Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Hammond-whiting Care Center during CMS and state inspections, most recent first.
Nursing staff did not inform a resident with multiple diagnoses about the name or purpose of her prescribed medication during administration on two occasions. The resident struggled to take the medication due to its taste and became upset, but staff only encouraged her to finish it without providing education or explanation, contrary to facility policy and staff expectations.
A resident requiring assistance with ADLs, including bathing, did not receive a bath or shower for multiple consecutive days, as evidenced by observation of poor hygiene and a lack of documented care or refusals, despite a care plan indicating the need for such assistance.
A resident with multiple medical conditions did not receive ordered doses of vancomycin and alprazolam due to missing hospital discharge paperwork, lack of timely verification of medication orders, and absence of a prescription for the antianxiety medication. The MAR reflected several missed administrations, and staff were unable to provide explanations for these omissions.
Two residents with pressure-related skin conditions did not receive ordered care, including off-loading of heels and proper wound dressing. One resident was found with her heels resting on the bed despite an order to off-load, and another was observed without a dressing on a sacral wound and with heels not off-loaded. In both cases, staff did not follow physician orders for pressure ulcer prevention and care.
A resident with pressure ulcers had two active, conflicting physician orders for wound care—one for Aquacel alginate and another for Xerofoam—both of which were documented as completed on the TAR. During wound care, a nurse prepared to use the incorrect treatment before clarifying the current order, but both orders remained in the record, resulting in incomplete and inaccurate clinical documentation.
A wound nurse failed to wear a gown while providing wound care to a resident on Enhanced Barrier Precautions, despite CDC guidance requiring both gown and gloves for such high-contact care activities. The resident had multiple medical conditions and required significant assistance, and the facility's infection prevention nurse indicated their policy allowed discretion in applying EBP, which did not align with current CDC recommendations.
The facility's main kitchen was found to have unsanitary conditions, including dried food spillage on storage bins, improper placement of scoops directly on food, and a bag of thawed chicken in the refrigerator that was not dated. These issues were observed during a kitchen sanitation tour with the Dietary Food Manager.
The facility's kitchen was found to be unsanitary during inspections, with dirty floor tiles, dried food spillage, and dust accumulation on pipes. The Dietary Food Manager acknowledged the need for cleaning.
The facility failed to label and store medications properly, with unlabeled acetaminophen found in a medication cart and a medication room. Staff identified these as house medications, which were later confirmed by a nurse consultant to be inappropriate.
The facility did not follow the prescribed menu for residents on pureed diets. Instead of serving pureed beef tips with mushrooms over parsley noodles, residents were given pureed ham, peas, mashed potatoes and gravy, and bread. The Dietary Food Manager confirmed the error, noting that the cook usually prepared a special meal for these residents, leading to the menu deviation.
A resident with cognitive impairment and mobility issues had their call light consistently placed out of reach, contrary to their care plan. Observations confirmed the call light was clipped above the bed, making it inaccessible. Staff interviews and the Interim Administrator acknowledged the oversight.
The facility failed to hold care plan meetings and invite families for two residents. One resident, who was cognitively intact, was not informed about his care plan meetings, and his daughter was not contacted. Another resident, who was cognitively impaired, was also not invited to his care plan meetings. The Social Service Director confirmed there was no documentation of attempts to reach out to the residents or their families.
The facility failed to provide timely assistance with ADLs for two residents who required meal assistance, leaving them without help for over 10 minutes. Additionally, a resident with hemiplegia and visual impairment was not shaved regularly despite her request, as observed on multiple occasions. The Interim Administrator acknowledged these deficiencies.
A facility failed to provide a personalized activity program for a cognitively impaired resident in isolation. Observations showed the resident was often awake and restless, with her television off, despite her care plan indicating she benefited from activities and one-to-one visits. The Activity Director noted staffing shortages affected the frequency of visits, leading to a deficiency in meeting the resident's needs.
The facility failed to administer insulin as ordered for two residents, leading to deficiencies in medication management. A resident with dementia and diabetes did not receive her prescribed insulin on multiple occasions, and it was administered when her blood sugar levels were below specified parameters. Another resident on anticoagulant therapy was observed with a discoloration on the wrist, which was not assessed or monitored. Additionally, a resident reported late insulin administration, confirmed by the Medication Administration Record.
A resident with hemiplegia, dementia, and Stage 4 pressure ulcers did not receive necessary pressure ulcer care as prescribed. Observations showed her pressure-reducing heel boots were not used while in bed, and her feet rested directly on the mattress, contrary to physician's orders. The Treatment Administration Record inaccurately indicated that interventions were completed, and the Wound Nurse confirmed the care was not provided as documented.
A facility failed to administer oxygen at the prescribed flow rate for a resident with COPD and other health conditions. Observations showed the flow rate was below the required 3 liters per minute, despite documentation indicating it was given correctly. The Interim DON acknowledged the issue without further information.
A facility failed to complete a post-dialysis assessment for a resident requiring dialysis services. The resident, with conditions including kidney disease and hemiplegia, had a care plan that included monitoring the dialysis access site. However, post-dialysis communication forms were not consistently filled out, and vital signs were not documented as required by the facility's policy.
A resident in prolonged isolation due to Candida auris did not receive ongoing psychosocial visits, despite being at risk for mood changes due to anxiety. The resident, with multiple health conditions, expressed distress over the isolation. The facility's Social Service Director acknowledged the lack of regular psychosocial checks, contributing to the deficiency.
A facility failed to implement proper infection control guidelines, leading to improper PPE use and staff confusion about a resident's isolation status. The resident, with multiple health conditions including Candida auris, was incorrectly placed under droplet precautions. Additionally, an antiseptic bath ordered for the resident was not administered or documented on one occasion.
The facility failed to implement gradual dose reductions (GDR) for psychotropic medications for two residents. One resident continued to receive a higher dose of Seroquel despite a GDR order, and another resident continued to receive a higher dose of Ativan despite a GDR recommendation. There was no documentation of physician declination for the GDRs, and the Nurse Consultant confirmed the medications were not reduced as ordered.
The facility did not have an RN on duty for 8 consecutive hours on one day, as required. This was discovered during a review of staffing schedules, and the Interim Administrator confirmed the absence of RN coverage, which could have impacted all 67 residents.
Two residents with non-pressure related skin conditions were not properly assessed or monitored. One resident had a bruise on their hand while on anticoagulant therapy, with no documentation or monitoring orders. Another resident had multiple bruises and a scab, but no documentation or monitoring orders were in place. The DON was unaware or mistakenly believed monitoring orders were entered.
A resident with a history of stroke-related hemiplegia and cognitive impairment was observed multiple times with their bed not in a low position, despite being at risk for falls. The care plan required the bed to be kept low, but this was not adhered to, as confirmed by the DON, who noted the resident's preference against it.
Failure to Inform Resident About Medication During Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed about her medication during administration. On two separate occasions, nursing staff prepared and administered the powdered medication Lokelma to a resident with diagnoses including high blood pressure, diabetes, and Bell's palsy. During both medication passes, the staff did not inform the resident about the name or purpose of the medication. The resident expressed difficulty consuming the medication due to its taste, gagged, and became visibly upset, but was only encouraged to finish the dose without any explanation or education provided. Record review showed that the resident was moderately impaired for daily decision making, and a physician's order was in place for daily Lokelma administration for high potassium. Interviews with staff confirmed that the expectation was for nurses and medication aides to inform residents about their medications prior to administration. The facility's medication administration policy also required staff to provide residents with information about the drugs they were receiving.
Failure to Provide Bathing Assistance for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including heart failure, kidney disease, anxiety, and diabetes, who was assessed as moderately impaired in daily decision-making and requiring assistance with activities of daily living (ADLs), did not receive proper assistance with bathing. Observation revealed the resident had greasy hair, and a review of shower records showed the resident had not received a bath or shower over a nine-day period, with no documented refusals for those dates. The care plan indicated the need for assistance with ADLs, but there was a lack of documentation and provision of bathing care as required.
Failure to Administer Antibiotic and Antianxiety Medications as Ordered
Penalty
Summary
A resident with diagnoses including paraplegia, osteomyelitis, anxiety, hypertension, muscle weakness, and ulcerative colitis was admitted to the facility and had physician orders for both an antibiotic (vancomycin) and an antianxiety medication (alprazolam). The Medication Administration Record (MAR) showed that vancomycin was not signed out as administered for four consecutive doses, and alprazolam was not signed out as given on multiple dates. The resident was cognitively intact and had reported to staff that she was supposed to be on antibiotics. The Assistant Director of Nursing (ADON) indicated that the facility did not receive the After Visit Summary (AVS) from the hospital at admission, which resulted in missing information about the vancomycin order. Despite attempts to obtain the AVS and follow up with the hospital, the facility did not verify the antibiotic order with the physician in a timely manner, leading to missed doses. Additionally, the pharmacy did not fill the alprazolam prescription because they never received a prescription, and nursing staff could not provide an explanation for the missed administration of the antianxiety medication.
Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents with pressure-related skin conditions. For one resident, observations revealed that her heels were not off-loaded as ordered while she was in bed, despite having wounds on her left foot. The wound nurse confirmed there was no current order for off-loading boots and stated she would contact the physician to obtain one. The resident's medical record indicated she was cognitively impaired, dependent for all activities of daily living, and at risk for developing pressure ulcers. A physician's order was in place to off-load heels while in bed and confirm every shift, but this was not followed. Another resident was observed without a dressing covering her sacral wound, which was open to air, and her heels were also not off-loaded as ordered. The wound nurse acknowledged the missing dressing and immediately applied one. During a subsequent wound treatment, the nurse failed to wear a gown despite the resident being on Enhanced Barrier Precautions, only realizing the omission after being prompted. The resident's record showed severe cognitive impairment, lower extremity impairment, and dependence on staff for care. Physician's orders required off-loading of heels and specific wound care, but these were not consistently implemented.
Conflicting Wound Care Orders and Incomplete Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with pressure ulcers, resulting in conflicting physician orders for wound treatment. During a wound care observation, a nurse prepared to apply Aquacel alginate to the wound bed, despite the current physician's order specifying the use of Xerofoam. The nurse stated she had confirmed with the physician that the Xerofoam order was correct and would remove the Aquacel order to prevent further confusion. However, both treatment orders remained active in the resident's record, and both were documented as completed on the Treatment Administration Record (TAR) on different dates. The resident involved had diagnoses including anemia, dysphagia, and high blood pressure, and was assessed as moderately impaired for daily decision-making, requiring dependent care for several activities of daily living. The care plan indicated the presence of pressure ulcers and directed staff to administer treatments as ordered. Despite this, the presence of two active, conflicting wound care orders led to inconsistent documentation and treatment practices, as evidenced by the TAR and direct observation.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a wound nurse failed to use the required personal protective equipment (PPE) while providing wound care to a resident who was under Enhanced Barrier Precautions (EBP). During the observed wound treatment, the nurse performed hand hygiene and donned gloves but did not wear a gown, despite an EBP sign being posted on the resident's door. The nurse acknowledged forgetting to put on the gown when questioned. The resident was in bed, covered with blankets, and was observed to be cold and crying at the time of care. The wound care involved opening the resident's brief, placing a new pad, and preparing a collagen dressing for application. The resident had significant medical conditions, including hemiplegia, dementia, and was at risk for pressure ulcers, requiring substantial assistance with daily activities and being dependent for toileting and lower body care. The facility's infection prevention nurse indicated that their policy allowed discretion regarding EBP, stating that if a wound could be covered and was not draining, EBP might not be necessary. However, current CDC guidance requires both gown and gloves for high-contact care activities, such as wound care, under EBP. The failure to follow these guidelines led to the cited deficiency.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as observed during a kitchen sanitation tour. There was an accumulation of dried food spillage on the outside and lids of the flour, sugar, and rice bins. Additionally, plastic scoops were found inside the flour and rice bins, positioned directly on the food, which is not in accordance with sanitary food handling practices. Furthermore, a bag of thawed chicken was found in a plastic bin in the walk-in refrigerator, which was twisted closed but not dated, indicating a lack of proper labeling and tracking of food items. These observations were made in the presence of the Dietary Food Manager, who acknowledged the issues.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen area in a functional and sanitary manner, as observed during two separate kitchen sanitation tours. On the first tour, the floor tile throughout the kitchen was found to have an accumulation of dirt and debris along the baseboards, with discolored and dirty grout. Additionally, there was dried spillage on top of and in front of the dishwasher, and an accumulation of dust on the metal pipes above it. During the second tour, dried liquid spillage was observed on the wall beneath the coffee and juice machines, and dried food spillage was found on the PVC pipes under the three-compartment sink. In both instances, the Dietary Food Manager acknowledged the need for cleaning.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store medications in accordance with accepted professional principles. During an observation of the north medication cart, two bottles of acetaminophen were found unlabeled in the top drawer. A Qualified Medication Aide (QMA) indicated these were house medications. Similarly, in the south medication room, a box of Benadryl and two bottles of acetaminophen were found without labels in the top left cabinets. A Licensed Practical Nurse (LPN) also identified these as house medications. The nurse consultant later confirmed that house medications should not be present and indicated that these medications had been removed.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets, which was identified through observation, record review, and interview. On October 3, 2024, it was observed that residents receiving a pureed diet were served pureed ham, peas, mashed potatoes and gravy, and bread, instead of the scheduled pureed beef tips with mushrooms over parsley noodles. This discrepancy was confirmed during an interview with the Dietary Food Manager, who acknowledged that the residents should have been served pureed beef tips as per the menu. The manager noted that the cook typically prepared a special meal for residents on pureed diets, which led to the deviation from the planned menu.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within reach, which is a deficiency in accommodating the needs of the resident. Observations on multiple occasions revealed that the call light was clipped to the cord above the head of the resident's bed, making it inaccessible. The resident, who was diagnosed with hemiplegia/hemiparesis following a stroke, dementia, and a history of falling, was cognitively impaired and required substantial to maximum assistance for mobility. Despite these needs, the call light was consistently out of reach, contrary to the care plan intervention that specified it should be within reach. Interviews with staff confirmed the oversight, and the Interim Administrator acknowledged that the call light should have been accessible to the resident.
Failure to Conduct and Communicate Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held and that families were invited to attend these meetings for two residents. Resident 35, who was cognitively intact, was not informed about his care plan meetings, and his daughter was not contacted by the staff as promised. Despite the resident's multiple diagnoses, including retention of urine, insomnia, chronic obstructive pulmonary disease, heart failure, gout, and type 2 diabetes mellitus, there was no documentation of any attempt to reach out to the resident or his family regarding the missed care plan meetings. Similarly, Resident 37, who was cognitively impaired, reported not being invited to his care plan meetings. The resident's diagnoses included psychotic disturbance, mood disturbance, anxiety, and atherosclerotic heart disease. The Social Service Director confirmed the lack of documentation showing any effort to contact the resident or his family about the care plan meetings. This oversight affected the facility's compliance with the requirement to develop and review care plans with the involvement of residents and their families.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for residents who were dependent on staff for meal assistance. Resident 28, diagnosed with dementia and diabetes, was observed seated in a broda chair with her lunch tray placed in front of her at 12:02 p.m., but she was not assisted with her meal until 12:15 p.m. Her care plan indicated she required supervision or touching assistance with eating due to cognitive impairment. Similarly, Resident 29, who had Alzheimer's, dementia, dysphagia, and severe protein calorie malnutrition, was left without assistance from 12:02 p.m. until 12:13 p.m. Her care plan required extensive assistance from staff for eating due to her cognitive impairment and dependency. Additionally, the facility did not adequately address the personal hygiene needs of Resident 27, who was observed with facial hair on her chin and above her lip on multiple occasions. Despite her expressed desire to be shaved, records indicated that her facial hair was not trimmed or shaved on scheduled bath days, and there was no shower sheet available for one of the dates. Resident 27 had multiple diagnoses, including hemiplegia, asthma, diabetes, and impaired visual function, which required assistance with personal hygiene. The Interim Administrator acknowledged that the resident should have been shaved at least weekly.
Failure to Provide Personalized Activity Program for Resident in Isolation
Penalty
Summary
The facility failed to provide a personalized activity program for a cognitively impaired and dependent resident, identified as Resident C, who was in isolation. Observations over several days revealed that Resident C was often awake and attempting to lift her head and feet off the mattress, with her television turned off. Despite her diagnoses, which included Alzheimer's disease, dementia with agitation, cognitive communication deficit, and delusional disorder, the resident's care plan indicated she benefited from small group activities and one-to-one visits. However, the September 2024 One to One Visit Log showed that her last one-to-one visit was on 9/20/24, consisting only of a hand massage. Interviews and record reviews indicated that the resident had expressed interest in listening to music and watching sports, such as baseball and football, but these preferences were not consistently met. The Activity Director acknowledged that the resident liked to watch television and should have had it turned on, but due to staffing shortages, one-to-one visits were not being completed as frequently as needed. This lack of personalized activity programming and stimulation for Resident C, especially while in isolation, contributed to the deficiency identified by the surveyors.
Insulin Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer insulin as ordered for two residents, leading to deficiencies in medication management. Resident 28, who has dementia and diabetes, did not receive her prescribed Lispro and Glargine insulin on multiple occasions in September 2024. The insulin was also administered when her blood sugar levels were below the specified parameters, contrary to the physician's orders. The Interim Administrator acknowledged that the insulin should have been administered as ordered. Resident 35, who is on anticoagulant therapy with Eliquis and Plavix, was observed with a discoloration on the right wrist, which was not assessed or monitored as required. Despite the care plan's directive to monitor for side effects of anticoagulant therapy, there was no documentation of a skin assessment for the discoloration. The MDS Coordinator confirmed the absence of a monitoring order for the discoloration. Resident 219, who has diabetes and uses insulin, reported that her insulin was administered late on several occasions. The Medication Administration Record confirmed that insulin was given late on 9/29/24, with delays of up to two hours. The Interim Administrator admitted that the insulin was not administered within the correct parameters, indicating a lapse in timely medication administration for this resident.
Failure to Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for a resident with a history of hemiplegia/hemiparesis following a stroke, dementia, and pressure ulcers on both heels. Observations on multiple occasions revealed that the resident's pressure-reducing heel boots were not in use while she was in bed, and her feet were resting directly on the mattress, contrary to the physician's orders for offloading and the use of Prevalon boots every shift. The resident was cognitively impaired and required substantial to maximum assistance for mobility, which further necessitated adherence to the prescribed interventions to prevent further deterioration of her condition. The resident's care plan and physician's orders clearly indicated the need for offloading her heels and using pressure-reducing boots to manage her Stage 4 pressure ulcers. However, the Treatment Administration Record for October 2024 inaccurately reflected that these interventions were completed, despite evidence to the contrary. During an interview, the Wound Nurse confirmed that the heel boots should have been applied, or at least the resident's heels should have been offloaded, and acknowledged that the documentation should not have been signed off if the care was not provided.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate as prescribed. Observations on multiple occasions revealed that the resident's oxygen flow rate was set below the prescribed 3 liters per minute. Specifically, on several dates, the flow rate was observed to be under 3 liters, including a specific instance where it was at 2.5 liters. The resident, who has a medical history including hemiplegia, COPD, and heart failure, requires continuous supplemental oxygen at 3 liters per minute as per the care plan and physician's order. Despite this, the Medication Administration Record indicated that oxygen was documented as being administered at the correct rate of 3 liters every shift, which was inconsistent with the observed flow rates. The Interim Director of Nursing acknowledged the concern but did not provide additional information.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident who required dialysis services. Resident 217, who had diagnoses including kidney disease, hemiplegia, hypertension, and anemia, was dependent on renal dialysis and had an arteriovenous fistula for dialysis access. The resident's care plan included interventions such as observing for bleeding at the dialysis access site and assessing the shunt site for bruit and thrill. However, the facility did not consistently fill out the post-dialysis communication forms on several occasions, specifically on 10/4/24, 9/30/24, and 9/25/24, and the form for 9/23/24 was missing. Interviews with LPN 1 revealed that vital signs and assessments of the bruit/thrill were supposed to be documented on the pre/post dialysis communication sheet. However, the Nurse Consultant confirmed that the post-dialysis communication sheet was not filled out consistently. The facility's policy required obtaining vital signs upon the resident's return from dialysis and completing the Pre/Post Dialysis Communication Form, which was not adhered to in this case.
Failure to Provide Psychosocial Support for Isolated Resident
Penalty
Summary
The facility failed to provide ongoing psychosocial visits for a resident who was in indefinite isolation. Resident 21, who was observed to be tearful and expressing distress about her prolonged isolation, was diagnosed with multiple conditions including hemiplegia, candidiasis, hyperlipidemia, anxiety, depression, heart failure, diabetes, and COPD. Her care plan indicated a risk for mood changes due to anxiety, and she had expressed preferences for leisure activities such as bingo, arts and crafts, listening to music, and going outside. Despite these needs, the facility did not ensure regular psychosocial support during her isolation period. The resident was placed in contact isolation due to a wound and Candida auris, with a physician's order for enhanced barrier precautions. Although there were some psychosocial notes indicating interactions with psych services and the interdisciplinary team, there was a lack of consistent psychosocial visits. The Social Service Director admitted to not conducting regular psychosocial checks for residents in prolonged isolation, which contributed to the deficiency in care for Resident 21.
Infection Control Deficiency Due to Improper PPE Use and Missed Antiseptic Bath
Penalty
Summary
The facility failed to implement proper infection control guidelines, as evidenced by the improper use of personal protective equipment (PPE) and a lack of staff awareness regarding the reasons for a resident's isolation. Observations revealed that staff and family members were using PPE inconsistently and without understanding the specific precautions required for the resident's condition. Interviews with various staff members, including an LPN, QMA, and CNAs, indicated confusion about the resident's isolation status, with some staff incorrectly attributing the droplet precautions to a condition the resident did not have. The MDS Coordinator clarified that the resident was only under contact and enhanced barrier precautions for Candida auris, not droplet precautions. Additionally, the facility failed to administer an antiseptic bath as ordered for the resident. The resident, who had multiple diagnoses including hemiplegia, candidiasis, and COPD, was supposed to receive a Chlorhexidine Gluconate body wash every evening shift for seven days as part of their care plan for Candida auris. However, the Medication Administration Record (MAR) indicated that the antiseptic soap was not signed out as given on one of the days. The Interim Administrator confirmed that the antiseptic soap was not administered or documented as given on that day, and no further information was provided to explain this lapse.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) of psychotropic medications for two residents, leading to a deficiency. Resident B, diagnosed with conditions including hemiplegia, dementia, Alzheimer's disease, and major depressive disorder, was prescribed Seroquel for restlessness. Despite a GDR being ordered to reduce the dosage from 25 mg to 12.5 mg, the resident continued to receive the higher dose from mid-September to early October. There was no documentation indicating that the GDR had been declined by the resident's physician, and the Nurse Consultant confirmed the medication had not been reduced as ordered. Similarly, Resident C, who had Alzheimer's disease, dementia with agitation, and delusional disorder, was prescribed Ativan for anxiety. A GDR was recommended to decrease the dosage from 0.5 mg to 0.25 mg, with the Interdisciplinary Team in agreement. However, the resident continued to receive the original dosage from mid-September to early October, with no documentation of a physician's declination of the GDR. The Nurse Consultant acknowledged that the medication had not been reduced as ordered. The facility's policy on psychotropic medication management requires GDR and non-pharmacologic interventions unless contraindicated, which was not adhered to in these cases.
Failure to Ensure Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours on one of the 14 days reviewed. This deficiency was identified during a review of staffing schedules for the period from September 16 to September 29, 2024. It was found that there was no RN coverage on September 29, 2024. During an interview, the Interim Administrator acknowledged the absence of an RN on that day and was aware of the requirement for daily RN coverage. This lapse had the potential to affect all 67 residents residing in the facility.
Failure to Monitor and Document Skin Conditions
Penalty
Summary
The facility failed to properly assess and monitor skin discoloration and scabbing for two residents with non-pressure related skin conditions. Resident D was observed with a reddish/purple discoloration on the top of their right hand on two separate occasions. Despite being on anticoagulant therapy, which requires monitoring for bruising, there was no documentation in the nursing progress notes regarding the discoloration, nor was there a physician's order to monitor the area. The Director of Nursing was unaware of the bruise on Resident D's hand. Resident E was observed with several reddish/purple bruises on their hands and arms, and a dressing on the left forearm covering a purple scab. Although a Skin Integrity Assessment noted skin tears on the resident's legs, there was no documentation or orders to monitor the discoloration on the hands and arms. The Director of Nursing was aware of the bruises but mistakenly believed that monitoring orders had been entered into the system. The facility's policy on skin integrity and wound management was not followed, as evidenced by the lack of proper documentation and monitoring.
Failure to Implement Fall Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to implement preventative fall measures for a resident at risk for falls. Resident B, who had a history of hemiplegia, hemiparesis following a stroke, seizures, and muscle weakness, was observed multiple times with their bed not in a low position, contrary to the care plan interventions. The resident had moderate cognitive impairment and was dependent on staff for bed mobility and transfers. The care plan, which was reviewed earlier, indicated that the resident was at risk for falls and had a history of putting themselves on the floor. Despite this, the bed was observed not in the low position on several occasions. The Director of Nursing acknowledged that the bed should have been in the low position and noted that the resident did not like the bed in that position, indicating a need for care plan updates.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Whiting
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of River Oaks | 4.7 mi | — | 14 | 0 |
| Harbor Health & Rehab | 4.9 mi | — | 38 | 0 |
| Aperion Care Dolton | 5.4 mi | — | 4 | 0 |
| Elevate Care Windsor Park | 5.7 mi | — | 4 | 0 |
| South Shore Rehabilitation | 6.3 mi | — | 0 | 0 |
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