F0550

E

Failure to Honor 24-Hour Visitation Rights and Improper Enforcement of Visiting Hours

Elmwood Park, Illinois Survey Completed on 01-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights to receive visitors of their choosing at the time of their choosing, as required by resident rights regulations and the facility’s own visitation policy. The facility maintained and enforced fixed visiting hours, generally from either 8 a.m. or 10 a.m. until 8 p.m., and staff reported that visitors were expected to leave after 8 p.m. Staff, including CNAs and LPNs, consistently described visiting hours ending at 8 p.m., and one LPN stated that no one was allowed after 8 p.m. except for hospice or critically ill patients. The DON stated that, for the sake of residents and to have some normalcy, the facility had visiting hours and that overnight stays required approval from the administrator or DON, usually for hospice, new admissions, or family comfort.

Two residents who were nonverbal and fully dependent on staff for care were directly affected by this practice. One resident, an older adult admitted in March 2025 with anoxic brain damage, acute and chronic respiratory failure, severe protein-calorie malnutrition, a stage 4 sacral pressure ulcer, tracheostomy status, anemia, and gastrostomy status, was unable to self-advocate. The resident’s family member reported typically visiting around 5:45–6 p.m. and stated that on one evening staff told her at 8 p.m. that visiting hours were over and it was time for her to leave. She reported refusing to leave until the resident’s tube feeding was turned back on, and stated that being asked to leave at 8 p.m. was consistent with how visiting hours had “always been.”

Another resident, an older adult admitted in November 2025 with anoxic brain damage, chronic respiratory failure, tracheostomy status, compression of the brain, dependence on supplemental oxygen, and gastrostomy status, was also nonverbal and fully dependent on staff. This resident’s family member reported that at 8 p.m. “on the dot” staff came and told her she had to leave because visiting hours were over, even though she was waiting for staff to come and clean the resident. She identified the LPN who told her to leave as the nurse working that evening. The family member also stated that the roommate’s wife had no objection to her presence and had even shared her phone number. No documentation was found to show that the visitation limits imposed on these residents’ visitors were based on individualized clinical need, resident preference, safety concerns, or the rights of others. The facility’s written visitation guidelines, last reviewed in September 2025, stated that residents have the right to receive visitors 24 hours a day and that open visitation is permitted at all times, with only “quiet hours” between 8 p.m. and 8 a.m., and that any restrictions must be reasonable, temporary, least restrictive, explained, and documented.