Inspection Report Summary
The most recent inspection on September 7, 2025, identified deficiencies related to the facility’s failure to promptly transfer a resident showing signs of sepsis, which resulted in hospitalization with septic shock and pneumonia. Earlier inspections showed a pattern of issues primarily involving resident transfer protocols, fall prevention, pressure ulcer care, and supervision, with multiple complaint investigations substantiating failures in these areas. Inspectors cited problems such as inadequate mechanical lift use, incomplete care plans for transfers, insufficient fall prevention measures, and lapses in timely communication with families and physicians. Several complaint investigations involved resident injuries from falls and financial abuse, with one staff member arrested for theft; enforcement actions or fines were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with resident safety and care coordination, with no clear trend of sustained improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
23.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
577% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to promptly transfer a resident exhibiting signs and symptoms of sepsis, which resulted in hospitalization and diagnosis of septic shock and pneumonia.
Complaint Details
The complaint investigation found that the facility failed to promptly transfer a resident (R1) who exhibited signs and symptoms of sepsis for six hours prior to transfer. This failure affected one of three residents reviewed and resulted in hospitalization with septic shock and pneumonia. Family members requested hospital transfer which was initially denied. The facility did not perform sepsis screening or order required labs as per policy.
Findings
The facility failed to follow its guidelines for timely transfer of a resident with sepsis symptoms, leading to actual harm. The resident was not promptly sent to the hospital despite abnormal vital signs and family requests, resulting in septic shock and pneumonia. The facility did not complete required sepsis screenings or order appropriate labs per policy.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically related to timely transfer of a resident with sepsis symptoms.
Report Facts
Residents reviewed for quality of care: 3
Residents affected: 1
Oxygen liter per minute: 2
Resident heart rate: 120
Resident heart rate: 140
Resident respiratory rate: 22
Resident blood pressure: 97
Resident blood pressure: 58
Resident pulse rate: 135
Resident respiratory rate: 30
Resident oxygen saturation: 85
Resident oxygen saturation: 90
Intravenous fluid rate: 83
Intravenous fluid volume: 1000
Oxygen liter per minute: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Documented resident's vital signs and notified Nurse Practitioner of condition |
| V5 | Registered Nurse | Sent resident to hospital upon family request and documented late-entry SBAR note |
| V6 | Nurse Practitioner | Provided orders and assessed resident; supervised by Medical Director |
| V7 | Speech Therapist | Notified nurse of resident's abnormal condition and vital signs |
| V2 | Director of Nursing | Reviewed resident's records and affirmed facility policies on sepsis |
| V3 | Infection Preventionist, Registered Nurse | Reviewed resident's records and lab work |
| V8 | Medical Director | Supervising physician; reviewed vital signs and facility sepsis guidelines |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 23, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to maintain resident room temperatures within a comfortable range, ensuring a safe, clean, and homelike environment.
Findings
The facility failed to maintain resident room temperatures within the comfortable range of 71 to 81 degrees Fahrenheit, affecting multiple residents and units. Broken fan belts and malfunctioning air conditioning units contributed to elevated temperatures, with some rooms measuring above 81 degrees Fahrenheit. Staff and residents reported discomfort and complaints about the heat, and the facility was working on corrective measures including portable AC units.
Deficiencies (2)
Failed to maintain resident room temperatures within a comfortable range of 71 to 81 degrees Fahrenheit, affecting seven residents.
Failed to assure that the resident environment remains comfortable and homelike with cooling system in proper working order to maintain acceptable temperature within 71 to 81 degrees Fahrenheit, affecting 100-unit and 200-unit wings.
Report Facts
Room temperature measurements: 81.6
Number of residents affected: 7
Fan units on roof: 20
Broken fan belts: 2
Temperature range noted by Assistant Maintenance Director: 76
Temperature range noted by Assistant Maintenance Director: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V8 | Maintenance Director | Present during facility tour and acknowledged temperature issues, suggested providing portable fans |
| V10 | Certified Nurse Assistant | Reported on heat conditions during shift and staff instructions regarding windows |
| V4 | Assistant Maintenance Director | Reported on temperature measurements and broken fan belts affecting cooling |
| V1 | Administrator | Acknowledged awareness of temperature problem on 06/22/25 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure care plans reflected the patients' care needs for safe transfer status and failure to follow mechanical lift transfer protocols, which resulted in a resident (R52) falling and sustaining a hip fracture.
Complaint Details
The complaint investigation found that resident R52 was not transferred according to care plan instructions, resulting in a fall on 5/1/25 and an acute impacted right femoral fracture. The facility failed to follow mechanical lift transfer protocols and use gait belts as required. The resident's transfer status was changed after the fall, and staff training and policy adherence were found lacking.
Findings
The facility failed to implement care plans that accurately reflected resident R52's transfer needs, specifically the use of mechanical lifts and gait belts. Staff did not follow proper transfer protocols, leading to R52 falling during a transfer and sustaining an acute impacted right femoral fracture. The facility's policies and staff training on transfer techniques were inadequate or not properly followed.
Deficiencies (2)
Failed to ensure care plans reflect the patient's care needs for safe transfer status including mechanical lift.
Failed to follow identified mechanical lift transfer status and failed to use a gait belt during transfers, resulting in a resident fall and hip fracture.
Report Facts
Residents reviewed for care plan interventions: 49
Residents affected: 1
Residents reviewed for safety during staff assisted transfers: 3
Residents affected: 1
Fall risk score: 13
Fall risk score: 8
Fall risk assessment date: May 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V9 | Certified Nursing Assistant (CNA) | Assisted resident R52 during transfers without using gait belt |
| V5 | Restorative Nurse | Responsible for training staff on gait belt use and transfer techniques |
| V7 | Certified Nursing Assistant (CNA) | Transferred resident R52 without equipment, did not recall using gait belt |
| V6 | Fall Nurse | Investigated fall incident and updated care plan |
| V2 | Director of Nursing | Oversaw staff training and transfer policies |
| V20 | Certified Nursing Assistant (CNA) | Reported use of gait belt for one person assisted transfers |
| V21 | Human Resources | Provided employee handbook and competency records for CNAs |
Inspection Report
Routine
Deficiencies: 14
Date: May 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, care planning, safety, infection control, medication management, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for electronic monitoring, inaccurate resident assessments, inadequate care plan implementation, failure to provide timely incontinence care, ineffective bowel management leading to hospitalization, improper pressure ulcer care, unsafe resident transfers resulting in injury, lack of oxygen orders and equipment maintenance, failure to assess and obtain consent for side rail use, medication labeling and storage issues, infection control lapses, inadequate antibiotic monitoring, and failure to maintain a clean and homelike environment.
Deficiencies (14)
Failed to follow electronic monitoring policy and obtain informed consent for video and audio monitoring of residents.
Failed to ensure call light was in reach for a dependent resident.
Failed to accurately code Minimum Data Set (MDS) assessments for residents.
Failed to ensure care plans reflect safe transfer status including mechanical lift use.
Failed to provide incontinence care/checks at least every two hours for a dependent resident.
Failed to ensure effective bowel management for a resident on pain medication, resulting in severe fecal impaction and hospitalization.
Failed to consistently assess, monitor, and implement interventions to prevent pressure ulcers and ensure proper use of low air loss mattress.
Failed to follow mechanical lift transfer status and use gait belt during resident transfers, resulting in a fall and femoral fracture.
Failed to assess residents for side rail use and obtain consent prior to use for multiple residents.
Failed to ensure oxygen therapy orders and equipment maintenance for a resident requiring oxygen.
Failed to label insulin pens with open and expiration dates and discard medications for discharged residents.
Failed to follow infection prevention and control policies including hand hygiene and PPE use in enhanced barrier precaution rooms.
Failed to develop and implement protocols to monitor antibiotic use for a resident with history of Clostridium difficile.
Failed to maintain a clean and homelike environment in a resident's room.
Report Facts
Residents reviewed: 49
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 7
Residents affected: 1
Residents affected: 5
Residents affected: 4
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in electronic monitoring and transfer training findings |
| V5 | Restorative Nurse | Named in transfer training and side rail assessment findings |
| V12 | Wound Care Director | Named in pressure ulcer and infection control findings |
| V15 | Nurse | Named in insulin labeling and infection control findings |
| V17 | Assistant Director of Nursing | Named in call light, oxygen therapy, and insulin labeling findings |
| V22 | MDS Coordinator/RN | Named in MDS coding and care plan findings |
| V23 | Registered Nurse | Named in environmental cleanliness findings |
| V24 | Housekeeper Supervisor | Named in environmental cleanliness findings |
| V27 | Nurse Practitioner | Named in bowel management findings |
| V3 | Infection Prevention Nurse | Named in infection control and antibiotic monitoring findings |
| V6 | Fall Nurse | Named in fall investigation findings |
| V7 | Certified Nursing Assistant | Named in unsafe transfer findings |
| V9 | Certified Nursing Assistant | Named in unsafe transfer findings |
| V20 | Certified Nursing Assistant | Named in transfer and gait belt use findings |
| V21 | Human Resources | Named in gait belt policy and training findings |
| V4 | Certified Nurse Aide | Named in incontinence care and side rail findings |
| V13 | Nurse Practitioner | Named in infection control and pressure ulcer findings |
| V14 | Nurse Practitioner | Named in infection control findings |
| V16 | Certified Nursing Assistant | Named in pressure ulcer mattress findings |
| V19 | Nurse | Named in insulin labeling findings |
| V25 | Power of Attorney | Named in electronic monitoring consent findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to document and notify family about a resident's fall.
Complaint Details
The complaint investigation found that the nurse on duty did not know the fall protocol, failed to complete risk management forms, did not notify the family, and did not document the fall in the resident's medical record. The Director of Nursing confirmed that notification to the family should have been done within the shift and that nurses are required to fill out risk management forms and follow new orders. The family was notified the next day.
Findings
The facility failed to document a resident's fall in the electronic health record and did not notify the resident's family in a timely manner. The nurse on duty did not follow the fall protocol, including proper documentation and notification procedures.
Deficiencies (1)
Failure to document a resident's fall in the electronic health record and notify family as required by facility policy.
Report Facts
Residents reviewed: 8
Residents affected: 1
Date of fall: Mar 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V12 | Fall Nurse | Reported the fall, investigated the incident, and educated nurse V13 on fall protocol |
| V13 | Licensed Practical Nurse | Nurse on duty during the fall who failed to document and notify family as required |
| V2 | Director of Nursing | Confirmed proper notification procedures and timing for family notification |
Inspection Report
Deficiencies: 1
Date: Dec 6, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with policies and procedures to prevent abuse, neglect, and theft, specifically regarding an allegation of rough handling of a resident.
Findings
The facility failed to follow its Abuse and Neglect Policy by not immediately reporting an allegation of rough handling to the Administrator for one of three residents reviewed. Interviews revealed that the Director of Nursing did not report the allegation received on 12-3-24, although the Administrator stated she would have initiated an investigation if informed.
Deficiencies (1)
Failed to report an allegation of rough handling to the Administrator immediately as required by the Abuse and Neglect Policy.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Director of Nursing | Named in failure to report allegation of rough handling |
| V2 | Assistant Director of Nursing | Informed about allegations of rough handling |
| V17 | Administrator | Responsible for reporting and investigation of abuse allegations |
| V10 | Social Service Director | Reported obligation to notify Administrator of abuse allegations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The inspection was conducted following a complaint related to a resident fall during a mechanical lift transfer, specifically investigating the failure to use two staff persons as required by facility protocol.
Complaint Details
The visit was complaint-related due to a resident fall during a mechanical lift transfer. The complaint was substantiated as the facility failed to follow its protocol requiring two staff members for such transfers.
Findings
The facility failed to follow protocol requiring two staff members during mechanical lift transfers, resulting in a resident (R1) falling while still attached to the lift sling. The lift tipped over during transfer, causing minimal harm with reported back pain. Staff acknowledged the failure to have a second person assist, and disciplinary action was taken against the involved CNA.
Deficiencies (1)
Failure to use two staff persons when transferring a patient with a full body mechanical lift, resulting in the lift tipping and resident falling.
Report Facts
Residents affected: 3
Suspension duration: 3
Date of incident: Nov 1, 2024
Date of survey completion: Nov 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Certified Nursing Assistant (CNA) | Involved in improper mechanical lift transfer resulting in resident fall; received disciplinary suspension |
| V6 | Licensed Practical Nurse (LPN) | Witnessed the fall incident and assisted in returning resident to bed |
| V2 | Restorative Nurse | Provided training information and documentation on mechanical lift use |
| V9 | Director of Nursing | Interviewed regarding the fall incident and facility procedures |
| V5 | Administrator | Present during Director of Nursing interview and provided definition of fall |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to complaints and allegations regarding the wrongful use of a resident's funds and multiple falls resulting in injuries among residents.
Complaint Details
The complaint involved allegations that the facility wrongfully withdrew funds from a deceased resident's account without proper consent and failed to provide adequate fall prevention and supervision, resulting in injuries to six residents (R1, R2, R4, R5, R6, R8). The investigation included interviews with family members, staff, and review of records and incident reports.
Findings
The facility failed to protect a resident's funds by withdrawing money without proper consent and failed to provide adequate supervision and fall prevention interventions, resulting in multiple residents sustaining injuries from falls.
Deficiencies (2)
Failure to protect a resident from wrongful use of their money; withdrawal of $5,504.06 without proper consent or itemized accounting.
Failure to ensure adequate supervision and fall prevention interventions, resulting in multiple residents sustaining injuries from falls including fractures and lacerations.
Report Facts
Amount withdrawn without consent: 5504.06
Balance owed: 398.42
Refund amount: 2156
Fall risk score: 15
Fall risk score: 13
Fall risk score: 18
Fall risk score: 17
BIMS score: 3
BIMS score: 7
BIMS score: 6
BIMS score: 11
Number of sutures: 8
Number of sutures: 6
Number of staples: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V13 | Business Office Manager | Named in findings related to wrongful withdrawal of resident funds |
| V19 | Resident R3's Power of Attorney involved in wrongful withdrawal complaint | |
| V3 | Registered Nurse | Interviewed regarding fall of resident R1 |
| V10 | Certified Nursing Assistant | Interviewed regarding fall of resident R1 |
| V6 | Certified Nursing Assistant | Interviewed regarding fall of resident R1 |
| V9 | Fall Coordinator | Interviewed regarding multiple falls and fall prevention |
| V24 | Certified Nursing Assistant | Witnessed fall of resident R8 |
| V25 | Licensed Practical Nurse | Interviewed regarding fall of resident R8 |
| V26 | Director of Rehab | Provided therapy evaluation and plan for resident R8 |
| V1 | Nurse | Witnessed fall of resident R4 |
| V2 | Certified Nursing Assistant | Interviewed regarding fall of resident R4 |
| V11 | Restorative Director | Interviewed regarding ambulation and therapy for resident R4 |
| V22 | Care Plan Coordinator | Interviewed regarding care plan for resident R4 |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including fall prevention, wound care, pressure ulcer prevention, hydration, and overall safety.
Findings
The facility was found deficient in multiple areas including failure to notify family and physician after a resident fall, failure to follow physician orders for wound care, inadequate pressure ulcer prevention and treatment, failure to implement effective fall interventions and incident reporting, and failure to ensure adequate hydration for a resident with a gastrostomy tube. These deficiencies resulted in actual harm such as a subacute subdural hematoma, wound infections, and dehydration.
Deficiencies (5)
Failed to notify family and physician following a resident fall on 8/17/24.
Failed to follow physician orders for no-pressure wound treatment for one resident.
Failure to develop effective pressure sore prevention plan, replace soiled wound dressings, and set air loss mattress according to resident weight, resulting in infected pressure wound.
Failed to implement new and effective fall interventions, complete incident reports, and prevent multiple falls resulting in subacute subdural hematoma.
Failed to ensure adequate hydration for a resident with gastrostomy tube leading to dehydration and fecal impaction.
Report Facts
Fall risk score: 16
Fall risk score: 15
Braden scale score: 9
Braden scale score: 6
Weight: 90.8
Air mattress setting: 120
Air mattress setting: 290
Water deficit: 1.9
Sodium level: 154
BUN level: 25
Sodium level: 158
Enteral feeding volume: 1040
Water flush volume: 100
Total water intake: 1439
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V14 | Nurse | Identified in fall incident report on 8/17/24 and involved in fall response for Resident R1. |
| V18 | Nurse | Assisted with fall response for Resident R1 on 8/17/24 and reported no notification made. |
| V11 | Fall Nurse | Reported no documentation of notification after Resident R1 fall on 8/17/24. |
| V7 | Wound Care Director | Reported failures in wound care and air mattress settings for Residents R2, R3, and R4. |
| V15 | Wound Nurse Practitioner | Provided expert opinion on wound care and mattress settings; noted dehydration and malnutrition for Resident R2. |
| V10 | Restorative Aide | Reported on restorative services and contracture prevention for Resident R2. |
| V5 | CNA | Provided care to Resident R3 and reported on wound dressing status. |
| V16 | Radiologist | Provided expert opinion on timing of subacute subdural hematoma for Resident R1. |
| V17 | Dietitian | Provided assessment on enteral feeding and hydration for Resident R2. |
| V19 | Dietician | Reported on dual feeding and hydration status for Resident R2. |
| V2 | Director of Nursing (DON) | Reported unawareness of Resident R2's left hand wound until hospital record review. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the alleged financial abuse and theft of a resident's purse and debit card at Avantara Evergreen Park.
Complaint Details
The complaint was substantiated. A staff member (V17) was caught on camera taking the resident's purse and using the resident's debit card at a vending machine. The staff member was arrested and is no longer employed by the facility.
Findings
The facility failed to prevent financial abuse and theft for one resident (R1). The resident's purse was missing and later found in another resident's room. A staff member (V17) was identified via video footage and arrested for taking the purse and using the resident's debit card at a vending machine. The facility took corrective actions including canceling the debit card and notifying police and family.
Deficiencies (1)
Failed to protect resident from financial abuse and theft.
Report Facts
Residents reviewed for abuse: 8
Amount used from debit card: 2.85
Date purse reported missing: Jun 17, 2024
Date of observation: Jul 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V17 | Certified Nursing Assistant (CNA) | Staff member arrested for theft of resident's purse and debit card misuse |
| V1 | Administrator | Provided statements regarding the incident and staff background check |
| V16 | Assistant Administrator | Investigated the missing purse and reported findings |
| V3 | Activity Director | First staff member informed about the missing purse |
| V5 | Licensed Practical Nurse (LPN) | Provided statements about staff behavior and assignments |
| V21 | Police Officer | Arrested the staff member and provided details of the investigation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to allow a resident's representative to exercise the resident's rights in choosing a long-term care facility, as well as concerns related to pressure ulcer care and fall prevention management.
Complaint Details
The complaint investigation revealed that the facility did not allow the resident's surrogate decision maker to choose an assisted living facility for the resident, transferring her without permission. Additionally, the facility failed to implement proper pressure ulcer care and fall prevention interventions, resulting in resident injuries.
Findings
The facility failed to allow a resident's representative to choose a long-term care facility for the resident, failed to implement appropriate pressure ulcer prevention interventions including proper use of low air loss mattresses, and failed to implement individualized fall prevention care plans resulting in resident injuries from falls.
Deficiencies (3)
Failed to exercise the right of the resident representative to choose a Long-Term Care Facility of their choice for one resident.
Failed to ensure implementation of pressure ulcer prevention interventions and manufacturer recommendations for using low air loss mattress for resident with Stage 4 pressure ulcers.
Failed to implement fall prevention interventions and individualized fall prevention care plans for residents with history of falls, resulting in an unwitnessed fall with fractures requiring hospitalization.
Report Facts
Residents reviewed for residents right: 32
Residents reviewed for Pressure Ulcer Prevention and Treatment Management: 32
Residents reviewed for Fall Prevention Management: 32
Stage 4 Pressure Ulcer Sacrum size: 10
Stage 4 Pressure Ulcer Sacrum depth: 5.5
Date of resident transfer to assisted living: May 1, 2024
Date of fall incident: Jan 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V37 | Surrogate Decision Maker | Resident R329's daughter and surrogate decision maker who reported issues with facility transfer |
| V7 | Social Service Director | Contacted assisted living facility and involved in referral process for resident R329 |
| V1 | Administrator | Provided information about referral and transfer of resident R329 |
| V5 | Unit Manager | Observed pressure ulcer care issues for resident R48 |
| V2 | Director of Nursing | Discussed expectations for pressure ulcer care and fall prevention interventions |
| V8 | Wound Care Director | Provided guidance on pressure ulcer care and mattress use for resident R48 |
| V6 | Restorative Nurse | Reported on fall incident and care plan issues for resident R229 |
| V9 | Fall Coordinator | Responsible for ensuring implementation of fall prevention policy |
| V27 | Registered Nurse | Completed unwitnessed fall incident report for resident R229 |
| V38 | Agency Nurse | Witnessed fall incident for resident R229 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 17, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to pressure ulcer care, restorative nursing program, fall prevention, catheter care, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to implement pressure ulcer prevention interventions, inadequate restorative nursing services for range of motion limitations, insufficient fall prevention interventions resulting in resident injury, improper catheter care with sediment buildup and missing documentation, failure to label thawing foods in the kitchen, and lapses in infection control practices including improper use of PPE and hand hygiene.
Deficiencies (6)
Failed to ensure implementation of pressure ulcer prevention interventions and manufacturer recommendations for low air loss mattress use for resident with Stage 4 pressure ulcers.
Failed to provide appropriate restorative services consistent with resident's functional needs, including lack of physician orders and care plan for bilateral hand splints.
Failed to implement fall prevention interventions and individualized fall prevention care plans, resulting in unwitnessed fall and fractures requiring hospitalization.
Failed to ensure ongoing assessment and implementation of catheter care, including presence of sediment in catheter tubing and missing documentation of catheter output.
Failed to label foods being thawed inside the refrigerator as required by facility policy.
Failed to implement appropriate infection prevention and control practices including improper use of PPE during high contact care activities and failure to perform hand hygiene after glove removal.
Report Facts
Residents reviewed: 32
Residents affected by pressure ulcer deficiency: 1
Residents affected by restorative nursing deficiency: 1
Residents affected by fall prevention deficiency: 2
Residents affected by catheter care deficiency: 1
Residents affected by infection control deficiency: 2
Facility capacity: 159
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 Director of Nursing | Director of Nursing | Discussed expectations for pressure ulcer care, fall care plan interventions, and infection control practices. |
| V5 Unit Manager | Unit Manager/Infection Coordinator | Assessed catheter tubing sediment, discussed pressure ulcer care, and infection control observations. |
| V6 Restorative Nurse | Restorative Nurse | Provided information on restorative nursing program and fall prevention, reviewed resident records. |
| V9 Fall Coordinator | Fall Coordinator | Responsible for ensuring implementation of fall prevention policy and interventions. |
| V25 Therapy Director | Therapy Director | Discussed occupational therapy evaluations and restorative nursing referrals. |
| V27 Registered Nurse | Registered Nurse | Completed unwitnessed fall incident report for resident R229. |
| V38 Agency Nurse | Agency Nurse | Witnessed resident fall and assisted resident back to bed. |
| V39 Agency CNA | Agency Certified Nursing Assistant | Worked with resident R229 on day of fall, unavailable for interview. |
| V4 Dietary Manager | Dietary Manager | Observed unlabeled thawing foods in refrigerator. |
| V20 Certified Nurse Assistant | Certified Nurse Assistant | Observed providing incontinence care without hand hygiene after glove removal. |
| V30 Certified Nursing Assistant | Certified Nursing Assistant | Observed emptying urinary catheter bag without gloves. |
| V1 Administrator | Administrator | Informed of multiple concerns including pressure ulcer care, fall prevention, catheter care, food safety, and infection control. |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with policies regarding indwelling urinary catheter care and related resident treatment.
Findings
The facility failed to follow policies for indwelling urinary catheter care by not identifying and promptly treating a catheter-related laceration in one resident and failing to document catheter care every shift or have care plans in place for residents with catheters. The deficiencies affected multiple residents and included inadequate documentation and delayed wound care follow-up.
Deficiencies (3)
Failure to identify and promptly treat a catheter-related laceration for one resident.
Failure to document catheter care and cleaning every shift for residents with indwelling urinary catheters.
Failure to ensure a care plan was in place for residents with indwelling urinary catheters.
Report Facts
Deficiencies cited: 3
Antibiotic dosage: 500
Dates of catheter care order initiation: Mar 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 DON | Director of Nursing | Provided information about policy on skin assessment and notification regarding catheter-related laceration |
| V1 Administrator | Administrator | Commented on availability of emergency room notes at time of resident return |
| V4 CNA | Certified Nurse Assistant | Provided catheter care to resident but did not document procedure |
| Nurse Practitioner | Nurse Practitioner | Assessed resident with open laceration and referred to wound care team |
| V5 Hospital Nurse | Hospital Nurse | Interviewed regarding resident's condition upon hospital arrival |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to assess compliance with safety and pharmaceutical service regulations, including proper resident transfer methods and accurate documentation of controlled medication administration.
Findings
The facility failed to ensure safe transfer of one resident (R3) by not using a mechanical lift as required, and failed to accurately document administration of a controlled medication for one resident (R15), with discrepancies between the Medication Administration Record and Controlled Drug Administration Record.
Deficiencies (2)
Failed to ensure residents were transferred in a safe manner; mechanical lift sling was not positioned under resident R3 as required.
Failed to accurately document administration of controlled medication for resident R15; discrepancies between MAR and Controlled Drug Administration Record.
Report Facts
Controlled medication doses documented: 17
Controlled medication volume delivered: 60
Controlled medication volume remaining: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V15 | Certified Nursing Assistant | Named in transfer deficiency for resident R3 |
| V21 | Restorative Aide | Named in transfer deficiency for resident R3 |
| V16 | Registered Nurse/Unit Manager | Named in transfer deficiency for resident R3 and medication documentation deficiency |
| V7 | Registered Nurse | Measured remaining hydromorphone in resident R15's bottle |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure that a resident's fall risk plan of care was properly implemented and that staff were aware of the resident's fall risk status.
Complaint Details
The complaint investigation found that staff were unaware of the resident's fall risk status, the chair alarm was broken and not functioning, and the resident fell resulting in a laceration. The fall occurred on 11/29/23, and staff interviews confirmed lack of awareness and supervision.
Findings
The facility failed to ensure adequate supervision and proper functioning of fall prevention devices for a resident at high risk for falls, resulting in a fall with injury. Staff were unaware of the resident's fall risk status, and the chair alarm was found to be broken and not functioning at the time of the fall.
Deficiencies (1)
Failure to ensure that a resident's plan of care related to falls was carried out accordingly and staff were aware of resident fall risk status to implement fall risk interventions.
Report Facts
Residents reviewed for falls: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | agency RN (Registered Nurse) | Nurse on duty at the time resident was found on the floor; unaware of resident's fall risk status |
| V10 | CNA (Certified Nursing Assistant) | Assisted resident with eating dinner prior to fall; unaware of resident's fall risk status |
| V3 | Restorative Nurse | Notified of fall incident; confirmed fall risk and chair alarm implementation after fall |
| V6 | Restorative Aid | Troubleshot chair alarm device and identified broken connecting line |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident (R1) who was allegedly transferred into bed without the use of a required mechanical assistance machine, resulting in injury.
Complaint Details
The complaint investigation found that the resident was transferred without mechanical assistance despite her stating she needed it, resulting in a closed fracture. The facility substantiated the complaint with interviews and record reviews confirming improper transfer by staff.
Findings
The facility failed to ensure that a resident was transferred using a mechanical lift as required, leading to the resident sustaining a closed fracture of the right tibial plateau and experiencing severe pain. Investigation confirmed improper transfer by two CNAs ignoring the resident's need for mechanical assistance.
Deficiencies (1)
Failure to ensure a resident was transferred into bed with the use of a mechanical assistance machine as required, resulting in injury.
Report Facts
Residents Affected: 1
Date of injury observation: Sep 26, 2023
Date of facility reportable: Sep 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V11 | C.N.A | Provided written statement regarding transfer assist; no longer employed at facility |
| V9 | RN | Responded to resident's call light, reported resident's complaint of leg pain and arranged x-ray order |
| V4 | LPN | Conducted investigation concluding improper transfer by CNAs caused resident's fracture |
| V6 | Restorative Nurse | Provided information on resident's transfer needs and therapy recommendations |
| V2 | DON | Provided facility policies on restorative nursing and mechanical lift transfer |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements, specifically to ensure each resident receives an accurate assessment regarding skin conditions and pressure ulcers.
Findings
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident (R3) with a stage 4 sacral pressure ulcer. Documentation and assessments did not properly reflect the resident's wound status, and there was no physician order for the use of an air loss mattress as required by wound care policy.
Deficiencies (1)
Failure to complete an accurate MDS regarding the skin condition of resident R3 with a stage 4 sacral pressure ulcer.
Report Facts
Pressure ulcer measurement: 14
Pressure ulcer measurement: 17
Pressure ulcer measurement: 2
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V8 | Licensed Practical Nurse | Did not properly document R3's admission assessment and acknowledged reviewing hospital nurse to nurse report indicating sacral wound |
| V10 | Wound Physician | Signed wound care notes documenting R3's pressure ulcer |
| V11 | Wound Care Nurse | Completed skin evaluation assessment for R3 |
Inspection Report
Deficiencies: 1
Date: Jul 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing care and assistance to perform activities of daily living for residents who are unable.
Findings
The facility failed to change one of seven residents reviewed for activities of daily living, despite policies requiring checks and changes at least every two hours. Observations and interviews confirmed the resident was left in soiled linens, posing a risk for pressure ulcers and other complications.
Deficiencies (1)
Failed to change 1 of 7 residents reviewed for Activities of Daily Living (ADLs) as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Mentioned as V7 who reported last changing resident R5 around 6:00 or 7:00 AM. | |
| Registered Nurse (RN) | Mentioned as V6 who stated residents are checked and changed at least every two hours. | |
| Director of Nursing (DON) | Mentioned as V2 who stated residents are to be checked, changed, and repositioned at least every two hours. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 6, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to notify physicians of changes in condition, failure to notify family of admission, mental abuse allegations, failure to initiate CPR timely, and inadequate supervision of residents at risk for falls.
Complaint Details
The complaint investigation included allegations of failure to notify physician of change in condition, failure to notify family of admission, mental abuse by staff, failure to investigate abuse allegations, failure to document and communicate code status leading to delayed CPR, and inadequate supervision of residents at risk for falls resulting in injuries.
Findings
The facility failed to immediately notify the physician of a resident's new onset of pain and abnormal radiology report, failed to notify a resident's family of admission, failed to prevent mental abuse of residents, failed to conduct a thorough investigation of abuse allegations, failed to document and communicate code status resulting in delayed CPR, and failed to adequately supervise residents at risk for falls leading to injuries.
Deficiencies (7)
Failure to immediately notify physician of new onset of pain and abnormal radiology report resulting in delayed treatment of fractured tibia.
Failure to notify resident representative of admission to the facility.
Failure to prevent mental abuse when a CNA told a resident not to push the call button and another resident had call light taken away.
Failure to conduct a thorough investigation of mental abuse allegation regarding call light taken away.
Failure to follow practice for newly admitted resident to ensure and document full code status, and failure to provide code status during nurse-to-nurse report resulting in delay in initiating CPR.
Failure to assign a certified nurse aide to monitor and provide direct care to a newly admitted resident, failure to enter code status into electronic medical record, and failure to provide plan to monitor resident with history of pulling dialysis catheter.
Failure to monitor and supervise residents with impulsive restless behavior and poor judgment, failure to ensure residents at risk for falls wore non-slip footwear, and failure to ensure direct care staff were aware of residents at risk for falling resulting in falls and injuries.
Report Facts
Distance: 75
Fall Risk Evaluation Score: 13
Fall Risk Evaluation Score: 17
Fall Risk Evaluation Score: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V15 | Nurse | Admitting nurse for resident R4, responsible for admission documentation and code status. |
| V16 | Nurse/Shift Supervisor | Discovered resident R4 unresponsive, initiated CPR after confirming code status. |
| V28 | Registered Nurse | Reported mental abuse allegations and investigated complaints. |
| V8 | Administrator | Interviewed residents and staff regarding abuse allegations and investigations. |
| V42 | Medical Director | Reviewed hospital records and provided medical opinions on resident R4's condition and death. |
| V10 | Fall Coordinator | Investigated falls and fall prevention interventions. |
| V17 | Certified Nursing Aide | Assigned to care for resident R4 but did not provide direct care or monitor adequately. |
| V20 | Family Member | Family of resident R4, provided information about admission and death. |
| V25 | Registered Nurse | Responded to fall incident involving resident R7. |
Inspection Report
Routine
Deficiencies: 12
Date: Apr 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including timely repair of resident equipment, quality of care by agency staff, call light response times, medication administration practices, incontinence care, skin care and wound management, pain management, medication storage and labeling, infection control practices, food storage, and call light system functionality.
Deficiencies (12)
Failed to repair or replace a resident's bed footboard timely, affecting resident safety and comfort.
Failed to ensure agency staff provided care aligned with professional standards, including call light response and medication administration.
Failed to provide timely and adequate care and services by not responding to call lights and providing incontinence care timely.
Failed to follow skin care treatment policy by not assessing a resident's skin for breakdown and lacking a plan of care for a resident with a soft cast, resulting in a vascular injury.
Used extension cords as primary power sources for resident medical equipment, contrary to manufacturer instructions.
Failed to immediately act upon a resident's report of burning with urination for over 14 days.
Failed to provide safe, appropriate pain management for residents, including inadequate pain assessment and medication administration.
Failed to maintain accurate controlled medication counts and failed to recognize missing controlled medication.
Failed to adequately label and dispose of insulin and expired medications, and failed to follow facility policy on medication storage and disposal.
Failed to adequately store food items by labeling, dating, and discarding expired food items.
Failed to follow infection prevention and control policies including hand hygiene during medication administration and labeling respiratory equipment when opened.
Failed to ensure a dependent resident's call light system was in working order.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 3
Residents affected: 133
Residents affected: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements on multiple deficiencies including bed repair, call light response, incontinence care, skin care, pain management, medication administration, and call light system |
| V6 | Maintenance Director | Provided statements regarding bed repair and use of extension cords for medical equipment |
| V7 | Registered Nurse | Involved in medication administration and narcotic reconciliation |
| V16 | Licensed Practical Nurse | Involved in medication cart review, narcotic reconciliation, and medication administration |
| V17 | Licensed Practical Nurse | Involved in medication cart review and narcotic reconciliation |
| V24 | Nurse Unit Manager | Provided statements on agency staff orientation and use of power strips for medical equipment |
| V30 | Licensed Practical Nurse | Observed administering medication and responding to resident pain |
| V32 | Infection Preventionist | Provided statements on infection control practices including oxygen equipment and hand hygiene |
| V33 | Emergency Contact | Provided statements regarding resident pain and dialysis refusal |
Inspection Report
Routine
Census: 139
Deficiencies: 4
Date: Feb 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication self-administration, reasonable accommodations, fall prevention, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to complete medication self-administration evaluations, failure to provide wheelchairs for residents needing mobility aids, inadequate fall prevention interventions resulting in actual harm to residents, and failure to ensure adequate toilet paper supply in resident bathrooms.
Deficiencies (4)
Failed to ensure a resident who was self-administering medications and keeping medications at bedside had a Self-Administration Evaluation completed.
Failed to provide a wheelchair for mobility to a resident who requested one and required it.
Failed to have identified fall prevention interventions in place, to develop individualized fall prevention interventions, to update the resident care plan post fall with new interventions, and failed to develop a resident specific root cause analysis for falls resulting in one resident sustaining a head laceration requiring sutures.
Failed to ensure that all residents have toilet paper for use in their bathrooms.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 139
Wheelchairs ordered: 8
Toilet paper cases ordered: 8
Toilet paper cases last shipment: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V35 | Registered Nurse | Reviewed medication administration record related to medication self-administration deficiency |
| V6 | Assistant Director of Nursing | Did not provide Medication Self Administration Evaluation for resident |
| V14 | Rehab Director | Discussed wheelchair availability and screening |
| V3 | Physical Therapy Assistant | Discussed wheelchair availability and resident mobility |
| V13 | Restorative and Fall Nurse | Provided information on fall risk and interventions |
| V10 | Maintenance Director | Discussed wheelchair inventory and availability |
| V1 | Infection Preventionist Nurse | Provided information on resident infection status and precautions |
| V7 | Administrator | Discussed wheelchair availability and toilet paper supply |
| V11 | LPN | Provided details on resident falls and interventions |
| V23 | CNA | Witnessed resident fall and described circumstances |
| V18 | CNA | Provided information on resident care needs |
| V20 | CNA | Discussed wheelchair condition and cleaning |
| V21 | RN | Provided information on resident fall risk |
| V31 | CNA | Discussed toilet paper use and supply |
| V27 | CNA | Discussed bathroom stocking and toilet paper supply |
| V33 | Maintenance | Toured supply closets and discussed toilet paper supply |
| V34 | Housekeeping | Discussed toilet paper ordering and supply |
| V36 | Housekeeper | Discussed toilet paper supply on cart |
| V37 | Housekeeper | Discussed toilet paper supply on cart |
| V38 | Housekeeper | Discussed toilet paper supply on cart |
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