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Citation history
Health deficiencies cited at George Ade Memorial Health Care Center during CMS and state inspections, most recent first.
A resident with dementia and a high risk for falls, who was care planned for two-person assistance with ADLs, was assisted by a single CNA during a shower. The resident attempted to stand from the shower chair, fell, and sustained a laceration requiring sutures, an abrasion, and later was diagnosed with a right hip fracture. Documentation and interviews confirmed the CNA did not follow the care plan, leading to the resident's injuries and decline.
A resident with cognitive impairment and a history of falls experienced a shower fall resulting in pain and decreased mobility. Despite ongoing complaints of right leg pain and worsening ambulation, nursing staff did not perform or document timely assessments of the affected limb. The lack of thorough evaluation led to a delay in diagnosing a right hip fracture, which was only identified after significant physical changes were observed.
A resident with a history of cognitive impairment and other medical conditions was admitted with a deep tissue injury (DTI) on the left foot. The facility failed to provide timely treatment for the DTI, as documented treatment did not begin until several days after admission, despite a physician's order for daily skin prep. The Director of Nursing acknowledged that treatment should have been initiated immediately, highlighting a deficiency in adhering to the facility's policy on pressure ulcer care.
A resident with a history of falls and cognitive impairment was observed multiple times without anti-rollback bars on her wheelchair, despite a care plan intervention requiring them. The resident had previously fallen and sustained injuries, and the facility's policy emphasized the need for safety interventions. The DON confirmed the bars should have been in place, indicating a failure to provide a safe environment.
A facility failed to provide proper oxygen therapy for a resident with chronic respiratory failure and heart failure. The resident was observed multiple times without oxygen, despite having a physician's order for 2-4 liters per nasal cannula every shift. The MAR indicated oxygen was signed off as administered, but the rate was not documented, and there were no documented refusals. The facility's policy required documentation of liter flow and response, which was not consistently followed.
A facility failed to assess the necessity for bed rails for a resident with cognitive impairment and receiving hospice services. The resident was observed with half-length side rails without any documented evaluation or assessment, and the Physician's Order Summary lacked orders for side rails. The DON acknowledged the absence of an assessment and was unsure if other interventions were attempted. A Side Rail Assessment was later provided, indicating the use of side rails for assistance with transfers and bed mobility.
The facility failed to maintain the dignity of two residents by not covering their urinary drainage bags, as required by policy. One resident with cerebral palsy and intellectual disabilities was observed with an uncovered bag multiple times. Another resident with dementia and urinary retention had an uncovered bag until after morning care. The facility's policy mandates the use of covers to preserve dignity.
The facility failed to provide necessary assistance with ADLs for two residents, specifically in oral care and eyeglass placement. A resident with Alzheimer's did not receive oral care as required by her care plan, and another resident with dementia did not receive oral care or have his eyeglasses placed, despite facility policies mandating these actions.
A resident with a urinary catheter did not receive proper care, as observed when a CNA placed the drainage bag and tubing on the floor multiple times during morning care. The outlet tube was not disinfected after emptying, and the catheter was not washed. The resident had a history of urinary tract infections, and the care plan required the drainage system to be kept off the floor and catheter care to be completed regularly, which was not adhered to.
The facility failed to ensure staff used PPE for residents on Enhanced Barrier Precautions (EBP). Two CNAs were observed entering residents' rooms without PPE, despite signs indicating EBP. The residents had conditions requiring EBP, and care plans specified PPE use. The facility's policy required gowns and gloves to be available near the rooms.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided shower assistance to a resident who was care planned for two-person assistance with activities of daily living (ADLs), including bathing and transfers. The resident had a history of Alzheimer's disease, dementia, moderate intellectual disabilities, and was identified as high risk for falls. The care plan specifically required care in pairs due to the resident's cognitive impairment, fall risk, and behavioral concerns, including threatening harm to staff. Despite these documented interventions, the CNA assisted the resident alone in the shower. During the shower, the resident attempted to stand from the shower chair without adequate support, resulting in a fall. The resident sustained a laceration above the right eye requiring four sutures, an abrasion to the right knee, and was transferred to the emergency room for evaluation. Initial assessments and imaging did not reveal a hip fracture, but the resident subsequently experienced a decline in mobility, increased pain, and difficulty ambulating. Over the following days, the resident's right leg became painful, discolored, and showed signs of injury, eventually leading to the diagnosis of a right femoral neck fracture eight days after the fall. Interviews and documentation confirmed that the CNA was aware of the care plan requirement for two-person assistance but proceeded alone. The Director of Nursing and the attending physician both indicated that the hip fracture was likely caused by the fall during the unsupervised shower. The facility's failure to follow the care plan and provide adequate supervision and assistance directly resulted in the resident's injuries and subsequent decline in function.
Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice following a fall, specifically by not conducting timely and thorough assessments after changes in the resident's condition. The resident, who had diagnoses including right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities, experienced a fall in the shower resulting in a laceration above the right eye and an abrasion to the right knee. After returning from the emergency room, the resident began to complain of right knee and leg pain and was placed in a wheelchair for safety. Despite these complaints and a recommendation for the physician to evaluate the leg, documentation shows that nursing staff did not perform or document comprehensive assessments of the right leg on multiple occasions over several days as the resident's pain and functional status worsened. Throughout the days following the fall, the resident exhibited increasing pain, difficulty with ambulation, and changes in mobility, including refusal to walk, reliance on a wheelchair, and eventually inability to stand without assistance. Nursing notes repeatedly failed to document assessments of the right leg even when pain was reported by the resident or observed by staff. It was not until several days after the initial fall, when the resident's right leg appeared shorter, discolored, and rotated, that an x-ray was ordered, revealing a right femoral neck fracture. Prior to this, only a right knee x-ray had been obtained, which was negative for injury, and the resident continued to experience significant pain and decreased mobility. Interviews with facility staff, including the PT and DON, confirmed that the resident's pain and functional decline were not adequately assessed or addressed in a timely manner. The DON acknowledged that no further assessments were completed by nurses when the resident's right leg pain increased and his functional status changed, until the significant physical changes were observed. This lack of timely and thorough assessment delayed the diagnosis and treatment of the resident's fractured right hip.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment for a resident with a pressure ulcer, leading to a deficiency in care. The resident, who was cognitively impaired and had a history of hypertension, cerebral infarction, and Alzheimer's disease, was admitted to the facility with a deep tissue injury (DTI) on the left foot. Upon admission, the DTI was noted to be a dark brownish purple area measuring 0.8 cm x 3 cm. Despite the presence of the DTI, the Treatment Administration Record (TAR) showed no documented treatment for the left lateral foot from the time of admission on November 22, 2024, until November 26, 2024, when a physician's order for daily skin prep was received. The deficiency was further highlighted during an interview with the Director of Nursing (DON), who acknowledged that a treatment plan should have been implemented immediately upon identifying the DTI. The facility's policy on Skin Condition and Pressure Ulcer Assessment mandates that at the earliest sign of a pressure ulcer, the resident, legal representative, and attending physician should be notified, and the condition should be documented in the nursing notes. However, the lack of timely treatment and documentation for the resident's DTI indicates a failure to adhere to this policy, resulting in inadequate care for the resident.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident with a history of falls. Resident 52, who was cognitively impaired and had a history of falls, was observed multiple times without anti-rollback bars on her wheelchair, despite a care plan intervention indicating their necessity. The resident's diagnoses included dementia with behavioral disturbance, anxiety disorder, and hypertension, and she required partial to moderate staff assistance with bed mobility. The resident had previously fallen and sustained injuries, prompting the interdisciplinary team to decide on the application of anti-rollback bars for her wheelchair. Observations on three separate occasions revealed that the anti-rollback bars were not present on the resident's wheelchair, contrary to the care plan's directives. The Director of Nursing confirmed that the anti-rollback bars should have been in place. The facility's Fall Prevention policy emphasized the need for safety interventions based on initial assessments, yet the required intervention for this resident was not implemented, leading to a deficiency in providing a safe environment for the resident.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure proper treatment and care related to oxygen administration for a resident with chronic respiratory conditions. Resident 4, who has diagnoses including congestive heart failure, chronic respiratory failure, and type 2 diabetes mellitus, was observed multiple times without oxygen in place, despite having a physician's order for oxygen administration of 2-4 liters per nasal cannula every shift. The resident's care plan indicated the need for oxygen therapy due to heart failure and chronic respiratory failure, with interventions to administer oxygen as ordered and as needed. The Medication Administration Record (MAR) for January 2025 showed that oxygen was signed off as administered every shift, but there was no documentation of the rate of oxygen administered or any refusals by the resident. Progress notes indicated that the resident sometimes refused oxygen during the day and was oxygen-dependent at night. However, there were no documented refusals in the MAR. The Director of Nursing later indicated that the physician had been updated, and the oxygen orders were changed to PRN. The facility's policy on oxygen therapy required documentation of the liter flow and response to treatment, which was not consistently followed.
Failure to Assess Necessity for Bed Rails
Penalty
Summary
The facility failed to attempt alternative measures and assess the necessity for bed rails for a resident reviewed for bed rails. The resident, who was cognitively impaired and receiving hospice services, was observed on two occasions with half-length side rails on both sides of the bed. The resident's record indicated diagnoses of dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment noted that the resident required partial to moderate staff assistance with bed mobility and that bed rails were not used as a physical restraint. However, there was no documented evaluation or assessment for the use of side rails, and the Physician's Order Summary lacked any orders for side rails. During an interview, the Director of Nursing (DON) acknowledged the absence of an assessment for the side rails and was unsure if any other interventions had been attempted prior to their use. A Side Rail Assessment was later provided, indicating the use of bilateral top half side rails for assistance with transfers and bed mobility. The facility's policy on side rails stated that an assessment should be performed to determine the need for full-length side rails to treat medical symptoms, and the use of full side rails requires a Physician's Order. The policy also mentioned that a half side rail should be used in accordance with assessed need and resident desires.
Failure to Cover Urinary Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of residents by not covering urinary drainage bags, as observed in two residents. Resident C was seen multiple times with an uncovered urinary drainage bag attached to the side of the bed, visible from the door. Resident C's medical history includes cerebral palsy and moderate intellectual disabilities, with a moderately impaired cognitive status and dependency on activities of daily living, as noted in a recent MDS assessment. Similarly, Resident D was observed with an uncovered urinary drainage bag while asleep and later when awake. Despite being assisted by a CNA, the urinary drainage bag remained uncovered until after morning care. Resident D's medical history includes dementia, a history of urinary tract infections, and urinary retention, with a moderately impaired cognitive status requiring supervision for hygiene. The facility's urinary catheter care policy mandates the use of catheter covers to preserve residents' dignity, which was not adhered to in these instances.
Failure to Provide Oral Care and Eyeglass Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, specifically in the areas of oral care and the placement of eyeglasses. Resident B, who has Alzheimer's disease and is dependent on staff for hygiene, was observed being transferred from bed to a Broda Chair without receiving oral care, despite her care plan indicating the need for assistance with oral hygiene twice daily. Similarly, Resident D, with a history of dementia and urinary issues, was observed receiving morning care without oral care being completed or eyeglasses being placed, even though his care plan required assistance with oral hygiene for his upper denture and lower natural teeth twice a day. The facility's policies, as confirmed by the Director of Nursing, require oral hygiene to be part of morning and evening care, and eyeglasses to be cleaned and placed on residents. However, these policies were not followed for Residents B and D. Interviews with staff revealed that oral care was expected to be provided daily, and while Resident D sometimes refused to wear glasses, there was no indication that this was the case during the observed deficiency. The failure to adhere to these care plans and policies resulted in the cited deficiencies.
Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide proper care for a resident with a urinary catheter, leading to a deficiency in catheter management and infection prevention. During an observation, a CNA was seen placing the urinary drainage bag on the floor multiple times while assisting the resident with morning care. The catheter tubing was also on the floor, and the resident was observed rolling the tubing with his foot. After draining the urine from the bag, the CNA did not disinfect the outlet tube before clamping it and returning it to the holder. The urinary catheter was not washed during the care process, and the drainage bag was placed under the wheelchair seat with the tubing still on the floor. The resident involved had a history of urinary tract infections and urinary retention, with a care plan indicating a risk for infections due to the indwelling catheter. The care plan specified that the urinary drainage bag should be stored in a protective bag, the drainage system should not touch the floor, and catheter care should be completed every shift and as needed. The facility's urinary catheter care policy also required that the drainage bags and tubing be positioned to prevent contact with the floor and that outlet tubes be disinfected after emptying. However, these protocols were not followed, as observed during the survey.
Failure to Use PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to residents under Enhanced Barrier Precautions (EBP). During an observation, CNA 1 entered a resident's room without wearing any PPE, despite a sign above the bed indicating the need for EBP. The resident had a history of dementia, urinary tract infections, and urinary retention, and required moderate assistance for daily activities. The care plan and physician's order specified the use of PPE, including gowns and gloves, during care. Similarly, CNA 6 was observed preparing to provide care to another resident without PPE. This resident had cerebral palsy and moderate intellectual disabilities, and was dependent on assistance for all activities of daily living. The care plan and physician's order also required EBP, with PPE to be used during care. The Director of Nursing noted that EBP signs had been moved to above the residents' beds for confidentiality, but the facility's policy required gowns and gloves to be available near or outside the resident's room.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rensselaer Care Center | 10.8 mi | — | 14 | 0 |
| Arcadia Care Watseka | 21.7 mi | — | 11 | 0 |
| Iroquois Resident Home, The | 22.5 mi | — | 0 | 0 |
| Aperion Care Demotte | 22.9 mi | — | 26 | 0 |
| Oak Grove Christian Retirement Village | 24.2 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.