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 Complete Care At The Boulevard during CMS and state inspections, most recent first.
A resident was given another resident’s Suboxone film after an RN entered a shared room and identified the wrong resident by calling out the bed number. The resident later reported feeling high, and the chart documented altered mental status and accidental ingestion of an unknown medication; he was observed weak, leaning over a bedside table, and unable to sit upright or eat independently before being sent to the ED for evaluation.
Failure to Complete and Document Ordered Wound Care: A cognitively intact resident with a right medial leg surgical wound repeatedly asked staff to change the dressing, but the dressing was not changed as ordered and was not documented on multiple days. The wound doctor’s treatment recommendations included specific cleansing and dressing orders, and later daily wound care plus doxycycline, but the wound care nurse said one order was omitted and another was not entered into the EHR. The resident reported changing the dirty, bloody dressing himself using supplies kept in his room, while the TAR showed multiple missed wound treatments and the progress note stated the resident was independently changing the dressing and the wound was not healing appropriately.
A resident with high fall risk, hemiplegia, contracture, and syncope/collapse was documented to require a mechanical lift with 2 staff for transfers, yet a CNA attempted a shower transfer and the resident fell, sustaining a skin tear and hospital evaluation. The record showed no fall risk assessments completed for months, and staff stated the resident’s post-fall risk assessment was missed and the transfer documentation reflected inconsistent levels of assistance.
The facility failed to ensure sufficient qualified dietary staff to prepare meals, as multiple dietary aides without cook certification were observed and reported to be cooking and baking for residents. Staff described being assigned to bake desserts and cook breakfast and lunch despite only holding food handler certificates, and one aide reported feeling scared to use the large oven. The Dietary Manager acknowledged that only she and one aide were qualified cooks, yet the schedule listed several food handlers as cooks, and these staff were actively preparing food and operating the tray line for residents receiving meals.
Surveyors found that dietary staff failed to follow hand hygiene protocols while working in the dish room. A dietary aide repeatedly handled soiled dish racks, pushed them into the dishwasher, and then removed clean trays and domes, changing gloves but not washing hands between dirty and clean tasks, despite a handwashing station being available. Another dietary aide reported that dishwashing was often done with fewer staff than intended, and the dietary manager confirmed that facility procedures and policies required handwashing between handling dirty and clean items. This failure had the potential to affect over one hundred residents who received meals from the kitchen.
A resident with multiple comorbidities and intact cognition, who had a care plan addressing a history or risk of abuse, reported that a former dietary manager aggressively approached and verbally confronted them in the dining room after misinterpreting a remark made during a conversation with a CNA. The resident stated they reported the incident to the administrator, completed a written report and statement, and that the event was witnessed by others and captured on camera; a former dietary aide confirmed that the confrontation occurred in front of others and was reported to administration. The administrator acknowledged that the event was initially treated only as a customer service issue, without initiating an abuse investigation or timely reporting as required by the facility’s abuse policy, and the facility could not produce an abuse investigation report when requested by surveyors, only later deciding to treat the incident as reportable abuse after further questioning.
A resident with multiple comorbidities and high risk for skin breakdown developed a severe, unstageable sacral pressure ulcer after staff failed to consistently implement and update individualized care interventions, including regular turning and repositioning. Despite clear physician orders and facility policies, the care plan was not revised after the wound developed, and the resident was left in a chair for extended periods without repositioning, leading to wound deterioration, infection, and hospitalization.
A resident with moderate cognitive impairment and high fall risk was allowed to use a wheelchair with a broken brake for at least two days. Staff were either unaware of the issue or did not act promptly to repair or remove the unsafe equipment, and required notifications to social services were not made when the resident refused to relinquish the chair. Facility policy requiring immediate removal and repair of malfunctioning equipment was not followed.
A resident with severe cognitive impairment and significant care needs experienced a fall resulting in a contusion and bruising around the right eye. The facility staff failed to notify the physician or follow protocol, delaying the resident's transfer to the hospital for necessary evaluation. Multiple staff members were involved in the incident and were terminated for not adhering to the facility's policies.
The facility failed to maintain adequate nursing staff, resulting in delayed call light responses. Residents reported insufficient CNA coverage during 2nd and 3rd shifts, with staffing data confirming low weekend staffing. The staffing coordinator acknowledged the shortfall, and records showed fewer CNAs than required, placing 104 residents at risk of inadequate care.
The facility failed to follow its food safety and sanitation protocols, affecting 101 residents on an oral diet. The dishwasher did not reach required temperatures for proper sanitization, and expired chlorine test strips were used in the three-compartment sink. Additionally, staff did not fully cover their hair, and open food items were not properly labeled, increasing the risk of contamination and foodborne illnesses.
The facility failed to ensure that the designated Infection Preventionist (IP), an LPN, completed the required specialized training for infection prevention and control in nursing homes. The IP, responsible for managing various infection control activities, had not completed the necessary training modules and test to demonstrate competency until after the survey began. This deficiency potentially affects the 104 residents in the facility.
The facility failed to complete required PASRR screenings for several residents before admission, impacting their placement and care. Residents with serious mental health conditions were admitted without necessary evaluations, contrary to facility policy. This deficiency highlights a lapse in the admission process, affecting the residents' access to appropriate care.
The facility failed to administer medications timely and maintain accurate narcotic counts for four residents. Discrepancies in medication counts were observed, and medications were not administered as scheduled due to unavailability. Nurses failed to document administration accurately and did not notify physicians of missed doses, violating facility policy.
The facility failed to manage medications and enteral feedings properly, with expired medications found in medication carts and storage rooms, and some medications lacking proper pharmacy labels. Expired enteral feeding containers were also found with visible spoilage. These deficiencies could affect 68 residents, including those with gastrostomy tubes.
The facility failed to properly document and administer influenza and COVID-19 vaccinations for several residents. Some residents were not offered or documented for influenza vaccinations, and others did not receive necessary education. One resident's consent form lacked a witness signature, and another resident did not receive the vaccines despite consenting, due to insurance issues and lack of follow-up. The IP nurse admitted to inconsistent documentation, contrary to facility policy.
A facility failed to maintain resident dignity and confidentiality for three residents. A CNA fed a resident while standing, against recommended practices, risking aspiration and compromising dignity. Additionally, dietary information for two residents was visibly posted, violating confidentiality. The residents had specific medical and dietary needs, and the facility's actions compromised their rights.
A resident was observed self-administering Fluticasone Propionate without a physician order or assessment, as required by facility policy. An LPN allowed the self-administration because the resident did not trust staff to administer it correctly. The facility's policy mandates assessment and a physician order for self-administration, which was not followed.
The facility failed to display information about the [NAME] program, affecting 12 residents' ability to make informed decisions about community transition. The Social Service Director confirmed the absence of educational materials and posters, which were not provided until after a surveyor's visit.
A resident at the facility was found wearing a hospital wristband displaying personal information, which should have been removed upon admission to protect privacy. The wristband, visible to others, contained the resident's full name, date of birth, and medical record number, violating HIPAA regulations. Staff acknowledged the oversight and confirmed that such wristbands should not be worn in the facility.
A resident with a history of paraplegia and polyneuropathy did not receive consistent restorative therapy, including leg exercises and splint application, as required by their care plan. The resident reported that these interventions were not regularly provided, and documentation was missing for several days. The Restorative Aide confirmed that CNAs should provide therapy on weekends, but there was a lack of documentation. This failure placed the resident at risk of not maintaining their highest practical level of function.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. Two residents did not receive their scheduled medications due to an LPN's failure to check available resources and notify physicians of the missed doses. The facility's policy on medication administration and physician notification was not followed.
A resident reported not consistently receiving nighttime snacks, as required by the facility's policy. The Dietary Manager confirmed that snacks are distributed to CNAs for residents, but acknowledged reports of missed distributions. The DON was aware of the issue but did not provide staff training. The resident, who is cognitively intact, was not offered snacks on several occasions, despite the facility's policy.
A facility failed to accurately classify a resident's psychotropic medication on the consent form, potentially affecting the resident's understanding of the medication's side effects. The resident, with severe cognitive impairment and a history of mental health disorders, had their medication Remeron misclassified as an antipsychotic instead of an antidepressant on a previous form. This error led to consent being given under the wrong classification, which could result in misunderstanding the side effects associated with the medication.
A resident in an LTC facility experienced two incidents of verbal abuse by CNAs, both of which were substantiated by facility investigations. The resident, who requires maximum assistance and uses a wheelchair, reported being cursed at by one CNA and receiving derogatory remarks about her hygiene from another. Witnesses corroborated the resident's accounts, leading to the termination of both CNAs. The facility's policy prohibits such abuse, but these incidents demonstrated a failure to protect the resident.
A cognitively impaired resident was tied to their bed with pillowcases by an RN due to staffing shortages, leading to physical and mental anguish. The incident was witnessed by a CNA who reported it as abuse, although the facility's administrator initially disagreed. The facility's policy defines such actions as abuse, but the incident was not immediately reported to the Illinois Department of Public Health.
A resident in an LTC facility was improperly restrained by a nurse using a pillowcase, without a physician's order or consent, due to staffing shortages. The resident, who had multiple medical conditions and a history of falls, was tied to the bed to prevent falling, which was against the facility's restraint-free policy. The incident was reported by another staff member and identified as an immediate jeopardy situation.
A resident's inhaler was left unattended and not properly labeled, with no physician order for self-administration. Additionally, a treatment cart was found unlocked and unattended, contrary to facility policy. The DON confirmed these actions posed safety issues.
A staffing shortage in an LTC facility led to a resident being improperly restrained by a nurse using a pillowcase to prevent falls. The facility was short one CNA on a weekend shift, leaving only two CNAs to care for 41 residents on the second floor. The nurse, overwhelmed with duties, resorted to tying the resident's hands to the bed rail, acknowledging the action was wrong but felt necessary due to insufficient staffing.
A facility failed to immediately report an alleged abuse incident where a resident was tied to the bedside rails with a pillowcase by a nurse. The incident was reported internally, but not to the Illinois Department of Public Health (IDPH) as required by the facility's policy. The initial report to IDPH was made 32 days after the incident, violating the policy that mandates immediate reporting or within 24 hours if no serious injury occurred.
The facility failed to conduct timely PASRR Level I and II assessments for five residents with serious mental disorders, due to a transition period in the social services department and lack of communication with the screening agency. This oversight left residents without necessary specialized programs and treatment goals.
Two residents in the facility did not receive proper wound care, leading to significant health issues. One resident was hospitalized due to a surgical wound dehiscence, while another did not have daily wound dressings changed as ordered. Staff interviews revealed a lack of documentation and awareness of wound care needs, and facility policies were not adhered to.
Two residents experienced abuse in a facility, one physically and the other verbally. A resident with Alzheimer's was slapped by a CNA during care, confirmed by witnesses. Another resident with COPD was verbally abused by a CNA using profanity, recorded on social media. Both CNAs were terminated for their actions, which violated the facility's Abuse Prevention Program.
Incorrect Medication Given to Resident in Shared Room
Penalty
Summary
The facility failed to ensure that a resident received the correct prescribed medication. R1, who had diagnoses including spinal stenosis, spondylosis with myelopathy, hypertension, and adult failure to thrive, had a BIMS score of 13 indicating intact cognition. The record did not show an order for Suboxone for R1, and the order summary for R3 documented Suboxone Sublingual Film 8-2 mg for opioid dependence. On 4/08/2026, V6, RN, documented that while entering the shared room to administer R3’s medication, she called out for the resident in R3’s bed, but R1 answered and she gave the medication to R1. R1 later stated that a nurse gave him a square film under his tongue that made him feel high, and his daughter had to make staff send him to the hospital. The hospital record documented altered mental status and ingestion of unknown medication, accidental or unintentional. R1 was observed leaning over a bedside table, weak, unable to maintain an upright sitting position or eat independently, with decreased strength and limited ability to respond appropriately. V13, LPN, notified the NP and R1 was sent to the local emergency department for further evaluation and treatment. R3 stated that he told V6 the medication was his, but she had already given the Suboxone film to R1.
Failure to Complete and Document Ordered Wound Care
Penalty
Summary
The facility failed to prevent neglect for a resident with a right medial leg surgical wound when ordered wound care was not completed and not documented. The resident had multiple diagnoses including cerebrum hemorrhage, atherosclerotic heart disease, colostomy, hypertension, COPD, cocaine abuse, acute kidney failure, and depression, and was cognitively intact with a BIMS score of 14. The admission assessment documented a surgical scar post CABG and a right lower extremity dressing, and the resident stated that he repeatedly asked nurses to change his leg wound dressing but they would not do it, so he changed it himself using supplies from the hospital. He also reported that the dressing would be dirty and bloody and that he had taken pictures of it. The wound care records showed physician treatment recommendations for the right medial leg surgical incision. On 3/5/26, the wound doctor documented a surgical wound with low sanguinous drainage and ordered cleansing with normal saline, Betadine, and bordered gauze every other day, with treatment to be done by the wound care team and other care by facility staff. On 3/26/26, the wound doctor documented the wound as worsening with moderate sanguinous drainage and malodor, and ordered cleansing with Dakin's solution, honey gel, silver alginate, and daily dressing changes, along with CBC and doxycycline 100 mg by mouth twice daily for 7 days. The wound care nurse stated that the doctor’s treatment recommendations were the orders and that she normally entered them into the computer, but she said the March order was omitted and she did not enter the March 26 recommendation into the EHR. The TAR showed no documented wound treatments for the resident’s right medial leg surgical incision on multiple days in March and April 2026. The resident’s progress note on 4/2/26 stated that he had been independently changing his own dressing using supplies kept in his room, and that wound healing was not progressing appropriately. Staff interviews confirmed that nurses were supposed to change the dressing when the wound nurse was not working and document the treatment when completed, and the DON stated that nurses were expected to carry out physician orders and verify that orders were entered into the EHR. The facility policy stated that wound treatments are to be provided according to physician orders and that if treatment orders are absent, the licensed nurse is to notify the physician to obtain orders.
Failure to Assess Fall Risk and Provide Required Transfer Assistance
Penalty
Summary
The facility failed to follow its fall risk policies and failed to provide supervision and assistive devices consistent with one resident’s needs. R6 was identified in the record as high risk for falls, with diagnoses including syncope and collapse, restlessness and agitation, hemiplegia and hemiparesis following cerebrovascular disease, and contracture. The care plan documented that R6 required a mechanical lift with two staff assistance for transfers, and the facility’s policy required residents to be assessed for fall risk on admission, quarterly, or with significant change, with care and services provided according to individualized risk. R6 stated that a CNA took her in a wheelchair to the shower room and, while assisting her to the shower chair, her foot got tangled and she fell. R6 reported that she was sent to the hospital for evaluation and denied major injuries or fractures. V12 stated that R6 requires two-person assistance for transfers from bed to wheelchair or to the shower chair and identified R6 as a fall risk. V15 stated that on the day of the fall, V16 was transferring R6 from the wheelchair to the shower chair when the fall occurred, and that R6 sustained a skin tear on her right hand that was cleaned and dressed. Record review showed that R6 had no fall risk assessments completed since 08/20/2025, despite the resident being high risk for falling. V17 stated that R6’s post-fall risk assessment was missed and that the resident’s plan of care should be current and accurate, noting that the shower transfer documentation reflected dependent and maximum assistance and that the CNAs should not have documented dependent because R6 was maximum assistance. The facility document also stated that when a resident falls, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, and review and update the care plan as indicated.
Unqualified Dietary Staff Used as Cooks and Bakers
Penalty
Summary
The facility failed to ensure there were sufficient qualified dietary staff available to cook meals for 127 residents who received meals from the kitchen. During interviews, multiple dietary aides reported that they were functioning as cooks or being required to perform cooking and baking tasks despite lacking cook certification. One former dietary aide stated that several individuals working as cooks did not have certification and that she was pressured to bake despite being a dietary aide and feeling scared to use the large, hot oven. During a kitchen tour, three dietary aides were observed performing meal preparation and tray line duties, including one aide who was cooking and plating breakfast while the others assembled and transported trays. The Dietary Manager reported that only she and one dietary aide were considered qualified cooks and that the remaining staff were food handlers, who she acknowledged were not supposed to prepare food because they had not taken the required classes. Despite this, the schedule listed several dietary aides as cooks, and staff interviews confirmed that food handlers were cooking breakfast and lunch and baking desserts. Documentation showed that most of these staff held only food handler certificates rather than cook certification, while the facility’s job description and safe food handling policy required appropriate procedures for preparing and cooking food in accordance with the FDA Food Code. The census showed 131 residents, with 127 receiving meals from the kitchen affected by these staffing and qualification issues.
Failure to Perform Hand Hygiene Between Handling Soiled and Clean Dishes in Dish Room
Penalty
Summary
Surveyors identified a deficiency in kitchen infection control practices when a dietary aide working in the dish room failed to perform required hand hygiene between handling soiled and clean dishes. One dietary aide was observed scraping and dumping trays, placing utensils, plates, and cups into sanitizer, and explained that with two people present, one would run dishes through the dishwasher while the second person would handle the clean dishes. A second dietary aide then entered the dish room and was observed repeatedly pushing racks of dirty dishes into the dishwasher and then removing clean trays and dishes without changing gloves or performing hand hygiene, despite a handwashing station being present in the dish room. The same dietary aide continued to alternate between handling dirty dish racks and removing clean domes, trays, and dishes from the dishwasher, changing gloves multiple times but never washing hands between tasks. Another dietary aide reported by telephone that dishwashing was supposed to be done by three staff, but they often only had two, and described scraping, loading the dishwasher, and pulling carts with an emphasis on changing gloves as much as possible. The dietary manager stated that the facility’s process required two people in the dish room, with one scraping and setting up dishes and the other pushing dishes through the dishwasher and pulling them out, and confirmed that hand hygiene should be performed after pushing dishes through, followed by glove changes before handling clean dishes to prevent cross contamination. Facility policies and training documents on cleaning, sanitizing, ware washing, and handwashing required staff to wash hands prior to donning gloves and between glove changes, including after touching waste or contaminated surfaces and after leaving the dish area. This failure had the potential to affect 127 residents who received meals from the kitchen, out of a census of 131 residents, with four residents NPO.
Failure to Immediately Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy by not immediately investigating and reporting an allegation of verbal abuse involving one cognitively intact resident. The resident, who had multiple medical diagnoses including Type 2 diabetes mellitus with complications, end stage renal disease, peripheral vascular disease, gangrene, acquired absence of foot, hypertension, dependence on renal dialysis, cataracts, obesity, and primary insomnia, had a BIMS score of 15 indicating intact cognition and had a care plan focus for history of abuse or factors increasing susceptibility to abuse. The care plan interventions included reviewing assessment information and emphasizing treatment of causal factors and mental health issues. Despite this, when the resident reported an incident in which a staff member allegedly verbally abused and threatened them, the facility did not treat it as an abuse allegation at the time. The resident reported that one morning in January, during breakfast in the first-floor dining room before going to dialysis, the former dietary manager approached them from behind, got in their face, and accused them of calling her a derogatory name after overhearing the resident’s conversation with a CNA about something seen on television. The resident stated they clarified they were not speaking to the dietary manager, reported the incident to the administrator, wrote a report, and provided a written statement. The resident also stated their family called the state and that the incident was captured on camera. A former dietary aide corroborated that everyone in the dining room witnessed the incident, that the dietary manager approached the resident and backed the resident up while accusing the resident of calling her a derogatory name, and that it was reported to administration and the resident’s family reported it. Another dietary aide stated the former dietary manager had multiple run-ins with the resident and that these were reported to administration. When interviewed, the administrator stated that when the interaction between the resident and the former dietary manager was initially reported, it was handled as a customer service concern rather than an abuse allegation. The administrator described the interaction as a verbal misunderstanding and reported providing verbal counseling to the staff member, but did not provide documentation of an abuse investigation or names of individuals interviewed at that time. The surveyor requested the abuse reportable/investigation multiple times and the facility was unable to produce it, with the assistant DON/HR stating they were trying to get a key to retrieve the reportable while the administrator was unavailable. Only after the surveyor’s request and a subsequent re-interview of the resident did the facility decide to treat the incident as reportable abuse and initiate an abuse investigation, contrary to the facility’s written policy requiring an immediate investigation and timely reporting of all alleged violations of abuse.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to develop and update an individualized care plan and did not ensure that a resident at high risk for skin breakdown received appropriate treatment and services to prevent the development and worsening of a pressure ulcer. The resident, who had multiple medical diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, cognitive communication deficit, depression, and hypertension, was admitted with intact skin but was identified as high risk for skin breakdown based on a Braden scale score of 12. Despite this, the care plan was not updated with new interventions after a skin impairment was reported, and preventive measures such as turning and repositioning every two hours were not consistently implemented, especially when the resident was in a wheelchair. Staff interviews and record reviews revealed that the resident was dependent on staff for repositioning and hygiene, requiring two staff members for transfers and repositioning. Multiple staff members, including CNAs and LPNs, acknowledged that the resident was not always repositioned every two hours while in the chair, sometimes remaining seated for more than four hours. There was no documentation of the resident refusing care, and social services were not notified of any refusals. The wound care nurse and other staff were aware of the resident's high risk and the need for frequent repositioning, but the interventions remained unchanged even after the development of a new wound. The wound was noted to have an odor for about a week before the resident was sent to the hospital, and the care plan was not individualized or updated to address the new wound. The resident's condition deteriorated, with the sacral wound progressing from a small opening to an unstageable pressure ulcer with necrotic tissue, ultimately requiring hospitalization for sepsis and necrotizing fasciitis. Hospital records documented a stage 4 sacral decubitus ulcer with extensive tissue destruction and infection, necessitating surgical debridement. Facility policies required turning and repositioning as part of pressure injury prevention and evidence-based wound treatment, but these were not consistently followed or documented. The lack of timely and individualized interventions, failure to update the care plan, and inconsistent implementation of preventive measures directly contributed to the resident's development and worsening of a severe pressure ulcer.
Failure to Remove Unsafe Wheelchair with Broken Brake
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including moderate cognitive impairment and a high risk for falls, was observed using a wheelchair with a broken right brake. The resident, who is dependent for transfers and uses the wheelchair as a primary mode of locomotion, reported the broken brake to the surveyor. Staff, including a CNA and the Maintenance Director, were either unaware of the issue or had not addressed it despite being informed. The Maintenance Director acknowledged being aware of the broken brake but had not inspected or repaired it, citing competing priorities. The Maintenance Assistant also did not check the maintenance log, and the Restorative Director attempted to remove the unsafe wheelchair but did not notify social services when the resident refused. Facility policy requires that malfunctioning equipment be immediately removed from use and reported for repair, and that social services be notified in cases of resident refusal. Despite these policies, the resident continued to use the unsafe wheelchair for at least two days, and the broken brake was not repaired or removed from service. Multiple staff members confirmed the wheelchair was unsafe and could lead to incidents, but the necessary steps to ensure resident safety were not taken in a timely manner.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, resulting in a delay in transferring the resident to the hospital for further evaluation. The resident, who has severe cognitive impairment and requires significant assistance with activities of daily living, was found with a contusion and bruising around the right eye after a fall. Despite the visible injuries, the responsible staff did not report the incident or the change in condition to the physician or the Director of Nursing, as required by the facility's policies. The incident involved multiple staff members who failed to follow protocol. A Licensed Practical Nurse (LPN) observed the resident with bruising but did not notify the physician or the Director of Nursing. Additionally, two Certified Nursing Assistants (CNAs) were involved in the incident but did not report the fall to the nurse on duty. This lack of communication and failure to adhere to the facility's policies on reporting falls and changes in condition contributed to the delay in the resident receiving necessary medical attention. The facility's policies clearly state that any change in a resident's condition should be immediately assessed and reported to the physician, with emergency medical care provided if necessary. The failure to follow these procedures resulted in a delay in care for the resident, who was eventually transferred to the hospital with a head contusion and edema. The staff members involved were terminated for gross misconduct and failure to adhere to the facility's policies and procedures.
Inadequate Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to ensure adequate nursing staff to respond to call lights in a timely manner, as evidenced by resident council meeting minutes and staffing data. Residents reported that during the 2nd and 3rd shifts, there were instances where only one or two CNAs were available, leading to delays in answering call lights. The facility's staffing data, submitted via the PBJ system, indicated excessively low weekend staffing, which triggered concerns. The facility's staffing coordinator, V26, confirmed that the facility aims to staff nine CNAs for the morning and evening shifts and eight for the night shift, but there were occasions when these numbers were not met. The facility assessment document from March 2024 indicated that the nursing services staffing should include 12 CNAs for the day shift, nine for the evening shift, and eight for the night shift. However, records from July 2024 showed that the facility was operating with fewer CNAs than required, with instances of only eight CNAs working the morning shift and as few as five CNAs on the night shift. Additionally, resident council minutes from July 2024 noted complaints about CNAs using cell phones during work hours and not responding to call lights promptly. This staffing inadequacy placed all 104 residents at risk of receiving inappropriate care and services to meet their physical, mental, and psychosocial needs.
Deficiencies in Food Safety and Sanitation Protocols
Penalty
Summary
The facility failed to adhere to its policies on sanitation and food safety, which has the potential to affect 101 residents on an oral diet. Observations revealed that the dishwasher temperatures were not reaching the recommended levels necessary for proper sanitization. The dishwasher's wash cycle was observed to be below the required 150 degrees F, and the sanitation cycle was not reaching the necessary 180 degrees F. Testing strips used to verify the sanitization process did not change color as expected, indicating that the dishes were not being properly sanitized. Additionally, the dishwasher had recently been serviced, but issues with the testing strips and clogged sprays were noted, which contributed to the problem. The facility also failed to properly sanitize dishes in the three-compartment sink. The sanitizing compartment contained cloudy water with whitish particles, and the chlorine concentration was not reaching the required 100 PPM. The chlorine test strips used were expired, and the Dietary Manager was unaware of the expiration date, which further compromised the sanitization process. This oversight could lead to cross-contamination and potential foodborne illnesses among residents. Furthermore, staff in the kitchen were not following proper hair restraint protocols. A Dietary Aide was observed wearing a hair net that did not fully cover her hair, which could lead to contamination of food. Additionally, an open bag of peas and carrots in the freezer was not labeled with an open date or use-by date, increasing the risk of using expired food. These lapses in following established food safety protocols highlight significant deficiencies in the facility's food service operations.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a Licensed Practical Nurse (LPN), completed the specialized training required for infection prevention and control in nursing homes. This deficiency was identified during a survey when the facility could not provide valid documentation or certification of the IP's completion of the necessary training program. The IP, who has been in the role since January 2024, is responsible for various infection control activities, including antibiotic surveillance, immunizations, and managing outbreaks of infections such as COVID-19, flu, and C. diff. Despite these responsibilities, the IP had not completed the required training modules and cumulative test to demonstrate competency in the role until after the survey began. The Director of Nursing (DON) emphasized the importance of having a certified IP to stay updated with CDC recommendations and to protect both staff and residents from infections. The facility's policy on the Infection Prevention Program states that the IP should serve as a resource for all staff and departments regarding infection prevention. However, the lack of completed training for the IP indicates a gap in ensuring that the individual in this critical role has the necessary knowledge and competence to effectively manage the infection prevention program, potentially affecting the 104 residents residing in the facility.
Failure to Complete PASRR Screenings Before Admission
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed for five residents prior to their admission. The Social Services Director, V16, acknowledged that PASRR screenings are crucial for determining the appropriate placement of residents and should be completed before admission. However, it was found that PASRR Level 1 screenings for residents R9, R16, and R37 were only submitted on February 4, 2025, after their admission. Additionally, R15 and R33 had inaccurate Level I PASRR screenings, and V16 admitted that new screenings were necessary to determine if Level II evaluations were required. Resident R9, diagnosed with schizophrenia, schizoaffective disorder, and major depression, and Resident R37, with severe cognitive impairment and multiple mental health diagnoses, both required Level II evaluations according to their PASRR Level 1 screenings. However, these evaluations were not conducted prior to their admission. Resident R16, diagnosed with major depression and psychosis, did not require a Level II evaluation according to the PASRR Level 1 screening. The facility's policy mandates compliance with state and appointed screening agencies, but this was not adhered to in these cases. Furthermore, Resident R54, with a history of schizoaffective disorder and major depressive disorder, was admitted without a completed PASRR Level 1 screening from the hospital. The Social Services Director, V17, stated that the admissions office should have ensured the completion of the PASRR Level 1 screening before admission. The lack of a PASRR Level II evaluation for R54 meant that the resident was not receiving the specialized treatment required for their mental health conditions. The facility's failure to conduct timely and accurate PASRR screenings for these residents highlights a significant deficiency in their admission process.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer prescribed medications in a timely manner and maintain accurate narcotic medication counts for four residents. During a controlled substance count, discrepancies were observed in the medication bingo cards for a resident, where the actual pill count did not match the documented count. The registered nurse admitted to administering the medications but failing to document the administration. Additionally, a resident's liquid medication count was also inaccurate, with one less bottle than recorded. Furthermore, medications were not administered as scheduled for two residents due to unavailability. A licensed practical nurse failed to administer a resident's Gemtesa medication on two consecutive days and did not notify the physician of the missed doses. Similarly, another resident's Mupirocin medication was not administered on two days, and the nurse erroneously documented its administration without notifying the physician. The facility's policy requires medications to be given within one hour of the specified time and narcotics to be recorded accurately, which was not adhered to in these instances.
Medication and Enteral Feeding Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications and enteral feedings, leading to several deficiencies. During a survey, expired medications were found in three of six medication carts, including an open bottle of Morphine Sulfate with an expiration date of 05/17/2024, and Bisacodyl Enteric Coated tablets with expiration dates of 12/2024 and 09/2023. Additionally, a vial of Lispro insulin was found without a proper pharmacy label, and a nasal medication, Fluticasone Propionate, was also missing a pharmacy label. These medications were not discarded as required by the facility's policy, which states that expired medications should not be administered and that medications must have proper labeling. Furthermore, expired enteral feeding containers labeled Nepro 1.8 CAL were found in a medication storage room, with visible milk curdles at the bottom, indicating spoilage. These containers had an expiration date of 11/2024 and were not removed from storage, posing a risk to residents who rely on enteral feedings. The facility's policy mandates that medications and feedings should be discarded after their expiration date and that any unmarked or improperly labeled medications should be returned to the pharmacy for proper labeling. These oversights have the potential to affect 68 residents in the facility, including those with gastrostomy tubes for enteral feedings.
Deficiency in Vaccination Documentation and Administration
Penalty
Summary
The facility failed to minimize the risk of acquiring, transmitting, or experiencing complications from influenza and COVID-19 for six residents. The deficiency was identified through interviews and record reviews, revealing that several residents were not properly offered or documented for influenza vaccinations. For instance, one resident was offered and refused the influenza vaccine in August 2024, but there was no documentation of subsequent offers or refusals for the current flu season. Additionally, three residents did not receive immunization education prior to vaccine administration or refusal, and another resident's consent form for the influenza vaccine lacked a witness signature. Furthermore, one resident consented to receive the influenza vaccine, but it had not been administered by the time of the report. The same resident also consented to the COVID-19 vaccine, which had not been given due to insurance issues and lack of follow-up with the pharmacy. The Infection Preventionist (IP) nurse, responsible for managing immunizations, admitted to not documenting offers and education consistently. The facility's policy requires offering influenza and pneumococcal vaccinations to all residents, with proper documentation of education and vaccination status, which was not adhered to in these cases.
Violation of Resident Dignity and Confidentiality
Penalty
Summary
The facility failed to maintain resident rights pertaining to dignity and confidentiality for three residents. One resident was not fed with dignity, as a Certified Nursing Assistant (CNA) fed the resident while standing, which is against the recommended practice of feeding at eye level to ensure the resident's ability to chew and swallow safely. The CNA continued to feed the resident without ensuring that the resident had finished chewing, which could potentially lead to aspiration. The Director of Nursing and the Director of Rehabilitation both confirmed that feeding should be done at eye level to prevent such issues and to maintain the resident's dignity. Additionally, the facility failed to protect the confidentiality of medical information for two residents. Signs indicating the residents' names and dietary information were visibly posted above their beds, which could be seen by visitors. This practice was confirmed by the Director of Rehabilitation, who acknowledged that the information on the swallow precaution signs is part of the residents' medical records and should be kept confidential. The visible posting of such information violates the residents' rights to confidentiality as outlined in the facility's Resident Rights policy. The residents involved had various medical conditions that required specific dietary needs and assistance. One resident had severe cognitive impairment and required one-on-one assistance during meals, while another resident was cognitively intact but had specific dietary instructions. The facility's failure to adhere to proper feeding practices and to protect the confidentiality of medical information compromised the dignity and rights of these residents.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess and monitor a resident for self-administration of medication, which was observed during a medication pass. A Licensed Practical Nurse (LPN) provided a nasal medication, Fluticasone Propionate 50mcg, to the resident, who then self-administered two sprays into both nostrils. The LPN stated that the resident was allowed to self-administer because she did not trust the facility staff to administer it correctly. However, a review of the resident's Physician Order Sheet, Medication Administration Record, and Electronic Health Record revealed that there was no physician order or assessment for the resident to self-administer her medication. The facility's policy on medication administration and storage requires that self-administration of medications by residents is only permitted when the resident has been assessed and deemed capable, and a physician order has been written for self-administration. This policy was not followed in the case of the resident, leading to the deficiency.
Failure to Display [NAME] Program Information
Penalty
Summary
The facility failed to display information about the [NAME] program in a public and accessible location, which is a requirement for informing residents of their rights regarding community transition. This deficiency was identified during a survey conducted on February 4, 2025, when it was observed that no posters or educational materials related to the [NAME] program were posted on any of the facility's floors, including the main dining room where residents frequently gather. The Social Service Director, identified as V16, was unaware of any postings and confirmed the absence of such materials after checking all floors. The deficiency affected 12 residents who were potential candidates for the [NAME] program, as they were not provided with the necessary information to make informed decisions about community transition. On February 5, 2025, V16 acknowledged that educational materials and information had not been distributed to residents until after the surveyor's visit. The lack of information potentially impacted the residents' ability to exercise their right to explore or decline community transition, as they were not informed of their rights or the contact information needed to participate in the program.
Failure to Remove Hospital Wristband Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal information, which is a violation of the Health Insurance Portability and Accountability Act (HIPAA). A resident, who was recently admitted to the facility, was observed wearing a hospital wristband that displayed his full name, date of birth, and medical record number. This wristband, which should have been removed upon admission, contained private information that was visible to other residents and visitors, thus compromising the resident's confidentiality. The resident, who has intact cognitive function as indicated by a BIMS score of 13/15, expressed a desire for his information to remain private. Despite this, the wristband remained on the resident until it was brought to the attention of the facility staff by a surveyor. The registered nurse acknowledged the oversight and identified it as a HIPAA violation. The unit manager and assistant director of nursing confirmed that hospital wristbands with identifying information should not be worn by residents in the facility, indicating a lapse in the facility's adherence to its policy on resident rights and confidentiality.
Inconsistent Restorative Therapy for Resident
Penalty
Summary
The facility failed to provide consistent restorative therapy to a resident, identified as R61, which compromised the resident's ability to maintain their highest practical level of function. R61, who is cognitively intact with a BIMS score of 15, has a medical history that includes rhabdomyolysis, paraplegia, and polyneuropathy. The resident reported that staff were supposed to assist with leg exercises and apply a splint, but these interventions were not consistently provided. During an observation, R61 mentioned that the splint was applied for the first time in a long period, coinciding with the presence of a state agency in the facility. The Restorative Aide, V12, confirmed that restorative aides document therapy in the resident's electronic medical record and that CNAs are responsible for providing therapy on weekends. However, there were multiple instances over the past 90 days where documentation of splint or brace assistance was missing. The Restorative Director, V24, acknowledged the importance of the restorative therapy program but was unsure why staff failed to document the interventions. The facility's failure to consistently provide and document restorative therapy placed residents at risk of receiving inappropriate care, potentially affecting their physical, mental, and psychosocial well-being.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate during the survey period. This deficiency was identified through the observation, interview, and record review of two residents. One resident, diagnosed with Type 2 Diabetes and other conditions, did not receive their scheduled dose of Metformin due to the medication not being available in the facility. The LPN responsible did not check the emergency automated medication dispenser (AMD), which had the medication in stock, nor did they notify the resident's physician about the missed dose. Another resident, with diagnoses including Multiple Sclerosis and hypertension, did not receive their scheduled Lidocaine patch. The LPN did not retrieve the patch from the central supply stock room, where it was available as house stock. The LPN admitted to being nervous and not thinking to check the available resources. Additionally, the LPN failed to inform the resident's physician about the missed medication. The facility's policy requires that physicians be notified when medications are not administered as per orders, which was not followed in these instances.
Inconsistent Nighttime Snack Distribution
Penalty
Summary
The facility failed to consistently offer and serve nighttime snacks to a resident, as per the facility's policy. During a resident council meeting, a resident expressed that they were not consistently receiving nighttime snacks. The Dietary Manager confirmed that snacks are supposed to be offered to all residents, and they are distributed to the floor CNAs to be given to residents. However, the Dietary Manager acknowledged that there are instances when residents report not receiving their snacks. The Director of Nursing was aware of the issue but did not conduct any in-services or training to address the concern. The resident involved is cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. The resident's medical history includes difficulty in walking, a non-pressure chronic ulcer, and low back pain. A review of the facility's records showed that the resident was not offered snacks on multiple occasions within a 30-day period. The facility's policy states that nourishments should be provided at bedtime and distributed by nursing staff, but this was not consistently followed.
Misclassification of Psychotropic Medication on Consent Form
Penalty
Summary
The facility failed to accurately classify a resident's psychotropic medication on the consent form, which could potentially affect the resident's understanding of the medication's side effects. The resident, who is severely cognitively impaired and unable to complete a mental status interview, has a medical history that includes dementia, anxiety disorder, major depression disorder, and psychotic disorder. The psychotropic medication form for this resident, dated 02/04/2025, incorrectly classified Remeron (Mirtazapine) as an antidepressant, whereas a previous form dated 03/03/2021 had incorrectly classified it as an antipsychotic. This misclassification led to consent being given under the wrong classification, which could result in misunderstanding the side effects associated with the medication. The Assistant Director of Nursing, who is responsible for updating psychotropic consents every 15 months, acknowledged the error in the classification of Remeron on the earlier form. According to the facility's policy, psychotropic medications should have appropriate indications for use and be monitored for side effects, with consents updated regularly. The FDA indicates that Remeron is used for treating major depressive disorder in adults, and the facility's consent form lists side effects for antidepressants that differ from those for antipsychotics. This discrepancy in classification and consent could lead to issues with informed consent regarding the medication's side effects.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal abuse, affecting one of the four residents reviewed for abuse. The resident, a female with epilepsy, anxiety disorder, and chronic embolism, is alert and oriented, requiring maximum assistance with activities of daily living and using a manual wheelchair. The resident reported two incidents of verbal abuse by CNAs. In the first incident, a CNA allegedly cursed at the resident after she requested assistance for another resident. Witnesses corroborated the resident's account, and the CNA was terminated. In the second incident, another CNA allegedly made derogatory remarks about the resident's hygiene, which the resident found offensive. Despite the CNA's denial, the investigation substantiated the claim, and the CNA was also terminated. The facility's abuse investigations confirmed both incidents of verbal abuse, with statements from the resident, other residents, and staff supporting the allegations. The facility's policy affirms residents' rights to be free from abuse, and the incidents were found to violate this policy. The administrator, who also serves as the Abuse Prevention Coordinator, conducted the investigations and confirmed the substantiation of the allegations. The facility's policy prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents, yet these incidents demonstrated a failure to uphold these standards, resulting in the termination of the involved CNAs.
Resident Tied to Bed with Pillowcases by Nurse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse and mental anguish by staff, as evidenced by an incident involving a cognitively impaired resident, R2. R2, who has a history of restlessness, agitation, and repeated falls, was found with their wrists tied to the bed side rails using pillowcases by a registered nurse, V6. This action was taken by V6 due to a staffing shortage and the nurse's inability to supervise R2, who was known for climbing out of bed and falling. V6 admitted to tying R2's wrists to prevent falls while they were busy with medication rounds, acknowledging that there was no physician order for such a restraint and that it constituted abuse. The incident was witnessed by a CNA, V21, who found R2 tearful and in discomfort, with gestures indicating pain. V21 reported the incident to another nurse and the Director of Nursing, expressing that tying a resident to the bedrail with a pillowcase was a form of abuse. The facility's administrator, V1, initially did not consider the action as abuse, attributing it to the nurse being busy and short-staffed. However, other staff members, including a nurse consultant and a restorative director, recognized the action as abuse, emphasizing the psychological and physical harm it could cause. The facility's policy on abuse prevention defines abuse as the willful infliction of injury, unreasonable confinement, or causing pain and mental anguish. Despite this, the facility initially failed to report the incident to the Illinois Department of Public Health as required. The incident was later identified as immediate jeopardy, highlighting the facility's failure to protect the resident from abuse and appropriately identify and report the incident.
Removal Plan
- R2 screened, reassessed for risk for abuse with care plan interventions.
- All staff in-serviced training completed by V1, V2 and V29.
- Documentation showed that all residents were re-educated on abuse.
- R2, R14, R15, R16, R17, R18, R19 and R20 were screened for potential abuse with care plan reviewed and initiated.
- All staff will be responsible for monitoring residents for behavior that can make them vulnerable for abuse.
- All residents determined to be vulnerable or those that will be affected by this deficiency citation R2, R14, R15, R16, R17, R18, R19 and R20 were identified, and plan of care initiated, with ongoing, on admission, quarterly and annually.
- Review Quality Assurance audit tool started weekly ongoing to ensure compliance.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary physical restraints, as evidenced by an incident involving a resident, R2, whose wrists were tied to the bed with a pillowcase by a registered nurse, V6, without a physician's order, consent, or medical justification. R2, who was admitted with multiple medical conditions including restlessness, agitation, and a history of falls, was restrained due to staffing shortages and the nurse's inability to supervise R2 adequately. The nurse admitted to tying R2's hands to prevent falls, acknowledging that it was wrong and not part of the facility's fall prevention interventions. R2's medical records did not document any medical symptoms or behaviors justifying the use of restraints, nor was there any physician order, restraint assessment, or consent obtained. The facility's policy requires that any use of restraints must be medically justified, ordered by a physician, and consented to by the resident or their representative. The incident was reported by another staff member who found R2 restrained and described the resident as experiencing psychosocial distress, including crying and agitation. Interviews with various staff members, including the Director of Nursing and the Restorative Director, confirmed that the facility is a restraint-free environment and that the use of a pillowcase as a restraint was inappropriate and considered abusive. The facility's policies on restraint use and fall prevention were not followed, and the incident was identified as an immediate jeopardy situation, highlighting a significant lapse in adherence to regulatory standards and resident care protocols.
Removal Plan
- All staff were trained on what constitute proper training, unnecessary use of restraint, with ongoing training scheduled Quarterly.
- All residents have been assessed to ensure that none are restrained improperly or unnecessarily.
- Assessment will be ongoing and conducted at admission, quarterly and annually.
- Outside consultant and V2 and V29 conducted in-service training on behavior management.
- Documentation showed all the facility residents were in-service on abuse and restraints.
- R2, R14, R15, R16, R17, R18, R19 and R20 were care planned/interventions with potential for abuse and proper restraints related to their diagnoses.
- A system put in place for audit to be done weekly to ensure compliance with unnecessary use of restraint to be monitored by V1, V2 and V29.
Medication and Treatment Cart Safety Lapses
Penalty
Summary
The facility failed to ensure that a treatment cart and resident medication were not left unattended, posing a potential accident hazard. An inhaler belonging to a resident was observed on an over-bed table, visible from the hallway, and not in its manufacturer's container or with a pharmacy label. The resident stated they used the inhaler to help with breathing, but there was no physician order for the resident to self-administer the medication. The nurse confirmed that the resident was not part of a self-administration program and had not received the inhaler as scheduled, despite the medication administration record indicating otherwise. Additionally, a treatment cart was found unlocked and unattended in the hallway, not within the visual proximity of the nurses. The nurse acknowledged forgetting to lock the cart, which is against the facility's policy that requires treatment carts to be locked when not in use or under direct supervision. The Director of Nursing confirmed that only nurses should have access to the cart keys and that leaving it unlocked poses a safety issue. The facility's policies on medication administration and storage emphasize that medications should not be administered without a physician's order and that self-administration is only permitted with a proper assessment and physician order.
Staffing Shortage Leads to Resident Restraint
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, particularly affecting a resident known for attempting to get out of bed without assistance. On a specific day, the facility was short-staffed, with only two CNAs available instead of the usual three for the second floor, which houses 41 residents. This shortage led to a situation where a registered nurse, overwhelmed with responsibilities, tied a resident's hands to the bed rail with a pillowcase to prevent falls, acknowledging the action was wrong but felt necessary due to the lack of staff. The facility's staffing policy requires adequate staffing levels and skills mix to deliver high-quality, person-centered care, with a designated nurse on-call for emergencies. However, on the day of the incident, a CNA called off, and the facility struggled to find a replacement, especially since it was a weekend. The Director of Nursing confirmed that the usual staffing for the second floor should include two nurses and three CNAs, but due to the call-off, only two CNAs were available, leading to the incident involving the resident being tied to the bed rail.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to immediately report an alleged abuse incident involving a resident who was tied to the bedside rails with a pillowcase by a nurse. This incident was reported to the facility's Administrator by the Director of Nursing, who sent the nurse home pending investigation. Despite the conclusion that the allegation was unfounded and there was no injury, the facility did not report the incident to the Illinois Department of Public Health (IDPH) as required by their policy. The facility's policy on abuse prevention mandates that any allegation of abuse should be reported to the Department of Public Health's regional office immediately, or within 24 hours if there is no serious bodily injury. However, the initial report to IDPH was made 32 days after the alleged incident. This delay in reporting was a violation of the facility's own policy, which requires timely reporting of such allegations to ensure proper investigation and response.
Failure to Conduct Timely PASRR Assessments for Residents with Serious Mental Disorders
Penalty
Summary
The facility failed to refer five residents for Preadmission Screening and Resident Review (PASRR) Level I and II assessments, which are necessary for residents with serious mental disorders. The Director of Social Services, identified as V4, acknowledged that these assessments were not completed for residents R2, R3, R4, R5, and R6. Each of these residents had diagnoses indicating serious mental illness, such as schizoaffective disorder, major depressive disorder, and bipolar disorder, which required timely PASRR evaluations to ensure they received appropriate care and services. The deficiency was partly due to a transition period in the facility's social services department, during which there was no Social Services Director to manage the PASRR process. V4, who was new to the facility, was unaware of the need for these assessments until the surveyor's interview. The facility's business office manager, V5, confirmed that the absence of a Social Services Director led to a lack of communication with the appointed screening agency, resulting in missed PASRR evaluations. The facility's policy requires that newly admitted residents with serious mental illness, intellectual disability, or developmental disability be assessed for PASRR Level II within a specified timeframe. However, due to the oversight, the necessary assessments were not conducted, leaving the residents without the specialized programs and treatment goals they needed. Notifications from the assessment tool and service letters from the screening agency were not acted upon, contributing to the deficiency.
Failure to Provide Adequate Wound Care for Residents
Penalty
Summary
The facility failed to provide appropriate wound care for two residents, leading to significant health issues. Resident 1, who was admitted with a surgical site on the left inner thigh, did not receive the necessary wound treatment and skin care plan interventions. The facility did not complete weekly wound skin assessments or Braden scale assessments as required. This lack of care resulted in the resident being admitted to the hospital for dehiscence of the wound in the groin area. Resident 4 also did not receive the prescribed wound treatment. The resident's wound dressings were not changed daily as ordered by the physician, and the treatment was not documented as provided on specific dates. This oversight in care was noted despite the resident having multiple pressure ulcers and being dependent on assistance for activities of daily living. Interviews with facility staff, including the wound care nurse and the Director of Nursing, revealed a lack of awareness and documentation regarding the residents' wound care needs. The facility's policies on surgical wound care and skin inspection were not followed, contributing to the deficiencies in care for both residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, affecting two residents. The first incident involved a female resident with Alzheimer's and other health conditions, who was reportedly slapped by a CNA during ADL care after she became combative and scratched the CNA. The incident was witnessed by another CNA and the resident's roommate, both confirming the slap. The facility's investigation led to the termination of the CNA involved, although the resident was unable to be interviewed due to her mental status. The second incident involved a female resident with COPD, paraplegia, and other health issues, who was involved in a verbal altercation with a CNA. The CNA used profanity during a conversation with the resident, which was recorded on social media. Despite the resident's claim that the CNA always spoke to her in such a manner, the facility determined the interaction to be verbal abuse. The CNA was terminated following the incident, as the use of profanity was deemed inappropriate and against facility policy. Both incidents highlight the facility's failure to ensure a safe environment free from abuse, as required by their Abuse Prevention Program. The facility's policy emphasizes the residents' right to be free from abuse and mistreatment, yet these incidents demonstrate lapses in adherence to this policy, resulting in the termination of the involved staff members.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Suburban Medical Ctr | 0.7 mi | ★★★★★ | 2 | 0 |
| Austin Oasis, The | 0.8 mi | ★★★★★ | 10 | 0 |
| Ryze West | 1 mi | ★★★★★ | 3 | 0 |
| Oak Park Oasis | 1.8 mi | ★★★★★ | 7 | 0 |
| Landmark Of Cicero Rehabilitation And Nursing Cent | 2.2 mi | — | 28 | 0 |
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