Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Hills Nursing & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to ensure nail care was provided for two residents who needed help with ADLs. One resident with CVA, hemiplegia, and DM had long, sharp fingernails with debris, while staff said nurses were responsible for trimming because he was diabetic. Another resident with impaired self-care and DM also had long nails with black debris, and staff said aides were responsible during shower days. Interviews showed the residents wanted their nails cut, but the care was not completed as expected.
Surveyors found two infection control lapses: a medical equipment provider entered a resident’s COVID isolation room without PPE, and a HA passed meal trays to multiple rooms without hand hygiene between residents. The resident was on COVID precautions with signage outside the room requiring N95, eye protection, gown, and hand hygiene, but the provider said he was not told about the isolation and did not see the sign. The HA acknowledged she did not sanitize between residents while touching items in the hall and resident rooms.
Care Plan Not Updated for In-House G-Tube Replacement: A resident with cerebral palsy, severe ID, dysphagia, G-tube status, and paraplegia had a care plan that still directed staff to send him to the ER for G-tube replacement, even though the tube had been replaced in-house after dislodgement and the family refused hospital transfer. Staff, including an RN, the ADON, MDS nurse, and Regional Nurse Consultant, acknowledged the care plan was not current and did not reflect the resident’s actual plan of care.
Failure to Re-clean Stage IV Heel Wound After Contact With Drawsheet: A resident with paraplegia, severe cognitive impairment, and a stage IV heel pressure ulcer had wound care performed by the WCN. During the treatment, the resident’s heel wound contacted the drawsheet after the protective gauze slipped, but the WCN continued the dressing change without re-cleansing the wound. The WCN and ADON both stated that open wounds should not touch surfaces after cleansing because of infection risk.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents were involved in separate incidents during facility van transport when staff failed to properly secure wheelchairs and safety devices, resulting in one resident's wheelchair tipping backward and another resident falling off a lift and sustaining a scalp abrasion. Both drivers had received prior training but did not follow established procedures, placing residents at risk for injury.
A facility failed to develop a comprehensive care plan for a resident with cerebral palsy, leading to unaddressed constipation risk. The resident experienced severe constipation and fecal impaction, resulting in hospitalization. The facility did not implement prescribed interventions or notify the Medical Director of the resident's condition change.
A resident with cerebral palsy at risk for constipation did not receive appropriate monitoring and interventions for bowel activity, leading to a hospital diagnosis of fecal impaction and stercoral colitis. The facility's software failed to alert staff of the resident's lack of bowel movements, and staff did not follow protocols to report or address the issue, resulting in an Immediate Jeopardy situation.
A resident with cerebral palsy was not administered a physician-ordered Bisacodyl Rectal Suppository, resulting in only one bowel movement over two weeks. The facility's software failed to alert staff of the issue, and aides did not report it to the charge nurse. This led to the resident being hospitalized with fecal impaction and stercoral colitis.
A facility failed to notify a resident's representative when Pramipexole was added to the resident's drug regimen for restless leg syndrome. The resident, with moderately impaired cognition and multiple health conditions, was not properly communicated about the medication change. Staff interviews revealed a lack of communication and documentation, with the night nurse not informing the family due to the late hour and the morning nurse not recalling any instructions to do so. The ADON highlighted the importance of documenting such notifications as per facility policy.
The facility's kitchen failed to comply with food safety standards by storing uncovered pork chops in the freezer, risking contamination. Staff interviews confirmed that all food items should be covered, labeled, and dated to prevent contamination, as per facility policy. The dietary department had been recently in-serviced on these procedures, highlighting a lapse in adherence.
A resident with a history of heart disease, end-stage renal disease, and stroke was denied the use of his electric wheelchair upon admission to a facility. Despite the facility's policy to assess residents for electric wheelchair use, no assessment was conducted, and the resident was provided with a manual wheelchair instead. The resident and his family were informed that the electric wheelchair was unnecessary, and the facility's staff were unaware of the resident's previous use of the electric wheelchair.
A facility failed to ensure appropriate post-dialysis assessments for a resident requiring hemodialysis, as per professional standards. The resident, with a history of renal disease and other conditions, did not have pre- and post-dialysis weights consistently documented, as required by the care plan and facility policy. Staff interviews confirmed the responsibility for these assessments and the potential health risks of inadequate monitoring.
A medication cart containing approximately 100 types of medications was left unlocked and unattended for about two minutes outside the dining room. MA A, who had been working at the facility for a year, admitted to leaving the cart unlocked while administering medications to a resident. The facility's policy requires carts to be locked when not in view to prevent unauthorized access.
Failure to Provide Nail Care for Two Residents
Penalty
Summary
The facility failed to ensure that two residents who were unable to complete activities of daily living received necessary nail care to maintain grooming and personal care. For one resident, the care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, with nurses responsible for toenail care because the resident had diabetes. For the other resident, the care plan identified a self-care performance deficit and diabetes, with staff responsible for assisting with personal hygiene and monitoring for signs of infection. In both cases, the report documented that the residents had long fingernails with debris underneath them and that nail care had not been completed as expected. One resident was cognitively intact, had diagnoses including stroke with hemiplegia, diabetes, lack of coordination, and gait abnormalities, and stated he was unable to move his left arm. During multiple observations, his fingernails were described as long, jagged, and sharp, with dark debris underneath. He stated he wanted his nails shorter and could not recall when they were last trimmed. Staff interviews showed that CNAs expected nurses to trim his nails because he was diabetic, and the treatment nurse stated she was not aware his nails were long. The ADON and other staff stated nails should be checked during showers, but no documentation of refusal of fingernail care was found. The second resident was cognitively intact and required partial/moderate assistance with bathing and set-up/clean-up for personal hygiene. He stated he wished staff would cut his nails and that he needed help because he had nothing to cut them with. Observation showed his nails were at least one-half inch long with black debris underneath each nail. Staff interviews indicated that aides were responsible for nail care during shower days, that the resident often refused showers but would sometimes agree when asked again, and that the debris under his nails had been noticed by staff. The facility’s nail care policy stated that nail management includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath.
Infection Control Lapses During COVID Isolation and Meal Tray Service
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed two infection control failures. Resident #86, a male admitted with diagnoses including cancer, atrial fibrillation, non-Alzheimer’s dementia, and respiratory failure, had a BIMS of 13 and was on COVID-19 precautions. The resident’s care plan directed staff to follow facility protocol for COVID-19 screening and precautions, and a sign outside the room required an N95 or higher respirator, eye protection, gown, hand hygiene on entry and exit, and keeping the door closed if possible. During observation, a medical equipment provider entered Resident #86’s room while the resident was awake and in bed, but the provider was not wearing PPE. The provider was inside the isolation room putting together a bed when the Regional Nurse Consultant approached and directed him to put on PPE from the cart outside the room. The provider then stepped out and donned the required PPE. In interview, the provider stated he had not been told the resident was in isolation and did not see the sign posted outside the room. The ADON stated that full PPE, including gloves, gown, N95 mask, and shield, should be worn before entering COVID-19 isolation rooms by staff and outside providers. A second observation on E Hall showed HA C passing lunch trays to three rooms without performing hand hygiene between residents. HA C was observed touching floor mats, wheelchairs, and other personal items between rooms without sanitizing her hands. In interview, HA C stated she had training on hand hygiene and thought she used the sanitizer on the hall between trays, but acknowledged she did not sanitize between residents. The ADON and Administrator both stated hand hygiene was expected between residents while passing meal trays and that failure to do so placed residents at risk of cross contamination and illness.
Care Plan Not Updated for In-House G-Tube Replacement
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident, including measurable objectives and timeframes that reflected his current needs. Resident #12 was a severely cognitively impaired male with cerebral palsy, severe intellectual disabilities, dysphagia, gastrostomy status, and paraplegia. His quarterly MDS reflected a BIMS score of 0, and his care plan noted that he required tube feeding related to dysphagia and that he sometimes pulled his tube out and was sent to the ER for replacement. Record review and staff interviews showed that the resident’s G-tube had been replaced in the facility after it became dislodged, with the nurse obtaining a physician order and using prior competency training to complete the replacement. The resident’s family had refused hospital transfer, and staff stated the tube had been changed in-house since admission. However, the care plan had not been updated to reflect the current plan of care for in-house G-tube replacement and still stated that the resident would be sent to the ER if the tube needed replacement. Multiple staff members, including the RN, Regional Nurse Consultant, ADON, MDS nurse, and Administrator, acknowledged that the care plan was not current and should have reflected the in-house replacement process. The facility policy stated that care plans are to be reviewed after admission, quarterly, annual, and significant change assessments, and revised based on changing goals, preferences, needs, and current interventions. The deficiency was based on the failure to update the resident’s care plan to match the actual G-tube replacement practice being used.
Failure to Re-clean Stage IV Heel Wound After Contact With Drawsheet
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for Resident #61, an [AGE]-year-old male with diagnoses including heart failure, paraplegia, cognitive communication deficit, a pressure ulcer of the right buttock, and a stage 4 pressure ulcer of the right heel. His quarterly MDS reflected a BIMS of 6, indicating severely impaired cognition, and his care plan identified him as at risk for impaired skin integrity related to noncompliance with the treatment plan, impaired mobility, and cognitive impairment. The order summary directed wound cleansing and dressing changes to the right heel stage IV three times weekly and as needed. During observation of wound care, the Wound Care Nurse removed the dressing from the resident’s right foot, cleansed the heel wound, and placed gauze as a barrier before putting the resident’s foot on the bed. She then picked up the foot, cleansed the wound again, and when the foot was placed back on the bed, the gauze slipped and the heel wound was placed on the drawsheet under the resident. The Wound Care Nurse proceeded with the wound treatment and dressing without re-cleansing the wound after it had contacted the drawsheet. In interview, the Wound Care Nurse stated she would normally have a CNA assist by holding the foot during wound care and acknowledged that the wound should not touch the bed or drawsheet after cleansing because it could introduce bacteria and cause infection. The ADON also stated that open wounds should not touch surfaces until they are clean, treated, and bandaged to prevent the introduction of new bacteria and keep the wound free of infection.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate Supervision and Accident Prevention During Resident Transport
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents during transportation, resulting in two separate incidents involving two residents. In the first incident, a female resident with diabetes, heart failure, and vision loss, who was cognitively intact and independent in her activities of daily living, was being transported in the facility van. The driver did not properly secure the resident's wheelchair, causing it to tip backward when the van accelerated. The resident reported hitting her head on the ramp and experiencing a headache, though she had a headache prior to the incident. The driver admitted to not fully securing the wheelchair and did not immediately report the incident to the Administrator, instead informing the nurse upon return to the facility. In the second incident, a male resident with kidney failure, diabetes, heart failure, and Parkinson's disease, who required minimal assistance with activities of daily living and used a wheelchair, was being unloaded from the facility van. The driver failed to secure the safety strap on the lift and lost her balance, falling onto the resident. This caused the resident's wheelchair to roll backward off the lift and tip over, resulting in the resident hitting his head on the ground and sustaining a scalp abrasion. The driver had previously received in-service training on transport procedures but did not follow the required protocols during this incident. Both incidents were attributed to staff failing to follow established procedures for securing residents and their wheelchairs during transport. In both cases, the drivers had received prior training on transport safety but did not adhere to the protocols, leading to the residents being placed at risk for injury. The facility did not have a specific policy for transporting residents and relied on the company's driver training manual.
Failure to Address Constipation Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The resident, who had a diagnosis of cerebral palsy, was at increased risk for constipation. However, the facility did not address this risk in the resident's care plan, leading to a lack of awareness among staff about the resident's risk factors for constipation. As a result of this oversight, the resident experienced a fecal impaction of the rectum with associated stercoral colitis, a rare inflammatory condition caused by impacted fecal material. The resident's medical records indicated that he had not had a bowel movement for several days, and the facility staff did not administer the prescribed medication for constipation during this period. The resident was eventually transferred to the hospital due to a change in condition, where he was diagnosed with severe constipation and fecal impaction. Interviews with facility staff revealed that the resident's risk factors for constipation were not adequately communicated or addressed in the care plan. The Medical Director had provided standing orders for the treatment of constipation, but there was no evidence that these interventions were implemented or that the Medical Director was notified of the resident's change in condition. The facility's failure to develop and implement an appropriate care plan placed the resident at risk of serious harm.
Removal Plan
- All residents in the facility were assessed for risk of constipation or other bowel issues, comprehensive care plans updated to include interventions and monitoring by the DON and/or the ADON and/or the Regional Compliance Nurse.
- The Compliance Nurse in-serviced the Administrator, the DON, and ADON 1:1 on the following topics: all residents who are at risk of constipation will have an active care plan with interventions and monitoring; upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues; upon admission the nurse will be responsible for developing and implementing the care plan of risk of constipation based upon their assessment; the DON and/or the ADON/and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues; the DON and/or the ADON/and/or the Designee will monitor admission assessment to ensure all resident care plans reflect their risk of constipation or other bowel issues; upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring; in-service on care plan location and how to access the care plan in software.
- The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics: all residents who are at risk of constipation will have an active care plan with interventions and monitoring; upon admission all residents will be assessed by a nurse on risk of constipation, history of constipation/fecal impaction, or other bowel related issues; the DON and/or the ADON and/or the Designee will monitor care plans to ensure all resident care plans reflect their risk of constipation or other bowel issues; ensure all resident care plans reflect their risk of constipation or other bowel issues; upon admission, and as needed, all residents will be assessed for risk of constipation or other bowel issues. The care plan will reflect findings, interventions, and monitoring; in-service on care plan location and how to access the care plan in facility software.
- The DON, the ADON, and the Regional Compliance Nurse in-serviced the non-licensed staff on the following: in-service on care plan location and how to access the care plan in facility software; all residents who are at risk of constipation will have an active care plan with interventions and monitoring.
- AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse.
- The QAPI committee will review findings and make changes as needed.
- Admitting nurse will assess all new residents for risk of constipation and/or bowel complications.
- All residents at risk of bowel complications will have a care plan with interventions and goals developed upon admission.
- The MDS Coordinator will review care plans with the interdisciplinary team at the resident's quarter care plan meetings and make necessary changes to the care plan.
- Care Plans will be monitored by the DON and/or the ADON to ensure that changes are updated quarterly and as needed.
- Licensed and Non-licensed staff know how to review residents' care plans in the facility software and will review resident's care plans for risk of constipation and monitor for risk of constipation.
Failure to Monitor and Address Constipation Risk
Penalty
Summary
The facility failed to ensure that a resident, who was at increased risk for constipation due to cerebral palsy, received appropriate monitoring and interventions for bowel activity. Despite having a comprehensive care plan, the resident did not have measures in place to monitor bowel movements, and physician-ordered interventions were not implemented when the resident did not have a bowel movement within 72 hours. This oversight resulted in the resident being diagnosed with fecal impaction and stercoral colitis after being transferred to the hospital. Interviews and record reviews revealed that the facility's software system, which was supposed to flag when a resident had not had a bowel movement in 72 hours, did not alert staff. Consequently, the aides and nurses did not report or address the resident's lack of bowel movements. The resident's care plan did not include a bowel toileting program, and the resident was always incontinent of bowel, which contributed to the oversight. Staff interviews indicated a reliance on the software system to trigger alerts, and there was a lack of communication and follow-up among staff regarding the resident's bowel movements. The facility's policies required that if a resident did not have a bowel movement within 72 hours, the aides were to report it to the charge nurse, and an as-needed medication for constipation should be administered. However, this protocol was not followed, and the resident's condition went unaddressed until the family requested a hospital transfer. The failure to monitor and implement physician-ordered interventions placed the resident at risk of serious harm, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- The Compliance Nurse in-serviced the Administrator, the DON, and the ADON on the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software.
- Promptly and correctly assessing a resident when a change of condition has been identified or reported using a SBAR tool so that all necessary information is communicated to the physician or nurse practitioner.
- In-service on Abuse and Neglect Policy.
- Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards.
- Residents who have not had a bowel movement will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported.
- In-service on potential complications of Bowel constipation.
- All residents who are at risk of constipation will have an active care plan with interventions and monitoring.
- If the nurse does not assess timely, the DON is to be notified.
- Accurate and timely documentation in the facility software, including resident bowel movement.
- The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software.
- The DON, the ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel movement.
- AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse.
- The QAPI committee will review findings and make changes as needed.
- Nursing Administration will monitor all residents at risk for bowel complications.
- CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software.
- Nurses will monitor the software dashboard for clinical alerts.
- Nurses will contact the physician when a resident has a change in condition.
- Nurses will provide a resident with an intervention medication if the resident has not had a bowel movement.
Failure to Administer Constipation Medication Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident, who was at increased risk for constipation due to cerebral palsy, was administered the physician-ordered Bisacodyl Rectal Suppository. The resident had only one bowel movement between February 11 and February 26, leading to a diagnosis of fecal impaction with associated stercoral colitis at the hospital. This condition is a rare inflammatory colitis caused by impacted fecal material leading to colon distention and hardened stool formation. Interviews and record reviews revealed that the facility's software system was supposed to flag a warning if a resident went 72 hours without a bowel movement. However, the system did not alert the staff, and the aides did not report the lack of bowel movements to the charge nurse. The resident's aides and nurses did not recall seeing any warning or being informed about the resident's lack of bowel movements, despite the facility's policy requiring notification to the charge nurse if a resident did not have a bowel movement within 72 hours. The resident's condition was not adequately monitored, and the necessary interventions were not provided, resulting in the resident being transferred to the hospital due to a change in condition. The facility's failure to monitor and address the resident's bowel movements placed the resident at risk of serious harm, as evidenced by the hospital diagnosis of severe constipation and fecal impaction.
Removal Plan
- The Compliance Nurse in-serviced the Administrator, the DON, and the ADON 1:1 on the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software.
- Promptly and correctly assessing a resident when a change of condition has been identified or reported using a SBAR (Situation, Background, Assessment, Recommendations tool) so that all necessary information is communicated to the physician or nurse practitioner.
- Reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards.
- Residents who have not had a bowel movement will be assessed for constipation and offered PRN interventions. If not successful, MD will be notified for additional instructions. Resident will be monitored each shift until success bowel movement is reported.
- All residents who are at risk of constipation will have an active care plan with interventions and monitoring.
- If the nurse does not assess timely, the DON is to be notified.
- Accurate and timely documentation in the facility software, including resident bowel movement.
- The DON, the ADON, and Regional Compliance Nurse in-serviced the licensed Nurses on the following topics: Abuse/Neglect Policy, the use of the Dashboard in the facility software, labeled clinical alerts for no bowel movements, Nurses will document Interventions in the facility software, promptly and correctly assessing a resident when a change of condition has been identified or reported using a SBAR, reporting changes of condition to the physician or nurse practitioner based on interact's Acute change in condition file cards, residents who have not had a bowel movement will be assessed for constipation and offered PRN interventions, potential complications of Bowel constipation, all residents who are at risk of constipation will have an active care plan.
- The DON, ADON, and Regional Compliance Nurse in-serviced the non-licensed staff on the following: Abuse/Neglect Policy, reporting changes in a resident's condition to a nurse immediately, including when a resident has not had a bowel movement, if the nurse does not assess timely, the DON is to be notified, accurate and timely documentation in the facility software, including resident bowel movements.
- AD Hoc QAPI Contributors met and assessed all residents in the facility for the risk of constipation or other bowel movement issues, comprehensive care plans updated to include interventions and monitoring by the DON/ADON/Regional Compliance Nurse.
- The QAPI committee will review findings and make changes as needed.
- Nursing Administration will monitor all residents at risk for bowel complications.
- CNAs will monitor residents for no bowel movements and notify nurses and document it in the facility software.
- Nurses will monitor the software dashboard for clinical alerts.
- Nurses will contact the physician when a resident has a change in condition.
- Nurses will provide a resident with an intervention medication if the resident has not had a bowel movement.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to immediately notify a resident's representative when there was a need to alter treatment. Specifically, the facility did not inform the representative of a resident when the medication Pramipexole was added to the resident's drug regimen to treat restless leg syndrome. The resident, a female with a moderately impaired cognition, was on multiple medications for various conditions, including coronary artery disease, high blood pressure, hemiplegia, anxiety disorder, depression, and pain. Despite the addition of Pramipexole to her treatment plan, there was no documented evidence that the resident's responsible party was informed of this change. Interviews with facility staff revealed a lack of communication and documentation regarding the notification of the resident's family about the new medication. The LVN who entered the medication order did not contact the family, citing the late hour as a reason, and expected the morning shift nurse to do so. However, the morning shift nurse did not recall being instructed to notify the family and did not document any such communication. The Assistant Director of Nursing (ADON) was unaware that the family had not been contacted and emphasized the importance of documenting such notifications as part of compliance. The facility's policy required timely notification of any resident change to the family, which was not adhered to in this case.
Uncovered Pork Chops in Freezer Violate Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, specifically in the storage of pork chops in the facility freezer. During an observation, it was noted that the pork chops were stored uncovered in a labeled metal pan, which is against the facility's policy. This oversight was confirmed through interviews with staff members, who acknowledged the importance of covering food to prevent contamination and the potential risk of foodborne illness to residents. Interviews with the staff, including a dietary manager, revealed that all items in the facility's refrigerators and freezers should be covered, labeled, and dated to prevent contamination. The dietary manager confirmed that the pork chops should have been covered according to facility policy, which mandates that open packages of food be stored in closed containers or sealed bags and dated. The dietary department had been in-serviced on food storage about a month and a half prior to the observation, indicating a lapse in adherence to the established procedures.
Resident Denied Use of Electric Wheelchair Without Assessment
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not allowing him to keep his electric wheelchair upon admission. The resident, who had a history of heart disease, end-stage renal disease, and stroke, was admitted with an electric wheelchair but was provided with a manual wheelchair instead. The resident expressed that he was told it was against the rules to have an electric wheelchair unless he passed a test, which he was never given. The facility's records indicated that the electric wheelchair was deemed unnecessary, and the resident was able to use a manual wheelchair with his legs. Interviews with the resident's family member and facility staff revealed that the resident was not assessed for the use of his electric wheelchair, despite the facility's usual practice of assessing residents for safety. The Director of Rehabilitation, who was new to the facility, was unaware of the resident's previous use of an electric wheelchair and confirmed that no assessment had been conducted. The Assistant Director of Nursing also could not recall the circumstances surrounding the decision but acknowledged that residents are typically assessed for electric wheelchair use. The facility's Resident Rights policy emphasizes treating residents with respect and dignity, which was not upheld in this case.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate post-dialysis assessments, consistent with professional standards of practice. Specifically, the facility did not complete post-dialysis assessments for a resident, identified as Resident #47, after returning from dialysis treatments. The resident, a female with a history of encephalopathy, end-stage renal disease, acute kidney failure, fluid overload, and difficulty in walking, was admitted to the facility and required hemodialysis three times a week. The care plan for the resident included monitoring for complications from dialysis, obtaining vital signs, and documenting weights before and after dialysis sessions. However, record reviews revealed that the facility failed to document pre-dialysis weights on multiple occasions and post-dialysis weights on another occasion. Interviews with facility staff, including an LVN, the ADON, and the Regional Clinical Consultant, confirmed that it was the responsibility of the charge nurse to ensure that vital signs and weights were documented before and after dialysis. The staff acknowledged the importance of these assessments in determining the amount of fluid removed during dialysis and the potential health risks if not properly monitored. The facility's current dialysis policy also required documentation of vital signs and other relevant data upon the resident's return from dialysis, which was not consistently followed in this case.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with the Hall C Medication Cart. On the morning of November 19, 2024, the medication cart was left unlocked and unattended for approximately two minutes outside the dining room. This cart contained around 100 different types of medications, including antihypertensives, anticonvulsants, and anticoagulants, which were accessible to anyone passing by. Although the narcotics were secured in a separately locked drawer, the rest of the medications were not properly secured, posing a risk of misappropriation or accidental ingestion. The incident occurred when MA A, a medication aide who had been working at the facility for about a year, left the cart unlocked while administering medications to a resident in the dining room. MA A acknowledged the oversight, stating that she typically locks the cart to prevent unauthorized access, especially considering the presence of dementia patients who might inadvertently take medications. The Director of Nursing (DON) was informed of the incident and confirmed that the facility's policy requires medication carts to be locked when not in view to ensure the security of medications.
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Illustrative
What surveyors actually found near you
We read the 64 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Decatur Medical Lodge | 0.7 mi | ★★★★★ | 15 | 0 |
| Heritage Place Of Decatur | 1.3 mi | ★★★★★ | 10 | 0 |
| Bridgeport Medical Lodge | 9.5 mi | ★★★★★ | 5 | 1 |
| Springtown Park Rehabilitation And Care Center | 18.9 mi | ★★★★★ | 4 | 0 |
| Longmeadow Healthcare Center | 19.7 mi | ★★★★★ | 0 | 0 |
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