence of completed lab work, despite orders being in the lab system. This deficiency was found during a complaint investigation.
A resident with dementia and pressure ulcers did not receive proper infection control during wound care. An LPN failed to don a gown and did not change gloves or perform hand hygiene between dressing changes, contrary to facility policy and CDC guidelines. The facility lacked a specific EBP policy, relying on CDC guidelines instead.
The facility failed to maintain a clean and sanitary environment, affecting several residents. Observations revealed issues such as peeling floors, broken wall bumpers, and unclean bathrooms in the Memory Care Unit. Interviews with staff and residents confirmed the poor condition, with reports of inadequate housekeeping services and unresolved maintenance issues. The Director of Housekeeping verified these problems during a walkthrough, indicating non-compliance with maintaining a safe and homelike environment.
A resident with a history of migraines did not receive prescribed medications due to a failure to transcribe physician orders into the EMAR. Despite the medications being delivered, they were not administered, leading to continued severe pain for the resident.
Failed Pest Control Program Allowed Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program. Resident #48, who had celiac disease, type 2 diabetes, pulmonary hypertension, atrial fibrillation, CHF, chronic pain, depression, psychosis, cognitive impairment, dependence for toileting and bed mobility, moderate assistance needs for personal hygiene, and unhealed pressure ulcers, was found with multiple ants crawling on her during a hospice RN visit. The RN documented that the CNA said the resident had been given ice cream the day before and ants were noticed then. A written staff statement also reported that the resident had been covered in ants when staff entered the room, and that the hospice nurse found the condition and reported it to the CNA and nurse. Additional interviews and records showed ant activity elsewhere in the facility, including a resident reporting ants on an overbed table and the Administrator stating he had ants in coffee cups on his desk. The pest control vendor confirmed routine commercial pest control covered ants, mice, roaches, and rats, but routine services had not been provided since 03/23/26 because the facility had a past due balance and services were suspended after the balance became more than 90 days overdue. The vendor also confirmed the facility had not reported increased ant activity before the resident incident. The facility policy stated it recognized the importance of pest and vermin control and used a licensed contractor for treatments.
Resident Found Covered in Ants
Penalty
Summary
The facility failed to ensure a dignified existence for a hospice resident when the resident was found with ants crawling all over her body. Resident #48 was admitted on 12/18/15 and had diagnoses including celiac disease, type 2 diabetes mellitus, pulmonary hypertension, atrial fibrillation, congestive heart failure, chronic pain, depression, and psychosis. The quarterly MDS showed the resident was cognitively impaired, dependent on staff for toileting and bed mobility, required moderate assistance for personal hygiene, and had unhealed pressure ulcers. A significant change in status MDS was in process, and the resident had an order for hospice services after a recent hospitalization. The resident’s care plan addressed impaired functional abilities and included assistance with bed mobility, toileting, and incontinence care on routine rounds and as needed if soiled or per request. However, there was no documentation in the medical record related to ants being found on the resident on 05/17/26. The hospice RN documented that upon entering the room, she found multiple ants crawling on the resident and notified the facility nurse and CNA to change the resident’s gown and bedding. A written staff statement also stated the resident had spilled ice cream the previous day and was not cleaned up, and that when staff entered the room the resident was covered in ants. Additional interviews confirmed the condition of the resident and the extent of the infestation. The roommate stated she overheard staff talking about ants on the resident and in her bed, and said staff gave the resident a bed bath and complete bed change. A CNA stated there were not just a few ants, but a lot of ants crawling all over the resident, including from mid-torso to mid-thigh, inside the incontinence brief, in the groin and perineal area, and underneath the lift pad. The hospice RN, facility nurse, and other staff confirmed the ants were observed during care, and the facility administrator stated he was made aware of the situation and directed staff to clean the resident and the room. The facility policy stated every resident had the right to be treated with dignity and respect.
Systemic Failure to Inventory, Label, and Track Residents’ Personal Clothing and Belongings
Penalty
Summary
The deficiency involves the facility’s failure to implement effective procedures to safeguard residents’ personal belongings, particularly clothing, as required by its own policies. Multiple residents with varying cognitive statuses reported missing clothing and personal items, and surveyors found that inventory forms were incomplete, inaccurate, undated, and often unsigned. For one resident with Alzheimer’s disease and impaired cognition, the admission inventory listed general categories of clothing and photographs but no quantities and did not include a recliner chair that remained in the facility after discharge. A concern form documented that this resident’s representative reported missing slippers, pajamas, and a shirt; some items were later found among unlabeled clothing, and one pair of slippers remained missing. The Administrator confirmed the recliner was not on the inventory sheet. Another resident with Huntington’s disease and moderately impaired cognition reported missing underwear, stating she had informed staff but received no follow-up. Her inventory form was undated and unsigned, listing only a few clothing items and a cell phone with charger. When surveyors and the ADON later checked her belongings, they found more clothing items than were documented, and several items were unlabeled. A resident with hemiplegia, schizoaffective disorder, and intact cognition reported missing shoes, leggings, jogging pants, a sentimental t‑shirt, and a hoodie, and stated she had reported these losses without staff follow-up. Her inventory form, completed by a social worker, listed only broad categories of clothing and a few specific items, with almost no quantities recorded. Observation showed she had numerous clothing items not accurately reflected on the inventory form, and some items were unlabeled. A resident admitted with a femur fracture and intact cognition reported missing three pairs of pajamas and said he had notified laundry staff, who did not follow up. His undated, unsigned inventory form listed only a small number of clothing items and dentures, while observation later revealed multiple additional clothing items, most of which were unlabeled and not on the inventory. Another resident with cerebral infarction, bipolar disorder, and intact cognition reported missing pajama pants, undershorts, dress pants, and shirts, and said staff told him he would need to sort through bags of clothes himself, which he refused. His inventory form, signed by therapy staff, listed general clothing and personal items without quantities. Subsequent observation showed numerous clothing items, including unlabeled pants the resident said he received as gifts, and the inventory remained inaccurate. Surveyors later observed racks of unlabeled clothing in the social worker’s office, including pajama pants matching this resident’s description. Staff interviews and laundry observations showed systemic failures in the processes for inventorying, labeling, and tracking clothing. The Laundry Account Manager stated that about 90% of inventory sheets had not been completed and clothing was not being labeled, with CNAs sending bags of unlabeled clothing to laundry. Laundry staff reported the tracking process was “broken,” that they lacked descriptions and sizes on inventory sheets, and that they had not received missing item forms for months. Surveyors observed large quantities of unlabeled clothing in the laundry room and on racks in the social worker’s office. CNAs and the DON gave inconsistent descriptions of who completes inventories, what details should be documented, and who is responsible for labeling clothing. The receptionist, who had labeling equipment, was unsure of her responsibility. The DON and ADON acknowledged that inventory sheets were not consistently completed, updated, or reviewed after admission, that many items were unlabeled, and that new items brought in by families were not routinely added to inventories. Despite facility policies requiring inventory of belongings, prompt investigation of complaints, and maintenance of lost-and-found records, there were no documented concern forms or nurse notes for the missing items reported by several residents, and the Resident Council President reported ongoing issues with clothing not being returned from laundry.
Failure to Promptly Notify Resident Representative of Fracture
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a significant change in condition, specifically a left radial fracture. The resident had diagnoses including cerebral infarction, Alzheimer’s disease, anxiety, and depressive disorder, and was documented as having severe cognitive impairment and dependence on staff for activities of daily living. On 01/22/26, a STAT x-ray of the resident’s left arm was ordered due to edema, along with an order for ice application. Nursing documentation that morning indicated the nurse practitioner was notified of the edema and that all parties were notified of the new x-ray and ice orders. An x-ray was completed that evening, and the radiology report later that night showed a non-displaced fracture of the distal left radius. On the following day, a nurse’s note documented that the nurse practitioner reviewed the x-ray results with no new orders, but there was no documentation that the resident’s representative was notified of the fracture at that time. Several days later, on 01/27/26, the nurse practitioner evaluated the resident onsite, reviewed the abnormal x-ray results, and new orders were written for a left wrist/hand splint; the nurse’s note again stated that all parties were notified. A hospice progress note that same day showed that hospice staff initially believed the x-ray was negative and only learned of the radial fracture when a staff member entered with a splint and stated the resident had a fracture. The hospice nurse then spoke with facility staff, who confirmed the nondisplaced radial fracture and indicated the resident’s representative would be updated. Documentation shows that the hospice nurse, not facility staff, notified the family of the x-ray results and treatment on 01/29/26. The unit manager LPN confirmed there was no documentation that the family was notified of the fracture when it was identified on 01/22/26, despite facility policy requiring prompt notification of the resident, physician, and resident representative of changes in condition.
Failure to Report and Investigate Allegation of Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s funds to the state agency and to initiate an investigation. The resident involved had diagnoses including malignant carcinoid tumor of the bronchus and lung, COPD, malignant neoplasm of the liver, depressive disorder, neoplasm of the brain, and anxiety, and was documented as having intact cognition on a recent quarterly MDS. On one morning, nursing documentation showed the resident was in his room going through his belongings, then moved into the hallway with belongings on his rollator, loudly stating he was leaving, that his accounts were hacked, and that all his money was stolen. The resident was yelling, not redirectable, and ultimately shoved his belongings to the ground and attempted to leave through the front doors while the hospice nurse and a facility nurse followed. Police and EMS were called, and the resident became combative with officers and was arrested. Review of the facility’s Self-Reported Incidents through the day after the event showed that no SRI had been submitted to the state agency regarding the resident’s allegation of misappropriation, and no investigation into the allegation had been started. The DON acknowledged the resident had called the sheriff and reported his account had been hacked, and confirmed the resident was combative with an officer and arrested, but did not indicate that an abuse/misappropriation report or investigation had been initiated. The Administrator stated she was not informed that the resident had alleged his account was hacked or that his money was stolen, and verified that no SRI had been submitted, stating she would have filed one if she had been aware. In contrast, the ADON reported that on the day of the incident the resident stated his account was hacked and his money was gone, and that this allegation was reported to the Administrator, DON, and Regional on call. Facility policy required that all alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property be reported within required timeframes and investigated, which did not occur in this case.
Failure to Implement Enhanced Barrier Precautions per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered enhanced barrier precautions (EBPs) for a resident with multiple high-risk conditions. The resident, admitted with paraplegia, hypertension, neuromuscular bladder dysfunction, and stage four pressure ulcers on both hips, had an indwelling urinary catheter, an ostomy, and two stage four pressure ulcers present on admission. The quarterly MDS showed the resident had intact cognition. Physician orders dated 08/05/25 required staff to use gowns and gloves for high-contact resident care activities, including dressing, bathing/showering, transfers, hygiene, toileting, changing linens, changing briefs, dressing changes, and care of any device such as wounds, catheters, or ostomies. The resident’s care plan also specified the need for EBPs related to wounds, colostomy, and indwelling urinary catheter, with interventions directing staff to wear EBP PPE during high-contact care. During observation, the resident was in bed with a sign posted on the door indicating EBPs and instructing staff to wear a gown and gloves during care, and a PPE bin with gowns was available outside the room. A CNA was observed providing care while wearing gloves but no gown. The CNA performed multiple high-contact activities, including oral care, placing a pillowcase on a pillow, repositioning the resident in bed, and emptying the urinary catheter drainage bag, all without donning a gown. In interview, the CNA confirmed these care activities, stated she was unaware the resident was on EBPs, reported she had not noticed the sign, and indicated that staff were not in the habit of wearing gowns and that she had not received training on EBPs. The DON confirmed that staff should be wearing PPE for residents on EBPs during high-contact care. Review of the facility’s Enhanced Barrier Precautions policy, revised 12/2024, showed that EBPs require gown and glove use for high-contact care for residents with wounds or indwelling devices and that staff were to be trained prior to caring for residents on EBPs, with signage used to communicate required PPE.
Failure to Accurately Manage and Document Controlled Substance Use for a Resident in Pain
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and compliant system for dispensing, administering, reconciling, and destroying controlled substances, specifically Oxycodone, for a resident with significant pain needs. The resident was admitted with malignant carcinoid tumor of the bronchus and lung, COPD, malignant neoplasm of the liver, and low back pain, and had intact cognition, independence in ADLs, and frequent pain. Physician orders initially included Oxycodone 30 mg every four hours as needed, later changed to Oxycodone 20 mg scheduled three times daily with additional 20 mg doses every four hours as needed. The scheduled and PRN Oxycodone 20 mg orders were placed on the same medication card, contrary to facility policy requiring one prescription per control record page. Review of the MARs and controlled substance records showed multiple discrepancies and missing documentation. The MARs indicated that the resident received 26 Oxycodone tablets over several days and an additional 28 tablets over a later period, but there were no corresponding controlled substance monitoring/control records for those administrations. On one date, two tablets of discontinued Oxycodone 30 mg were removed from the medication card at 3:00 A.M., with no documentation on the MAR or in nurse’s notes that the medication was administered, disposed of, or wasted. On another date, the MAR showed administration of two Oxycodone 20 mg tablets, but the control record did not show that the medication had been removed from the card, and there was no nursing documentation explaining why the medication was charted as given when it had not been pulled according to the control record. Further record review revealed inconsistencies in the documented counts and destruction of Oxycodone 30 mg tablets. A disposal record showed nine tablets documented as destroyed, while the corresponding control record indicated only four tablets remained, and the entry for destruction of nine tablets was crossed out and changed to four. The DON verified that nine tablets had been incorrectly documented as destroyed. Facility leadership and nursing staff acknowledged they could not locate all of the resident’s Oxycodone control records and that nurses were not consistently documenting and initialing shift-change controlled substance inventory count sheets when medication cards and control records were removed from the controlled substance binder. The resident reported that pain medication was not administered when requested and stated that management had been notified. Interviews with the ADON and other staff confirmed that required documentation practices, including progress notes when medications were not given and proper witnessing and recording of destruction, were not followed, and that the ADON had not reviewed the missing control records as required by policy.
Failure to Implement Proper PPE Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during a COVID-19 outbreak, specifically regarding the use of personal protective equipment (PPE). Observations revealed that staff and residents were generally wearing surgical masks, but multiple instances occurred where staff did not don the required PPE, such as N95 masks, gowns, gloves, and face shields, when entering rooms of residents with confirmed COVID-19 or when providing care in areas under droplet precautions. In several cases, staff entered rooms of residents in isolation without appropriate PPE, and some staff were unaware of or did not follow posted PPE requirements. For example, a certified nursing assistant (CNA) entered a room shared by a COVID-19 positive resident without donning any PPE, and another CNA provided care to COVID-19 positive residents while only wearing a surgical mask, despite signage indicating the need for an N95 mask and other protective equipment. Interviews with staff indicated confusion and lack of consistent education regarding PPE protocols. Some staff reported not receiving education on proper donning and doffing procedures, while others were unsure about mask requirements or believed that wearing a face shield alone was sufficient. There were also reports of staff being unable to locate N95 masks on the memory care unit (MCU), despite the facility stating that adequate stock was available. This led to staff providing care to COVID-19 positive residents without the recommended respiratory protection. Additionally, staff sometimes failed to review or follow the PPE instructions posted on isolation signage before entering resident rooms. The deficiency affected both residents diagnosed with COVID-19 and those not diagnosed, as improper PPE use increased the potential for transmission. The facility census was 68, with 14 residents identified as having COVID-19 during the outbreak. The facility's own policy required staff to use a NIOSH-approved N95 respirator, gown, gloves, and eye protection when entering the room of a resident with suspected or confirmed COVID-19, but these protocols were not consistently followed as observed and confirmed through staff interviews.
Failure to Provide Ordered Bed Rails for Resident Mobility
Penalty
Summary
The facility failed to ensure that bed rails were in place as ordered to assist a resident with bed mobility. The resident, who had diagnoses including morbid obesity, muscle weakness, and Type II Diabetes Mellitus, was care planned and assessed to require bilateral half side rails to promote independence with bed mobility, self-positioning, and transfers. The physician order also specified half side rails on both sides of the bed. However, during observation, it was noted that only the left side of the bed had a grab bar, while the right side, which was against the wall, did not have one installed. The resident reported that both grab bars were necessary to assist with mobility during personal care in bed. The Maintenance Director confirmed the absence of the right-side grab bar, attributing it to the way the mattress fit the bedframe. Further interview revealed that the Maintenance Director had not assessed the mattress or bedframe for proper fit since beginning employment and had not made any changes to the resident's bed setup. This resulted in the resident not having the necessary equipment in place as indicated by their care plan and physician order.
Failure to Supervise Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to provide adequate supervision, resulting in an incident of sexual abuse involving two residents with dementia. One resident, who had severely impaired cognition and was dependent on staff for all activities of daily living, was found in a wheelchair in the lounge area with another resident kneeling beside her and his hand inside her brief at the peri area. The incident was witnessed by a CNA, who observed the resident's hand entering the brief from the side and making contact with the peri area. The CNA described the resident's posture as appearing to enjoy the interaction, and the event occurred in a common area near the nurse's station. At the time of the incident, staffing in the area included a nurse passing medication and another CNA providing care in a different room, leaving the lounge area unsupervised. The resident who initiated the contact had impaired cognition but was physically able to move independently. The incident was discovered when the CNA exited another resident's room and observed the inappropriate contact. The written statement provided by the CNA was brief, as directed by the DON, but during a subsequent interview, the CNA provided more detailed observations about the nature and extent of the contact. The facility's investigation included review of witness statements, medical records, and interviews with staff. The administrator acknowledged the discrepancy between the CNA's written and verbal statements but maintained that the investigation did not indicate sexual abuse. However, the facility's policy required monitoring for sexually aggressive behavior and potential abuse in resident-to-resident altercations. The lack of supervision in the lounge area directly contributed to the incident, as staff were not present to prevent or immediately intervene in the inappropriate contact.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of sexual abuse to the State Agency, as required by federal and state regulations. A resident with severe cognitive impairment, dependent on staff for all activities of daily living and diagnosed with Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease, was found in her wheelchair in the lounge with another resident's hand in her brief. The incident was documented by the DON, and the residents were immediately separated and placed on 15-minute checks. Despite the immediate intervention, the Administrator did not report the incident to the State Agency within the required two-hour timeframe. The Administrator stated that the delay was due to his belief that no abuse had occurred. Facility policy mandates that all alleged violations involving abuse must be reported within the proper time frame, but this procedure was not followed in this case.
Failure to Administer Medications as Ordered Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for two residents. For one resident with multiple diagnoses including a fractured femur, osteoarthritis, anxiety, schizoaffective disorder, and venous thrombosis, several prescribed medications such as Senna, Cefuroxime Axetil, Eliquis, Risperidone, and Methocarbamol were not administered upon admission due to the medications not being available. Documentation in the Medication Administration Record (MAR) and nurses' progress notes confirmed that these medications were missed, and the provider was notified of the missed doses, but no new orders were received. Additionally, the resident received only nine out of ten ordered doses of Cefuroxime Axetil. Another resident with a history of spondylolisthesis, chronic pain, and cervical disc disorder did not receive multiple doses of Lyrica (pregabalin) as ordered for nerve pain. The MAR and nursing notes indicated that the medication was not available on several occasions, resulting in missed doses. The resident reported experiencing neck pain and confirmed that the facility ran out of his medication for six doses during the previous week. The DON confirmed the missed doses upon review of the MARs for both October and November.
Failure to Properly Label and Monitor Expiration of Thickened Liquids
Penalty
Summary
Staff failed to properly label food items with open dates and did not demonstrate knowledge regarding the expiration of packaged foods. During an observation of food storage, several opened cartons of nectar thickened beverages were found in a reach-in cooler, each with only a handwritten date indicating when the product was received into inventory, not when it was opened. The Dietary Manager confirmed that no other date was written to indicate the opening of the product and believed the product was safe to consume until the manufacturer’s stamped date. However, the cartons were labeled to be used within seven days of opening if refrigerated, a fact the Dietary Manager was unaware of. This deficiency affected a resident with impaired cognition and multiple diagnoses, who was the only individual in the facility on thickened liquids. Review of facility training records showed that dietary staff, including the Dietary Manager, had been educated on expired food disposal and labeling and dating foods, but the facility’s policy did not provide guidance on dating food items with multiple servings in original containers. The lack of proper labeling and staff knowledge led to the failure to ensure food safety standards were met for the resident requiring thickened liquids.
Incompatible Mattress and Bed Frame Resulting in Unsafe Bed Setup
Penalty
Summary
The facility failed to ensure that a mattress and bed frame were compatible for a resident with morbid obesity, muscle weakness, and Type II Diabetes Mellitus. The resident, who was cognitively intact and required a low air loss mattress at all times, reported that the mattress was too large for the bed frame. Observation confirmed that the mattress overhung the bed frame by approximately five inches, and a grab bar could not be installed on one side of the bed due to the mattress's size. The Maintenance Director acknowledged that the mattress was not fully supported by the frame and confirmed awareness of the issue.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report an allegation of staff-to-resident abuse to the State Survey Agency, as required by regulation and facility policy. A resident with multiple diagnoses, including sepsis, seizures, bipolar disorder, and major depressive disorder, who was rarely or never understood by staff, was at risk for falls and had interventions in place for safety and engagement. On the evening in question, a CNA and an LPN witnessed another LPN repeatedly snatch a stuffed animal from the resident, refuse to return it unless the resident complied with demands, and make statements such as the toy being in 'jail' and the resident being 'bad.' These actions caused the resident to become visibly upset and agitated, prompting staff to report the incident to the unit manager immediately. Despite the immediate internal reporting, the facility did not notify the State Survey Agency of the abuse allegation until two days after the incident. Review of the facility's self-reported incidents and interviews with staff and the administrator confirmed the delay in reporting. Facility policy required that allegations of abuse and the results of investigations be reported within required timeframes, which was not followed in this case. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for abuse.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in the medication storage areas. Resident #13, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease, obesity, major depressive disorder, chronic pain syndrome, and other conditions, had a four mg/three mL Ozempic syringe on the 200-hall medication cart that was approximately one-quarter used. The syringe was observed without a label showing the date it was opened or the expiration date after opening. An LPN verified that the Ozempic syringe was in the cart without the required opening and expiration information, and the facility policy stated Ozempic can be stored at room temperature for 56 days after opening. The medication storage refrigerator in the room at the intersection of the 100 and 200 halls was observed with a freezer compartment completely encased in ice. The same refrigerator was also observed at 52 degrees Fahrenheit, and an LPN verified that temperature. The facility policy stated refrigerated medications required storage between 36 degrees Fahrenheit and 46 degrees Fahrenheit. These conditions were observed in the area used to store medications requiring refrigeration for eight residents identified by the facility as using such medications. The refrigerator also contained two opened one mL vials of PPD with the manufacturer’s instruction to discard 30 days after opening, but neither vial was labeled with the date opened. In the memory care medication storage room, expired supplies were also found, including multiple boxes of tuberculin safety syringes and hypodermic needles with manufacturer expiration dates that had passed. The DON verified the expired supplies, and the facility policy stated outdated or deteriorated drugs or biologicals were not to be used and were to be returned to the dispensing pharmacy or destroyed.
Insufficient Dietary Staffing Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services, affecting all residents in the 60-resident census. On 09/08/25 at 8:00 A.M., observation of the kitchen showed only the Dietary Manager was working and preparing breakfast, even though the staffing schedule showed a cook and two dietary aides were scheduled, with two open shifts also listed. The Dietary Manager stated that two additional staff were scheduled but did not come to work. Later that day, at 12:45 P.M., Resident #26 was observed in the main lobby asking staff where lunch was because she was hungry, and lunch service was not provided until 1:00 P.M. to 1:42 P.M. Residents #22, #26, and #30 stated that lunch was very late. At 2:22 P.M., the Dietary Manager stated that the Medical Records Coordinator was transferred into the kitchen to assist with meal service. The Administrator stated the contingency plan was to have other qualified staff work in the kitchen if the department was understaffed.
Improper Food Storage and Expired Food in Kitchen
Penalty
Summary
The facility failed to dispose of expired foods and failed to store food properly in the kitchen. During observation of the walk-in refrigerator, several expired items were found, including a plastic container of pears dated 08/30/25 with a use-by date of 09/03/25, a large plastic container of jelly dated 08/04/25 with a use-by date of 09/04/25, and another plastic container dated 09/07/25 with a use-by date of 09/07/25. Two five-pound rolls of ground beef were also observed sitting on a tray with a red liquid substance on the tray, and the meat was not labeled with dates. In the walk-in freezer, a plastic bag of frozen chicken patties was left open to air. In the dry storage area, a plastic bin containing bread crumbs was sitting on the floor with the lid not attached properly, leaving the contents open to air. The Dietary Manager verified these foods were not stored properly per facility policy. Review of the facility policy stated that food containers must be leak-proof, sanitary, NSF approved, tightly covered, and labeled and dated.
Water Management Program Not Effectively Implemented
Penalty
Summary
Provide and implement an infection prevention and control program. Based on record review and staff interview, the facility failed to implement and monitor an effective water management program to minimize the risk for Legionella growth in the facility's building. The facility census was 60. Review of the facility's undated policy titled Legionella Infection Control Protocol revealed that the facility will flush toilets and run sinks in resident rooms daily to flush any standing water, but the protocol did not address flushing water in any other areas or provide a way to track and monitor areas that had been flushed. Interview with the Director of Maintenance #458 revealed that maintenance runs water in all rooms and that water is tested with an instant read tester for Legionella randomly, with a sample sent out yearly for testing. The Director of Maintenance did not know whether tracking sheets for the flushes or the yearly test results were available because he had only worked there since June. A later interview revealed a document titled Monthly Flushing and Faucet Inspection with all rooms checked off for June 2025, July 2025, and August 2025, but none of the months prior to June 2025 had any checks marked. The Director of Maintenance also stated he could not find verification of yearly water testing or any further information about the Legionella control measures being taken at the facility.
Failure to Schedule Required RN Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse was scheduled for eight consecutive hours when the census exceeded 60 residents. Review of staffing documentation and schedules from 09/01/25 through 09/07/25 showed that the facility had 61 residents on 09/04/25, 09/05/25, and 09/06/25, but the Director of Nursing was the only RN listed in the facility. During an interview on 09/11/25 at 1:07 P.M., the Scheduling Coordinator confirmed that no additional RN was scheduled on those three days and verified that the facility exceeded a census of 60 residents on each of those days. This deficiency affected all 60 residents residing in the facility and was cited under Complaint Number 2608577.
Inadequate Linens and Poor Room Maintenance
Penalty
Summary
The facility failed to ensure an adequate supply of linens was available to meet resident needs. During observation, Resident #10 required a linen change, but there was no linen in the room, and an LPN pressed the call light to request linens. The LPN stated there was minimal linen in the linen room and no flat sheets. Further observation of the 300-hall linen room showed only two flat sheets, three fitted sheets, and five bath towels, while the 100- and 200-hall linen room contained five fitted sheets, no flat sheets, and approximately 10 bath towels. The LPN stated the facility often did not have enough linen in the morning to perform incontinence care or change bedding, so those tasks were delayed until linens became available. The facility also failed to ensure shower chairs in the 100-hall shower room were in good repair and functional. Observation of the shower room with a CNA revealed two wheeled shower chairs were broken: one had broken wheels, and the other had a broken handle. The CNA stated the chair with broken wheels would not turn right and the chair with the broken handle did not turn when a resident was in it because of the handle condition. These chairs were identified as being used by residents from the 100 and 200 halls. The facility further failed to maintain a clean and homelike environment in resident rooms. Resident #17's room had cobwebs in the window corner and chipped paint exposing drywall, and the resident stated she was not pleased with the environmental conditions or cleanliness of her room. Resident #10's room contained an empty chip bag, crumbs on the floor, unidentified stains, and food and crumbs in the bed, and the resident stated the room cleanliness was not maintained to his preference. Additional observations showed bent window blinds that did not provide privacy for two residents, an uncovered baseboard heater with exposed rusty and bent metal fins and damaged wall and door surfaces in one resident room, and multiple unfinished drywall repairs with hanging tape in another resident room.
Failure to Provide Scheduled Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide care and services for personal hygiene for residents who were unable to perform ADLs independently. The deficiency involved four residents reviewed for ADLs, including residents with cognitive impairment, dependence on staff for bathing and grooming, and care plans that included assistance with hygiene, bathing, dressing, and grooming. The facility policy stated residents unable to carry out ADLs independently were to receive appropriate support and assistance with hygiene in accordance with the plan of care. Resident #31 was admitted with diagnoses including thyroid disorder, CVA, non-Alzheimer's dementia, and anxiety disorder, and the most recent MDS showed moderate cognitive impairment and substantial assistance needed with bathing. Observation found the resident sitting in the common area with greasy, unkept hair and approximately three-quarter to one inch hair growth on the chin. Staff interviews confirmed the unkept appearance. Shower documentation showed the resident was scheduled for showers twice weekly, but the shower sheets for the prior three months showed only a few completed entries, and the electronic task report showed several showers, partial showers, and one refusal in August. Resident #8 had severe cognitive impairment and required substantial or maximal assistance with all ADLs. Observation showed a large matted section of hair on the right rear of the head, and the resident stated she did not like the matted hair. Shower documentation showed missed scheduled showers in July and August without documentation of refusal. Resident #20 was dependent on staff for ADLs and had a care plan for assistance with personal hygiene, bathing, and grooming; observations showed the resident in bed with long, unkept hair and a long beard, and the resident stated he had not been offered a haircut or beard grooming for an undetermined time and had been waiting for a bed bath. Resident #44 required substantial to maximal assistance with ADLs and had a care plan for hygiene and grooming; observations showed heavy beard growth and greasy hair, and the resident stated showers were often not provided as scheduled. Shower records showed only four of nine scheduled shower opportunities were provided, and the DON verified showers were not all provided as scheduled.
Insect Infestation in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to ensure effective insect control was implemented, affecting 10 of 16 residents reviewed for physical environmental conditions in a census of 60. Survey observations found multiple black flying insects in resident rooms and common areas, including insects landing on residents, bedside beverages, meal trays, personal property, privacy curtains, and other surfaces. Residents #20, #17, #18, #22, #38, #44, #45, and #51 were among those observed or interviewed about the insects, and several residents stated the insects bothered them while eating or in their rooms. Resident #20 was observed with black flying insects in the room and landing on the resident and bedside beverages, and the resident stated the insects had been visible for an undescribed time and at times landed on food. Resident #17’s room had approximately five dark flying insects, and the resident stated the insects bothered her, especially when eating, and that she had voiced concerns without resolution. Resident #18’s room contained 37 small dark insects with wings on the privacy curtain, multiple insects on the lunch tray and cups, and more flying throughout the room; the resident stated the insects bothered her and that she had reported the issue without resolution. Additional observations showed insects in other resident areas and facility spaces, including the medical supply storage room, conference room, and nurses’ stations. The administrator confirmed the presence of black flies in resident rooms and common areas, while RN #448 stated black flies were throughout the facility and that she took her personal bag to her car because of the amount of flies. Facility pest control documentation showed treatments only in employee areas and laundry or employee areas, with no documented treatments in resident areas. A resident’s window screen was also observed with an approximate one-inch gap that allowed insects to enter the room, and gnats were seen around the resident’s bed and later around a nurse at bedside.
Inaccurate MDS Vision Assessment
Penalty
Summary
The facility failed to properly complete the Minimum Data Set (MDS) for one resident who was reviewed for vision. The resident was admitted with diagnoses including acute kidney failure, altered mental status, and malnutrition. His quarterly MDS indicated intact cognition, that his vision was adequate, and that no corrective lenses were required, while his care plan noted that he received optical services but did not include vision loss. The resident’s medical record and interviews showed that his vision status was not accurately captured. A physician note stated that before entering the facility he began losing his vision and became nearly blind. An outside eye exam reported other eye problems and a referral for cataract surgery, with dense cataract in the left eye and moderate cataract in the right. A social service note documented that the resident was concerned about seeing the eye doctor and about losing his vision, and the resident stated he had no vision in his left eye and low vision in his right. The MDS Coordinator and Social Service Director both acknowledged that the vision assessment was inaccurate and that the vision section had been completed by reviewing the medical record and by knowing the resident rather than completing the assessment as directed.
Baseline Care Plan Not Individualized for Cognitive and ADL Needs
Penalty
Summary
The facility failed to ensure the baseline care plan was individualized to meet Resident #08’s needs within 48 hours of admission. Resident #08 was admitted on 07/02/25 with diagnoses including acute cystitis, cerebral infarction, heartburn, anorexia, history of TIA, nicotine dependence, hypomagnesemia, major depressive disorder, adult failure to thrive, altered mental status, Alzheimer’s disease, and unspecified protein-calorie malnutrition. The admission MDS showed a BIMS score of 06, indicating severe cognitive impairment, and also showed that she required substantial or maximal assistance with all ADLs. On 09/09/25, review of the care plan found no care-planned interventions addressing Alzheimer’s disease or ADL needs, and on 09/15/25 the DON verified that no interventions had been care-planned for those needs. The facility policy on Resident Participation-Assessment/Care Plans states that the care planning process includes assessment of the resident’s strengths and needs.
Failure to Implement Ordered Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention devices were implemented as indicated for two residents reviewed for fall prevention interventions. Resident #38 had diagnoses including bipolar disorder, dysphagia, epilepsy, major depression, and acute and chronic respiratory failure with hypoxia, and was assessed with severely impaired cognition, behavioral symptoms, dependence in activities of daily living, incontinence, and use of a mechanically altered diet. A care plan identified fall risk related to confusion and lack of safety awareness, and a physician order directed use of a soft helmet at all times. Despite this, progress notes documented multiple falls in common areas and hallways, with no documentation of what fall prevention measures were in place at the time of the falls. Observations of Resident #38 on multiple occasions showed the resident unattended, ambulating throughout the facility barefoot and without the helmet applied. A later progress note stated the resident had multiple falls that week and new interventions were added, including frequent checks in the morning, medication review, and lab orders, but the record still did not document fall interventions in place at the time of the falls. The facility’s fall policy stated that staff, with physician input, would implement a resident-centered fall prevention plan and monitor and document the resident’s response to interventions. Resident #44 had diagnoses including congestive heart failure, COPD, epidural hemorrhage, bipolar disorder, hypertension, anemia, vascular myelopathies, and fracture of the fourth lumbar vertebra, and was assessed with intact cognition, mobility impairment, use of a walker or wheelchair, substantial to maximal assistance with ADLs, and a history of multiple falls. The care plan included interventions such as appropriate footwear, grippy socks, nonskid strips, and a siderail to be replaced with a grab bar, and a physician order later directed half side rails. Progress notes documented several unwitnessed falls, including tripping over oversized shoes, losing balance while standing, and slipping while trying to stand, but the record did not document fall interventions in place at the time of those falls. Observations later showed the resident without slip-resistant footwear and without accessible siderails or grab bars while seated or in bed, and an LPN verified the same condition during one observation.
Failure to Provide Ordered Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care and maintenance as ordered for a resident with chronic respiratory failure with hypoxia, a tracheostomy, acute kidney failure, atrial fibrillation, type 2 diabetes mellitus, hypertension, and an anxiety disorder. The resident’s most current MDS indicated intact cognition, dependence on staff for activities of daily living, and receipt of oxygen and tracheostomy treatments. Physician orders directed that trach skin around the stoma and under the ties be assessed during trach care every shift, with trach care completed every shift and as needed, and that the physician be notified if redness, irritation, drainage, or altered skin integrity was noted. During observation, the resident was seen with supplemental oxygen via nasal cannula, a capped tracheostomy, and a tattered dressing over the stoma. The resident stated she was unaware when trach care had last been provided and that it was not provided each shift. Later observation showed an LPN performing trach care and finding moderate green drainage, a soiled and tattered dressing, and mucus buildup inside the inner cannula. The LPN stated the dressing did not appear to have been changed during the previous shift and that the inner cannula did not appear to have been replaced. An RN stated trach care did not populate in the treatment administration record for the shift and would not be performed, and another LPN stated only an observation of the stoma had been done while the trach was not cleansed or the dressing changed, despite documenting the treatment as completed. The LPN also stated they were not aware how to complete trach care and were unfamiliar with the policy and procedure.
Failure to Provide Ordered Venous Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure venous ulcer prevention measures were in place for a resident with multiple skin and wound diagnoses, including chronic venous hypertension with ulcers of both lower extremities, non-pressure chronic ulcers, and pressure-induced deep tissue damage to the buttocks and sacral region. The resident’s record showed orders for offloading boots to both lower extremities every shift, a low air loss mattress to be provided at all times with functioning checked every shift, and compression stockings to be applied in the morning and removed at bedtime. The care plan also identified fragile skin, venous ulcer related to peripheral vascular disease, and interventions including heel elevation and use of a low air loss mattress. During observation, the resident’s low air loss mattress was flat and not functioning, with a red light flashing on the control panel, and the resident’s feet were lying flat on the bed. The resident was not wearing compression stockings or off-loading boots. A CNA verified the mattress was not working properly and that the compression stockings had not been applied in the morning; she also found boots in the closet but was unsure which boots belonged to the resident. The resident stated he wanted the compression stockings applied and had requested a new mattress multiple times because he was lying on a hard surface, but a new mattress had not been supplied. Later observation showed a new mattress in place and functioning, compression stockings on, but no offloading boots in place; an LPN verified the boots were not on the resident. The wound specialist PA stated the wounds were slow to heal and that the lack of a functioning air mattress and not elevating the lower extremities could contribute to the slow healing.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the ordered treatment and services to support wound healing. Resident #10 was admitted with a stage four sacral pressure ulcer, diabetes mellitus type 2, insulin use, and multiple other diagnoses. A physician order dated 09/09/25 directed the coccyx wound to be cleansed, packed with calcium alginate, and covered with Dermafilm once daily and as needed. On 09/15/25, the resident stated that after a large bowel movement the prior night, the dressing came off during incontinence care and had not been replaced despite repeated requests. The resident also stated the wound was uncomfortable without the dressing. During interview, the LPN stated she had no knowledge the dressing was not in place because she was not notified in report and there was no documentation in the electronic medical record. Observation during incontinence care confirmed the ordered dressing was not in place. Resident #45 was admitted with diagnoses including chronic venous hypertension with ulcers of both lower extremities, non-pressure chronic ulcers, pressure-induced deep tissue damage of the right buttock, right sacral region, and left buttock, along with bowel and urinary incontinence and a risk for pressure ulcers. The current physician orders for the stage III pressure ulcer to the bilateral gluteal area directed cleansing with wound solution, application of zinc oxide, and a bordered dressing three times a week, with offloading on an alternating air mattress. However, observation of the buttock wound showed the area was red, open to air, and had four deep red areas, with no dressing in place. The facility policy titled Wound Care stated the purpose of wound care is to provide care of wounds to promote healing.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by facility staff to maintain a safe, clean, and homelike environment for residents, as evidenced by direct observations and staff interviews. Numerous resident rooms and restrooms were found with significant maintenance and cleanliness issues, including spider webs, broken or missing laminate on window sills, cracked and damaged walls, peeling paint, exposed drywall, holes in doors and walls, loose or non-functional electrical outlets, and broken or missing shower fixtures. In several cases, attempts to repair damage were incomplete or used unidentified substances, and some areas had unidentified stains or substances present. Additional deficiencies included the absence of basic hygiene supplies, such as hand soap or sanitizer in shared restrooms, and non-functional lighting in resident restrooms. In the memory care unit, only one of three showers was operational, with the others having broken or non-functioning components. Several restrooms and resident rooms had missing or damaged shower curtains, cracked flooring, and loose or broken radiant heater covers. These conditions were consistently verified by interviews with LPNs, CNAs, and housekeeping staff, who confirmed the observations made by surveyors. The facility's own policy, dated February 2021, requires the provision of a safe, clean, comfortable, and homelike environment, but the observed conditions did not meet these standards. The issues affected at least ten residents, as confirmed by the facility administrator, and were investigated under two complaint numbers. No information was provided regarding the medical history or specific conditions of the affected residents at the time of the deficiency.
Failure to Hold Required Care Conferences for Resident
Penalty
Summary
The facility failed to ensure that care conferences were held as required for a resident during their admission. Medical record review showed that the resident, who was admitted with multiple diagnoses including encephalitis, dementia, abnormal lung findings, latent tuberculosis, hypokalemia, and restlessness/agitation, had only one care conference documented during their stay. The resident was cognitively impaired, with a BIMS score of 03, and required assistance with all functional abilities. Interviews with the Social Services Designee and the Administrator confirmed that only one care conference was held for the resident, despite facility policy and regulatory requirements for care conferences to occur at admission, quarterly, and with significant changes in condition. The Social Services Designee indicated she was trying to catch up on overdue care conferences due to a staffing change. Review of facility policy also confirmed the expectation for regular care conferences, which was not met in this case.
Failure to Implement Physician-Ordered Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent skin breakdown for a resident with multiple risk factors, including multiple sclerosis, coronary artery disease, hypertension, major depressive disorder, metabolic encephalopathy, muscle weakness, and dementia. The resident was assessed as having moderately impaired cognition, was dependent on staff for activities of daily living, incontinent of bowel and bladder, and at moderate risk for pressure ulcer development. Physician orders included the use of a pressure-reducing cushion in the wheelchair at all times and offloading boots to both lower extremities. The care plan was updated to address these risks and included specific interventions such as the use of a Roho cushion and offloading boots. Despite these orders and care plan interventions, observations revealed that the resident was repeatedly found seated in a geri-chair without the required pressure-relieving cushion or offloading boots in place. Staff interviews confirmed that the devices were not in use and could not be located in the resident's room. Additionally, review of the CNA's electronic resident-specific information lacked instructions regarding the use of these devices. The nursing supervisor verified that the devices were ordered and not in place, and acknowledged the resident's recent history of a healed stage III pressure ulcer to the coccyx.
Failure to Maintain Safe, Comfortable, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a comfortable and homelike environment for residents, as evidenced by multiple observations and interviews. In the memory care unit, two residents were found wearing heavy winter clothing and blankets due to cold temperatures, with the thermostat set at 69°F, below the facility's policy range of 71°F to 81°F. Staff confirmed the temperature was uncomfortably low and adjusted the thermostat during the survey. The facility's policy requires maintaining comfortable and safe temperatures, which was not adhered to at the time of observation. Additional deficiencies were observed in resident rooms, including significant physical damage and lack of maintenance. One resident's room had a large area of wall damage present since admission, another had peeling paint behind the bed, and a third had both peeling paint and a window sill with broken and chipped laminate. In the same room, the toilet was not properly secured and moved when used, and there was missing drywall at the base of the shower exit. Staff interviews confirmed these environmental issues, which were inconsistent with the facility's policy to provide a safe, clean, and homelike environment.
Unsafe Storage of Hazardous Chemicals
Penalty
Summary
Facility staff failed to store chemicals in a safe and secure manner, resulting in open and accessible canisters of Sani-Cloth germicidal disposable wipes and Sani-Cloth bleach germicidal disposable wipes being left on a linen cart near resident rooms. Both canisters were observed to be open and within reach of residents, including four individuals identified as cognitively impaired and independently mobile who resided outside of the memory care unit. Product labels and Safety Data Sheets (SDS) for these chemicals indicated they are hazardous, with warnings to keep them out of reach of children, use personal protective equipment, and avoid contact with skin and eyes. An LPN confirmed during interview that the chemicals were accessible to residents and stated that facility protocol required such items to be stored in a locked room or compartment. Facility policies reviewed emphasized the importance of maintaining an environment free from accident hazards and providing a safe, clean, and comfortable setting for residents. The failure to secure hazardous chemicals was found to be inconsistent with these policies and had the potential to affect the safety of cognitively impaired residents.
Facility Fails to Maintain Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as required, due to pervasive foul odors throughout the facility, excluding the secured memory care unit. Observations made on February 19, 2025, revealed that the reception area and resident halls had a strong, unpleasant odor, particularly near the nurses' station. Interviews with staff, including a Certified Nursing Assistant and Licensed Practical Nurses, confirmed the presence of the odor, which was attributed to certain resident rooms where individuals declined assistance with care. The odor was noticeable from the nurses' station, approximately 20 feet from the affected resident rooms. Family members visiting a resident also reported the persistent foul odor from the entrance to the resident's room, indicating that the issue was ongoing and noticeable to visitors. A resident interviewed on February 20, 2025, corroborated the presence of the foul odor in the facility's halls. The facility's policy on maintaining a homelike environment, which includes minimizing institutional odors, was not adhered to, leading to this deficiency. This issue was investigated under Complaint Number OH00161393.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding abnormal laboratory results for a resident. The resident, who had multiple diagnoses including dementia, anxiety, psychotic disorder, hypertension, chronic kidney disease stage 3B, and schizoaffective disorder, had routine labs drawn. The results, which included an elevated sodium level, were reported to the facility, but there was no evidence that the physician was notified of these abnormal values on the day they were received. Interviews with the Medical Director and the Director of Nursing revealed uncertainty and lack of documentation regarding when the physician was informed of the lab results. The Medical Director was unsure of the notification timeline, and the Director of Nursing confirmed that there was no evidence of notification on the day the results were received. The facility's policy required timely notification of the physician when there was a need to alter the resident's medical treatment significantly, which was not adhered to in this case.
Failure to Ensure Timely Physician Follow-Up for Elevated Sodium Levels
Penalty
Summary
The facility failed to ensure timely and adequate follow-up by the physician for a resident's care needs, specifically regarding elevated sodium levels. Resident #19, who had multiple diagnoses including dementia, anxiety, and chronic kidney disease, had a lab report showing an abnormal sodium level of 156 mEq/L, which was outside the normal range. The lab results were reported to the facility, and the Medical Director (MD) reviewed them but did not provide any new orders or follow-up until several days later. The illegible handwriting on the lab report was confirmed to be the MD's signature, dated the day after the lab results were received. Interviews with the MD and the Nephrology Nurse Practitioner (NNP) revealed a lack of awareness and follow-up on the elevated sodium levels. The MD was unable to recall reviewing the lab results or providing any subsequent treatment, and the NNP was not informed of the elevated sodium level until several days later. The facility's Director of Nursing (DON) confirmed that the lab report was placed in the MD's folder for review, but no action was taken until days later, despite the facility's policy requiring timely medical assessments and information sharing. This deficiency was identified during a complaint investigation.
Facility Fails to Maintain Required Air Temperatures
Penalty
Summary
The facility failed to maintain air temperatures at a comfortable and acceptable level, affecting 18 out of 68 residents. During an observation tour, it was noted that the heating, ventilation, and air conditioning system was provided by forced air and multiple room furnaces, with each room equipped with an electric radiant heat baseboard local control unit. However, the ambient air temperature readings in the memory care unit common corridors and resident rooms were below the required temperature of 71 degrees Fahrenheit. Specifically, temperatures ranged from 65.3 to 70.1 degrees Fahrenheit, with the common shower room also recording low temperatures and non-operational electric radiant heat wall heaters. Interviews with CNAs assigned to the memory care unit confirmed that the temperatures were cool during resident bathing, and they had no access to adjust the heat. The Maintenance Director verified that the ambient air temperatures in the memory care unit were below the required level and was unaware of the issue despite conducting weekly random temperature checks. The facility's homelike environment policy, revised in February 2021, mandates maintaining comfortable and safe temperatures between 71 to 81 degrees Fahrenheit, which was not adhered to, leading to this deficiency.
Failure to Complete Ordered Lab Services
Penalty
Summary
The facility failed to ensure that laboratory services were collected and completed according to physician orders for a resident. The resident, who had been re-admitted and later discharged, had diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), right-sided heart failure, cerebral vascular accident (CVA), and alcohol abuse. The physician had ordered weekly laboratory work for a complete blood count (CBC) and basic metabolic panel (BMP) to monitor the resident's condition. However, a review of the Medication Administration Record (MAR) revealed that the lab work was not completed on the specified dates, and there were no results for the CBC and BMP from the specified period. An interview with the Director of Nursing (DON) confirmed that the orders were in the lab system, but the medical record lacked evidence of the lab work being completed. This deficiency was discovered during a complaint investigation, indicating a lapse in following the facility's policy for prevention and screening.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to adhere to infection control practices during wound care for a resident with dementia and pressure ulcers. The resident was admitted with unhealed pressure ulcers and was care planned for wound care with enhanced barrier precautions (EBP). However, during an observation, an LPN did not don a gown as required by EBP before performing wound care. The LPN removed the old dressing from the resident's left knee without changing gloves or performing hand hygiene before applying a new dressing, which is against the facility's wound care policy and CDC guidelines. Additionally, the LPN repeated the same procedure on the resident's left outer leg wound, again failing to change gloves or perform hand hygiene between removing the soiled dressing and applying a new one. The facility's Director of Nursing confirmed that there was no specific EBP policy in place, and the facility was following CDC guidelines. The facility's policy and CDC guidelines both emphasize the importance of hand hygiene and proper use of personal protective equipment to prevent the spread of infections.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting four out of six residents sampled for the environment. Observations in the Memory Care Unit revealed several issues, including a peeling and bulging laminate floor, broken wall bumpers with jagged edges, peeling carpeting, holes in the wall, and a thick layer of dust on fan paddles. Additionally, there were food items on the floor, deep grooves in the paint exposing drywall, and a missing electrical plate over an active outlet. The shower room had a constant stream of water running from a shower hose, black slimy substances on grout and flooring, and a missing tile exposing drywall. The main dining room had peeling and missing paint on the ceiling. Interviews with staff and residents confirmed the poor condition of the facility. A State Tested Nursing Assistant (STNA) described the environment as awful and not clean. A family member of a resident expressed dissatisfaction with the facility's physical appearance and lack of response to concerns. Residents reported issues such as missing laminate on window ledges, missing heater vent covers, and unclean bathrooms with strong odors of urine. One resident mentioned having to sweep their own room due to inadequate housekeeping services. The Director of Housekeeping verified the presence of gnats, unclean bathrooms, and other maintenance issues during a walkthrough with the Administrator. The housekeeping job routine checklist indicated that resident rooms and bathrooms should be cleaned daily using a specified process, but these procedures were not followed. The deficiency was investigated under Complaint Number OH00155465, highlighting the facility's non-compliance with maintaining a safe, clean, and homelike environment for residents.
Failure to Administer Prescribed Migraine Medications
Penalty
Summary
The facility failed to ensure medications to treat migraine headaches were provided as ordered by the physician, resulting in a significant medication error for Resident #12. The resident, who was admitted with diagnoses including anxiety disorder, mononeuropathy, major depression, and cervicalgia, had a nursing plan of care that included interventions for pain management. Despite attending a neurology appointment and receiving new medication orders for Nurtec and Aimovig, these orders were not transcribed into the electronic medication administration record (EMAR), and the medications were not administered as required. The resident reported experiencing daily migraine headaches with pain levels reaching eight out of ten, and the previously administered medications were not consistently effective. Interviews with the resident, the Director of Nursing (DON), and a Licensed Practical Nurse (LPN) revealed that the medications were delivered to the facility but were not made available for administration due to the lack of transcription into the EMAR. The facility's policy on administering medications, which requires medications to be administered in accordance with prescriber orders, was not followed. This oversight resulted in the resident not receiving the prescribed medications for migraine treatment, highlighting a significant lapse in medication management and adherence to physician orders.
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.
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What surveyors actually found near you
We read the 558 citations issued within 25 miles in the last 12 months — including the 4 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Maumee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgewood Manor | 1 mi | ★★★★★ | 8 | 0 |
| Lakes Of Monclova Health Campus The | 1.3 mi | ★★★★★ | 14 | 0 |
| Elizabeth Scott Community | 1.5 mi | ★★★★★ | 0 | 0 |
| Otterbein Monclova | 2 mi | ★★★★★ | 4 | 0 |
| Lutheran Village At Wolfcreek | 2.3 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.