Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspyre Of Bronzeville during CMS and state inspections, most recent first.
Failure to Maintain Comfortable Room Temperatures: Several residents were found in hot, stuffy rooms with weak or nonworking AC units, and room temps were measured above 81 F, including one room at 89.5 F. Residents reported feeling hot and uncomfortable, and some were not offered a room change while the issue persisted. The facility did not follow its Hot Weather policy for relocating residents to cooler areas and monitoring room temps.
Failure to provide ROM services and individualized care plans for two residents with LUE impairment and hand contractures. One resident with prior CVA, hemiplegia, and dysarthria had a left hand contracture with no splint or restorative ROM documented, and the care plan did not address the contracture. Another resident with PVD, HIV, and a BKA developed a left hand contracture while in the facility; OT notes recommended PROM and splint/brace use, but the EHR lacked documentation that these services were provided, and the care plan did not address the contracture.
A resident with repeated falls was not provided adequate supervision, assessment, or updated care plan interventions after multiple incidents, including falls that resulted in a closed R humeral fracture and later a R 5th metacarpal fracture. Records showed the fall care plan was not updated to address the repeated falls, the resident had only one fall risk assessment in years, and staff confirmed the falls were not addressed in the plan of care.
Food storage and kitchen hygiene deficiencies were identified when a carton of 2% milk past its best-by date was found in the main cooler and an employee entered the kitchen without a hair restraint. The Dietary Manager stated expired dairy should be discarded and that hair restraints are required in food prep, storage, and service areas to prevent contamination.
Improperly Covered and Overflowing Garbage Containers: Surveyors observed two dumpsters with lids not fully closed because they were overflowing, along with uncovered garbage bins and a cart overflowing with kitchen waste in the basement hallway by the kitchen. The Dietary Manager stated the garbage had not been picked up that morning and that overflowing garbage could attract pests. The facility policy required tight-fitting lids and no overflow, and the roster showed 144 residents.
Expired and undated meds were found in multiple med carts and the med room. An RN, LPN, and DON identified open inhalers, multi-dose insulin vials, and Tuberculin PPD without open dates, along with several expired meds left in cart drawers and on a med room shelf, including stool softeners, vitamins, and insulin products.
A facility failed to follow infection control practices during resident care and equipment use. A CNA provided catheter care, bathing, dressing, and transfer assistance to a resident on EBP without hand hygiene or the required gown and glove changes, and a RN later handled a resident’s nephrostomy/urinary drainage equipment without full PPE. In addition, a RN used the same blood pressure monitor on multiple residents and returned it to the med cart without cleaning it between uses.
Loose Corridor Handrails: A resident in a wheelchair was observed using hallway handrails for locomotion when the rail near the nurse station moved and wobbled with slight pressure. The Mnt Dir checked the rail and found one missing bracket and two brackets with only one loose screw instead of two. The Administrator stated the facility had no handrail-specific policy and only a general maintenance policy.
A resident with intact cognition and significant medical history was unable to access his monthly personal funds allowance in a timely manner, despite multiple requests to staff. The resident only received the funds after threatening to report the issue, and records confirmed that sufficient funds were available but not disbursed until late in the month, contrary to facility policy on resident rights.
Baseline care plans were not developed within the required 48 to 72 hours for 3 residents. One resident’s record showed no baseline care plan data and a closed care plan tied to discharge, another had only a single fall-risk focus in the interim care plan, and a third had an incomplete care plan with placeholder language for behavior, fall risk, and psychosocial needs. The MDS BIMS scores ranged from intact cognition to severe cognitive impairment, and the records showed only limited or generic care plan content.
A nurse stored folic acid in a medication cup instead of the original package and administered it to a resident. The nurse also held BP meds for two residents after low BP readings, including antihypertensives such as amlodipine, HCTZ, losartan, lisinopril, and metoprolol, without documented provider notification. The DON stated that when BP meds are held, the provider should be consulted immediately, and the facility policy required meds to be administered safely, not prepared ahead of time, and documented after delivery.
A resident with abnormal weight loss and significant recent weight loss did not receive the weekly weights documented in the physician’s plan of care. The chart showed only monthly weights, no weekly weight order in the MAR/order summary, and the care plan did not include weekly weight monitoring. Staff said the restorative dept completed weights, but the RN did not review the MD progress notes that listed weekly weights as part of the plan.
A resident with a nephrostomy tube, CKD, and other urinary tract conditions was observed with a urinary drainage leg bag wrapped in a wet brief and the blue screw cap missing from the bag. The resident stated the bag was not closed and tried to reattach the cap. An RN later attempted to replace the cap, emptied the urine, and handled the soiled brief without the required PPE, while the DON stated that EBP precautions and proper nephrostomy care should be followed.
A resident with CHF, CKD, COPD, and nicotine dependence was observed with oxygen tubing and a nasal cannula left on the bed, no humidification bottle attached, and oxygen running at 3L/min despite an order for oxygen PRN via nasal cannula at 2L/min. The RN and DON stated tubing should be stored in a bag when not in use and humidification should be available, but the EHR had no care plan for oxygen use.
Controlled medication counts and documentation were inaccurate for two residents when a medication cart review found mismatches between the punch cards and the controlled substance records for lacosamide and phenobarbital. The RN noted one resident’s lacosamide had been given but was not signed for on the controlled record, and the controlled substances check form was missing initials for multiple shifts. The DON stated narcotic accountability requires shift-change counts and proper signing of medication administration.
Medication Administration Errors and Held BP Meds Without MD Notification A RN committed multiple med admin errors, resulting in a 30% error rate. The nurse held ordered BP meds for two residents after checking BP, but there was no documented MD notification or BP recheck after the meds were withheld. The nurse also administered expired vitamin B12, gave folic acid that had been removed from its original packaging and stored in a med cup, and substituted chewable aspirin for ordered enteric-coated aspirin.
An RN held ordered BP medications for two residents after obtaining low BP readings, including amlodipine, HCTZ, losartan, lisinopril, and metoprolol. The RN did not document physician notification, and there was no BP recheck after the meds were held. The DON stated staff should consult the MD immediately when BP is outside parameters, and the RN stated that if it is not documented it did not happen.
A resident with cognitive impairment and significant physical limitations was physically assaulted by another resident with a known history of aggression, resulting in facial injuries. Staff intervened after the altercation began, but the facility did not effectively implement its abuse prevention policy to protect vulnerable individuals from harm.
The facility did not report an allegation of physical abuse between two residents to IDPH within the required timeframe and failed to submit the final investigation report within five business days. The incident involved a cognitively impaired male with multiple medical conditions who was assaulted by another male with a history of violent behavior, resulting in visible injuries and emergency medical care. Staff and leadership were aware of the incident, but reporting requirements were not met according to facility policy.
A resident with multiple chronic conditions and intact cognition was not assisted by staff in obtaining a Social Security card, despite repeated requests and attempts to arrange transportation. Staff were aware of the need but did not follow up or document any actions, resulting in the resident not receiving necessary identification for housing and financial assistance.
A resident with a history of violent behavior physically assaulted another cognitively intact resident in the dining room, causing pain and emotional distress. The LPN present noticed the aggressor's anxious behavior but did not intervene before the attack, and the facility failed to implement preventive measures despite the known risk. The incident resulted in the victim feeling humiliated, fearful, and depressed.
A resident experienced ongoing issues with cold water in their hand sink, resulting in uncomfortable bed baths. Staff and the resident confirmed the water temperature was below comfortable levels, and the facility lacked consistent monitoring, documentation, and a policy for water temperatures. Concerns reported by the resident and their emergency contact were not effectively resolved, and no water temperature logs or policy were provided to the surveyor.
The facility was found deficient in maintaining proper food storage and preparation standards. Ice build-up was observed in the walk-in freezer, and the food prep area was not adequately separated from the sanitization area. Additionally, improper drying practices were noted for kitchen equipment, violating the facility's policies on safe food handling.
The facility failed to implement Enhanced Barrier Precautions (EBP) correctly, with signs not posted on doors and PPE not accessible, leading to staff not using gowns and gloves as required. Residents with medical devices or wounds did not have EBP included in their care plans, and staff were unaware of the need for such precautions, increasing the risk of infection spread.
A facility failed to obtain a code status order for a resident with multiple health conditions, despite completing a POLST form. Interviews with staff indicated that the process involves obtaining a physician's order to document the resident's code status, but a review showed no such order was present, highlighting a lapse in following the facility's policy.
A resident with a history of falls and severe cognitive impairment was not provided with the prescribed non-slip socks, as per their care plan, leading to a fall and injury. The facility failed to update the care plan with new interventions after the fall, and staff were unaware of the necessary precautions. The Director of Nursing and MDS Coordinator acknowledged that the care plan was not revised, and the new intervention of one-to-one supervision was not documented.
A resident with multiple health conditions, including cachexia and diabetes, experienced significant weight loss due to the facility's failure to conduct a nutritional evaluation upon readmission. Despite the resident's poor appetite and multiple hospitalizations, the required assessment was not completed, leading to an 8.5% weight loss over a month. The facility's policy mandates such evaluations, but this was not adhered to, resulting in delayed nutritional intervention.
A facility failed to date and store a nebulizer mask for a resident, leading to potential contamination risks. The mask was observed undated and not in a plastic bag over several days. A nurse and the DON confirmed the expectation for proper storage to prevent infection. The resident had an active order for Albuterol Sulfate Nebulization Solution for shortness of breath, and facility policy requires labeled and dated storage of nebulizer equipment.
The facility failed to follow professional standards for medication management, including leaving medications at a resident's bedside, not dating an opened insulin vial, and improperly storing insulin. An LPN acknowledged the potential for administering expired insulin, and the DON confirmed that medications should not be left at the bedside without a doctor's order. These actions reflect a lapse in adhering to medication storage and administration protocols.
A resident expressed a desire for dentures, but the LTC facility failed to schedule a dental appointment despite a care plan intervention. Staff interviews revealed a lack of communication and follow-through, with no dental visit order in the resident's records. The facility's guidelines emphasize necessary dental services, but these were not effectively implemented, leading to the deficiency.
A resident with severe dysphagia was not provided with nectar-thick liquids as ordered by the physician, leading to coughing episodes. Observations showed that staff, including a CNA and an Activity Aide, failed to properly thicken the resident's drinks, indicating a lack of adherence to the facility's policies on therapeutic diets.
The facility did not follow its Antibiotic Stewardship Program, failing to develop a report for residents on antibiotics without active infection criteria and maintain accurate surveillance tracking. Four residents were prescribed antibiotics without documented symptoms, and their antibiotic use was not recorded. The IP and DON had conflicting accounts regarding testing protocols, leading to incomplete logs and unsupported antibiotic use.
The facility failed to administer influenza and pneumococcal vaccines to three residents who had consented, despite their eligibility due to medical conditions. The IP and DON confirmed that vaccines should be given promptly upon consent, but the facility did not follow its policy, resulting in missed vaccinations.
A resident's call light was found non-functional during a survey, and the issue had persisted since a storm two weeks prior. The resident, unable to leave bed independently, expressed distress over the inability to call for assistance. Staff interviews revealed a lack of communication and awareness about the broken call light, with the RN, CNA, DON, and Maintenance Manager all acknowledging the importance of functioning call lights but unaware of the specific issue. The call light remained unfixed the next day, leaving the resident dissatisfied.
The facility failed to provide and acquire medications as ordered, affecting two residents. One resident did not receive her COPD inhalers since admission, despite staff awareness. Another resident received insulin at an incorrect time, deviating from the prescribed schedule. The facility's medication administration policy emphasizes the importance of correct timing to prevent errors.
A resident with a history of elopement and multiple psychiatric disorders successfully eloped from the facility due to the failure to complete an elopement risk assessment, develop an elopement care plan, and provide adequate supervision. The resident was found two days later at his mother's home. Insufficient staff monitoring and an unsecured gate on the smoking patio contributed to the incident.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure resident rooms remained at comfortable temperatures and failed to offer room changes to residents whose rooms exceeded 81 F when air cooling units were not working properly. On 7/1/2026 at about 10:30 AM, R6 was in a hot, uncomfortable room and stated the floor air conditioning wall unit was not working because no air came from the vent. R8’s unit was on but only weak air came through, and R8 appeared uncomfortable and said he was hot. R9 and R10 were in a dark, warm, and stuffy room with the windows closed and curtains pulled shut, and R7 was in a very hot room with weak air blowing from the floor unit and said the room was hot. When the surveyor returned with the Maintenance Director at 10:42 AM, the room temperatures were measured at 84.5 F for R6, 89.5 F for R7, 85.2 F for R8, and 82.9 F for R9 and R10. At 4:00 PM, R7 and R8’s rooms were still hot, with temperatures of 85.6 F and 83.1 F, respectively, and both residents remained in their rooms. R6 stated a room change had been offered only a few minutes earlier, while R7 and R8 stated they had not been offered a room change during the hot room temperatures. The facility did not follow its Hot Weather policy, which stated residents would be relocated to the cooler part of the facility and temperatures and humidity would be measured in several rooms on each floor identified as the warmest area.
Failure to Provide ROM Services and Care Plans for Residents With Contractures
Penalty
Summary
The facility failed to provide treatment or services, equipment or devices, and failed to develop comprehensive care plans to address contractures for two residents reviewed for limited ROM. One resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysarthria following cerebrovascular disease, a history of traumatic brain injury, and pain in the left upper arm. On observation, this resident was sitting on the side of the bed, alert and oriented, nonverbal, and communicating by gestures. The resident had a left hand contracture with no device in place, and indicated by shaking the head that no device or splint was being worn. The record showed impaired LUE ROM on OT evaluation, restorative nursing recommendations for ROM, and restorative programs for communication and dressing/grooming, but the EHR did not reflect that restorative nursing ROM services were provided. The care plan also did not reflect a plan of care for the left hand contracture. The second resident was admitted with diagnoses including peripheral vascular disease, thrombosis of atrium, hypertensive heart disease, left below-knee amputation, HIV disease, and an unspecified mental disorder. On observation, this resident was sitting in a wheelchair, verbally responsive, and had a left hand contracture with inability to open the middle, ring, and little fingers. No device or splint was in place. The resident stated the contracture developed while residing in the facility after a fracture from a fall. The record showed that at admission the resident had no upper extremity impairment, but later OT evaluations documented impaired LUE ROM and then left hand contracture. OT discharge summaries recommended restorative PROM to the left hand, splint and brace use, and a left hand contracture cushion, yet the EHR contained no documentation that PROM or splint/brace services were provided. The care plan also did not include a focus on the left hand contracture. During interview, the restorative nurse stated that residents with limited ROM or contractures should receive restorative programs such as AROM/PROM or rehab evaluation and treatment if appropriate, and that care plans should be individualized to address the problem. The DON stated that residents with limited ROM/contractures should have restorative nursing programs such as ROM as appropriate. The OT director reviewed the records and confirmed that the residents had documented LUE impairment and contracture-related treatment recommendations, including splinting for one resident and PROM for both, but the chart did not show that these services were provided. The facility policy stated that restorative care approaches should be integrated into the individualized plan of care and that the restorative nurse should initiate individualized goals and objectives based on therapy recommendations.
Failure to Address Repeated Falls and Related Injuries
Penalty
Summary
The facility failed to provide supervision, assistance, assessments, and interventions to keep one resident free from accidents, hazards, and injuries. Resident 6 had multiple falls documented on 1/30/25, 1/31/25, 3/15/25, 5/21/25, 6/2/25, and 6/12/25, with injuries occurring on 5/21/25 and 6/12/25. On 9/2/25, the resident was observed alert but having difficulty elaborating, with limited movement of both extremities, more on the right side, grimacing with slight movement, and positioned in bed with items out of reach. Review of records showed the resident fell while reaching for a TV remote on 3/15/25, and the fall care plan dated 3/15/25 stated to determine and address causative factors, but no intervention was done to determine or address the cause of that fall. After the 5/21/25 fall in the bathroom, the resident was sent to the hospital and admitted with a closed right humeral fracture; hospital records dated 5/27/25 documented the fracture, and the resident later used a right cast/wrap mold and sling. After the 6/12/25 fall in the bedroom in front of the wheelchair, the resident developed swelling and pain in the right hand, and x-ray results showed a right fracture of the fifth metacarpal, leading to transfer to the hospital. The resident’s fall care plan did not address the falls on 5/21/25, 6/2/25, and 6/12/25, and the most current intervention was dated 4/21/25. The resident was assessed as high risk for falls on 5/27/25, but this was the only fall assessment done since 11/24/20. Records also showed a decline in functional ability, with the 5/16/25 MDS showing partial moderate assistance needed for transfers and ambulation, while the 6/4/25 MDS after the fracture showed the resident dependent on staff for transfers and unable or not attempted to walk due to medical condition or safety concerns.
Food Storage and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to follow its policy and procedure for preventing foodborne illnesses when a carton of 2% milk with a best-by date of 6/11/25 was found in the main cooler during the initial kitchen tour with the Dietary Manager. The Dietary Manager stated the milk should have been discarded and not stored in the main cooler. The facility's resident roster documented 144 residents in the facility, including 1 resident who was NPO. The facility also failed to ensure staff entering the kitchen wore hair restraints. During observation, the Director of Rehab entered the kitchen without a hair restraint on, and the Dietary Manager stated that everyone entering the kitchen should wear hair restraint to prevent hair contaminating the food. The Dietary Manager further stated that foods or dairies stored in the main cooler should be discarded the day of the best-by date because it may not be any good and should not be given to residents, and that nothing spoiled should be given to residents because it could cause food poisoning or food borne illness.
Improperly Covered and Overflowing Garbage Containers
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the facility’s dumpsters and garbage bins not being properly covered and overflowing. On 9/2/25 at approximately 10:00 AM, the Dietary Manager accompanied the surveyor outside and the surveyor observed two dumpsters with lids not fully closed because garbage was overflowing. The Dietary Manager stated the dumpsters should be fully closed to prevent rodents and other pests, and said the garbage had not been picked up that morning. The Dietary Manager also stated that pests would be all over the overflowing garbage and residents would be at risk to get sick, and reported that the garbage company had been called the day before because the garbage was overflowing. In the basement hallway by the kitchen, the surveyor observed one black garbage bin and two gray garbage bins without covers filled with kitchen waste, along with one yellow cart without a cover overflowing with black garbage bags. The facility’s Garbage Disposal policy stated that garbage cans should be leak-proof, non-absorbent, have tight-fitting lids, be emptied as they become full, and not be allowed to overflow. The facility roster documented 144 residents.
Expired and Undated Medications Found in Carts and Medication Room
Penalty
Summary
The facility failed to label and date medications when opened and failed to remove expired medications from medication carts and the medication room. During review of the 3rd floor A medication cart, R100’s Breo Ellipta inhalation aerosol was observed in the cart with no open date, and a multi-dose vial of Lantus insulin was open with no date despite the label indicating it should be discarded after 28 days. R101’s multi-dose vial of Lispro insulin was also found in the cart with an open date of 06/25/25 and an expiration/discard date of 07/23/25. The RN stated that inhalers are supposed to be dated when opened and that the insulin should have been discarded on the listed date. Additional expired and undated medications were found in other storage areas. In the 2nd floor Team B medication cart, Docusate Sodium, Senna Plus, and Vitamin C were observed with expiration dates of 07/25, 06/25, and 08/25, respectively, and the LPN stated they should have been removed from the cart. In the 2nd floor medication room, a vial of Tuberculin PPD was open and undated, R112’s multi-dose Lantus and Humulin R insulin vials were open and undated, and floor stock Vitamin C and Vitamin D were observed with expiration dates of 12/24 and 05/25. On the 1st floor medication cart, Senna Plus and One Daily Multi Vitamin were also found expired. The DON stated expired medications should be removed from carts and the medication room, and that opened multi-dose insulin vials, Tuberculin vials, and inhalers should be dated and stored properly.
Infection Control Failures During Resident Care and Equipment Use
Penalty
Summary
The facility failed to provide infection prevention and control measures during care of a resident on Enhanced Barrier Precautions who had a urinary catheter and wounds. The resident, who had type 2 diabetes, a kidney transplant, and a BIMS score of 15, was observed being changed, bathed, and transferred by a CNA without hand hygiene being performed during or after the care. The CNA used a single glove without changing it and did not wear a gown while performing catheter care and other direct care activities. The CNA later stated that he forgot to use a gown and change gloves during care, and the DON stated that nursing staff need to use gloves and gowns and perform handwashing before and after care. The facility also failed to ensure reusable medical equipment was cleaned and sanitized between residents. A RN used the same blood pressure monitor on multiple residents, including residents with diagnoses such as cerebrovascular disease, heart failure, atrial fibrillation, peripheral vascular disease, and other chronic conditions. The monitor was taken from the medication cart, used on one resident, placed back on the cart without cleaning, then used on another resident and again returned to the cart without sanitizing. The RN stated that the blood pressure monitor should be cleaned between each resident with infection control wipes, and the DON stated that the monitor should be cleaned between residents with antibacterial wipes. A separate observation involved a resident on Enhanced Barrier Precautions with a nephrostomy tube and urinary drainage leg bag. The resident was seen with the drainage bag wrapped in a brief, the brief was wet with a large yellow stain, and the drainage bag was without the blue screw cap. The resident attempted to reattach the cap, and a RN later entered the room, put on gloves only, and attempted to screw the cap back on, emptied urine from the bag, and handled the soiled brief without the required PPE. The RN stated she should have had gloves, a mask, and a gown when doing care, and the DON stated that if the screw cap was off it would be best to change the leg bag.
Loose Corridor Handrails
Penalty
Summary
Firmly secured handrails were not maintained on the 3rd floor corridor near the nurse station. During observation, a resident in a wheelchair was using the hallway handrails for locomotion, and the handrail was seen moving when the resident held it to move the wheelchair. A close view showed the handrail easily wobbled with slight pressure, and the brackets were loose and could detach with further pressure. When the Walker Maintenance Director checked the handrail, he held and moved the loose rail and found one bracket missing and two brackets with only one loose screw instead of two screws; the handrail had four brackets total. He stated that the handrail was loose and that handrails are required because they provide support to those who need to get up while using a wheelchair. The Administrator stated the facility did not have a policy specific to handrails and only had a maintenance policy requiring maintenance of buildings, grounds, and equipment in a safe and operable manner.
Delay in Resident Access to Personal Funds
Penalty
Summary
The facility failed to maintain a resident's right to timely access to personal funds, impacting one resident who was unable to support his wants and needs due to lack of financial resources. The resident, who has a history of type 2 diabetes and a kidney transplant and is cognitively intact, reported requesting his monthly allowance of $30 at the beginning of the month but was repeatedly told by staff that it was not available. Despite multiple requests to the activity staff, the resident did not receive his allowance until he threatened to report the issue to the State, at which point the funds were provided. Review of records showed that the resident's itemization indicated sufficient funds were available at the start of the month, but the receipt for the August allowance was dated much later in the month. The business manager confirmed that while itemization is handled by the corporate office, the actual disbursement date may differ from the recorded date. The activity director stated that funds are given to residents as soon as they are received from the business office, but acknowledged that the allowance for the month in question was not provided until late in the month. Facility policy affirms residents' rights to manage their own money, but this was not upheld in this instance.
Baseline Care Plans Not Developed Within Required Timeframe
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 to 72 hours of admission for 3 of 3 residents reviewed for baseline care plans in a sample of 29. For R11, who was admitted with diagnoses including hypertensive heart disease, atherosclerotic heart disease of native coronary artery, GERD, primary open-angle glaucoma bilaterally, polyosteoarthritis, schizophrenia, hyperlipidemia, and recurrent major depressive disorder, the Care Plan Report showed no data found and the report presented to the surveyor showed care plan areas marked cancelled and/or resolved with a closed date and reason of discharge. The Initial Nursing Assessment interim care plan dated 08/23/25 had no marked areas. For R103, who was admitted with diagnoses including recurrent major depressive disorder, schizoaffective disorder, hypertensive heart disease with heart failure, unspecified psychosis, dysphagia, constipation, secondary osteoarthritis, hyperlipidemia, and alcohol dependence with alcohol-induced persisting dementia, the Care Plan Report contained only one focus related to moderate fall risk with a goal to remain free of falls and an intervention to anticipate and meet needs; the Initial Nursing Assessment interim care plan dated 08/24/25 reflected only that fall focus. For R125, who had diagnoses including paranoid schizophrenia, type 2 diabetes mellitus with diabetic neuropathy, hypertensive heart disease, schizoaffective disorder, bipolar disorder, anemia, GERD, and hyperlipidemia, the Care Plan Report was incomplete and included placeholder language for behavior, fall risk, and psychosocial wellbeing problems, with generic goals and interventions such as anticipating and meeting needs and encouraging participation from the resident who depends on others to make own decisions.
Medication Storage and Held BP Medications Without Provider Notification
Penalty
Summary
Medication administration did not follow professional standards when a registered nurse stored folic acid in a medication cup rather than in its original packaging and then administered it to a resident. The nurse stated she took folic acid from another medication cart because the resident’s cart did not have it, and later stated that medications should not be transferred from the original container and stored in a medication cup for administration. The facility policy stated medications are to be administered safely, medications are not to be prepared ahead of time, and medications should be documented after delivery. The nurse also held blood pressure medications for two residents without documented provider notification. One resident had diagnoses including acute on chronic diastolic congestive heart failure, atrial fibrillation, hypertensive heart disease with heart failure, nonrheumatic aortic valve disorder, cardiomegaly, peripheral vascular disease, atherosclerosis of native arteries of the right leg, and hypertrophic cardiomyopathy. After blood pressure readings of 81/54 and 104/75, the nurse held amlodipine besylate 10 mg daily, hydrochlorothiazide 25 mg daily, and losartan potassium 50 mg daily and said she would revisit the blood pressure after lunch. Another resident had a blood pressure of 112/48 with pulse 63, and the nurse held lisinopril 10 mg twice daily and metoprolol tartrate 25 mg twice daily, stating she would check the blood pressure again after lunch. The DON stated that when blood pressure or other medications are held outside parameters, the nurse should use nursing judgment and consult the doctor immediately for directions, and that if a medication is not given or is given late, the provider should be notified for additional orders. The report also states the nurse said she notified the doctor, but if it is not documented it did not happen. The physician order policy stated the physician or extender is consulted when changes in condition occur or when an alteration to prescribed treatments or medications is needed.
Failure to Follow Physician Weight Monitoring Plan
Penalty
Summary
The facility failed to follow a physician’s plan of care for a resident with abnormal weight loss and a documented history of significant weight loss. The resident’s record showed a diagnosis of abnormal weight loss acquired during the stay, and a nutrition/dietary note documented that the resident lost 11.6% of body weight over six months, from 191 pounds to 168.8 pounds. The physician’s progress notes repeatedly identified abnormal weight loss and included weekly weights as part of the plan of care, with this noted in multiple entries over several months. Despite the physician’s plan, the resident’s weight summary showed only monthly weights, with no weekly weights completed in July or August. The order summary report included diet orders, supplement drinks, and frozen nutritional treats, but no order for weekly weight monitoring. The care plan identified unplanned/unexpected weight loss related to poor food intake and risk for complications, but the interventions did not include weekly weight monitoring. Staff interviews showed the restorative nurse was doing resident weights and had not completed weekly weights because there was no order, and had not reviewed the physician’s progress notes. Other nurses stated that progress notes should communicate updates to the interdisciplinary team and that if a physician documents an intervention that is not in the orders, the nurse should clarify it with the physician and document the clarification.
Improper Care of Urinary Drainage Leg Bag and PPE Noncompliance
Penalty
Summary
Facility staff failed to provide appropriate care for a resident with a nephrostomy tube and urinary drainage leg bag. The resident had multiple diagnoses, including hydronephrosis with ureteropelvic junction obstruction, chronic kidney disease, artificial openings of the urinary tract, presence of urogenital implants, and neuromuscular dysfunction of the bladder. The care plan identified the resident as having a nephrostomy tube and being on enhanced barrier precautions for transfers, bathing, hygiene, linen changes, brief changes, incontinent care, and nephrostomy tube care. On observation, the resident was lying in bed with the urinary drainage leg bag wrapped in a brief. The brief was wet with a large yellow stain, and the drainage bag was observed without the blue screw cap in place. The resident unwrapped the bag from the brief, threw the brief on the floor near the garbage can, and stated they did not know why it was wrapped in the diaper because it was not leaking. The resident then attempted to screw the blue cap onto the extension of the leg bag and stated the leg bag was not closed. When the RN assessed the bag, she attempted to put the blue cap back on, emptied urine from the drainage bag into a urinal, removed her gloves, and picked up the soiled brief from the floor without the required PPE. The DON stated that care for a resident with a nephrostomy tube should be provided as ordered, that EBP precautions should be followed with gloves and gowns, that a leaking urinary drainage bag should not be wrapped in a brief, and that if the screw cap was off it would be best to change the leg bag. The report also noted that there was a potential for infection.
Failure to Follow Ordered Oxygen Therapy and Care Plan Requirements
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident, R33, by not following the physician-ordered oxygen liter flow, not providing humidification for oxygen use, not properly storing oxygen tubing when not in use, and not developing a care plan for oxygen use. R33 was admitted with diagnoses including acute on chronic systolic congestive heart failure, hypertensive heart disease with heart failure, chronic kidney disease stage 3, chronic obstructive pulmonary disease, and nicotine dependence. The MDS indicated cognition was intact. During observation, R33 was ambulatory, alert and oriented x3, and verbally responsive, while oxygen tubing and the nasal cannula were seen placed on the bed and not properly stored, the oxygen concentrator was running at 3L/min, and no humidification bottle was attached. R33 stated he had been using oxygen most of the time. The RN said oxygen tubing should be stored in a clear plastic bag when not in use and that a humidification bottle should be available, though she was unsure why it was not present. The DON stated oxygen should be administered as ordered by the physician, tubing and nasal cannula should be stored properly in a bag when not in use, humidification should be available and changed weekly and as needed or as ordered, and oxygen use should be care planned. The physician order summary showed an active order for oxygen with tubing and humidifier changes weekly and oxygen PRN via nasal cannula at 2L/min, but the electronic health record contained no care plan for oxygen use. The facility policy also stated that when oxygen is not in use, tubing and nasal cannula should be stored in a labeled plastic bag.
Controlled Medication Counts and Documentation Were Inaccurate
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when staff failed to reconcile and account for controlled medications accurately in 1 of 3 medication carts reviewed. During review of the third floor A medication cart, the RN found that R100 had 25 Vimpat (lacosamide) 100 mg tablets remaining on the punch card, while the Controlled Drug Receipt/Record/Disposition Form documented 26 tablets remaining after a 30-tablet dispense on 08/30/25. The RN stated the medication had not been signed for on the controlled substance record, and that it had been given at 9:00 AM. The same review found that R105’s phenobarbital 64.8 mg punch card had 13 tablets remaining, while the controlled substance record documented 14 tablets remaining after a 30-tablet dispense on 08/06/25. The Controlled Substances Check Form also had no initials for 09/01/25 on the 7-3, 3-11, or 11-7 shifts, and no initials for 09/02/25 on the 7-3 shift. The RN stated the controlled substances check form is signed at the beginning and end of each shift. The DON stated that medication administration should be signed after it is given unless it is a narcotic, and that narcotic accountability includes counting narcotics during shift change and signing accordingly. The policy stated controlled substances are signed out upon dispensing, counts are maintained by nurses of off-going and oncoming shifts, irregularities are reported to the DON, and controlled medications are verified by inventory every 8 hours and/or each shift change.
Medication Administration Errors and Failure to Notify Physician
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 9 errors identified out of 30 opportunities for an error rate of 30%. During observation, interview, and record review, a registered nurse administered medications to residents while also holding ordered blood pressure medications without documented physician notification or documented follow-up blood pressure rechecks. For one resident, the nurse obtained blood pressure readings of 81/54 and 104/75, then held amlodipine, hydrochlorothiazide, and losartan and administered the remaining medications in the cup. The nurse later stated she needed to write a note explaining why the blood pressure medications were not given. For another resident, the nurse obtained a blood pressure reading of 112/48 and held lisinopril and metoprolol, stating the blood pressure was low and that she would check it again after lunch. The record review found no documentation that the physician was notified for the held medications and no blood pressure recheck after the medications were held. The Director of Nursing stated that when blood pressure medications are held, the nurse should consult the doctor immediately for directions and that medications should be administered according to the physician order. The survey also identified medication administration errors involving expired and improperly stored medications. The nurse administered vitamin B12 that was expired and later acknowledged it was not labeled and should not have been given. The nurse also removed folic acid from another medication cart, placed it in a medication cup rather than the original packaging, and administered it from that cup. In addition, the nurse gave chewable aspirin when enteric-coated aspirin had been ordered for one resident, and the record review showed no documentation of physician notification for the held medications or the expired medication administration.
Medication Administration Errors Involving Held Blood Pressure Medications
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the residents’ physicians, resulting in significant medication errors for 2 of 3 residents reviewed during medication administration. One resident with diagnoses including cerebrovascular disease, hypertensive heart disease with heart failure, and hyperlipidemia had blood pressure checked at the medication cart, with readings of 81/54 pulse 100 and then 104/75 pulse 101. The RN stated the resident’s blood pressure was too low and held three ordered blood pressure medications: amlodipine besylate 10 mg daily, hydrochlorothiazide 25 mg daily, and losartan potassium 50 mg daily. The RN said the medications would be revisited after lunch, and there were 7 pills in the medication cup when the medications were held. Another resident with diagnoses including acute on chronic diastolic CHF, atrial fibrillation, hypertensive heart disease with heart failure, nonrheumatic aortic valve disorder, cardiomegaly, peripheral vascular disease, atherosclerosis of native arteries of the right leg, and hypertrophic cardiomyopathy had blood pressure checked in the hallway with a reading of 112/48 pulse 63. The RN stated the blood pressure was low and held the resident’s blood pressure medications, lisinopril 10 mg twice a day and metoprolol tartrate 25 mg twice a day, with 6 pills remaining in the medication cup. Record review showed no documentation that the physician was notified about the held medications for either resident, and there was no recheck of blood pressure after the medications were held. The DON stated the nurse should hold blood pressure medications if outside parameters and consult the doctor immediately for abnormal blood pressures, and the RN stated that if it is not documented it did not happen.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to follow its abuse prevention policy, resulting in a resident with cognitive impairment and multiple medical conditions sustaining physical injuries. The resident, who required maximal assistance with activities of daily living and was unable to ambulate, was involved in a physical altercation with another resident known to have a history of violent behavior and psychotic disturbances. The incident took place in a common area, where the aggressive resident struck the vulnerable resident multiple times in the facial area, causing bruising and swelling to the right eye and face. Staff interviews and clinical records confirm that the aggressive resident had previously exhibited physical aggression toward other residents and staff, and was being monitored for such behaviors. During the incident, staff responded after hearing commotion and yelling, intervening to separate the residents. The injured resident was promptly sent for an emergency eye appointment, and the aggressor was placed on one-to-one monitoring and later transferred for psychiatric evaluation. However, the facility's abuse policy required identification and prevention of potential mistreatment, which was not effectively implemented in this case, as the aggressive resident was able to physically harm another resident. The investigation revealed that the administrator could not recall the details or outcome of the incident investigation, despite the abuse allegation being substantiated. Documentation showed that the facility had policies affirming residents' rights to be free from abuse and required timely investigation and reporting of such incidents. The failure to prevent the altercation and protect the resident from physical harm constituted a breach of the facility's abuse prevention policy.
Failure to Timely Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Program Policy by not reporting an allegation of physical abuse between two residents to the Illinois Department of Public Health (IDPH) within the required two-hour timeframe. The incident involved a cognitively impaired male resident with multiple medical conditions, including Parkinson's Disease and schizophrenia, who was physically assaulted by another male resident with a history of violent behavior and psychotic disturbance. The assault resulted in visible injuries, including a bruised and discolored eye, and required emergency medical attention. Staff present at the time of the incident separated the residents and notified facility leadership, but the initial report to IDPH was not submitted until ten days after the event. Additionally, the facility did not submit the final investigation report to IDPH within the mandated five business days. The administrator acknowledged the delay and indicated that the final report was not uploaded until more than a month after the incident. The facility's policy requires immediate reporting of abuse allegations and submission of the final investigation report within five working days, but these procedures were not followed in this case, as confirmed by interviews and record reviews.
Failure to Assist Resident with Access to Social Security Card
Penalty
Summary
The facility failed to assist a resident with communication and access to services, specifically in obtaining a Social Security card. The resident, who has multiple medical conditions including type 2 diabetes, chronic kidney disease, and bilateral below-knee amputations, was cognitively intact and expressed a clear need for his Social Security card to apply for housing and financial assistance. Despite the resident's repeated requests and attempts to arrange transportation to the Social Security office, facility staff did not provide the necessary assistance. Staff members acknowledged being aware of the resident's request but did not follow up or document any actions taken to help him obtain the card. Interviews with the Business Office Manager, Admissions Director, and Psychiatric Rehabilitation Services Coordinator revealed a lack of coordination and follow-through. The staff discussed the resident's need but failed to ensure he was assisted, either by phone or in person, and did not document any efforts or appointments related to his request. The facility's policy requires meeting with residents to resolve issues and providing resources to exercise their rights, but there was no evidence that these steps were taken in this case. The resident's progress notes did not reflect any assistance or scheduled appointments for obtaining the Social Security card.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to follow its abuse prevention policy, resulting in a resident being subjected to physical and mental abuse by another resident. The incident took place in the dining room, where one resident, who had a documented history of violent behavior and schizoaffective disorder, aggressively struck another resident multiple times in the head, face, and chest while she was seated. The staff member present, an LPN, was administering medications and noticed the aggressor's anxious and pacing behavior but did not remove him from the area or call for additional assistance, despite feeling that something was wrong. The attack was only interrupted after the LPN intervened by yelling and physically separating the residents. The resident who was attacked, a female with schizoaffective disorder and other medical conditions, reported experiencing pain, humiliation, fear, and emotional distress as a result of the incident. She described being shocked, scared, and embarrassed, and expressed ongoing fear of retaliation. The aggressor admitted to the attack, stating he was provoked by the victim's yelling and used physical force to make her stop. The incident was witnessed by staff, and the victim was observed to be crying uncontrollably and unable to answer questions immediately after the event. The facility's records indicate that the aggressor had a known history of physical aggression and inappropriate behaviors, including previous altercations with other residents and staff. Despite this, the staff did not take preventive measures to separate or closely monitor the resident prior to the incident, even when warning signs were present. The facility's abuse policy affirms residents' rights to be free from abuse, but the failure to act on observed behavioral changes and to ensure adequate supervision directly contributed to the occurrence of abuse.
Failure to Maintain Comfortable Hot Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain hot water at a comfortable level in a resident's hand sink, as observed and confirmed by both staff and the surveyor. The Maintenance Director received a complaint from a resident on the third floor regarding cold water in the hand sink, which was corroborated by the resident, who reported receiving cold bed baths and stated that the issue had persisted for three to four weeks. The Maintenance Director acknowledged that water temperatures were not consistently logged or monitored, and no temperature logs were provided to the surveyor. When the water temperature was measured in the resident's room, it was found to be 97.3 degrees Fahrenheit, which was described as cold by both the Maintenance Director and the resident. Further investigation revealed that the issue was not isolated to the resident's room, as the shower room on the same floor also had water temperatures at 97 degrees Fahrenheit. The Maintenance Director admitted to not keeping a log of water temperatures and only checking them sporadically as part of the water management program, without recording the results. The facility did not have a specific policy for water temperatures, and no documentation was provided to show regular monitoring or corrective actions taken in response to the complaints. Interviews with staff and the resident's emergency contact confirmed that concerns about cold water and inadequate bathing had been reported but not resolved to the satisfaction of the resident or their family. Maintenance requests and concern forms documented the ongoing issue, but there was no evidence of timely or effective resolution. The lack of consistent monitoring, documentation, and policy regarding water temperature contributed to the deficiency in providing a safe and comfortable environment for residents.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as evidenced by several observations during a survey. In the walk-in freezer, there was significant ice build-up on the condenser, food boxes, metal shelves, and the floor, which was attributed to the freezer door being left open by a cook. This condition violates the facility's policy on refrigerator and freezer maintenance, which requires regular inspections and immediate repairs for any maintenance needs. Additionally, the food preparation area was not adequately separated from the sanitization area, as observed when a cook was slicing potatoes next to buckets filled with soapy solutions, which were part of the sanitation process. Further deficiencies were noted in the dishwashing and drying process. After pureeing bread, a cook rinsed the blender container and blade, ran them through a high-temperature dishwasher, and then used a paper towel to dry the inside, leaving liquid residue. This practice contradicts the facility's policy that requires items to air-dry after washing. Similarly, a metal pan used for pureed potatoes was not properly dried before use. These practices were inconsistent with the facility's food preparation policy, which mandates that food be prepared in a manner that complies with safe food handling practices.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement Enhanced Barrier Precautions (EBP) for several residents, as observed during a survey. Signs indicating EBP were not posted on the doors of residents' rooms, but rather above their beds, which led to confusion among staff and residents. For instance, a resident with a gastric feeding tube had the EBP sign over her bed instead of the door, and another resident with a wound had an outdated sign from a previous resident. Additionally, personal protective equipment (PPE) was not readily accessible, as the PPE carts were located far from the residents' rooms, making it inconvenient for staff to use them when needed. The facility also failed to include EBP in the comprehensive care plan for a resident with an indwelling urinary catheter. There was no order for EBP in place for this resident, and the staff was unaware of the need for such precautions. The lack of signage and accessible PPE contributed to the staff not consistently using gowns and gloves when providing care, which is a requirement under the facility's policy for residents with indwelling medical devices or wounds. Furthermore, another resident on reverse isolation due to IV access did not have appropriate signage or PPE supplies near the room. The resident reported that nurses were not using disposable gowns when administering IV antibiotics. These deficiencies highlight a systemic issue in the facility's infection prevention and control program, as staff were not following the established protocols for EBP, potentially increasing the risk of infection spread.
Failure to Obtain Code Status Order for Resident
Penalty
Summary
The facility failed to adhere to its policy regarding obtaining a code status order from a prescriber for a resident, identified as R45, who was reviewed for advance directives. The resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disease, hypertensive heart disease, type 2 diabetes mellitus, and several other serious health conditions. Despite the completion of a POLST (Practitioners Order for Life Sustaining Treatment) form, the facility did not secure a corresponding code status order from the physician, which is crucial for guiding staff during emergencies. Interviews with the Director of Nursing and the Psychiatric Rehabilitation Services Director revealed that the facility's process involves assisting residents or their representatives in completing the POLST form and then obtaining a physician's order to document the resident's code status in their health record. However, a review of R45's physician order sheet showed no code status order, indicating a lapse in following the facility's POLST policy. This oversight could potentially impact the care provided to the resident during an emergency, as staff would be unaware of the resident's resuscitation preferences.
Failure to Update and Implement Fall Care Plan Interventions
Penalty
Summary
The facility failed to adhere to the fall care plan interventions for a resident identified as R204, who had a history of falls and was at high risk for further incidents. R204 was admitted with multiple diagnoses, including seizures, epilepsy, repeated falls, and severe cognitive impairment. Despite being identified as high risk for falls, the care plan interventions, such as ensuring the resident wore non-skid socks, were not consistently followed. On one occasion, R204 was observed wearing regular socks instead of the prescribed non-slip socks, which was contrary to the care plan. The deficiency was further compounded by the facility's failure to update the care plan after R204 experienced a fall resulting in a fractured right femur. Although the care plan was supposed to be revised with new interventions after the fall, it remained unchanged, continuing with the same interventions that were in place before the incident. The Director of Nursing acknowledged that no changes were made to the care plan interventions after the fall, and the new intervention of one-to-one supervision was not documented in the care plan. Interviews with staff revealed a lack of awareness and communication regarding the specific interventions required for R204. A CNA was unaware of the need for non-slip socks, and the LPN incorrectly stated that no special socks were needed. The Director of Rehabilitation confirmed that R204 should be wearing non-slip socks due to the resident's impulsivity and high fall risk. The MDS Coordinator, responsible for updating care plans, confirmed that the interventions had not been updated following the fall, highlighting a breakdown in the facility's process for reviewing and revising care plans as required by their policies.
Failure to Conduct Nutritional Evaluation on Readmission
Penalty
Summary
The facility failed to perform a nutritional evaluation upon readmission for a resident, identified as R45, who experienced significant weight loss. R45 was admitted with multiple health conditions, including chronic obstructive pulmonary disease, type 2 diabetes, and cachexia, among others. Observations noted that R45 appeared underweight, with a protruding collarbone, and had a BMI of 16, indicating an underweight status. Despite eating 75% of his meals, R45 had a significant weight loss of 8.5% over the last month, with his weight dropping from 101.9 lbs in June to 93.2 lbs in July. The facility's policy required a nutritional evaluation upon readmission, which was not completed for R45 in June, contributing to his continued weight loss and hospitalization due to poor appetite and malnutrition. The Director of Nursing acknowledged the importance of referring residents with weight loss to a dietician for evaluation. However, the Registered Dietician, who worked remotely, confirmed that a nutritional assessment was not conducted upon R45's readmission in June, despite multiple hospitalizations. The dietician admitted responsibility for the oversight, noting that coverage was in place during her absence. The facility's policy mandates nutritional evaluations for new admissions, readmissions, and significant changes, but this was not adhered to in R45's case, as evidenced by the lack of a documented evaluation in June. This oversight led to a delay in addressing R45's nutritional needs, contributing to his significant weight loss and subsequent health issues.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to properly date and store a nebulizer mask for a resident, identified as R103, which was observed by a surveyor to be left undated and not stored in a plastic bag when not in use. This observation was made over several days, from July 30 to August 2, 2024. A registered nurse, V6, acknowledged that the nebulizer mask should be dated and stored in a plastic bag to prevent contamination and potential infection. The Director of Nursing, V2, confirmed the expectation that nebulizer masks should be dated and stored properly to prevent infection, noting that undated equipment could lead to uncertainty about when it was last changed, increasing infection risk. R103 had an active physician order for Albuterol Sulfate Nebulization Solution to be administered every four hours for shortness of breath. The facility's policy on nebulizer mist therapy, dated March 2021, requires that nebulizer equipment be stored in a labeled and dated plastic bag.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for medication management, resulting in several deficiencies. During an inspection, a surveyor observed that a multi-dose vial of Humulin R Insulin for a resident was opened and undated, contrary to the facility's policy which requires dating upon opening. This oversight was acknowledged by an LPN, who noted that the lack of dating could lead to the administration of expired insulin, potentially reducing its effectiveness. Additionally, an unopened vial of Lantus Insulin was found stored improperly in a medication cart instead of being refrigerated as recommended by the pharmacy. The LPN confirmed that the insulin should have been refrigerated to maintain its potency, as per the pharmacy's instructions. Another deficiency was noted when three unidentified pills were found at a resident's bedside. The DON confirmed that medications should not be left at the bedside without a doctor's order, and the RN on duty could not identify the pills, stating that the resident's scheduled morning medications had already been administered in the dining room. The facility's policy mandates that medications be stored securely and not left unattended, highlighting a lapse in following established procedures. These incidents reflect a failure to comply with medication storage and administration protocols, potentially compromising resident safety.
Failure to Provide Dental Care Services
Penalty
Summary
The facility failed to provide dental care services to a resident, identified as R20, who expressed a desire to obtain dentures. Despite having a care plan intervention dated January 28, 2024, to coordinate dental care arrangements, R20 had not been scheduled for a dental appointment. The resident mentioned that someone at the facility had promised to make an appointment with a dentist, but this had not occurred. Upon review of R20's electronic health record, it was confirmed that there was no order for a dental visit, although the care plan included an intervention to coordinate dental care as needed. Interviews with facility staff, including a Registered Nurse, the Minimum Data Set/Care Plan Coordinator, and the Director of Nursing, revealed a lack of communication and follow-through regarding R20's dental care needs. The Director of Nursing acknowledged the absence of a dental appointment and later entered an order for R20 to be seen by an outside clinic. The facility's guidelines and policies emphasize the importance of providing necessary dental services and maintaining a person-centered care plan, yet these were not effectively implemented in R20's case, leading to the deficiency.
Failure to Follow Physician's Orders for Nectar-Thick Liquids
Penalty
Summary
The facility failed to follow physician's orders for a resident with a medical diagnosis of moderate to severe oropharyngeal dysphagia, which required a pureed diet with nectar-thick liquids to prevent aspiration. Despite the documented orders, the resident was served thin liquids on multiple occasions. During an observation, a CNA provided the resident with a thin consistency pink lemonade, which caused the resident to cough. The CNA admitted to not having stirred the thickener into the drink before serving it. Additionally, the CNA was unsure of the exact consistency required for the resident's liquids. Further observations revealed that an Activity Aide also failed to thicken the resident's coffee to the required nectar consistency, as the aide did not measure the thickener and was unaware of the specific liquid consistency needed. The facility's Director of Nursing stated that nurses are responsible for thickening liquids, but CNAs and aides can do it if trained. However, the Activity Director indicated that activity aides should inform nurses to thicken the liquids, as they are not CNAs. The facility's policies require that therapeutic diets, including altered consistency, be provided as per the physician's orders.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program by not developing a report for the number of residents on antibiotics that did not meet criteria for active infection and by failing to maintain accurate surveillance tracking. Specifically, the facility's Infection Control Log from January 1, 2024, to July 23, 2024, revealed that four residents were prescribed antibiotics without documented signs or symptoms of an active infection. These residents were tested for urinary bacterial growth upon admission, and despite the absence of symptoms, they were prescribed antibiotics. The organism causing the bacterial growth was not documented, and their antibiotic use was not recorded on the facility's surveillance tracking log. The Infection Preventionist (IP) and Director of Nursing (DON) provided conflicting accounts regarding the protocol for ordering urinary tests and cultures upon admission. The IP stated that they were instructed by nursing administration to conduct these tests on all admissions, while the DON was unaware of such a directive and emphasized the need for symptoms before testing. This miscommunication and lack of adherence to the established criteria for testing and antibiotic prescription led to the deficiency, as the facility's logs were incomplete and did not reflect the necessary information to support the use of antibiotics in these cases.
Failure to Administer Vaccinations as Consented
Penalty
Summary
The facility failed to adhere to its Influenza and Pneumococcal Immunization policy, resulting in three residents not receiving their vaccinations as consented. Resident 5 consented to both the influenza and pneumococcal vaccines on January 17, 2024, but did not receive either vaccine. Despite having a diagnosis of type II diabetes, heart disease, and chronic obstructive pulmonary disease, which made him eligible for the pneumococcal vaccine, there was no documentation of the vaccines being administered or any contraindication provided by the attending physician. Similarly, Resident 11 consented to both vaccines on February 16, 2024, but there was no record of administration in his clinical records. Resident 46, who consented to the pneumococcal vaccine on February 3, 2024, also did not receive the vaccine despite being eligible due to his diagnoses of type II diabetes and hypertensive heart disease. The Infection Preventionist (IP), who began tracking vaccinations in April 2024, was unaware of the missed vaccinations and stated that vaccines should be administered within one to two days of receiving consent. The Director of Nursing confirmed that vaccines are offered upon admission and should be administered promptly once consent is given. The facility's policy, dated October 2020, mandates offering the pneumococcal vaccine to eligible residents and requires documentation of any medical contraindications by the attending physician. However, the facility failed to follow these procedures, leading to the oversight in administering the vaccines to the residents.
Resident's Call Light Malfunction Unaddressed
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning, which was observed during a survey. The resident, identified as R22, was found lying in bed with a non-functioning call light. R22 reported that the call light had been broken since a storm occurred two weeks prior and that staff were aware of the issue. R22, who is unable to get out of bed independently, expressed distress over the inability to call for assistance, stating that they had to wait for staff to check on them. The resident also mentioned being wet and unhappy due to the non-functioning call light. Staff interviews revealed a lack of communication and awareness regarding the broken call light. A registered nurse (RN) confirmed the call light was not working and acknowledged the potential risk of skin breakdown due to the resident's inability to communicate needs. A certified nursing assistant (CNA) emphasized the importance of a functioning call light for resident safety and identified potential risks such as falls and emotional distress. The Director of Nursing (DON) stated that it is expected for staff to ensure call lights are operational and expressed unawareness of the issue. The Maintenance Manager also noted the critical nature of call lights but was not informed of the malfunction. Despite these acknowledgments, the call light remained unfixed the following day, leaving the resident dissatisfied.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide and acquire medications as ordered by the doctor to meet the needs of each resident, specifically affecting two residents. One resident, admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD), reported not receiving her prescribed inhalers (Symbicort and Albuterol) since admission. Despite being aware of the issue, the facility staff did not ensure the availability of these medications, which are crucial for managing her COPD. The resident expressed having constant mucus in her lungs and occasional breathing problems, although she was observed breathing easily at the time of the survey. Another resident, with a history of Type 2 diabetes mellitus and other chronic conditions, was administered Humulin R insulin at an incorrect time, deviating from the prescribed schedule. The Director of Nursing acknowledged that medications should be administered as prescribed, following the 5 R's of medication administration. The facility's medication administration policy also emphasizes the importance of adhering to the correct timing to prevent medication errors. The failure to provide timely and available medications as ordered could potentially lead to adverse reactions or unmet medical needs for the residents.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to complete an elopement risk assessment, develop and implement an elopement care plan, and provide a secure physical environment for a resident with a known history of successful elopement. This resulted in the resident eloping from the facility without staff awareness. The resident was found two days later at his mother's home. The resident had a history of Major Depressive Disorder, Paranoid Schizophrenia, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Delusional Disorders, Bipolar Disorder, and Hallucinations, and was cognitively intact with a BIMS score of 15. Despite being identified as high risk for elopement, the elopement risk assessment and care plan were only completed after the resident had already eloped. The incident note documented that the resident was last seen going for a smoke break, and staff were unable to locate him afterward. The facility initiated a missing person protocol and notified 911, but the resident was not found until two days later at his mother's home. Interviews with staff revealed that there were insufficient staff members monitoring the smoking patio, and the gate on the patio was not secure, which allowed the resident to elope. Staff members acknowledged that there should have been at least three staff members on the patio during smoking breaks to ensure resident safety. The facility's elopement policy required residents to be evaluated for elopement risk on admission and throughout their stay, but this was not followed in the case of the resident. The resident's history of elopement from a previous facility was known, but appropriate measures were not taken to prevent a similar incident from occurring at this facility.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,616 citations issued within 25 miles in the last 12 months — including the 26 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Kenwood Vlge Nrsg And Rhb Ctr | 1.1 mi | ★★★★★ | 10 | 0 |
| Kensington Place Nrsg & Rehab | 1.1 mi | ★★★★★ | 5 | 0 |
| Ryze On The Avenue | 1.2 mi | ★★★★★ | 5 | 0 |
| Southview Manor | 1.3 mi | — | 0 | 0 |
| Landmark Of Hyde Park Rehabilitation And Nursing C | 2.8 mi | ★★★★★ | 14 | 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 August 2026) and official state health department websites.