Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Symphony Northwoods during CMS and state inspections, most recent first.
The facility failed to consistently provide and care plan restorative walking programs for three residents with mobility limitations and muscle weakness. One resident on a twice-daily walking program reported staff no longer walked him, and CNA documentation showed many days marked as not applicable, with no restorative walking reflected in his care plan. Another resident with multiple medical conditions had an order for walking twice daily; although an LPN documented walks on the MAR, the resident and a CNA reported he was walked only a few times over two weeks, and his CNA tasks lacked walking on even surfaces and his care plan lacked a restorative program. A third resident with a care-planned ambulation goal had walking tasks documented as not applicable most days and was walked only once daily on limited dates. Staff interviews revealed that the restorative CNA had stepped down, there was no designated restorative staff, floor CNAs were expected to provide restorative services when able, and leadership acknowledged that restorative programs should be in care plans and documented but were not consistently implemented.
A resident with dementia, confusion, repeated falls, and multiple comorbidities was identified by staff as a very high fall risk who was agitated, attempting to crawl out of bed, and unable to walk independently. Progress notes and staff interviews showed the resident experienced several falls, including a witnessed slide from bed causing a skin tear and subsequent falls resulting in head trauma and other injuries. Although the care plan called for a 1-inch floor mat beside the bed, staff reported that mats were not initially used and were not consistently in place, citing concern the resident might trip. An LPN described hearing a thud and finding the resident face down on the floor with blood around the head and no mat present. The DON acknowledged that the mat intervention was implemented only after multiple falls, and hospital records documented multiple cervical vertebral fractures and other injuries from three falls within 24 hours, with the resident’s death certificate attributing death to complications from these fall-related fractures.
Surveyors identified multiple dietary service failures, including expired refrigerated foods left in storage beyond their labeled use-by dates, a cook working without a required hair net, and improper manual sanitizing of a blender that was washed and rinsed without immersion in sanitizer or air drying, while sanitizer solution was absent from the third sink compartment. The same cook prepared pureed vegetables in the inadequately sanitized blender, with solution dripping from the blender onto the counter during use. Additionally, required food temperatures for hot and cold items were not taken or documented on the meal temperature log, despite facility policies and staff statements that all foods must be temped and recorded. These issues had the potential to affect all residents receiving meals from the kitchen.
The facility failed to follow its own policy and CMS requirements to educate staff on COVID-19 vaccination, offer the COVID-19 vaccine, and document each employee’s vaccination status. The Infection Prevention Nurse reported that the facility does not offer the COVID-19 vaccine to employees and does not keep records of who has been vaccinated. A restorative CNA stated she had not been offered the vaccine, had not been asked about her vaccination status, and had not received education on the current COVID-19 vaccine. An RN and an LPN reported they work throughout the building without designated areas, while the written policy requires annual offering of CDC-recommended vaccines, provision of vaccine education, completion of declination forms, and maintenance of a staff vaccination list and education forms.
The facility failed to provide meaningful, resident-centered activities for several residents with dementia. A resident with Alzheimer’s disease was kept in a dining room for hours with a TV program she disliked, minimal staff interaction, and no individualized engagement, and her care plan lacked activity interests. Another resident with dementia lost access to a baby doll she was nurturing when another resident took it without staff noticing, then sat idle after an activity aide removed nearby comfort items, despite her documented interests in socializing, going outside, dogs, and card games. Two additional residents with dementia were left to wander or sit facing away from the TV with no individualized activities, even though their care plans identified preferences such as arts and crafts, music, religious observance, TV, walking the unit, and visiting others. The activity director reported that, despite a posted calendar of group programs, no communal activities were being conducted and staff were supposed to provide one-on-one activities during an influenza outbreak, which were not observed.
Staff failed to follow PPE and hand hygiene protocols for residents on contact and droplet isolation for influenza. An LPN wore an improperly secured N95 mask, did not remove the mask or face shield when exiting an isolation room, and then entered a non-isolation room wearing the same PPE to administer medications. In a separate event, an activity aide entered an isolation room of a resident with influenza wearing only a mask, without a gown or face shield, and did not perform hand hygiene when entering or exiting before proceeding to deliver a meal tray to another resident who was not on isolation.
A resident admitted from a rehab hospital with anoxic brain injury and bipolar disorder had a PASARR Level I screening that authorized only a 60-day convalescent stay and indicated possible serious mental illness or IDD. After the 60-day approval period ended, no follow-up PASARR screening was completed as required. The Social Service Director reported that corporate staff handled initial PASARRs while social services was supposed to track and follow up on 60-day approvals, but the responsible social services staff at that time did not complete the needed follow-up, and the current director was unaware it was required.
A resident with an indwelling urinary catheter and a history of UTI was observed on multiple occasions lying in bed with the catheter drainage bag resting on the floor, including instances where the bedside table wheels were running over the bag. A CNA reported that staff were responsible for all catheter care for this resident and acknowledged that the drainage bag should not touch the floor to prevent contamination or infection. The facility’s written catheter care policy required that drainage bags be kept off the floor, but this was not followed in the resident’s care.
A resident with poor oral intake and identified risk for malnutrition had physician orders and a care plan directing fortified foods three times daily, including fortified mashed potatoes at lunch and dinner. During a meal observation, the resident’s tray did not contain any potatoes, and the resident reported this omission occurred from time to time. The dietitian confirmed the resident should have received fortified mashed potatoes, which are prepared with whole milk and protein powder to help manage weight. The dietary manager stated that fortified items are identified on meal tickets, reviewed the resident’s lunch ticket, and confirmed it did not indicate fortified foods despite both mashed potatoes and a baked potato being selected, resulting in the resident not receiving the ordered fortified potatoes.
A resident with liver failure and complications including hepatorenal syndrome, metabolic encephalopathy, and portal hypertension had an order for midodrine three times daily with instructions to hold the dose if systolic BP was greater than 120 mm Hg. Review of the MAR showed that on multiple days the resident’s systolic BP exceeded this parameter, yet midodrine was still documented as given. An LPN confirmed that check marks on the MAR indicated the medication was administered, and the DON stated that nurses were expected to follow ordered parameters, while facility guidelines required medications to be given according to prescriber orders.
Surveyors found that several opened insulin pens on a medication cart, including Lantus, Glargine, and Humalog pens used by multiple residents, were not labeled with the date of opening as required. An LPN confirmed that all insulin pens must be dated when opened and are only usable for 28 days, and the DON verified that facility policy requires documenting both the opening date and the 28-day expiration date. This omission resulted in noncompliant labeling and storage of insulin medications.
The facility failed to follow its pneumococcal vaccination policy for two residents by not assessing or documenting their pneumococcal (PNA) vaccine status at admission and not offering the vaccine at move-in as required. Review of vaccine and admission records showed no pneumococcal vaccine information for these residents, and the Infection Prevention Nurse confirmed they had not been offered the vaccine before the surveyor interview, despite stating that all residents are to be screened on admission and offered the vaccine if due.
The facility did not ensure that nurse staffing information was posted and updated each day as required. A scheduler reported that the ADON is responsible for posting daily staffing on the bulletin board, but the staffing information observed on the board was several days out of date. This practice did not follow the facility’s written policy, which requires completion and daily updating of the staffing report, including census and date, in a prominent and accessible location.
A resident with severe cognitive impairment and total care needs was found with new bruising to her left shoulder. Facility staff did not notify the physician or NP or obtain an X-ray order, instead waiting for hospice direction, which led to a delay of over 24 hours before the injury was properly assessed. The X-ray, eventually ordered by hospice, revealed a shoulder dislocation, and the resident was sent to the hospital for evaluation. Facility documentation and staff interviews confirmed a lack of timely assessment, physician notification, and follow-up as required by policy.
A resident with severe cognitive impairment and total dependence on staff for care suffered a left shoulder dislocation after being repositioned in bed by a CNA working alone, despite the care plan requiring two staff for safe repositioning. The injury was discovered when bruising and swelling were noted, and subsequent assessment and imaging confirmed the dislocation. Staff interviews confirmed the resident could not move independently and that the care plan protocol was not followed.
Facility staff did not inform a resident's POA of new bruising and a shoulder dislocation, despite discovering the injury and initiating medical interventions such as an X-ray and hospital transfer. The POA was only notified by the hospice agency, not by facility staff, which was contrary to facility policy requiring immediate notification of responsible parties following a change in condition.
A resident with a history of falls and multiple comorbidities experienced an unwitnessed fall, after which only a urinalysis was performed to rule out infection due to confusion, with no additional fall prevention interventions implemented. The resident subsequently suffered another fall resulting in multiple rib fractures and required hospital evaluation. Staff confirmed that no further interventions were put in place between the two incidents.
A resident with a history of psychosis, recent medication changes, and acute delusions was placed at the nurses station for monitoring but was able to leave the facility unsupervised in her wheelchair when staff supervision lapsed. The resident was found outside without injury after staff initiated a search, revealing a deficiency in maintaining adequate supervision for residents experiencing acute cognitive changes.
A resident with a history of aggressive behavior and undergoing a gradual dose reduction of quetiapine unexpectedly slapped another resident in the dining room, causing her glasses to fall. A CNA witnessed the incident and noted the aggressive resident's frequent behaviors. The facility's administrator acknowledged the incident, which coincided with a recent medication adjustment.
A resident with severe cognitive impairment and mobility issues fell from bed during incontinence care, resulting in multiple fractures and a laceration. The CNA involved was unsure if the resident was rolled too far, and staff interviews revealed the resident's care needs were underestimated, leading to inadequate supervision during the incident.
A resident with severe cognitive impairment was physically harmed by another resident with known behavioral issues in an LTC facility. Despite the facility's abuse prevention policy, the two residents continued to share a bathroom, contributing to the incident. The harmed resident sustained cuts and bruises, and expressed feeling unsafe.
The facility failed to timely identify and address pressure injuries for two residents, leading to advanced-stage ulcers. One resident, at high risk due to immobility and cognitive issues, developed multiple stage 3 pressure injuries. Another resident with a stage 4 heel ulcer did not receive required offloading interventions. The facility's skin care policy was not adequately followed.
A resident with cognitive and swallowing disorders experienced significant weight loss, but the facility failed to notify the dietician promptly, delaying dietary interventions. The resident lost 8 lbs. over 24 days and an additional 3.4 lbs. in the following week. The facility's policy requires notifying the dietician for weight changes of 5% or more in a month, but this was not done until later, resulting in a delay in implementing necessary dietary measures.
A resident with a non-pressure wound on the left foot did not have her dressing changed as per physician orders, which required daily changes. The wound care nurse forgot to input the orders, and the responsible nurse did not change the dressing due to the absence of an order. The resident's care plan highlighted the need for treatment as ordered, considering her condition of congestive heart failure.
The facility failed to safely transfer a resident, resulting in bruising, and improperly used a non-medical grade power strip for medical devices. A CNA used a sit-to-stand lift instead of a mechanical lift, contrary to the resident's care plan. Additionally, a resident's bed and air mattress were plugged into a non-medical grade power strip, with no facility policy available.
A resident with a history of pneumonia and respiratory issues did not receive proper respiratory care due to the facility's failure to maintain bedside suction equipment. The equipment was improperly stored and not dated, and staff were unaware of maintenance protocols. The resident's care plan lacked interventions for oral suctioning, and there were no physician orders for PRN suctioning. The facility did not provide a relevant policy during the survey.
Two CNAs failed to wear gowns while providing care to residents on Enhanced Barrier Precautions, despite facility policy requiring PPE for high-contact care. One resident had a pressure ulcer, and another had a suprapubic catheter and a healing pressure ulcer. The facility's policy mandates gowns and gloves for such care, but the CNAs did not comply, as confirmed by the DON.
A resident with multiple health issues developed a necrotic pressure ulcer on the right heel due to the facility's failure to identify and treat it in a timely manner. Despite being at risk, the resident's care plan lacked specific interventions for heel protection, and staff did not conduct adequate skin checks or documentation, leading to the ulcer becoming unstageable.
Failure to Provide and Care Plan Restorative Walking Programs for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document restorative services, particularly walking programs, to maintain or improve residents’ range of motion and mobility. One resident, who was alert and oriented and used a wheelchair and walker, reported that he had been "cut out of therapy" and that staff did not walk him because they were too busy, despite his desire to ambulate with assistance. His restorative progress note showed he was on a walking program twice daily with specific instructions for ambulation using a two-wheeled walker, yet CNA nursing rehab task documentation for walking showed that on 11 out of 30 days the service was marked not applicable, indicating it was not provided. Additionally, his current care plan did not include his restorative walking program or the services to be provided. Another resident with multiple diagnoses including muscle weakness, malnutrition, metabolic encephalopathy, atrial fibrillation, and dizziness had a physician order for restorative walking 15–20 minutes on first and second shifts. The MAR reflected that an LPN documented the resident was being walked twice per day, including during the survey period. However, the resident stated he was no longer walked daily since the previous restorative CNA stepped down, reporting that he previously completed 12 laps but had only been walked about three times in the last two weeks for only three laps each time. His assigned CNA confirmed that restorative walking was not occurring consistently, that no staff had walked him that day, and that staffing levels made it difficult to walk residents. CNA task documentation for this resident did not include walking on even surfaces, only on uneven or sloping surfaces, and his care plan did not include a restorative program despite an ADL self-care deficit related to limited mobility and impaired balance. A third resident, admitted with conditions including primary disorder of muscle, difficulty in walking, abnormal posture, and muscle weakness, had a care plan for a restorative ambulation program with a goal to ambulate 110–200 feet using a four-wheeled walker with extensive assist and wheelchair follow. CNA task documentation for walking 150 feet twice daily showed the task was marked not applicable 22 out of 26 times in the last 14 days, and when the resident was walked, he required maximal assistance or was dependent. Documentation of minutes spent in walking training showed he was walked only once daily on several specific dates rather than twice daily as planned. The resident reported that staff did not walk him, while an LPN stated he was able to walk with staff assistance. Facility leadership, including the DON, ADON, and nursing staff, acknowledged that the previous restorative CNA had stepped down, that there was no designated restorative staff, that floor CNAs were now responsible for restorative services, and that there was uncertainty about which residents were on restorative programs. The facility’s Nursing Rehab policy required the interdisciplinary team to develop and implement care-planned interventions and to record nursing rehab tasks as part of daily care, which was not consistently done for these residents.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions to prevent and/or minimize injury for a resident identified as very high risk for falls, resulting in multiple unwitnessed and witnessed falls. Staff interviews and record review showed that the resident had dementia, confusion at baseline, insomnia, hearing loss, major depressive disorder, adjustment disorder with depressed mood, and a history of repeated falls. Progress notes documented that the resident was aggravated and attempting to crawl out of bed, had a witnessed slide from bed with a resulting skin tear, and later experienced additional falls. Nursing staff, including LPNs and the DON, acknowledged that the resident was a definite fall risk, was very agitated, kept trying to get out of bed, and was unable to walk independently. Despite this, the resident did not have floor mats in place at the time of at least one fall, and staff reported that fall mats were not used initially because they believed the resident would trip over them. The resident’s care plan identified a potential to fall and risk of injury from falls, with an intervention for a one‑inch floor mat to be placed beside the bed beginning on a specified date. However, staff statements and documentation showed that the floor mat intervention was not consistently implemented, including after the resident returned from the hospital with a scalp laceration requiring staples and other injuries from a prior fall. One LPN reported hearing a “thud” from the nurse’s station and finding the resident face down on the floor with blood around the head, noting that no fall mat had been placed because of concern the resident would trip. The DON stated that a one‑inch floor mat was implemented only after the second fall that shift, and the resident subsequently fell again about an hour after returning from the hospital. Hospital records confirmed that the resident sustained multiple cervical vertebral fractures, nasal and septal fractures, a tooth fracture, scalp laceration, and blunt head trauma as a result of three falls within 24 hours, and the death certificate linked the resident’s death to multiple vertebral fractures due to falls.
Food Safety, Sanitation, and Hair Restraint Failures in Dietary Services
Penalty
Summary
The deficiency involves multiple failures in food storage, preparation, sanitation, temperature monitoring, and use of hair restraints in the facility kitchen, with the potential to affect all 81 residents. During a kitchen tour, surveyors observed several refrigerated food items past their labeled use-by dates, including applesauce and sliced apples dated 12/3–12/9, shredded cheddar cheese with a use-by date of 1/3, and half a ham dated 12/28–1/3, despite facility policy requiring refrigerated foods to be covered, labeled, and dated with a use-by date. The Dietary Manager confirmed that staff write use-by dates on containers and that these foods should have been used by those dates. The menu review showed that Caribbean pork roast was served on a different day than originally scheduled because the roasts were not available on the planned day. Surveyors also observed a cook working in the kitchen without a hair net, instead wearing a winter stocking hat, contrary to the facility’s Hair Restraints/Jewelry/Nail Polish Policy requiring hairnets at all times in the kitchen. The same cook was seen washing and rinsing a dirty blender and lid in the three-compartment sink, then using a sanitizer hose to rinse them without submerging them in sanitizer solution for at least one minute, and without allowing them to air dry, even though the sanitizer compartment contained no solution. After preparing pureed green beans in the blender, solution was seen dripping from the bottom of the blender onto the counter as the food was poured into a pan. When the lunch meal was being plated and sent to the units, the food temperature log for that meal had no recorded temperatures, and the cook stated he forgot to record them, despite facility policy and another cook’s statement that all hot and cold foods should be temperature-checked and documented at the end of cooking. The Dietary Manager later stated that anyone entering the kitchen must wear a hair net and that equipment must be fully submerged in sanitizer for at least one minute and then air dried, consistent with posted manufacturer instructions and the facility’s manual sanitizing policy.
Failure to Educate, Offer, and Document Staff COVID-19 Vaccination
Penalty
Summary
The facility failed to provide COVID-19 vaccination education, offer the COVID-19 vaccine, and document vaccination status for its employees, contrary to its own policy and CMS regulations. The CMS-671 dated 1/5/26 showed a facility census of 81 residents. During an interview, the Infection Prevention Nurse stated that the facility does not offer the COVID-19 vaccine to employees and does not keep records of which employees have or have not received the vaccine. The facility’s written policy, reviewed in 10/25, states that employees will be offered CDC-recommended vaccines annually, including COVID-19, that staff will be provided information and education regarding the vaccine, that declination forms will be completed and filed for those who refuse, and that a list of vaccinated employees will be maintained by the Infection Prevention Nurse designee. The policy also states that CMS regulations require staff to receive education on COVID-19 and be offered the vaccine, with staff completing a COVID-19 staff education form as proof. Staff interviews confirmed that the facility was not implementing these requirements. A restorative CNA who had worked at the facility for 13 years reported that the facility was not currently offering COVID-19 vaccines to employees, that no one had asked about her current COVID-19 vaccination status, and that she had not received any education regarding the current COVID-19 vaccine. An RN and an LPN both reported that they work throughout the building without designated areas, indicating that staff who move across all units were not being tracked or documented for COVID-19 vaccination status. These observations and interviews demonstrate that the facility was not following its own policy or CMS requirements to educate staff on COVID-19 vaccination, offer the vaccine, and maintain documentation of each employee’s vaccination status.
Failure to Provide Resident-Centered, Dementia-Appropriate Activities
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident-centered, meaningful activity program for multiple residents with dementia. One resident with late-onset Alzheimer’s disease was repeatedly placed in the dining room for extended periods, seated at a table with many other residents while a 1990s Western drama played on the television that she did not like and did not watch. Activity staff were seated in a corner with only one resident coloring, and most residents were asleep. This resident was observed propelling herself in her wheelchair, asking how long she had to sit there, stating she wanted to return to her room to watch TV, and describing the situation as “torture” and that residents were left with “no water.” Staff initially refused to let her return to her room due to fall risk, left her without engagement, and later only provided coloring materials at a table in the corner. Her care plan did not address her activity interests or abilities. Another resident with unspecified dementia sat in the dining room in a wheelchair holding a baby doll, kissing and cradling it, until another resident took the doll away without staff noticing or intervening. This resident then sat without any activity, commented to another resident that they were just “set out here,” and placed a small activity blanket on the floor, stating someone else would pick it up. An activity aide later removed the stuffed animal, pillow, and blanket from the area and put them away, and the resident was turned to face the table as preparations for lunch began. No structured or individualized activities were provided during this time, despite the resident’s care plan noting that she likes to sit and talk with others, go outside, loves dogs, and enjoys card games such as poker and rummy. Two additional residents with dementia were also not provided with meaningful, individualized activities. One resident repeatedly walked between her room and the dining room, briefly sitting and then leaving, and when she asked for help finding food, staff confirmed she had already eaten and only offered cookies before seating her in front of the same television program that had been playing all day; no staff attempted to engage her in activities consistent with her care plan, which documented interests in arts and crafts, music, bowling, and Catholic faith, and noted that she primarily speaks Spanish. Another resident with dementia spent the morning hours seated in a wheelchair in the dining room with her back to the television, mostly asleep, with no staff engagement and no access to the TV she could not see, despite a care plan stating she would attend meaningful activities such as watching TV, listening to music, going outside, walking the unit, and visiting other residents. The activity director later stated that due to an influenza outbreak there were to be no communal activities, that staff were instructed to focus on one-on-one activities, and that the posted activity calendar listed multiple group activities that were not observed occurring on the days of the survey.
Failure to Follow PPE and Hand Hygiene Protocols for Residents on Influenza Isolation
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to PPE use and hand hygiene for residents on contact and droplet isolation for influenza. One resident had active orders for contact and droplet isolation for influenza, with signage posted instructing staff to remove PPE before exiting the room. An LPN entered this resident’s room wearing the required PPE, including an N95 mask, but the N95 was not properly secured because the top loop was not in use and there was no surgical mask over it. After administering medications, the LPN removed only the gown and gloves when exiting the isolation room and did not remove the face shield or N95 mask, despite posted instructions and facility signage stating that the face shield and mask are considered contaminated and should be removed when exiting an isolation room. The same LPN then entered another resident’s room, who was not on isolation, wearing the same face shield and N95 mask that had been used in the isolation room, and administered medications. In a separate incident, another resident with a positive test for Influenza A and on droplet and contact precautions had a door sign instructing staff to perform hand hygiene before entering and exiting, to fully cover eyes, nose, and mouth, to remove face protection before exiting, and to don gloves and gown before entry. During lunch service, an activity aide entered this resident’s room wearing only a mask, without a gown or face shield, and did not perform hand hygiene upon entering or exiting. The aide then delivered a lunch tray to another resident who was not on isolation and did not have influenza. The infection control nurse confirmed the facility was in a flu outbreak and stated that all staff entering the isolation room should wear a mask (preferably N95), face shield, gown, and perform hand hygiene as preventative measures.
Failure to Complete Required PASARR Follow-Up After 60-Day Convalescent Approval
Penalty
Summary
The facility failed to ensure that a required PASARR (Preadmission Screening and Resident Review) follow-up screening was completed for a resident whose initial PASARR Level I determination authorized only a 60-day convalescent stay. The resident was admitted from a rehabilitation hospital with diagnoses including anoxic brain injury and bipolar disorder, and the PASARR Level I screening dated 11/29/23 documented a convalescence categorical determination with an approval period of 60 days, noting that the resident may have a serious mental illness or intellectual/developmental disability and could remain in the nursing facility for up to 60 days without further PASARR assessment. After this 60-day approval period expired, no subsequent PASARR screening was completed as required. According to the Social Service Director, corporate staff had been completing the initial PASARR screenings and social services staff were responsible for following up on cases with a 60-day limit, but the social services staff member in place at that time did not complete the follow-up screening, and the current Social Service Director, who started in April, was unaware that it needed to be done.
Failure to Keep Indwelling Catheter Drainage Bag Off the Floor
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter drainage bag for one resident, resulting in the bag resting on the floor on multiple occasions. The resident had an indwelling urinary catheter and a history of urinary tract infection, as documented in a care plan reviewed on 01/05/26. On 01/05/26 at 8:58 AM, the resident was observed in bed with the indwelling urinary drainage bag positioned at the side of the bed, with the bottom portion of the bag resting on the floor. On 01/06/26 at 8:38 AM, the resident was again observed in bed with the drainage bag not hanging from any support and lying flat on the floor, while the wheels of the bedside table were running over the drainage bag. During an interview on 01/06/26 at 11:04 AM, a CNA stated that staff provided all indwelling urinary catheter care and management for the resident and acknowledged that a drainage bag should not touch the floor to prevent contamination or infection. The facility’s Indwelling Catheter Care and Maintenance policy, reviewed in 03/2025, directed staff to keep the drainage bag off the floor. These observations and statements show that staff did not follow the facility’s catheter care policy or accepted practices for maintaining the drainage bag off the floor for this resident with an indwelling urinary catheter and a history of urinary tract infection.
Failure to Provide Ordered Fortified Foods for Nutritionally At-Risk Resident
Penalty
Summary
The facility failed to provide ordered fortified foods to a resident identified as being at risk for malnutrition. The physician order summary dated 01/07/26 directed that the resident receive fortified food three times daily for poor oral intake, specifically super cereal at breakfast and fortified mashed potatoes at lunch and dinner. The resident’s dietary profile effective 12/23/25 documented a nutritional supplement of fortified foods and a preference for potatoes, and the care plan initiated 4/18/25 identified the resident as at risk for malnutrition with an intervention to provide fortified foods three times a day, including fortified mashed potatoes at lunch and dinner. On 01/05/26 at 11:47 AM, surveyors observed the resident in his room with a covered meal tray; when the lid was removed, there were no potatoes on the tray. The resident stated he was supposed to receive potatoes and that not receiving them happened from time to time. On 01/06/26 at 11:55 AM, the dietitian explained that fortified mashed potatoes are prepared with whole milk and protein powder and are used to help manage a resident’s weight, and confirmed the resident should have received fortified mashed potatoes. At 12:59 PM the same day, the dietary manager stated that the kitchen relies on the meal ticket to identify fortified foods, reviewed the resident’s lunch meal ticket from 01/05/26, and confirmed it did not indicate fortified foods. She reported assisting the resident in filling out the meal ticket, with both mashed potatoes and a baked potato circled, and acknowledged the resident should have received mashed potatoes and a baked potato.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not follow ordered blood pressure parameters for administering a prescribed medication. A resident with liver failure who was not a transplant candidate, and who had complications including hepatorenal syndrome, metabolic encephalopathy, and portal hypertension, had a provider order for midodrine to be given three times daily for portal hypertension, with instructions to hold the medication if the systolic blood pressure exceeded 120 mm Hg. Review of the resident’s December 2025 MAR showed that on ten days during the month, the resident’s systolic blood pressure was above 120 mm Hg, yet midodrine was documented as administered. An LPN who gave several of these doses confirmed that a check mark on the MAR indicated the medication was given, and the DON stated that nurses were expected to follow medication parameters when administering medications. The facility’s written Medication Administration – General Guidelines, dated November 2021, required that medications be administered in accordance with the prescriber’s written orders, but the documented administration of midodrine despite blood pressure readings above the ordered threshold on multiple days demonstrated noncompliance with these guidelines and the provider’s parameters.
Failure to Date Opened Insulin Pens per Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when multiple opened insulin pens on a first-floor medication cart were not dated in accordance with facility policy and professional standards. During a medication storage review, an LPN and the surveyor observed that insulin pens assigned to three residents, including Lantus KwikPens for morning and bedtime administration and a Glargine KwikPen for morning use, as well as a Humalog KwikPen used per sliding scale, had been opened but were not labeled with the date of opening. The LPN acknowledged that all insulin pens were required to be dated when opened and stated that these pens were only good for 28 days, so without dates they did not know when to discard them or whether the insulin was still effective. The DON also confirmed that all insulin pens should be dated upon opening because they are only good for 28 days after opening, and the facility’s written policy on insulin pen usage required pens to be labeled with the date of opening and the expiration date, defined as 28 days after opening. This failure to date opened insulin pens for these residents constituted noncompliance with the requirement that drugs and biologicals be labeled in accordance with accepted professional principles and facility policy.
Failure to Assess and Offer Pneumococcal Vaccinations on Admission
Penalty
Summary
The deficiency involves the facility’s failure to assess and offer pneumococcal vaccinations upon admission as required by its own policy. Record review on 1/6/26 showed that two residents’ vaccine records contained no information regarding their pneumococcal vaccine status. Admission records indicated both residents had been admitted prior to that date, yet there was no documentation that they had been screened for or offered the pneumococcal vaccine at the time of admission. During interviews, the Infection Prevention Nurse stated that all residents are supposed to be screened on admission for pneumococcal vaccine status and that, if due, the vaccine can be ordered and administered in the facility, with offers continued annually as applicable. However, the Infection Prevention Nurse acknowledged that these two residents had not been offered the pneumococcal vaccine prior to the day of the interview, despite the facility’s Pneumovax Vaccine Policy stating that all guests will be offered the pneumococcal vaccination at the time of move-in. This failure to follow the established pneumococcal vaccination policy for these two residents at admission, and the lack of documentation of their pneumococcal vaccine status, led to the cited deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis as required, affecting a census of 81 residents. On review of the CMS-671 dated 1/5/26, the facility census was confirmed as 81. During an interview on 1/6/26 at 9:19 AM, the scheduler stated that the ADON is responsible for posting the daily staffing on the bulletin board. However, at 10:09 AM on the same day, the nurse staffing information posted on the facility’s bulletin board was found to be dated 1/2/26, indicating that it had not been updated daily. The facility’s Posting of Staffing Report Policy, reviewed in 2/25, states that staff will complete and update the daily Staffing Report each day and post it in a prominent, readily accessible place with the daily census and date displayed, which was not followed in this instance. This failure to update and post the staffing report daily was identified through observation, staff interview, and record review, and was determined to be inconsistent with the facility’s own policy and applicable state and federal requirements for daily staffing postings.
Failure to Timely Assess and Treat New Shoulder Injury
Penalty
Summary
Facility staff failed to assess, intervene, and implement timely treatment for a resident who was found with new bruising to her left shoulder. The resident, who was severely cognitively impaired, nonverbal, and dependent on staff for all care due to Alzheimer's disease, was discovered with a large, purple bruise on her left upper arm during the early morning hours. Despite this significant change in condition, facility staff did not notify the resident's physician or nurse practitioner, nor did they attempt to obtain an order for an X-ray. Instead, staff notified the hospice agency and waited for their direction, resulting in a delay of over 24 hours before an X-ray was performed. The X-ray, eventually ordered by the hospice nurse after her own assessment, revealed a dislocated left shoulder with a possible glenoid fracture. The resident was subsequently sent to the hospital for evaluation, where surgical intervention was recommended but declined by the resident's power of attorney. The resident was returned to the facility with orders for conservative management and comfort care. Throughout this period, facility progress notes showed no documentation of reassessment of the injury, no follow-up with the mobile X-ray company to expedite imaging, and no direct communication with the resident's primary medical providers regarding the acute change in condition. Interviews with facility staff, including the RN, ADON, and DON, confirmed that none of them contacted the resident's physician or nurse practitioner after discovering the injury. Staff indicated they were waiting for hospice to take the lead, despite facility policy requiring immediate notification of the attending physician for acute changes in condition. The facility's own policy emphasized the need for prompt assessment, physician notification, and documentation when a resident experiences an acute change, none of which were followed in this case.
Failure to Follow Care Plan Results in Resident Shoulder Dislocation
Penalty
Summary
A deficiency occurred when staff failed to provide care in accordance with a resident's care plan, resulting in a left shoulder dislocation. The resident was severely cognitively impaired, nonverbal, and fully dependent on staff for all activities of daily living due to Alzheimer's disease. The care plan specified that two staff members were required to safely reposition the resident in bed. However, a CNA reported providing incontinence care and repositioning the resident alone on multiple occasions during a night shift, contrary to the care plan instructions. The incident was discovered when the CNA noticed bruising and swelling on the resident's left shoulder while dressing her. The CNA reported the finding to the RN, who assessed the resident and found the area to be purple and warm to the touch. The hospice nurse was notified and, upon assessment, found the shoulder to be floppy and unstable, prompting an X-ray order. The X-ray revealed a dislocated left shoulder with a possible glenoid fracture, and the resident was subsequently sent to the hospital for evaluation. Interviews with facility staff confirmed that the resident was unable to move independently and had no history of falls or injuries during the relevant period. The nurse practitioner and hospice nurse both stated that the injury could not have occurred spontaneously and must have resulted from trauma or force. The DON confirmed that staff are expected to follow the care plan, which required two staff for repositioning, and that this protocol was not followed in this case.
Failure to Notify POA of Resident's Injury and Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's Power of Attorney (POA) of a significant change in the resident's condition, specifically the discovery of new bruising and a subsequent shoulder dislocation. On the early morning of 9/5/25, staff discovered new bruising on the resident's left upper arm and shoulder. The hospice agency was notified, and an X-ray was ordered, which later revealed a dislocated shoulder. The resident was then sent to a local hospital for further evaluation. Throughout this period, there was no documentation or evidence that the resident's POA was informed by facility staff about the new injury, the X-ray, or the change in condition. Interviews with facility staff, including the RN, Assistant Director of Nursing (ADON), and Director of Nursing (DON), confirmed that none of them notified the POA of the new bruising or the subsequent medical interventions. The facility's own policy requires immediate notification of the responsible party when a resident experiences an acute change in condition. Despite this, the POA only learned of the injury and the need for hospital evaluation from the hospice agency, not from the facility. Documentation showed that the POA was contacted about a room change, but not about the resident's injury or medical status.
Failure to Implement Fall Prevention Interventions After Initial Fall
Penalty
Summary
The facility failed to implement additional fall prevention interventions after a resident experienced a fall. Following an unwitnessed fall in the resident's room, the resident was found on the floor next to his bed, having attempted to get up and slid to the floor. The care plan identified the resident as high risk for falls with a history of previous falls, and the only intervention initiated after the incident was a urinalysis to rule out infection due to observed confusion. No other interventions were documented or put in place to address the resident's fall risk after the initial event. Subsequently, the resident experienced another unwitnessed fall while attempting to self-transfer to the restroom, resulting in four fractured ribs and requiring transfer to the emergency department for further evaluation and treatment. The resident's medical history included chronic obstructive pulmonary disease, chronic kidney disease, difficulty walking, unsteadiness on feet, depression, history of falling, and metabolic encephalopathy. Staff interviews confirmed that no additional fall prevention measures were implemented between the two falls, despite the resident's high risk status and recent change in mental status.
Resident Elopement Due to Inadequate Supervision During Acute Delusional Episode
Penalty
Summary
A deficiency occurred when a resident with a history of unspecified psychosis, cerebral infarction, hypertension, adjustment disorder with depressed mood, weakness, and unsteadiness on her feet was not adequately supervised, resulting in her leaving the facility unsupervised. The resident, who had recently been admitted from the hospital and had a recent urinary tract infection and changes to her antipsychotic medications, exhibited acute delusions and agitation during the night. Despite being placed at the nurses station for monitoring due to her behaviors, staff supervision lapsed when a CNA left to answer a call light, and the resident was able to leave the facility in her wheelchair without being noticed. Staff interviews revealed that the resident was being checked every 15 minutes and was considered calm and not displaying exit-seeking behaviors prior to the incident. However, during a period when the CNA was away from the nurses station, the resident left the area and exited the building. The staff initiated a search and found the resident outside on the sidewalk, approximately 130 feet from the facility, fully dressed and in her wheelchair. The resident was returned to the facility without injury. The facility's records indicated that the resident was previously assessed as alert, oriented, and free from confusion, qualifying her for independent pass privileges. However, during the incident, she was experiencing acute cognitive changes, including delusions and agitation, which were not adequately addressed through increased supervision. The facility's elopement policy outlines procedures for searching and notification in the event of a missing resident, but the lapse in supervision allowed the resident to leave the facility unsupervised.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. During a meal in the dining room, one resident, who has a history of aggressive behaviors and was undergoing a gradual dose reduction of quetiapine, unexpectedly slapped another resident, causing her glasses to fall to the floor. A Certified Nursing Assistant witnessed the incident and noted that the aggressive resident frequently exhibits such behaviors. The facility's administrator acknowledged the incident, noting that it was unexpected and coincided with a recent medication adjustment for the aggressive resident.
Resident Injury Due to Inadequate Incontinence Care
Penalty
Summary
The facility failed to ensure safe incontinence care for a resident, resulting in the resident rolling off the bed and sustaining multiple injuries, including a cervical fracture, a left clavicle fracture, and a laceration to the left eyebrow requiring sutures. The resident, who was admitted with severe cognitive impairment and required substantial assistance for bed mobility, was being changed by a CNA when the incident occurred. The CNA reported that the resident continued to roll after being turned, leading to the fall. The resident's care plan indicated a need for extensive assistance with bed mobility and incontinence care. However, the CNA involved in the incident was unsure if the resident was rolled too far and noted that the resident was a difficult turn, requiring more assistance than listed. The RN who responded to the incident emphasized the importance of ensuring stability when turning residents, highlighting a lapse in supervision and care during the incident. Interviews with facility staff revealed that the resident's condition had been declining, making incontinence care more challenging. Despite this, agency staff often attempted care without seeking additional help until realizing the difficulty. Following the incident, the facility updated the resident's care plan to require two-person assistance for bed mobility and incontinence care, indicating a previous oversight in assessing the resident's needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R1, from physical abuse by another resident, R2. R1, who was admitted with severe cognitive impairment and various medical conditions including dementia, was found to have been physically harmed by R2. R2, also with severe cognitive impairment and a history of behavioral disturbances, was noted to have grabbed R1's wrists and caused injuries, including cuts and bruises, during an incident in R1's room. This incident occurred after R2 mistakenly believed R1 was in her bed, leading to aggressive behavior. The incident was reported to the Director of Nursing, and upon investigation, it was found that R1 had sustained a scratch on her left wrist and pinky, a bruise on her left hip, and complained of pain in her left hip and shoulder. X-rays were performed, which showed no acute findings. R1 expressed feeling scared and unsafe following the incident. The facility's investigation revealed that R2 had been aggressive throughout the day and had previously shown physical aggression towards staff but not towards other residents. Despite the incident, R1 and R2 continued to share a connecting bathroom, which both residents believed was theirs. The facility's policy on abuse prevention was in place, but the shared bathroom arrangement and R2's known behavioral issues contributed to the failure to prevent the abuse. Staff interviews indicated that R2's confusion and aggression were known issues, yet the environmental setup remained unchanged, leading to the incident where R1 was harmed.
Failure to Identify and Address Pressure Injuries
Penalty
Summary
The facility failed to identify and address pressure injuries in a timely manner for two residents, leading to the development and worsening of pressure ulcers. One resident, who was at high risk for pressure injuries due to cognitive impairment, immobility, and nutrition issues, developed multiple pressure injuries that were not identified until they reached advanced stages. Despite being completely dependent on staff for care, including repositioning and incontinence care, the resident's pressure injuries were not discovered until they had progressed to stage 3, with some wounds containing necrotic tissue. The facility's former wound care nurse was let go, and the new wound care nurse confirmed that the pressure injuries should have been identified earlier. Another resident with an active stage 4 pressure injury to the left heel did not receive appropriate pressure relief interventions. The care plan required the use of protective heel boots to offload pressure, but the resident was observed with heels flat against the mattress without any offloading measures in place. This oversight occurred despite the resident being at high risk for pressure injuries, as indicated by their Braden Scale score. The facility's Skin Care Prevention policy, which mandates daily evaluation of residents' skin conditions and specific interventions for those at risk, was not adequately followed. The failure to implement these interventions and promptly identify pressure injuries contributed to the deficiencies observed in the care of these residents.
Delayed Notification of Significant Weight Loss
Penalty
Summary
The facility failed to notify the dietician in a timely manner regarding a significant weight loss experienced by a resident, identified as R77. R77, who has diagnoses including cognitive communication deficit, other disorders of the brain, need for assistance with personal care, and dysphagia, experienced an 8 lbs. (6.2%) weight loss over 24 days, followed by an additional 3.4 lbs. (2.81%) weight loss in the subsequent week. Despite the facility's policy requiring notification of the dietician and healthcare provider for significant weight changes of 5% or more in one month, the dietician was not informed until the evening of 10/21/24, delaying the implementation of dietary interventions. The delay in notification resulted in a lack of timely dietary interventions, which included a high-calorie drink and double portions at meals, only being implemented on 10/22/24. The Director of Nursing, who was new to the facility, admitted to being unsure of the process for reporting weight loss to the dietician. The dietician confirmed that she was not notified of the significant weight loss until 10/21/24 and stated that earlier notification would have allowed for earlier intervention. The facility's Weight Change Investigation policy, reviewed in 7/14, outlines the procedure for addressing significant weight changes, which was not followed in this instance.
Failure to Change Wound Dressing as Ordered
Penalty
Summary
The facility failed to change a non-pressure wound dressing for a resident, R83, according to physician orders. R83, who has a diagnosis of local infection of the skin, cellulitis of the left lower limb, and chronic embolism and thrombosis of unspecified deep veins, reported that her wound dressing had not been changed over the weekend. The dressing on her left foot was last changed on October 18, 2024, despite the physician's order to change it daily. The treatment administration record showed no treatment orders for the wound since October 13, 2024, except for a PRN dressing change, which had not been utilized since it was ordered on October 5, 2024. The wound care nurse, V3, acknowledged noticing the unchanged dressing on October 21, 2024, and admitted to forgetting to input the orders on October 18, 2024, when the wound care doctor was present. The nurse responsible for changing the dressing did not do so, citing the absence of an order. R83's care plan, dated August 19, 2024, indicated the need for treatment as ordered by the physician, highlighting the resident's condition of congestive heart failure as a factor inhibiting wound healing. The facility's policies emphasize the importance of accurate documentation of physician orders and appropriate care to prevent skin breakdown, which was not adhered to in this case.
Deficiencies in Resident Transfer and Medical Device Safety
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a large bruise on the resident's left chest and rib area. The incident occurred when a CNA, in a hurry to get the resident up for breakfast, used a sit-to-stand lift instead of the required mechanical lift (hoyer lift) for a two-person assist. The CNA admitted to transferring the resident alone and without proper knowledge of the transfer procedure, which was against the resident's care plan and the facility's safe resident policy. The resident, who is mildly impaired, was sent for further evaluation due to the bruising. Additionally, the facility failed to ensure that a resident's medical devices were plugged into a medical-grade power strip. An extension cord and non-medical grade power strip were used to power the resident's bed and pressure-relieving air mattress, which was necessary due to a pressure wound on the resident's heel. The facility did not have a power strip policy available at the time of the survey, and the issue was observed on consecutive days without correction.
Failure to Maintain Proper Respiratory Care for Resident
Penalty
Summary
The facility failed to maintain appropriate respiratory care for a resident with a history of pneumonia, as evidenced by the improper maintenance of bedside suction equipment. The resident, a female with a history of hemiplegia/hemiparesis following a cerebral infarction and dysphagia, was readmitted with pneumonia, sepsis, and acute respiratory failure. Observations revealed that the suction canister was full of a clear liquid, likely water, and the equipment, including the tubing and yankauer, was not dated. The tubing and yankauer were improperly stored, with the yankauer tip resting against the nightstand. The resident, despite communication difficulties, indicated through gestures that staff had used the suction equipment for her. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, revealed a lack of knowledge regarding the maintenance and exchange frequency of suction equipment. The resident's care plan did not include focuses or interventions related to oral suctioning and airway management, and there were no physician orders for PRN oral suctioning. The Director of Nursing confirmed the absence of such orders and emphasized the need for an order and proper maintenance of the equipment. The facility did not provide a policy on oral suctioning or suctioning equipment during the survey.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that the required Personal Protective Equipment (PPE) was worn by staff when providing care to residents on Enhanced Barrier Precautions. During an observation, two Certified Nursing Assistants (CNAs) were seen providing care to two residents without wearing gowns, despite the presence of an enhanced barrier sign on the door indicating the need for gowns and gloves during high-contact care. The CNAs assisted one resident, who had a pressure ulcer on her heel, by transferring her using a mechanical lift and changing her brief without wearing gowns. Similarly, they provided incontinence care to another resident with a suprapubic catheter and a healing pressure ulcer, again without wearing gowns. The facility's Enhanced Barrier Precautions policy, last reviewed in April 2024, mandates the use of gloves and gowns for residents with urinary catheters and wounds during specific care activities. The Director of Nursing confirmed that staff should wear gowns and gloves when providing direct care to residents on Enhanced Barrier Precautions. One of the CNAs admitted feeling overwhelmed and acknowledged the failure to adhere to the PPE requirements. The deficiency was identified through observation, interview, and record review, highlighting a lapse in following established infection control protocols.
Failure to Prevent and Identify Pressure Ulcer
Penalty
Summary
The facility failed to identify and treat a pressure ulcer for a resident who was dependent on staff for care, resulting in the ulcer becoming necrotic and unstageable. The resident, who had multiple diagnoses including Type 2 Diabetes, Atrial Fibrillation, and Morbid Obesity, was admitted to the facility without any mention of a pressure sore. However, on 3/17/24, necrotic tissue was noted on the resident's right heel, and by 3/18/24, the wound was unstageable and necrotic, prompting a transfer to the ER for further evaluation. Interviews with staff revealed that the resident was resistive to care, including wearing foam boots and having heels elevated, which contributed to the development of the pressure ulcer. The wound nurse, who was responsible for dressing changes, noted that the resident's legs were weeping and that the wound likely developed over the weekend when she was not present. Despite the resident's non-compliance, there was a lack of documentation and proactive measures to prevent the ulcer, such as orders for heel lift boots or off-loading of the heels. The facility's policy on skin management required regular assessments and preventative measures for residents at risk of pressure injuries, as indicated by a Braden Scale score of 18 or less. However, the resident's care plan did not include specific interventions for heel protection, and the staff failed to conduct adequate skin checks and documentation, leading to the oversight of the pressure ulcer until it became severe.
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Illustrative
What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — including the 2 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 Belvidere
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belvidere Health And Rehab | 0.5 mi | — | 2 | 0 |
| Symphony Maple Crest | 3.8 mi | — | 2 | 0 |
| Alden Debes Rehab & Hcc | 8.3 mi | — | 13 | 0 |
| Alden Park Strathmoor | 8.7 mi | — | 4 | 0 |
| Forest City Rehab & Nrsg Ctr | 8.7 mi | — | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.