Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
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 Hillcrest Retirement Village during CMS and state inspections, most recent first.
A resident reported that a CNA used a condescending tone of voice while providing care, which the resident perceived as discourteous. The administrator confirmed the resident’s complaint and documentation showed the CNA had previously received a disciplinary warning for discourteous behavior toward the resident. This reflects a failure to provide care and communication that support the resident’s dignity and right to a respectful, dignified existence.
A resident with dementia, depression, hallucinations, CKD, and multiple other comorbidities experienced a fall associated with catheter removal, but staff failed to document the fall event itself, including date, time, and location, in the EMR or risk management system. Although the resident’s care plan already identified a high fall risk related to hallucinations, psychotropic use, and self-lowering behaviors, it was not reviewed or revised after the fall. An LPN described the expected process for post-fall assessment and incident reporting, and the DON stated that care plans are to be updated after falls and that she is responsible for those updates, but she was unaware the fall had occurred. The facility’s fall policy requires incident documentation and immediate interventions for witnessed and unwitnessed falls, which were not completed in this case.
Surveyors found that kitchen staff did not maintain quaternary ammonium (quat) sanitizing solution at the required 200–400 ppm concentration or change it every 2 hours as required by facility policy, with test strips repeatedly reading 0 ppm despite staff acknowledging it should be effective for sanitizing food prep areas. During the same kitchen tour, surveyors observed a bag of hot dog buns on the bread cart that was dated beyond the facility’s 6‑day discard timeframe, contrary to the facility’s labeling and dating policy intended to control foodborne illness for all residents.
Surveyors found that multiple residents with G-tubes, indwelling urinary catheters, and chronic wounds had active orders for Enhanced Barrier Precautions (EBP), but their rooms lacked EBP signage and PPE availability at the doorway. One resident receiving enteral nutrition via gastrostomy tube, another with a long-term urinary catheter, and a third with a stage 4 pressure wound all had no posted EBP indicators or PPE outside their rooms. Additional residents sharing a room, one with G-tube bolus feedings and another with sacral wound treatments, also had no EBP signs posted. The facility’s infection prevention nurse and written EBP policy both specified that residents with these devices and chronic wounds should be on EBP and clearly identifiable as such.
A resident repeatedly reported feeling uncomfortable and upset due to her roommate’s jealous and inappropriate behaviors, especially when she had visitors, and stated she did not want to return to her room. Observations showed the roommate crying, calling out for the resident, and hovering over her while the resident attempted to rest, without staff intervention or redirection. The resident’s spouse reported that these behaviors were significantly affecting his wife, including multiple distressed phone calls, and voiced concerns to the DON and social services, who were aware of the situation but had only discussed, not implemented, a room change or other boundaries.
A resident with severe cognitive impairment and limited physical mobility, who required substantial/maximal assistance with personal hygiene per the MDS and care plan, was observed in a common area with prominent whiskers on her chin. CNAs and the Administrator stated that residents receive showers at least twice weekly and that shaving is included on shower days for both men and women. Despite a facility policy requiring staff to assist with grooming facial hair to maintain proper hygiene, the resident did not receive appropriate shaving assistance, resulting in visible facial hair.
Two residents at risk for pressure injuries did not receive ordered pressure-relieving interventions. One resident had an order for an air mattress to be on at all times, but surveyors twice observed the resident in bed with the air mattress pump unplugged and off, despite documentation of pressure-injury risk and a care plan listing an air mattress as an intervention. Another resident, dependent on staff for care and identified as at risk for pressure, was transferred to bed and provided incontinence care by CNAs without application of ordered protective boots, even though a sign above the bed and the care plan directed that cradle/protective boots be on at all times in bed. The facility’s pressure injury policy requires implementation of interventions for all residents assessed as at risk.
A resident with an indwelling urinary catheter and a history of frequent UTIs was observed in a wheelchair with a leg drainage bag attached high on the thigh, positioned above bladder level and without slack in the tubing, preventing gravity-assisted drainage. A CNA acknowledged that catheter drainage bags should be kept below the waist to prevent UTIs/infections. The resident’s care plan and the facility’s catheter care policy both required that the catheter drainage bag and tubing be maintained below the level of the bladder to discourage backflow of urine, but this was not followed.
A resident with moderate dementia and anxiety exhibited escalating behaviors including yelling, crying, delusions, pacing, and intense preoccupation with a roommate, yet staff did not consistently intervene or document specific behavioral interventions during observed episodes. On one day, the resident loudly yelled and became agitated after a CNA delivered a meal tray; an RN attempted redirection but the resident remained distressed, and later that day two CNAs provided care to the roommate while the resident continued crying and calling out without staff engagement. Staff interviews and social services notes confirmed ongoing anxiety, hallucinations, and obsessive focus on the roommate, with acknowledged increases in behaviors after an antidepressant dose reduction, but progress notes lacked documentation of the observed behavioral incidents or targeted interventions, contrary to the facility’s dementia care policy requiring person-centered, non-pharmacological approaches and individualized care plan implementation.
A resident with COPD, whose principal diagnosis was COPD, had an order for an ipratropium-albuterol inhaler to be given four times daily, but two scheduled doses were not administered when the inhaler was not available at the time of medication pass. The MAR documented the missed doses and referenced notes indicating the medication was unavailable, and the resident reported missing two doses of the inhaler. An LPN later stated the inhaler was not in the med cart when she attempted to give it and was later found at the end of the resident’s bed, although it should have been stored in the cart. The DON confirmed the inhaler had been misplaced, despite the care plan and facility policy requiring medications to be administered as ordered.
Surveyors found that controlled medications and insulin were not managed according to facility policy. In one medication room, an LPN left the medication refrigerator unlocked while it contained a new box of Methadone Oral Concentrate, a Schedule II controlled substance, despite facility policy requiring locked storage. In a separate case, a resident with diabetes had a Humalog KwikPen labeled with an expiration date that had already passed, and an RN acknowledged it should have been discarded, while the facility’s insulin pen policy required disposal after 28 days.
A resident with documented oral/dental health problems did not receive routine or preventative dental care during more than two years in the facility. The resident’s spouse reported that no dental services had been provided and that he was only notified in writing much later that a dentist could see the resident if she was enrolled in a dental program. The Administrator confirmed the resident had never seen a dentist there and explained that, although eligible, she was not enrolled in the dental program. The DON stated there was no dental policy in place and acknowledged the resident was not offered enrollment in the dental plan at admission, noting she was Medicaid pending and was not informed about the program after Medicaid coverage began.
A resident with mobility issues and requiring mechanical lift assistance was found with a displaced left hip fracture after being put to bed early due to not feeling well. Despite staff reports of no falls or complaints of pain, the resident was discovered in pain with a hip deformity and cheek redness, suggesting a fall. The facility's investigation classified the injury as of unknown origin, highlighting a deficiency in supervision and monitoring.
A facility failed to supervise residents with a history of falls, resulting in injuries. One resident sustained a hip fracture due to lack of close supervision, while another suffered a head wound from improper transfer by a single CNA, against policy. A third resident's care plan was not updated after multiple falls, violating the facility's policy on monitoring and modification.
A facility failed to properly sanitize a blender pitcher used for pureed diets, affecting four residents. The dietary staff did not ensure the presence of sanitizer in the three-compartment sink, compromising the sanitization process. The dietary director confirmed the absence of sanitizer and corrected the issue, but not before the blender was used for meal preparation.
The facility failed to implement enhanced barrier precautions (EBP) for six residents with specific medical needs, such as urinary catheters, a urostomy, wounds, and a PEG tube. Observations revealed the absence of EBP signage and PPE stations outside residents' rooms. The Infection Control Nurse was unaware of the mandatory nature of EBP and admitted the facility lacked a policy on it.
A resident with psoriatic arthritis and other health issues was not provided with a necessary rheumatology consultation after her initial appointment was canceled due to insurance issues. Despite being in pain and expressing a desire to see a specialist, the facility did not reschedule the appointment, as confirmed by the DON.
Failure to Ensure Respectful and Dignified Communication During Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to a dignified existence, self-determination, communication, and exercise of rights. On 02/17/2026 at 9:50 AM, R1 was observed sitting in her room in an overstuffed reclining chair. Earlier that morning, at 9:31 AM, the Administrator (V1) stated that R1 reported disliking the tone of voice used by a CNA (V3) during care, describing it as condescending. R1 communicated this concern to the Administrator. Record review showed that V3 had received a Disciplinary Warning Notice dated 01/14/2026 for “discourteous behaviors to resident,” confirming that the CNA’s manner of interaction with R1 had been identified as inappropriate. This conduct reflects a failure to provide care and communication that support the resident’s dignity and quality of life.
Failure to Document Fall and Update Care Plan After Incident
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall and to update the resident’s care plan following that fall. Progress notes for the resident showed entries on one day indicating that the resident’s catheter had been dislodged and reinserted in the morning, and later that the catheter was removed during a recent fall, with another note stating the catheter was removed during a fall that evening. However, there was no documentation in the progress notes of the date, time, location, or any additional information related to the fall itself. The DON later confirmed that the nurse did not enter a note in the facility’s risk management system or any incident note in the electronic medical record about the fall, and that she was not aware the fall had occurred. The resident’s care plan, dated prior to the fall, identified the resident as being at risk for falls related to hallucinations, antidepressant use, and behaviors such as intentionally sliding out of a wheelchair to the floor when up longer than desired. Despite this identified fall risk and the documented references to a fall in the catheter-related notes, the care plan was not reviewed or revised after the fall. The DON stated that care plans are to be updated after a fall and that she is responsible for updating them, but acknowledged that the resident’s care plan was not updated because she was unaware of the fall. The facility’s fall policy requires the nurse to complete risk management documentation for witnessed or unwitnessed falls and to complete an incident note under progress notes at the time of the incident, as well as to initiate interventions immediately based on the resident’s specific needs, which did not occur in this case.
Improper Sanitizer Concentration and Failure to Discard Expired Bread
Penalty
Summary
Surveyors identified that the facility failed to maintain appropriate sanitizing solution levels for food contact surfaces in the kitchen. During an observation, the dietary manager tested the quaternary ammonium (quat) sanitizing solution in a bucket and the test strip registered a light orange color corresponding to a 0 ppm level, both after 10 seconds and again after approximately 20–30 seconds. The dietary manager stated the solution should be between 200–400 ppm and that the strip should turn dark blue to be effective for sanitizing food preparation areas. The dietary manager also stated the sanitizing solution was only effective for 2 hours and needed to be replaced. A dietary aide later reported that the sanitizing solution had been mixed at 6:00 AM and should have been replaced at 8:00 AM to remain effective, indicating it had not been changed in accordance with facility policy. Surveyors also found that the facility failed to discard expired bread products in the kitchen. During a kitchen tour, a bag of hot dog buns on the bread cart was observed with a date of 8/8/25. The dietary manager stated that all bread products were dated on the day of delivery and were to be discarded within six days, confirming that the buns should have been discarded by 8/15/25. The facility’s policies on manual sanitizing and on labeling and dating of foods documented that quat sanitizing solution must be maintained at 200–400 ppm and changed every 2 hours, and that food must be labeled with dates received, opened, and discard dates to decrease the risk of foodborne illness and provide the highest quality food. At the time of the survey, the CMS-671 form documented 126 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions for Residents With Devices and Wounds
Penalty
Summary
Surveyors identified a failure to implement the facility’s Enhanced Barrier Precautions (EBP) policy for multiple residents who met criteria for these precautions. For one resident with a gastrostomy tube receiving enteral nutrition, there was a current physician order for EBP, but no EBP signage was posted on or near the room entrance and no PPE was available outside the room. Another resident with an indwelling urinary catheter in place for at least three months had current orders for EBP and for monthly catheter changes, yet the room lacked EBP signage and PPE outside the door. A third resident with a stage 4 pressure wound on the left lateral knee, receiving wound treatment and with a current EBP order, also had no EBP sign posted and no PPE located outside the room. Additional residents with qualifying conditions similarly did not have EBP implemented as required. One resident with an indwelling urinary catheter, whose drainage bag was changed to a leg bag during the day and who had current orders for EBP and monthly catheter changes, had no EBP signage or PPE outside the room. Two other residents sharing a room, one with orders for G-tube maintenance and bolus tube feeding and the other with orders for sacral wound treatments and dressings, had no EBP signs posted on or around their shared room. The facility’s own EBP policy stated that residents with medical devices such as catheters and feeding tubes, and residents with chronic wounds, must be on EBP precautions and that residents on EBP isolation must be identifiable as being on that status. The Infection Prevention Nurse confirmed that residents with chronic wounds, G-tubes, or indwelling urinary catheters should be on EBP.
Failure to Accommodate Resident’s Needs and Preferences Regarding Roommate Behaviors
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences regarding her roommate’s behaviors. During an initial tour, one resident in a wheelchair reported she was having problems with her roommate, stating the roommate became jealous when she had visitors and made inappropriate comments, leading her to say she did not want to return to her room. Later the same day, the resident again expressed discomfort, stating that although the facility had discussed moving rooms, she felt she should not have to move because she liked her room and felt uncomfortable when her roommate exhibited behaviors toward her. Further observations showed the roommate lying in bed crying while the resident sat next to her, holding her hand. When CNAs entered to transfer and provide care to the resident, the roommate repeatedly called out for the resident, asking her not to leave, while crying. The resident attempted to rest in her bed, but the roommate continued calling out, and the CNAs did not intervene or redirect the roommate. The resident’s spouse reported to management that the roommate’s behaviors were affecting his wife, including multiple upset phone calls about the roommate issues. The DON acknowledged that the spouse reported the roommate was “driving” the resident “insane” and that a room change had been discussed but not implemented due to concerns the roommate might follow her. Social services also stated that the roommate hovered over the resident, causing her to become upset, and that the spouse wanted more boundaries and limits to protect his wife.
Failure to Assist Dependent Resident With Facial Hair Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) by not ensuring a female resident was shaved and free of facial hair. On one observation, the resident was seen in the dining room with prominent whiskers covering her chin. Certified Nursing Assistants (CNAs) reported that all residents receive showers at least twice a week and that shaving for both men and women is included on shower days, and the Administrator confirmed that shaving occurs on shower days. The resident’s care plan documented an ADL self-care performance deficit and limited physical mobility, and her Minimum Data Set (MDS) indicated severe cognitive impairment and a need for substantial/maximal assistance with personal hygiene, including shaving. The facility’s policy on grooming a resident’s facial hair states that staff are to assist residents with grooming facial hair to maintain proper hygiene, but this was not carried out for this resident as evidenced by the observed facial hair. This deficiency is based on observation, staff interviews, and record review showing that the resident, who required significant assistance with personal hygiene due to cognitive and physical limitations, did not receive the grooming care outlined in her care plan and the facility’s grooming policy.
Failure to Implement Ordered Pressure-Relieving Interventions for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions for residents identified as at risk for pressure injuries. For one resident (R5), the Medication Review Report dated 8/26/25 showed an order for an air mattress to be on at all times. Observations on 8/25/25 at 2:06 PM and on 8/26/25 at 1:42 PM found the resident in bed with the air mattress pump hanging at the foot of the bed, with the lights off and the pump unplugged on both occasions. On 8/27/25 at 9:01 AM, an LPN (V13) confirmed that an air mattress pump is a pressure-relieving intervention. R5’s Braden Scale dated 8/18/25 indicated the resident was at risk for pressure injuries, and the care plan revised 8/19/25 documented potential for skin impairment with an air mattress listed as an intervention. The deficiency also includes failure to apply ordered protective boots for another resident (R30) at risk for pressure injuries. On 8/25/25 at 1:35 PM, two CNAs (V10 and V11) transferred R30 to bed with a mechanical lift and provided incontinence care, then positioned the resident’s feet on the mattress without applying the protective boots. A bright-colored sign above the bed displayed a turning schedule and directed that cradle boots be on at all times when the resident was in bed. On 8/26/25 at 12:33 PM, an RN (V8) stated that R30 is at risk for pressure, dependent on staff for care, and should have protective boots applied when in bed. R30’s current care plan documented potential impairment to skin integrity related to fragile skin, with interventions including an air mattress, wheelchair cushion, and protective boots while in bed. The facility’s Pressure Injury Prevention and Management Policy states that interventions will be implemented for all residents assessed and considered at risk.
Improper Positioning of Indwelling Catheter Drainage Bag
Penalty
Summary
Surveyors identified a deficiency in catheter care when a resident with an indwelling urinary catheter and a history of frequent UTIs was observed sitting in the dining room in a wheelchair with a leg drainage bag attached high on the top of the thigh, positioned above the level of the bladder and without slack in the tubing, which did not allow gravity to aid urine drainage. On a subsequent interview, a CNA stated that urinary catheter drainage bags should be kept below the waist to prevent UTIs/infections. The resident’s care plan indicated the presence of an indwelling urinary catheter and the need for the drainage bag and tubing to be maintained below the level of the bladder, and the facility’s catheter care policy likewise stated that drainage bags should be located below the level of the bladder to discourage backflow of urine. Despite these documented requirements, the drainage bag was not maintained below bladder level for this resident.
Failure to Implement and Document Dementia-Related Behavioral Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document individualized interventions and services for a resident with dementia and anxiety who was exhibiting escalating behavioral and emotional distress. The resident had documented diagnoses of unspecified dementia (moderate) with anxiety, anxiety, hypertension, and muscle weakness, and her care plan indicated moderately impaired cognition and dependence on staff for emotional, intellectual, physical, and social stimulation. Despite a dementia care policy requiring person-centered, non-pharmacological approaches and care plan interventions related to each resident’s symptomatology, the resident’s increased anxiety, crying, yelling, delusions, and preoccupation with her roommate were not consistently addressed with observable interventions or documented in the clinical record. On one observed day, the resident was initially sleeping when a CNA delivered her meal tray, after which she began loudly yelling statements such as “Stay out of my life” and “Get out of it.” The CNA left to notify an RN, and the resident continued to yell and appear agitated. The RN attempted redirection but the resident remained distressed; the RN reported that the resident had earlier accused staff of trying to kill her and believed she might have a urinary tract infection. Later that day, the resident was observed crying in bed, repeatedly calling out to her roommate not to leave her, while the roommate attempted to console her. Two CNAs entered to provide care and transfer assistance to the roommate but did not approach or intervene with the crying, anxious resident, who remained tearful and asking for a kiss when the surveyor left the room. On the following day, the resident was observed wandering, pacing, and appearing restless in her room. Multiple staff interviews confirmed that the resident frequently cries, hallucinates, worries, misses her family, and becomes very anxious and nervous, particularly in relation to her roommate, over whom she “hovers” and becomes preoccupied. Staff, including CNAs, an LPN, the DON, and Social Services, acknowledged that the resident has ongoing behavioral symptoms, including delusions and emotional lability, and that her behaviors had increased after a decrease in antidepressant medication at family request. Social Services documentation noted her anxiety and preoccupation with the roommate and with the roommate’s spouse. Despite these ongoing and escalating behaviors, the progress notes contained no documentation on the day of the observed increased behaviors regarding the episodes or any interventions implemented, and the existing care plan interventions remained general (e.g., consults, encouragement of activities, monitoring) without evidence of being actively implemented during the observed episodes of distress.
Missed COPD Inhaler Doses Due to Misplaced Medication
Penalty
Summary
The facility failed to provide ordered pharmaceutical services when a resident with chronic obstructive pulmonary disease (COPD), whose principal diagnosis was COPD, did not receive two scheduled doses of an ipratropium-albuterol inhaler. The resident’s medication review showed an order for the inhaler to be administered four times daily for COPD, and the August medication administration record documented that the 3:00 PM and 8:00 PM doses on 8/18/25 were not given, with a code directing to progress notes. The corresponding progress notes stated the medication was not available for those doses. The resident reported missing two doses of the inhaler about a week prior and did not know why. A nurse stated that when she attempted to administer the inhaler at the scheduled time, it was not in the medication cart, resulting in the missed doses, and that the inhaler was later found at the end of the resident’s bed, although it should have been stored in the medication cart. The DON confirmed the inhaler had been misplaced and should have been kept in the medication cart, and the resident’s care plan and the facility’s medication administration policy both required that medications be administered as ordered.
Failure to Secure Controlled Drugs and Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure controlled medications were secured with a dual lock system and failed to discard an outdated insulin pen. During an observation of the 100-200 hall medication room, an LPN opened the medication room and the resident medication refrigerator was found with an open lock hanging on the latch, leaving it unlocked. Inside the unlocked refrigerator was a new box of Methadone Oral Concentrate, a Schedule II controlled substance, for a resident who had a physician’s order for Methadone 10 mg/ml, 4 ml by mouth once daily for pain. The DON confirmed that the medication room refrigerator should be locked. The facility’s Medication Storage Policy stated that all drugs and narcotics must be stored in a locked storage area with limited access by authorized personnel. In a separate incident, a resident’s Humalog KwikPen insulin was observed with a written expiration date that had already passed. An RN stated that the insulin pen should have been thrown away and explained that nurses label insulin with a “use by” date 30 days from when it is opened. The resident’s records showed a diagnosis of diabetes and an active order for Humalog KwikPen to be administered before meals and at bedtime per a sliding scale. The facility’s Insulin Pen Policy specified that insulin pens should be disposed of after 28 days, indicating that the insulin pen in use was outdated according to the facility’s own policy.
Failure to Provide Routine Dental Care and Enrollment in Dental Program
Penalty
Summary
The facility failed to ensure that a resident received routine dental care despite documented oral/dental health problems and over two years of residency. The resident’s husband reported on 8/25/25 that the resident had been in the facility for more than two years and had not received any preventative dental care, and later stated he was notified in writing in early July 2025 that a dentist would come to the facility and see the resident if he enrolled her in the program, but she had not seen a dentist since admission. The admission record dated 8/25/25 shows the resident was admitted on an earlier date, and the current care plan indicates the resident has oral/dental health problems. The Administrator confirmed on 8/27/25 that the resident had not seen a dentist since admission, explaining that although she was eligible for the dental program, she was not enrolled and therefore did not receive dental care. The DON stated on 8/27/25 that the facility had no dental policy and acknowledged that the resident was not offered enrollment in the dental plan upon admission, noting she was Medicaid pending and should have been informed about the program after Medicaid coverage began. These actions and omissions resulted in the resident not receiving routine or preventative dental services during her stay, despite eligibility for a dental program and identified oral/dental health needs.
Resident Safety Lapse Leads to Hip Fracture
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in a displaced left hip fracture. The resident, who had diagnoses including osteoarthritis, dementia, and unspecified abnormalities of gait and mobility, required substantial assistance for mobility and was typically transferred using a mechanical lift. On the evening of the incident, the resident was put to bed early due to not feeling well, and throughout the night, staff reported no falls or complaints of pain. However, during the morning medication pass, the resident was found with an internally rotated left hip and was in immense pain, leading to an emergency hospital transfer. The hospital records confirmed a comminuted fracture in the left hip, suggesting a fall might have occurred, although staff denied any falls. The paramedic noted a hip deformity and redness on the resident's cheek, which appeared bruised, raising suspicions of a fall. Despite an investigation by the facility, the injury was classified as of unknown origin, and abuse was ruled out. The lack of clear documentation or observation of a fall indicates a deficiency in supervision and monitoring, contributing to the resident's injury.
Inadequate Supervision and Safety Measures Lead to Resident Injuries
Penalty
Summary
The facility failed to adequately supervise and ensure the safety of residents with a history of falls, resulting in significant injuries. One resident, with a history of falls and moderate risk for falling, sustained a right hip fracture. Despite being known for attempting to get up on his own and having impaired cognitive function, the resident was not provided with close supervision as indicated in his care plan. The incident was not witnessed, and there were no documented signs of pain or abnormal behavior prior to the discovery of the injury, indicating a lack of proper monitoring and intervention. Another resident, identified as high risk for falls, suffered a head wound due to improper transfer procedures. The resident was transferred using a mechanical sling lift by a single CNA, contrary to the facility's policy requiring two staff members for such transfers. This lapse in protocol led to the resident falling forward and sustaining a wound on the forehead. The CNA involved acknowledged the deviation from the standard procedure, which was confirmed by the Director of Nursing. A third resident, also at high risk for falls, experienced multiple unwitnessed falls without subsequent revision of their care plan. Despite having a care plan focus on fall risk due to conditions like Parkinson's disease and confusion, the interventions were not updated following the falls. The facility's policy on monitoring and modification of care plans was not adhered to, as there was no evaluation or adjustment of interventions after the incidents, highlighting a systemic issue in addressing fall risks effectively.
Improper Sanitization of Blender Pitcher for Pureed Diets
Penalty
Summary
The facility failed to ensure proper sanitization of a blender pitcher used for preparing pureed diets for residents. On the morning of September 23, 2024, a dietary aide filled the three compartments of the sink, and shortly after, a cook began pureeing couscous for lunch. After finishing, the cook washed the blender pitcher and lid in the three-compartment sink, allowing them to air dry. However, the sanitization process was compromised as the test strip used to check the concentration of the sanitizer solution in the third sink did not register any sanitizer, indicating that the sink lacked the necessary sanitizing solution. The dietary director confirmed the absence of sanitizer in the sink and subsequently refilled it with a pre-diluted sanitizer and water mixture, achieving the correct concentration. This deficiency affected four residents who were on pureed diets, as the blender used for their meals was not properly sanitized according to the facility's policy. The facility's manual sanitizing policy requires utensils and equipment to be sanitized in the third sink by immersion in a chemical sanitizing solution used according to the manufacturer's instructions.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for six residents who required them due to their medical conditions. During an initial tour, it was observed that residents with urinary catheters and a urostomy did not have EBP signs on their doors. Additionally, a resident with wounds on his toes also lacked appropriate signage. The Infection Control Nurse admitted to being unaware that EBP was mandatory and acknowledged the absence of a facility policy on EBP. Further observations revealed that a resident with an indwelling catheter had their catheter bag visibly exposed, and there was no EBP signage or personal protective equipment (PPE) station outside their room. Another resident receiving nutrition through a PEG tube also lacked EBP signage and a PPE station. These oversights indicate a systemic failure in the facility's infection prevention and control program, as evidenced by the lack of EBP implementation for residents with specific medical needs.
Failure to Schedule Rheumatology Consultation
Penalty
Summary
The facility failed to provide necessary care and services to a resident who required a rheumatology consultation. The resident, a female with multiple diagnoses including age-related osteoporosis, psoriatic arthritis, and protein-calorie malnutrition, was observed to be in pain and expressed a desire to see a rheumatologist. Despite having an appointment scheduled for July 24, 2024, it was canceled because the provider did not accept her insurance, and no follow-up appointment was made. The Director of Nursing confirmed that the resident is alert, oriented, and in discomfort due to her arthritis, and acknowledged that a new appointment was not scheduled after the cancellation.
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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 Round Lake Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village At Victory Lakes, The | 3.4 mi | — | 18 | 1 |
| Libertyville Manor Ext Care | 7.8 mi | — | 0 | 0 |
| Alta Rehab At Wauconda | 9.2 mi | — | 2 | 0 |
| Alden Terrace Of Mchenry Rehab | 10.7 mi | — | 5 | 0 |
| Avantara Libertyville | 10.9 mi | — | 0 | 0 |
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