Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Avenora Elmhurst during CMS and state inspections, most recent first.
A resident with impaired UE ROM, weakness, and need for meal set-up spilled hot oatmeal onto his abdomen while eating in bed and sustained a burn. Staff gave conflicting accounts about supervision and assistance, and the RN initially found no visible injury before an open area and full-thickness burn were later identified. The wound MD stated the facility did not follow its burn protocol for immediate treatment, which required a thick, dry, sterile dressing to keep air out.
The facility failed to provide adequate hygiene and grooming assistance to several dependent residents. One resident with significant physical impairments was repeatedly observed with long, dirty fingernails, crusted eyes, and overgrown facial hair and expressed a desire for nail and beard care. Another resident with Parkinson’s disease was seen on multiple occasions in the dining room wearing the same dirty, stained clothing, with long dirty fingernails and unkempt facial hair, and reported being unable to perform his own grooming. A cognitively impaired resident requiring maximum ADL assistance was observed for hours in soiled pants and with overgrown facial hair. A resident with dementia and malnutrition was repeatedly seen in bed with extremely oily hair and heavy dandruff flakes on his shirt; a CNA reported not seeing this resident showered in three months, while an LPN stated the resident often refused showers, and bathing documentation was largely incomplete despite a care plan indicating the need for assistance. The DON stated staff are expected to provide grooming, nail care, facial hair care, and clean clothing, and to individualize and document care for bathing and grooming refusals.
A resident with dementia, depression, anxiety, anorexia, and protein-calorie malnutrition repeatedly refused bathing and meals, yet the facility failed to include individualized interventions for these refusals in the care plan. Over several observations, the resident was noted to have extremely oily hair and heavy dandruff, with CNAs and an LPN reporting consistent shower refusals and bathing documentation showing mostly missing entries and only two recorded refusals. The resident frequently left meals untouched, with CNAs removing trays after minimal intake without offering alternatives or providing cueing or prompting, despite documented underweight status, high malnutrition risk, and increased nutritional needs. Facility leadership and policies stated that refusals of bathing, grooming, and meals should be addressed with personalized, resident-specific care plan interventions, but such interventions were absent for this resident.
The facility did not provide required written documentation, including bed hold notices and involuntary discharge notifications, to residents or their representatives during transfers or discharges. Multiple staff members, including the DON, LPNs, and RNs, indicated confusion about who was responsible for issuing these documents, resulting in residents and families not receiving information about their rights or the facility's policies.
A resident with a history of hip issues experienced a change in condition after a shower transfer, resulting in a hip dislocation. The CNA did not immediately notify the nurse, leading to a delay in care. The resident was eventually sent to the hospital after the oncoming nurse discovered the issue. The facility's policy requires notification of changes, but lacks specific time frames.
A resident developed unstageable pressure injuries on both heels due to the facility's failure to identify and manage the wounds. Despite orders for heel protectors, they were not consistently used, and necessary wound assessments and interventions were delayed. The resident's care plan lacked documentation of pressure injuries and interventions, contrary to the facility's policy.
A resident with severe cognitive impairment and multiple diagnoses experienced a 5.87% weight loss in one week, which was not promptly addressed by the facility. The resident's physician and dietician were not notified in a timely manner, and the care plan lacked interventions for the weight loss. The dietician was informed 10 days to 2 weeks later and ordered supplements, but the resident initially refused them. The facility's policy for communication between the nurse and dietician was not followed.
The facility failed to store kitchen utensils properly and ensure appropriate glove use, risking cross-contamination for all 33 residents. A cook was observed not changing gloves between tasks and handling utensils stored haphazardly, which was confirmed by staff as not meeting infection control standards. The administrator admitted there was no specific policy for utensil storage and cross-contamination prevention.
The facility lacked policies for enhanced barrier precautions and legionella management, affecting infection control. Residents with medical devices like gastrostomy tubes and urinary catheters were not under proper precautions, and staff were observed without PPE. The facility's water treatment policy did not address legionella, potentially impacting all residents.
The facility failed to maintain the kitchen freezer in a safe condition, affecting all 33 residents. The freezer and refrigerator door handles were broken, preventing proper sealing, and there was significant ice buildup inside the freezer. The maintenance staff and administrator were unaware of these issues, and the facility's Equipment and Maintenance policy was not followed.
Two residents were not treated with dignity in a LTC facility. One resident, with severe cognitive impairment, was placed over a trash can during incontinence care instead of being toileted properly. Another resident, also with severe cognitive impairment, had his meal tray withheld, causing him to express hunger and thirst. The DON acknowledged these actions as dignity concerns.
A resident with Alzheimer's and dementia was left in a saturated incontinence brief for an extended period, as observed by a surveyor. The CNA admitted the resident had not been checked since the morning, contrary to the facility's policy requiring checks every two hours. The DON emphasized the importance of regular checks to prevent infections.
Two residents with cognitive impairments were restrained by having their wheelchair wheels locked, preventing independent movement. Staff members, including a CNA and an LPN, locked the wheels to keep the residents in one place, despite their attempts to move. The DON confirmed this action as a restraint, which is against facility policy unless medically necessary.
The facility failed to ensure safe transfers for a resident with severe cognitive and lower extremity impairments by not using a gait belt, leading to potential injury. Additionally, a resident with dysphagia was left unsupervised during meals, despite being on aspiration precautions, which violated facility policy.
A facility failed to label oxygen tubing for a resident with chronic respiratory conditions, as required by policy. The resident's oxygen tubing and humidifier were observed without labels on two occasions, and the MAR did not document the change schedule. The DON and an RN confirmed the policy of weekly changes and labeling, but the care plan lacked specific interventions for tubing changes.
A resident with severe cognitive impairment and multiple diagnoses was inappropriately administered Seroquel on a PRN basis for behaviors such as resistance to assistance and refusal to follow commands. The facility failed to document the use of non-pharmacological interventions prior to administering the medication, and the Director of Nursing confirmed that the medication was used for staff convenience, contrary to the facility's policy.
A facility failed to properly store a Pneumovax 23 vaccine for a resident, as it was found unrefrigerated in a medication cart. The vaccine, received on a previous date, was supposed to be refrigerated but was instead stored in a bag labeled 'Refrigerate.' An RN confirmed the vaccine was no longer viable, and the DON explained it was kept in the cart while the resident was out for surgery. The facility's policy requires medications to be stored according to manufacturer recommendations.
A resident with a DNR order was found unresponsive, and the facility staff initiated CPR, failing to honor the resident's end-of-life wishes. The staff was unsure of the resident's code status, and CPR was performed until the DNR status was confirmed. The facility's policy on maintaining and referring to advance directives was not followed.
A resident with hydrocephalus and dementia fell from a wheelchair, but the incident was not properly documented or assessed by the LPN. The facility's fall management protocols, which require immediate assessment, documentation, and notification, were not followed.
The facility failed to safely position a resident during care, resulting in a fall and injuries, and did not properly document or communicate another resident's transfer status, leading to unsafe conditions. The lack of policies on bed mobility and positioning contributed to these deficiencies.
A resident with multiple health issues was transferred to the hospital after a fall, but the facility failed to notify the resident's physician and family. The DON confirmed that the assigned Agency RN did not document the incident or notify the necessary parties, contrary to facility policy. The physician was unaware of the fall and hospital transfer, and the family expressed concerns about the lack of notification and medical attention.
A resident with severe cognitive impairment and multiple medical conditions was found with significant bruising, which was not reported to the State Survey Agency as required by the facility's policy. The DON and staff were aware of the bruises, but the injury was not communicated to the abuse coordinator or reported, leading to a deficiency.
A resident was not readmitted to the facility after hospitalization, despite the facility's bed-hold policy allowing for such a return. The resident's daughter took her to the hospital due to unresolved symptoms, and the facility later refused readmission, citing the resident's complexity and the daughter's complaints. The facility failed to notify the attending physician and did not adhere to their own policies regarding family concerns and Medicaid residents' rights.
A resident with dementia was sexually abused by another resident with a known history of inappropriate sexual behavior and wandering. The facility failed to implement a care plan or take adequate action despite staff reports of the resident's behavior, leading to an immediate jeopardy situation.
A facility failed to thoroughly investigate an abuse allegation involving two residents in the Dementia unit. Despite video evidence provided by a resident's family, the administrator did not review the footage or notify necessary authorities. The accused resident had a history of inappropriate behavior, but the facility lacked a care plan to address these issues. Staff reports of inappropriate behavior were not adequately documented or addressed, leading to a deficiency in handling the abuse allegation.
Inadequate Supervision During Meal Service and Failure to Follow Burn Treatment Protocol
Penalty
Summary
The facility failed to provide adequate supervision for a resident with impaired upper extremity range of motion and weakness. The resident was cognitively intact, required set-up or clean-up assistance for eating, and had documented impairment in both upper extremities, including the shoulders, elbows, wrists, and hands. Therapy staff described the resident as severely deconditioned on admission, with weak grip strength and impaired fine motor skills, and noted that he would have benefitted from supervision initially for eating. According to the incident information and staff interviews, the resident spilled hot oatmeal onto his abdomen while eating in bed. The resident stated that the tray was placed on the bedside table and left there, that he was not used to eating in bed, and that he could not pull his shirt down fully because of weakness and limited movement. He reported that the oatmeal was hot when it was served and that he may have held the bowl at an angle, causing it to tip over. The resident’s spouse also stated that the oatmeal was watery and that the resident had been affected by chemotherapy, with reduced steadiness and hand function. Staff accounts differed regarding who was present and what assistance was provided. One CNA stated she set up the tray, told the resident the oatmeal was hot, and that he pulled the table and tipped the bowl onto his abdomen. Another CNA stated she later observed a burn mark with an open area on the upper abdomen when the resident returned from an appointment. The RN stated she was told the resident spilled coffee or oatmeal, assessed the abdomen, and initially found no redness or skin tear, then later observed an open area and white paste on the upper abdomen. The wound nurse identified a full thickness burn wound on the left upper abdomen, and the wound doctor stated the facility should follow its burn policy protocols for any burn injury so the area is covered and safe until orders are obtained. The facility’s burn policy required applying a thick, dry, sterile dressing or bandage to keep air out, but the report states the facility failed to follow its immediate treatment procedures after the burn incident.
Failure to Provide Hygiene and Grooming Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate hygiene and grooming assistance to multiple residents who required help with activities of daily living (ADLs). One resident with hemiplegia, hemiparesis, and muscle wasting, who was alert and oriented and required extensive to total assistance with ADLs, was repeatedly observed in bed with long, dirty fingernails containing brown/black material underneath, overgrown and unkempt facial hair, and crusty eyes. This resident stated he wanted someone to clip his nails and trim his facial hair. Another alert and oriented resident with Parkinson’s disease and gait abnormalities was observed in the dining room on consecutive days wearing the same dirty, stained clothing, with crumbs on his clothes, long dirty fingernails with dark material underneath, and unkempt overgrown facial hair. He reported that it would be nice if staff would clip his nails and trim his facial hair and later stated he could not perform this grooming himself and needed staff assistance. A CNA confirmed that this resident’s condition had declined and he now required assistance with grooming and hygiene. A third resident with vascular dementia, severe cognitive impairment, and a need for maximum assistance with ADLs was observed in group activities and later in a hallway wearing soiled pants stained with an unidentified substance and with overgrown facial hair/whiskers on the chin, with no change in clothing noted over several hours. A fourth resident with dementia, protein calorie malnutrition, depression, anxiety disorder, and anorexia was observed lying in bed on two separate days with extremely oily hair and a thick layer of white flakes, identified by a CNA as likely dandruff, on the front of his shirt. The CNA reported she had not seen this resident showered during her three months of employment. An LPN stated this resident consistently refused showers, while point-of-care bathing records over nearly a month showed missing documentation for most days and only two refusals, despite a care plan indicating the resident needed supervision or touching assistance for bathing. The DON stated that staff are expected to provide grooming and hygiene, including nail care, facial hair care, and ensuring clean clothing, and that personalized care plan interventions and documentation of refusals should be in place for bathing and grooming, which were not evident in these cases.
Failure to Care Plan for Resident’s Refusal of Personal Care and Meals
Penalty
Summary
Surveyors identified a failure to develop and implement care plan interventions for a male resident with dementia, protein calorie malnutrition, depression, anxiety disorder, and anorexia who was admitted on 10/21/2024 and was known to refuse personal care and meals. On multiple observations in early January 2026, the resident was found lying in bed wearing a gown, with extremely oily hair and a thick layer of white flakes on the front of his shirt, which a CNA identified as likely dandruff. A CNA reported she had not seen the resident shower during her three months of employment, and an LPN stated the resident consistently refused showers. Review of point-of-care bathing documentation from 12/10/2025 to 01/06/2026 showed missing bathing information on most days and only two refusals documented. Despite this pattern, the resident’s current care plan did not include any interventions addressing refusal of bathing or showering. The resident was also observed repeatedly refusing or minimally consuming meals. On one occasion, he did not eat his lunch and stated he might eat later, but his tray was removed with most of the meal untouched, and the CNA did not offer alternative choices, explaining that he was a picky eater with a poor appetite and usually asked if he wanted something different. On another observation, the resident ate only a piece of bread and declined the rest of a full meal; his tray was again removed by a CNA without offering alternative foods or providing cueing or prompting, with the CNA stating he did not eat much and mainly drank fluids. The resident’s nutritional risk assessment documented that he was underweight with increased nutritional needs and would benefit from gradual weight gain, and the dietitian’s notes indicated he was at high risk for malnutrition, averaging 50–75% meal intake with 25% of the time less than 50% intake. Nonetheless, his care plan did not include interventions for refusing meals, despite facility leadership acknowledging that refusals of bathing, grooming, and meals should be care planned with personalized interventions, as required by the facility’s Care Planning Policy.
Failure to Provide Required Written Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide written documentation of transfer or discharge, including required bed hold notices and involuntary discharge notifications, for four residents who were transferred or discharged from the facility. In each case, the residents or their representatives did not receive the necessary written information regarding their rights, the facility's bed hold policy, or the reasons for non-admittance, as required by facility policy and federal regulations. Staff interviews revealed a lack of clarity regarding responsibility for providing these documents, with nursing staff, the DON, and social services each indicating it was not their role to issue the notices. One resident with multiple diagnoses, including dementia and chronic kidney disease, was transferred to the hospital due to behavioral issues and was not allowed to return to the facility. The resident's family member expressed that she did not want the resident discharged and would have preferred he remain at the facility while awaiting placement elsewhere. Both the DON and CEO confirmed that no involuntary discharge notice, judiciary petition, or bed hold notification was provided, citing lack of awareness or misunderstanding of the requirements. Other residents were transferred to the hospital for medical reasons such as lethargy, wound care, and complications related to chronic conditions. In each instance, staff provided paramedics with medical documents but did not issue written bed hold notices to the residents or their representatives. Staff interviews consistently indicated that the responsibility for providing these notices was unclear, and the facility was unable to produce any documentation showing that the required notifications had been given.
Failure to Notify Nurse of Resident's Change in Condition
Penalty
Summary
The facility staff failed to immediately notify the nurse when a resident experienced a change in condition and could no longer stand or bear weight on her leg after a transfer. This delay in care and treatment resulted in a hip dislocation for the resident. The incident occurred when the resident was being transferred after a shower, and the CNA did not inform the nurse of the resident's inability to stand, assuming it was a common complaint from residents who did not want to stand. The resident, who had a history of left femur fracture, joint replacement surgery, and dislocation of the left hip prosthesis, among other conditions, was in pain and had a misaligned leg after the incident. The CNA did not report the change in condition to the oncoming nurse, who later discovered the issue while passing medication. The nurse then assessed the resident, noted the misalignment and swelling, and contacted the physician for further instructions. The resident was eventually sent to the hospital after a delay in obtaining an X-ray. The facility's policy on patient change of condition requires the charge nurse to notify the attending physician and responsible family member of any sudden changes, but it does not specify time frames for notification. The delay in notifying the nurse and subsequent delay in treatment were acknowledged by the facility's staff, including the Administrator, Nurse Practitioner, and Director of Nursing, who all stated that the CNA should have reported the change in condition immediately.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to identify and manage pressure injuries for a resident, leading to the development of two unstageable pressure injuries on the resident's heels. The resident, a female admitted post-surgery for a right distal femur fracture, initially showed no skin lesions upon admission. However, observations revealed that the resident's feet were often left uncovered and in a dependent position, which contributed to the development of pressure injuries. The facility did not conduct timely wound assessments or implement necessary interventions such as offloading to prevent the progression of the pressure injuries. Despite having orders for heel protectors, these were not consistently applied, and the resident's medical records lacked documentation of wound assessments prior to the physician's evaluation. The wound doctor identified the pressure injuries as unstageable due to necrosis, and the facility's records showed a delay in initiating treatment orders for the left heel. The facility's policy required a care plan to be developed for residents with skin integrity issues, but the resident's care plan did not include any mention of pressure injuries or interventions to offload pressure. The Director of Nursing acknowledged that an initial wound assessment should have been conducted by the primary nurse, and the lack of documentation and intervention could lead to complications such as infection or sepsis.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to identify and address a significant weight loss in a resident, resulting in a 5.87% weight loss over one week. The resident, who has severe cognitive impairment and multiple diagnoses including hydrocephalus, hypertension, mood disorder, dementia with behaviors, and major depressive disorder, experienced this weight loss without timely notification to the physician or dietician. The resident's weight log indicated a drop from 167 lbs to 157.2 lbs within a week, yet the facility's records showed no immediate action or notification to relevant healthcare professionals. The care plan for the resident did not include interventions related to the significant weight loss, and the dietician was not informed of the weight loss until 10 days to 2 weeks later. The dietician noted that supplements were ordered once the weight loss was identified, but the resident initially refused them. The Director of Nursing acknowledged the oversight and emphasized the importance of early identification of weight loss to improve the chances of recovery. The facility's policy required communication between the nurse and dietician for residents with weight loss trends, but this protocol was not followed in this case.
Improper Kitchen Utensil Storage and Glove Use
Penalty
Summary
The facility failed to ensure proper storage and handling of kitchen utensils, as well as appropriate glove use, which could lead to cross-contamination affecting all 33 residents. During an observation, a cook was seen checking the temperature of various food items without changing gloves between tasks, including touching kitchen counters and rummaging through a drawer of utensils. The utensils were stored haphazardly, with scoops, ladles, and spatulas facing different directions, which was confirmed by kitchen staff as not adhering to infection control standards. The facility's administrator acknowledged the absence of a specific policy for the storage of kitchen utensils and prevention of cross-contamination. The existing Sanitation and Infection Control policy required kitchen and storage areas to be neat and orderly but did not provide guidance on how utensils should be stored to prevent cross-contamination. This lack of policy and improper handling practices were identified as deficiencies during the survey.
Lack of Infection Control Policies in LTC Facility
Penalty
Summary
The facility failed to implement an infection prevention and control program, specifically lacking policies and procedures for enhanced barrier precautions and a water management plan for legionella. During the survey, it was observed that the facility did not have signs indicating enhanced barrier precautions on the doors of residents with specific medical conditions such as gastrostomy tubes, urinary catheters, and neutropenia. Staff were seen entering and exiting these rooms without wearing personal protective equipment (PPE), and there was no PPE available near the rooms. The Director of Nursing admitted to being unaware of enhanced barrier precautions until the day before the survey, and the facility lacked a protocol for these precautions. Additionally, the facility did not have a legionella policy or water management plan, despite having a water treatment system in place. The Administrator and Director of Nursing confirmed the absence of a legionella-specific policy, which could potentially affect all 33 residents in the facility. The facility's existing water treatment policy did not address legionella, focusing instead on the processes of water purification through reverse osmosis and other methods.
Failure to Maintain Kitchen Freezer in Safe Condition
Penalty
Summary
The facility failed to maintain the kitchen freezer in a safe operating condition, affecting all 33 residents. During an inspection, it was observed that the walk-in refrigerator and freezer door handles were broken and did not latch properly, preventing the doors from sealing tightly. This issue was noted by the kitchen staff, who were unsure when the handles broke, possibly over the weekend when maintenance was unavailable. Additionally, a panel of the plastic curtain at the freezer entrance was missing, and there was significant ice buildup inside the freezer, including a large icicle hanging from the ceiling. The thermometer inside the freezer was missing, and the cook recorded temperatures from an external thermometer. The kitchen staff were unaware of the missing thermometer and the reason for the freezer intermittently shutting off. The maintenance staff, who had only been employed for a month, were unaware of the maintenance logs and had not been informed of the freezer's issues until the day before the inspection. The administrator also claimed to be unaware of the freezer problems, including the broken handles and ice buildup. The facility's Equipment and Maintenance policy requires the food service director to instruct dietary employees on equipment use and care, order repairs, and maintain records, but these procedures were not followed, leading to the deficiency.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat two residents with dignity, as observed in two separate incidents. The first incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and bipolar disorder. During incontinence care, two CNAs placed a trash can under the resident while she was in a standing mechanical lift, instead of providing proper toileting assistance. This action was acknowledged by one of the CNAs as a dignity concern, and the Director of Nursing confirmed that such practice was unacceptable and degrading. The second incident involved another resident with severe cognitive impairment and diagnoses such as dementia and dysphagia. The resident's meal tray was initially placed out of reach, and when he attempted to drink water, a staff member removed it and delayed his meal, stating it was easier to feed him later. The resident expressed hunger and thirst, even attempting to drink from a paper towel roll. The Director of Nursing stated that residents should be encouraged to be as independent as possible and that the delay in providing the meal was a dignity concern.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident diagnosed with Alzheimer's disease, lack of coordination, altered mental status, dementia with behaviors, and cognitive communication deficit. The resident was noted to be always incontinent of bladder according to the facility assessment. During an observation, a surveyor found the resident's pants appeared wet, and upon further inspection, it was discovered that the resident's incontinence brief was saturated with urine, and the wheelchair seat was also wet. The Certified Nursing Assistant (CNA) responsible for the resident admitted that the resident had been toileted earlier in the morning but had not been checked since then, resulting in the resident sitting in urine for an extended period. The Director of Nursing (DON) stated that all residents should be checked and changed every two hours and as needed, especially those who cannot communicate their needs, like the resident in question. The facility's policy on incontinence and catheter management requires that residents who are incontinent receive appropriate treatment and services to prevent urinary tract infections and restore normal bladder function. The failure to adhere to this policy and the lack of timely incontinence care for the resident increased the risk of infection, as noted by the DON.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, identified as R27 and R26, were free from physical restraints. R27, who has severe cognitive impairment and is a fall risk, was repeatedly observed with his wheelchair wheels locked by staff members, preventing him from moving independently. Despite R27's attempts to move his wheelchair, staff members, including a CNA and an LPN, locked his wheels to keep him in one place, citing his unpredictable behavior and the need to monitor him. This action was taken without considering R27's inability to comprehend or unlock the wheelchair himself, effectively restraining him. Similarly, R26, who has mild cognitive impairment and was unable to be interviewed due to cognitive issues, was also observed with his wheelchair wheels locked, restricting his movement. R26 attempted to move his wheelchair multiple times but was unable to do so due to the locked wheels. Staff members acknowledged that R26's wheels were locked to prevent him from moving around the unit, despite his expressed desire to move. The Director of Nursing confirmed that holding residents in a position where they cannot move independently constitutes a restraint, which is against the facility's policy unless required for medical treatment.
Failure to Ensure Safe Transfers and Supervision During Mealtimes
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R16, who has severe cognitive impairment, lower extremity impairment, and requires substantial assistance with transfers. On October 8, 2024, a Certified Nursing Assistant (CNA), V18, attempted to transfer R16 without using a gait belt, which is against the facility's policy. During the transfer, R16 expressed pain and discomfort, yelling that her knee hurt and that she couldn't stand. Despite this, V18 continued to lift R16 under her arms and used his back to support her, which could have resulted in injury to both the resident and the staff member. The Director of Nursing confirmed that a gait belt should have been used to ensure safety during the transfer. Additionally, the facility failed to provide adequate supervision during mealtimes for a resident, identified as R28, who has a diagnosis of dysphagia and is on aspiration precautions. On multiple occasions, R28 was observed alone in his room with his meal tray, without any staff present to monitor him. The facility's policy requires that residents on aspiration precautions be supervised during meals to prevent aspiration. Despite this, R28's care plan did not include any interventions for aspiration precautions, and staff were not familiar with his eating habits. The Director of Nursing acknowledged that R28 should have been observed while eating, especially given his refusal to comply with dietary recommendations and speech therapy referrals.
Failure to Label Oxygen Tubing
Penalty
Summary
The facility failed to label oxygen tubing for a resident, identified as R31, who was receiving oxygen therapy. R31's medical conditions included chronic obstructive pulmonary disease, chronic respiratory failure, and chronic congestive heart failure, with a physician's order for oxygen via nasal cannula if oxygen saturations fell below 90%. On two separate observations, the oxygen tubing and humidifier for R31 were found without labels indicating when they were last changed. The Director of Nursing and a Registered Nurse confirmed that the facility's policy required oxygen tubing and humidifiers to be changed weekly and labeled with the change date. However, the Medication Administration Record for R31 did not document any date or time for changing the oxygen tubing, and the care plan lacked interventions regarding the frequency of tubing changes.
Inappropriate Use of Psychotropic Medication for Resident
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication was used appropriately to treat a medical condition. The resident, who has diagnoses including hydrocephalus, hypertension, mood disorder, dementia with behaviors, and major depressive disorder, was administered Seroquel 50mg on a PRN basis on multiple occasions. The medication was given on 7/28/24, 7/30/24, and 7/31/24, in response to the resident's resistance to assistance and refusal to follow commands, such as getting out of bed or standing up for toileting. These actions were taken without documented use of non-pharmacological interventions prior to administering the medication. The Director of Nursing acknowledged that antipsychotic medications should only be given when residents are in danger of harming themselves or others, and not for staff convenience. The facility's policy on psychotropic medication clearly states that such medications should not be used for discipline or staff convenience and must be required to treat the resident's symptoms. The administration of Seroquel in this case was deemed inappropriate as it was used for staff convenience without attempting alternative approaches, as evidenced by the lack of documentation of non-pharmacological interventions.
Improper Storage of Pneumovax 23 Vaccine
Penalty
Summary
The facility failed to ensure proper storage of a vaccine for a resident, identified as R87, who was reviewed for medication storage. During an observation on the first floor, west medication cart, a Pneumovax 23 syringe intended for R87 was found in the top drawer. The syringe, which was received on 9/7/24, was supposed to be refrigerated but was instead stored in a medication bottle inside a clear bag labeled 'Refrigerate.' V11, an RN, confirmed that the vaccine was no longer viable as it had not been refrigerated. V2, the DON, explained that R87 was out for surgery, and the medications were kept in the cart in anticipation of the resident's return. The facility's policy on medication storage, dated 1/4/24, mandates that medications and biologicals be stored according to manufacturer or pharmacy recommendations to maintain their integrity and ensure safe administration. R87's physician orders, dated 10/10/24, included the Pneumovax 23 injectable. The resident's face sheet, also dated 10/10/24, listed several diagnoses, including acute kidney failure, atherosclerotic heart disease, atrial fibrillation, type 2 diabetes mellitus, hyperlipidemia, hypertension, chronic kidney disease, coronary artery dissection, heart failure, aortic valve stenosis, and anemia.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) order, resulting in improper nursing care. The resident, who had multiple serious health conditions including sepsis, multiple sclerosis, and a stage IV pressure injury, was found unresponsive. Despite having a documented DNR order, the nursing staff initiated cardiopulmonary resuscitation (CPR) and called a code blue. The registered nurse on duty was unsure of the resident's code status and did not document the CPR in the resident's chart. CPR was performed for one to two minutes before the staff realized the resident was a DNR, at which point the nurse checked the electronic medical record to confirm the DNR status. The certified nursing assistant present during the incident confirmed that CPR was continued until paramedics arrived, and the facility did not follow the resident's or her family's wishes. The Director of Nursing, who was not present during the incident, acknowledged the importance of adhering to residents' advanced directives. The facility's policy requires maintaining advance directives in the medical record and referring to them throughout the resident's stay. However, in this case, the policy was not followed, leading to the failure to respect the resident's end-of-life wishes.
Failure to Document and Assess Resident After Fall
Penalty
Summary
The facility failed to ensure proper assessment and documentation following a fall incident involving a resident with hydrocephalus, dementia, and major depressive disorder. The resident, who was at high risk for falls, experienced a fall from his wheelchair, which was witnessed by a CNA. The CNA reported the incident to an LPN, who checked the resident and found no injuries but decided not to document the incident or conduct a full assessment. The Director of Nursing later confirmed that no incident report was filled out, and no neurological checks or assessments were documented in the resident's medical record. The facility's policy on fall management requires immediate assessment, documentation, and notification of relevant parties following a fall. However, these procedures were not followed in this case. The LPN did not complete an incident report or update the resident's medical record with the necessary observations and assessments. Additionally, the resident's doctor and Power of Attorney were not informed, and no post-fall monitoring was conducted, which is contrary to the facility's established protocols.
Deficiencies in Resident Safety and Transfer Procedures
Penalty
Summary
The facility failed to safely position and supervise a resident (R1) during incontinence care, leading to a fall and subsequent injuries. R1, who was cognitively intact but dependent on staff for bed mobility, was left unsupervised by a CNA during care, resulting in a fall from the bed. The CNA then improperly assisted R1 back to bed without a nurse's assessment. R1 sustained multiple rib fractures and other injuries, necessitating hospital transfer. The facility lacked specific policies on bed mobility and positioning, contributing to this incident. Another resident (R2), who was severely cognitively impaired and dependent on staff for transfers, was not properly supported in his wheelchair, leading to unsafe leaning and bruising. R2's transfer status was not documented in the care plan or facility's transfer status list, causing inconsistency in transfer methods. Staff were unsure of R2's transfer requirements, leading to varied assistance levels, contrary to the recommendation for a total mechanical lift with two-person assistance. The facility's failure to document and communicate R2's transfer status and ensure proper wheelchair positioning contributed to the resident's unsafe conditions. The lack of policies regarding bed mobility and positioning further exacerbated these deficiencies, as staff were not guided on how to safely manage residents' mobility and transfer needs.
Failure to Notify Physician and Family After Resident's Fall
Penalty
Summary
The facility failed to notify a resident's physician and representative after the resident experienced a change in condition that required hospitalization following a fall. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, dementia, and osteoporosis, was transferred to the hospital after her daughter called emergency paramedics due to the resident's complaints of generalized pain. The Director of Nursing (DON) confirmed that the Agency Registered Nurse (RN) assigned to the resident did not document the fall incident or the hospital transfer, nor did they notify the resident's physician and representative. The physician confirmed that he was not informed of the resident's fall and subsequent hospital transfer, expressing that he expects to be notified of such changes in condition to determine the need for further evaluation. The facility's policy mandates that nursing staff notify physicians of acute changes in a resident's condition, including falls. The resident's hospital records indicated that the family was concerned about the lack of notification and medical attention following the fall, prompting them to call 911.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy for reporting abuse in the case of a resident with an injury of unknown origin. The resident, who was severely cognitively impaired and dependent on staff for assistance with transfers and ADLs, was found to have significant bruising on the right inner arm and right lateral torso, extending across the anterior chest area. The bruises were noted by a CNA and an RN, who reported them to the physician and the Director of Nursing (DON). Despite the absence of any reported falls or incidents, the facility did not report the injury to the State Survey Agency as required by their policy. The resident's daughter was informed of the bruises but did not receive an update on the investigation's findings. The DON acknowledged being aware of the bruises and having conducted an internal assessment, but was unaware of the requirement to report the injury to the State Survey Agency. The facility's administrator, who serves as the abuse coordinator, was also unaware of the injury and confirmed that it was not reported. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, resulting in a deficiency.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, which was a violation of their bed-hold policy. The resident, a female with intact cognition, was initially admitted to the facility and later experienced symptoms of nausea, vomiting, and abdominal pain. Despite these symptoms, the facility did not adequately address the resident's condition, leading her daughter, who held power of attorney, to take her to a hospital against medical advice (AMA). The facility did not provide any documentation or inform the daughter that the resident could not return. The Director of Nursing later informed the daughter over the phone that the resident could not be readmitted due to the complexity of her condition and the daughter's complaints. The facility's records showed a lack of communication with the resident's attending physician regarding the transfer to the hospital. The attending physician stated that they were not contacted and would have supported the transfer if informed. The facility's policy required notifying the physician in cases of family concerns, which was not followed. Additionally, the facility's bed-hold policy allowed Medicaid residents the right to return to the first available bed after a hospital transfer, which was not honored in this case. The facility's failure to adhere to these policies and procedures resulted in the resident not being readmitted after her hospitalization.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with dementia from sexual abuse by another resident, who also had dementia and a known history of sexual behaviors and wandering into other residents' rooms. This incident occurred when the second resident entered the first resident's room during the night and sexually assaulted her. The first resident was unable to give consent due to her cognitive impairment, and the facility's failure to prevent this interaction resulted in an immediate jeopardy situation. The facility's records and interviews revealed that the second resident had a documented history of wandering and inappropriate sexual behavior, which was known to the staff. Despite this, there was no care plan in place to address these behaviors, and the interventions that were documented were not implemented. Staff members had reported the second resident's inappropriate behavior during personal care and other interactions, but the facility did not take adequate action to address these reports or prevent further incidents. The incident was discovered when the first resident's family, who had installed a camera in her room, observed the second resident entering the room and engaging in inappropriate behavior. The family reported the incident to the facility and the police, leading to an investigation. The facility's policies on abuse prevention and reporting were not effectively implemented, contributing to the failure to protect the resident from abuse.
Removal Plan
- Facility wide abuse in-service. Information included to recognize and report sexual behaviors and that Dementia residents are at high risk for abuse as they are unable to communicate or give consent.
- A skin check was conducted on each resident on Dementia floor by staff, with attention directed specifically at potential areas on bodies, most vulnerable for abuse.
- A three questions survey was conducted with each resident of the Dementia floor, to rule out additional occurrences and responses entered in resident charts with notification of V1 and V2 of any additional findings.
- Abuse prevention questionnaire implemented to be completed by staff upon admission, quarterly and as needed.
- Nightly hallway security implemented. Nursing staff to ensure one person is always sitting in the hallway monitoring resident's movements.
- Continued screening of background checks with denial of potential abusers.
- Families of Dementia residents contacted for wellness checks and no additional concerns or reports of suspected abuse provided by families.
- Quality Assurance to be completed by Director of Nursing.
- Emergency Quality Assurance conducted with Medical Director and interdisciplinary staff to discuss implementation of abatement plan.
Inadequate Investigation of Abuse Allegation in Dementia Unit
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an allegation of sexual abuse involving two residents in the Dementia unit. The incident was reported by the family of one resident, who claimed that another resident had touched their family member during the night shift. Despite the family providing video evidence of the incident, the facility's administrator did not review the footage and concluded the investigation without corroborating the allegation. The administrator also failed to notify the local State Ombudsman, Adult Protective Services, or the police, relying on the family's report to law enforcement instead. The facility's investigation was inadequate, as it did not include comprehensive interviews or statements from staff who had previously reported inappropriate behavior by the accused resident. The accused resident had a documented history of wandering and inappropriate behavior, yet the facility did not have a care plan addressing these issues. Staff members had reported incidents of inappropriate behavior by the resident, but these reports were not adequately addressed or documented in the investigation. The facility's policies and procedures for preventing and investigating abuse were not followed. The administrator did not notify the necessary authorities as required by the facility's policies. Additionally, the facility failed to implement care plans for residents with behaviors that could lead to conflict or abuse, as outlined in their abuse prevention policy. This lack of adherence to policy and thorough investigation procedures contributed to the deficiency in handling the abuse allegation.
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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 Elmhurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Of Elmhurst, The | 1.2 mi | ★★★★★ | 3 | 0 |
| Citadel At Casa Scalabrini | 1.7 mi | ★★★★★ | 0 | 0 |
| Bridgeway Senior Living | 2.5 mi | ★★★★★ | 8 | 0 |
| Park Place Christian Community | 3 mi | ★★★★★ | 0 | 0 |
| Pearl Of Hillside,the | 3.4 mi | ★★★★★ | 8 | 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.