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 Sunny Acres Nursing Home during CMS and state inspections, most recent first.
The facility failed to follow its controlled drug disposal policy, which requires two licensed staff to destroy CII–CV medications and complete destruction records. Review of controlled drug records for several residents receiving morphine, lorazepam, oxycodone/APAP, and hydrocodone/APAP showed multiple entries where pills were documented as dropped or wasted by an RN or another nurse without evidence of proper destruction or complete documentation, including one instance where a pill was taken with no date, time, or nurse signature. The Administrator later acknowledged that nursing staff were not discarding controlled substances correctly after an internal audit revealed that these issues were not isolated.
The facility failed to maintain an accurate count and reconciliation of a controlled substance for a resident receiving Lorazepam concentrate. Policy required between-shift counts, accurate documentation on controlled drug records, and immediate reporting of any shortages or overages to the DON and pharmacist. Despite the controlled drug record indicating only a small remaining volume, observation confirmed that the Lorazepam bottle contained a substantially larger amount. An RN acknowledged continuing to deduct doses based solely on the record even though the bottle clearly held more medication, and the Administrator confirmed that staff continued to sign off on the inaccurate controlled drug record while the actual volume in the bottle remained significantly higher than documented.
The deficiency involves a failure to provide adequate supervision to prevent verbal and physical abuse between two residents sharing a bathroom. One resident with dementia, agitation, and a documented history of behavioral symptoms, including recent physical behaviors, repeatedly sang an embarrassing phrase, provoking a verbal exchange with another cognitively intact, wheelchair-propelled resident. The situation escalated into a physical assault in which the aggressive resident punched the other in the face and struck both shins multiple times with a walker, as witnessed by a CNA who responded to calls for help and separated them. The assaulted resident sustained a facial laceration and large bilateral shin hematomas requiring ED evaluation and pain medication, and later continued to have an open shin wound and painful hematomas, while photos also showed bruising to the aggressor’s hand. These events occurred despite an abuse prohibition policy intended to protect residents from verbal and physical abuse.
Staff did not follow fall management protocols when a resident with a recent femur fracture was manually lifted from the floor to a wheelchair by a nurse and CNA after a fall, instead of using a mechanical lift as required by facility policy. Both staff members acknowledged not using the lift, and the DON confirmed this was against protocol.
Two residents with wounds and indwelling medical devices did not receive wound care in accordance with Enhanced Barrier Precautions. An LPN failed to sanitize scissors used during wound care and did not initially apply gauze as ordered, while another LPN placed wound care supplies on an unsanitized surface and returned partially used supplies to a communal cart for use on other residents. The interim DON confirmed that standard precautions and infection control measures were not followed.
A resident with severe cognitive impairment and multiple health conditions was left unsupervised in the dining room and not assessed for hot liquid risk as required by facility policy. The resident spilled hot chocolate on her thigh, resulting in second-degree burns. Staff were not present at the time of the incident, and the required hot liquid risk assessment and interventions were not in place.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Two residents experienced mental and verbal abuse from a CNA, including rude and discourteous behavior during care and yelling in response to requests for assistance. One resident, with a history of childhood abuse, reported feeling belittled and verbally abused after the CNA questioned her need for help and refused to assist with personal hygiene.
A resident reported being verbally abused and belittled by a CNA when requesting assistance, but the facility did not suspend the CNA or conduct an investigation as required by its abuse policy. The CNA continued to work and have contact with all residents, affecting the safety of all 78 residents.
Multiple residents experienced unsanitary and uncomfortable living conditions due to unclean and poorly maintained rooms and restrooms, including non-functioning sinks and toilets, stained floors and walls, missing toilet tank lids, unlined waste receptacles, and improper disposal of soiled items. Staff and resident interviews confirmed these issues had persisted for extended periods, and facility records documented ongoing complaints about housekeeping and maintenance.
A resident reported to an SLP that a CNA was mean, yelled, and refused restroom assistance. The SLP documented the allegation and gave it to the DON, but neither reported it to the Administrator or the State Agency as required. The Administrator and DON were unaware of the incident until much later, and the allegation was never reported to the State Agency.
A resident with severe cognitive impairment suffered finger bruising when a CNA failed to ensure the resident's hand was inside the wheelchair during a transfer, resulting in the hand being pinched between the wheelchair and table. The facility did not investigate the incident, complete required occurrence documentation, or update the care plan with interventions to prevent future injuries.
A resident, assessed as cognitively intact, reported discomfort with a male CNA's actions during care to both the Activity Director and Activity Aide, but neither staff member reported the allegation to the Administrator/Abuse Coordinator as required by facility policy.
A resident with a history of arthritis and neuropathy did not receive her prescribed Fentanyl Transdermal Patch for over a week, leading to severe pain. The facility failed to perform adequate pain assessments, notify the physician for a refill, or address the resident's complaints. Staff interviews revealed a lack of communication and follow-up, resulting in the resident experiencing significant distress and uncontrolled pain.
The facility failed to maintain proper food safety and hygiene standards, as observed during a survey. The Dietary Manager did not properly cleanse a food thermometer between uses and wore a hairnet incorrectly. Food items in the kitchen were not labeled or dated, and freezers lacked proper temperature monitoring. The dishwashing process did not verify the required temperature, and juice and coffee dispensers were found unclean. These issues could potentially affect all 85 residents.
The facility failed to follow proper hand hygiene and Enhanced Barrier Precautions during medication administration and resident care. An LPN did not sanitize hands between residents, and a CNA provided care without necessary precautions for residents with specific medical needs. Staff were unaware of the required precautions, despite existing protocols.
A facility failed to evaluate and prevent the improper use of physical restraints for a resident with severe cognitive impairment. The resident's care plan included a body pillow tucked under the fitted sheet to prevent falls, but this was used as a restraint without proper assessment or documentation. Staff confirmed the use of the body pillow as a restraint, and the administrator acknowledged the misuse, indicating non-compliance with the facility's restraint policy.
The facility failed to request a PASRR for a resident admitted with Vascular Dementia and other diagnoses. Despite the resident being cognitively intact and having no behavioral issues, the facility did not obtain a PASRR Level I prior to admission, as confirmed by the administrator.
A facility failed to refer a resident for a Level II PASRR evaluation after being diagnosed with Delusional Disorder. The resident, who was already diagnosed with Major Depressive Disorder and Anxiety Disorder, was prescribed Quetiapine for the new diagnosis. The facility's administrator confirmed that a Level II PASRR was not requested.
A facility failed to develop a comprehensive care plan for a resident's oxygen use, despite the resident having a physician's order for oxygen to maintain saturation levels. The resident, diagnosed with Parkinson's Disease and Dementia, did not have an oxygen care plan included in their care plan, as confirmed by a Restorative RN.
The facility failed to provide adequate nail care for a resident with Multiple Sclerosis, resulting in long, jagged nails with brown matter. Additionally, another resident with multiple health conditions did not receive a shower or bath for over two weeks, despite needing assistance with bathing twice a week. The resident expressed dissatisfaction with the inconsistency of bathing schedules.
A facility failed to follow a physician-ordered wound care regimen for a resident with multiple chronic conditions. The resident's treatment, which included daily dressing changes, was not documented as completed on several occasions, as confirmed by the resident and facility staff.
The facility failed to develop and implement services to maintain or improve range of motion (ROM) for two residents with documented limitations. Both residents lacked care plans addressing their ROM needs, and staff confirmed the absence of ROM exercises. Observations showed one resident unable to move her legs independently and another with a foot pointed inward, indicating a lack of necessary restorative care.
A resident with severe cognitive impairment experienced multiple falls despite interventions like a perimeter mattress and bed alarms. The room arrangement and use of a body pillow obstructed staff visibility, hindering effective supervision.
The facility failed to provide proper catheter care for two residents, leading to deficiencies in hygiene and infection control. A CNA did not follow proper procedures during catheter care, failing to use multiple washcloths, change gloves, or perform hand hygiene. Additionally, another resident's catheter bag was repeatedly observed resting on the floor, contrary to facility policy. The Infection Preventionist confirmed the improper positioning of the catheter bag.
A facility failed to label oxygen tubing and a humidifier bottle with the date and initials as required by their policy. A resident receiving oxygen therapy had equipment that was not tagged, despite a physician's order for oxygen to maintain saturation levels. This was confirmed by a registered nurse.
A facility failed to properly monitor and document urinary output for residents with indwelling catheters, leading to significant health issues for two residents. One resident was hospitalized with a UTI and encephalopathy due to lack of physician notification and follow-up on abnormal urinalysis results. Another resident experienced inadequate documentation of urine output without physician notification. These deficiencies resulted in an Immediate Jeopardy situation.
A resident experienced a significant decline in health due to the facility's failure to notify the physician of decreased urinary output and delayed urinalysis collection. The resident, suffering from a UTI, was hospitalized twice, receiving IV fluids and antibiotics. The facility did not follow its guidelines for notifying physicians of significant changes in condition, leading to a lack of timely medical intervention.
A facility failed to ensure a physician was available for emergency calls when a resident experienced significant health changes, including a rash, discharge, and lack of urination. Despite attempts to contact the physician, no response was received, and the resident was eventually sent to the emergency room after the family was informed. The facility's administrator acknowledged issues with reaching a physician while the medical director was on vacation.
A facility failed to timely obtain a physician-ordered urinalysis for a resident, leading to a delay in diagnosis and treatment. The urinalysis was ordered due to decreased urinary output and foul-smelling urine but was not collected until several days later. The resident was eventually hospitalized with a urinary tract infection and encephalopathy. The delay was not communicated to the physician, contrary to facility policy.
Improper Disposal and Documentation of Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of controlled substances in accordance with its own Controlled Drug Handling, Reconciling, Count Discrepancy, & Disposal Policy and Procedure dated 5/30/2017. The policy requires that CII–CV controlled drugs be destroyed by two licensed staff and that records of destruction include the medication name, strength, quantity destroyed, patient name, prescription number, and both signatures and dates destroyed. Review of controlled drug receipt/ disposition records showed multiple instances where controlled medications were documented as dropped or wasted without evidence of proper destruction or complete documentation. For one resident with an order for Morphine Sulphate IR 30 mg every six hours, the record showed entries on two dates by an agency RN indicating “dropped/wasted.” Another resident with an order for Lorazepam 0.5 mg twice daily had an entry documented as “dropped” by the same agency RN. Additional controlled drug records showed similar issues for three more residents. One resident with an order for Oxycodone/APAP 5/325 every eight hours had two separate entries documented as “dropped/wasted” by the same agency RN. Another resident with an order for Hydrocodone/APAP 5-325 mg every six hours as needed had an entry documented as “dropped” by an unidentified nurse. A fifth resident with an order for Hydrocodone/APAP 7.5/325 mg five times daily had a record showing one pill taken with no date, no time, and no nurse signature. In an interview, the Administrator stated she became aware of multiple controlled drug record issues after an agency RN contacted her about medications being packed incorrectly and, upon conducting a house audit, she realized that improper discarding of controlled substances was not an isolated incident. She confirmed that nursing staff were not discarding controlled substances correctly.
Failure to Maintain Accurate Controlled Substance Count for Lorazepam
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate reconciliation and accounting of a controlled substance for one resident receiving Lorazepam concentrate. The facility’s written policy dated 5/30/2017 requires that controlled medications be counted between shifts or whenever there is a change in nurses, that each controlled medication received from the pharmacy be counted and a count sheet initiated by a nurse, and that all shortages or overages be reported immediately to the DON and pharmacist on call. For this resident, the Controlled Drug Receipt Record/Disposition Form dated 1/2/2026 documented an order for Lorazepam concentrate 2 mg/mL, 0.5 cc (1 mg) PO every 2 hours as needed, and showed that only 2 mL remained as of 3/26/2026. However, on 3/25/2026 at 1:10 PM, observation and confirmation by an RN showed that the Lorazepam bottle actually contained 12 mL, which was significantly more than the 2 mL documented on the controlled drug record. The RN stated that she continued to deduct doses from the bottle based on the sheet, despite the visible discrepancy between the recorded amount and the actual volume in the bottle. On 3/26/2026 at 2 PM, the Administrator confirmed that the Lorazepam concentrate for this resident was over by far too much and that nursing staff continued to sign off on the controlled drug record even though the amount in the bottle was far greater than what was being recorded, demonstrating a failure to ensure the narcotic count was correct in accordance with facility policy.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent verbal and physical resident-to-resident abuse, resulting in one resident physically assaulting another. The facility’s Abuse Prohibition Policy, dated 1/29/2026, states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, as well as neglect and exploitation, and defines physical and verbal abuse. One resident (R1) was an older adult with Alzheimer’s disease, dementia with agitation, major depressive disorder, and anxiety disorder, with an MDS indicating moderate cognitive impairment and behaviors occurring every one to three days. R1’s care plan documented behaviors including yelling out, being demanding, making inappropriate sexual comments, touching staff, and, most recently, physical behavioral symptoms. Another resident (R2) was an older adult with osteoarthritis, cardiomyopathy, aortic aneurysm, hypertensive heart disease with heart failure, and idiopathic peripheral autonomic neuropathy, and was cognitively intact and self-propelled in a wheelchair. On the evening of 2/7/26, R1 and R2, who shared a common bathroom, became involved in a verbal altercation in that bathroom. According to the final abuse report, police report, and interviews, R1 and R2 argued, and R1 then struck R2 in the face with closed fists and hit R2’s legs multiple times with R1’s walker. A CNA (V3) reported hearing someone yell for help, entering R2’s room, and observing R1 in the bathroom punching R2 in the chin with closed fists while holding onto R2’s wheelchair, requiring the CNA to physically separate them. R2 reported that R1 had been in the bathroom repeatedly singing a phrase that R2 found embarrassing and aggravating, leading R2 to yell at R1 and call him a derogatory name, after which R1 slammed the walker into R2’s legs repeatedly and punched R2 in the face. Emergency department documentation noted an abrasion to the left side of R2’s face and bilateral hematomas to the shins from being hit multiple times with the walker, with R2 receiving tramadol for pain. Police photographs showed a laceration to R2’s left upper cheek and a softball-sized dark purple hematoma to the right lower leg, and discoloration to R1’s right hand. On later observation, R2 still had an open area on the left shin with a dressing and a large dark red hematoma on the right shin, and R2 stated that the shins remained swollen and painful every day. These events occurred despite the facility’s abuse prohibition policy and R1’s known history of behavioral symptoms, demonstrating a failure to adequately supervise and prevent resident-to-resident abuse.
Failure to Use Mechanical Lift After Resident Fall
Penalty
Summary
Staff failed to follow established fall management safety protocols when a resident with multiple medical conditions, including a recent non-displaced fracture of the left femur, experienced an unwitnessed fall in their room. After the fall, the nurse and a CNA manually lifted the resident from the floor and transferred them to a wheelchair without using a mechanical lift, as required by facility policy. The resident was assessed by the nurse and denied pain at the time of the incident. Facility records, including progress notes, incident logs, and staff disciplinary forms, confirm that the mechanical lift was not used during the transfer. Both staff members involved acknowledged not following the protocol, and the DON verified that the facility's fall management policy mandates the use of a mechanical lift for resident transfers after a fall. The deficiency was identified through record review and staff interviews.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow infection control standards for Enhanced Barrier Precautions during wound care for two residents with wounds and indwelling medical devices. For one resident with a neck wound and an enteral feeding device, an LPN performed wound care without sanitizing the bandage scissors before or after use, and initially failed to cover the wound with gauze as ordered. The LPN also placed the used scissors in her pocket without cleaning them, and there was no wound care policy outlining standard precautions available at the facility. For another resident with a left thigh wound and an enteral feeding device, an LPN placed wound care supplies directly onto the overbed table without sanitizing the surface or using a clean barrier. The LPN also placed an opened roll of gauze and absorbent dressings directly on the table, then returned the partially used supplies to a communal wound cart for use on other residents. The interim Director of Nursing confirmed that standard precautions and infection control measures were not followed during these wound care procedures.
Failure to Supervise and Assess Hot Liquid Risk Leads to Resident Burn
Penalty
Summary
The facility failed to follow its own hot liquids policy, did not identify potential hazards related to hot liquids, and did not provide adequate staff supervision to prevent an accident involving hot liquids. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including dementia, hallucinations, and repeated falls, was not assessed for hot liquid risk as required by facility policy. The resident was left unsupervised in the dining room during meal service, despite being at risk for injury from hot liquids. No hot liquid burn interventions were in place for this resident prior to the incident. As a result, the resident spilled hot chocolate on her left thigh during lunch, sustaining second-degree burns with three blisters. The incident was unwitnessed by staff, and the resident reported that no staff were present in the dining room at the time. Documentation confirmed that the required Hot Beverage Use Assessment had not been completed for the resident, and the Director of Nursing acknowledged that the facility had not been following its hot liquids policy prior to the incident.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Prevent Staff-to-Resident Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident mental and verbal abuse, as evidenced by two separate incidents involving a Certified Nursing Assistant (CNA). In one case, a resident reported that the CNA was repeatedly rude and discourteous during care, which was confirmed by a complaint form and resulted in a verbal warning for the CNA. The resident described the CNA as appearing frustrated while providing care, which made the resident feel uncomfortable and disrespected. In another incident, a cognitively intact resident with a documented history of childhood abuse reported that the same CNA responded to a call light with a loud and mean tone, questioned the resident's need for assistance, and verbally stated she would not help with personal hygiene. The resident felt belittled, verbally abused, and treated like a child. These actions were corroborated by both the resident and a speech language pathologist who received the complaint and documented the resident's distress.
Failure to Investigate and Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Prohibition Policy after an allegation of staff-to-resident verbal abuse was reported. According to the facility's policy, any employee accused of abuse must be immediately suspended from resident contact pending investigation, and a thorough investigation must be conducted. However, after a resident reported that a CNA yelled at and belittled her when she requested assistance to the restroom, the facility did not suspend the CNA or initiate an investigation. The administrator-in-training confirmed awareness of the allegation but took no action to remove the CNA from resident care or to investigate the incident. The resident involved was cognitively intact and reported feeling verbally abused and belittled by the CNA's actions and words. Documentation showed that the CNA continued to work regular shifts and had contact with all residents during the period following the allegation. The facility's failure to follow its own abuse policy and to protect residents from the alleged perpetrator affected all 78 residents in the facility.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of unclean and poorly maintained resident rooms and restrooms. Surveyors found that several shared restrooms had non-functioning sinks and toilets, with one restroom containing a sink full of standing water and a toilet that would not flush, both of which had been in disrepair for over a year according to staff and residents. Floors around toilets were stained with dark or orange-brown substances, and walls had missing drywall and paint. Additionally, some toilets were missing tank lids, and used washcloths were left on sinks. Waste receptacles were found unlined and contained trash, and there was a strong odor of urine in some restrooms. Interviews with residents and staff confirmed the ongoing nature of these issues, with residents stating that their restrooms had not been properly cleaned or repaired for extended periods. Resident council meeting minutes also documented complaints about agency staff improperly disposing of soiled briefs and housekeeping failing to remove trash on weekends. The facility's own job descriptions for maintenance and housekeeping staff outlined responsibilities for cleaning, repairs, and refuse disposal, but these duties were not being fulfilled as required, resulting in unsanitary and uncomfortable living conditions for multiple residents.
Failure to Timely Report Alleged Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to implement its Abuse Policy by not immediately reporting an allegation of abuse involving a resident to the Administrator and the State Agency. According to the facility's policy, any employee who becomes aware of alleged abuse or neglect must immediately report it to the Administrator, who is then responsible for notifying the resident's representative and the Illinois Department of Public Health (IDPH) both by telephone and in writing. In this case, a resident reported to a Speech Language Pathologist (SLP) that a Certified Nursing Assistant (CNA) was mean, yelled at her, and refused to assist her to the restroom. The SLP documented the allegation and provided it to the Director of Nursing (DON), but neither the SLP nor the DON reported the incident to the Administrator as required by policy. Further review of the facility's records and interviews with staff revealed that the allegation was not reported to the State Agency, and key administrative staff, including the Administrator and DON, were unaware of the incident until much later. Even after the Administrator became aware of the allegation, the facility did not report it to the State Agency, with the Administrator stating that since the report was already late, it did not matter if it was reported at that point. This sequence of actions and inactions resulted in the facility's failure to follow its own abuse reporting procedures and regulatory requirements.
Failure to Investigate and Prevent Resident Injury During Wheelchair Transfer
Penalty
Summary
A resident with severe cognitive impairment sustained bruising to the left third and fourth fingers after a certified nursing assistant (CNA) failed to ensure the resident's hand was inside the wheelchair during a transfer from the dining room table. The CNA admitted to pinching the resident's fingers between the table and the wheelchair, resulting in dime-sized purple bruises. The incident was observed and reported by therapy staff, and the resident was noted to have no pain or issues with finger movement at the time of assessment. Despite the injury, the facility did not complete a Risk Watch Occurrence Form, conduct an investigation into the cause of the injury, or update the resident's care plan with interventions to prevent future injuries. The facility's policy requires immediate care, monitoring, notification of physician and family, completion of an occurrence report, and documentation of the facts and witness statements for any incident or accident affecting a resident. These steps were not followed in this case, as confirmed by the facility administrator.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the Administrator/Abuse Coordinator as required by its Abuse Prohibition Policy. A resident, who was cognitively intact according to her most recent MDS assessment, reported that a male CNA patted her bottom while assisting her at bedtime. She expressed her discomfort to the CNA and requested that he leave, after which the female CNA completed her care. The resident later shared her concerns with both the Activity Director and the Activity Aide, mentioning her discomfort with the male caregiver and specifying that she did not want men providing her care. Despite these disclosures, neither the Activity Director nor the Activity Aide reported the resident's statements to the Administrator/Abuse Coordinator. The Activity Director acknowledged that she did not recognize the statement as a potential abuse allegation at the time, attributing it to confusion with other care-related complaints discussed during a resident council meeting. The Activity Aide also admitted to not reporting the conversation, only realizing in hindsight that it should have been communicated. The Administrator confirmed that both staff members were required by policy to immediately report such concerns.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to administer a prescribed opioid medication, specifically a Fentanyl Transdermal Patch, to a resident, resulting in uncontrolled pain. The resident, who was cognitively intact and had a history of arthritis, neuropathy, and GERD, did not receive her scheduled pain medication from February 17 to February 24. This lapse in medication administration led to the resident experiencing severe pain, rated as high as seven out of ten, which significantly impacted her daily activities and caused distress. The facility's pain management policy emphasizes the importance of promptly assessing and managing pain, involving physicians in the process, and ensuring residents' comfort and dignity. However, during the period in question, the facility did not perform adequate pain assessments or notify the physician about the resident's need for a medication refill and her increased pain levels. The resident repeatedly expressed her discomfort and frustration to staff, but no action was taken to address her pain or secure the necessary medication. Interviews with facility staff, including the administrator and pharmacist, revealed a lack of communication and follow-up regarding the resident's medication needs. The pharmacist confirmed that a refill request for the Fentanyl patch was not received until February 24, and the physician's office was not notified of the need for a refill until the same day. The administrator acknowledged that the staff should have contacted the physician or management to resolve the issue, but this did not occur, leaving the resident in excruciating pain for over a week.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene protocols, as observed during a survey. The Dietary Manager, identified as V7, did not properly cleanse a food thermometer before use and between checking different food items on the steam table. Instead of using a food-safe sanitizing wipe or alcohol wipe, V7 rinsed the thermometer under tap water and wiped it with a paper towel. Additionally, V7 did not wear a hairnet correctly, leaving a portion of her ponytail uncovered, which is against the facility's policy on personal hygiene. Further deficiencies were noted in the labeling and dating of food items. The kitchen's reach-in refrigerator contained a large tub of lettuce that was not labeled or dated, and the dry food storage room had several opened and undated food items, including bags of pasta, dried milk, breadcrumbs, and cereal. The walk-in refrigerator contained a mislabeled container of ham salad and another container with sandwiches that were not labeled or dated. The facility's freezers also lacked proper temperature monitoring, with one thermometer broken and another missing entirely. The facility's dishwashing procedures were inadequate, as the Dietary Aide, V8, did not use temperature testing strips to ensure the dishwasher reached the required temperature during the rinse cycle. Instead, V8 relied on the digital reading of the machine, which did not verify the surface temperature of the dishes. Additionally, the juice and coffee dispensers in the main dining room were found to be unclean, with visible slime and debris, and there was no documentation to confirm regular cleaning. These failures have the potential to affect all 85 residents residing in the facility.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper hand hygiene and Enhanced Barrier Precautions during medication administration and resident care. A Licensed Practical Nurse (LPN) did not perform hand hygiene between administering medications to different residents, despite handling items such as a television remote and medication cups. The LPN admitted to typically using hand sanitizer, which was missing from the medication cart on the day of observation. This lapse in protocol was observed during the administration of medications to multiple residents, including one who had experienced emesis earlier that day. Additionally, the facility did not implement Enhanced Barrier Precautions for residents with specific medical needs, such as a gastrostomy tube and an indwelling catheter. A resident with a gastrostomy tube did not have the required Enhanced Barrier Precaution sign outside their room, and a Registered Nurse was unaware of the need for such precautions. Similarly, a Certified Nursing Assistant (CNA) provided incontinence care to a resident with an indwelling catheter without sanitizing hands or wearing a gown, as required by the facility's protocol. The CNA was also unaware of the resident's need for Enhanced Barrier Precautions, despite the administrator having a list of residents requiring such measures.
Failure to Evaluate and Prevent Improper Use of Physical Restraints
Penalty
Summary
The facility failed to evaluate and prevent the use of physical restraints for a resident who was at risk of falls. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia with agitation, was found to have a body pillow tucked under the fitted sheet on the left side of the bed. This setup was intended to prevent the resident from getting out of bed or rolling out of bed. The resident's care plan included interventions such as a low bed, concave mattress, body pillow, alarm to bed, and a mat to maintain a safe environment. However, the use of the body pillow as a restraint was not properly assessed or documented as required by the facility's policies. Observations and interviews with staff revealed that the body pillow was used to prevent the resident from self-transferring out of bed, which was not in compliance with the facility's restraint policy. The staff, including CNAs and a restorative registered nurse, confirmed the use of the body pillow as a restraint without a proper assessment. The facility's administrator acknowledged that the staff should not have been using the body pillow in this manner, indicating a lack of adherence to the facility's policies on restraint use and documentation.
Failure to Obtain PASRR for Resident
Penalty
Summary
The facility failed to request a Pre-Admission Screening and Resident Review (PASRR) for a resident, identified as R10, who was part of a sample of 35 residents reviewed for PASRR compliance. R10 was admitted to the facility with diagnoses including Vascular Dementia, Major Depressive Disorder, and Anxiety Disorder. Despite R10's cognitive intactness and lack of behavioral issues as documented in the Minimum Data Set (MDS) Assessment, the facility did not obtain a PASRR Level I prior to R10's admission. This oversight was confirmed during an interview with the facility's administrator, who acknowledged that the PASRR Level I had not been obtained for R10.
Failure to Obtain Level II PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to refer a resident to the PASRR State Agency for a Level II PASRR evaluation after the resident was diagnosed with a mental illness. The resident, identified as R10, was admitted with diagnoses including Major Depressive Disorder and Anxiety Disorder. On November 24, 2023, R10 was diagnosed with Delusional Disorder, a serious mental illness, and was prescribed Quetiapine, an antipsychotic medication, to be taken at bedtime. Despite this diagnosis, the facility did not obtain a Level II PASRR for R10, as confirmed by the facility's administrator, who stated that the request was never made.
Failure to Develop Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident's oxygen use, which was identified during a survey. The facility's Resident Care policy requires a comprehensive, person-centered care plan to be developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This care plan should include goals, measurable objectives, and interventions, and must be completed by day 21 of the resident's stay. The resident in question, who was admitted on 9/28/23, has diagnoses including Parkinson's Disease with Dyskinesia and Dementia, and has a physician's order for oxygen at two liters as needed to maintain oxygen saturation above 91 percent. However, the resident's care plan, printed on 3/5/25, did not include an oxygen care plan, which was confirmed by a Restorative Registered Nurse on 3/4/25.
Deficiencies in Nail Care and Bathing Frequency
Penalty
Summary
The facility failed to maintain proper nail care for a resident diagnosed with Multiple Sclerosis, Osteoporosis, and Hypertension, who was at risk for an ADL self-care deficit. Observations on two separate occasions revealed that the resident's fingernails were long, jagged, and had brown matter underneath. The resident could not recall the last time their nails were clipped and cleaned, and a CNA acknowledged that the nails needed attention, stating they should be trimmed with every bed bath. Additionally, the facility did not ensure that another resident, with a range of medical conditions including Acute and Chronic Diastolic Congestive Heart Failure and Chronic Obstructive Pulmonary Disease, received a shower or bath at least once a week. Despite the resident's care plan indicating the need for assistance with bathing twice a week, records showed a period of over two weeks without a shower or bath. The resident expressed dissatisfaction with the inconsistency of bathing schedules, noting a lack of hygiene maintenance during a bout of influenza.
Failure to Follow Physician-Ordered Wound Care
Penalty
Summary
The facility failed to adhere to a physician-ordered treatment plan for a resident with skin alterations. The resident, a female with a history of multiple chronic conditions including congestive heart failure, respiratory failure, and chronic kidney disease, was admitted with a wound on the umbilical area of her abdomen. The physician's order required daily cleansing, packing with collagen, and application of calcium alginate with silver, covered with a gauze island dressing. However, the Treatment Administration Record (TAR) indicated that the treatment was not performed on several specified dates. The deficiency was confirmed through interviews and record reviews. The resident herself reported that the dressing changes were not conducted as ordered. This was further verified by the facility's administrator and a registered nurse, who acknowledged that the treatment was not documented as completed on the specified dates. This lapse in following the prescribed treatment regimen constitutes a failure to provide appropriate care according to the physician's orders and the resident's needs.
Failure to Implement ROM Services for Residents
Penalty
Summary
The facility failed to develop and implement services to maintain and/or improve range of motion (ROM) for two residents, R3 and R36, who were identified with limitations in ROM. R3's Minimum Data Set (MDS) assessments indicated functional limitations in both lower extremities and a high risk of developing contractures, yet there was no care plan in place to address these limitations. Observations revealed that R3 was unable to move her legs independently and confirmed that staff did not perform ROM exercises with her. Similarly, R36's MDS assessments documented limitations in one side of the upper and lower extremities, with a moderate risk of contractures, but also lacked a care plan for ROM. Observations showed R36's right foot pointed inward, and the resident confirmed the absence of ROM exercises. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Restorative Nurse, corroborated the lack of ROM exercises for both residents. The CNA stated that neither resident received ROM exercises or restorative care, while the Restorative Nurse acknowledged the absence of care plans addressing the residents' ROM limitations. This deficiency highlights the facility's failure to provide necessary restorative programs to prevent further decline in the residents' physical conditions.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident who was severely cognitively impaired. The resident experienced six falls out of bed over a period of several months, with three of these falls resulting in bruising or skin tears. Despite the implementation of various interventions such as a perimeter defining mattress, a body pillow, a concave mattress, a low bed, a fall mat with an alarm, and a bed alarm, the resident continued to fall. The resident's bed was positioned against the wall, and a body pillow was tucked under the fitted sheet, which obstructed visibility from the doorway, making it difficult for staff to supervise the resident effectively. The Restorative Registered Nurse acknowledged that the resident's falls were primarily due to self-transferring or rolling out of bed. The facility's administrator noted that the room arrangement, including the placement of the resident's roommate's recliner, further hindered the ability to supervise the resident from the hallway. The body pillow also contributed to the lack of visibility. The facility's Fall Assessment and Management Policy required assessments on admission, quarterly, and after each fall, but the interventions in place were insufficient to prevent the resident from falling.
Deficiencies in Catheter Care and Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to deficiencies in maintaining hygiene and infection control. For one resident, a Certified Nursing Assistant (CNA) did not follow proper procedures during catheter care. The CNA used a single washcloth to clean the resident's meatus without folding it to use clean parts, did not use a separate washcloth to rinse, and failed to wash the catheter tubing. Additionally, the CNA did not change gloves or perform hand hygiene between handling soiled and clean items, which was acknowledged by the CNA during an interview. Another resident's urinary catheter bag was observed on multiple occasions to be improperly positioned, with half of the bag resting on the floor. This was noted over two consecutive days, despite the facility's policy that the catheter bag should not touch the floor. The resident had a history of chronic kidney disease and benign prostatic hyperplasia with lower urinary tract symptoms, and the improper positioning of the catheter bag was confirmed as inappropriate by the facility's Infection Preventionist.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to adhere to its Oxygen Administration policy by not labeling the oxygen tubing and humidifier bottle with the date and initials for a resident who was receiving oxygen therapy. The policy, dated 1/28/25, requires that nasal cannulas, oxygen tubing, humidifiers, and reservoirs be tagged with the date and initials of the person who changed them, with guidelines specifying that oxygen tubing and humidifier bottles should be changed weekly. On 3/3/25, it was observed that the resident's oxygen tubing and humidifier bottle were not labeled as required. This was confirmed by a registered nurse, who verified the absence of labeling on the equipment. The resident had a physician's order for oxygen at two liters as needed to maintain oxygen saturation above 91 percent, with the order dated 2/3/25.
Failure to Monitor and Document Urinary Output Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure proper care and monitoring of residents with indwelling urinary catheters, leading to significant health issues for two residents. One resident, identified as R1, experienced a lack of documented urinary output for two days without physician notification or medical intervention. This resident was subsequently sent to the emergency room and hospitalized with a urinary tract infection (UTI) positive for ESBL and E. coli, as well as cystitis and hydronephrosis. The facility did not notify the physician of the abnormal urinalysis results or follow up with treatment orders, resulting in a repeated hospitalization for the resident due to a UTI and encephalopathy. The facility's failure to document and communicate changes in the resident's condition, such as decreased or absent urinary output, was evident in the case of R1. Despite the facility's policy requiring notification of significant changes in condition, there was no documentation of physician notification from 12/23/24 to 12/28/24. Additionally, the facility did not obtain a urinalysis as ordered by the physician, and the resident's medical chart lacked documentation of urinary output on multiple occasions. This lack of communication and documentation contributed to the resident's deteriorating health condition and subsequent hospitalizations. Another resident, R5, also experienced issues with urinary output documentation. The facility failed to document urine output on several shifts and did not notify the physician of absent or decreased urinary output. This pattern of inadequate monitoring and communication posed a risk to the health and safety of residents with indwelling urinary catheters, leading to the identification of an Immediate Jeopardy situation. The facility's deficiencies in monitoring, documenting, and communicating changes in residents' conditions were significant factors in the adverse health outcomes experienced by the residents.
Removal Plan
- Implement a new process for shift-to-shift communication and medical provider notification and follow-up to ensure physician orders and labs are obtained timely and the physician is notified of results. This includes a practice to exchange information related to urinary output on each shift verbally with a signature from the CNA and the nurse they are giving report to.
- In-service all clinical staff on monitoring outputs for residents with indwelling catheters, which includes completing, monitoring, reporting, and documenting.
- In-service all licensed staff on physician orders and labs being obtained timely and the notification of the physician timely.
- In-service all licensed staff on physician notification of change in urinary status or any change in condition.
- Educate new staff during onboarding and have an in-service sign-off sheet to show the education has been completed.
- Create a binder for agency staff with the educational documents of the same information all of the in-house staff was educated on, and they are to read and sign off on prior to starting their next shift.
- Monitor for compliance to ensure compliance of intervention by auditing.
Failure to Notify Physician of Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition, specifically decreased or absent urinary output, and did not follow up on abnormal urinalysis results. The resident, identified as R1, had a urinary tract infection (UTI) with no antibiotic medication orders, and the urinalysis lab work was collected four days after it was ordered. These failures led to R1 being transferred to the emergency room for evaluation and subsequent hospitalization, where she received intravenous fluids and antibiotics for a UTI. The resident was diagnosed with urinary retention, cystitis, and hydronephrosis, which could potentially be life-threatening. The facility's guidelines required nurses to notify the physician of significant changes in a resident's condition before the end of each shift. However, there was no documentation of the physician being notified about R1's condition from 12/23/24 to 12/28/24. The medical director and the on-call physician confirmed they did not receive any communication from the facility regarding R1's condition. Additionally, there was a delay in collecting a urinalysis ordered on 1/9/25, which was not collected until 1/13/25, leading to another hospitalization for R1 with a diagnosis of UTI and encephalopathy. The Director of Nursing confirmed the urinalysis should have been collected the same day it was ordered, and the medical director was not informed of the delay.
Failure to Ensure Physician Availability for Emergency Calls
Penalty
Summary
The facility failed to ensure a physician was available for emergency calls related to changes in condition for a resident. The facility's policy requires nurses to notify a physician of significant changes in a resident's condition before the end of their shift. If unable to contact the physician, the nurse may send the resident to the hospital for evaluation. On 12/28/24, a nurse documented that a resident had a rash, brown mucous and discharge from the vagina, and had not urinated in her catheter for two days. The resident's urine culture from 12/23/24 showed an antibiotic-resistant urinary tract infection. Despite these significant changes, there were no new treatment orders or documentation of a physician's response in the resident's medical chart. The facility's administrator acknowledged that nursing staff had issues reaching a physician while the medical director was on vacation. The administrator instructed staff to send residents to the emergency room if they could not reach a physician. The resident was eventually sent to the emergency room after the family member was informed of the situation and agreed to the transfer. The emergency room nurse confirmed that the facility reported being unable to reach the physician for three days. The nurse on duty on 12/28/24 confirmed multiple attempts to contact the physician without success, leading to the decision to involve the family member and send the resident to the emergency room.
Failure to Timely Obtain Urinalysis Leads to Hospitalization
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis result in a timely manner for one resident. On January 9, 2025, a Licensed Practical Nurse (LPN) received an order for a urinalysis due to the resident's decreased urinary output and foul-smelling urine. However, the LPN did not have time to collect the sample and passed the task to the oncoming nurse. The urinalysis was not collected until January 13, 2025, despite the resident's condition worsening, with urine described as dark yellow, containing sediment, and murky. The delay in obtaining the urinalysis was not communicated to the physician, as required by the facility's policy. The resident was eventually catheterized on January 13, 2025, to obtain a urine sample, which was green, thick, and foul-smelling. The resident was subsequently sent to the hospital, where they were diagnosed with a urinary tract infection and encephalopathy, requiring intravenous antibiotics. The Director of Nursing confirmed the lack of documentation for the urinalysis collection on January 9, 2025, and the Medical Director stated that lab tests should be completed the same day they are ordered unless otherwise notified.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Health Care East | 13.6 mi | — | 6 | 1 |
| Arc At Sangamon Valley | 14.3 mi | — | 4 | 0 |
| Regency Care | 14.9 mi | — | 1 | 0 |
| Springfield Suites Rehab And Nursing | 15.2 mi | — | 15 | 0 |
| Arcadia Care On The Hill | 15.2 mi | — | 30 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.