Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Aperion Care Chicago Heights during CMS and state inspections, most recent first.
Two residents with psychiatric histories, one with a known violent criminal background and one at moderate risk for abuse/neglect, became involved in an altercation in the dining room during which one resident struck the other in the head and face multiple times with a closed fist. Staff accounts and documentation focused primarily on the aggressor’s agitation and transfer to the hospital, while key personnel did not interview the victimized resident about the event, did not verify whether physical contact occurred, and did not document the altercation in that resident’s record. An undated statement purportedly from the victimized resident was later disputed by the resident, who denied making or signing it and demonstrated a signature that did not match, all in contrast to the facility’s abuse policy that prohibits and defines physical abuse such as hitting.
Two residents with psychiatric diagnoses, one with a known history of violent criminal behavior and care-planned risk for aggression, were involved in a dining room altercation in which one resident admitted to hitting the other in the head with a closed fist after an exchange of words. A behavior aide reported seeing the aggressor deliver several closed-fist "taps" and stated this met the definition of physical abuse and was reported to the administrator, while other staff acknowledged being told of aggression but did not directly verify with the alleged victim whether physical contact occurred. The administrator conducted an internal review, characterized the event as horseplay, relied on an undated statement attributed to the alleged victim that the victim later denied signing, and concluded there was no need to report the incident externally. The alleged victim’s clinical notes contained only wellness checks indicating he felt safe, there was no documentation of the altercation in his record, and review of abuse reportables showed no incident report submitted to the state survey agency, despite facility policy and staff statements that resident-to-resident hitting constitutes abuse requiring reporting.
The facility failed to ensure that meals were matched to physician-ordered diets during meal service. Surveyors observed dietary staff plating food without tray cards and without receiving diet information from a CNA who was holding, but not using, a Diet Type Report. Residents were served and consumed meals without verification that trays reflected ordered diets, including mechanical soft diets for swallowing difficulties, no concentrated sweets, low concentrated sweets/no added salt, no added salt, and other specialized diets, allergies, and preferences. The DON and an RN confirmed that diets were supposed to be verbally called but were not, and the Dietary Manager acknowledged that staff could not be expected to know all diets by memory. The Administrator provided diet reports and a written policy requiring tray cards for diet identification, but tray cards were not in use, and no effective system was in place to ensure tray accuracy for the 139 residents receiving oral diets.
Surveyors found that the facility failed to maintain sanitary conditions in key food service areas used to provide oral nutrition to all residents. During a kitchen observation with the Dietary Manager, the dry storage room floor had visible accumulated dust and dirt, a food cart had dried food spills and visible dirt despite expectations for daily cleaning, and a wall air return vent in the kitchen had a significant buildup of dust. These conditions were not consistent with the facility’s own dietary policies and daily kitchen cleaning schedule for floors, food carts, and vents.
Surveyors found that outside dumpsters were left uncovered and overflowing, with bags of trash and spilled garbage on the surrounding ground. The Dietary Manager reported that scheduled garbage pickup had not occurred, leading to the overflow, and acknowledged that open dumpsters could attract rodents. These conditions were inconsistent with the facility’s policy requiring tight-fitting lids on outdoor trash receptacles, timely emptying to prevent overfilling, and maintaining the surrounding area free of litter for all 139 residents.
Surveyors observed that during meal service, residents were brought into a single dining room in an unorganized manner, with new diners seated immediately at spots just vacated by others, where tables still had food crumbs and trash. Staff present in the dining area did not assist residents with hand hygiene before eating and did not sanitize tables between diners, despite the Administrator and Infection Control Nurse stating that tables were supposed to be sanitized after each resident and that residents should be called in small groups with cleaning between groups. The facility’s hand hygiene policy required hand hygiene before eating, and cleaning instructions called for regular cleaning and sanitizing of dining tables and chairs, but no specific policy for hand hygiene and table sanitizing during meals was provided.
Surveyors found that the facility did not follow its own laundry safety policy for cleaning dryer lint screens. During a tour with the EVS supervisor, a dryer lint compartment was observed with loose lint on the floor and a lint screen fully covered with lint, and the supervisor acknowledged it had not been cleaned that day. Facility records showed lint compartments were only cleaned three times per week, rather than at least every three loads or every two hours as required by the written policy. This failure to maintain the laundry equipment in accordance with policy conflicted with facility obligations to provide a safe, clean, and comfortable environment for all residents.
Surveyors found multiple corridor handrails loose, hanging, or detaching from walls, including one that fell to the floor while the administrator, who was ambulating with a cane and abnormal gait, was testing it near a resident. A resident with ADL self-care deficits who uses a cane and splint to the left lower extremity and requires supervision/touching assistance during ambulation was startled by the falling handrail. An LPN and the Maintenance Director both confirmed that several handrails were not secured, despite facility policy requiring properly installed handrails on both sides of corridors and routine inspection and maintenance.
Surveyors found that a shared bathroom used by five residents was not maintained in a clean and sanitary condition, with a strong urine odor and a large puddle of urine on the floor around the toilet. Several cognitively intact residents reported that urine had been present on the bathroom floor on prior occasions, sometimes causing them to use a different bathroom, and described another resident as frequently urinating on the floor. A housekeeper confirmed the substance was urine, acknowledged that the room had not yet been cleaned, and stated that one resident often urinated on the floor, despite facility expectations that housekeeping maintain a clean, safe, and comfortable environment consistent with residents’ rights.
A resident with multiple chronic conditions, including anemia, Type 2 DM, HTN, and hyperlipidemia, had these diagnoses documented in the comprehensive assessment and was receiving related medications such as sodium chloride, carvedilol, hydralazine, metformin, and atorvastatin. However, review of the admission and current care plans showed that these medical conditions were not included, and there were no measurable objectives or timeframes addressing them. During interview, the MDS coordinator confirmed the resident’s diagnoses and medications and acknowledged that these issues were not reflected on the care plan, despite facility policy requiring a person-centered comprehensive care plan based on identified needs.
A resident with a history of cellulitis, diabetes, and other conditions had very dry, scaly skin on the hands and legs and reported not receiving ordered topical treatment. After an urgent dermatology visit, the after-visit summary included multiple new orders (Triamcinolone and Fluocinonide ointments to hands and feet BID, Diphenhydramine BID, a one-time dose of Ivermectin, and BID antihistamines Allegra and Zyrtec), but these were not entered as active orders until about two weeks later, after a surveyor requested documentation. The DON confirmed the orders from the dermatology visit had not been carried out, while an RN reported she was unaware the resident had gone out for an appointment and had not seen the after-visit summary, despite facility policy and RN/LPN job descriptions requiring nurses to receive, verify, and accurately enter physician orders.
A resident with diabetes and multiple comorbidities was found unresponsive with elevated blood glucose. An RN administered both scheduled and sliding scale insulin to the unresponsive resident before initiating emergency procedures or contacting a physician. Facility leadership and the physician confirmed this was not appropriate, and the facility lacked a specific policy for insulin administration during emergencies.
A resident with epilepsy continued to receive Keppra alongside Brivaracetam despite multiple orders from a neurologist to discontinue Keppra. The neurologist's instructions were communicated to facility staff by phone and fax, but there was no documentation that the order was relayed to or verified with the attending physician, and the resident continued to receive the medication for several weeks.
A resident with multiple medical conditions did not receive prescribed pain and acid reflux medications as ordered, despite repeated requests to the nurse on duty. The nurse did not document administration or provide a reason for withholding the medications in the eMAR, and the facility's policy requires such documentation and adherence to physician orders.
A resident with schizophrenia and other disorders was involuntarily discharged after assaulting staff, but the facility failed to provide a written notice of discharge to the resident's representative, as required by policy. The guardian received only a verbal notice, and the opportunity for a hearing was not communicated in writing.
A facility failed to report an incident where a resident displayed aggression and made threats towards another resident and staff. The resident was not easily redirected, refused medication, and required police intervention. Despite the facility's policy requiring such incidents to be reported, the administrator did not report it, citing it did not involve a peer altercation.
A facility failed to notify a resident's guardian when the resident was transferred to the hospital for a psychiatric evaluation due to increased agitation and delusions. The nurse on duty did not inform the guardian because the resident was under observation and not admitted by the end of her shift. The facility's policy requires timely notification of the resident's power of attorney or guardian during transfers, which was not followed in this case.
A resident's Link card was misappropriated by a former staff member who failed to return it after being entrusted to make a purchase. The incident was reported to the facility's psychosocial rehabilitation director and the police, leading to the card's cancellation. The card was eventually retrieved and returned to the resident, highlighting a failure to protect the resident's property as per the facility's policy.
The facility failed to implement its abuse prevention policies, affecting four residents. A resident with schizophrenia and bipolar disorder did not receive an abuse assessment upon admission or after an altercation. Another resident involved in the incident also lacked an updated care plan. Staff interviews revealed non-compliance with policies requiring incident reports and care plan updates after altercations.
A resident did not receive their prescribed appetite stimulant medication as ordered, despite an LPN claiming it was administered. The medication bottles were found unopened, and the resident confirmed no medication was given before lunch. The facility's policy requires medication to be administered as prescribed and refusals to be reported, which was not followed in this case.
The facility failed to maintain a functional eyewash station in areas with hazardous chemicals, affecting all units reviewed. The Maintenance Director noted the station had not been logged since February due to broken caps, initially reported in January. The Infection Preventionist and Administrator were unaware of the issue, and the facility's policy requiring weekly checks was not followed, as shown by empty logs.
A resident was physically assaulted by another resident over a candy bar, resulting in an eye injury. The incident was reported to staff, and the aggressor admitted to the altercation. The injured resident received medical attention, and the aggressor was sent for psychiatric evaluation. The facility's policy against abuse was not upheld.
Failure to Protect Resident From Peer Physical Abuse and Inadequate Incident Assessment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to properly assess and document the incident. One resident (R1), with diagnoses including schizophrenia and bipolar-type schizoaffective disorder and a documented history of criminal behavior (aggravated battery with great bodily harm and attempted murder), physically struck another resident (R2) in the dining room. R2, who has major depressive disorder, post-traumatic stress disorder, nonsuicidal self-harm, and a moderate risk score for abuse/neglect, reported being hit multiple times in the head and face by a heavy-set Black man after an exchange of words. R1 confirmed hitting R2 in the head with a closed fist because R1 believed R2 was making fun of R1’s laugh, and a behavior aide reported seeing R1 give R2 “a couple taps” with a closed fist, which the aide stated would be considered physical abuse. Following the altercation, facility staff did not adequately investigate or document the event from R2’s perspective. The PRSC stated being told there was verbal back-and-forth between residents but denied being informed that any resident had gotten physical and denied speaking with R2 about the incident. An LPN reported being told that R1 was aggressive toward R2 and that R1 tried to hit R2, but did not ask staff whether the residents made contact and did not ask R1 if R1 hit R2, relying only on what others reported. There was no documentation of the altercation in R2’s notes, despite R2’s later account that there was definite physical contact and multiple hits before staff intervened, and that the touching was unwanted. The facility’s documentation and statements also show inconsistencies regarding R2’s involvement and the nature of the incident. Social service notes for R2 on the days following the event only record wellness checks, stable mood, and R2 reporting feeling safe, with no mention of the physical altercation. The administrator provided an alleged written statement from R2 about the incident, but the document was undated, and R2 denied ever seeing or signing it. When shown the document, R2 stated the signature was not his and demonstrated his usual signature, which did not match the one on the paper. The facility’s abuse prevention policy defines abuse as willful infliction of injury and specifies that physical abuse includes hitting and other non-accidental infliction of injury, yet the facility failed to ensure that R2 was free from physical abuse by R1 and failed to accurately assess, interview, and document R2’s experience of the incident.
Failure to Report Resident-to-Resident Physical Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident‑to‑resident physical abuse to the state survey agency. One resident with schizophrenia and bipolar-type schizoaffective disorder (R1), who had a documented history of aggravated battery with great bodily harm and attempted murder and was care planned as an identified offender with potential for physical/verbally aggressive behavior, became agitated toward another resident (R2) in the dining room. R2 had diagnoses of major depressive disorder, PTSD, and nonsuicidal self-harm, was assessed as at moderate risk for abuse/neglect, and had no cognitive impairment. R2 later reported that a heavy-set Black male resident hit him in the head and face more than once in the dining room after an exchange of words, describing the contact as unwanted touching and stating there was definite physical contact and multiple hits before staff intervened. R1 admitted to the surveyor that he hit R2 in the head with a closed fist because he believed R2 was making fun of his laugh, acknowledging he knew he should not be hitting anyone but was very mad at the time. A behavior aide (V16) reported hearing commotion, going to the area, and seeing R1 give R2 “a couple taps” with a closed fist, and stated this would be considered physical abuse and that all altercations must be reported to a supervisor or administrator. V16 stated that he informed the administrator (V18) about the incident and described the altercation as he later did to the surveyor. Nursing and social service notes for R1 on the date of the incident documented increased agitation toward a peer, responding to internal stimuli, inability to be redirected, 1:1 monitoring, and transfer to the hospital for psychiatric evaluation, but did not document the physical assault itself. Despite these accounts, the administrator (V18) stated that his internal investigation concluded the incident was “horse playing,” that R1 only admitted to tapping R2 on the shoulder, and that under facility policy there was no need to report the incident. V18 provided an alleged written statement from R2 about the incident, which contained a signature without a date; R2 denied ever seeing or signing the document, and when R2 signed the paper in the surveyor’s presence, the two signatures did not match. Staff who were aware of the event, including the PRSC (V7) and an LPN (V10), either believed or were told it was an attempted hit or verbal altercation and did not confirm with R2 whether physical contact occurred; neither spoke directly with R2 about the incident. There was no documentation of the altercation in R2’s notes, only wellness checks indicating R2 felt safe, and review of abuse reportables for the prior three months showed no incident report submitted to the state agency, despite facility policy requiring employees to report any incident, allegation, or suspicion of potential abuse to the administrator and defining physical abuse as hitting and similar acts. The facility’s abuse prevention and reporting policy affirmed residents’ rights to be free from abuse and required immediate internal reporting of any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation. The policy defined abuse as willful infliction of injury or intimidation with resulting physical harm, pain, or mental anguish, and physical abuse as non-accidental infliction of injury requiring medical attention, including hitting and slapping. Multiple staff, including V10 and V16, acknowledged that if a resident hits or touches another resident in this manner it is considered abuse and must be reported. Nonetheless, the facility did not treat the event as a reportable allegation of abuse and did not submit an incident report to the state survey agency, resulting in the cited failure to timely report suspected abuse and the results of the investigation to the proper authorities.
Failure to Match Physician-Ordered Diets to Meals Served
Penalty
Summary
The facility failed to ensure that residents received meals prepared and served according to their individual diet orders, allergies, and preferences. During a lunch meal service observed by surveyors, dietary staff were seen plating food and preparing trays without using tray cards and without receiving any diet information from the CNA who was holding the Diet Type Report. Residents were given trays, ate their meals, and left the dining room without any verification that the food matched their prescribed diets. When questioned, the CNA confirmed he had the Diet Type Report but was not using it to call out or communicate diet orders to dietary staff. The DON, who was present, acknowledged that the CNA was supposed to call the diets so that each resident would receive the correct physician-ordered diet. An RN assisting in the dining room also confirmed that there were no tray tickets in use and that staff were expected instead to verbally call out diets before handing trays to residents. The Dietary Manager later stated that she could not confirm that dietary staff knew each resident’s diet order by memory, noting that there were multiple diet types in use, including mechanical soft diets for residents with swallowing difficulties, no concentrated sweets diets, low concentrated sweets/no added salt diets, no added salt diets, and other specialized diets such as no added salt/low fat/low cholesterol. The Diet Type Report also listed residents with food allergies, food preferences, and large-portion orders. The Administrator provided an alphabetically arranged Diet Type Report showing the different diets for each resident and acknowledged that the facility did not use tray cards, despite having a written policy titled “Meal Identification, Resident Meal Card” requiring that each resident have a tray card indicating diet orders, allergies, preferences, and other nutritional needs, and that these tray cards be used during meal service to ensure accurate meal delivery. All 139 residents in the facility were reported to receive oral foods from the kitchen, and the observed practices showed that the facility did not follow its own policy or have an effective system in place to ensure tray accuracy and that prescribed diets were served.
Unclean Kitchen Carts, Dry Storage Floor, and Air Vent in Food Service Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service sanitation practices when observing the kitchen and dry storage areas. The facility census was 139 residents, all of whom received oral nutrition from the kitchen. During a kitchen tour with the Dietary Manager, the dry storage room floor was observed to have visible accumulated dust and dirt, despite the facility’s written daily cleaning schedule requiring sweeping and mopping of the storeroom and kitchen floor. A kitchen cart used in food service was also observed with dried food spills and visible dirt, contrary to the stated expectation that food carts be cleaned daily. In addition, the wall air return vent in the kitchen had a significant accumulation of dust, despite a facility dietary policy requiring ceiling vents to be cleaned at least quarterly, or more often if needed, by Maintenance with support from dietary staff. These observations showed that the facility did not maintain food carts, the dry storage floor, and the wall air return vent in a clean condition as required by its own policies and cleaning schedules, affecting the environment where food for all residents was stored, prepared, and distributed.
Uncovered, Overflowing Dumpsters and Littered Area Create Unsanitary Conditions
Penalty
Summary
Surveyors identified a deficiency related to improper disposal of garbage and refuse in the facility’s outside dumpster area. On 1/26/26 at 9:52 a.m., following a kitchen observation with the Dietary Manager, the outside dumpster was observed to be open without lids, with bags of trash and spilled trash on the ground around it. The same unsanitary condition was again observed at 11:20 a.m. that day, with the dumpster still uncovered and trash remaining on the floor. The Administrator had reported a facility census of 139 residents at the time of the survey. The Dietary Manager stated that the garbage truck should have come on Friday and that, because of the weekend, the garbage was overflowing. On 1/27/26 at 10:20 a.m., the Dietary Manager acknowledged that leaving dumpsters open could cause rodents to come around the building. The facility’s written policy on Garbage and Rubbish Disposal, dated 2020, requires that all garbage be placed in waste containers emptied as often as necessary to prevent overfilling, that all containers have tight-fitting lids and be covered when not in immediate use so as to be inaccessible to vermin, and that outdoor trash receptacles be kept covered with the surrounding area free of litter. The observed conditions were not in compliance with this policy.
Failure to Perform Hand Hygiene and Sanitize Dining Tables Between Diners
Penalty
Summary
The deficiency involves the facility’s failure to implement effective infection prevention and control practices during meal service in the dining room. During a lunch observation, surveyors noted that all residents used a single dining room, with some residents already eating while others waited in the hallway to be called in. Residents who finished their meals left the dining area with their trays, and new residents immediately sat in the same spots without the tables being cleaned or sanitized. Some tables had visible food crumbs and garbage left by prior diners, and incoming residents sat and ate at these dirty tables. There was no apparent organization regarding seating assignments or the number of residents eating at one time before others were brought in. Surveyors also observed multiple staff members present in the dining area, including those assisting with trays and others standing nearby, but none were seen assisting residents with hand hygiene before eating or sanitizing tables between residents. The Administrator stated that staff were supposed to sanitize tables after each resident before another resident sat in the same spot. The Infection Control Nurse reported that the facility’s process was to call residents in groups of five, sanitize the tables after they finished eating, and then seat the next group of five, but this process was not being followed. The facility’s hand hygiene policy required hand hygiene before eating, and a cleaning instruction document stated that dining room tables and chairs would be cleaned and sanitized on a regular basis, with chairs wiped down after each meal or as needed. However, when surveyors requested a specific policy on hand hygiene and sanitizing the dining area during meals, none was provided.
Failure to Follow Dryer Lint Cleaning Policy and Maintain Safe Laundry Environment
Penalty
Summary
The facility failed to follow its own laundry safety policy and procedure regarding dryer lint screen cleaning, resulting in an unclean and potentially unsafe environment. During a tour of the laundry room with the Environmental Services (EVS) Supervisor, surveyors observed that the lint compartment for dryer #3 had loose lint on the compartment floor and the lint screen was fully covered with lint. The EVS Supervisor acknowledged that the laundry staff had not cleaned the lint that day, then manually removed the lint from the screen and compartment floor and discarded it. The EVS Supervisor stated that laundry staff clean the lint compartments every Monday, Wednesday, and Friday, explaining that the facility launders out most of the laundry and that the on-site dryers are used for rags and a few other items, and that lint is cleaned out for safety and to prevent a fire. Record review showed that the facility’s documentation for dryer lint compartment cleaning, dated over a one‑month period, reflected cleaning only on Mondays, Wednesdays, and Fridays, with no indication of more frequent cleaning. This practice did not align with the facility’s written policy titled “Safety Procedures or Dryers in Laundry Department,” which required lint screens to be cleaned at least every three loads or every two hours, whichever came first, as part of preventative maintenance to maintain safety and prevent motor overheating and damage. Additionally, facility-provided resident rights information stated that the facility must provide a safe, clean, comfortable, and homelike environment and must care for residents in a manner that promotes their quality of life. The failure to adhere to the established lint cleaning schedule and policy had the potential to affect all 139 residents documented as residing in the facility.
Unsecured Corridor Handrails Create Safety Hazard for Ambulating Residents
Penalty
Summary
The facility failed to ensure that corridor handrails were firmly secured to the walls, despite a census showing 139 residents residing in the facility. During observation, a handrail next to a resident room was found to be loose and able to be displaced 4–5 inches from the wall, indicating it was unsecured. The administrator observed and confirmed this condition and acknowledged that the purpose of handrails is for safety and to prevent falls. Further down the corridor, while the administrator was testing other handrails and ambulating with a cane and abnormal gait, the handrail outside the master shower room near another room fully detached from the wall and fell to the floor, startling a resident nearby. That resident’s care plan documented activity of daily living self-care deficits, use of a cane and splint to the left lower extremity during ambulation, and a need for supervision/touching assistance while ambulating. Additional observation revealed another handrail hanging from the wall near the nurse’s station and a resident room, with visible holes in the wall approximately 3–4 inches in diameter where the rail had been affixed. An LPN confirmed that this handrail was not secured and described it as a hazard. The Maintenance Director also confirmed the loose and hanging handrails and stated that handrails are intended to help residents who do not walk properly maintain balance so they do not fall, and further stated that facility expectations are that handrails are checked every day to ensure they are firmly secured. The facility’s written policy required handrails to be properly installed and maintained, with routine monthly inspections and prompt repair by maintenance staff.
Failure to Maintain Clean and Sanitary Shared Bathroom Environment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a clean and sanitary bathroom environment for five residents sharing a room and bathroom. On 1/26/26 at 10:29 a.m., upon entering the shared room of residents R52 and R64, which is also shared with R93, R119, and R136, surveyors detected a strong, pervasive odor of urine. A large puddle of urine was observed spreading out from the area around the toilet in the shared bathroom. During an observation at 10:39 a.m. with a housekeeper (V11), the staff member confirmed that the substance on the floor was urine, stated that the resident identified as R52 was “always urinating on the floor,” and acknowledged that they had not yet gotten to that room to clean it. The facility’s housekeeper job description requires maintaining the facility in a clean, safe, and comfortable manner, including cleaning and disinfecting floors. Resident interviews further confirmed that the unsanitary condition was recurrent. At 10:30 a.m., R52, who has diagnoses including psychosis, schizophrenia, hallucinations, and violent behavior and a BIMS score of 12 indicating moderately impaired cognition, stated that they did not know who urinated on the floor but that the room “always smells like piss.” At 10:33 a.m., R64, who has COPD and schizoaffective disorder and a BIMS score of 15 indicating intact cognition, reported that there had been urine on the bathroom floor before and that they sometimes had to use a different bathroom, expressing a preference for not having urine on the floor. At 10:35 a.m., R119, who has diabetes, COPD, and a psychotic disorder with a BIMS score of 15, stated that another resident in the room was “always pissing on the floor” and described this as “nasty.” Facility-provided resident rights information states that the facility must be safe, clean, comfortable, and homelike and must provide care in a manner that promotes quality of life, which was not met in this instance.
Failure to Develop Comprehensive Care Plan for Resident’s Chronic Medical Conditions
Penalty
Summary
Surveyors identified that the facility failed to develop a person-centered comprehensive care plan with measurable objectives and timeframes for a cognitively intact resident with multiple active medical diagnoses. The resident, who has Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anemia, Pyothorax without Fistula, Emphysema, Paranoid Personality Disorder, Pneumonia, and Paranoid Schizophrenia, had these conditions documented in the admission comprehensive assessment and active diagnoses section. Despite this, the resident’s admission and current care plans did not include the medical conditions of Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia, even though these needs were identified in the comprehensive assessment. Record review showed that the resident was receiving multiple physician-ordered medications related to these diagnoses, including Sodium Chloride for anemia, Carvedilol and PRN Hydralazine for hypertension, Metformin for Type 2 diabetes, and Atorvastatin for hyperlipidemia, all administered as prescribed over several months. During an interview, the MDS Coordinator acknowledged that the resident had these diagnoses and related medications, and confirmed that they were not reflected on the care plan. The MDS Coordinator stated that the resident should have a care plan so caregivers know the diagnoses and how to provide appropriate care. This omission occurred despite the facility’s written comprehensive care plan policy, which requires development and implementation of a person-centered care plan with measurable objectives and timeframes for all medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
Failure to Implement Dermatology Medication Orders for Skin Condition
Penalty
Summary
Staff failed to carry out physician orders and ensure a resident received ordered medications for a skin condition. The resident, with a history including major depressive disorder, bipolar disorder, cellulitis of the lower limb, type 2 diabetes, hypertension, and hypothyroidism, had very dry, scaly skin on both hands and legs. During observations on two consecutive days, the resident reported that he was supposed to receive a cream three times a day for eczema but stated that nurses did not provide it and told him he was supposed to remind them. Record review showed an urgent dermatology appointment order dated 10/9/2025, and an after-visit summary from a dermatology appointment on 1/12/2026 with multiple new medication orders for his skin condition and related symptoms. The after-visit summary dated 1/12/2026 included orders for Triamcinolone 0.1% ointment to hands and feet twice daily for 14 days with Vaseline, Diphenhydramine 25 mg twice daily for 14 days, a one-time dose of Ivermectin 3 mg (4 tablets), Fluocinonide 0.05% ointment to hands and feet twice daily for 2 weeks, and antihistamines twice daily (Allegra in the morning and Zyrtec in the evening. These medications did not appear in the resident’s active orders until 1/27/2026, the day the surveyor inquired about the appointment. The DON acknowledged that the resident went to the dermatologist on 1/12/2026 and that the orders were not carried out for approximately two weeks. The assigned RN stated she was not aware the resident had gone out for an appointment, received no report, and did not see the after-visit summary or new orders. Facility job descriptions and policy require nurses to receive and transcribe physician orders and ensure orders are complete and accurate, but this process was not followed, resulting in the resident missing the ordered medications for his skin condition.
Insulin Administered to Unresponsive Resident Without Emergency Response
Penalty
Summary
The facility failed to provide care in accordance with professional standards for medication administration during an emergency when a resident was found unresponsive and subsequently administered insulin. The resident, who had a history of Type 2 Diabetes Mellitus, epilepsy, seizures, unsteadiness, and schizoaffective disorder, was found unresponsive at 5:30am with a blood glucose level of 290 mg/dL. The nurse on duty documented administering both a scheduled dose and a sliding scale dose of Humalog insulin to the unresponsive resident before initiating emergency procedures such as calling a code, 911, or notifying a physician. The nurse's documentation was inconsistent and could not be clarified, as she was no longer employed at the facility at the time of the investigation. Interviews with facility leadership and the resident's physician confirmed that insulin should not have been administered to an unresponsive resident and that emergency services should have been contacted first. The facility did not have a specific policy regarding insulin administration during an emergency crisis, and the general medication administration policy only stated that medications are to be administered as prescribed and in accordance with good nursing practices. The physician and DON both indicated that the nurse's clinical judgment and documentation were inappropriate in this situation.
Failure to Discontinue Medication as Ordered by Physician
Penalty
Summary
The facility failed to follow its Physician's Order Policy by not discontinuing a medication as ordered by the resident's neurologist. A resident with a diagnosis of symptomatic epilepsy and complex partial seizures was admitted with several anti-seizure medications, including Brivaracetam and Levetiracetam (Keppra). The neurologist communicated on multiple occasions, both by phone and fax, that Keppra should be discontinued because it should not be prescribed concurrently with Brivaracetam. Despite these communications, the medication administration records show that the resident continued to receive Keppra for several weeks after the discontinuation order was given. Interviews and record reviews revealed that the neurologist's office contacted the facility to clarify the medication list and specifically instructed discontinuation of Keppra. The Assistant Director of Nursing (ADON) stated that she did not recall receiving follow-up communication from the neurologist's office after sending the medication list, and there was no documentation that the discontinuation order was relayed to or verified with the attending physician. Progress notes did not reflect any action taken regarding the neurologist's order, and the resident continued to receive Keppra alongside Brivaracetam, contrary to the specialist's instructions.
Failure to Administer and Document Prescribed Medications
Penalty
Summary
A resident with a medical history including bipolar disorder, schizophrenia, hemiplegia, and traumatic brain injury did not receive prescribed pain and acid reflux medications as ordered. On the night in question, the resident reported not receiving pain medication despite repeated requests to the nurse on duty, who stated the medication was unavailable. The resident experienced significant pain throughout the night until the morning nurse administered the medication. The nurse responsible did not document the administration of the medication or the reason for not providing it in the electronic medical administration record (eMAR). The facility administrator confirmed that the nurse on duty was responsible for administering the medications and that there was no documentation to support that the medications were given or withheld for a documented reason. The Director of Nursing stated that nurses are required to follow physician orders and document any reasons for not administering medications, and that emergency medication storage is available for such situations. Review of the resident's records confirmed that the pain and acid reflux medications were not administered as ordered, and the facility's policy requires medications to be administered and documented according to prescriber orders.
Failure to Provide Written Discharge Notice to Resident's Representative
Penalty
Summary
The facility failed to adhere to its discharge policy by not providing a written notice of involuntary transfer or discharge to the resident's representative. The resident, who has a diagnosis of schizophrenia, anxiety disorder, schizoaffective disorder, and non-compliance with medication regimen, was involuntarily discharged after physically assaulting staff, which was deemed to endanger the safety of individuals in the facility. Although the resident's guardian received a verbal notice of the transfer and discharge, they were not given a written copy of the notice or informed of the opportunity for a hearing, as required by the facility's policy. The facility's policy mandates that prior to discharge or transfer, the resident and their representative must be notified in writing, in a language and manner they understand, and a copy of the notice should be sent to the long-term care ombudsman. However, the staff member responsible for the discharge confirmed that the written notice was not provided to the resident's representative, despite having checked the box indicating that it was. This oversight resulted in a failure to comply with the required notification procedures, as outlined in the facility's policy.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency, involving two residents. On 12/18/24, a resident (R292) displayed increased agitation, making verbal threats towards peers and staff, and was not easily redirected. The resident refused medication and targeted female staff, resulting in physical aggression. The situation escalated to the point where police assistance was required, and the resident was transported to the hospital for a psychiatric evaluation. Despite these events, the facility did not report the incident to the State Survey Agency as required by their policy. The facility's administrator, V1, did not consider the incident reportable because it did not involve a peer altercation, despite evidence that R292 threatened another resident (R105) with physical violence. The facility's policy mandates that any allegation of abuse or incident resulting in serious bodily injury be reported immediately, or within 24 hours if it does not involve abuse or serious injury. The failure to report this incident was a violation of the facility's abuse prevention and reporting policy, as the incident involved threats and aggression towards another resident, which should have been reported to the Department of Public Health.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
The facility failed to adhere to its notification policy by not informing the responsible party of a resident's transfer to the hospital. This deficiency was identified during a review of three residents, affecting one resident who was discharged to the hospital without proper notification to their guardian. The incident involved a resident who exhibited increased agitation and delusions, leading to a decision by the nurse practitioner to send the resident to the hospital for a psychiatric evaluation. However, there was no documentation of notification to the resident's guardian in the electronic record prior to the transfer. Interviews conducted with the staff revealed that the nurse on duty, V29, did not notify the resident's guardian because the resident was under observation and not yet admitted to the hospital by the end of her shift. The facility's administrator confirmed the absence of any notification in the resident's electronic record. The facility's policy, dated October 1, 2015, mandates that the resident's power of attorney or guardian should be notified in a timely manner when a resident is transferred or discharged from the facility. This oversight in communication represents a failure to comply with the established notification procedures.
Misappropriation of Resident's Link Card by Former Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of his property, specifically his Link card, which was given to a staff member to purchase beverages. The staff member, who was no longer employed at the facility at the time of the report, did not return the card to the resident. The resident expressed concern about the missing card and the involvement of the police, which caused him distress. The incident was reported to the facility's psychosocial rehabilitation director, who then informed the superiors and took steps to address the issue. The resident's progress notes indicate that the incident was reported to the police, and the card was canceled to prevent further misuse. The facility's activity aide eventually retrieved the card from the former employee and returned it to the resident. The corporate psychosocial rehabilitation director confirmed that the card was taken while the staff member was still employed, but it was not returned until after her employment ended. The facility's policy on abuse prevention and reporting emphasizes the residents' right to be free from misappropriation of property, which was not upheld in this case.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and theft, affecting all four residents reviewed in the sample. Resident R192, admitted with diagnoses including schizophrenia and bipolar disorder, did not receive an abuse/neglect screening assessment upon admission or after a resident-to-resident altercation. Despite being involved in a physical altercation with another resident, R192's care plan was not updated to address abuse prevention. The incident was reported to the hospital, but inconsistencies in R192's account were noted, and no incident report was completed by the facility. Resident R81, also involved in the incident with R192, was admitted with schizoaffective disorder and was assessed as a moderate risk for abuse. However, the abuse prevention care plan was not updated following the allegation of physical/sexual abuse. Similarly, Resident R103, with a history of physical altercations, did not have an updated care plan or abuse/neglect screening assessment after an altercation with R192. Resident R29, who had a previous altercation resulting in injury, did not receive an abuse assessment or care plan update until two months after the incident. Interviews with facility staff revealed a lack of adherence to the facility's policies on abuse prevention and incident reporting. The Social Service Director and Administrator acknowledged the failure to conduct necessary assessments and update care plans following incidents. The Director of Behavioral Services incorrectly believed that no incident report was needed if no physical injury occurred. The facility's policies require incident reports for all resident-to-resident altercations, regardless of injury, and mandate that abuse assessments and care plans be updated after each incident or allegation.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for one resident, identified as R135, during a survey. On July 17, 2024, an LPN, referred to as V13, claimed to have administered an appetite stimulant to R135 in the morning and discarded the bottle, stating that the next dose was not due until the following morning. However, upon inspection, two bottles of the appetite stimulant were found with unbroken seals, indicating that the medication had not been administered. When questioned, R135 confirmed that no medication was given before lunch, and they did not refuse it. V13 later claimed that R135 had refused the medication, which was inconsistent with the resident's statement. The Director of Nursing, V2, stated that nurses are expected to administer medications as ordered and report any refusals to the physician. A review of R135's records showed a diagnosis of type 2 diabetes mellitus and an order for megestrol acetate oral suspension to be given before meals as an appetite stimulant. The facility's policy requires medications to be administered as prescribed and refusals to be reported after three doses are refused. The failure to administer the medication as ordered and the lack of proper documentation and reporting of refusal led to the deficiency.
Non-functional Eyewash Station in Hazardous Chemical Areas
Penalty
Summary
The facility failed to maintain a functional eyewash station in areas where hazardous chemicals are used, affecting all units reviewed for environmental safety. The Maintenance Director acknowledged that the eyewash station had not been logged since February 2024 due to broken caps, which were initially reported in January 2024. Despite an order being placed for replacement caps in January, no invoice was presented to confirm this, and no further logs were available after February. The Infection Preventionist was unaware of the eyewash station's non-functionality, highlighting a lapse in communication and oversight. The Administrator also expressed unawareness of the eyewash station's non-functionality since January 2024, only learning of the issue when the Maintenance Director mentioned it in July 2024. The facility's policy requires weekly activation and maintenance of eyewash stations, but this was not adhered to, as evidenced by the empty maintenance logs for February 2024 and beyond. This deficiency indicates a failure to ensure the safety equipment was operational and properly documented, as required by the facility's environmental health and safety policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved two residents, where one resident (R3) physically assaulted another resident (R4) by hitting her in the eye after R4 refused to share a candy bar. This altercation was reported by R4 to a staff member, and it was confirmed by R3 during an interview. The incident resulted in R4 having redness in her right eye, which was documented by a registered nurse (RN) and later evaluated by a physician. The facility's policy on abuse prevention and reporting affirms the right of residents to be free from abuse, yet this incident indicates a failure to uphold that policy. The incident was reported to the Social Services Director, who was the manager on duty at the time. The director took R4 to a nurse for assessment and then spoke with R3, who admitted to the physical altercation. Documentation in R4's chart confirmed the incident, and R3 was sent to the hospital for a psychiatric evaluation. Despite the facility's policy against physical abuse, the incident was not prevented, and the response involved medical attention for R4's injury and further evaluation for R3.
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What surveyors actually found near you
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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 Chicago Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of Chicago Heights | 1.4 mi | ★★★★★ | 2 | 0 |
| Prairie Manor Nrsg & Rehab Ctr | 1.7 mi | ★★★★★ | 14 | 0 |
| Generations At Applewood | 3.1 mi | ★★★★★ | 12 | 0 |
| Ryze At Homewood | 3.3 mi | ★★★★★ | 13 | 1 |
| Landmark Of Richton Park Rehab & Nsg Ctr | 4 mi | ★★★★★ | 25 | 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.