Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Terrace Of Mchenry Rehab during CMS and state inspections, most recent first.
Two residents experienced a lapse in dignified, resident‑centered care when one cognitively intact resident observed a Spanish‑speaking resident appearing to need help and asked a Spanish‑speaking CNA to assist. The CNA declined, stating she was busy, told the resident to ask an activity aide, and left the dining room without assessing or assisting the Spanish‑speaking resident. The activity aide, who did not speak Spanish, confirmed she could not help. The administrator later confirmed that the CNA had refused the request for assistance and that the facility lacked a specific written dignity policy, despite expectations that all residents be treated with dignity and respect.
The facility failed to notify a resident’s state-appointed guardian of the resident’s death, despite the guardian being listed as the resident representative on the face sheet. Nursing notes documented the resident’s death with family and a hospice nurse present and the subsequent removal of the body, but there was no record that the guardian was contacted. An LPN and the DON both stated that facility practice requires notifying the physician, POA/emergency contacts, guardian, and hospice as applicable, and documenting the time of death and all notifications. The hospice director confirmed that a new hospice nurse at the bedside did not verify or notify additional contacts, and hospice records also lacked any documentation of guardian notification, contrary to the facility’s change-of-condition policy requiring notification of the responsible party.
A resident with dementia and a known history of verbal and physical aggression toward peers and staff approached another cognitively impaired resident who was seated in the memory care dining area. Witnesses reported that the seated resident tapped the aggressive resident on the shoulder and asked for space, leading to an argument during which the seated resident placed a hand on the other resident’s chest to push away. The aggressive resident then slapped the seated resident in the face, causing a minor nosebleed. The aggressive resident later claimed being stabbed, though witnesses denied seeing any stabbing or hitting by the seated resident. The administrator substantiated that this incident met the facility’s definition of physical abuse under its abuse policy.
A resident with multiple sclerosis and left-sided weakness, who required two staff for mechanical lift transfers, was transferred by only one agency CNA. Despite being reminded of the need for two staff, the CNA proceeded alone, resulting in the resident and shower chair tipping over and falling to the floor. The incident was confirmed through interviews and record review, showing a failure to follow the care plan and ensure safe transfer procedures.
A resident diagnosed with pneumonia and started on antibiotics was not reported to have her designated representative, her daughter, notified of this change in condition, despite facility policy and updated contact information. Staff confirmed the representative should have been informed and that the contact details were current.
A resident with multiple medical conditions, who was cognitively intact and assessed as not at risk for elopement, left the facility without staff knowledge or supervision. Staff became aware of the departure after a door alarm and a report from another resident, but did not notify police as required by facility policy. Instead, staff and the administrator searched for the resident and contacted his family, with police only being notified several hours later by the family member. The resident was later found safe in another state.
A resident with a history of aggressive behavior did not receive their prescribed depakote upon re-admission to the facility after a hospital stay, leading to aggressive behavior towards a roommate. The facility failed to reconcile the medication discrepancy with the physician, resulting in the resident being sent to the hospital for a psychiatric evaluation.
The facility failed to provide coffee between meals as per resident preferences, affecting their social interactions. Several residents expressed concerns about the absence of coffee service, which was previously a part of their social routine. Despite activities staff being present, coffee was not available, and the issue was raised in resident council meetings without resolution.
The facility failed to provide nutritional supplements as ordered for residents experiencing significant weight loss. One resident did not receive fortified pudding despite a physician's order, while another resident, who had undergone a leg amputation, did not receive a mighty shake as required. Additionally, a resident with Alzheimer's disease lost weight without receiving the ordered mighty shake, and another resident did not receive fortified pudding as prescribed. The dietitian confirmed the importance of following dietary recommendations.
A facility failed to follow proper infection control protocols during incontinence care for four residents. CNAs did not change gloves or perform hand hygiene after handling soiled materials and before touching clean items. The Director of Nursing confirmed the requirement for glove changes and hand hygiene, as outlined in the facility's Infection Prevention and Control Manual.
Two residents experienced privacy breaches during personal care in the facility. One resident was exposed to a roommate during incontinence care due to a partially pulled privacy curtain. Another resident's room door was left open while her urinary drainage bag was emptied and her buttocks were cleaned, allowing visibility from the hallway. The facility's policy requires staff to ensure privacy by closing doors and pulling curtains.
The facility failed to protect residents from physical abuse in a locked memory care unit. A resident with dementia was involved in multiple incidents of aggressive behavior, including hitting another resident. The facility did not conduct abuse investigations or document these events in the residents' care plans or electronic medical records, leaving gaps in addressing the aggressive behaviors and risks for abuse.
The facility failed to follow its abuse policy by not investigating or documenting several physical altercations between residents. Despite incidents occurring over a four-month period, the administrator admitted to not having any abuse investigations, indicating a lapse in compliance with procedures meant to protect residents.
The facility failed to report and investigate allegations of physical abuse involving four residents. Incidents included physical altercations and hitting, but no abuse investigations or documentation were provided. A nurse was unsure if reports were made, while another claimed to have informed the Administrator and DON. The Administrator did not conduct investigations, as incidents were reported as behaviors, not abuse.
The facility failed to investigate allegations of physical abuse involving four residents. Despite incidents where a resident hit another and a physical altercation occurred between two residents, no abuse investigations or documentation were provided. The administrator stated that the incidents were reported as behaviors, not physical exchanges, and thus were not considered abuse allegations.
A facility failed to provide timely incontinence care to a resident with dementia and bladder incontinence. The resident's care plan required frequent checks, but it was observed that her incontinence brief was saturated and had not been changed for several hours, contrary to the facility's policy of providing care every two hours. The DON confirmed the policy, indicating a lapse in care.
The facility failed to follow care plans and physician orders for three residents. One resident continued to receive stool softeners despite having loose stools, another had a neglected nail condition, and a third was not weighed as required, missing several scheduled weigh-ins. These deficiencies indicate lapses in care and monitoring protocols.
A resident with a stage 4 pressure injury to the sacrum was observed with her heels flat on the mattress, despite care plan instructions to offload heels using protectors or pillows. The wound nurse confirmed the absence of an order for padded heel boots, and the resident's care plan highlighted her risk for further skin breakdown due to impaired cognition, decreased mobility, and incontinence.
A facility failed to monitor and implement interventions for a resident with a left hand contracture due to a stroke. The resident reported occasional use of a washcloth in her palm, but no splint or brace was provided. The Restorative LPN was unaware of any therapy recommendations, and the care plan lacked documentation or interventions for the contracture. An Occupational Therapy Discharge Summary had recommended a splint, but this was not followed through.
The facility failed to implement fall interventions for three residents at risk for falling. A resident with a history of falls was observed in a wheelchair without appropriate footwear and a fall mat not positioned correctly. Another resident's wheelchair lacked anti-tippers, leading to a fall incident. A third resident's call light was out of reach, increasing fall risk. These oversights indicate a failure to execute the facility's Fall Management Program effectively.
A facility failed to maintain a urinary drainage bag below a resident's bladder, violating catheter care protocols. The resident, with multiple diagnoses including neuromuscular dysfunction of the bladder, had a care plan requiring the drainage bag to be kept below bladder level. However, CNAs lifted the bag above the bladder while assisting the resident, contrary to the care plan. The DON confirmed the correct procedure.
A facility failed to implement appropriate interventions for a resident with an excoriated G-tube site. The site lacked a dressing and showed red excoriation, which was not previously documented or addressed. The wound nurse obtained treatment orders only after being informed of the issue, and the facility's policy to prevent irritation and excoriation was not effectively executed.
A resident with heart failure and other conditions missed doses of Sacubitril-Valsartan due to the facility's failure to order medications in a timely manner. The DON was unaware of the issue, and the physician noted that missing a single dose would not harm the resident.
A facility failed to administer medications on time for two residents, resulting in a medication error rate of 6.67%. An RN identified the delay and obtained permission from doctors to administer the medications late. One resident with psychosis received her 9:00 AM medications over an hour late, while another resident with respiratory issues expressed concerns about the timing of her inhaler. The facility's policy requires timely administration according to physician orders.
The facility failed to meet the dietary preferences of two residents. One resident, who can eat despite having a tube feeding, was not consistently provided with preferred items like soup and apple juice, despite these being documented preferences. Another resident, on a weight loss plan requiring double portions of scrambled eggs and milk, frequently received incorrect meals. These deficiencies highlight issues in the facility's dietary service processes.
The facility failed to provide a clean, sanitary, and odor-free environment for multiple residents. Observations revealed stained bed sheets and strong odors in residents' rooms over several days. Staff interviews indicated inconsistencies in linen-changing practices, and the facility lacked a formal policy for linen changes.
The facility failed to ensure a safe environment and adequate supervision for several residents, leading to multiple deficiencies. One resident with severe cognitive impairment was observed tipping his wheelchair backwards without staff intervention. Another resident was improperly transferred without the required equipment. Additionally, two residents lacked proper smoking assessments, despite their significant health issues.
The facility failed to ensure a resident's request for Advance Directives regarding CPR was accurately documented, resulting in conflicting 'full code' and 'Do Not Resuscitate' (DNR) statuses in the medical record. Staff members confirmed the discrepancy, highlighting the importance of accurate documentation to honor the resident's wishes in an emergency.
The facility failed to provide adequate bathing assistance for a resident with severe cognitive impairment and left another resident unattended in her wheelchair for over an hour, resulting in significant discomfort and frustration. Staff acknowledged the deficiencies and the need for better adherence to care protocols.
The facility failed to complete dressing changes for a resident with non-pressure wounds and did not implement preventative measures for another resident with non-pressure wounds. One resident's dressing changes were not completed as ordered, and another resident's heels were not offloaded despite having a history of pressure injuries and diabetic ulcers. The facility's staff confirmed the lack of adherence to care plans and policies.
A resident with Alzheimer's and other conditions was observed without pressure-relieving devices on her feet, contrary to her care plan. Both the LPN and DON confirmed the need for offloading to prevent further pressure injury, but staff failed to adhere to this requirement.
The facility failed to ensure proper urinary catheter care for two residents, leading to potential infection risks. One resident experienced repeated instances of urine backing up into the catheter tubing, while another had her catheter drainage bag mishandled during a transfer, violating infection control protocols.
A resident with severe cognitive impairment and a history of aggression was not appropriately managed during an episode of agitation. Despite staff presence, no intervention was made to address the resident's behavior, which included yelling and throwing objects. Interviews with staff confirmed that the facility's behavior management protocols were not followed.
A resident did not receive a scheduled losartan potassium tablet, and a docusate sodium capsule was not documented as given, resulting in an 8% medication error rate. The RN acknowledged the errors, and the Director of Nurses confirmed that medications should be documented immediately and administered within a one-hour window.
The facility failed to label and store medications properly for two of four medication carts reviewed. Unlabeled pills and prepackaged medications without resident information were found, posing risks of incorrect dosing and administration mistakes. The DON emphasized the importance of proper labeling and daily review of medication carts.
The facility failed to provide proper incontinent care and infection control for two residents. One resident's groin area was not cleaned thoroughly, and her hands were not washed after contamination. Another resident with a catheter did not receive care in accordance with enhanced barrier precautions, as staff did not wear the required gowns. The facility's policies on perineal care, hand hygiene, and enhanced barrier precautions were not followed.
Failure to Respond to Resident Request for Assistance and Maintain Dignity
Penalty
Summary
The deficiency involves a failure to honor residents' rights to dignity and respectful treatment when a cognitively intact resident requested staff assistance for another resident who spoke only Spanish. The first resident reported that while in the dining room he observed an elderly, Spanish‑speaking resident appearing to plead for help and, unable to understand her, asked a Spanish‑speaking CNA to assist. According to the resident, the CNA refused to help both him and the other resident, told him "no," and directed him instead to ask the activity aide for help before leaving the dining room without providing assistance. The activity aide corroborated that she was present in the dining room conducting an activity when the resident asked the CNA to help the Spanish‑speaking resident, that the CNA responded she was busy and not right now despite the resident stating it was very important, and that the CNA told him to ask the activity aide, who could not assist because she did not speak Spanish. The CNA later stated she had been bringing another resident to the dining room after a shower when the resident asked her to help the Spanish‑speaking resident, and that she told him she would look for the other resident’s CNA and then left the dining room. The administrator confirmed that the resident was upset because the CNA refused to help when he requested assistance for the Spanish‑speaking resident and acknowledged that the CNA told him she was busy and could not help. A disciplinary memorandum for the CNA documented that a resident had requested assistance and did not receive a response, characterizing the failure to acknowledge or respond to a resident’s request for help as discourteous and not meeting expectations for resident‑centered care. The facility did not provide a policy on dignity, and the administrator stated they did not have a dignity policy, although residents have the right to be treated with dignity as referenced in the disciplinary memorandum.
Failure to Notify Resident’s Guardian of Death
Penalty
Summary
The facility failed to notify a resident’s state-appointed guardian of a significant change in status, specifically the resident’s death, for one of four residents reviewed. The resident’s face sheet identified a state guardian as the resident representative. Nursing documentation showed that the resident expired during the night with family and a hospice nurse present at the bedside, and that the body was later picked up by a funeral home. However, there was no documentation in the resident’s progress notes that the guardian was notified of the death, nor any additional entries regarding the death beyond the initial note. Interviews with facility staff and hospice personnel confirmed that the guardian was not notified. An LPN stated that when a resident dies, the nurse is responsible for notifying the physician, the resident’s POA, emergency contacts, and guardian if applicable, and for documenting the time of death and who was notified in the progress notes. The DON similarly stated that upon a resident’s death, nursing must notify hospice if applicable, emergency contacts/POA or guardian, and the physician, and document these notifications. The hospice director reported that a hospice nurse was present at the time of death but was new, lacked access to the electronic medical record, and did not think to ask about additional emergency contacts or a guardian; there was no hospice documentation that the guardian was notified. The facility’s Change of Condition policy requires notification of the responsible party for changes in condition, but this did not occur for the resident’s guardian in this case.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident slapped another in the face following a verbal altercation. Both residents involved had dementia; the aggressor was care planned as mildly cognitively impaired with a documented history of verbal and physical aggression toward peers and staff, including striking another resident with a television remote and pushing a CNA on prior occasions. On the date of the incident, the aggressor approached the other resident, who was seated at a table in the memory care unit dining room. Witnesses reported that the seated resident tapped the aggressor on the shoulder and asked the aggressor to move away, which led to an argument. According to a CNA and an Activity Aide who witnessed the event, the seated resident then placed her hand on the aggressor’s chest in an attempt to push the aggressor away, at which point the aggressor slapped the seated resident in the face. The impact caused a minor bloody nose for the seated resident. The aggressor later stated that the other resident had “stabbed” his arm, but was unable to identify with what, and both witnesses stated they did not see the seated resident stab or hit the aggressor at any time. The seated resident, who was severely cognitively impaired, had no recollection of the incident when interviewed. The facility’s abuse policy affirms residents’ rights to be free from abuse, including physical abuse such as hitting and slapping, and the administrator substantiated that the aggressor physically abused the other resident.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis and left-sided weakness, who was assessed as requiring two staff members and a mechanical lift for safe transfers, was transferred by only one agency CNA using the mechanical lift. Despite the resident reminding the CNA that two staff were needed, the CNA proceeded alone. During the transfer to the shower chair, the chair moved and tipped over, causing both the resident and the chair to fall to the floor. The resident reported that the mechanical lift sling broke the fall, preventing injury. Facility records and staff interviews confirmed that the resident consistently reported being transferred by one staff member, contrary to the care plan which required two staff for safety. The incident was reported to the nursing staff the following morning, and the assistant administrator confirmed that the agency CNA involved was placed on do not return status. The facility's failure to follow the resident's care plan and provide adequate supervision during the transfer resulted in an accident hazard and an actual fall.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition. Specifically, a resident who was diagnosed with pneumonia and prescribed antibiotics did not have her designated representative, her daughter, informed of this change. The resident's electronic face sheet clearly listed her daughter as the resident representative, emergency contact, care conference person, and customer care representative, with updated contact information. Both the Director of Nursing (DON) and a Registered Nurse confirmed that the daughter was the appropriate person to notify for any changes in the resident's condition, including new medication orders. Despite the facility's policy requiring notification of the responsible party in the event of a change in condition, there was no documentation in the medical record that the resident's daughter was informed about the pneumonia diagnosis or the initiation of antibiotic treatment. The resident herself expressed a desire for her daughter to be kept informed about her health status. Staff interviews confirmed that the notification should have occurred and that the contact information was current at the time of the incident.
Failure to Follow Missing Resident Policy After Unsupervised Departure
Penalty
Summary
The facility failed to follow its own policy for reporting and responding to a missing resident when a cognitively intact resident, with multiple medical diagnoses including COPD, malnutrition, anemia, alcohol dependence, mood disorder, and hypertension, left the facility without staff knowledge or supervision. The resident was allowed to go out on a community pass alone and was assessed as not at risk for elopement, but on the day of the incident, he left the facility at 4:45 AM with his belongings without notifying staff. The door alarm was triggered, and staff became aware of his absence only after another resident reported seeing him leave. Staff searched for the resident and notified the administrator, but did not contact the police as required by facility policy. Instead of immediately reporting the resident missing to law enforcement, staff and the administrator attempted to locate the resident by visiting his family member's home and other local places. The family member eventually encountered police and filed a missing person report several hours after the resident's departure. The resident was later found in another state, determined to be of sound mind, and not at risk to himself or others. The facility's documentation and interviews confirmed that the required steps of notifying police and filing a missing person report were not followed, despite the facility's written policy mandating these actions for any missing resident who did not sign out or notify staff.
Failure to Reconcile Medication Leads to Aggressive Behavior
Penalty
Summary
The facility failed to ensure that a discrepancy with a resident's psychotropic medication was reconciled with a physician upon re-admission after a hospitalization. This involved a resident with a history of depression, anxiety, traumatic brain injury, and suicidal behavior, who was previously prescribed depakote for aggressive behaviors. Upon re-admission to the facility after a hospital stay for hypertension, the resident did not receive depakote as previously prescribed, leading to aggressive behaviors towards another resident. The resident's medical records indicated that depakote was part of their medication regimen to manage anger and aggressive behaviors. However, after returning from the hospital, the medication was not administered from the date of re-admission until a week later. The resident expressed aggression towards a roommate, resulting in a threat and subsequent hospitalization for a psychiatric evaluation. The facility's physician noted that discrepancies in medication orders should be clarified with the hospital or prescribing physician, especially for critical medications like depakote.
Failure to Provide Coffee Between Meals
Penalty
Summary
The facility failed to honor the residents' preferences for having coffee available between meals, impacting their social interactions and self-determination. Four residents expressed concerns about the lack of coffee service between meals, which they previously enjoyed as a social activity in the dining room. The residents reported that the kitchen stopped providing coffee until just before meal times, disrupting their routine of gathering early to socialize over coffee. One resident even attempted to address this by using a personal coffee maker in their room, but it was removed by the facility due to safety concerns. The Activities Director confirmed that residents had raised this issue in resident council meetings, and it was communicated to the Administrator. Despite the presence of activities staff in the dining room during the times when coffee was previously served, coffee was not made available. The Administrator acknowledged the need for staff to monitor residents with hot liquids and mentioned plans to introduce a coffee social activity, but no such activity had been implemented at the time of the survey. The lack of coffee service between meals was noted in the resident council minutes, indicating ongoing dissatisfaction among the residents.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for residents with significant weight loss and did not ensure weekly weights were obtained for a newly admitted resident. This deficiency affected four residents who were reviewed for nutrition. For instance, one resident, who was admitted on a specific date, experienced a weight loss from 100 pounds to 95 pounds over a month. Despite a physician's order for fortified pudding twice a day, the resident did not receive the pudding with meals on multiple occasions. The dietitian confirmed that the dietary department should follow the nutritional orders, but the resident's meal ticket did not reflect the order for fortified pudding. Another resident, who had undergone a right leg amputation, expressed concern about weight loss from 149 pounds to 128 pounds. Although a mighty shake was ordered as a nutritional supplement, it was not provided during meals as required. The dietitian had recommended the shake due to the resident's increased calorie needs for wound healing, but the dietary recommendations were not followed. A third resident, diagnosed with Alzheimer's disease and other conditions, lost 12.4 pounds in 27 days. Despite an order for a mighty shake twice a day, the resident did not receive it with meals. The dietitian emphasized the importance of receiving the supplements daily. Similarly, another resident with multiple diagnoses experienced a weight loss of 8.7 pounds over two months. Although fortified pudding was ordered twice a day, it was not provided during meals. The dietitian confirmed that the resident should receive all supplements with every meal as ordered.
Infection Control Deficiency in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in changing gloves and performing hand hygiene, during the provision of incontinence care for four residents. Resident 60, diagnosed with heart failure and vascular dementia, was observed receiving incontinence care from a CNA who did not change gloves or perform hand hygiene after handling soiled materials and before touching clean items and the resident's environment. Similarly, Resident 85, with diagnoses including Parkinson's disease and respiratory failure, received peri care from CNAs who also failed to change gloves or perform hand hygiene after contact with soiled materials. Additionally, Resident 27, diagnosed with vascular dementia and malnutrition, and Resident 62, with sepsis and heart failure, were provided incontinence care by a CNA who did not change gloves or perform hand hygiene between handling soiled and clean items. The Director of Nursing confirmed that gloves should be changed and hand hygiene performed when switching from dirty to clean tasks. The facility's Infection Prevention and Control Manual mandates changing gloves and performing hand hygiene after contact with body fluids and before touching non-contaminated items.
Privacy Breach During Personal Care
Penalty
Summary
The facility failed to ensure privacy during personal care for two residents, R60 and R85, as observed by surveyors. R60, who was admitted with diagnoses including heart failure and vascular dementia, was receiving incontinence care from a CNA while the privacy curtain was only half pulled, exposing her private areas to a roommate who was facing her bed. This lack of privacy was noted during an observation on March 24, 2025, and was a concern expressed by R60's daughter, who hoped that her mother's personal care was being conducted privately. Similarly, R85, who has multiple diagnoses including Parkinson's disease and respiratory failure, experienced a breach of privacy when her urinary drainage bag was being emptied and her buttocks were being cleaned. During this process, the door to her room was left open, allowing visibility from the hallway. The Assistant Director of Nursing entered the room to assess an open area on R85's buttocks while the door remained open, further compromising her privacy. The Director of Nursing later confirmed that staff should ensure privacy by closing doors and pulling curtains during personal care, as per the facility's Resident Rights Policy.
Failure to Protect Residents from Physical Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving residents in a locked memory care unit. Resident R32, diagnosed with dementia, delirium, mood disorder, and unspecified psychosis, was involved in several incidents where she exhibited aggressive behavior. On January 19, 2025, R32 was observed hitting another resident, R92, in an attempt to take his coffee. Despite this incident, the facility did not conduct an abuse investigation or document the event in R92's electronic medical record. Additionally, R32's care plan indicated a history of aggressive behaviors, yet there was no documentation of interventions to address these behaviors. Further incidents involved R32 hitting another resident on December 22, 2024, and R105 being involved in a physical altercation with R80 on January 19, 2025. R105, who has Alzheimer's disease, dementia, mood disorder, and anxiety disorder, was noted to be a 'grabber,' yet her care plan did not reflect any aggressive behaviors or risk for abuse. Similarly, R80, diagnosed with bipolar disorder, major depressive disorder, dementia, alcohol dependence, and unspecified psychosis, was involved in the altercation with R105. The facility failed to document these incidents properly or conduct investigations, leaving gaps in the residents' care plans and electronic medical records.
Failure to Investigate and Document Abuse Incidents
Penalty
Summary
The facility failed to adhere to its own abuse policy, resulting in a deficiency related to the handling of abuse incidents among residents. Specifically, the facility did not conduct abuse investigations or provide documentation for several incidents involving physical altercations between residents. On December 22, 2025, a resident hit another resident, and on January 16, 2025, a different resident was involved in a physical altercation with another. Additionally, on January 19, 2025, the same resident from the December incident hit yet another resident. Despite these occurrences, the facility did not produce any abuse investigations, incident reports, or related documentation. The facility's abuse policy, dated September 2020, outlines the requirement for employees to immediately report any potential mistreatment to a supervisor or the administrator. It also mandates the appointment of an investigator to look into allegations and obtain relevant documentation. However, during an interview on March 26, 2025, the administrator admitted to not having any abuse investigations for the past four months, indicating a clear lapse in following the established policy. This failure to investigate and document abuse incidents highlights a significant deficiency in the facility's compliance with its own procedures designed to protect residents from abuse and neglect.
Failure to Report and Investigate Allegations of Physical Abuse
Penalty
Summary
The facility failed to ensure that staff identified and reported allegations of physical abuse to the administrator, affecting four residents. On December 22, 2025, a resident's progress notes indicated that they hit another resident. On January 16, 2025, another resident was involved in a physical altercation with a different resident. On January 19, 2025, the same resident from the December incident hit yet another resident. Despite these incidents, the facility did not provide any abuse investigation, incident report, or documentation. Interviews revealed that a Registered Nurse was unsure if the incidents were reported, while a Licensed Practical Nurse claimed to have reported them to both the Administrator and the Director of Nursing. The Administrator stated that no abuse investigations were conducted in the past four months, as the incidents were reported to him as behaviors rather than physical exchanges, and thus not considered abuse allegations.
Failure to Investigate Allegations of Physical Abuse
Penalty
Summary
The facility failed to investigate allegations of physical abuse involving four residents. On December 22, 2025, one resident hit another, and on January 16, 2025, a different resident had a physical altercation with another. Additionally, on January 19, 2025, the same resident from the first incident hit yet another resident. Despite these incidents, the facility did not provide any abuse investigations, incident reports, or documentation regarding these events. The administrator stated that no abuse investigations had been conducted in the past four months, as the incidents were reported to him as behaviors rather than physical exchanges, and thus he did not consider them as abuse allegations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate ADL assistance to a resident, identified as R60, who is dependent on staff for care. R60 was admitted with diagnoses including heart failure, vascular dementia, and a history of falling. Her care plan, initiated in 2019, indicated a need for assistance with ADL tasks and frequent checks for incontinence due to dementia-related bladder incontinence. On March 24, 2025, it was observed that R60's incontinence brief was saturated with dark urine and contained stool, and the incontinence pad was wet. The CNA, V9, stated that the brief was last changed at about 6:30 AM, indicating a lapse in the facility's policy of providing incontinence care every two hours and as needed. The Director of Nursing confirmed the care policy, highlighting the deficiency in adhering to the established care protocols.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for three residents. One resident experienced loose stools for approximately nine days, despite having a physician's order to administer loperamide and hold stool softeners. The resident continued to receive stool softeners and laxatives until the morning of March 26, 2025, indicating a delay in implementing the physician's recommendations. Another resident had a right thumb nail that was extremely long and partially detached, posing a risk of snagging. Despite being under wound care, the wound care nurse was unaware of the condition until March 25, 2025, and the resident's care plan included interventions to inspect and trim nails frequently, which were not followed. Additionally, a third resident, admitted with multiple diagnoses including sepsis and heart failure, had an order for weekly weights to monitor potential weight gain. However, the resident was not weighed on several occasions as required by the facility's policy, missing four scheduled weigh-ins in March 2025. This failure to adhere to the weight monitoring protocol could have impacted the resident's health management, as there was no record of the resident refusing care. These deficiencies highlight lapses in following care plans and physician orders, potentially compromising resident care.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for a resident at risk for pressure injuries. The resident, identified as R108, was observed in bed with her heels flat on the mattress, contrary to the care plan and wound doctor's recommendations to offload heels using heel protectors or pillows. Despite having a stage 4 pressure injury to the sacrum, first identified on 1/10/24, and a care plan indicating the need to avoid direct pressure on bony prominences, the resident did not have an order for padded heel boots. The wound nurse confirmed the absence of such an order and stated that the facility follows the wound doctor's treatment and intervention orders. The resident's care plan also highlighted her risk for further skin breakdown due to impaired cognition, decreased mobility, and incontinence, yet the necessary interventions to offload pressure from her heels were not implemented during the observations.
Failure to Monitor and Implement Interventions for Resident's Contracture
Penalty
Summary
The facility failed to monitor and implement necessary interventions for a resident with a contracture. The resident, who had a contracture in her left hand due to a stroke, reported that a washcloth was sometimes placed in her palm, but only upon her request. A Certified Nursing Assistant was unaware of any splint or brace for the resident's hand. The Restorative Licensed Practical Nurse (LPN) mentioned that the resident was seen by therapy some time ago, but no recommendations were known. The LPN also stated that the restorative quarterly assessment only noted if there was a splint, without assessing the contracture itself. The Occupational Therapy Discharge Summary from June 2023 recommended ordering a splint for the resident's left hand, but this was not followed through. The resident's care plan included a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side, and noted a self-care performance deficit related to a past stroke and left hand contracture. However, there was no documentation or interventions listed for the contracture, and the most recent quarterly Restorative Nursing assessment did not indicate the use of a splint or brace.
Failure to Implement Fall Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for residents at risk for falling, as observed in three cases. Resident R403, who has a history of falling and a diagnosis of a nondisplaced intertrochanteric fracture of the right femur, was observed self-propelling in a wheelchair wearing regular socks, which are not appropriate footwear for fall prevention. Despite having a fall mat under his bed, it was not positioned correctly to prevent injury if he attempted to get out of bed. The resident frequently tried to get out of bed on his own, and the staff was not aware of this behavior, which could have prompted additional interventions. Resident R105, who has a history of falls, was observed in a wheelchair without anti-tippers during meals and activities. An incident report from January 22, 2025, documented that R105 fell backward in her wheelchair and hit her head, indicating the absence of anti-tippers as a contributing factor. The care plan for R105 included the use of anti-tippers, but this intervention was not implemented, leading to a fall incident. Resident R27, diagnosed with vascular dementia and other conditions, was identified as at risk for falls. The care plan included ensuring the call light was within reach, but during observation, the call light was attached to a teddy bear on the floor, out of the resident's reach. This oversight in implementing the care plan intervention could have contributed to an increased risk of falls for R27. The facility's Fall Management Program emphasizes proactive measures to identify and assess residents at risk for falls, but these were not effectively executed for the residents in question.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to maintain a urinary drainage bag below the level of a resident's bladder, which is a deficiency in catheter care. The resident, identified as R85, was admitted with diagnoses including Parkinson's Disease, neuromuscular dysfunction of the bladder, bipolar disorder, anxiety disorder, urinary retention, and a history of falling. The care plan for R85, initiated in December 2023, required the use of an indwelling catheter with specific instructions to keep the collection bag below the bladder level. However, during an observation, two CNAs lifted the urinary drainage bag above the level of R85's bladder while preparing the resident to get out of bed using a mechanical lift. This action was repeated when placing the bag into the resident's pants, contrary to the care plan instructions. The DON confirmed that urinary drainage bags should be kept below the bladder level.
Failure to Implement Interventions for Excoriated G-tube Site
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with an excoriated gastrostomy tube (G-tube) site. During an observation, a Certified Nursing Assistant (CNA) revealed that the resident's G-tube site lacked a dressing and exhibited noticeable red excoriation around the site. The CNA indicated that she would inform the nurse about the redness. The following day, the wound nurse confirmed the presence of red excoriation and obtained an order for zinc oxide and a drain sponge dressing. However, the wound nurse was not previously aware of any skin issues at the site. The resident's Treatment Administration Record indicated that the G-tube site was to be cleansed daily and as needed, with no documentation of skin breakdown noted the previous night. The resident's care plan required monitoring of the stoma site for size, color, and skin breakdown, but there was no documentation of the doctor or wound nurse being notified of the issue, nor were treatment orders implemented. The facility's policy on enteral feeding tube site care aimed to decrease potential irritation, excoriation, infection, or discomfort, but these measures were not effectively executed in this case.
Medication Ordering Deficiency
Penalty
Summary
The facility failed to ensure that medications were ordered in a timely manner, resulting in a resident missing doses of a critical heart medication. The resident, who has diagnoses including diabetes mellitus type two, systolic heart failure, hypertensive heart disease with heart failure, and cardiomyopathy, reported missing doses of Sacubitril-Valsartan, a medication prescribed for heart failure and heart disease. The resident's Medication Administration Records (MAR) for December 2024 and January 2025 indicated that the 9:00 PM doses on two separate occasions were not administered because the medication was unavailable. The Director of Nursing was unaware of the missed doses and stated that the process for ordering medications is through the electronic medical records system, which should ensure medications are ordered before they run out. The physician was notified of the missed doses at the time they occurred and acknowledged that while the resident should not have missed the dosage, missing a single dose would not cause harm. Despite the facility's process for medication ordering, the failure to maintain an adequate supply led to the resident missing critical medication doses.
Medication Administration Delays Result in High Error Rate
Penalty
Summary
The facility failed to ensure timely administration of medications for two residents, resulting in a medication error rate of 6.67 percent, which exceeds the acceptable threshold of 5 percent. On March 24, 2025, a registered nurse (RN) identified that medications for residents R30 and R97 were late, as indicated by a red background on the Electronic Medication Administration Record (EMAR). The RN subsequently contacted the residents' doctors and received permission to administer the medications late. R97, who has multiple diagnoses including psychosis, received her 9:00 AM medications at 10:07 AM, which included quetiapine, sertraline, and a multivitamin. Similarly, R30, with multiple respiratory and other chronic conditions, received her 9:00 AM medications at 10:15 AM, which included a range of medications such as aspirin, digoxin, and an inhaler. The delay in medication administration was further highlighted by R30's comments on March 25, 2025, expressing a desire to keep her inhaler at bedside to manage her respiratory condition effectively. R30 reported that medication passes had improved but noted that there were instances when 9:00 AM medications were administered as late as 2:00 PM. The facility's Medication Administration policy requires that drugs be administered according to the written orders of the attending physician, which was not adhered to in these instances, leading to the identified deficiency.
Failure to Meet Dietary Preferences for Two Residents
Penalty
Summary
The facility failed to accommodate the dietary preferences of two residents, leading to deficiencies in their care. One resident, who has a tube feeding but can eat, expressed dissatisfaction with being served pureed meals instead of the preferred items like soup and apple juice. Despite having specific dietary preferences documented, including apple juice, chicken broth, pudding, and ice cream, these items were not consistently provided. The resident reported having to repeatedly ask for apple juice and noted that the facility often failed to provide the requested items, leading to frustration and a sense of giving up on making requests. Another resident, who is on a weight loss plan and requires a double portion of scrambled eggs and milk to maintain muscle mass, frequently did not receive the correct meal portions. The resident reported receiving incorrect meals, such as French toast instead of the preferred scrambled eggs, and noted that the kitchen staff often made errors in fulfilling meal requests. The registered dietitian confirmed the importance of the double portion of eggs and milk for the resident's dietary needs, yet these preferences were not consistently met, indicating a failure in the facility's dietary service processes.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a clean, sanitary, and odor-free environment for multiple residents. Observations revealed that residents' fitted bed sheets and pillowcases were stained with yellow and brown marks, and rooms had strong urine and feces odors. Specifically, Resident R7's bed sheets had large yellow and brown stains over several days, and the room had a persistent urine odor. Resident R97's bed sheets also had large brown and yellow stains that remained unchanged over multiple days. Resident R99 was found with yellow stains on the bed sheets and urinals in the bed and on the garbage can, with additional brown stains appearing over time. Resident R120's bed sheets had yellow and brown stains, and the room had a strong odor that extended into the hallway. All four residents were not interviewable during the survey period. Staff interviews revealed inconsistencies in the facility's linen-changing practices. Certified Nursing Assistant V8 and Memory Unit Coordinator V5 stated that bedding is changed as needed and on shower days, even if a resident refuses a shower. However, during a tour with V5, it was acknowledged that the rooms had strong odors and that the stained sheets were unacceptable. The Director of Nursing, V2, confirmed that linens are changed when soiled and if a resident is perspiring heavily. The facility was unable to provide a policy regarding linen changes, indicating a lack of formal guidelines for maintaining a clean and sanitary environment for residents.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for several residents, leading to multiple deficiencies. One resident with severe cognitive impairment and a history of falls was observed tipping his wheelchair backwards on multiple occasions without staff intervention, despite being in the presence of multiple staff members. The resident's care plan indicated the need for close supervision to prevent falls, but this was not adhered to, resulting in a significant safety concern as acknowledged by the Director of Nursing and a Registered Nurse. Another deficiency involved the improper transfer of a resident who required the use of a sit-to-stand lift due to multiple medical conditions. The resident and her spouse reported that staff often did not use the required equipment, opting instead to manually lift her without a gait belt. This was confirmed during an observation where staff used a loose sling for the transfer, contrary to the care plan and facility policy. The Director of Nursing confirmed that not following the care plan for transfers posed a safety risk. Additionally, the facility failed to conduct proper smoking assessments for two residents. One resident, who had a left above-the-knee amputation and other significant health issues, was observed smoking without a documented smoking assessment in his electronic medical record. Another resident with chronic obstructive pulmonary disease and other serious conditions also lacked a smoking assessment. Staff confirmed that smoking assessments were necessary to determine residents' ability to smoke safely, but these assessments were not completed as required by the facility's smoking policy.
Failure to Accurately Document Resident's Advance Directives
Penalty
Summary
The facility failed to ensure a resident's request for Advance Directives regarding Cardiopulmonary Resuscitation (CPR) was accurately incorporated into the medical record. The resident's electronic medical record (eMAR) showed conflicting information, with both 'full code' and 'Do Not Resuscitate' (DNR) statuses documented. The resident's POLST (Practitioner Order for Life-Sustaining Treatment) indicated 'Do not attempt Resuscitation,' while the care plan documented the resident as a 'full code.' This discrepancy was confirmed during interviews with staff members, who acknowledged the importance of accurate code status documentation to honor the resident's wishes in an emergency situation. Staff members, including a Licensed Practical Nurse (LPN), the Memory Care Director/Social Services, and a Corporate Nurse Consultant, reviewed the resident's electronic record and identified the conflicting code statuses. The Memory Care Director/Social Services noted that any contradiction in code status would cause confusion during an emergency. The facility's Advance Directives policy requires that all advanced directive preferences be documented in the resident's care plan and updated regularly. However, the policy was not followed in this case, leading to the deficiency in accurately reflecting the resident's advance directive wishes in the medical record.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate bathing assistance for a resident diagnosed with severe cognitive impairment, dementia, and other medical conditions. The resident had not received a shower for 11 days, despite the facility's policy of providing showers twice a week. Observations revealed the resident had a strong urine and body odor, red and inflamed groin, and was unshaved. Staff interviews confirmed the resident's need for regular bathing assistance and the failure to provide it, even though the resident did not refuse care during the observed period. Another resident, who required two-person assistance for transfers and had recently undergone surgery, was left unattended in her wheelchair for over an hour after requesting to be transferred to bed. The resident's meal tray was left out of reach, and she was unable to eat without assistance. Despite multiple staff members passing by her room, the resident did not receive the necessary help until much later. Staff interviews corroborated the resident's need for assistance and the excessive delay in providing it. Both incidents highlight the facility's failure to adhere to care plans and policies designed to ensure residents' well-being. The lack of timely assistance with activities of daily living, such as bathing and meal setup, resulted in significant discomfort and frustration for the residents involved. Staff acknowledged the deficiencies and the need for better adherence to care protocols to prevent such occurrences in the future.
Failure to Complete Dressing Changes and Implement Preventative Measures
Penalty
Summary
The facility failed to complete dressing changes for a resident with non-pressure wounds and did not have preventative measures in place for another resident with non-pressure wounds. One resident, who had a left above-the-knee amputation and multiple diagnoses including PVD, diabetes, and chronic kidney disease, was observed with a gauze dressing extending from his shoe. The dressing changes for his right foot were not completed on several dates as per the physician's orders, and there were no progress notes documenting the dressing changes or refusals of care on those dates. The resident's wounds had 100% necrotic tissue, and the treatment plan was not followed as ordered, which was confirmed by the facility's staff during interviews. The facility's policy required the implementation of preventative measures and appropriate treatment modalities for skin alterations, which was not adhered to in this case. Another resident was observed with her heels resting on the mattress without offloading, despite having offloading boots available in her room. The resident had a history of pressure injuries and diabetic ulcers and was noted to have an open wound with drainage on her right heel. The care plan for this resident included elevating her heels off the bed and inspecting her skin daily, which was not followed. The Director of Nursing confirmed that heels should be offloaded at all times and that staff should offer alternatives if the resident does not want to wear offloading boots. The facility's policy also required the implementation of preventative measures and appropriate treatment modalities for skin alterations, which was not followed in this case. The facility's failure to adhere to physician orders for dressing changes and to implement preventative measures for skin alterations resulted in deficiencies in the care provided to these residents. The lack of documentation and adherence to care plans and policies contributed to the inadequate treatment and care of the residents' wounds, as observed and confirmed by the facility's staff during the survey.
Failure to Offload Heels for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure a resident's heels were offloaded, leading to a deficiency in pressure ulcer care. The resident, who had diagnoses including Alzheimer's disease, aphasia, anxiety disorder, and psychotic disorder with hallucinations, was observed sitting in a geriatric hospice chair without any pressure-relieving devices on her feet. Both of her heels were touching the footrest, contrary to her care plan which required offloading to prevent pressure ulcers. The resident's husband confirmed that the pressure-relieving boots were not on her when he arrived and had to request staff to put them on. The Licensed Practical Nurse/Corporate Wound Consultant and the Director of Nursing both acknowledged that the resident's heels should have been offloaded to optimize blood flow and prevent further pressure injury. The resident's care plan, initiated on 4/8/2021, indicated a history of pressure injuries to her right heel, left heel, and sacral area. The current wound on her right heel was identified as a deep tissue injury with specific measurements. The facility's wound doctor had also noted the need for offloading as a preventative measure. Despite these documented requirements, the facility staff failed to adhere to the care plan, resulting in the resident's heels being in direct contact with the footrest, thereby compromising her pressure ulcer care.
Improper Urinary Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure proper urinary catheter care for two residents, leading to potential infection risks. One resident, diagnosed with stage 3 chronic kidney disease and other urinary conditions, experienced repeated instances where his catheter bag was not emptied in a timely manner. On multiple occasions, the catheter bag was observed to be full, causing urine to back up into the tubing. The resident reported feeling bladder pressure and had to use the call light to get assistance. Staff interviews confirmed that the catheter bag should be emptied before urine backs up to prevent infections, but this protocol was not consistently followed, as evidenced by the resident's care plan and staff statements. Another resident with multiple medical conditions, including neuromuscular dysfunction of the bladder, had her catheter drainage bag mishandled during a transfer. The catheter bag was placed on the floor and later on the bed, both of which are against infection control protocols. The staff involved acknowledged that the drainage bag should not be on the floor and must be kept below the bladder level to prevent urine reflux and potential infections. The resident's care plan lacked specific interventions for catheter care, despite her recent treatment for a urinary tract infection.
Failure to Intervene for Resident with Dementia
Penalty
Summary
The facility failed to intervene appropriately for a resident diagnosed with dementia who was experiencing aggressive behaviors. The resident, who has severe cognitive impairment and a history of physical aggression, was observed yelling at other residents, banging on a table, and throwing a plastic coffee mug. Despite several staff members being present in the dining area, no intervention was made to address the resident's behavior or to remove him from the situation. The resident's care plan indicated the need for behavior tracking and removal from potentially aggressive situations, but these measures were not followed during the incident. Interviews with staff, including a Registered Nurse and the Director of Nursing, revealed that the appropriate protocol for handling such behaviors was not implemented. The staff acknowledged that the resident's behaviors were not managed correctly and that the situation could have escalated to physical harm. The facility's policy on behavior symptom tracking and management emphasizes the importance of maintaining safety and intervening as necessary, but this was not adhered to in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered, resulting in an 8% medication error rate. Specifically, a registered nurse (RN) administered a docusate sodium capsule but did not document it in the medication administration report (MAR). Additionally, the RN failed to administer a losartan potassium tablet at the scheduled time. This deficiency was observed during a medication pass for one resident diagnosed with heart failure, diabetes mellitus, irritable bowel syndrome, diverticulosis, and hypertension. The RN acknowledged the errors, stating that the docusate should have been documented immediately and was unsure how the losartan was missed. The Director of Nurses confirmed that medications should be documented immediately after administration and given within a one-hour window of the scheduled time to ensure effectiveness. The facility's Medication Administration policy supports these practices, stating that each dose should be recorded immediately following administration and that medications should be administered within one hour of the prescribed time. The failure to adhere to these procedures led to the observed deficiencies.
Failure to Label and Store Medications Properly
Penalty
Summary
The facility failed to label and store medications according to their policy for two of four medication carts reviewed. During an observation on the 100-hall medication cart, three medication cups filled with unlabeled pills were found. The RN present could not identify the pills or their intended recipients, acknowledging the potential for administration mistakes. Similarly, the memory unit medication cart contained prepackaged medications without any resident names or information, posing a risk of incorrect dosing or missed medications. The LPN present confirmed that the packets should be in individual resident's dispenser boxes and not loose in the drawer. The Director of Nurses stated that nurses should not dispense medications prior to the scheduled time and should destroy any medication that cannot be given immediately. The Director emphasized that unlabeled medications could be given to the wrong person and that medication carts should be reviewed daily. The facility's policy mandates that each resident's medications be stored in original containers and properly labeled, which was not adhered to in these instances.
Inadequate Incontinent Care and Infection Control
Penalty
Summary
The facility failed to provide proper incontinent care and infection control for two residents. For one resident with Alzheimer's disease and incontinence, staff did not follow proper procedures during incontinence care. The resident's groin area was not cleaned thoroughly, and her hands, which were contaminated during the process, were not washed. Additionally, no barrier cream was applied to her skin. The Director of Nursing and other staff acknowledged that the care provided was inadequate and did not meet the facility's policies for perineal care and hand hygiene. Another resident, who had a catheter and was on enhanced barrier precautions (EBP), did not receive care in accordance with the facility's infection control policies. Staff members providing care did not wear the required gowns, and there was no isolation bin or PPE supply visible near the resident's door. The staff admitted to not wearing gowns due to the lack of available PPE, despite the facility having an overflowing supply. The Corporate Nurse Consultant confirmed that the staff should have been wearing gowns and gloves during high-contact activities such as transfers, incontinence care, and catheter care. The facility's policies on perineal care, hand hygiene, and enhanced barrier precautions were not followed, leading to deficiencies in infection control. The staff's failure to adhere to these policies put the residents at risk of infection and skin breakdown. The facility's infection preventionist and other staff members acknowledged the importance of thorough cleaning and proper use of PPE to prevent the spread of infectious organisms and protect residents with indwelling medical devices or chronic wounds.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 181 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mchenry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Mchenry | 1.2 mi | — | 3 | 0 |
| Pearl Of Crystal Lake, The | 4.9 mi | — | 0 | 0 |
| Fair Oaks Health Care Center | 6.8 mi | — | 2 | 0 |
| Hearthstone Manor | 8 mi | — | 0 | 0 |
| La Bella Of Woodstock | 8.1 mi | — | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.