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 Chateau Nrsg & Rehab Center during CMS and state inspections, most recent first.
A resident experienced a fall and subsequently complained of significant left hip pain, with pain scores escalating from 7/10 to 10/10 and documented difficulty with bed mobility. An NP ordered a STAT hip X-ray after the resident refused range of motion due to pain, but the RN initially entered it as a routine order and later changed it to STAT. Despite the facility’s policy that STAT imaging be completed within four hours and that nursing follow up with the radiology provider and notify the MD/NP if delays occurred, there was no documentation that the MD was notified of the resident’s worsening pain or that the incomplete X-ray was escalated that day. The X-ray was not performed until the next day, when another RN noticed it had not been done and contacted the X-ray company, and imaging then revealed an acute intertrochanteric femur fracture.
A resident experienced a fall, was found on the floor with a left elbow skin tear, and later reported significant left hip pain with inability to tolerate ROM. An NP ordered a STAT hip X-ray and indicated that STAT imaging should occur within four hours, with nursing responsible for contacting radiology. The assigned RN initially entered the order as routine, later changed it to STAT, and called the X-ray company, but the physician orders did not reflect STAT status. The X-ray was not performed until the following day, at which time imaging revealed an acute comminuted left femoral intertrochanteric fracture.
A resident with severe cognitive impairment and multiple medical conditions fell off the bed during incontinence care, resulting in a femur fracture. The CNA involved turned the resident away from her, causing the fall. The facility lacked a specific policy on bed mobility, leading to inconsistent practices among staff. Other staff indicated the resident often required two-person assistance due to her weight and inability to assist in turning.
A resident with impaired cognition and a history of falls fell out of bed and sustained a forehead laceration requiring stitches after a CNA removed fall interventions to provide care. The CNA left the resident unattended to retrieve a mechanical lift sling, during which the resident fell. Staff interviews highlighted the need for fall mats and bolsters to be in place at all times, but the resident's care plan did not mention fall mats.
A resident with severe cognitive impairment was verbally abused by a CNA during a lunchtime incident, where the CNA used explicit language and threatened the resident. Despite being reported to the ADON and DON, the incident was not classified as abuse, violating the facility's abuse prevention policy.
A facility failed to report a verbal abuse incident involving a resident with severe cognitive impairment. A CNA used explicit language towards the resident during a dining room altercation. Despite staff witnessing and discussing the incident, it was not reported to the state agency as required. The DON sent the CNA home but did not classify the incident as abuse, leading to a deficiency in reporting.
A resident's personal gift check was improperly handled by the facility, as it was deposited into the resident's account for care costs without her consent. The resident, who is alert and oriented, was expecting a $500 gift check from the Policemen's Annuity and Benefit Fund of Chicago, which was not delivered to her. The facility's admission contract did not authorize handling of personal checks, yet the check was deposited into the transferring account. The facility issued a replacement check after the resident's inquiries.
The facility failed to maintain sanitary conditions in its kitchen, affecting food storage, preparation, and serving. Observations revealed improper use of the 3-compartment sink, incorrect sanitizer testing, and staff with long artificial nails. The walk-in cooler and freezer had unsanitary conditions, with food products improperly stored and freezer burnt. Staff did not adhere to hygiene practices, and facility policies on food storage and sanitation were not followed.
The facility failed to assist residents with personal hygiene, as observed in four residents with cognitive and physical impairments. Residents were found with unclean fingernails, food debris on clothing, and unshaven facial hair, despite care plans indicating the need for maximum assistance. The Director of Nursing acknowledged the expectation for staff to assist with ADLs, but these were not met, resulting in deficiencies.
The facility failed to follow the approved recipe for chef salad, resulting in residents receiving inadequate meals with only lettuce and minimal additional ingredients. Several residents expressed dissatisfaction, noting they were left hungry, and some filed grievances. The Dietary Director and Cook acknowledged the issue, but discrepancies in meal preparation persisted.
The facility failed to follow standard infection control practices during incontinence care and medication administration. CNAs and a nurse did not change gloves or perform hand hygiene between tasks, such as cleaning perineal areas, handling catheter bags, and administering medications via a g-tube. The facility's policy requires hand hygiene before and after glove use and between tasks to prevent infection.
Two residents with urinary catheters did not receive proper care, as CNAs failed to clean the catheter tubes and lifted urinary bags above the bladder, causing urine backflow. This was contrary to facility policy, which aims to prevent infections.
A nurse failed to check the placement of a gastrostomy tube (g-tube) before administering Hydrocodone-Acetaminophen to a resident, contrary to the care plan and medication administration record. The nurse admitted to forgetting this step, and the ADON confirmed the necessity of verifying g-tube placement by aspiration or auscultation to ensure proper medication delivery.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, was not properly assessed or managed for pain during care. Despite moaning and showing signs of pain, CNAs continued applying hand splints without informing a nurse. A nurse later administered Morphine Sulfate, documenting a pain level of 10. The facility's policy emphasized pain assessment and management, which was not followed in this instance.
The facility failed to inform residents of their rights both orally and in writing. During a Resident Council meeting, residents expressed unawareness of their rights, and an Ombudsman found the display frame for rights empty. The Activity Director confirmed rights were not discussed in meetings, and the Administrator's claim of rights being posted was contradicted by their absence in common areas. Meeting minutes from the past year showed no discussion of resident rights.
Two residents experienced delays in receiving incontinence care, despite being cognitively intact and having care plans requiring frequent checks. One resident was left in soiled briefs for an extended period, while another was left wet for at least two hours. Staff failed to adhere to the facility's policy of checking residents every two hours, and there were ongoing issues with delayed response to call lights.
Failure to Timely Assess Post-Fall Pain and Complete STAT Hip X-Ray
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess a resident for post-fall complications, including failure to identify worsening acute pain and to obtain timely diagnostic testing after a fall. The resident was found on the floor in front of his wheelchair in an upright sitting position at 5:30 AM, with a skin tear to the left elbow. A progress note documented cleansing and dressing of the elbow wound and notification of the resident’s wife and the NP. The ADON later stated that the resident had gotten up from his wheelchair, ambulated with a rolling walker to bed without assistance, then got up from bed, tripped over his leg rest, and fell to the floor. The NP reported that when she assessed the resident, he complained of left hip pain and refused range of motion due to pain, leading her to order a STAT hip X-ray. The record shows that the resident’s pain was documented as 7/10 on a post-fall monitoring form at 8:50 AM, and PRN Tylenol 650 mg was given. A medication administration note at 9:35 AM documented that the Tylenol was ineffective, that the resident complained of left hip pain, requested to be put back to bed, had an ice pack applied to the left hip, and refused therapy due to pain. The NP stated that a STAT X-ray should be completed within four hours and that if the X-ray company did not arrive within that time, nursing staff should call the company and notify her so the situation could be reassessed. The DON and NP both indicated that if a STAT X-ray was not completed within the expected timeframe, the nurse should follow up with the X-ray company and the provider. However, there was no documentation on the date of the fall that the MD was notified of the resident’s increased pain or that the X-ray had not been completed. The RN assigned to the resident on the day of the fall stated that she initially entered the X-ray as a regular order and later changed it to STAT after being instructed by the NP. She reported calling the X-ray company and being told they would come as soon as they could, and that if they did not come within four hours, the nurse was to call the X-ray company and notify the doctor. Documentation showed that the resident’s pain escalated to 10/10 by mid-afternoon and again at 9:09 PM, with increased difficulty in bed mobility related to left hip pain, and additional PRN Tylenol was administered. The X-ray was not completed until the following day, when another RN noticed it had not been done and contacted the X-ray company. The radiology report then showed an acute comminuted left femoral intertrochanteric fracture. Facility policies on physician orders, pain, and falls required execution of orders, appropriate testing to clarify pain, notification of the physician and family of significant pain changes, and follow-up on falls with injury until delayed complications such as fractures were ruled out, but the documentation and interviews showed these processes were not fully carried out on the day of the fall. The resident’s wife reported receiving an early morning call about the fall and arriving later that morning to find the resident in his wheelchair with an undressed elbow wound, an ice pack on his leg, and a bruise on his forehead, and stated that he was in a lot of pain. She described that a PT or PTA came to the room and asked if the resident was going to therapy, and that they informed therapy staff about the fall and the resident’s pain. She stated that the resident remained in significant pain, required a mechanical lift for transfer, and that the X-ray staff did not arrive until the next day, after which he was sent to the hospital when the fracture was identified. The facility’s own policies emphasized resident safety, timely execution of physician orders, and follow-up on falls to rule out delayed complications, but the record lacked evidence of timely diagnostics, escalation, or provider notification in response to the resident’s worsening pain and the uncompleted STAT X-ray order on the day of the fall.
Delay in STAT Hip X-Ray After Resident Fall With Hip Pain
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely STAT hip X-ray for a resident following a fall. According to progress notes, the resident was found on the floor in front of his wheelchair in an upright sitting position with a skin tear to the left elbow in the early morning, and the NP and the resident’s wife were notified. Later that day, the NP documented that the resident reported left hip pain and was unable to participate in range of motion, and ordered a STAT hip X-ray. The NP stated that a STAT X-ray should be completed within four hours and that nursing staff are responsible for contacting the X-ray company. The DON and ADON confirmed that the X-ray was not performed until the following morning, and the ADON recalled the resident’s daughter questioning why it took until the next morning for the X-ray to be done. The RN assigned to the resident that day reported that the resident complained of pain rated 7/10 and that she initially entered the X-ray as a regular order, then changed it to STAT after being instructed by the NP and called the X-ray company to communicate the STAT status. Progress notes from the next morning show the nurse contacting the X-ray company for an estimated time of arrival, and the radiology report indicates that the hip X-ray results, showing an acute comminuted left femoral intertrochanteric fracture, were not reported until the next day. The physician orders show two one-time hip X-ray orders entered on the day of the fall, neither marked as STAT, despite the facility policy requiring the nurse who takes the order to execute it, including contacting radiology services as required.
Failure to Prevent Resident Fall During Bed Mobility
Penalty
Summary
The facility failed to prevent a resident from falling off the bed during care, resulting in the resident sustaining a femur fracture. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including lack of coordination, morbid obesity, and muscle wasting. The resident required moderate assistance for bed mobility, and the incident occurred when a CNA attempted to change the resident's incontinence brief. The CNA turned the resident away from her, causing the resident's legs to fall off the bed, leading to the fall. The CNA involved in the incident stated that the resident was positioned closer to the right side of the bed rather than being centered. The CNA attempted to reposition the resident by turning her away, which resulted in the resident falling off the bed. The CNA acknowledged that the air mattress should have had bolsters to prevent such falls. Other staff members, including RNs and CNAs, indicated that the resident should have been pulled closer to the staff before being turned away to ensure safety. They also noted that the resident's weight and deconditioned muscles contributed to the risk of falling if not properly positioned. The facility lacked a specific policy regarding bed mobility, which contributed to inconsistent practices among staff. Several staff members reported that the resident often required two-person assistance for bed mobility due to her weight and inability to assist in turning. Despite this, the CNA involved in the incident attempted to provide care alone, which was contrary to the practices followed by other staff members. The absence of a clear policy and the failure to adhere to safe positioning practices led to the resident's fall and subsequent injury.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident at high risk for falls, resulting in the resident falling out of bed and sustaining a laceration to her forehead that required stitches. The resident, who has impaired cognition and a history of falls, was found by a CNA with her upper body out of the bed and her head on the floor after the CNA had removed the fall mat and bed bolsters to provide incontinence care. The CNA had left the resident unattended to retrieve a mechanical lift sling, during which time the resident fell. Interviews with staff revealed that the resident was known to be very active and at high risk for falls, requiring fall mats and bolsters to be in place at all times when in bed. The facility's policy on falls and fall risk monitoring emphasizes the need for staff to identify and implement interventions to prevent falls and minimize complications. However, the resident's care plan did not mention the use of fall mats, and the CNA did not have all necessary supplies ready before starting care, leading to the incident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, violating its abuse prevention policy. The incident involved a resident with severe cognitive impairment who was verbally abused by a Certified Nursing Assistant (CNA) identified as V4. During a lunchtime incident, V4 removed the resident's tray, leading to a confrontation where the resident hit the tray, causing items to fall. V4 then verbally threatened the resident using explicit language, which was witnessed by other staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN). Despite the incident being reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the severity of the verbal abuse was not recognized or reported as such to the abuse coordinator. The DON sent V4 home for disruptive behavior but did not classify the incident as abuse. The facility's abuse prevention policy clearly states that residents have the right to be free from verbal abuse, which includes the use of disparaging and derogatory language. However, the failure to report and address the incident as abuse indicates a lapse in following the established policy.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not reporting a verbal abuse allegation involving a resident with severe cognitive impairment. The incident occurred when a CNA verbally abused the resident during a dining room altercation, using explicit language. Despite multiple staff members witnessing and discussing the incident, the verbal abuse was not reported to the state agency as required. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed, but the incident was not escalated appropriately, leading to a failure in reporting. The resident involved, who has vascular dementia, was unable to clearly recall the incident. Staff members, including RNs and LPNs, provided accounts of the event, indicating that the CNA used inappropriate language towards the resident. The DON sent the CNA home for being disruptive but did not classify the incident as abuse, resulting in a lack of formal reporting. The facility's abuse prevention policy allows employees to report directly to the state agency, but this was not utilized in this case, leading to a deficiency in the facility's handling of the situation.
Improper Handling of Resident's Personal Gift Check
Penalty
Summary
The facility failed to honor a resident's right to manage her financial affairs by improperly handling a personal gift check. The resident, who is alert and oriented, was expecting a $500 gift check from the Policemen's Annuity and Benefit Fund of Chicago, which she usually receives every Christmas. However, the check was not delivered to her, and after multiple follow-ups, it was discovered that the check had been deposited into the facility's account without her consent. The former Business Office Manager admitted that the check was deposited into the resident's trust fund account, which is used for care costs, rather than being given to the resident. The resident's daughter, who is also her Power of Attorney for medical decisions, confirmed that the facility was only entitled to deposit the resident's social security and pension checks for room and board, not personal checks like the one from the PABF. The facility eventually issued a replacement check to the resident after her inquiries. The facility's admission contract with the resident allowed for business mail to be directed to the business office, but personal mail was to be delivered to the resident. The contract did not authorize the facility to handle personal checks or other financial resources beyond the social security and pension checks. Despite this, the facility deposited the PABF check into the resident's transferring account, which was intended for care costs, without the resident's permission.
Unsanitary Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, affecting the storage, preparation, and serving of food. During an inspection, it was observed that the 3-compartment sink used for washing, rinsing, and sanitizing dishes was improperly used, with dirty dishes found in the sanitizing sink. A dietary aide, V6, was unsure of how to properly test the sanitizer's strength and used incorrect test strips initially. Both V6 and another dietary aide, V7, were noted to have long artificial nails, which is against the facility's policy for handling food. Additionally, the high-temperature dish machine area was found to have grayish patches and food debris, and washed bowls were not stored properly, with some still containing food debris. The walk-in cooler and freezer were also found to be in unsanitary conditions. The cooler had open bowls of pudding, and the freezer had extensive ice buildup and debris, with food products improperly stored on the floor and covered in ice. Some of the frozen meat products were freezer burnt, and the administrator, V1, acknowledged the issue but stated that repairs were scheduled. A resident's power of attorney reported that residents were served inedible, freezer-burnt food, which was confirmed by the dietary director, V4, who admitted to using the compromised food items before discarding them. Further observations revealed that staff members, including V4, V5, and V10, did not adhere to proper hygiene practices, such as using hair restraints effectively. V4 was seen using a contaminated spatula during meal preparation, and both V5 and V10 had long dreadlocks that were not fully covered. The facility's policies on food storage, dishwashing, and personnel sanitation were not followed, contributing to the unsanitary conditions and potential food safety risks for the residents.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for residents who were identified as needing help with activities of daily living (ADLs). This deficiency was observed in four residents, each with varying degrees of cognitive impairment and physical limitations. The residents were found with unclean fingernails, food debris on clothing, and unshaven facial hair, indicating a lack of proper grooming and hygiene care by the staff. One resident with severe cognitive impairment and dementia was observed with black substances under her fingernails and food debris on her clothing. Despite being totally dependent on staff for ADLs, the resident's care plan was not adequately followed, resulting in poor personal hygiene. Another resident with chronic kidney disease and diabetes also exhibited long, jagged fingernails with black substances and food debris on her clothing, despite requiring maximum assistance for personal hygiene and dressing. Additional observations included a resident with cerebrovascular disease and dementia who had long facial hair and unclean fingernails, and another resident with Parkinson's disease and hemiplegia who expressed a desire for assistance with shaving and nail care. The facility's Director of Nursing acknowledged the expectation for staff to assist residents with ADLs to maintain dignity, comfort, and hygiene, yet these expectations were not met, leading to the identified deficiencies.
Failure to Follow Approved Recipe for Chef Salad
Penalty
Summary
The facility failed to ensure that the dietary staff followed the approved recipe for chef salad, affecting eight residents. The Spring/Summer 2024 menu specified a chef salad with turkey, ham, cheese, and other ingredients, but residents reported receiving only lettuce with minimal or no additional components like meat or cheese. This discrepancy was noted by several residents who expressed dissatisfaction with the meal, stating that it left them hungry and was not what they expected based on the menu. Interviews with residents revealed that they received a bowl of lettuce with little to no meat, cheese, or other expected ingredients. Some residents mentioned receiving a grilled cheese sandwich as an addition, but this was not part of the chef salad meal. The residents expressed their displeasure, with some filing grievances about the inadequate meal portions. A resident's family member even took pictures of the meal and considered escalating the issue to the media. The facility's staff, including the Administrator and Dietary Director, acknowledged the residents' complaints. The Dietary Director noted that the chef salad should have included turkey as the protein, and the Cook claimed to have followed the recipe, which included turkey, ham, cheese, and other ingredients. However, a CNA observed that the salad had less chicken and lacked other components like egg or cheese, leading to resident dissatisfaction.
Infection Control Deficiencies in Hand Hygiene and Gloving Practices
Penalty
Summary
The facility failed to adhere to standard infection control practices during the provision of incontinence care and medication administration, as observed in multiple instances involving certified nursing assistants (CNAs) and a nurse. In one instance, two CNAs provided peri-care to a resident without changing gloves or performing hand hygiene between tasks, such as cleaning the perineum, handling an indwelling urinary catheter bag, and straightening bed linens. Another CNA assisted a resident with toileting and incontinence care, but did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before assisting the resident back to the wheelchair. Similarly, two CNAs provided incontinence care to another resident, failing to change gloves or perform hand hygiene between cleaning the perineum, changing bed linens, and handling a catheter bag. Additionally, a nurse administered medications via a gastrostomy tube to a resident without changing gloves or performing hand hygiene between tasks such as touching the bedside floor mattress, drawing the privacy curtain, and checking the placement of the g-tube. The facility's Director of Nursing confirmed that staff should perform hand hygiene before donning gloves, after contact with residents, and between different tasks to prevent infection. The facility's handwashing policy emphasizes the use of alcohol-based hand rubs when hands are not visibly soiled, particularly before and after putting on or removing personal protective equipment, and after contact with potentially contaminated objects.
Improper Catheter Care and Handling
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. One resident, who had multiple medical diagnoses including Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, was observed with an indwelling urinary catheter. During peri-care, the Certified Nursing Assistants (CNAs) did not clean the catheter tube, and the urinary bag was lifted above the bladder, causing urine to flow back towards the bladder. This improper handling of the catheter and urinary bag was observed during the care process. Another resident, also diagnosed with BPH and a urinary tract infection, was observed with a suprapubic urinary catheter. During incontinence care, the CNAs failed to clean the catheter and lifted the urinary bag above the bladder, resulting in urine flowing back into the bladder. The Director of Nursing confirmed that the facility's policy requires the catheter tube to be cleaned near the insertion site and the urinary bag to be kept below the bladder to prevent backflow and potential infections.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to check the placement of a gastrostomy tube (g-tube) before administering medication to a resident. On August 7, 2024, a nurse administered Hydrocodone-Acetaminophen to a resident via g-tube without verifying the tube's placement, as required by the resident's care plan and medication administration record. The nurse flushed the g-tube with water before and after administering the medication but admitted to forgetting to check the tube's placement. The Assistant Director of Nursing confirmed that staff should check g-tube placement by aspiration of residual or auscultation with a stethoscope to ensure proper medication administration.
Failure to Manage Resident's Pain During Care
Penalty
Summary
The facility failed to recognize, evaluate, and manage a resident's pain during care. The resident, who had multiple diagnoses including senile degeneration of the brain and dementia, was severely impaired with cognition and required total assistance with activities of daily living. On a specific day, the resident was heard moaning from outside her room, and upon entering, it was observed that she was in bed, confused, and unable to verbalize pain. Two CNAs had just finished providing morning care and were unaware if the resident had received any pain medication prior to care. Despite the resident's increased moaning and apparent pain when her hand was touched to apply hand splints, the CNA continued with the application without informing the nurse. A registered nurse later assessed the resident and administered Morphine Sulfate for pain, documenting a pain level of 10. The resident's care plan indicated she was at risk for pain and included interventions such as monitoring non-verbal signs of pain and administering medications. However, there was no evidence that any pain medication was administered before the Morphine Sulfate. The Director of Nursing and a Nurse Practitioner both stated that the CNA should have stopped the application of the hand splints and informed the nurse to assess the resident for pain and administer appropriate medication before continuing with care. The facility's pain management policy emphasized the importance of assessing and managing pain, especially when residents are unable to describe it verbally.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to provide residents with both oral and written information regarding their resident rights. This deficiency was identified during interviews and record reviews, affecting 7 out of 10 residents reviewed in a sample of 25. The residents, who were mostly cognitively intact, reported during a Resident Council meeting that they were unaware of their rights and did not know where to find a list of them. An Ombudsman pointed out that the rights were supposed to be displayed on a wall in the dining room, but the frame was empty. Additionally, the Activity Director confirmed that resident rights had not been discussed during council meetings. The facility's Administrator stated that resident rights are included in the admission packet and posted in common areas such as dining rooms and hallways. However, during an inspection, the rights were not visible in the first-floor dining room or near the elevators. A review of the Resident Council meeting minutes from September 2023 to July 2024 showed no documentation that resident rights were discussed, indicating a lack of communication and reinforcement of these rights to the residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. The first resident, a cognitively intact individual with a history of pressure ulcers and incontinence, reported having a bowel movement at 10:00 a.m. but did not receive assistance until much later, despite using the call bell and expressing distress. The resident was left in soiled briefs for an extended period, which was confirmed by the presence of dry feces on the inner thighs when care was finally provided. The staff, including a Registered Nurse and Certified Nursing Assistants, failed to respond promptly to the resident's needs, and there was a lack of communication and coordination among the staff to address the resident's incontinence care in a timely manner. The second resident, also cognitively intact and with limited functional abilities, experienced a delay in receiving incontinence care. The resident was left wet for at least two hours before staff changed her briefs, despite being on diuretic medications and having a care plan that required frequent checks and care to prevent skin breakdown. The facility's policy required residents to be checked every two hours, but this was not adhered to, as evidenced by the resident's report and the staff's acknowledgment of the care schedule. Additionally, the facility had a history of grievances and resident council meeting notes indicating ongoing issues with delayed response to call lights and care needs, further highlighting the deficiency in providing timely incontinence care.
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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.
Illustrative
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Nursing homes near Willowbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eden Vista Burr Ridge | 0.4 mi | ★★★★★ | 7 | 0 |
| Bria Of Westmont | 2.1 mi | ★★★★★ | 14 | 0 |
| Briar Place Nursing | 2.3 mi | ★★★★★ | 25 | 0 |
| Burgess Square Healthcare Ctr | 2.5 mi | ★★★★★ | 10 | 0 |
| Oak Trace | 3 mi | ★★★★★ | 6 | 0 |
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