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F0689
D

Failure to Supervise Resident with Wandering and Hoarding Behaviors

Cicero, Illinois Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a known history of wandering and hoarding behavior was observed entering other residents' rooms without staff supervision. The resident took personal belongings, including a pair of blue sweat pants and an orange tee shirt, from two different residents and added them to her own possessions. No staff were present to monitor or redirect the resident during these incidents. Interviews confirmed that this behavior was ongoing, with one resident stating that the wandering resident frequently entered her room and took belongings. The Director of Nursing acknowledged that the resident's care plan addressed hoarding but did not specifically address wandering behavior. The care plan included interventions such as familiarizing staff with the resident's patterns, providing tasks to redirect her, and checking her room for hoarded items, but did not ensure adequate supervision to prevent the resident from entering other residents' rooms.

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