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 Complete Care At Margate Park during CMS and state inspections, most recent first.
The facility failed to protect residents from repeated resident‑to‑resident physical and verbal abuse and did not implement effective interventions to prevent recurrence. Two cognitively intact residents with psychiatric diagnoses engaged in multiple altercations involving racial slurs, other derogatory remarks, coffee being thrown, and hitting in common areas, while staff present did not consistently recognize, report, or investigate these events as abuse under facility policy. In a separate situation, a cognitively intact resident reported being bullied and followed by a former roommate with a documented history of manipulative and aggressive behavior, culminating in being pushed in the face in a public area, despite prior complaints and staff awareness of ongoing harassment. The facility did not complete individual abuse and aggression assessments and failed to ensure timely reporting, investigation, and protective measures, resulting in multiple unaddressed episodes of resident‑to‑resident abuse.
Two cognitively intact residents with significant psychiatric histories engaged in multiple altercations involving physical contact and derogatory, including racial, language, which staff observed or were informed about but did not consistently recognize, report, or investigate as abuse in accordance with facility policy. One resident reported being struck in the chest on two occasions by another resident after exchanges of insults and, in one case, after throwing coffee, while staff intervened only to separate them and did not promptly notify the administrator or initiate an abuse investigation. Social services and business office staff documented or acknowledged verbal and physical incidents but either failed to escalate them as abuse allegations or provided conflicting accounts about who was informed, and the administrator, serving as abuse coordinator, stated she was unaware of these resident-to-resident abuse events until questioned by surveyors, despite a written policy requiring immediate reporting and investigation of suspected abuse.
A resident with severe cognitive impairment and multiple comorbidities sustained a full thickness burn on the leg while unsupervised. Staff were unaware of how the injury occurred, and the incident was not reported or investigated as required by policy. The facility failed to provide adequate supervision and did not follow procedures for reporting and investigating injuries of unknown origin.
A resident with severe cognitive impairment and multiple chronic conditions sustained a significant burn of unknown origin. Facility staff documented the injury but did not notify the resident's representative until nearly two weeks later, despite policy requiring prompt notification. The delay was confirmed by staff interviews and absence of documentation in the health record.
A resident with multiple chronic conditions and cognitive impairment sustained a severe full-thickness burn of unknown origin. Staff observed and documented the injury, but the DON was not notified, and no investigation or report to the State was initiated as required by facility policy. The incident was not reported or investigated until much later, despite clear procedures mandating immediate action for injuries of unknown origin.
A resident with multiple comorbidities and severe cognitive impairment sustained a full-thickness burn of unknown origin. Staff observed the injury and provided wound care, but no immediate investigation or State report was initiated as required by facility policy. The DON and administrator confirmed that the incident was not reported or investigated until prompted by surveyors.
The facility did not ensure that a resident was protected from abuse, punishment, or neglect by any individual, resulting in a deficiency related to resident safety and well-being.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, as evidenced by insufficient demonstration of required skills and knowledge to meet residents' individualized needs.
A resident with a known history of violent behavior physically assaulted another resident in the dining room, resulting in a facial bruise and hospital evaluation. Staff, including an LPN and CNA, were present but unable to prevent the attack. The incident was substantiated as abuse, and both residents were sent to the hospital.
The facility did not provide timely, approved x-ray services and did not have an agreement with an approved provider to obtain them, resulting in a deficiency.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with cognitive impairment, seizure history, and moderate fall risk was left unsupervised in the dining room during a busy meal period when all CNAs were occupied elsewhere. The lack of supervision led to the resident attempting to rise from a wheelchair, resulting in a fall, head laceration, and subsequent hospitalization. Facility policies required continuous supervision, but staff failed to ensure coverage in the dining area.
Two residents experienced abuse: one was physically struck by another resident during a dispute in an elevator, and another was verbally abused with derogatory language by a receptionist during a disagreement in the lobby. Both incidents were witnessed by staff, confirmed through interviews and facility documentation, and found to be substantiated cases of abuse according to facility investigations.
A resident with multiple complex medical conditions and intact cognition was subjected to verbal abuse by a staff member during a late-night altercation. Although the incident was witnessed by several staff, internal communication delays and the unavailability of key personnel led to the abuse report being submitted to the state agency well beyond the required two-hour window, in violation of facility policy and state regulations.
A resident was twice petitioned for involuntary hospital admission without adequate documentation or substantiation of the behaviors cited as justification. Staff cited medication refusal and alleged aggressive behaviors, but records lacked supporting notes and staff interviews revealed inconsistencies regarding the events described.
The facility failed to maintain accurate and consistent medical records for two residents, including discrepancies between physician orders, MAR, and controlled substance documentation for one resident, and unsupported behavioral documentation in petitions for involuntary hospital admission for another. Staff interviews confirmed that required documentation was either missing or not based on direct observation.
A resident with multiple diagnoses and a recent functional decline was not provided with individualized fall interventions after a significant change in condition. Despite being at high risk for falls and requiring substantial staff assistance, only standardized fall prevention measures were in place. The resident was able to ambulate unassisted, leading to a fall and head injury, as staff were not adequately informed of the resident's fall risk or the need for specific interventions.
A resident in an LTC facility did not receive their blood pressure medication as ordered on multiple occasions. The resident, who is non-verbal, reported that an LPN attempted to crush their medication, leading to refusal. The LPN did not notify the physician or check the resident's blood pressure, which is consistently high. The facility's policy requires physician notification for medication refusals, which was not followed.
A facility failed to maintain effective pest control, resulting in cockroach sightings in resident rooms. A resident, who is aphasic, reported seeing roaches, confirmed by staff and other residents. The Maintenance Director stated pest control visits weekly, but cockroaches are still seen. The facility's policy emphasizes cleanliness, yet the presence of pests indicates a lapse in maintaining a safe environment.
The facility did not update fall care plans for two residents after fall incidents, contrary to its Fall Prevention Program policy. One resident had multiple falls without timely care plan revisions, and another resident's care plan was updated only after a delay. Interviews confirmed that care plans should be updated after each fall, but this protocol was not followed.
A resident at moderate risk for falls fell in the washroom after waiting over 15 minutes for assistance that never arrived. Despite requiring partial to moderate assistance, the resident attempted to transfer independently, resulting in a fall. Staff interviews revealed that call lights were not answered promptly, contrary to the facility's Fall Prevention Program, which mandates timely responses and assistance for residents at risk of falling.
A resident with bilateral below-knee amputations did not receive consistent restorative therapy, as required by the facility's policy. Despite being cognitively intact and expressing a desire for therapy, the resident reported only receiving three therapy sessions over three months. Staff shortages and errors in documentation contributed to the inconsistency, placing the resident at risk of not maintaining their highest practical level of function.
A facility failed to provide enough restorative nurse aides, causing a resident to miss multiple therapy sessions over 90 days. The resident, who uses a prosthesis, reported losing strength due to inconsistent therapy. Staffing shortages led to restorative aides being pulled to assist CNAs, disrupting the restorative program. The facility's schedule confirmed the shortage, with only one aide working on certain days.
A resident with severe cognitive impairment and multiple medical conditions was found with a large bruise on her thigh, diagnosed as a hematoma, after being restrained by staff during care. Despite the resident's protests, staff continued care without documenting refusal, contrary to facility policy. The facility's policies emphasize residents' rights to be free from abuse, but staff actions were inconsistent with these guidelines.
A resident with severe cognitive impairment and high fall risk experienced multiple falls due to inadequate supervision at an LTC facility. Despite the Care Plan requiring one-on-one monitoring, staffing issues led to a lack of proper oversight, resulting in serious injuries. The facility's failure to adhere to fall prevention policies and the resident's Care Plan contributed to these incidents.
A resident with schizoaffective disorder and other conditions received psychotropic medication without documented informed consent, despite a previous refusal. The ADON claimed verbal consent was given but lacked documentation, violating the facility's policy requiring signed or witnessed verbal consent.
A resident with severe cognitive impairment was found with a bruise on her thigh, which was not reported to the state survey agency by the facility. The CNA noticed the bruise but delayed reporting it, and the DON and administrator did not consider it abuse. The resident's daughter raised concerns, leading to a hospital visit where elder abuse was diagnosed. The facility's policy mandates immediate reporting of such incidents, which was not followed.
A facility failed to investigate an allegation of injury of unknown origin involving a resident with a large bruise on her thigh, which was reported by her daughter as potential elder abuse. The DON did not see the bruise before the resident was sent to the hospital, and the Administrator attributed the bruise to the resident's behavior, neglecting to investigate as required by the facility's abuse prevention policy.
A resident experienced multiple falls due to inaccurate fall assessments, which failed to reflect their need for substantial assistance and use of furniture for support. Despite severe cognitive impairment and a history of falls, the assessments did not align with the resident's care plan, which indicated a high risk for falls and required extensive assistance for mobility.
A resident with vascular dementia and cognitive impairments left an LTC facility unsupervised due to a lack of a physician pass privilege order. The resident got lost in the community and returned late at night. Staff interviews revealed communication lapses and failure to follow the facility's policy on pass privileges, contributing to the incident.
A resident's clothes went missing due to the facility's failure to document personal belongings upon admission. The resident, with conditions like cerebral palsy and reduced mobility, reported seeing others wearing their clothes. The facility's policy requires CNAs to inventory and label belongings, but this was not done, and the laundry department does not track unlabeled items. The DON confirmed the lack of an initial inventory list, and complaints were noted in resident council meetings.
A facility failed to schedule a cataract surgery for a resident, leading to continued visual difficulties. The resident, who is cognitively intact, had been waiting for nearly six months for the surgery. Additionally, two other residents missed doctor's appointments due to the facility's failure to provide necessary escorts and transportation. The facility's policy requires follow-up with physicians to ensure appointments are scheduled, but this was not done.
A resident with anxiety and PTSD reported discrepancies in the administration of Lorazepam, a psychotropic medication. The facility's records showed administration on certain dates, but these were not documented in the MAR. Interviews with the DON and LPNs revealed lapses in documentation, contrary to facility policy requiring narcotics to be signed out in the EHR and narcotic sheet.
The facility failed to implement a policy on strip searches, leading to two residents feeling humiliated and violated after being subjected to such searches. Both residents, who were cognitively intact, reported feeling coerced and exposed during the searches conducted by facility staff, despite no contraband being found.
A facility failed to investigate an alleged abuse incident involving a resident and a dietary aide in an elevator. Despite reports of the incident, no formal investigation or interviews were conducted with the involved parties. The Director of Nursing and Administrator did not take necessary steps to gather all sides of the story, resulting in a deficiency in the facility's response to the alleged abuse.
A resident with a history of opioid dependence tested positive for illegal drug use, but the facility failed to develop and implement a care plan addressing this issue. Despite the facility's policy requiring comprehensive care plans, the resident's plan was not updated to reflect their current needs after testing positive for cocaine, marijuana, and methadone.
A resident experienced a significant delay in receiving a necessary tongue biopsy due to a lack of coordination between the facility's staff and external medical providers. Despite multiple attempts to schedule the procedure, the biopsy was not completed in a timely manner, delaying critical diagnosis and treatment.
The facility failed to report an abuse incident involving two residents to IDPH within the required timeframe. One resident pushed another during an altercation, and the incident was reported the next day instead of within two hours. The final report was also submitted late, eight days after the incident, contrary to the five-business-day requirement.
The facility failed to ensure call lights were within reach for two residents, leading to their inability to contact staff when needed. One resident with moderate cognitive impairment and another with intact cognition but dependent on staff for transfers were both unable to reach their call lights, which were either hanging behind the bed or tangled with bed remote wires. Staff interviews confirmed the expectation that call lights should be accessible, aligning with the facility's policy.
The facility failed to document post-surgical wound assessments for two residents, including one whose surgical wound was not monitored after stitch removal. Interviews revealed confusion among staff about responsibilities, and the Wound Director noted the absence of a 'monitor wound order' for one resident. The facility's policy required documentation of wound care activities, which was not adhered to.
Two residents experienced delays in receiving therapy services due to the facility's process of obtaining administrative approvals for Medicaid patients. Therapy orders for a resident were placed, but occupational therapy was delayed by over a month, while another resident's physical therapy evaluation was delayed by nearly two weeks. The facility's policy required therapy assessments within 48 hours, which was not met, leading to dissatisfaction among residents.
A resident with a history of opioid dependence and mental disorders was involuntarily discharged to a hospital after becoming verbally aggressive when their community pass was revoked. The facility failed to document that the resident was notified of the reason for the transfer or discharge, as required by policy. The resident's progress notes lacked documentation of the necessary 30-day notice for involuntary discharges in April and June.
A resident with a history of opioid dependence and mental disorders was involuntarily discharged from the facility without receiving the required Bed Reserve Notification. The resident exhibited aggressive behavior towards the Social Service Director after being informed of the revocation of his community pass. Despite facility policies mandating written notice of a 10-day bed hold period during transfers, no documentation was found indicating that the resident was informed, resulting in a deficiency.
A resident with a history of opioid dependence and mental disorders was not allowed to return to the facility after hospitalization, despite the facility's bed-hold policy. The resident was involuntarily discharged following aggressive behavior towards the Social Service Director. The facility did not document the discharge notice properly and did not coordinate with the hospital regarding the resident's status, ultimately deciding not to accept the resident back based on legal advice.
A resident with a history of stroke and diabetes did not receive prescribed medications, including insulin, as documented in the MAR. The resident's blood pressure and blood sugar levels were uncontrolled, and the facility failed to notify the physician as required by policy. The DON acknowledged the need for physician notification but was unsure if it occurred.
Failure to Prevent and Address Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical and verbal abuse and to implement effective interventions to prevent recurrence. Two cognitively intact residents, R1 and R2, both with bipolar and other psychiatric diagnoses, were involved in multiple altercations that included racial slurs, other derogatory remarks, and physical aggression. R1 reported that on one occasion near the elevator, she called R2 derogatory names, including a racial slur, and threw coffee at him; R2 then wheeled toward her and punched her in the chest three times, resulting in a red scratch on her chest. R1 also described a prior incident near the bookkeeper’s office and dietary door where R2 told her to move, called her a derogatory name, and hit her across the chest. R2 corroborated that he had several altercations with a white female resident, including being called a racial slur, having coffee thrown in his face, and then hitting the resident when she would not move out of his way. Staff interviews and documentation show that these incidents were not consistently recognized, reported, or investigated as abuse in accordance with facility policy. The Business Office Manager (V6) recalled hearing R2 call R1 a derogatory name and hearing others in the hallway say, “Don’t hit her,” after which she entered the hallway, confirmed with R1 that R2 had hit her, instructed R2 not to hit R1 again, and directed R1 to move. V6 stated she reported the incident to the Social Service Manager (V7) and informed the Administrator (V1) the next morning. However, V7 denied being informed by V6 of any incident involving hitting and stated she only knew of verbal name‑calling reported by R1, with no physical component. The Psychiatric Rehabilitation Social Service Coordinator (V4) documented on 3/16/26 that R1 reported an incident with another resident involving name‑calling and that it had been reported to another social worker, but there was no documentation of a physical altercation or an abuse investigation. The Administrator, who is the abuse coordinator, stated she had no knowledge of staff reporting derogatory remarks, coffee being thrown, or hitting between R1 and R2. The facility’s own abuse policy defines physical abuse as including hitting and verbal abuse as including disparaging and derogatory terms, and requires immediate investigation, identification and interviewing of all involved persons, and thorough documentation when abuse is suspected or reported. Despite this, the repeated episodes of derogatory language, racial slurs, and physical contact between R1 and R2 were not treated as abuse events requiring immediate reporting and investigation. The Administrator acknowledged that hitting another resident or throwing coffee at another resident’s face are acts of physical abuse and that failure of staff to report such incidents prevents the facility from knowing how to prevent recurrence. The lack of timely recognition, reporting, and investigation of these resident‑to‑resident altercations, and the absence of effective interventions to prevent further incidents, constitute the deficiency. A separate deficiency component involves the facility’s handling of resident‑to‑resident abuse between R3 and R4. R3, who was cognitively intact, reported that R4, a former roommate, had been bullying her, following her throughout the facility, and making it uncomfortable for her to remain in their shared room, leading to a room change. Staff, including the PRSC (V5) and an LPN (V17), stated that R4 followed R3 to her new room, insisted she could go into any room she wanted, and continued to bother R3. R3 later reported that while she was in the receptionist area, R4 approached her, made threatening statements, jumped into her face, and pushed her on the left side of her face. The Administrator (V1) stated that R3 came to her office and reported that R4 had pushed her in the face in the receptionist area, and that video footage confirmed R4 pushing R3. Although the facility ultimately reported the incident between R3 and R4 to the state and sent R4 to the hospital for aggressive behavior, the report shows that the facility did not perform individual abuse and aggression assessments for R3 and R4, and the Administrator stated that such assessments were not done and that this information was only included in the care plan. R3’s care plan stated that she would remain safe and free of mistreatment, while R4’s care plan documented a pattern of manipulative behaviors, false claims, verbal aggression, and attempts to cause negative interactions between peers and staff. Despite this known behavioral history, R4 was able to continue following and bullying R3, including entering R3’s new room without authorization and ultimately making physical contact by pushing R3 in the face. The failure to prevent and protect R3 from resident‑to‑resident abuse, in the context of R4’s documented aggressive and manipulative behaviors, further demonstrates the facility’s failure to ensure residents were free from abuse. Across these events involving R1, R2, R3, and R4, the facility did not consistently implement its abuse, neglect, and exploitation policy, which requires immediate investigation of suspected abuse, identification and interviewing of all involved persons, and complete documentation. Staff did not uniformly recognize or report resident‑to‑resident physical contact and derogatory, racially charged language as abuse, and the Administrator was not promptly informed of all incidents. The absence of timely reporting, investigation, and effective interventions allowed repeated altercations between residents, including physical hitting, pushing, and the use of racial slurs and other derogatory remarks, affecting three of three residents reviewed for abuse.
Failure to Report and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that allegations of resident-to-resident abuse were reported and investigated in accordance with facility policy and regulatory requirements. Two cognitively intact residents, R1 and R2, were involved in multiple altercations that included physical contact and derogatory, racially charged language. R1 has diagnoses including unilateral primary bipolar disorder in full remission and generalized anxiety disorder, and R2 has diagnoses including violent bipolar disorder, bipolar disorder, major depressive disorder, schizophrenia, and schizoaffective disorder. Despite these behavioral and psychiatric histories, staff did not consistently recognize or report the incidents as abuse, and the facility’s abuse coordinator (the Administrator) was not made aware of the events at the time they occurred. R1 later reported to the Administrator that there had been two altercations with R2. In one incident near the elevator, R1 admitted to calling R2 derogatory names, including racial slurs, and throwing coffee at R2. R1 stated that R2 then wheeled toward her and punched her in the chest three times, causing a red scratch on her chest. R1 reported that staff, specifically the Activity Director, were present in the dining room near the elevator, intervened by standing between the residents and telling them to stop, and that R1 then left in the elevator. In a separate incident near the bookkeeper’s office and dietary door, R1 stated that R2 told her to move, called her a derogatory name, and hit her across the chest. R1 reported that the Business Office Manager came out, told R2 to stop hitting, and separated the residents. R1 stated she did not sustain injury from that punch and was not afraid of R2, but these events were not reported to the Administrator as abuse at the time. Staff interviews and record review showed additional failures to report and investigate. The Psychiatric Rehabilitation Social Service Coordinator documented that R1 reported an incident involving name-calling with another resident and that it had been reported to another social worker, but there was no indication that this was treated as an abuse allegation or reported to the Administrator. The Business Office Manager recalled hearing R2 call R1 a derogatory name and hearing others say “Don’t hit her,” then learning from R1 that R2 had hit her; she stated she reported this to the Social Service Manager and informed the Administrator the next day in morning meeting, but there is no evidence that an abuse investigation was initiated at that time. The Social Service Manager acknowledged being told of a verbal altercation initiated by R1 but denied being informed of any physical hitting and denied receiving a report from the Business Office Manager about the incident near dietary. R2 confirmed having several altercations with peers, including hitting a female resident at the elevator after coffee was thrown at him and hitting the same resident near the bookkeeper’s office when she would not move, and stated staff were present but did not address the incidents. The facility’s abuse policy requires immediate investigation and thorough documentation when suspicion or reports of abuse occur, but the Administrator, as abuse coordinator, denied knowledge of staff reporting these incidents of physical and verbal abuse until questioned by surveyors, demonstrating that the required reporting and investigative processes were not followed.
Failure to Provide Adequate Supervision Resulting in Resident Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision for a resident, resulting in the resident sustaining a full thickness burn on his left leg with a surface area of 136.90 cm^2. The incident was discovered when a staff member noticed the burn during a routine activity and sent the resident back to his floor. Multiple staff interviews revealed that no one knew how or when the injury occurred, and the resident, who is nonverbal and has severe cognitive impairment, was able to move independently between floors using the elevator without direct supervision. The resident's medical history included deafness, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease, and chronic systolic heart failure. Documentation showed that the resident had severely impaired cognitive skills for daily decision making and memory problems. Despite these vulnerabilities, staff were unclear about the resident's whereabouts and level of supervision at the time of the injury. The wound was described as severe and required specialized wound care. Facility leadership, including the DON and administrator, were not notified of the injury in a timely manner, and no investigation or report to the State was initiated as required by facility policy. The injury was classified as of unknown origin, which should have triggered an abuse investigation and mandatory reporting. Staff interviews confirmed that the resident was not adequately supervised, and the facility failed to follow its own policies regarding accident prevention, supervision, and incident reporting.
Failure to Timely Notify Resident Representative of Injury
Penalty
Summary
The facility failed to notify a resident's representative of an injury of unknown source in a timely manner. On the day of the incident, a staff member observed the resident with a significant burn on his leg and directed him to return upstairs. The agency RN on duty documented the injury in the progress notes but did not contact the family. Interviews with staff confirmed that there was no immediate notification to the resident's family or representative regarding the injury, and review of the electronic health record showed no documentation of family notification at the time of the incident. The resident involved had multiple complex medical diagnoses, including type 2 diabetes mellitus, chronic kidney disease, and congestive heart failure, and was noted to have severely impaired cognitive skills. The wound was later evaluated as a full-thickness burn, and the family was not notified until 13 days after the injury, when consent was needed for a surgical debridement. Facility policy requires prompt notification of a resident's representative in the event of an injury, but this was not followed, as confirmed by staff interviews and record review.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the reporting and investigation of an injury of unknown origin for one resident. On the day of the incident, a staff member observed a significant burn on the resident's leg and sent the resident upstairs, noting that the injury could not have occurred in the patio area. The agency RN who received the resident upstairs cleaned the wound, informed the incoming nurse, and stated she notified the DON before leaving. However, the DON later reported not being notified of the injury and confirmed that no investigation or report to the State was initiated at that time. The resident in question had multiple complex medical diagnoses, including type 2 diabetes, chronic kidney disease, and heart failure, and was cognitively impaired. Documentation showed that the injury was a full-thickness burn of significant size, described as severe by the wound care doctor. The injury was first documented in a progress note as a skin tear, and a subsequent wound evaluation confirmed the extent of the burn. Despite the seriousness of the injury and the facility's policy requiring immediate reporting and investigation of injuries of unknown origin, no such actions were taken until much later. Interviews with facility staff, including the new administrator and DON, revealed a lack of awareness and follow-through regarding the required reporting and investigation procedures. The administrator acknowledged that the injury was not reported or investigated as required by policy and federal regulations. Additionally, an email from the administrator indicated no reportables for injury of unknown origin in the relevant period, further confirming the failure to report this incident. The facility's own policy mandates immediate reporting of such events to the State and other authorities, which was not followed in this case.
Failure to Investigate and Report Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source sustained by a resident, as required by policy and regulation. On the day of the incident, a staff member observed a significant burn on the resident's leg when the resident came to the dining room for a scheduled activity. The staff member immediately sent the resident upstairs and noted that the injury could not have occurred in the patio area. Despite this observation, the staff member was not interviewed about the incident at the time, and no immediate investigation was initiated. A registered nurse on duty at the time recalled seeing the injury when the resident was brought upstairs and provided initial wound care. She reported the injury to the incoming nurse and the DON before leaving her shift. The wound was later evaluated by a wound care physician, who determined it to be a full-thickness burn with severe pain and significant size. Despite the seriousness of the injury and the facility's policy requiring immediate investigation and reporting of injuries of unknown origin, the DON stated she was not notified of the injury and no investigation or report to the State was made at the time. The facility's policy defines injuries of unknown source as potential abuse and mandates immediate investigation and reporting. However, the administrator and DON both confirmed that the injury was not reported or investigated as required. The resident involved had multiple complex medical conditions, including diabetes, heart failure, and chronic kidney disease, and was noted to have severely impaired cognitive skills, making thorough investigation and protection particularly important. Documentation showed that the injury was only reported to the State and investigated after the issue was raised during the survey.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. This deficiency indicates that there was an incident or observation where a resident was not safeguarded from such harm, as required by regulations. Specific details about the actions or inactions leading to the deficiency, or about the residents involved, are not provided in the report.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the optimal well-being of residents as required.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with a history of violent behavior, schizophrenia, and schizoaffective disorder physically attacked another resident in the dining room. The incident occurred when the aggressor confronted the other resident about seating, and after a brief interaction, ran towards the resident and struck them in the face, resulting in both residents falling to the floor. The assaulted resident sustained a bruise over the right eye and required hospital evaluation. Staff members, including an LPN and a CNA, were present in the dining room at the time of the incident but were unable to intervene before the assault occurred. The resident who committed the assault had a documented diagnosis of violent behavior, but staff reported they did not anticipate physical aggression towards others. The facility's abuse prevention policy was in place, but the event still occurred, resulting in physical harm to a resident. The incident was substantiated as abuse by the facility's Director of Nursing. Both residents were sent to the hospital following the event, and the aggressor was not present in the facility at the time of the report.
Failure to Provide Timely, Approved X-Ray Services
Penalty
Summary
The facility failed to provide timely, approved x-ray services or to have an agreement with an approved provider to obtain such services. This deficiency was identified based on the absence of either in-house x-ray capabilities or a documented agreement with an external, approved provider to ensure residents could receive necessary x-ray services as required.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who was at moderate risk for falls and had a history of seizures and cognitive impairment. The resident required substantial to maximal assistance with activities of daily living, was incontinent, and used a wheelchair. The care plan included interventions to anticipate and meet the resident's needs and to monitor for signs and symptoms of tremors, rigidity, dizziness, changes in consciousness, and slurred speech. Despite these documented needs and interventions, the resident was left unsupervised in the dining room during a busy lunch period. On the day of the incident, all four CNAs assigned to the floor were occupied with passing meal trays and feeding other residents in their rooms, leaving the dining room without staff supervision. The nurse supervisor was also engaged in another resident's care and not present in the dining room. The CNA assignment sheet indicated that staff were scheduled to monitor the dining room in 30-minute increments, but at the time of the fall, no staff were present to supervise the residents in the dining room. The staff responsible for monitoring the dining room did not inform anyone before leaving, resulting in a lapse in supervision. As a result, the resident attempted to get up from the wheelchair and fell, sustaining a laceration to the right temple that required sutures. The fall was unwitnessed, and the resident was found on the floor exhibiting seizure-like symptoms. The incident was reported to the state agency, and the resident was transported to the hospital for evaluation and treatment. Facility policies required supervision of residents, especially those at risk for falls and seizures, but these were not followed at the time of the incident.
Failure to Prevent Physical and Verbal Abuse of Residents
Penalty
Summary
The facility failed to protect residents from both physical and verbal abuse, as evidenced by two separate incidents involving residents and staff. In the first incident, a resident with multiple medical conditions, including chronic obstructive pulmonary disease, amputation, and chronic pain, was physically struck in the arm by another resident while in an elevator. The aggressor, who has a history of schizoaffective disorder, violent behavior, and cognitive impairment, admitted to hitting the other resident after a dispute over space in the elevator. This event was corroborated by a third resident who witnessed the altercation and confirmed that the aggressor used a closed fist to strike the victim. Facility staff and documentation confirmed the occurrence of physical abuse. In the second incident, a resident with paraplegia and multiple pressure ulcers was verbally abused by a staff member, specifically a receptionist, during a disagreement in the lobby area. The resident and the staff member exchanged words, and the staff member was reported by two nursing supervisors to have used derogatory and profane language towards the resident, including telling the resident to "shut up" followed by a curse word. Witness statements from both supervisors and facility documentation confirmed the use of abusive language by the staff member towards the resident. Both incidents were substantiated through interviews with the involved parties, witnesses, and review of facility records. The facility's own investigations concluded that abuse had occurred in both cases, with the physical abuse incident involving resident-to-resident aggression and the verbal abuse incident involving a staff member. The facility's policies prohibit such abuse and require the protection of residents from mistreatment by anyone, including staff and other residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely submit an initial abuse report to the state agency within the required two-hour window after an incident involving a resident and a staff member. The incident occurred in the early morning hours when a resident, who is cognitively intact and uses a manual wheelchair, had a verbal altercation with a receptionist. During the disagreement, the staff member directed derogatory and abusive language toward the resident, which was witnessed by multiple staff members, including two LPNs and a CNA. Witness statements confirm that the staff member told the resident to 'shut up b****,' and both parties exchanged curse words. Following the incident, staff attempted to notify the facility's administrator, who serves as the abuse coordinator, but were unable to reach them due to a religious holiday. The staff then attempted to contact the DON, who also missed the initial call. Eventually, the DON was informed of the incident close to 7:00 am, several hours after the event. The preliminary abuse report was submitted to the state agency at 8:33 am, which exceeded the two-hour reporting requirement outlined in both facility policy and state regulations. The resident involved had significant medical conditions, including paraplegia, multiple stage 4 pressure ulcers, chronic osteomyelitis, and other complex diagnoses, but was assessed as cognitively intact. The facility's own abuse prevention policy requires immediate reporting of abuse allegations to the administrator or designated personnel and mandates that such incidents be reported to the state agency within two hours. Despite these requirements, the delay in internal communication and subsequent reporting resulted in noncompliance with regulatory timelines.
Failure to Document and Substantiate Involuntary Transfer and Discharge
Penalty
Summary
The facility failed to meet regulatory requirements for the involuntary transfer and discharge of a resident, as evidenced by two separate petitions for involuntary admission to a hospital that lacked adequate supporting documentation. In the first instance, the petition cited ongoing medication refusals, non-compliance with care, and behavioral concerns such as irritability, agitation, aggression, and emotional distress. However, a review of the resident's records for that day revealed no documentation of these behaviors, aside from a note about medication refusal and the resident's response to education about high blood pressure. Both the social worker and the LPN confirmed that while the resident had a history of non-compliance, there was no documentation of behavioral concerns on the day of the transfer to support the petition. In the second instance, the petition alleged that the resident was physically aggressive, including slamming a laptop against a wall and pushing a door into a nurse. However, there were no notes in the record to support these claims, and interviews with staff revealed inconsistencies regarding the events described. The social worker who signed the petition did not witness the alleged behavior and acknowledged that no one had seen the resident throw the laptop. The nurse involved could not recall if the resident had a laptop, only that the resident used an iPad for communication. These failures resulted in the resident being twice petitioned for involuntary hospital admission without the required documentation or substantiation of the behaviors cited as justification.
Inaccurate and Inconsistent Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and consistent documentation in the medical records of two residents. For one resident with multiple complex diagnoses, there were inconsistencies between the physician's orders, medication administration records (MAR), and controlled substance documentation. Specifically, a nurse reported receiving a verbal order for laboratory blood work but did not enter it as an official order in the electronic record. Additionally, the MAR indicated that Methadone was administered on a day when the resident was out for an appointment, while the controlled substance proof of use form did not reflect administration on that date. The Director of Nursing acknowledged that documentation should have indicated the medication was not given due to the resident's absence, rather than being signed as administered in the facility. For another resident, documentation related to petitions for involuntary or judicial admission to the hospital was inconsistent with the clinical notes. The first petition described behaviors such as medication refusal, non-compliance, irritability, agitation, aggression, and manipulative behavior, but there was no supporting documentation in the resident's notes for the day the petition was filed. The Social Service Director confirmed that while the behaviors were ongoing, there was no specific documentation on the day of the petition to support the claims made. In a second petition for the same resident, the documentation stated that the resident was physically aggressive, including slamming a laptop against a wall and hitting a nurse with a door. However, there were no clinical notes to support these events, and staff interviews revealed uncertainty about whether the resident had a laptop and confirmed that no one witnessed the alleged incident. The Social Worker who completed the petition admitted that the documentation was not based on direct observation.
Failure to Individualize Fall Interventions After Resident Decline
Penalty
Summary
The facility failed to ensure individualized and appropriate fall interventions were identified and implemented for a resident at high risk for falls. The resident, who had diagnoses including chronic obstructive pulmonary disease, schizophrenia, dementia, and exhibited restlessness and agitation, was re-admitted to the facility with a significant decline in function. The resident required substantial maximal staff assistance for walking, transferring, and toileting, and had a history of falls and impaired gait. Despite these risk factors, the resident's fall care plan was not revised or individualized following a significant change assessment, and only standardized interventions were in place. On the evening of the incident, the resident was observed walking unassisted in front of the nursing station, carrying a Foley catheter, when he lost balance and fell, hitting the back of his head. Staff interviews revealed that the resident was considered bedridden and not at risk for falls by some staff, leading to a lack of fall interventions such as non-skid socks or staff assistance when ambulating. There was also confusion among staff regarding the resident's fall risk status and the need for individualized interventions, with one LPN stating they were not informed of the resident's high fall risk and that no interventions were in place because the resident was thought to be bedridden. The facility's policy required that fall risk assessments and individualized interventions be implemented and updated as needed, especially after significant changes in a resident's condition. However, the resident's care plan was not updated to reflect his increased needs and functional decline, and staff were not adequately informed or prepared to provide the necessary supervision and interventions to prevent the fall. The lack of individualized care planning and communication contributed to the resident's unassisted ambulation and subsequent fall.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's medication was administered as ordered by the physician, resulting in significant medication errors. The resident, who is non-verbal and uses a tablet to communicate, reported that they were not provided with their morning medications, including blood pressure medication, on two separate occasions. The resident expressed that they have no issues swallowing whole medications, yet a Licensed Practical Nurse (LPN) attempted to crush the medication, leading to the resident's refusal to take it. The LPN did not notify the physician of the refusal or check the resident's blood pressure, which is consistently high. The LPN admitted to not administering the blood pressure medication on one occasion because the resident requested it after the scheduled time. The LPN acknowledged that they should have contacted the physician to adjust the medication timing. The failure to administer the medication as ordered and the lack of communication with the physician could potentially increase the resident's blood pressure, posing a risk of another stroke. The resident's electronic medical record confirmed that the blood pressure medication was not administered on three specific dates, and there was no documentation of physician notification for the refusals. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both stated that it is expected for nurses to document medication refusals and notify the physician immediately. The DON confirmed that there was no specific order to crush the resident's medication and emphasized the importance of notifying the physician to prevent medical emergencies. The facility's policy on medication administration requires that the physician be notified when medications are not administered as per orders, which was not adhered to in this case.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in a resident's room. A resident, who is aphasic and uses a tablet to communicate, reported seeing roaches in their room, pointing out three dead roaches on the floor and one in a dresser drawer. This resident has a history of hemiplegia, aphasia, and major depressive disorder, among other conditions, and is cognitively intact with a BIMS score of 15. Another resident, with moderate cognitive impairment, reported seeing both live and dead cockroaches daily, although the surveyor did not find any in their bathroom. A third resident, also cognitively intact, mentioned seeing cockroaches in the bathroom, noting a hole in the wall as a possible entry point, but no roaches were observed by the surveyor in their room. The Maintenance Director confirmed responsibility for pest control, stating that pest control services visit weekly, although cockroaches are occasionally seen. The Housekeeping Supervisor and a CNA also acknowledged seeing roaches, with the Housekeeping Supervisor noting a recent sighting and reporting it to the front desk. The Director of Nursing was unsure of the exact frequency of pest control visits. The facility's pest control policy and job descriptions emphasize maintaining a clean and safe environment, yet the presence of cockroaches indicates a lapse in these responsibilities.
Failure to Update Fall Care Plans After Incidents
Penalty
Summary
The facility failed to adhere to its Fall Prevention Program policy by not revising fall care plan interventions after each fall incident for two residents. One resident experienced falls on three separate occasions, yet their care plan, initiated months prior, was not updated to reflect new interventions after these incidents. The care plan history showed that a new intervention was only added weeks later, indicating a lack of timely updates following each fall. Another resident also experienced a fall, but their care plan was not revised until ten days later. Interviews with the Restorative Director and the Director of Nursing confirmed that the facility's protocol requires care plan updates after each fall, based on a root cause analysis. The facility's policy mandates immediate changes in interventions following falls, but this was not followed, leading to the deficiency.
Failure to Follow Fall Prevention Program Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its Fall Prevention Program and a resident's comprehensive care plan, resulting in a fall incident involving a resident (R2). R2, who was assessed as being at moderate risk for falls, required partial to moderate assistance with activities of daily living, including toileting. On the day of the incident, R2 pressed the call light for assistance to go to the washroom but waited over 15 minutes without receiving help. Consequently, R2 attempted to transfer independently to the washroom, where R2 lost balance and fell while trying to stand from the wheelchair. Interviews with staff revealed that the call light was not answered promptly, and R2 was found on the bathroom floor by an LPN. The facility's policy mandates that call lights should be answered within 15 minutes and that residents at risk for falls should not be left alone during toileting. Despite R2's care plan indicating the need for staff assistance, a CNA stated that R2 often performed tasks independently and did not call for help. The incident highlights a lapse in the facility's protocol to provide necessary supervision and assistance to prevent falls.
Inconsistent Restorative Therapy for Resident with Bilateral Amputations
Penalty
Summary
The facility failed to provide consistent restorative therapy to a resident, identified as R10, who has a history of heart failure, peripheral vascular disease, and bilateral below-knee amputations. R10, who is cognitively intact, expressed a preference for speaking in Spanish and reported that he had not received consistent restorative therapy for the past three months. He mentioned that he had only received three therapy sessions, each lasting 15 minutes, during this period. R10 expressed concerns about losing strength and not being able to use his prostheses effectively due to the lack of regular therapy. Observations and interviews with facility staff revealed that the restorative therapy program was not consistently implemented for R10. A Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) confirmed that R10 was alert and oriented, capable of making his needs known, and able to perform transfers independently. However, they could not recall when R10 last participated in restorative therapy. The Restorative Nurse Assistant indicated that restorative therapy sessions were often disrupted due to staff shortages, leading to inconsistent therapy for residents like R10. The facility's documentation showed discrepancies in R10's restorative care plan and assessments. The Restorative Director acknowledged errors in R10's assessments, including incorrect documentation regarding the use of prostheses. The facility's policy required obtaining a physician's order for restorative therapy, but R10's physician order set did not include such an order. The lack of consistent restorative therapy and accurate documentation placed R10 at risk of not maintaining his highest practical level of function.
Inadequate Restorative Staffing Leads to Missed Therapy Sessions
Penalty
Summary
The facility failed to ensure adequate staffing of restorative nurse aides, resulting in a resident missing restorative therapy sessions multiple times over the past 90 days. The resident, who uses a prosthesis, expressed concerns about losing strength and not improving due to the lack of consistent therapy. The resident reported that when other CNAs call off or there is a staffing shortage, restorative aides are pulled to work on the floor, leaving the therapy room closed. This situation was confirmed by the Lead CNA/Staffing Coordinator, who stated that pulling restorative aides to the floor is a last resort when there are call-ins, as it affects the residents' range of motion. The Restorative Director and a Restorative Nurse Assistant both acknowledged that restorative aides are frequently pulled to assist with CNA duties, which disrupts the restorative program. The Restorative Director noted that when aides are pulled, residents do not receive the necessary exercise to maintain their maximum capacity. The Restorative Nurse Assistant mentioned being behind on tasks due to illness and the closure of the facility's gym. The facility's nursing schedule and restorative staff time sheets corroborated the shortage of restorative aides, with only one aide working on specific dates. The resident's Minimum Data Set indicated cognitive intactness, and records showed several undocumented days for walking and active range of motion tasks.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R4, from physical abuse by staff, resulting in harm. R4, who has a severely impaired cognitive status with a BIMS score of 3, was found to have a large bruise on her right thigh, which was diagnosed as a hematoma. The resident's medical history includes conditions such as hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and major depressive disorder. The incident was reported by R4's family member, who noticed the bruise and suspected abuse, leading to R4 being sent to the hospital for further evaluation. Interviews with staff revealed that R4 was often combative during care, requiring two staff members to manage her, with one holding her down while the other provided care. This practice was confirmed by multiple staff members, including CNAs and LPNs, who noted R4's resistance and the need to restrain her legs to prevent kicking. Despite R4's verbal protests during care, staff continued to provide care without documenting refusal, contrary to the facility's policy. The facility's policies emphasize the residents' right to be free from abuse and mistreatment, and the Director of Nursing acknowledged that holding a resident down would be considered abuse. The facility's abuse prevention policy outlines the need for a resident-sensitive environment and proper training for staff to handle difficult situations. However, the actions taken by the staff in R4's case were inconsistent with these policies, leading to the deficiency noted in the report.
Inadequate Supervision Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to follow the Care Plan and provide adequate supervision to a resident assessed as a high fall risk, resulting in multiple falls and injuries. The resident, who has a severely impaired cognitive status and requires substantial assistance for mobility, experienced falls on several occasions, including two significant incidents that required hospitalization. The resident's Care Plan indicated the need for one-on-one monitoring due to poor safety awareness and impulsive behavior, but this was not consistently implemented. Interviews with staff revealed that the resident was not receiving the required one-on-one monitoring at the time of the falls. The Director of Nursing acknowledged staffing issues as a reason for the lack of one-on-one monitoring, which was a critical intervention outlined in the resident's Care Plan. Despite the resident's high fall risk and history of falls, the facility did not ensure the necessary supervision to prevent further incidents. The facility's policies on fall prevention and comprehensive care planning emphasize the importance of assessing fall risks and implementing appropriate interventions. However, the failure to adhere to these policies and the resident's Care Plan resulted in serious injuries, including a head laceration requiring staples. The lack of adequate supervision and monitoring contributed to the resident's repeated falls, highlighting a deficiency in the facility's care practices.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication to a resident diagnosed with schizoaffective disorder bipolar, violent behavior, generalized anxiety disorder, and paranoid schizophrenia. The resident, identified as R2, had a documented refusal of psychotropic medication consent dated nearly a year prior, yet continued to receive Fluphenazine Decanoate injections over several months. Despite the resident's refusal to sign the psychotropic consent, the Assistant Director of Nursing claimed that verbal consent was given, although no documentation was provided to support this claim. The Director of Nursing acknowledged that consent should be obtained before administering psychotropic medication and affirmed the resident's right to refuse medication. The facility's policy on psychotropic medication consent requires either signed or verbal consent, with verbal consent needing to be witnessed by two staff members. However, in this case, there was no evidence of such consent being documented or witnessed, leading to the deficiency in ensuring informed consent was obtained prior to medication administration.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R4, to the state survey agency. R4, who has a severely impaired cognition with a BIMS score of 3, was found to have a bruise on her right thigh by a CNA on the morning of 11/10/24. The CNA initially forgot to report the bruise but did so later in the afternoon. Despite this, the Director of Nursing (DON) and the administrator did not report the incident to the state survey agency, as the administrator did not believe the bruise was a result of abuse. R4's daughter expressed concerns about potential abuse, leading to R4 being sent to the hospital, where elder abuse and a hematoma were diagnosed. The facility's policy requires immediate reporting of any suspicion of abuse to the administrator and the state survey agency within two hours if it involves serious bodily injury. However, the facility's preliminary incident investigation report was not completed until 11/19/24, nine days after the bruise was discovered. The facility's documentation indicated that the DON did not find the bruising concerning, despite the daughter's insistence on hospital evaluation. This inaction and delay in reporting violated the facility's abuse prevention policy and state reporting requirements.
Failure to Investigate Allegation of Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an allegation of injury of unknown origin, affecting one resident. The incident involved a resident who had a large bruise on her right thigh, which was reported by her daughter, who expressed concerns about potential elder abuse. The resident's hospital report documented a diagnosis of elder abuse and hematoma. Despite these concerns, the Director of Nursing (DON) did not investigate the bruise, as she was not present at the facility when it was reported and did not see the bruise before the resident was sent to the hospital. The Administrator also did not investigate the allegation, attributing the bruise to the resident's known behavior of thrashing during care. The facility's policy on abuse prevention requires prompt and aggressive investigation of all reports and allegations of abuse, neglect, and mistreatment. However, in this case, the policy was not followed. The DON and Administrator failed to initiate an investigation into the injury, despite the policy's stipulation that any incident involving abuse or injury of unknown origin should be investigated. The facility's failure to adhere to its own policy resulted in a lack of investigation into the resident's injury, which was classified as suspicious due to its location and the circumstances under which it was discovered.
Inaccurate Fall Assessments for Resident
Penalty
Summary
The facility failed to accurately complete fall assessments for a resident, identified as R1, which has the potential to affect the resident's safety and care. On 10/12/24, R1 was found on the floor with a laceration on the back of the head and was subsequently transferred to the hospital for treatment. The fall risk assessment conducted on 10/13/24 did not accurately reflect R1's mobility status, as it failed to note that R1 uses furniture for support. Additionally, the post-fall observation inaccurately documented R1 as independent with or without a device, despite the Minimum Data Set indicating that R1 requires substantial assistance for mobility tasks. R1's medical history includes severe cognitive impairment, unsteadiness on feet, and multiple diagnoses such as chronic obstructive pulmonary disease and schizoaffective disorder. The care plan indicates that R1 is at risk for falls due to weakness and requires extensive assistance for transfers and mobility. Despite these needs, R1 experienced six falls within the past year, highlighting discrepancies in the fall assessments and the care provided. The facility's policy mandates accurate assessments and individualized fall prevention measures, which were not adhered to in this case.
Failure to Supervise Resident with Dementia Leads to Unsupervised Departure
Penalty
Summary
The facility failed to provide adequate supervision and follow their policy regarding pass privileges for a resident diagnosed with vascular dementia and other cognitive impairments. The resident, who was moderately cognitively impaired, signed himself out of the facility without a physician pass privilege order in place. This incident occurred after a room change, and the resident left the facility unaccompanied, later getting lost in the community. The resident was eventually returned to the facility via transportation arranged by the night shift receptionist. Interviews with staff revealed a lack of communication and oversight regarding the resident's whereabouts and pass privileges. The Licensed Practical Nurse on duty did not recall being informed of the resident's intention to leave, and the Director of Nursing confirmed that no pass privilege order was in place. The Social Services Director assumed the order was being handled by another staff member. The resident's care plan indicated a need for supervision due to cognitive impairment, but this was not adequately followed, leading to the resident's unsupervised departure and subsequent distress.
Failure to Document Resident's Personal Belongings
Penalty
Summary
The facility failed to properly document a resident's personal belongings upon admission, leading to the resident's clothes going missing. The resident, who has diagnoses including morbid obesity, cerebral palsy, and reduced mobility, reported missing clothes and observed other residents wearing them. Despite raising the issue in resident council meetings, no action was taken. The facility's policy requires CNAs to inventory and label residents' belongings upon admission, but this was not done for the resident in question. Interviews revealed that the laundry department does not keep an inventory of residents' personal items, and misplaced clothes are only returned if labeled. The Director of Nursing confirmed the absence of an initial inventory list for the resident, with the only list dated months after admission. The facility's policy mandates that an inventory list be completed and uploaded to the resident's medical chart, which was not adhered to in this case. Complaints about missing clothes were also documented in resident council meeting minutes.
Failure to Schedule Surgery and Ensure Doctor's Appointments
Penalty
Summary
The facility failed to ensure that a cataract surgery was scheduled for a resident, resulting in the resident experiencing continued visual difficulties. The resident, who is cognitively intact, had been waiting for almost six months for the surgery and reported difficulties with reading and watching television due to the cataracts. The Director of Nursing acknowledged that the facility did not follow up with the ophthalmology office to confirm the surgery date, despite having received an order for an ophthalmology consult and findings of cataracts documented in the resident's records. Additionally, the facility failed to ensure that two other residents attended their scheduled doctor's appointments. One resident missed an orthopedic follow-up appointment because the facility did not provide an escort, which is their responsibility. Another resident missed several consultation appointments due to transportation issues. The facility's policy requires charge nurses to follow up with residents' physicians to ensure appointments are scheduled as per physician orders, but this was not adhered to, leading to missed appointments and necessary care not being provided.
Failure to Document Psychotropic Medication Administration
Penalty
Summary
The facility failed to properly document the administration of a psychotropic medication, Lorazepam, for a resident with a history of generalized anxiety disorder, PTSD, primary insomnia, and other conditions. The resident, who is cognitively intact, reported receiving Lorazepam on three occasions without requesting it and noted a discrepancy in the administration record for a dose supposedly given at 1:00 AM, which she did not recall receiving. The controlled substance accountability record indicated administration on specific dates, but these were not reflected in the Medication Administration Record (MAR). Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) revealed lapses in documentation. The DON confirmed that all medications should be signed off in the MAR to prevent errors and account for controlled substances. However, the LPNs involved admitted to either forgetting to document the administration or not recalling administering the medication. The facility's policies require that narcotics be signed out in both the electronic health record and the narcotic sheet, which was not adhered to in this case.
Failure to Implement Policy on Resident Strip Searches
Penalty
Summary
The facility failed to develop and implement a policy addressing strip/body searches of residents, which led to two residents feeling humiliated and violated. Resident R13, a cognitively intact individual with a BIMS score of 15, reported being subjected to a strip search approximately 1.5 months prior due to a missing credit card belonging to his former roommate. The search was conducted in the office of the Psychiatric Rehabilitation Services Coordinator (V25) with the Restorative Director (V24) present. R13 was coerced into compliance under the threat of contacting his parole officer, leading to feelings of humiliation and shame. Similarly, Resident R4, also cognitively intact with a BIMS score of 15, experienced a strip search upon returning to the facility. Initially, R4 refused a purse search at the front desk but was later subjected to a strip search by the Social Service Director (V4) and the Restorative Nurse (V24) in V4's office. R4 described the search as invasive and felt violated. Despite the facility's policy on routine resident checks and safety room checks, it did not address strip searches, leading to these incidents where no contraband was found.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct appropriate interviews following an alleged incident of abuse involving a resident and a staff member. The incident occurred when a dietary aide, who was transporting a food cart, and a resident were in an elevator together. The resident reportedly pushed the food cart out of the elevator, causing the dietary aide to exit as well. Despite the incident being reported by a patient escort to the Director of Nursing (DON) and the overnight supervisor, no formal investigation or interviews were conducted with the involved parties, including the resident, dietary aide, and witnesses. The report highlights that the facility's Director of Nursing and Administrator did not take the necessary steps to investigate the incident thoroughly. The DON acknowledged that she did not document her conversation with the resident and did not pursue further investigation, citing the information as hearsay. The Administrator, who is also the abuse coordinator, did not initiate an investigation, assuming that nursing or social services were handling the situation. This lack of action resulted in a failure to gather all sides of the story and understand the full context of the incident. The facility's policy requires immediate reporting and investigation of all incidents or allegations of abuse, neglect, or mistreatment. However, in this case, the policy was not followed, as the incident was not reported to the Illinois Department of Public Health (IDPH), and no comprehensive investigation was conducted. The failure to adhere to the policy and conduct a proper investigation represents a deficiency in the facility's response to alleged abuse incidents.
Failure to Implement Care Plan for Resident with Substance Abuse
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a history of opioid dependence, who tested positive for illegal drug use. The resident, who is cognitively intact, was admitted with multiple diagnoses including opioid dependence. Despite testing positive for cocaine, marijuana, and methadone, there was no care plan addressing the resident's illegal drug use. The facility's policy requires comprehensive care plans to be developed using the results of a comprehensive assessment, including measurable objectives and timetables to meet all resident needs. The resident's care plan was not updated to reflect the current needs after the resident moved floors and tested positive for illegal substances. The facility's policy mandates that care plans be reviewed and revised as necessary after each MDS assessment and quarterly. However, the interdisciplinary team did not update the care plan to address the resident's substance abuse issues, leading to a deficiency in meeting the resident's care needs.
Delay in Scheduling Biopsy for Resident
Penalty
Summary
The facility failed to provide timely medical care for a resident, R5, who required a tongue biopsy as ordered by an ENT doctor on April 15. Despite multiple attempts by the patient escort, V3, to bring the necessary paperwork from the hospital to the facility, the biopsy was not scheduled. The ENT doctor and the oncology doctor were both awaiting the biopsy results to proceed with further treatment. The transportation scheduler, V15, acknowledged the delay, stating that the hospital required the ordering doctor to schedule the biopsy, and this information was relayed to a nurse on the fourth floor. However, no follow-up was conducted to ensure the biopsy was scheduled. The Director of Nursing, V2, was aware of the situation and had inquired about the status of R5's appointments. Despite efforts to schedule follow-up appointments with the ENT doctor, the biopsy had not been completed by the time of the report. The facility's policy indicated that the charge nurse or designee was responsible for scheduling appointments, but there was a lack of coordination and communication between the nursing staff and the scheduler, leading to the delay. The biopsy was crucial for diagnosing potential cancerous lesions, as indicated in the hospital discharge paperwork. The report highlights the breakdown in communication and responsibility within the facility's staff, which resulted in a significant delay in obtaining necessary medical care for R5. The ENT doctor had recommended immediate action, but the facility's failure to follow through on scheduling the biopsy left the resident without a critical diagnosis for several months. This deficiency in care was identified during a survey, emphasizing the need for improved processes in managing resident appointments and follow-ups.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse policy procedures by not reporting an incident of abuse to the Illinois Department of Public Health (IDPH) within the required timeframe. The incident involved two residents, where one resident pushed another during a verbal altercation, causing the latter to fall. The initial incident report did not include the actual time of occurrence, only stating it happened in the evening. The facility reported the incident to IDPH the following day, which was not within the regulatory requirement of reporting within two hours. Additionally, the final report was submitted eight days after the incident, exceeding the five-business-day requirement. The facility's administrator, who was not employed at the time of the incident, confirmed the late reporting upon reviewing the reports. The facility's abuse policy mandates immediate reporting to the state licensing agency after assessing the resident and removing the alleged perpetrator, including the time and date of the incident. The policy also requires a complete written report of the investigation's conclusion within five days, which was not adhered to in this case.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to accommodate the needs of residents by not ensuring that call lights were within reach for two residents, R2 and R3. R2, who has a medical history including bipolar disorder and moderate cognitive impairment, was observed in bed unable to reach his call light, which was hanging behind the bed and touching the floor. R2 expressed that he was experiencing a stomachache but did not call the nurse because he could not locate his call light. Similarly, R3, who has intact cognition but is dependent on staff for various transfers and is frequently incontinent, was unable to find his call light after a bowel movement. The call light was tangled with bed remote wires and out of reach. Staff interviews confirmed the expectation that call lights should be within reach of residents to ensure they can contact staff in case of emergencies. A Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant, and the Director of Nursing all acknowledged that call lights should be accessible to residents. The facility's policy also states that call lights should be within reach when residents are in bed or confined to a wheelchair. Despite this policy, the observations and interviews revealed that the facility did not adhere to these standards, resulting in the deficiency.
Failure to Document Post-Surgical Wound Assessments
Penalty
Summary
The facility failed to adhere to professional standards of practice and its own policy regarding the documentation of post-surgical wound assessments for two residents. One resident, R5, reported that after their stitches were removed by a spine surgeon, no further assessments of their surgical wound were conducted by the nursing staff, which was confirmed by the surgeon's dissatisfaction. Observations revealed that R5's wound was well-approximated and healed, but there was a lack of documented assessments following the initial evaluation upon admission. Interviews with staff, including an LPN and the Wound Director, revealed a misunderstanding of responsibilities regarding surgical wound monitoring. The Wound Director stated that floor nurses should monitor surgical wounds and report concerns, but there was no 'monitor wound order' entered for R5. The Director of Nursing confirmed that documentation was insufficient, with only two notes found in R5's record, neither of which included a wound assessment. The facility's Wound Management Policy emphasized the need for documentation of wound care activities, which was not followed in this case.
Delayed Therapy Services for Residents with Medicaid
Penalty
Summary
The facility failed to provide timely therapy services and adhere to its policy for two residents, R1 and R5, out of a sample of 15. For R1, orders for physical, occupational, and speech therapy were placed on 5/7/2024, but there was a significant delay in initiating occupational therapy, which only began on 6/17/2024. The Director of Rehabilitation Services, V21, stated that the delay was due to the facility's process of obtaining approvals based on the resident's insurance type, particularly for Medicaid patients. R1 expressed dissatisfaction with the delay, stating that she could have sought therapy elsewhere had she been informed. For R5, therapy orders were placed on 6/6/2024, but the physical therapy evaluation was not completed until 6/19/2024. The delay was attributed to a new requirement for administrative approval for Medicaid patients, which was implemented on 6/7/2024. R5 reported feeling neglected during the initial week of her stay, as no therapy services were provided until after a friend intervened. The facility's policy required therapy assessments within 48 hours of referral, which was not met in these cases. The facility's policies and procedures for therapy services were not followed, leading to delays in therapy initiation for residents with Medicaid. The Director of Restorative Nursing, V12, noted that prior to V21's tenure, all residents were evaluated upon admission regardless of insurance, but changes in the process have led to inconsistencies. The facility's failure to adhere to its own policies and the lack of communication between departments contributed to the deficiencies observed.
Failure to Provide Proper Notice for Involuntary Discharge
Penalty
Summary
The facility failed to provide proper notice requirements to a resident who was involuntarily transferred to the hospital. The resident, who has a medical history of opioid dependence and mental and behavioral disorders, was initially admitted to the facility in October 2023. On June 3, 2024, the resident was involuntarily discharged to the hospital after becoming verbally aggressive towards the Social Service Director when informed that their community pass was revoked due to non-compliance with the facility's substance abuse policy. Despite the aggressive behavior and the subsequent transfer, the facility did not document that the resident was notified of the reason for the transfer or discharge, nor was there documentation of a 30-day notice being given as required by the facility's policy. The report highlights that the facility's Social Worker and Social Service Director acknowledged the lack of documentation regarding the notice given to the resident. The facility's policy on involuntary discharge requires that a 30-day notice be provided to the resident, along with the reason for the notice, and that public health authorities be informed via certified mail. However, the resident's progress notes for April, May, and June 2024 did not contain any documentation of such notifications for both the April 9, 2024, and June 3, 2024, involuntary discharges. This oversight affected the resident's right to be informed or notified of the reasons for their transfer or discharge.
Failure to Provide Bed Reserve Notification During Involuntary Transfer
Penalty
Summary
The facility failed to provide a Bed Reserve Notification to a resident (R1) during an involuntary transfer to a hospital, as required by their policy. R1, who has a medical history of opioid dependence and mental and behavioral disorders, was involuntarily discharged on 6/3/2024 after exhibiting aggressive behavior towards the Social Service Director (V4) when informed that his community pass was revoked. This incident was not the first, as R1 had a previous involuntary discharge in April of the same year. The facility's policy mandates that a Bed Reserve Notification be given to residents at the time of transfer, but this was not documented or provided to R1. Interviews with facility staff, including the Social Worker (V5) and the Social Service Director (V4), revealed that R1 was not informed about the bed hold policy, which allows a 10-day period for the resident to return to the facility. The facility's policy on Bed Reserve, dated 2008, and the Notice of Bed Hold and Return, dated 11/20/2017, both require that residents be given written notice of the bed hold policy at the time of transfer. However, there was no documentation in R1's progress notes for April, May, and June 2024 indicating that such notice was provided, leading to a deficiency in the facility's adherence to its own policies and federal regulations.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating their own bed-hold policy. The resident, who had a history of opioid dependence and mental and behavioral disorders, was initially admitted to the facility in October 2023. On June 3, 2024, the resident was involuntarily discharged to a hospital following an incident where they became verbally aggressive and threatening towards the Social Service Director after being informed that their community pass was revoked due to non-compliance with the facility's substance abuse policy. The facility's Social Worker and Social Service Director noted that the resident had a history of aggression and had previously been involuntarily discharged in April 2024. The facility's policy on involuntary discharge was not properly followed, as there was no documentation of notice given to the resident or the reason for the notice. The facility's Admission Director was informed by the hospital that the resident was returning, but the Director of Nursing and Social Service Director instructed that the resident should not be accepted back due to the involuntary discharge. The facility's Administrator stated that the decision not to accept the resident back was based on advice from the facility's attorney, following the incident on June 3, 2024. The facility's policy on bed-hold and return, which allows residents to return after hospitalization if their stay exceeds the bed-hold period, was not adhered to. The facility did not coordinate with the hospital to assess the resident's status post-hospitalization, and the resident's right to return was not honored.
Failure to Administer Medications and Document Physician Coordination
Penalty
Summary
The facility failed to document physician coordination for medications not received by a resident, and also failed to administer insulin as ordered by the physician for one resident. This resident, who has a history of stroke and diabetes mellitus, was observed to have swelling in the left foot and expressed concerns about not receiving medication. A review of the resident's medication administration records (MAR) for April, May, and June 2024 showed multiple instances where medications for diabetes and hypertension were not given, with reasons such as drug refusal, medication hold, or no documentation provided. The resident's blood pressure and blood sugar levels were not controlled, with systolic blood pressure reaching as high as 200 and blood sugar levels as high as 268. The MAR and progress notes indicated that on May 23, 2024, Humalog insulin was held by a nurse despite the physician's order to hold only if blood sugar was less than 100. The MAR for June 2024 showed that the resident did not receive the prescribed insulin on most days. The Director of Nursing (V2) was informed of these issues and acknowledged the need for physician notification when medication is refused. However, it was unclear if the physician was notified in this case. The facility's MAR policy requires physician notification and documentation in the Nurse's Notes when a resident refuses medication, but this was not consistently followed for the resident in question.
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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.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Selfhelp Home Of Chicago | 0.2 mi | — | 0 | 0 |
| Admiral At The Lake, The | 0.3 mi | — | 0 | 0 |
| Alden Lakeland Rehab & Hcc | 0.4 mi | — | 13 | 1 |
| Mado Healthcare - Uptown | 0.5 mi | — | 0 | 0 |
| Aperion Care Wesley | 0.6 mi | — | 3 | 0 |
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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.