Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Unger Park Post Acute during CMS and state inspections, most recent first.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to provide required Medicare non-coverage notices to four residents. Review of records showed each resident had a Medicare Part A skilled stay, and several had intact cognition with BIMS scores of 15; one resident had a BIMS score of 13. The SNF ABN and NOMNC were not given, and the MDS nurse confirmed social services was unaware these beneficiary notices were required.
Staff failed to use gowns during high-contact care for residents on EBP, including catheter care, incontinence care, and PICC line use, even though orders and door signage required gown and glove use. An LPN also changed gloves during wound care without performing hand hygiene between glove changes. The DON confirmed the expected PPE and hand hygiene practices.
Surveyors found that the facility did not maintain resident dignity in grooming and dining. A cognitively intact female resident with psychiatric diagnoses and a need for assistance with personal care was repeatedly observed in common areas with long white hairs on her chin, with documentation showing recent bed baths but no shaving, and she reported staff did not shave or offer to shave her chin. A CNA confirmed the presence of the chin hair and that the resident would allow shaving. In a separate instance, a visually impaired resident with dementia who was dependent for eating was assisted by a CNA who stood beside the resident for the entire meal rather than sitting, despite the CNA stating she normally sits to assist with feeding. These practices conflicted with the facility’s dignity policy requiring grooming as residents wish and a dignified dining experience.
Surveyors found that the facility did not maintain a homelike environment when a hole with exposed wiring remained in the dining room ceiling over several days while residents ate beneath it, and meal service was disorganized, with trays left intact, tables not served together, and one resident taking food from another’s uncovered tray before staff intervened. In addition, a resident with a pressure mattress and multiple medical conditions repeatedly had an ill-fitting bed sheet that did not fully cover the mattress, causing discomfort, a problem acknowledged by the resident’s representative and the Maintenance Director.
Failure to obtain informed consent before psychotropic medication use. A cognitively intact resident with morbid obesity, DM2, and a L femur fracture received buspirone for anxiety and duloxetine for depression as ordered, but the Psychotropic Medication Administration Disclosure was not completed until after the meds had already been administered. RN confirmed the disclosure was not done at admission or before treatment, despite the facility policy requiring informed consent and documentation before psychotropic use.
A resident with intact cognition and diagnoses including DM2, paranoid schizophrenia, bipolar disorder, and COPD reported a missing undergarment for months and said she had raised it with staff and at a Resident Council meeting. The concern was not documented in the Resident Council minutes or grievance log, and interviews showed the AD, DON, and former Administrator did not ensure follow-up. During observation, laundry staff found unlabeled undergarments in the laundry room, and the resident identified one as the missing item.
Inadequate Monitoring for Psychotropic Medication Adverse Effects: A resident with morbid obesity, type II DM, and a left femur fracture received buspirone for anxiety and duloxetine for depression, with orders for behavior and adverse effect monitoring. The MAR showed the meds were administered as ordered, but the adverse effect monitoring order was discontinued and there was no current monitoring order despite the resident being cognitively intact and having no documented behaviors or adverse reactions.
Missing Bed Hold and Transfer Notices: A resident with schizophrenia, depression, anxiety, HTN, and cognitive communication deficit had multiple hospitalizations, but the facility could not locate transfer notices for any of them. Bed hold forms were only signed for two hospital stays, while later forms were unsigned and had blank certified mail labels attached, and staff confirmed there was no way to verify when or where the notices were sent.
Failure to initiate and revise a care plan for a resident's diabetic heel ulcer. A resident with dementia, DM2, anxiety, depressive disorder, and dysphagia had a left heel diabetic ulcer documented in the record, but no care plan interventions were in place for the wound. The MDS RN confirmed the care plan should have been started, and the DON verified the MDS nurse was responsible for ensuring wound care plans were initiated; the facility policy stated care plans are revised as resident conditions change.
A resident with broken teeth, dental pain, and diagnoses including DM2 and ataxia was not identified for dental services because the facility lacked a reliable process to determine which residents needed ancillary services. The resident said she had reported her pain to nursing staff, but no one had asked about dental care, and staff confirmed there was no documentation showing residents accepted or declined dental, vision, or hearing services; the resident was also not on the dental clinic list.
A dietary aide was hired and began working without a completed BCI background check, as confirmed by review of employee files, the BCI log, and staff interview. Facility policy requires background checks to be completed before employment for all direct access staff, but this process was not followed, potentially affecting all residents.
The facility failed to prevent and respond to an increased pattern of UTIs, affecting two residents with multiple infections identified as E. coli. Despite the infection control logs showing at least 58 residents with UTIs not present upon admission, no specific in-services for UTI prevention were conducted. The infection preventionist admitted the facility did not recognize or address the increase in UTIs, contrary to their policy requiring ongoing surveillance and preventative interventions.
The facility failed to conduct timely care conferences for several residents, affecting six out of 19 reviewed. Residents with various medical conditions, including hemiplegia, PTSD, and dementia, missed scheduled care conferences in specific months. Interviews with staff confirmed the absence of these conferences, and the facility's policy encouraged resident and family participation in care planning, but there was no documentation of attempts or explanations for the missed conferences.
The facility failed to provide adequate activities for residents in the memory care unit, affecting all 13 residents. Observations showed a lack of engaging activities and an absence of an activity calendar. Interviews revealed that residents were often unaware of activities, and staff struggled to conduct activities due to understaffing and limited involvement from the activity director.
The facility failed to ensure required physician visits for several residents, as mandated by policy. Despite frequent visits by NPs, some residents did not receive physician visits for extended periods, affecting those with conditions like Alzheimer's and chronic obstructive pulmonary disease. Interviews confirmed the lack of adherence to the policy, which requires physician visits every 30 days for the first 90 days and every 60 days thereafter.
The facility failed to provide palatable and appetizing meals to residents, as observed through resident and staff interviews. Issues included cold food, dry chicken, and mushy Brussel sprouts, affecting residents with various medical conditions. The Dietary Manager confirmed the food quality issues, which did not align with the facility's policy on food preparation and serving.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents except one. Observations revealed splattered food debris and chipping walls near the dishwasher, and paint strips hanging from the ventilation hood. The Dietary Manager and District Manager confirmed these findings, which violated the facility's Environment policy requiring cleanliness in food preparation and service areas.
The facility failed to maintain the kitchen's walk-in and reach-in coolers at safe temperatures, with readings consistently above the required 41 degrees Fahrenheit. This affected all residents except one who did not receive meals from the kitchen. Various food items were stored at unsafe temperatures, violating the facility's food storage policy.
A facility failed to ensure a resident's code status was consistent across records, with a DNRCCA documented in the paper chart and a full code order in the EMR. The resident, who was cognitively intact, had a documented DNRCCA status, but the EMR was not updated, as confirmed by an RN. The facility's policy requires annual review and updates of advance directives, which was not adhered to, leading to this discrepancy.
A resident reported that their bathroom was not cleaned regularly, and observations confirmed the presence of dried feces, a towel, and a paper towel in the bathroom. A CNA verified these conditions, acknowledging that the bathrooms were supposed to be cleaned daily, indicating a failure to maintain a clean and safe environment.
A facility failed to administer tube feedings according to physician orders for a resident with severe malnutrition and other medical conditions. The resident's tube feeding was observed running outside the prescribed hours, and the MAR showed missed feedings on several days. Staff interviews revealed confusion about the feeding schedule, leading to improper administration.
A resident with type two diabetes did not receive insulin dose adjustments as ordered by the physician, leading to significant medication errors. The facility's medication administration record showed fixed doses were given without adjustments based on blood sugar levels, as confirmed by the DON and the physician.
The facility did not complete reference checks for four new employees, including an RN, a SW/AA, a MT, and a CNA. This was confirmed through personnel records and an interview with the HRD, potentially impacting all 74 residents.
A resident with cognitive impairments was found inappropriately touching another resident who was unable to consent, due to a failure in monitoring and care planning. The incident was reported to the police as a sexual assault, but the facility marked it as unsubstantiated physical abuse. The care plan for the resident with behavioral issues lacked new interventions post-incident.
A facility failed to ensure medications were fully ingested, affecting a resident with Alzheimer's and potentially impacting others. A resident was found with partially dissolved pills left at the bedside, contrary to facility policy. Staff interviews revealed inconsistencies, with an LPN initially denying but later confirming the oversight.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that required beneficiary notices were provided to four residents reviewed for Medicare coverage notices. Resident #2 was admitted with diagnoses including COPD, bipolar disorder, rheumatoid arthritis, muscle wasting and atrophy, and acute respiratory failure with hypoxia, and had intact cognition with a BIMS score of 15. Resident #41 was admitted with generalized osteoarthritis, immunodeficiency, anxiety, severe protein-calorie malnutrition, and adult failure to thrive, and also had intact cognition with a BIMS score of 15. Resident #76 was admitted with generalized osteoarthritis, pulmonary fibrosis, muscle wasting and atrophy, thrombocytopenia, and chronic kidney disease, and Resident #77 was admitted with COPD, mild protein-calorie malnutrition, anemia, muscle weakness, bipolar disorder, and hyperlipidemia; Resident #77 had intact cognition with a BIMS score of 13. Review of the SNF Beneficiary Protection Notification Review documents showed each resident had a Medicare Part A skilled services episode and a last covered day of Part A service, but the facility did not provide the required SNF ABN and NOMNC to any of the four residents. During interview, the Regional MDS Nurse verified that social services was not aware it was required to provide beneficiary notification including the SNF ABN and NOMNC, and confirmed that Residents #2, #41, #76, and #77 should have received the notices but did not due to facility oversight. The facility policy stated that a completed NOMNC must be delivered to beneficiaries receiving covered skilled nursing services at least two calendar days before Medicare-covered services end.
Failure to Use PPE During Enhanced Barrier Precautions and Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure staff wore personal protective equipment during high-contact resident care for residents on enhanced barrier precautions. Resident #23 had an indwelling urinary catheter and was ordered to receive gown and glove use for high-contact care, including catheter care. During observation of catheter care, a CNA wore gloves but did not wear a gown, even though an enhanced barrier precaution sign on the door indicated a gown was required. The CNA confirmed the resident was on enhanced barrier precautions and acknowledged not wearing a gown, and the DON later verified staff should have been wearing a gown during catheter care. Resident #72 had severe cognitive impairment, was receiving enteral nutrition via PEG tube, and had an order for gown and glove use for high-contact care. During observed incontinence care, two CNAs wore gloves but did not wear gowns. Both CNAs confirmed the resident was on enhanced barrier precautions and acknowledged they were not wearing gowns while providing care. The DON later verified staff should wear a gown while providing incontinence care for a resident on enhanced barrier precautions. Resident #75 had diagnoses including COPD, morbid obesity, and calculus of kidney, and had an order for enhanced barrier precautions due to a PICC line. During administration of IV Ertapenem through the PICC line, an LPN wore gloves but did not wear a gown while accessing and using the line. The LPN confirmed a gown was not worn during the antibiotic administration. The facility policy stated enhanced barrier precautions include gown and glove use for high-contact resident care and device care or use. In addition, during wound care for Resident #28, the RN removed soiled gloves and applied new gloves without performing hand hygiene after glove removal. The RN confirmed hand hygiene was not completed, and the DON verified nurses should perform hand hygiene between glove changes.
Failure to Maintain Resident Dignity in Grooming and Dining Assistance
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and personal grooming, and to provide a dignified dining experience. One cognitively intact female resident with paranoid schizophrenia, depression, anxiety, and a need for assistance with personal care was documented as requiring partial/moderate assistance for bathing/showering and setup or clean-up assistance for personal hygiene. Shower documentation for two dates showed she received bed baths with no shaving documented. Over multiple observations on consecutive days, surveyors noted long white hairs on the resident’s chin while she was in common areas, including sitting by the nurse’s station. The resident stated she sometimes shaved her chin herself, that staff did not shave it for her, and that staff did not offer to shave the hairs. A CNA reported that female residents were shaved on shower days and confirmed this resident would allow staff to shave her chin and that she had long white hairs present. The facility also failed to ensure a dignified dining experience for a resident with Alzheimer’s disease with early onset, dementia with agitation, severely impaired vision, and dependence on staff for eating. Physician orders and the MDS indicated the resident required assistance with feeding. During a meal observation, a CNA stood beside the resident for the entire meal while assisting with eating, rather than sitting. In a subsequent interview, the CNA acknowledged that she normally sits down to assist residents with meals, verified that she stood beside this resident during the observed meal, and explained that because the resident was blind, staff could hand finger foods but had to physically assist with the rest of the meal. These actions and inactions were inconsistent with the facility’s dignity policy, which states residents are to be groomed as they wish and provided with a dignified dining experience.
Failure to Maintain Homelike Environment, Dining Experience, and Proper Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its Homelike Environment policy. Surveyors observed a missing tile in the dining room drop ceiling on multiple occasions, creating a rectangular hole with visible wiring exposed. This condition persisted over several days, including during meal service when residents were seated and eating directly beneath the opening. One resident with dementia, congestive heart failure, and type 2 diabetes, who had moderate cognitive impairment, noticed the hole and reported feeling worried about the ceiling falling and people getting hurt. A staff member confirmed the presence of the hole and stated that maintenance had been doing work above the ceiling but could not say how long the hole had been there. The facility also failed to ensure a homelike dining experience for residents who routinely ate meals in the dining room. During a lunch observation, staff delivered meal trays in a random order and left the food on the trays rather than placing plates and drinks on the tables. Residents at the same table did not receive their meals at the same time, with one resident receiving a tray significantly earlier than tablemates. While trays sat uncovered in front of residents waiting for assistance, another resident turned her wheelchair away from her own table and reached over to grab a hamburger from another resident’s tray. Staff intervened, removed the touched plate, and replaced it, but the initial service pattern and handling of trays were confirmed by the Business Office Manager, who stated that plates, drinks, and silverware were not normally removed from trays and that tables were not served together, and by the Dietary Director, who stated that staff should have removed items from trays and served tables together. Additionally, the facility did not provide comfortable and well-fitting bed linens for a resident with a history of cerebral infarction due to occlusion or stenosis of a small artery, type II diabetes, and a cognitive communication deficit, who had moderate cognitive impairment. On two separate observations, the resident’s pressure mattress was not fully covered by the bed sheet, leaving portions of the mattress exposed near the resident’s head. The resident’s representative reported that the sheets tended to slide off the mattress, and the resident stated that the sheets were bothersome, did not fit correctly, and that this issue had been reported to staff without resolution. The Maintenance Director confirmed that the sheet was not covering the mattress and identified this as a problem related to the pressure mattress in use. These conditions were inconsistent with the facility’s policy requiring clean bed linens in good condition as part of a comfortable, homelike environment.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to one cognitively intact resident. Resident #26 was admitted with diagnoses including morbid obesity, type II diabetes mellitus, and a fracture of the left femur, and the MDS 3.0 assessment submitted on 4/15/26 identified the resident as cognitively intact. The medical record showed active physician orders for buspirone 5 mg twice daily for anxiety and duloxetine 60 mg at bedtime for depression, and the MAR showed both medications were administered as ordered between 4/10/26 and 4/28/26. A Psychotropic Medication Administration Disclosure form was found in the record, signed by Resident #26 on 4/29/26 and by RN #133 as the clinician reviewing the form. During interview on 4/30/26 at 2:35 P.M., RN #133 confirmed that no Psychotropic Medication Administration Disclosure was completed at admission or before the psychotropic medications were given. The facility policy titled Psychoactive/Psychotropic Medication Use, dated 04/25, states that prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident and document it in the medical record.
Failure to Timely Address Resident Clothing Concern
Penalty
Summary
The facility failed to ensure timely response and follow-up of a resident concern involving a missing clothing undergarment. Resident #3, admitted on 11/19/18 with diagnoses including type 2 diabetes mellitus, paranoid schizophrenia, bipolar disorder, and COPD, had intact cognition on the quarterly MDS. The resident reported that the undergarment had been missing for a few months and stated she had told staff about it many times and had also raised the issue at a Resident Council meeting. Review of the Resident Council meeting minutes dated 01/26/26, 02/25/26, 03/26/26, and 04/26/26 showed no documentation of the missing clothing item, and the grievance/concern log from 01/01/26 through 04/26/26 also contained no entry for the concern. Interviews showed staff awareness and documentation failures related to the concern. The Activity Director stated the resident voiced the missing undergarment at the 02/25/26 Resident Council meeting, but it was not documented in the minutes because the former Administrator told her what items to document. The DON stated the former Administrator was going to follow up with the resident's family, but there was no documentation in the medical record or grievance log of any follow-up. During observation in the laundry room, two unlabeled undergarments were found in a basket, and one was identified by Resident #3 as the missing item she had been without since February. Laundry staff stated she had not been notified of the missing item and would have looked for it if informed.
Inadequate Monitoring for Psychotropic Medication Adverse Effects
Penalty
Summary
The facility failed to ensure adequate adverse effect monitoring for a resident receiving psychotropic medications. Resident #26 was admitted with diagnoses including morbid obesity, type II diabetes, and a left femur fracture, and was documented as cognitively intact on the MDS assessment. The resident had physician orders for buspirone 5 mg twice daily for anxiety and duloxetine 60 mg at bedtime for depression, along with an order for behavior monitoring each shift and an order for monitoring for psychotropic drug adverse effects such as dry mouth, constipation, blurred vision, disorientation, confusion, drowsiness, slurred speech, dizziness, restlessness, muscle tremor, agitation, headache, rash/photosensitivity, increased falls, increased behavior, nausea/vomiting, disturbed gait, and involuntary movement. The MAR showed the resident received buspirone and duloxetine as ordered between 04/10/26 and 04/28/26. Review of the MAR also showed no behaviors and no documented adverse reactions on the night shift of 04/08/26 and the day shift of 04/09/26. The adverse effect monitoring order was discontinued on 04/09/26, and at the time of interview the DON confirmed there was no current order for adverse effect monitoring and that the resident was not experiencing any behaviors. The facility policy stated residents receiving psychotropic medications will be monitored for medication effectiveness, behavioral symptoms, and potential adverse events.
Missing Bed Hold and Transfer Notices
Penalty
Summary
The facility failed to ensure bed hold notices and transfer notices were given to a resident who had multiple hospitalizations. Resident #68 had diagnoses including paranoid schizophrenia, depression, anxiety, hypertension, and cognitive communication deficit, and the record showed hospital transfers on multiple occasions. Bed hold notices were found for two hospitalizations, but only one set was signed by the resident on the day the resident went to the hospital. For two later hospitalizations, the bed hold forms were not signed and had blank certified mail labels stapled to them. No transfer notices could be located for any of the resident’s hospitalizations. During interview, the Business Office Manager stated the certified mail labels did not contain a date or name and address showing where the forms were sent, and verified there was no way to know when or where the notices were sent from the labels alone. The Regional MDS also stated that no transfer notices were sent for any of the resident’s hospitalizations. Facility policy required written bed hold information to be provided in advance of transfer and at the time of transfer, and required transfer notices to be provided as soon as practicable before transfer.
Failure to Initiate and Revise Care Plan for Diabetic Heel Ulcer
Penalty
Summary
The facility failed to ensure care plans were timely initiated and revised for a resident with a new wound. Resident #28 was admitted on 06/13/25 and had diagnoses including dementia, depressive disorder, type 2 diabetes mellitus, anxiety, and dysphagia. The quarterly MDS showed impaired cognition, and the resident was dependent on staff for bed mobility, toileting, and transfers. A wound nurse practitioner progress note dated 04/22/26 documented a diabetic ulcer to the left heel measuring 1 cm by 1 cm with an undetermined depth; the wound was 100 percent scabbed and crusted, dry and callused, with no exudate and no signs of infection. The medical record also showed the wound had been present since 01/02/26. Review of the resident's plan of care showed no care plan with interventions in place for the diabetic ulcer to the left heel. During interview, the MDS RN verified a care plan should have been initiated for the resident's diabetic ulcer but was unsure whether the wound care nurse or she was responsible for ensuring wound care plans were in place. The DON later verified the MDS nurse was responsible for ensuring wound care plans were initiated. The facility policy on Care Plans, Comprehensive Person-Centered, revised 03/2022, stated assessments were ongoing and care plans were revised as information about residents and their conditions changed.
Failure to Identify and Schedule Dental Services
Penalty
Summary
The facility failed to ensure a procedure was in place to determine which residents required ancillary services, including dental services. Resident #51 was admitted with diagnoses including muscle wasting and atrophy, type 2 diabetes mellitus, osteoarthritis, GERD without esophagitis, and ataxia. The resident’s quarterly MDS showed intact cognition with a BIMS score of 15 and no dental pain. The care plan identified the resident as at risk for difficulty chewing related to broken teeth and included dental consultation and follow-up as indicated, along with notification of the physician for signs of dental infection or complications. Resident #51 told surveyors she had damaged teeth and dental pain, and stated she had reported the pain to nurses and aides but nothing had been done. She also stated no one from the facility had asked whether she needed dental services. Staff interviews showed the CNA responsible for ancillary services asked residents on admission if they wanted vision, dental, and hearing services, but there was no documentation of residents accepting or declining these services. The Social Service Representative and Marketing Director both verified there was no documentation regarding acceptance or declination of ancillary services. Review of the dental clinic list showed Resident #51 was not scheduled for dental clinic, and the facility policy stated social services representatives would assist residents with dental appointments and transportation arrangements.
Failure to Complete Employee Background Checks Prior to Employment
Penalty
Summary
The facility failed to ensure that employee background checks were completed prior to employment, as required by facility policy. Specifically, review of an employee file for a dietary aide revealed that the individual began employment without evidence of a completed Bureau of Criminal Investigation (BCI) background check. The BCI log did not show that a background check was performed for this employee, and the Human Resource Director confirmed that the check had not been completed. Facility policy mandates that background and criminal checks, including fingerprinting, must be initiated within two days of an employment offer and completed before the employee starts work. This lapse had the potential to affect all 56 residents in the facility.
Failure to Prevent and Respond to Increased UTIs
Penalty
Summary
The facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs) among its residents, specifically affecting two residents who were reviewed for UTIs. Resident #16, who was cognitively intact and frequently incontinent of urine, experienced multiple UTIs over a period of several months, with urine cultures consistently identifying Escherichia coli (E. coli). Similarly, Resident #60, who was always continent of bladder and bowel, also had multiple UTIs with E. coli identified in the urine cultures. The infection control logs indicated that at least 58 residents were diagnosed with UTIs that were not present upon admission. The facility's infection prevention and control program was found lacking, as there were no in-services conducted specifically for the prevention of UTIs during the review period. Although a handwashing in-service was conducted, it was related to another infection control concern and not the increase in UTIs or E. coli. The facility's infection preventionist acknowledged the lack of recognition and response to the increase in UTIs, which was contrary to the facility's policy that required ongoing surveillance and preventative interventions for significant infections.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences for several residents, affecting six out of the 19 residents reviewed. These residents had various medical conditions, including hemiplegia, PTSD, bipolar disorder, schizophrenia, anxiety, dementia, COPD, diabetes, and depression. The review of medical records and progress notes revealed that care conferences were not held as required in specific months for each resident. For instance, Resident #07 did not have care conferences in May and August 2024, while Resident #08 missed a conference in July 2024. Similarly, other residents also missed their scheduled care conferences in different months. Interviews with facility staff, including the Social Worker/Administrative Assistant and the Director of Nursing, confirmed the absence of these care conferences. The facility's policy on care planning indicated that the interdisciplinary team was responsible for developing care plans and encouraged resident and family participation. However, there was no documented evidence of care conferences being held or attempted for the affected residents, nor was there documentation explaining why participation was not practicable.
Inadequate Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to ensure that activities on the memory care unit met the needs and preferences of all 13 residents. Observations revealed that there was no activity calendar posted in the memory care unit, and residents were often left without engaging activities. For instance, during several observations, residents were found in common areas with a television playing, but none were actively watching or participating in any structured activities. Interviews with residents and staff indicated a lack of awareness and participation in activities, with one resident expressing boredom and another unaware of scheduled activities. The care plans for residents, such as Resident #04 and Resident #175, highlighted the need for structured activities to prevent social isolation and engage residents with cognitive impairments. However, the facility's activity program did not adequately address these needs. The activity director admitted to limited presence in the memory care unit and a lack of specialized training for memory care activities. The activity calendar, when eventually posted, included basic daily routines but lacked engaging and varied activities tailored to the residents' needs. Staff interviews revealed that the memory care unit was often understaffed, with only two CNAs available, making it challenging to conduct activities, especially when managing residents' behaviors. The activity director's limited involvement and the absence of a consistent and engaging activity schedule contributed to the deficiency in meeting the residents' needs for meaningful engagement and social interaction.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed as required for five out of nine residents reviewed. The policy mandates that attending physicians must visit residents at least once every 30 days for the first 90 days following admission, and then every 60 days thereafter. However, the review of medical records and interviews with staff revealed that several residents did not receive the required physician visits. For instance, one resident was seen by a nurse practitioner monthly but had no documented physician visit for nearly ten months. Another resident, with severe cognitive impairment, was seen by a physician only three times over several months, despite frequent visits by a nurse practitioner. The deficiency affected residents with various medical conditions, including fibromyalgia, Alzheimer's, chronic obstructive pulmonary disease, and major depressive disorder. Interviews with the facility's administrator and assistant director of nursing confirmed the lack of physician visits as per the policy. The facility's policy allows for alternating visits by a physician assistant or nurse practitioner after the initial 90 days, but the schedule must not exceed every 60 days. The absence of documented physician visits for the affected residents indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that residents received food that was palatable and appetizing, which met their nutritional recommendations. This deficiency was identified through observations, resident interviews, and staff interviews. Four residents were affected, all of whom reported issues with the food served during lunch. The issues included food being served cold, chicken being too dry to chew, and Brussel sprouts being mushy or lacking taste. The Dietary Manager confirmed these observations, noting that the chicken was dry and the food temperatures were not consistently maintained at the desired levels. The medical records of the affected residents revealed various diagnoses, including type 2 diabetes mellitus, paranoid schizophrenia, chronic obstructive pulmonary disease, and dementia. Despite these conditions, the residents were cognitively intact and able to articulate their dissatisfaction with the meals. The facility's Food Quality and Palatability policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature. However, the observations and interviews indicated that the facility did not adhere to this policy, resulting in the identified deficiency.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, affecting all residents except one who did not receive meals from the kitchen. During an observation of the kitchen, it was found that the wall across from the dishwasher had splattered food debris and parts of the wall were chipping. The Dietary Manager confirmed these findings. Additionally, the ventilation hood above the clean pan rack and stove top had paint strips hanging down, which the Dietary Manager attributed to excessive cleaning. A follow-up observation with the District Manager confirmed that the white paint strips were chipping from the ventilation hood. The facility's Environment policy required all food preparation and service areas to be maintained in a clean and sanitary condition, which was not adhered to in this instance.
Failure to Maintain Safe Cooler Temperatures
Penalty
Summary
The facility failed to ensure that the kitchen's walk-in cooler and reach-in cooler were functioning in a safe and operable condition, which had the potential to affect all residents except one who did not receive meals from the kitchen. During an observation on December 16, 2024, the reach-in cooler was found to have an ambient internal temperature of 44 degrees Fahrenheit, and the walk-in cooler had a temperature of 47 degrees Fahrenheit. These temperatures were verified by the Dietary Manager (DM) #333. Further inspection revealed that various food items stored in the walk-in cooler, such as cottage cheese, cream cheese, whole milk, pre-sliced cheese, sliced ham, homemade coleslaw, and buffet ham log, were also above the required temperature of 41 degrees Fahrenheit. The temperature logs for the walk-in cooler showed consistent readings above the required 41 degrees Fahrenheit over several days in December 2024, with temperatures ranging from 42 to 47 degrees Fahrenheit. The facility's policy on food storage mandates that all perishable foods be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. The Equipment policy also requires that all food service equipment be clean, sanitary, and in proper working order. Despite these policies, the facility did not maintain the coolers at the appropriate temperatures, leading to the deficiency.
Discrepancy in Resident Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status of a resident matched across different records, leading to a discrepancy in the medical documentation. Resident #12, who was cognitively intact, had a documented code status of Do Not Resuscitate Comfort Care Arrest (DNRCCA) in the hard/paper chart dated 10/23/24. However, the electronic medical record (EMR) contained a physician's order dated 12/16/24 indicating the resident was a full code. This inconsistency was confirmed during an interview with Registered Nurse (RN) #230, who acknowledged the discrepancy and stated that the order in the EMR had not been updated to reflect the resident's DNRCCA status. The facility's policy on advance directives requires the interdisciplinary team to review and update the resident's advance directives annually during the assessment process, ensuring that the directives align with the resident's current wishes. However, in this case, the policy was not followed, resulting in conflicting information between the paper chart and the EMR. This oversight affected the accuracy of the resident's medical records and could potentially impact the care provided to the resident.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as required. A resident, who was cognitively intact and always continent of bladder and bowel, reported that their bathroom was not cleaned regularly. During an observation, dried feces were found on the lower left side of the toilet, along with a towel on the floor and a brown paper towel behind the toilet. A follow-up observation confirmed that these conditions remained unchanged, and a small puddle was also noted in front of the toilet. A CNA verified these conditions and acknowledged that the bathrooms were supposed to be cleaned daily, indicating a lapse in maintaining the cleanliness of the resident's environment.
Failure to Administer Tube Feedings Per Physician Orders
Penalty
Summary
The facility failed to administer tube feedings in accordance with physician orders for a resident with multiple medical conditions, including cerebral infarction and severe protein-calorie malnutrition. The resident was prescribed Osmolite 1.2 Cal via nasogastric tube at 80 mL per hour from 6:00 P.M. to 6:00 A.M. daily. However, on the morning of December 16, 2024, the tube feeding was observed to be running at 10:25 A.M., contrary to the physician's order. Interviews revealed that the tube feeding was mistakenly connected by a staff member who believed it was supposed to be administered during the day. Additionally, the medication administration record (MAR) indicated that the resident did not receive their tube feeding as ordered on December 11, 12, and 13, 2024. The Director of Nursing confirmed the discrepancies in the MAR and acknowledged the failure to administer the tube feeding per the physician's order on those dates. This oversight in following the prescribed feeding schedule potentially impacted the resident's nutritional intake and appetite during mealtimes.
Failure to Adjust Insulin Doses as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in significant medication errors for a resident with multiple diagnoses, including type two diabetes. The resident was cognitively intact and had an active physician order for Humulin 70/30 insulin, which required dose adjustments based on blood sugar levels. However, the medication administration record for December 2024 showed that the nurses consistently signed off on administering fixed doses of insulin without adjusting them according to the physician's orders and the resident's blood sugar readings. The Director of Nursing (DON) confirmed that the insulin order was not updated after the physician made changes, and acknowledged that the order was confusing. The DON verified that the insulin doses should have been adjusted on specific dates in December, but the facility could not provide evidence that these adjustments were made. An interview with the physician further confirmed that the insulin should have been adjusted according to the active orders, indicating a failure to follow the prescribed medication regimen for the resident.
Failure to Complete Reference Checks for New Employees
Penalty
Summary
The facility failed to ensure that reference checks were completed for four new employees, which included a Registered Nurse, a Social Worker/Administrative Assistant, a Medication Technician, and a Certified Nursing Assistant. This deficiency was identified through a review of employee personnel records, background check logs, and staff interviews. The absence of documented evidence of reference checks for these employees was confirmed during an interview with the Human Resource Director. This oversight had the potential to affect all 74 residents residing in the facility.
Failure to Prevent Resident-to-Resident Sexual Altercation
Penalty
Summary
The facility failed to prevent an inappropriate resident-to-resident altercation that was sexual in nature, affecting one resident. Resident #105, who was admitted for a short-term respite stay, was involved in an incident where another resident, Resident #82, was found in her room with his hand up her dress on her breast area. Resident #105 had a history of hemiplegia, cerebrovascular disease, and was on psychotropic medications for depression. She required substantial assistance for mobility and was unable to provide a statement or recall the incident due to her cognitive state. Resident #82, who had diagnoses of paranoid schizophrenia and bipolar II disorder, was found to have impaired cognition and socially inappropriate behaviors. On the day of the incident, Resident #82 was observed by LPN #63 to be pacing the hallways, entering and exiting rooms, and eventually lying in bed with Resident #105. Despite being redirected earlier, Resident #82 was found groping Resident #105, which led to immediate intervention by LPN #63. The facility's investigation revealed that Resident #82 had a recent change in cognition and was experiencing a decline in mental health, which was not adequately addressed in his care plan. The facility's response included notifying the police, who documented the incident as a sexual assault due to Resident #105's inability to consent. The facility's investigation and documentation, however, marked the incident as physical abuse and unsubstantiated. The care plan for Resident #82 did not include new interventions for sexual behaviors after the incident, and the facility's policy on abuse and neglect was not effectively implemented to prevent the incident. The deficiency highlights a failure in monitoring and care planning for residents with known behavioral issues.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were fully ingested and not left at the bedside, affecting one resident and potentially impacting eight others who were independently mobile and cognitively impaired. Resident #21, who was admitted with Alzheimer's and dementia with behavioral disturbance, was observed with a plastic medication cup containing four partially dissolved pills on her overbed table. This observation was made despite the facility's policy requiring that residents be observed to ensure complete ingestion of medications. Interviews with staff revealed inconsistencies in medication administration practices. A State Tested Nursing Assistant confirmed the presence of the pills, noting that such occurrences were not uncommon. An LPN initially denied leaving medications at the bedside but later acknowledged that the medications were from her administration, as the handwriting on the cup was hers. The LPN had relied on the resident's non-verbal indication that she had taken the pills, which was not in compliance with the facility's medication administration guidelines.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 175 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bucyrus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Of Bucyrus Center Fo | 2.5 mi | ★★★★★ | 3 | 0 |
| Galion Pointe, Llc | 10.9 mi | — | 0 | 0 |
| Galion Meadows Skilled Nursing And Rehabilitation | 11.2 mi | ★★★★★ | 38 | 0 |
| Mill Creek Nursing & Rehabilitation | 11.5 mi | ★★★★★ | 0 | 0 |
| Crestline Rehabilitation And Nursing Center | 13.3 mi | ★★★★★ | 2 | 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.