Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ambassador Nursing & Rehab Center during CMS and state inspections, most recent first.
Failure to Prevent Resident-to-Resident Physical Abuse: Two residents became involved in a verbal dispute near the elevator that escalated into physical contact, with conflicting accounts from both residents and a third resident about who struck first. An LPN and RN assessed both residents and documented no visible injuries or pain, while the Administrator stated there was no video footage of the incident. The report notes a prior roommate conflict between the residents and that one resident had a history of making unfounded allegations against the other.
A resident with a history of TBI, ataxia, epilepsy, and moderate cognitive impairment sustained a serious head injury after falling in a hallway without 1:1 supervision or a sitter. The resident was non-compliant with wearing a protective helmet, and the falls care plan did not include close monitoring. Staff were unclear about when and why increased supervision was discontinued, and documentation lacked evidence of alternative interventions to address the resident's persistent fall risk.
A resident, who was cognitively intact and had multiple medical conditions, reported being struck in the mouth by a roommate following a verbal exchange. The incident resulted in redness to the resident's lower lip, as documented by staff, but there were no witnesses to the event. The facility did not ensure the resident's right to remain free from abuse, as required by its abuse prevention policy.
A resident with multiple medical conditions alleged that another resident made contact with his arm, leading to an unwitnessed abuse allegation. The MOD completed an incident report and notified the Administrator immediately, but the incident was not reported to IDPH within the required two-hour window, resulting in a delay that did not meet facility policy.
The facility did not provide enough nursing staff to meet resident needs and failed to have a licensed nurse in charge on every shift, as required.
Surveyors found that staff failed to discard expired food, stored food near cleaning chemicals, and distributed uncovered food items to residents, exposing them to potential contaminants. Facility policy requires food to be stored away from chemicals and all expired goods to be discarded, and staff confirmed that food should be covered during distribution for infection control.
Multiple residents did not receive their scheduled medications on time or at all, with some doses administered hours late and others not documented as given. Staff interviews and record reviews confirmed that medication administration and documentation did not follow physician orders or facility policy, often due to short staffing and medication availability issues.
The facility did not ensure that essential equipment, such as wheelchairs and call lights, were safe and accessible for several residents. A resident's wheelchair had worn and unstable armrests secured with tape, and multiple residents were found without call lights within reach or with missing components, despite staff and policy requirements for accessibility and safety. Staff confirmed the importance of these measures, but they were not consistently followed.
Four residents requiring respiratory care did not have their oxygen nasal cannula tubing properly stored in bags when not in use, and one resident's nebulizer tubing and mask were not changed weekly as required. Staff confirmed these lapses, and the facility lacked a written policy on oxygen tubing storage.
Staff did not consistently follow Enhanced Barrier Precautions for two residents with wounds, including failing to post required signage upon admission and not wearing gowns during high-contact care activities, despite facility policy and available PPE. This resulted in lapses in infection prevention and control as required for residents with wounds.
A resident with a chronic cough was evaluated by a nurse practitioner who ordered a chest x-ray, but the order was not promptly entered or completed. Despite attempts by nursing staff to contact the contracted radiology provider and endorse the need for follow-up, the x-ray was never performed, and the resident continued to experience symptoms, eventually seeking hospital evaluation. Facility policy requires prompt provision of diagnostic services, which was not met in this instance.
Two residents, both cognitively intact, were found with Ventolin HFA inhalers at their bedside and reported self-administering the medication without documented physician orders or completed assessments for self-administration. Staff confirmed that facility policy requires such orders and assessments, but these were not present in the clinical records.
Three residents experienced prolonged exposure to unresolved maintenance issues, including a missing ceiling panel with exposed piping and a broken cabinet, which were not addressed despite facility policies requiring daily inspections and prompt repairs. Staff were unaware of these issues until notified by surveyors, and no work orders had been submitted for the repairs.
A resident with multiple mental health diagnoses and recent behavioral changes was not accurately assessed in the PASRR Level I screening, and was not referred for a Level II PASRR evaluation after a significant change in condition. The assessment omitted key diagnoses and medications, and was signed by non-clinical administrative staff due to inconsistent staffing in Admissions and Social Services.
A resident with multiple mental health diagnoses was not referred for a required Level II PASRR evaluation, despite documentation indicating the need for further assessment. Facility staff were unable to provide evidence of the completed assessment, and inconsistent follow-up on PASRR requirements was noted, with the referral only being made during the survey.
A resident with a recent below knee amputation and diabetes did not receive daily wound care as ordered by the physician, with missed dressing changes over a weekend and inaccurate documentation in the TAR. Nursing staff did not verify or follow the wound care orders, resulting in a lapse in care and incomplete records.
A resident with cognitive and functional impairments was found with disposable razors at the bedside, despite facility policy requiring staff supervision and secure storage of such items. Staff interviews confirmed there was no assessment of the resident's ability to use razors safely, and razors were not to be left at the bedside, indicating a failure to prevent accident hazards and ensure adequate supervision.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A nurse failed to sign the controlled substances check form during a shift change, resulting in incomplete documentation for several residents receiving medications such as morphine, hydrocodone-acetaminophen, and lorazepam for chronic pain, anxiety, and depression. Facility policy and job descriptions require both incoming and outgoing nurses to count and sign for controlled substances at each shift change, but this was not done as required.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, resulting in a breakdown of required communication.
A controlled substance was found to be improperly labeled when the instructions on the medication bottle did not match the current physician order, as confirmed by an LPN and the DON. A resident with chronic pain and other diagnoses had a Morphine Sulfate order changed from every 1 hour to every 4 hours as needed, but the medication label was not updated accordingly, resulting in a labeling discrepancy.
A resident with a history of aggressive behavior physically assaulted a roommate, causing facial swelling. The incident occurred after the aggressive resident, who had previously exhibited violence toward staff and others, was placed in a shared room. Staff responded to the altercation and separated the residents, but the injured resident required hospital evaluation. Despite physical evidence and consistent staff reports of aggression, the facility's investigation did not substantiate the abuse allegation due to lack of direct witnesses and uncertainty about intent.
A resident at high risk for falls was found on the floor without injury due to inadequate supervision and failure to implement safety measures such as non-skid socks and proper bed positioning. Despite being cognitively intact, the resident frequently forgets to use the call light and attempts to stand without assistance. Staff interviews revealed that the resident's wheelchair is kept outside the room, contributing to the resident's attempts to move independently. The facility's care plan for the resident was not consistently followed, leading to the fall.
A resident reported an alleged abuse incident involving another resident, which was recorded and shared with staff. However, the facility failed to report the incident to the IDPH within the required timeframe due to miscommunication and delayed action by staff members.
A facility failed to prevent an altercation between two residents on the smoking patio, resulting in one resident sustaining a hip fracture. Despite staff supervision, a verbal altercation escalated when one resident reportedly pulled the other's wrist, causing a fall. The incident was investigated, but the abuse allegation could not be substantiated. Medical evaluation confirmed fractures, and the incident was reported to the police.
A cognitively intact 85-year-old resident with a history of mobility issues had her cane removed by the Social Service Director without prior intervention or family notification, despite using it safely for short distances. The removal was due to concerns about the resident using the cane to propel her wheelchair, although no incidents had occurred. This action contradicted the facility's policy on maintaining residents' health and required care planning.
A staff member, V11, was found to be physically and verbally abusive towards multiple residents in an LTC facility. Incidents included yanking a gown off a resident's head, twisting a resident's leg, knocking a resident down, and making inappropriate comments. These actions resulted in emotional trauma and fear among the residents.
The facility failed to store, label, and protect food items according to professional standards, with issues such as expired and improperly stored food, uncovered items, and a fly in the kitchen. These deficiencies could impact 135 residents who consume food from the kitchen.
Surveyors observed that the facility failed to properly contain waste in its dumpsters. The recycling dumpster had an open lid, and the garbage dumpster was missing a lid for half of it, leading to overfilled trash bags with disposable chucks and briefs. The Maintenance Director acknowledged the missing lid and had not contacted the dumpster company for a replacement. Facility policy requires dumpsters to be closed at all times and to contact garbage service if full.
A CNA in an LTC facility was allowed to continue working despite multiple allegations of inappropriate behavior, including rough handling and verbal abuse, reported by several residents. The facility's administration initially categorized these actions as poor customer service rather than abuse, allowing the CNA to work until a recent suspension. This oversight potentially affected all residents.
The facility failed to follow infection control policies in laundry handling, Legionella prevention, and medication administration. A dusty fan was used near clean linens, and soiled linen was improperly sorted, risking contamination. The maintenance director could not provide recent Legionella testing records or risk assessments. A nurse administered medication without hand hygiene, increasing infection risk.
The facility failed to dispose of expired Ibuprofen for a resident and improperly stored insulin for three residents. Expired medication was found in the cart, risking administration errors, while insulin requiring refrigeration was left unrefrigerated without proper labeling, potentially affecting its effectiveness.
The facility failed to maintain correct food temperatures, as observed during a survey. Three residents reported that their food was often cold, and a test tray revealed a hamburger temperature of 120°F, below the facility's standard of 150°F. The facility's policy requires hot foods to be served at a palatable temperature, generally not less than 125°F. A cook acknowledged that cold food could make residents sick, indicating a failure to adhere to the facility's policy.
A resident with schizophrenia and impaired cognition did not have an advance directive care plan in place until the day of the survey. The Social Service Director admitted there was no documentation of discussions about advance directives, and the resident's State Guardian was only contacted the day before the survey. Hospital records indicated the resident lacked decisional capacity, and the facility's policy on advance directives was not followed.
A resident's privacy was compromised when an RN left a computer screen open, displaying the resident's medical information, while attending to another task. This allowed other residents and staff to view the confidential data, violating HIPAA regulations. The DON confirmed the requirement for nurses to lock screens to protect resident information.
A resident's bathroom had a one-foot hole in the ceiling for about a month, which was not repaired despite requests. The Maintenance Director stated the hole was left to dry out after a leak, but no work order was received. The facility's protocol for urgent maintenance requests was not followed, leading to a deficiency in maintaining a homelike environment.
A cognitively intact resident with mobility issues was not placed on a bowel and bladder toileting program, despite being able to feel the need to urinate and have bowel movements. The resident was frequently left to wait for assistance and was changed in bed after episodes of incontinence. The restorative nurse admitted to overlooking the resident's suitability for a training program, and the CNA confirmed the resident was not taken to the toilet, contrary to facility policy.
A resident was improperly positioned during enteral feeding administration, with her head dangling off the bed, which was not corrected until pointed out. The facility's policy and physician's orders require the head of the bed to be elevated 30 to 45 degrees to prevent aspiration.
The facility failed to provide adequate education on the benefits and risks of influenza and pneumococcal vaccinations to two residents. One resident, with intact cognition, did not receive direct education, while another, with cognitive impairment, only received partial information and no follow-up was conducted. The facility's guidelines require that residents or their representatives be informed about the benefits and risks of immunizations.
The facility failed to maintain a safe and functional bathroom for two residents, with a broken sink and non-working toilet observed. The issues persisted for about a month, forcing one resident to use facilities in another room. Staff interviews revealed a lack of communication and reporting of maintenance issues, and incomplete maintenance records indicated a lapse in oversight.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident physical abuse involving two residents, R1 and R2. The incident occurred near the first-floor elevators when the residents became involved in a verbal confrontation that escalated into physical contact. R1 and R2 each gave conflicting accounts of who initiated the altercation, and a third resident also provided changing statements about what happened. Staff members did not witness the actual striking, but they responded after hearing the residents' voices and found the residents already separated. According to the statements documented in the report, R1 and R2 had a prior history of conflict as former roommates. R1 stated that R2 punched him in the face after verbal insults were exchanged, and R1 said he defended himself by blocking punches and then striking R2 back. R2 gave inconsistent statements, first saying R1 bumped him with a rollator walker and insulted him, then stating R1 swung first and he blocked before punching R1 in the face. R3 also gave inconsistent accounts, initially describing R1 as the aggressor and later stating R2 punched R1 only after R1 pushed the rollator walker into him. Staff assessments documented no visible bruising or other new abnormalities for either resident, and both residents denied pain at the time of assessment. The LPN and RN each documented that the residents alleged another resident made contact with them and that the physician was notified. The Administrator stated there was no video footage of the incident. The report also notes that R1 and R2 had a prior roommate dispute, that R2 had a history of making unfounded allegations regarding R1, and that the facility reported the allegations of abuse to the state agency and police report #JK-246935 documented a simple battery report.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent a serious fall-related injury for a resident with multiple risk factors, including a history of traumatic brain injury, ataxia, epilepsy, schizophrenia, and moderate cognitive impairment (BIMS score of 10). The resident was known to be non-compliant with wearing a protective helmet and had a documented behavior of repeatedly getting out of bed despite education. At the time of the incident, the resident was not under 1:1 supervision or assigned a sitter, and was housed in a room far from the nurse's station, making monitoring difficult. The resident was found on the floor in the hallway with an open area to the back of the head and was subsequently diagnosed with a subarachnoid hemorrhage and required staples to the head. Staff interviews revealed uncertainty regarding when and why 1:1 supervision or sitter services were discontinued, and the falls care plan did not include close monitoring as an intervention. The resident's helmet was often not worn correctly or at all, and staff acknowledged that re-education was likely ineffective due to the resident's cognitive status. Documentation did not clarify the rationale for changes in supervision, and there was no evidence of alternative or additional interventions being implemented to address the resident's ongoing fall risk and non-compliance with safety measures.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
The facility failed to ensure that a resident remained free from abuse, as required by policy, for one of four residents reviewed for abuse. The incident involved a resident who alleged that his roommate struck him in the mouth after a verbal exchange regarding slamming the door. The affected resident was found to have redness on the lower lip, which was documented in both the incident report and nursing progress notes. Staff statements confirmed that the resident reported being struck, although there were no witnesses to the event, and the resident denied experiencing pain or discomfort. The medical records indicate that the resident who reported the abuse was cognitively intact, with a BIMS score of 15, and had multiple diagnoses, including specified disorders of the brain and seizures. The roommate involved in the alleged incident had a history of chronic medical conditions and was no longer in the facility at the time of the investigation. The facility's abuse prevention policy prohibits and aims to prevent all forms of abuse, including physical abuse, but the incident was not substantiated due to lack of witnesses. Nevertheless, the documentation shows that the facility did not ensure the resident's right to remain free from abuse, as required.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required two-hour timeframe after notification. A resident with multiple diagnoses, including spinal stenosis, morbid obesity, and heart failure, alleged that another resident made contact with his arm while he was in bed. The incident was unwitnessed and reported by the resident to the Manager on Duty (MOD) shortly after 7:00 am. The MOD completed an incident report and notified the Administrator immediately by telephone. An in-house X-ray was performed due to the resident's complaint of arm pain, but no injuries or redness were found. Despite the facility's policy requiring that all abuse allegations be reported to the appropriate authorities within two hours, the incident involving the resident was reported to the Illinois Department of Public Health (IDPH) at 10:22 am, which was more than two hours after the initial allegation was made. Interviews with facility staff, including the DON, MOD, and Administrator, confirmed the timeline and the facility's reporting requirements. The deficiency was identified through interviews and record review, showing a delay in reporting the alleged abuse as required by policy.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements to maintain adequate nursing staff coverage and proper supervision by licensed personnel on all shifts.
Deficient Food Storage and Unsanitary Meal Distribution
Penalty
Summary
Surveyors identified several deficiencies related to food storage, preparation, and distribution within the facility. During a kitchen tour, an opened box of powdered non-dairy creamer packets was found with a 'best use by' date that had already passed, and the Dietary Manager was unsure if the product was still safe to use. Additionally, a large box of bananas was stored on a bottom shelf next to a sanitation bucket containing cleaning solution, contrary to the facility's policy that prohibits storing food near chemicals. The facility's own policy also requires that all out-dated goods be discarded the day after expiration, which was not followed in this instance. Further observations revealed that staff distributed lunch trays to residents' rooms with uncovered food items, such as mandarin oranges in dessert bowls and juice in plastic cups, leaving them exposed to potential contaminants. Both the Dietary Manager and the Regional Director of Operations confirmed that food items should be covered during distribution to prevent contamination, and the Director of Nursing stated that staff are expected to distribute meal trays in a sanitary manner with all food items covered. These actions and inactions resulted in food being stored, prepared, and served in a manner not consistent with professional standards and facility policy.
Failure to Administer Medications as Ordered and Document Timely Administration
Penalty
Summary
Surveyors identified that the facility failed to administer medications to residents according to physician orders and facility policy, resulting in multiple instances of late or missed medication administration. Several residents, all cognitively intact, reported receiving their scheduled medications hours late or not at all, particularly on a specific date when staffing was insufficient. Observations and interviews confirmed that medications intended for administration at 9am were instead given between 11:29am and 12:40pm, exceeding the facility's policy of a 60-minute window before or after the scheduled time. In some cases, medications were not available, and staff had to order them from the pharmacy, further delaying administration. Documentation review revealed that medication administration records (MARs) were not consistently signed, indicating that medications were either not given or not properly documented as administered. For example, one resident's MAR showed that fourteen medications were not signed or administered during a specific shift, while another resident's MAR showed fifteen medications not signed or administered during another shift. Staff interviews confirmed that if the MAR is not signed, the medication is considered not given, which could affect resident well-being. Residents also reported that the timeliness of medication administration depended on which nurse was working and that short staffing contributed to delays. The facility's policies and job descriptions require that medications be administered as ordered by the physician and within the specified time frame, and that the MAR be signed after each medication is given. The Director of Nursing and other staff acknowledged these expectations during interviews. However, the survey findings demonstrated that these procedures were not consistently followed, leading to late or missed medication doses for multiple residents. Resident council meeting minutes and grievance forms further corroborated ongoing concerns about medication administration timeliness.
Failure to Maintain Safe and Accessible Equipment for Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents by not ensuring that essential equipment, such as wheelchairs and call lights, were in safe and functional condition. One resident, who was cognitively intact and dependent on a wheelchair for mobility, reported that both armrests of his wheelchair were worn out, wobbly, and secured with blue tape. Despite informing staff about the issue, the problem persisted, and the maintenance director acknowledged that taped or broken equipment is unsafe and should be addressed immediately. The restorative nurse and director of nursing both confirmed that wheelchairs used by residents should be in proper working order for safety. Additionally, the facility failed to ensure that call lights were within reach and in good working order for multiple residents. One resident, who had been in the facility for six months, stated he had no call light and could not call for help when needed. Observations confirmed that his call light was not visible or within reach, and staff had to retrieve it from the floor and attach it to his bed sheet. Other residents were also found without accessible call lights, with some missing the necessary string to activate the system. Staff interviews confirmed that call lights should always be within reach and attached to the bed or resident's clothing, as outlined in facility policy. The care plans for residents at risk for falls specifically included interventions to keep call lights within reach and encourage their use for assistance. However, observations revealed that call lights were often found on the floor, missing strings, or otherwise inaccessible, directly contradicting both care plans and facility policy. Staff acknowledged the importance of accessible call lights for resident safety and the need to replace missing components promptly, but these measures were not consistently implemented.
Failure to Maintain Proper Respiratory Equipment Storage and Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents by not maintaining proper storage of oxygen nasal cannula tubing and not ensuring timely changes of nebulizer tubing and masks. Specifically, three residents with diagnoses including chronic obstructive pulmonary disease (COPD), heart failure, and respiratory failure were observed with their oxygen nasal cannula tubing hanging on wheelchairs or concentrator tanks when not in use, rather than being stored in a bag as required by facility practice. Staff interviews confirmed that the tubing should be stored in a bag to prevent contamination, but this was not consistently done. Additionally, one resident with a history of asthma and cardiac issues received nebulizer treatments with tubing and a mask that had not been changed for over two weeks, despite the facility's policy requiring weekly changes. Staff acknowledged the lapse, and the Director of Nursing confirmed expectations for weekly changes and proper storage. The facility was unable to provide a written policy regarding the storage of oxygen nasal cannula tubing when not in use.
Failure to Implement Enhanced Barrier Precautions and PPE Use for Residents with Wounds
Penalty
Summary
Staff failed to consistently implement appropriate infection prevention and control measures related to Enhanced Barrier Precautions (EBP) for residents with wounds. One resident with a new left below-knee amputation and additional wounds was admitted to the facility, but EBP signage was not posted on the resident's door upon admission, despite an order for EBP being present. The signage was only put up the day after admission, resulting in staff not being alerted to the need for EBP and potentially not wearing required personal protective equipment (PPE) such as gowns and gloves during direct care activities. In another instance, a certified nursing assistant was observed providing incontinence care to a resident on EBP while wearing only a mask and gloves, but not a gown, despite adequate PPE supplies and EBP signage being present outside the resident's door. The CNA stated she sometimes wore a gown but did not consistently do so unless she saw an isolation sign. Interviews with nursing and infection control staff confirmed that gowns and gloves are required for high-contact care activities for residents on EBP, and that signage is essential to alert staff and visitors to the necessary precautions. Documentation and interviews further revealed that both residents had wounds requiring EBP, and that the facility's policy mandates the use of gowns and gloves during high-contact care activities for such residents. The lack of timely signage and inconsistent use of PPE by staff during direct care activities led to a failure in adhering to established infection control protocols for residents on EBP.
Failure to Provide Timely Radiology Services Following Provider Order
Penalty
Summary
The facility failed to provide timely radiology services as ordered for one resident who experienced chronic coughing. After the resident reported coughing spells, a nurse practitioner evaluated the resident and ordered a chest x-ray as part of the treatment plan. The order was not immediately entered into the electronic medical record; instead, it was entered two days later by a nurse after a verbal order was relayed. Despite the order being in the system, the chest x-ray was not completed, and there were no results available for the resident. The nurse responsible attempted to contact the contracted radiology company twice during their shift and endorsed the need for follow-up to the oncoming shift, but the x-ray was still not performed. Facility staff interviews revealed that nurses are expected to acknowledge and confirm new orders in the electronic medical record, and if an order is not seen, they are to verify with the provider or consult with nursing leadership. Documentation showed that the resident continued to complain of cough and was still due for the chest x-ray several days after the order. Ultimately, the resident called emergency services for hospital evaluation. The facility's own policy requires that radiology and diagnostic services be provided promptly to meet residents' needs, but this was not followed in this case.
Failure to Obtain Physician Orders and Assessments for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain physician orders and conduct appropriate assessments for residents to self-administer medications at their bedside. Specifically, two residents, both assessed as cognitively intact according to their Minimum Data Set (MDS) and Brief Interview Scores, were observed with Ventolin HFA inhalers at their bedside tables. Both residents reported having the inhalers at their bedside for over a month and confirmed recent use. However, a review of their clinical records revealed no documentation of a physician order permitting self-administration or to keep the medication at bedside, nor was there evidence of a completed assessment to determine their ability to safely self-administer the medication. Staff interviews confirmed that facility policy requires a physician order and an interdisciplinary team assessment before allowing residents to self-administer medications or keep them at bedside. Both an LPN and the Director of Nursing stated that these steps are necessary to prevent misuse, overuse, or access by other residents. Despite this, the required documentation and orders were not present in the records for either resident, and the medications remained accessible at their bedside.
Failure to Maintain Safe and Homelike Resident Environment Due to Unresolved Maintenance Issues
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for three residents, as evidenced by unresolved maintenance issues in their shared room. One resident reported that a ceiling panel by the window had been missing for weeks following a leak, with exposed piping and multiple towels and linens placed on the floor beneath the opening. Both residents occupying the room confirmed that the ceiling panel had not been replaced for an extended period, and that the facility had not addressed the issue. Additionally, a cabinet in the room was missing a side panel and door, which had fallen off days prior and remained unrepaired. One resident stated the cabinet was already broken upon moving into the room. Interviews with housekeeping and maintenance staff revealed that the broken cabinet had been reported previously, but there was no record of a work order for either the ceiling panel or the cabinet in the facility's maintenance system. The Maintenance Director and Assistant were unaware of the missing ceiling panel until informed by the surveyor, despite facility policies requiring daily inspections and prompt attention to repairs. The facility's own policies mandate the provision of a safe, clean, and comfortable environment, as well as daily inspection and immediate response to maintenance issues, which were not followed in these instances.
Failure to Complete Accurate PASRR Assessment and Referral After Significant Change
Penalty
Summary
The facility failed to submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for one resident and did not refer the resident for a Level II PASRR evaluation after a significant change in condition. The resident exhibited symptoms such as being withdrawn, having a flat affect, and requiring more assistance with activities of daily living. Despite these changes and a documented history of schizoaffective disorder, bipolar disorder, PTSD, anxiety disorder, homicidal ideations, auditory hallucinations, and mild intellectual disabilities, the Level I PASRR assessment did not include these mental health diagnoses, behaviors, symptoms, or related medications. The resident was also prescribed multiple psychotropic medications, including antipsychotics and medications for anxiety and behavior disturbances. The office manager, who was not a clinical professional, signed and submitted the PASRR assessment without conducting or reviewing the clinical information, as required by policy. There was a lack of consistent staff in the Admissions and Social Services departments, leading to administrative staff handling clinical documentation. The facility's own policy requires compliance with federal and state PASRR standards, but the process was not followed, resulting in the resident not being properly assessed or referred for necessary services after a significant change in their condition.
Failure to Refer Resident for Required Level II PASRR Evaluation
Penalty
Summary
The facility failed to follow up and refer a resident with multiple mental health diagnoses, including schizoaffective disorder, bipolar disorder, insomnia, and depression, for a required Level II PASRR (Pre-admission Screening and Resident Review) evaluation. The resident's admission records and clinical physician orders documented these diagnoses and included prescriptions for medications such as Ziprasidone Hydrochloride, Trazadone, and Amitriptyline Hydrochloride. The initial PASRR Level I screen indicated the need for a Level II onsite assessment, but there was no evidence that this assessment was completed. Throughout the survey, multiple facility staff, including the Administrator, DON, Social Service Coordinator, Nurse Consultant, and Social Service Director, were unable to provide documentation of a completed Level II PASRR for the resident. The Social Service Director confirmed that the staff responsible for admissions had not consistently followed up on PASRR requirements, and that the current admissions staff was new and still learning the process. The facility's own policy requires compliance with PASRR procedures and timely follow-up, but the necessary referral to the state-designated authority for the Level II assessment was not made until the time of the survey.
Failure to Follow Physician Orders and Perform Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide daily wound care for one resident with a recent left below knee amputation (BKA) and diabetes. The resident was admitted for wound care and other skilled services, with physician orders specifying daily dressing changes to the amputation site. Despite these orders, the resident reported that wound care was not performed over the weekend following admission, and the first dressing change occurred only on the following Monday. The Treatment Administration Record (TAR) inaccurately indicated that wound care was completed on Saturday, but the nurse responsible confirmed that the dressing change was not performed as documented. Further review revealed that the wound care coordinator placed the necessary orders after being contacted by staff, but the assigned wound care nurse did not carry out the dressing change as required. Additionally, there was no documentation of wound care being performed on Sunday, and the wound care coordinator was unsure why the scheduled nurse did not complete the task. Facility policies require adherence to physician orders and timely wound care, but these were not followed in this instance, resulting in a lapse in care and inaccurate recordkeeping.
Failure to Secure Hazardous Items and Provide Supervision During Resident Grooming
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, mood disorder, and dependence on a wheelchair, was found to have two disposable razors stored in plastic cups on their overbed table. The resident's medical records indicated significant cognitive and functional impairments, with documentation showing a self-care deficit and dependence on staff for personal hygiene tasks. Despite this, the resident reported shaving independently and keeping razors at the bedside, which was not in accordance with facility policy or the care plan that required staff assistance and supervision for grooming activities. Interviews with facility staff, including the Regional Nurse Consultant, DON, and Restorative Nurse, revealed that there was no documented assessment for the resident's ability to safely use razors. Staff confirmed that razors should be stored securely and only provided to residents under supervision, with immediate disposal after use. The lack of a shaving assessment and the presence of razors at the bedside represented a failure to ensure hazardous items were stored securely and that adequate supervision was provided to prevent accidents, as required by facility policy and resident care plans.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Document Controlled Substance Count at Shift Change
Penalty
Summary
The facility failed to ensure that the outgoing nurse signed the Controlled Substances Check Form for the First Floor Team II medication cart, specifically missing a signature for the 3-11 shift on 7/11/2025. This omission was identified during a medication storage and labeling review with an LPN, who confirmed that nurses are required to sign the form to document that controlled medications have been counted and accounted for at each shift change. The Director of Nursing also stated that both incoming and outgoing nurses are expected to count and sign for controlled substances during shift changes to ensure none are missing. This deficiency affected four residents who were prescribed controlled medications, including morphine sulfate, hydrocodone-acetaminophen, and lorazepam, for conditions such as chronic pain syndrome, anxiety disorder, and depression. Facility policy and the registered nurse job description both require accurate narcotic records and dual signatures for controlled substance counts at each shift change, but this procedure was not followed as documented by the missing signature.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.
Controlled Substance Labeling Discrepancy
Penalty
Summary
A deficiency occurred when a controlled substance, Morphine Sulfate, was not properly labeled in accordance with the resident's current physician order. During an observation, a surveyor found that the medication label on the resident's Morphine Sulfate bottle instructed administration every 1 hour as needed, while the active physician order specified administration every 4 hours as needed. The LPN confirmed that the label and the active order did not match, and the expectation was for the label to reflect the current order to ensure accuracy in medication administration. The resident involved was cognitively intact and had diagnoses including abdominal pain, restless leg syndrome, and chronic pain syndrome. The medication order had been changed from every 1 hour to every 4 hours as needed, but the label on the medication bottle had not been updated to reflect this change. Facility policy required that medication labels, physician orders, and the MAR be consistent and uniform, and that improperly labeled medications be rejected or returned. However, the outdated label remained on the medication, creating a discrepancy between the label and the current physician order.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in one resident sustaining swelling to the left side of the face near the eyebrow. The incident involved a resident with multiple complex medical diagnoses, including moderate cognitive impairment, who was physically assaulted by a roommate with a documented history of aggressive and violent behaviors. The aggressive resident had previously exhibited both verbal and physical aggression toward staff and other residents, including being sent to the hospital for psychiatric evaluation due to these behaviors. On the day of the incident, the aggressive resident was observed by staff charging toward the other resident, who was in bed eating lunch. The assaulted resident reported that the aggressor was slamming drawers, taking belongings, and then struck him on the left side of the face, causing swelling. Staff responded to the commotion, separated the residents, and called a Code Gray. The assaulted resident was sent to the hospital for evaluation, where swelling to the left eyebrow was noted. Multiple staff interviews confirmed the aggressive behaviors of the perpetrator, including previous incidents of violence toward staff and other residents, and the need for 1:1 monitoring upon return from the hospital. Despite the physical evidence of injury and consistent reports of aggressive behavior, the facility's internal investigation concluded the allegation was unsubstantiated, citing lack of direct witnesses and uncertainty about the intent due to the aggressor's cognitive status. However, staff statements and resident interviews consistently described a pattern of aggression and the specific incident leading to injury. The facility's policies require the prevention of abuse, but the actions taken prior to the incident were insufficient to prevent the assault and resulting injury.
Failure to Prevent Fall for High-Risk Resident
Penalty
Summary
The facility failed to provide appropriate supervision and reduce the risk of falls for a resident identified as R5, who is at high risk for falls. On the morning of January 8, 2025, R5 was found on the floor by a night shift nurse, with his bottom on the floor next to his bed. Observations revealed that R5 was not wearing non-skid socks, and his bed was not in the lowest position, which are both measures that could have potentially prevented the fall. R5, who has a history of repeated falls and requires assistance with personal care, was noted to have a cognitive status that is mostly intact, with a BIMS score of 13/15. Despite this, R5 frequently forgets to use the call light for assistance and does not like to remain in bed or a wheelchair for extended periods. Interviews with staff, including a CNA and an RN, indicated that R5 often attempts to stand without assistance and forgets to use available aids such as the urinal and bed commode. The RN mentioned that R5's wheelchair is kept outside the room due to space constraints, which may contribute to the resident's attempts to move independently. The facility's documentation and care plan for R5 highlight the need for a safe environment, including appropriate footwear and bed positioning, but these measures were not consistently implemented. The Director of Nursing acknowledged the oversight regarding the non-skid socks, and the facility's incident documentation suggests that the care plan should address measurable goals with appropriate interventions, which were not adequately in place at the time of the incident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Illinois Department of Public Health (IDPH) within the required two-hour timeframe and did not submit a final report within five days as mandated. The incident involved a resident who was allegedly pushed by a staff member, as reported by another resident who overheard the incident and recorded it. The recording was shared with various staff members, including the Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator, but the report was delayed due to miscommunication and lack of immediate action by the staff. The incident was first reported by a resident to the ADON on the morning of the alleged abuse, but the Director of Nursing (DON) and the Administrator were not informed until several days later. The facility's Abuse Prevention Program requires immediate reporting of such incidents, but the staff failed to adhere to these procedures. The delay in reporting was further compounded by the Administrator's absence from the facility, leading to a lack of timely investigation and notification to the IDPH.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse prevention policy, resulting in an incident involving two residents, R1 and R3, on the smoking patio. R1 reported that R3 pulled R1's wrist, causing R1 to fall and sustain a right hip fracture. However, R3, who primarily speaks Polish, denied the accusation and claimed that R1 pulled R3's wheelchair. The incident was witnessed by staff, who reported a verbal altercation between the two residents, with R1 bumping R1's rollator into R3's wheelchair. Despite the presence of a smoking monitor, the altercation escalated, leading to R1's fall. The incident was investigated by the facility's abuse coordinator, who could not substantiate the abuse allegation. Medical evaluation revealed fractures in R1's right superior and inferior pubic rami, potentially related to the fall. The facility's abuse policy mandates the prevention of resident abuse, and the smoking policy requires supervision during smoking activities. Despite these policies, the altercation occurred, and staff members acknowledged that bumping is considered a form of resident-to-resident physical abuse. The incident was reported to the police, and a battery report was filed.
Failure to Accommodate Resident's Mobility Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as R1, who is an 85-year-old with a medical history including transient cerebral ischemic attack, vitamin D deficiency, atherosclerotic heart disease, chronic obstructive pulmonary disease, weakness, and urinary retention. R1, who is cognitively intact, expressed that she experienced back pain and required the use of her cane for short distances and a walker for longer distances. Despite this, her cane was taken away by the Social Service Director without explanation or prior intervention, leading to distress and difficulty in maintaining her independence and mobility. The Social Service Director removed R1's cane because R1 was using it to propel her wheelchair, raising concerns about potential safety risks, although R1 had not hit anyone or fallen. The Director of Therapy and the Restorative Nurse confirmed that R1 was safe to use her cane and had not had any incidents with it. The facility's administration did not implement any interventions or notify R1's family before taking the cane, and the behavior was not care planned until after the issue was raised. This action was contrary to the facility's policy on residents' rights, which emphasizes maintaining residents' physical and mental health at the highest practical level and requires documentation of any negotiated risk agreements in the care plan.
Staff Member Abusive Towards Residents
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a staff member, V11, who was physically and verbally abusive towards several residents. The incidents involved four residents experiencing physical abuse and one resident experiencing verbal abuse. The abuse led to emotional trauma, fear, and anxiety among the residents. The facility's policy to ensure residents are free from abuse was not followed, resulting in these deficiencies. One incident involved a resident, R119, who experienced physical abuse when V11 yanked a gown off the resident's head, causing distress and fear. The resident's husband, R120, witnessed the incident and expressed feeling vulnerable and scared of V11. Another resident, R104, reported that V11 was rough during care, twisting the resident's leg aggressively. Although R104 did not initially report the incident, it was mentioned in a casual conversation with another CNA. Additional incidents included R64, who reported being knocked down on the bed by V11, resulting in a head injury. R50 experienced verbal abuse when V11 made inappropriate comments about the resident's age and worth, causing sadness and isolation. R32 also reported physical contact by V11, which was addressed through education on customer service expectations. Despite these incidents, some staff members did not report any issues with V11, indicating a possible lack of awareness or communication regarding the abuse.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen was found to have several deficiencies, including improperly labeled and stored food items. Peeled eggs were found in the walk-in cooler without a use-by date, and a whipped cream bottle was past its use-by date. Additionally, opened and uncovered meat was left unattended on the counter, and approximately forty uncovered chocolate puddings were observed on a tray cart. A fly was also seen in the kitchen, indicating potential contamination risks. Further inspection of the dry storage room revealed expired food items, including cans of evaporated milk and a box of raisins past their expiration dates. The facility's food service policy and storage guidelines were not followed, as evidenced by the presence of expired and improperly stored food items. These deficiencies have the potential to affect the 135 residents who consume food from the kitchen, as the facility's census documented a total of 138 residents, with three on an NPO diet.
Improper Waste Containment in Facility Dumpsters
Penalty
Summary
The facility failed to properly contain waste in its dumpsters, as observed by surveyors. During the inspection, the Maintenance Director showed the surveyor the location of the facility's two dumpsters. It was noted that the recycling dumpster had an open lid, while the garbage dumpster was missing a lid for half of the dumpster. The garbage dumpster was overfilled with clear trash bags containing disposable chucks and briefs. The Maintenance Director acknowledged the missing lid and mentioned that it might have been thrown away, and he had not yet contacted the dumpster company to order a new lid. A facility document from April 2022, titled 'Garbage Disposal,' states that dumpsters should be kept closed at all times and that the garbage service should be contacted for removal if the dumpster becomes full. This indicates a failure to adhere to the facility's own waste management policy.
Failure to Address Multiple Abuse Allegations Against CNA
Penalty
Summary
The facility failed to manage staff effectively, allowing a Certified Nursing Assistant (CNA), identified as V11, to continue working despite multiple allegations of inappropriate behavior towards residents. These allegations include incidents of rough handling and verbal abuse, which were reported by several residents. The facility's records indicate that V11 was involved in multiple incidents where residents felt threatened or were physically mishandled, yet V11 was allowed to continue working until a recent suspension pending investigation. One resident, R119, reported feeling distressed and vulnerable when V11 yanked a gown off their head, causing their glasses to become skewed. Another resident, R104, described an incident where V11 aggressively twisted their leg during care, causing pain. R64, a resident with severe cognitive impairment, reported feeling threatened by V11 after being knocked down on their bed, resulting in a head injury. Additionally, R50 reported inappropriate verbal interactions with V11, which led to re-education on customer service expectations. Despite these allegations, the facility's administration, including the Director of Nursing and a Nurse Consultant, initially deemed V11's actions as poor customer service rather than abuse. The facility's abuse prevention policy clearly prohibits any form of abuse or mistreatment, yet V11 was allowed to work from January to March 2024, and again in July 2024, before being suspended. This oversight in staff management and failure to act on multiple allegations of abuse potentially affected all residents in the facility.
Infection Control and Policy Failures in Laundry, Legionella Prevention, and Medication Administration
Penalty
Summary
The facility failed to adhere to its laundry policy, resulting in potential contamination of clean linens. During an observation, a laundry aide was seen folding clean linens near a dusty fan, which was circulating air in the laundry room. The aide acknowledged the fan's dirtiness and the potential for contamination but continued to use it due to the heat. Additionally, the soiled linen area was found to be overflowing, with bags of soiled linen on the floor, indicating a failure to sort and handle soiled linen properly. The laundry supervisor confirmed the issue, noting that staff had not sorted the soiled laundry into designated containers, which were found to be empty. The facility also failed to follow its Legionella prevention policy. The maintenance director was unable to present the current policy or provide recent records of water testing for Legionella. The last documented test was over three years ago, and the director was unaware of any recent testing or specific areas at risk within the facility. The facility's water management program outlined procedures for identifying and monitoring potential Legionella risks, but the necessary documentation and worksheets were not available, indicating a lapse in preventive measures. Furthermore, the facility did not comply with its medication administration policy regarding hand hygiene. A registered nurse was observed administering medication to a resident without washing hands or using gloves. The nurse handled the medication and inhaler device without performing hand hygiene, even after the resident used the inhaler. The nurse admitted to neglecting hand hygiene due to being busy, acknowledging the risk of spreading germs. The director of nursing confirmed that hand hygiene should be performed before and after medication administration to prevent infections.
Improper Medication Disposal and Insulin Storage
Penalty
Summary
The facility failed to adhere to its policy on disposing of expired medications and properly storing insulin, leading to deficiencies in pharmaceutical services. Specifically, the facility did not dispose of expired Ibuprofen for one resident, R127, whose medication was found in the medication cart despite being discontinued and expired. The Registered Nurse, V5, acknowledged that expired medications should not be in the cart as they could be mistakenly administered, and they should be sent to the pharmacy for destruction. The Director of Nursing, V2, confirmed that expired medications should be removed immediately to maintain their potency and effectiveness. Additionally, the facility did not properly store insulin for three residents, R4, R7, and R90. During an observation, unopened insulin pens/vials labeled for refrigeration were found in the medication cart without a received-on date. The Licensed Practical Nurse, V15, and Nurse Consultant, V28, both stated that insulin should be refrigerated to maintain potency and effectiveness. If left unrefrigerated, the insulin should be labeled with a received-on date to ensure it is discarded after 28 days. The lack of proper labeling and storage could affect the medication's effectiveness, as noted by V28.
Failure to Maintain Correct Food Temperatures
Penalty
Summary
The facility failed to maintain correct food temperatures when delivering meals to residents, as observed during a survey. Three residents expressed dissatisfaction with the temperature of their food, stating that it was often cold. One resident mentioned that the food was bad and cold, while another stated that the food was 90% always cold. A third resident suggested that the food was cold because it was handed out late. These observations were made during interviews and record reviews, indicating a pattern of inadequate food temperature management. During the survey, a test tray was used to measure the temperature of a hamburger, which was found to be 120 degrees Fahrenheit, below the facility's standard of at least 150 degrees Fahrenheit. The facility's policy, dated April 2017, requires hot foods to be served at a temperature palatable and acceptable to residents, generally not less than 125 degrees Fahrenheit. A cook at the facility acknowledged that cold food could potentially make residents sick, as not all stomachs can tolerate cold food. This deficiency highlights the facility's failure to adhere to its own policy regarding food temperature, potentially impacting resident satisfaction and health.
Failure to Provide Advance Directive Planning for a Resident
Penalty
Summary
The facility failed to uphold the resident's right to formulate an advance directive and engage in advance care planning for a resident with schizophrenia and impaired cognition. The resident, who was admitted with a medical diagnosis of schizophrenia and a BIMS score indicating impaired cognition, had a documented code status of full code. However, there was no care plan for advance directives in place until the day of the survey, and the Social Service Director admitted that there was no documentation of discussions about advance directives in the progress notes. The Social Service Director stated that although there was no documentation, a discussion about advance directives had occurred with the resident. However, the resident's appointed State Guardian was only contacted the day before the survey to clarify the resident's intentions regarding code status. The hospital records indicated that the resident lacked decisional capacity to make some or all decisions, demonstrating poor insight, understanding, and reasoning. The facility's policy requires that upon admission, it should be determined if a resident has an advance directive and if not, the resident should be provided with information and education about advance directives, which was not adequately done in this case.
Privacy Breach of Resident's Medical Records
Penalty
Summary
The facility failed to protect the privacy and confidentiality of a resident's personal and medical records. During an observation, a registered nurse (RN) was seen administering medication to a resident on the first floor. The RN left the computer screen open, displaying the resident's personal and medical information, while attending to another matter at the nursing station. This lapse allowed other residents and staff passing by to view the confidential information, which included the resident's medications and medical diagnoses such as schizophrenia, major depressive disorder, and bipolar disorder. The RN acknowledged forgetting to lock the computer screen, recognizing it as a violation of the Health Insurance Portability and Accountability Act (HIPAA). The Director of Nursing (DON) confirmed that nurses are required to lock their computer screens when stepping away to prevent unauthorized access to residents' protected health information. The facility's policy on resident rights emphasizes the right to privacy over personal and clinical records, which was not upheld in this instance.
Failure to Maintain Homelike Environment Due to Unattended Maintenance Issue
Penalty
Summary
The facility failed to maintain a homelike environment for a resident, identified as R80, due to a significant maintenance issue in the resident's bathroom. On two separate occasions, a surveyor observed a one-foot hole in the ceiling tile above the toilet, which had been present for about a month. The resident reported that she had requested the repair, but no action had been taken to address the issue. This deficiency was noted during a review of the facility's maintenance practices and procedures. The Maintenance Director, identified as V16, acknowledged the presence of the hole, explaining that it was left open to allow the area to dry out following a water leakage from the room above, to prevent mold growth. However, V16 stated that he had not received any work order regarding this issue, despite the facility's protocol for entering maintenance requests into the TELS system. The facility's maintenance request log indicated that urgent issues should be addressed promptly, but no work order for R80's bathroom was found, highlighting a lapse in communication and follow-up on maintenance requests.
Failure to Provide Appropriate Bowel and Bladder Care
Penalty
Summary
The facility failed to provide appropriate services to restore continence for a resident who was incontinent of bowel and bladder. The resident, a cognitively intact male with end-stage renal disease and mobility issues, required substantial assistance for toilet transfers. Despite being able to feel the need to urinate and have bowel movements, the resident was not placed on a bowel and bladder toileting program. Instead, the resident was frequently left to wait for assistance and was changed in bed after episodes of incontinence. The restorative nurse admitted to overlooking the resident's suitability for a bowel and bladder training program, stating that the resident could have been placed on such a program if he could verbalize the need to use the restroom. The certified nursing assistant confirmed that the resident was not taken to the toilet and was instead changed in bed, despite the resident's previous use of a bedpan and urinal. The facility's policy requires maintaining and improving residents' abilities in activities of daily living, but this was not adhered to in the resident's case.
Improper Positioning During Enteral Feeding Administration
Penalty
Summary
The facility failed to ensure proper positioning of a resident during the administration and flushing of enteral feeding, which could potentially lead to aspiration. On July 9, 2024, a registered nurse was observed flushing a resident's feeding tube while the resident was lying on her side with her head dangling off the bed at the level of her knees. This positioning was not corrected until it was pointed out by an observer, at which point the nurse repositioned the resident to an upright position. The nurse acknowledged that the head should be maintained at least 30 degrees to avoid aspiration. The Director of Nursing confirmed that the facility's policy requires the head of the bed to be elevated 30 to 45 degrees during and after enteral feeding to prevent aspiration. The resident in question had recently had an enteral tube placed following a hospital visit. The physician's order also specified that the head of the bed should be elevated 30 to 45 degrees at all times, except during activities of daily living care. The facility's guidelines and national recommendations emphasize the importance of maintaining the head of the bed at the correct angle to reduce the risk of aspiration.
Failure to Provide Adequate Vaccination Education
Penalty
Summary
The facility failed to provide adequate education on the benefits and risks of influenza and pneumococcal vaccinations to two residents, R147 and R29, as per their policy. R147, who has an intact cognitive status with a BIMS score of 13, did not receive direct education about the vaccinations. Instead, the education was provided to R147's granddaughter, which was not in accordance with the facility's guidelines that require education to be given directly to the resident if they are cognitively intact. This oversight potentially affected R147's understanding of the vaccinations. For R29, who has a BIMS score of 7 indicating cognitive impairment, the education on vaccinations was incomplete, as R29 only heard part of the information. Despite R29's documented lack of decisional capacity, no education was provided to R29's representative, and there was no follow-up education after R29 initially refused the vaccinations. The facility's guidelines require that residents or their representatives be informed about the benefits and risks of immunizations, which was not fulfilled in this case.
Facility Fails to Maintain Safe and Functional Bathroom Facilities
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, specifically in the case of two residents, R4 and R6. The surveyor observed that the shared bathroom for these residents had a broken sink faucet with no water coming out and a non-working toilet that was not flushing properly, with water surrounding the area on the floor. The administrator, V1, was unaware of these issues until the surveyor pointed them out. R4 reported that the bathroom sink had been broken for about a month, and the toilet kept leaking, forcing her to use facilities in another room. R6, who is bedridden, confirmed that staff had to fetch water from another room to provide care. Staff interviews revealed a lack of communication and reporting regarding the maintenance issues. V9, an LPN, stated that maintenance issues are either verbalized or submitted through a work order system, but was unaware of the plumbing issues in the room. V17, a CNA, mentioned that before going on vacation, the sink and toilet were functioning, but upon return, they were not. V19, a housekeeper, noticed the broken faucet handles but did not report it. The housekeeping director, V20, stated that housekeepers should report such issues immediately. The facility's preventative maintenance program policy requires regular inspection and repair of faucets and toilets, but records for recent months were incomplete, indicating a lapse in maintenance oversight.
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What surveyors actually found near you
We read the 1,635 citations issued within 25 miles in the last 12 months — including the 28 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Healthcare & Rehab Ctr | 0.7 mi | ★★★★★ | 2 | 0 |
| Alta Rehab At Fairmont | 0.7 mi | ★★★★★ | 27 | 0 |
| Foster Health & Rehab Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Irving Park Living & Rehab Ctr | 1 mi | ★★★★★ | 0 | 0 |
| Continental Nursing & Rehab Center | 1.4 mi | ★★★★★ | 7 | 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 July 2026) and official state health department websites.