20 CMS Surveys
Inspection Report — Sep 25, 2025
Date: Sep 25, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to develop and implement an adequate plan of care for a resident at high risk for skin breakdown, resulting in the development and worsening of an unstageable pressure ulcer requiring hospitalization and surgical intervention.
Deficiencies (1)
F0686 (Pressure Ulcer Care) - The facility failed to develop a plan of care and assure that one resident at high risk for skin breakdown received appropriate treatment and services, resulting in the development and deterioration of an unstageable pressure ulcer requiring hospitalization and surgical intervention.
Report Facts
Residents affected: 1
Inspection Report — Jul 22, 2025
Date: Jul 22, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to ensure the safety of a resident using a mobility device due to a broken wheelchair brake that was not repaired in a timely manner, posing a fall risk to the resident.
Deficiencies (1)
F0689 - The facility failed to ensure the safety of a resident using a mobility device with a broken wheelchair brake, which posed a fall risk to the resident.
Report Facts
Residents affected: 1
Residents reviewed: 5
Inspection Report — Mar 9, 2025
Complaint Investigation
Date: Mar 9, 2025
Visit Reason
Complaint investigation of failure to notify physician of resident's change in condition and failure to report a fall, resulting in delayed hospital transfer.
Complaint Details
Complaint investigation regarding failure to notify physician and report resident fall resulting in delayed care and hospital admission.
Findings
The facility failed to notify the physician of a resident's change in condition and delayed hospital transfer. Three staff members were terminated for not reporting the fall and change in condition as required by facility policy.
Deficiencies (1)
F0684 (No specific Illinois section cited) - The facility failed to notify the physician of a resident's change in condition and delayed hospital transfer, and staff failed to report a resident fall, resulting in actual harm to the resident.
Report Facts
Residents affected: 1
Inspection Report — Feb 7, 2025
Annual Inspection
Date: Feb 7, 2025
Visit Reason
Annual Licensure Survey. For this survey, the establishment is in compliance with Part 295 except for the cited deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, medication administration errors, inadequate staffing, failure to provide consistent restorative therapy, improper medication storage and labeling, inconsistent provision of nighttime snacks, and incomplete immunization documentation. The infection preventionist lacked prior certification but completed training during the survey period.
Deficiencies (15)
F0550 (295.5500 Resident Rights) - The facility failed to maintain resident rights pertaining to dignity for three residents by failing to provide feeding assistance with dignity and protect confidentiality of medical information.
F0554 (295.5504 Self-Administration of Drugs) - The facility failed to assess and monitor one resident for self-administration of medication without a physician order.
F0575 (295.5575 Resident Rights Program) - The facility failed to post required information about the [NAME] program in a public and accessible location for twelve residents.
F0583 (295.5583 Confidentiality) - The facility failed to protect the privacy and confidentiality of personal information for one resident by allowing a hospital wristband with identifying information to remain visible.
F0645 (295.5645 PASARR Screening) - The facility failed to ensure Pre-admission Screening and Resident Review (PASARR) were completed for five residents prior to admission.
F0688 (295.5688 Restorative Nursing Program) - The facility failed to provide consistent restorative therapy and splint application for one resident, placing the resident at risk of functional decline.
F0725 (295.5725 Nursing Services Staffing) - The facility failed to provide enough nursing staff to meet resident needs, with documented complaints of inadequate CNA coverage and delayed call light response.
F0755 (295.5755 Pharmaceutical Services) - The facility failed to administer prescribed medications timely and maintain accurate narcotic counts for four residents.
F0759 (295.5759 Medication Error Rates) - The facility failed to maintain medication error rates below 5%, with errors documented for two residents.
F0761 (295.5761 Drug Storage and Labeling) - The facility failed to remove expired medications and enteral feedings, and failed to properly label medications, risking resident safety.
F0809 (295.5809 Food Service) - The facility failed to ensure proper sanitation and food safety, including dishwasher temperatures not reaching required levels, improper sanitizing, inadequate hair restraints, and unlabeled open food items.
F0812 (295.5812 Food Service) - The facility failed to maintain dishwasher temperatures and sanitizing levels per manufacturer specifications, risking cross contamination.
F0842 (295.5842 Medical Records) - The facility failed to accurately classify psychotropic medication on consent forms for one resident, potentially affecting informed consent.
F0882 (295.5882 Infection Preventionist) - The facility failed to ensure the designated Infection Preventionist completed required specialized training prior to the survey.
F0883 (295.5883 Immunizations) - The facility failed to properly document education, consent, and administration of influenza and Covid-19 vaccinations for multiple residents.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 12
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 104
Residents affected: 4
Residents affected: 2
Residents affected: 68
Residents affected: 101
Residents affected: 1
Residents affected: 104
Residents affected: 6
Inspection Report — Dec 19, 2024
Complaint Investigation
Date: Dec 19, 2024
Visit Reason
Complaint investigation of verbal abuse allegations involving resident R1, substantiated by facility investigations and resulting in termination of involved CNAs.
Findings
The facility substantiated two verbal abuse incidents involving resident R1 and terminated the responsible CNAs. The facility follows a no tolerance abuse prevention policy and updated care plans accordingly.
Deficiencies (1)
F0600 (Abuse Prevention Program) - The facility failed to protect resident R1 from verbal abuse by staff, substantiated by multiple investigations and witness statements.
Report Facts
Residents affected: 1
Inspection Report — Dec 9, 2024
Annual Inspection
Date: Dec 9, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including abuse by staff tying a resident to bed rails without orders, failure to obtain physician orders for restraints, failure to report abuse timely, unsafe medication storage, and insufficient staffing. The facility implemented corrective actions including staff training, resident assessments, and weekly audits to ensure compliance.
Deficiencies (5)
F0600 (295.6000 Resident Rights) - The facility failed to protect a resident from physical abuse when a nurse tied the resident's wrists to bed rails with a pillowcase without consent or physician order, causing humiliation and pain.
F0604 (295.6004 Physical Restraints) - The facility failed to ensure residents were free from unnecessary physical restraints, lacking physician orders, consent, and medical justification for restraining a resident with a pillowcase.
F0609 (295.6009 Reporting) - The facility failed to timely report an alleged abuse incident involving a resident tied to bed rails with a pillowcase to the Illinois Department of Public Health, reporting it 32 days late.
F0689 (295.6089 Accident Hazards) - The facility failed to ensure treatment and medication carts were locked and unattended medications were not left at bedside, risking tampering and hazards to residents.
F0725 (295.6125 Staffing) - The facility failed to provide sufficient nursing staff to meet resident needs, resulting in a resident being restrained due to inadequate supervision during a staffing shortage.
Report Facts
Residents affected: 1
Residents affected: 39
Residents affected: 41
Inspection Report — Oct 25, 2024
Date: Oct 25, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to refer five residents for required PASARR Level I and II screenings in a sample of five, due to delays and lack of follow-up during a transition period in social services. The new Social Services Director has created assessment tools and is training to ensure timely PASARR screenings going forward.
Deficiencies (1)
F0644 (Coordinate assessments with the pre-admission screening and resident review program) - The facility failed to refer five residents for required PASARR Level I and II screenings, resulting in residents not receiving needed specialized programs and treatment goals.
Report Facts
Residents affected: 5
Inspection Report — Oct 7, 2024
Date: Oct 7, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to provide wound treatments and proper wound care documentation for two residents, resulting in actual harm including hospital admission for one resident. The facility's policies require wound assessments and treatments, but these were not consistently completed or documented.
Deficiencies (1)
F0684 (no Illinois section number) - The facility failed to provide wound treatment for two residents, including lack of treatment orders, missing weekly wound assessments, absent care plan interventions, and failure to sign treatment administration records, resulting in actual harm.
Report Facts
Residents affected: 2
Inspection Report — Aug 29, 2024
Complaint Investigation
Date: Aug 29, 2024
Visit Reason
Complaint investigation of alleged abuse involving two residents (R1 and R2) was conducted. The facility investigated incidents of physical and verbal abuse by staff members V3 and V6 toward residents R1 and R2 respectively.
Complaint Details
Complaint #145885: Two staff members were terminated for physical and verbal abuse toward residents. The facility concluded verbal abuse occurred toward R2 and physical abuse toward R1.
Findings
The facility failed to protect two residents from physical and verbal abuse by staff. Staff members V3 and V6 were terminated following investigations into the incidents.
Deficiencies (1)
F0600 (Abuse Prevention Program) - The facility failed to protect residents from physical and verbal abuse by staff, affecting two residents of four reviewed.
Report Facts
Residents affected: 2
Residents reviewed for abuse: 4
Inspection Report — Mar 22, 2024
Annual Inspection
Date: Mar 22, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to protect residents from abuse, failure to provide appropriate care and treatment, medication errors, infection control lapses, inadequate staffing, expired medications and supplies, and failure to properly offer and document vaccinations. The facility committed to retrain staff on infection control, medication administration, and staffing adequacy, and to update care plans and policies accordingly.
Deficiencies (16)
F0557 (295.2057 Resident Rights) - The facility failed to protect a resident's right to privacy and dignity when a resident was seen without clothes on through an open door and staff did not immediately address the situation.
F0600 (295.2060 Abuse Prevention) - The facility failed to protect residents from physical and mental abuse by another resident and failed to establish a resident sensitive and secure environment after a physical abuse incident involving two residents.
F0644 (295.2044 PASRR) - The facility failed to refer a resident to the state-designated authority for Level II PASRR evaluation after new onset of possible serious mental disorder.
F0684 (295.2084 Treatment and Care) - The facility failed to provide proper positioning for a dependent resident during mealtime, risking aspiration.
F0686 (295.2086 Pressure Ulcer Care) - The facility failed to ensure low air loss mattresses were set correctly for two residents at risk for pressure ulcers.
F0688 (295.2088 Range of Motion) - The facility failed to follow physician's order and implement an individualized plan of care for a resident requiring a left hand splint to prevent contracture.
F0693 (295.2093 Enteral Tube Care) - The facility failed to disconnect and flush a resident's gastric tube per physician order, risking tube clogging.
F0695 (295.2095 Respiratory Care) - The facility failed to provide safe and appropriate respiratory care, including proper labeling, storage, and cleaning of oxygen tubing and nebulizer equipment, and failed to follow physician orders for oxygen therapy for multiple residents.
F0725 (295.2125 Staffing) - The facility failed to provide enough nursing staff daily to meet residents' needs, resulting in late medication administration and incomplete care.
F0759 (295.2159 Medication Error Rate) - The facility failed to maintain a medication error rate below 5%, with 5 errors out of 31 opportunities (16.13% error rate) including missed and incorrect medication administration.
F0760 (295.2160 Medication Administration) - The facility failed to ensure residents were free from significant medication errors, including missed insulin and other medications, and failure to notify physicians of held medications.
F0761 (295.2161 Medication Storage) - The facility failed to store and label medications and supplies properly, with expired medications and supplies found in medication rooms, carts, and crash carts, and failure to maintain crash carts according to policy.
F0812 (295.2212 Food Procurement and Storage) - The facility failed to discard expired food and failed to ensure staff washed hands between handling dirty and clean dishes, risking cross contamination.
F0880 (295.2280 Infection Prevention and Control) - The facility failed to clean and disinfect reusable medical equipment between residents, failed to wear proper PPE during tracheostomy care, failed to have isolation precautions care planned, and failed to update infection control policies annually.
F0883 (295.2283 Influenza and Pneumococcal Vaccinations) - The facility failed to offer, educate, and document influenza and pneumococcal vaccinations for 4 of 5 sampled residents.
F0887 (295.2287 COVID-19 Vaccinations) - The facility failed to offer, educate, and document COVID-19 vaccinations for residents and staff, with no documentation of recent vaccination clinics or education for staff.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 4
Residents affected: 3
Residents affected: 4
Residents affected: 4
Medication errors: 5
Inspection Report — Mar 22, 2024
Annual Inspection
Date: Mar 22, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to obtain physician orders for urine drug screening, inadequate assistance with resident relocation, medication administration delays, improper use of assistive devices, insufficient pain management, and inadequate staffing levels. The facility's policies and procedures were reviewed and found lacking in several areas.
Deficiencies (6)
F0550 (295.2050 Resident Rights) - The facility failed to obtain a physician's order prior to administering a urine drug screen and failed to have a nurse conduct the screening for one resident.
F0558 (295.2058 Resident Rights) - The facility failed to reasonably accommodate the needs and preferences of one resident by not providing assistance in relocating the resident to another facility closer to family.
F0658 (295.2068 Quality of Care) - The facility failed to ensure medications were administered within the facility's 2-hour window for medication administration for five residents.
F0689 (295.2089 Accident Hazards) - The facility failed to ensure the appropriate assistive device was provided for one resident with a history of multiple falls, using a geriatric chair without proper assessment or physician order.
F0697 (295.2097 Pain Management) - The facility failed to ensure timely ordering, sufficient supply, administration, and documentation of pain medication for one resident, resulting in multiple days without pain medication.
F0725 (295.2125 Staffing) - The facility failed to provide enough nursing staff daily to meet the needs of residents, resulting in delayed medication administration, incomplete ADL care, and resident complaints of inadequate staffing.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: All residents potentially affected by staffing shortages (F0725)
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
Visit Reason
Complaint investigation of an incident where resident R2 aggressively grabbed resident R1 by the neck on 02/13/24.
Complaint Details
Complaint investigation of an incident involving R2 grabbing R1 by the neck on 02/13/24.
Findings
The facility failed to ensure resident R1 remained free from physical abuse when R2 grabbed R1 by the neck. The incident was investigated and documented with no injuries found.
Deficiencies (1)
F0600 (Physical Abuse) - The facility failed to ensure a resident (R1) remained free from physical abuse when R2 aggressively grabbed R1 by the neck from behind on 02/13/24.
Report Facts
Residents affected: 1
Residents reviewed for abuse: 3
Inspection Report — Feb 29, 2024
Complaint Investigation
Date: Feb 29, 2024
Visit Reason
Complaint investigation of physical abuse involving residents R1, R5, and R7 at Complete Care at the Boulevard.
Complaint Details
Complaint involving physical abuse by resident R1 towards residents R5 and R7 was substantiated.
Findings
The facility failed to protect residents from physical abuse by another resident, resulting in a left hip fracture for R5 and a periorbital contusion for R7. The abuse was substantiated by interviews, record reviews, and staff statements.
Deficiencies (1)
F0600 (Protect each resident from all types of abuse) - The facility failed to ensure a resident was free from physical abuse, resulting in R5 being pushed by R1 causing a left hip fracture and R7 being punched in the face by R1 causing a periorbital contusion.
Report Facts
Residents affected: 2
Inspection Report — Jan 19, 2024
Complaint Investigation
Date: Jan 19, 2024
Visit Reason
Complaint investigation of an incident where a restorative aide sprayed pepper spray at resident R6, causing eye irritation and pain requiring emergency treatment. The investigation included review of surveillance footage, staff interviews, and policy review.
Complaint Details
Complaint investigation of an incident involving resident R6 being sprayed with pepper spray by staff member V26 on 11/15/2023, resulting in immediate jeopardy which was removed on 1/12/2024.
Findings
The facility failed to protect resident R6 from abuse when a staff member sprayed pepper spray in R6's face and failed to remove the staff member from contact with R6 immediately. The facility implemented a removal plan, conducted in-services on abuse prevention, de-escalation, and code of conduct, and terminated the responsible employee.
Deficiencies (3)
F0600 (295.6000 Resident Rights) - The facility failed to protect resident R6 from abuse when a staff member sprayed pepper spray in R6's face causing eye irritation and pain, and failed to remove the staff member from contact with R6 immediately after the incident.
F0684 (295.6840 Resident Care) - The facility failed to carry out physician orders timely, notify the physician of delayed services and family requests, and administered an incorrect dosage of medication for resident R5.
F0689 (295.6890 Accident Hazards) - The facility failed to assess resident R1 immediately after a fall and notify the physician, resulting in delayed care for a displaced right hip fracture requiring surgery.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Inspection Report — Nov 28, 2023
Date: Nov 28, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a deficiency report for Complete Care at the Boulevard.
Findings
The facility failed to ensure adequate supervision to prevent accidents related to illicit drug use by residents. Two residents overdosed due to lack of effective monitoring and control measures.
Deficiencies (1)
F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to develop and implement appropriate measures to ensure adequate supervision for 2 residents out of 3 reviewed, resulting in multiple overdoses.
Report Facts
Residents affected: 2
Residents reviewed: 3
Inspection Report — Sep 11, 2023
Complaint Investigation
Date: Sep 11, 2023
Visit Reason
Complaint investigation regarding multiple incidents of resident-to-resident abuse involving four residents (R1, R2, R3, and R4) at Complete Care at the Boulevard.
Complaint Details
Complaint investigation regarding resident-to-resident abuse involving four residents (R1, R2, R3, and R4).
Findings
The facility failed to maintain a safe resident environment and protect residents from abuse for four residents involved in multiple physical altercations. Staff intervened and placed residents on 1:1 observation as appropriate.
Deficiencies (1)
F0600 (Protect each resident from all types of abuse) - The facility failed to protect four residents from physical abuse by other residents, as evidenced by multiple incidents of hitting and physical altercations documented between residents R1, R2, R3, and R4.
Report Facts
Residents affected: 4
Inspection Report — Aug 22, 2023
Date: Aug 22, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility was found to have multiple deficiencies related to abuse prevention and discharge planning. The facility failed to prevent abuse resulting in injury to a resident and failed to properly plan and document discharge for a resident, placing the resident at risk.
Deficiencies (3)
F0600 (Protect each resident from all types of abuse) - The facility failed to follow the abuse prevention policy and failed to ensure two of four residents reviewed for abuse remained free from abuse, resulting in one resident sustaining injury requiring first aid.
F0622 (Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged) - The facility failed to meet discharge requirements for one resident discharged without coordination of needed services, resulting in the resident residing in a cemetery without proper follow-up.
F0660 (Plan the resident's discharge to meet the resident's goals and needs) - The facility failed to document a discharge plan of care for one resident reviewed for discharge planning process.
Report Facts
Residents affected: 2
Residents affected: 1
Inspection Report — Aug 6, 2023
Date: Aug 6, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to protect a resident from physical abuse by another resident, resulting in injury requiring hospital evaluation. The incident involved two residents and was witnessed by staff.
Deficiencies (1)
F0600 (Physical Abuse) - The facility failed to protect a resident from physical abuse by another resident, resulting in injury requiring hospital evaluation.
Report Facts
Residents affected: 1
Inspection Report — Apr 7, 2023
Annual Inspection
Date: Apr 7, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to ensure call lights were within reach for residents, incomplete care plans, improper medication administration, inadequate infection control practices, food safety violations, and incomplete COVID-19 vaccination documentation and testing protocols.
Deficiencies (18)
F0558 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to ensure 2 of 2 residents' call lights were within reach in a sample of 26.
F0657 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to revise a resident's comprehensive care plan after significant weight loss for 1 of 26 residents reviewed.
F0677 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to follow a resident's comprehensive care plan and provide turning and repositioning every two hours or as needed for 1 of 26 residents reviewed.
F0684 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to identify presence of PICC or midline lines, provide needed care and services, follow policy for dressing changes, measuring external catheter, flushing, and care planning for four residents in a sample of 26.
F0689 (Level of Harm - Actual harm) - The facility failed to complete a fall risk assessment on a resident who fell and sustained a left clavicle fracture.
F0693 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to ensure proper placement of a gastrostomy tube prior to medication administration and provide gastrostomy care per orders for 1 of 3 residents with gastrostomy tubes.
F0695 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to follow policy on oxygen administration including checking physician's orders and changing tubing and humidifier bottle for 1 resident.
F0697 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to follow a resident's comprehensive care plan to ensure a pain patch was applied as ordered for 1 resident.
F0755 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to ensure the system for accountability of controlled medications was followed for 1 of 3 medication carts reviewed, resulting in a missed dose of Phenobarbital for a resident.
F0759 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to ensure medication error rates were less than 5%, with 2 residents having medications held without physician orders or parameters.
F0761 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to ensure medications were not left unattended on medication carts, failed to properly label and store medications, and failed to discard insulin open beyond 28 days in 2 of 3 medication carts reviewed.
F0812 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to prepare food under sanitary conditions, failed to ensure frozen meat was not thawed at room temperature, failed to date perishable items, failed to monitor and log food temperatures, had leaking dishwasher pipeline, and failed to maintain cold food at 41F or cooler.
F0814 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to properly dispose of garbage and maintain dumpster area clean and free of waste to prevent pest harborage.
F0880 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to implement infection prevention and control program including failure to perform hand hygiene during bedside care, maintain linen bags off the floor, clean reusable equipment between residents, and failed to follow water management program for Legionella risk assessment.
F0883 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to properly monitor and record influenza and pneumococcal vaccinations in the immunization log for 4 of 5 residents reviewed.
F0886 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to follow COVID-19 testing policy for residents and staff exposed to confirmed cases, including lack of documentation of testing and contact tracing.
F0887 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to monitor and document staff vaccination status including contractual and agency staff, and failed to provide education and documentation for residents' COVID-19 vaccination status.
F0888 (Level of Harm - Minimal harm or potential for actual harm) - The facility failed to ensure all staff were vaccinated for COVID-19 and failed to develop policy and procedure to ensure full staff vaccination compliance.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 124
Residents affected: 128
Residents affected: 1
Residents affected: 4
Residents affected: 128
Inspection Report — Mar 12, 2023
Date: Mar 12, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, the inspection type is classified as 'other'.
Findings
The facility failed to follow its fall prevention policy by not adequately monitoring a high fall risk resident, resulting in the resident sustaining a head injury.
Deficiencies (1)
F0689 (Fall Prevention) - The facility failed to provide adequate monitoring and fall prevention for one high-risk resident, resulting in a fall with head injury.
Report Facts
Residents affected: 1
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