Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grove Of Elmhurst, The during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity by using personal cell phones while providing care. A resident’s daughter reported CNAs frequently on their phones, including one CNA who paused a personal call, with earbuds in, only after being approached. A resident stated she sees staff on their phones during care “all the time,” and another resident also reported observing staff phone use during care. The mother of a nonverbal, non-alert, and non-oriented resident stated she often sees staff on their phones, including while they provide care, and described this as disrespectful. The DON acknowledged that staff should not use cell phones during care and that doing so is disrespectful, even though facility policy already strongly discourages personal calls or texting during work time except under extraordinary circumstances or during breaks.
A resident with functional quadriplegia, ventilator dependence, and heart failure had an order and facility policy requiring daily cleansing and dry gauze dressing changes to the enteral tube site on the night shift. During observation, surveyors noted a foul odor and found the feeding tube dressing dated nine days earlier, with dried black drainage and a pronounced odor. When the nurse removed the dressing, the underlying skin was reddened, inflamed, and appeared raw. Review of treatment records showed night shift staff had documented daily dressing changes during this period, despite the unchanged, dated dressing, and the DON confirmed that dressings are to be changed daily and not documented unless actually performed.
A resident with functional quadriplegia, ventilator dependence, and heart failure received incontinence care during which a CNA wiped stool from the buttocks toward the vagina twice, contrary to clean technique and facility policy. The resident’s perineal area had to be cleaned a second time, and the shift coordinator/CNA later stated he had instructed the CNA to wipe away from the vagina, noting that wiping stool toward the vagina could lead to a UTI. The DON confirmed that perineal care should be performed by wiping away from the vagina to prevent contamination and infection, as required by the facility’s incontinence and perineal care policy.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and were linked to failures in following established protocols.
A resident sustained a significant laceration on her right lower leg after her skin caught on the uncapped right front wheel connector of her wheelchair during a transfer. The injury required hospital treatment and sutures. Staff interviews and observations confirmed the wheelchair was not in safe repair, and the facility's maintenance policy requires equipment to be properly maintained.
Surveyors found that multiple insulin pens and vials were not labeled with resident names, open dates, or expiration dates, and expired medications were not removed from storage. Staff confirmed that labeling and timely disposal were required, but these procedures were not followed according to facility policy.
Three residents with cognitive impairments and documented needs for assistance with personal hygiene were observed with long, dirty, or broken nails, indicating that required nail care was not provided. Nursing staff confirmed that nail care should be performed on shower days, but observations and care plans showed this was not consistently done.
A resident who returned from the hospital with a stitched leg laceration was not assessed by staff, and the wound dressing was not changed for several days. No wound care orders were transcribed into the POS, and staff relied on hospital records for treatment guidance. Facility policy requiring prompt wound assessment and treatment was not followed.
Two residents with pressure injuries did not receive wound care as prescribed by their providers. In one case, a stage 4 sacral wound was not treated with the ordered collagen and calcium alginate dressings, and in another, a right heel wound did not receive the specified medihoney with calcium alginate dressing. Nursing staff did not implement the documented treatment orders, and the required protocols for wound care were not followed.
Two residents with indwelling urinary catheters did not receive care in accordance with infection control protocols, including improper cleaning of catheter tubing, drainage bags resting on the floor or placed on beds, and drainage bags positioned above the bladder causing urine backflow. Staff failed to document catheter care as ordered, and both residents reported that catheter care was not performed regularly.
Three residents with significant weight loss or malnutrition were not provided their prescribed nutritional supplements as ordered. In one case, a dietician's recommendation to increase a supplement was not implemented, and in two other cases, residents were not served their required supplements with meals despite clear orders. Staff confirmed the omissions, and no facility policy on nutritional supplements was in place.
Several residents experienced missed or canceled outside medical appointments due to the facility's failure to coordinate transportation, communicate appointment details to nursing staff, and document cancellations or refusals in the medical record. Issues included lack of notification to nurses, incomplete documentation, and failure to arrange required escorts, despite facility policy requiring such coordination.
Surveyors found that staff failed to administer medications as ordered, resulting in a 12% medication error rate. One resident received an incorrect dose of Zinc due to stock issues and lack of documentation, while another received a lower dose of Duloxetine and was not instructed to rinse their mouth after a steroid inhaler, contrary to policy. Errors were linked to improper medication storage and failure to follow physician orders.
The facility did not promptly implement contact precautions or cohorting for a resident with confirmed C. difficile infection, resulting in a roommate at risk for infection remaining in the same room for several days. Additionally, an LPN failed to wear a gown while providing high-contact care to a resident on enhanced barrier precautions for a gastrostomy tube and MDRO colonization, contrary to facility policy.
The facility did not properly implement its antibiotic stewardship program, resulting in incomplete monitoring and documentation of antibiotic use for two residents. One resident's assessment form for a UTI was not completed, and a required sensitivity analysis was not performed. Another resident received two antibiotics, but only one was reviewed, and the assessment form was incomplete and unclear about the indication. The facility's policy requiring documentation and reassessment of antibiotic use was not followed.
A resident with Alzheimer's and other conditions had a scrotal wound that was not assessed or treated when first identified. Despite a CNA claiming it was reported and documented, there was no record of the wound in the resident's EHR. The wound was later assessed by the Wound Care Director and Nurse Practitioner, who were unaware of it, and identified as moisture-associated skin damage. The facility's policy requires documentation of skin alterations, which was not followed.
A facility failed to prevent cross-contamination by improperly handling soiled items during incontinence care. A CNA placed soiled bedding on the floor and a stool-covered washcloth on a nightstand. A resident's name band was also smeared with feces, which was confirmed by an LPN. The DON stated that soiled items should be placed in a plastic bag, as per policy.
A resident with severe cognitive impairment engaged in a physical altercation with two other residents, using a decorative flagstick and headphones to hit them on the head. One resident sustained a small skin tear and bleeding, while the other did not have any injuries. Staff members intervened by separating the residents and calling for assistance. The facility's policy emphasizes providing care in an environment free from abuse, but this incident highlights a failure to protect residents from physical abuse.
A resident was physically abused by an agency CNA, resulting in bruising on her face and arm. The abuse occurred after the resident expressed discomfort with the CNA's care. Despite the resident's pleas, the CNA continued the abuse, causing significant physical and psychological harm. The facility's care guidelines and abuse policy were not followed.
The facility failed to provide a resident with hand splints as recommended by the Therapy Department, leading to a lack of contracture prevention. The resident, in a persistent vegetative state, was observed multiple times without the prescribed orthotics, and a glitch in the EMR system prevented staff from seeing the task for applying the hand braces.
A facility failed to administer scheduled pain medication to a resident with multiple diagnoses, including traumatic subdural hemorrhage and respiratory failure, on several occasions. The resident's MAR showed multiple unsigned entries, and there were no nursing progress notes explaining the omissions. The resident's daughter expressed concerns about the resident experiencing pain, and the NP confirmed the need for the medication due to the resident's inability to communicate pain levels.
The facility failed to identify, report, assess, and obtain physician orders for new skin breakdowns, and did not ensure that treatment dressings were in place or that soiled dressings were changed for residents with stage 3 and stage 4 pressure ulcers. This resulted in several residents having untreated wounds, some of which contained necrotic tissue, and the deterioration of their conditions.
The facility failed to obtain physician orders and complete self-administration assessments for four residents who were found with medications at their bedside. These residents, who were cognitively intact, reported self-administering their medications without instruction or supervision. The facility did not follow its policy requiring evaluations and physician orders for bedside medication storage.
The facility failed to ensure that intravenous medications were administered by qualified staff, specifically LPNs who were not authorized to perform this task. This deficiency affected five residents who received IV therapy from LPNs, contrary to the facility's policies and the Illinois Nurses Act.
The facility failed to provide timely incontinence care and respond to call lights, affecting eight residents. Observations revealed residents in saturated briefs and unsanitary conditions. Interviews and Resident Council Meeting minutes indicated slow response times from agency CNAs, particularly during the 3 PM - 11 PM shift, with reports of residents waiting hours for assistance.
The facility failed to maintain proper hand hygiene and infection control practices for four residents. A respiratory therapist and a CNA were observed handling soiled items and providing care without changing gloves or performing hand hygiene, violating the facility's infection control policies.
The facility failed to use McGeer's criteria to determine the necessity of antibiotics for four residents. The Infection Preventionist confirmed that the forms were not completed due to the presence of many agency nurses and the absence of a facility policy on McGeer's criteria.
The facility failed to ensure that call lights were within reach for three residents, leading to potential delays in care. Observations revealed that call lights were either on the floor or placed on a dresser, making them inaccessible. The residents, who had no upper extremity impairments, expressed frustration about the inaccessibility of call lights, which is against the facility's policy.
The facility failed to document required details for residents with pacemakers, including orders for checking the pacemaker and specific information about the device. This deficiency was identified in two residents, leading to incomplete care planning and potential gaps in pacemaker management.
The facility failed to change a resident's midline catheter dressing, measure, and document the external length of the catheter and arm circumference as per policy. The resident had a midline catheter with a dressing dated 3/24/2024, which was not changed by 4/04/2024. The Infection Preventionist acknowledged the oversight, attributing it to the resident's hospital visit.
A resident with multiple diagnoses, including severe intellectual disabilities and schizoaffective disorder, was left in pain for over an hour due to a transfer sling left under her. Despite continuous screaming, staff did not promptly address her pain, and the resident only received pain relief after the surveyor's intervention. The DON confirmed that staff should check on residents immediately if they hear screaming and that transfer slings should not be left under residents.
The facility failed to dispose of controlled medications per its policy, as observed in three residents. Medications were found inappropriately returned to punch cards with tape or band-aids over the slots. The Director of Nursing confirmed that controlled medications should be discarded properly and witnessed by two nurses.
Staff Cell Phone Use During Resident Care Undermining Resident Dignity
Penalty
Summary
The facility failed to respect residents’ dignity and right to a dignified existence and self-determination by allowing staff to use personal cell phones while providing resident care. A resident’s daughter reported that CNAs were on their phones “all the time,” including an incident where a CNA, wearing earbuds and engaged in a personal call, told the person on the phone to “hold on,” reached into her pocket to pause the call, and only then addressed the daughter. The same daughter stated she had recently observed CNAs on their phones while providing care to her mother. One resident stated she sees staff on their phones during resident care “all the time,” and another resident stated she does see staff on their phones while providing care. A nonverbal, non-alert, and non-oriented resident’s mother also reported seeing staff on their phones frequently, including during care, and described it as disrespectful and something that should not happen. The DON confirmed that cell phones should not be used while providing care and acknowledged that it is disrespectful for staff to be on their phones while caring for residents, despite the facility’s written policy that strongly discourages personal calls or texting during work time except under extraordinary circumstances or during scheduled breaks.
Failure to Perform and Accurately Document Daily Feeding Tube Dressing Changes
Penalty
Summary
A resident with functional quadriplegia, ventilator dependence, and heart failure had an active physician order, dated 12/4/24, for cleansing the enteral tube feeding site with normal saline and applying a dry dressing every night shift. During surveyor observation, the resident was noted in bed with a foul odor that was not consistent with stool. Later that morning, during incontinence care, staff exposed the resident’s abdominal tube feeding site and observed a split 4x4 gauze dressing with dried black drainage near the tube and a pronounced odor. The dressing was dated 12/29, indicating it had not been changed for approximately nine days despite the daily dressing change order and the facility’s policy requiring daily cleansing and dry gauze coverage of the enteral tube site. The resident’s nurse confirmed that the date on the dressing reflected the last time it was changed and acknowledged that the dressing should have been changed before the day of the survey, stating that tube feeding dressings are typically changed daily on the night shift. When the dressing was removed, the skin underneath was described as reddened, inflamed, and appearing raw. Review of the December and January Treatment Administration Records showed that night shift staff had documented completion of the tube feeding dressing changes on multiple days after 12/29, even though the physical condition and date of the dressing indicated those changes had not been performed. The DON stated that feeding tube dressings should be changed daily on the night shift to prevent infections and that staff should not document dressing changes unless they are actually completed.
Improper Perineal Care Technique During Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care in a manner that prevented potential urinary tract infections for one resident. The resident was admitted with diagnoses including functional quadriplegia, ventilator dependence, and heart failure. During observed incontinence care, a CNA began by cleaning the resident’s vaginal area while the resident was on her back, then, after the resident was rolled onto her side, the CNA wiped stool from the top of the buttocks toward the vagina twice, despite the presence of a moderate, tar-like bowel movement. As a result, the resident’s vaginal area required a second cleaning after she was rolled back onto her back. The shift coordinator/CNA later stated he had quietly instructed the CNA to wipe away from the vagina, acknowledging that wiping stool toward the vagina could lead to a urinary tract infection, and the DON confirmed that stool should be wiped away from the vagina to prevent contamination or infection. The facility’s incontinence and perineal care policy required maintaining clean technique to ensure cleanliness, comfort, and prevention of infection and skin irritation. These observations, interviews, and record review showed that staff did not consistently follow the facility’s incontinence and perineal care policy or accepted clean technique during perineal care for this resident.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the facility's failure to follow established protocols for continence care, catheter management, and infection prevention.
Failure to Maintain Wheelchair in Safe Repair Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's wheelchair was maintained in safe repair, resulting in an accident. The resident sustained a 7 cm L-shaped laceration on her right lower leg after her skin caught on the uncapped right front wheel connector of her wheelchair while transferring from the wheelchair to the toilet. The injury was severe enough to require the resident to be sent to the hospital, where she received 11 sutures. Observations on subsequent days confirmed that the right front wheel connector of the wheelchair remained uncapped. Interviews with facility staff revealed that the LPN who responded to the incident did not notice the uncapped connector at the time, but the Rehab Director and Nurse Practitioner later confirmed that the connector should have been capped and that its condition likely contributed to the injury. The Director of Nursing stated that staff are expected to report any medical equipment in disrepair, including wheelchairs, and that all equipment should be kept in good, safe repair to prevent injuries. The facility's maintenance policy requires the maintenance of equipment and the building environment.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications, specifically insulin pens and vials, for multiple residents. Insulin pens and vials for seven residents were found without required labeling, such as the resident's name, the date the medication was opened, and the expiration date. Additionally, some medications, including a Humalog Kwik pen and a vial of Humulin R insulin, were found without any resident identification. Staff interviews confirmed that all insulin pens should be labeled with the resident's name and the open and expiration dates, as some insulins are only viable for a specific number of days after opening. Further, expired medications were not removed from storage as required. Two vials of Ativan, which had expired, were found in the medication room refrigerator, and there were no current orders for Ativan for the resident in question. The facility's own policy requires that all opened medication vials be labeled with the date opened and discarded within the specified timeframe, yet this was not followed. These findings were based on direct observation, staff interviews, and review of physician orders and facility policy.
Failure to Provide Required Nail Care to Dependent Residents
Penalty
Summary
The facility failed to provide necessary nail care to three residents who required assistance with activities of daily living (ADLs). One male resident with severe cognitive impairment and contracted hands was observed with long nails and a brownish substance underneath, despite being care planned for total staff participation in personal hygiene. A female resident with mild cognitive impairment, who required partial assistance, was found with a broken nail and long, dirty nails on all fingers. Another male resident with moderate cognitive impairment and a documented need for partial assistance was observed with long nails and a broken, jagged nail. Interviews with nursing staff confirmed that nail care, including trimming and grooming, should be provided on shower days, as outlined in the facility's policy. However, observations and record reviews indicated that these residents did not receive the required nail care, despite their documented deficits and care plans specifying the need for staff assistance with personal hygiene.
Failure to Assess and Obtain Wound Care Orders After Hospital Return
Penalty
Summary
A resident returned from the hospital with a laceration on the right lower leg that required eleven stitches. Upon observation, the resident's wound was covered with a gauze dressing that was brown with dried blood stains and was unraveling. The resident reported that no staff had assessed the wound or changed the dressing since returning from the hospital. Three days after the resident's return, the wound dressing remained unchanged, and the same dried blood stains and unraveling gauze were observed. Review of the resident's Physician Order Sheet (POS) by both an LPN and the Wound Care Director revealed that there were no wound care orders documented for the resident's leg wound. The Wound Care Director confirmed that she had not assessed the wound since the resident's return and stated that prompt assessment and obtaining wound care orders should have occurred. The Treatment Nurse later changed the dressing and stated that she used orders from the hospital records, as no orders had been transcribed into the POS. The facility's policy requires prompt identification, documentation, and treatment for residents with skin breakdown, which was not followed in this case.
Failure to Follow Prescribed Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to follow prescribed treatment orders for pressure wounds in two residents. In one case, a wound care nurse and aide changed a resident's sacral wound dressing and did not apply the ordered collagen and calcium alginate dressings, instead using only a white bordered gauze dressing. The nurse was unsure why the prescribed treatment was not followed, despite clear orders and care plans specifying the use of collagen and calcium alginate with a bordered gauze dressing. The resident's wound was present on admission, classified as stage 4, and exhibited slough tissue and undermining. In another case, a resident developed a facility-acquired unstageable pressure injury to the right heel. The wound care nurse applied a dressing that included medihoney ointment and adaptic, but did not follow the specific order to use medihoney with calcium alginate, ABD pad, and rolled gauze. The treatment administration record did not show that the nurse practitioner's order was implemented. The wound care nurse stated she believed she was following the correct order, and indicated that the wound care team was responsible for reviewing and transcribing treatment orders. Facility policy required prompt identification and appropriate treatment for skin breakdown, but the prescribed wound care protocols were not followed in these cases.
Failure to Provide Proper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care to residents with indwelling urinary catheters, resulting in multiple infection control breaches. For one resident with a neurogenic bladder and a history of urinary tract infections (UTIs), staff were observed emptying the drainage bag but not cleaning the catheter tubing as required. During catheter care, the drainage bag was seen resting on the floor and later placed on the resident's bed, both actions contrary to infection control protocols. Staff also used a soiled towel to drape the resident and placed dirty linens on a clean area of the bed. Additionally, the staff did not clean the top inch of the catheter tubing near the insertion site and touched clean surfaces with soiled gloves after providing perineal and catheter care. Another resident with an indwelling urinary catheter due to obstructive and reflux uropathy was observed with the drainage bag positioned above the bladder, causing urine to backflow into the bladder. The drainage bag was also seen resting on the floor and later placed on the bed during care. After catheter care, the drainage bag was again raised above the resident's body, resulting in visible backflow of urine. Both residents reported that staff did not regularly clean their catheter tubing, and one noted frequent hospitalizations for UTIs and regular antibiotic use. Review of care plans and physician orders confirmed that catheter care was to be performed every shift, and the drainage bag was to be kept below the level of the bladder. However, there was no documentation in the electronic medical records for either resident indicating that catheter care was performed as ordered. Facility policy required cleaning the catheter from the insertion site outward and maintaining the drainage bag off the floor and below the bladder, but these procedures were not followed during the observed care.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to process and implement dietary recommendations for nutritional supplements for three residents identified as at risk for or experiencing significant weight loss and malnutrition. For one resident, despite a registered dietician's recommendation to increase the frequency of a nutritional supplement due to ongoing weight loss, the order was not updated in the electronic medical record, and the resident continued to receive the supplement at the previous, lower frequency. This resident's weight continued to decline over several months, and staff interviews confirmed the dietary recommendation was not implemented. Two additional residents, both with documented needs for nutritional supplements due to malnutrition or increased nutritional requirements, were not served their prescribed supplements with their meals on multiple observed occasions. Meal tickets indicated the supplements were ordered, but the items were missing from their trays. Staff interviews confirmed that the kitchen was responsible for including these supplements, but they were not provided as required. The facility did not have a policy regarding nutrition or nutritional supplements at the time of the survey.
Failure to Coordinate Transportation and Appointment Procedures Resulting in Missed Medical Appointments
Penalty
Summary
The facility failed to properly coordinate and document transportation and appointment procedures for residents requiring outside medical appointments, resulting in multiple missed or canceled appointments. One resident, who was cognitively intact, was unable to see her orthopedic physician because the necessary paperwork was not prepared, as the nurse was not notified of the appointment. This resident reported that this was not the first time appointments were missed due to lack of communication between the transportation coordinator and nursing staff. Review of the electronic medical record confirmed that appointment details were not entered, and the transportation coordinator admitted to not notifying the nurses or updating the resident's calendar in the EMR. Another resident reported missed doctor's appointments in the past due to the transportation coordinator's failure to arrange transportation. The transportation coordinator kept records of scheduled and canceled appointments on paper but did not document canceled appointments or resident refusals in the medical record. The resident's care plan and progress notes did not reflect any refusals or reasons for missed appointments, and the transportation coordinator was unable to provide clear reasons for the cancellations. A third resident, also cognitively intact, expressed concern about a canceled doctor's appointment, stating it was due to transportation issues and lack of an escort, which was the responsibility of the transportation coordinator. The transportation service had no record of the appointment being scheduled, and there was no documentation in the progress notes explaining the cancellation. Nursing staff confirmed that the resident was prepared for the appointment, but the absence of an escort and poor communication led to the cancellation. The facility's policy required timely scheduling and coordination of transportation and escorts, but these procedures were not consistently followed.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
Surveyors identified that the facility failed to administer medications as ordered, resulting in a medication error rate of 12% (3 errors out of 25 opportunities) during observation of medication passes. In one instance, a registered nurse administered only 50 mg of Zinc to a resident, despite the physician's order specifying 110 mg twice daily. The nurse acknowledged the error, noting that the available stock was insufficient and that she sometimes attempted to compensate by giving an additional 50 mg later, but this was not documented and still did not meet the prescribed dose. In another case, an LPN administered three 20 mg capsules of Duloxetine (totaling 60 mg) to a resident instead of the ordered three 30 mg capsules (90 mg). The LPN also failed to provide water and encourage the resident to rinse their mouth after administering a steroid inhaler, contrary to both facility policy and manufacturer guidelines. The medication cart was found to contain both 20 mg and 30 mg Duloxetine capsules, which contributed to the error. The facility's policies require strict adherence to physician orders and proper administration techniques, including mouth rinsing after certain inhalers.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement infection prevention and control measures for residents with acute gastrointestinal infections and those requiring enhanced barrier precautions. One resident began experiencing acute diarrhea and was later confirmed to have a C. difficile infection. Despite this, the resident was not immediately placed on contact precautions, and their roommate, who was at risk for infections due to multiple comorbidities, was not moved to another room until three days after the onset of symptoms and one day after the positive test result. Facility policy and CDC guidelines require immediate implementation of contact precautions and cohorting only with other residents with the same infection, but these were not followed. Additionally, a nurse failed to adhere to enhanced barrier precautions for another resident with a gastrostomy tube and colonization with a multidrug-resistant organism. The nurse entered the resident's room and performed high-contact care activities, including medication administration through the feeding tube, without wearing a gown as required by facility policy. The resident's care plan and facility policy both specified the need for gown and glove use during such activities to prevent the transmission of infectious agents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in incomplete monitoring and documentation of antibiotic use for two residents. For one resident who was started on Ceftriaxone for a urinary tract infection (UTI), the Infection Preventionist (IP) Nurse identified that the McGeer Criteria assessment form was not completed to determine if the prescribed antibiotic was appropriate. Additionally, the urinalysis specimen was not analyzed for sensitivity as ordered, and the assessment form lacked documentation to confirm a review of the antibiotic's appropriateness. The resident's urinalysis was collected and reported without sensitivity analysis, and the antibiotic order remained active without proper review. For another resident receiving both Vancomycin and Meropenem, the IP Nurse was unsure of the indication for Vancomycin and noted that the McGeer assessment form was only initiated for Meropenem, not Vancomycin. The form for Meropenem was incomplete and did not clarify the reason for its use, as there was confusion regarding whether it was prescribed for MRSA in the blood, urine, or both. The facility's policy requires documentation of dose, route, duration, and indication, as well as reassessment of antibiotic use after three days, but these steps were not followed for the residents reviewed.
Failure to Document and Treat Resident's Wound
Penalty
Summary
The facility failed to assess and treat a wound on a resident's scrotum when it was first identified. The resident, who was admitted with diagnoses including Alzheimer's, pressure ulcer, contractures of the legs, failure to thrive, and was under palliative care, was dependent on staff for all activities of daily living. The wound was first noticed by the resident's family member during incontinence care, and it was reported to the state health department. Despite the Certified Nursing Assistant (CNA) stating that the wound had been reported weeks ago and documented in the Electronic Health Record (EHR), there was no documentation of the wound in the resident's records. On a subsequent visit by the state surveyor, the wound was assessed by the Wound Care Director and the Wound Care Nurse Practitioner, who were both unaware of the wound prior to this assessment. The wound was identified as moisture-associated skin damage (MASD) and measured 3.0 cm by 1.5 cm. The facility's wound report and Treatment Administration Record (TAR) showed no documented wounds or treatments for the resident's scrotum. The facility's Wound Care Guideline policy requires that skin alterations be documented in the resident's clinical records, which was not adhered to in this case.
Improper Handling of Soiled Items Leads to Cross-Contamination Risk
Penalty
Summary
The facility failed to handle soiled cleaning supplies and soiled bedding properly, leading to potential cross-contamination. During an observation, a CNA was providing incontinence care to a resident who had a bowel movement. The CNA placed the resident's soiled bedding on the floor and a stool-covered washcloth on the bedside nightstand. Additionally, the resident's name band had a brown smear that appeared to be feces, which was not removed by the CNA. A Licensed Practical Nurse later confirmed the substance on the name band appeared to be feces. The resident's family member also reported that during a visit, the resident's hands and name band were covered in stool, requiring two washcloths to clean. The Director of Nursing stated that all soiled items should be placed directly into a plastic bag to prevent cross-contamination, as per the facility's policy.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in an incident where one resident, with diagnoses including hemiplegia, hemiparesis, depression, dementia, and PTSD, engaged in a physical altercation with two other residents. The incident occurred when the resident obtained a decorative flagstick and used it to hit two other residents on the head. One of the affected residents, who had a history of hemiplegia, hemiparesis, dementia, anxiety disorder, PTSD, and mild cognitive impairment, was hit on the head but did not sustain any injuries. The other resident, with a history of scalp contusion, epilepsy, and falls, was hit on the head with headphones, resulting in a small skin tear and bleeding. The incident was witnessed by staff members, including LPNs and CNAs, who responded by separating the residents and calling for assistance. The facility's Abuse Investigation Report and staff interviews indicate that the resident who initiated the altercation was agitated and had severely impaired cognition. The facility's policy on abuse and neglect defines abuse as the willful infliction of mistreatment or injury, and the policy emphasizes providing care in an environment free from abuse. Despite these policies, the facility's failure to prevent the altercation led to the physical abuse of two residents.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by an agency CNA. The incident occurred when the CNA punched the resident in the face and grabbed her lower arm, resulting in bruising on her face and arm. The resident reported that the abuse happened after she expressed discomfort with the way the CNA was changing her. Despite her pleas for the CNA to stop, the abuse continued, causing significant physical and psychological harm to the resident. The resident, who has multiple diagnoses including dementia, depression, and chronic pain syndrome, was found with dark purple bruising under her left eye, above her right eye, across the bridge of her nose, and on her left forearm. The resident recounted the incident, stating that the CNA hit her with a pillow multiple times before punching her in the face. The resident did not use her call light due to fear and later requested pain medication from an LPN, who then discovered the injuries and reported the incident. The facility's records show that the resident is cognitively intact and requires substantial assistance with daily activities. The resident's care plan includes specific instructions to create a warm and safe environment, emphasizing dignity and patience. However, these guidelines were not followed by the CNA, leading to the abusive incident. The facility's policy on abuse and neglect clearly defines physical abuse and outlines the need for professional care free from any type of abuse, which was not adhered to in this case.
Removal Plan
- R1 remains in the facility with psychosocial services available to R1.
- R1 was seen by a psychotherapist and wellness checks by the Social Services Department have been ongoing and will continue three times a week for 30 days.
- V3 (Agency CNA) was removed and placed on the do not return list and has not returned to the facility since. Police were notified.
- The facility notified the staffing agency that V3 was asked not to return due to an abuse allegation.
- The facility opened an abuse allegation related to R1 and this investigation was concluded and substantiated. V3 (Agency CNA) was reported to the State Agency Healthcare Worker Registry.
- All agency staff will be provided abuse training prior to the start of their shift by the DON (Director of Nursing) or designee. This will include an audit questionnaire to validate return demonstration of understanding.
- Staff were re-educated on the facility Abuse and Neglect Policy by the Administrator and/or designee and is ongoing. This re-education will continue and be completed. Return demonstration of understanding was provided by way of conducting an audit questionnaire.
- An audit was conducted on all residents cared for by V3 (Agency CNA) to ensure abuse did not occur with anyone else.
- Residents with specific preferences and/or behaviors are being identified. Care cards listing these items will be placed in a binder at the nurse's station on each floor for staff knowledge. This will be updated as needed by the Social Services Department.
- All staff, including agency staff will be educated on the care card location, and to check the care card prior to providing care.
- Quality assurance audit will be conducted daily by the Administrator and/or designee to ensure agency staff have been educated on abuse with return demonstration of understanding. All identified trends will be reviewed by the monthly QAPI (Quality Assurance and Performance Improvement) Committee, and a plan will be discussed and implemented until resolution.
- The incident and abatement plan will be discussed and reviewed with the facility Medical Director.
- Emergency QAPI meeting will be conducted.
Failure to Provide Hand Splints as Recommended
Penalty
Summary
The facility failed to ensure a resident was provided with hand splints to prevent further decrease in range of motion as recommended by the Therapy Department. The resident, who was in a persistent vegetative state and dependent on staff for all activities of daily living, was observed multiple times without the prescribed hand splints. The resident's care plan indicated the need for bilateral resting hand orthotics for six hours per day, but there was no documentation to show that the splints were applied on several dates in April 2024. The Director of Rehab confirmed that the resident was recommended to wear hand splints to prevent contractures and further decline. The facility's Restorative Nurse acknowledged that the hand splints had not been placed on the resident due to the absence of a restorative aide. Additionally, the Regional Nurse Consultant identified a glitch in the electronic medical record system that prevented nursing staff from seeing the task for applying the hand braces. The facility's policy on the Restorative Nursing Program emphasized the need for comprehensive assessments and appropriate restorative services, including splint/orthotic management, but these were not consistently provided to the resident.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure a resident received scheduled pain medication as ordered. The resident, who has multiple diagnoses including traumatic subdural hemorrhage, respiratory failure, and is in a persistent vegetative state, was prescribed Norco to be administered twice daily via gastrostomy tube for pain management. However, the facility's records show that the medication was not administered on multiple occasions, specifically on April 3, 4, 6, 11, 12, 13, 14, 15, 16, 19, and 26, 2024, at 9:00 PM. The Medication Administration Record (MAR) for these dates remained unsigned, indicating the medication was not given as ordered, and there were no nursing progress notes explaining the omission. The resident's daughter expressed concerns about the resident experiencing pain, noting facial grimaces when touched or when her hair was combed, which further underscores the importance of the prescribed pain management regimen. The Nurse Practitioner (NP) who examined the resident noted that the resident had sinus tachycardia and ordered Norco for pain management, as the resident is unable to communicate pain levels due to her condition. The Director of Nursing (DON) acknowledged the failure to administer the medication as ordered and confirmed that the facility staff should have documented the removal and administration of the medication. This deficiency highlights a significant lapse in the facility's adherence to prescribed pain management protocols for a resident with complex medical needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to identify, report, assess, and obtain physician orders for new skin breakdowns, and did not ensure that treatment dressings were in place or that soiled dressings were changed for residents with stage 3 and stage 4 pressure ulcers. This resulted in several residents having untreated wounds, some of which contained necrotic tissue. For instance, one resident had an unidentified right ischium wound with 25% necrotic tissue that was uncovered and without treatment, while another resident had a right ischium wound with necrotic muscle tissue exposed and no treatment. Additionally, a third resident had a right ischium wound that increased in size from previous assessments and was also without treatment. These deficiencies were observed in 5 out of 5 residents reviewed for pressure ulcers in a sample of 30 residents. The facility's failure to implement pressure ulcer interventions and maintain proper wound care protocols was evident in multiple cases, leading to the deterioration of residents' conditions. For example, one resident was found with a soiled dressing and an open wound on the right ischium without a treatment dressing in place. The wound care nurse admitted it was her first time seeing the wound and had to request an assessment from the wound nurse practitioner. Another resident had a sacrum and left ischium dressing that was saturated and had a foul odor, with the right ischium wound exposed and necrotic muscle tissue visible. The wound care nurse acknowledged that the wounds should have been covered and that the floor nurses were expected to change soiled dressings as ordered. In another instance, a resident's right ischium pressure ulcer was observed without a treatment dressing and was soiled with stool. The wound care nurse confirmed that the wound should have been covered as per the treatment order. The facility's documentation and communication regarding wound care were also found to be lacking. For example, one resident's electronic medical record did not show a treatment order for a newly identified left heel wound and right ischium wound. Another resident's care plan and order review report did not reflect the current status of their wounds, and the wound care nurse was unaware of the new wounds until they were discovered during the survey. Additionally, the facility's policy on wound care guidelines was not consistently followed, as evidenced by the lack of timely assessment, documentation, and communication of new wounds to the physician or wound care specialist.
Failure to Obtain Physician Orders and Complete Self-Administration Assessments
Penalty
Summary
The facility failed to obtain physician orders for resident medications to be kept at the bedside and did not complete self-administration of medication assessments for four residents. Specifically, medications were found on the bedside tables of residents R62, R109, R21, and R88 without proper physician orders or assessments. These residents, who were cognitively intact according to their BIMS scores, reported that they self-administered their medications without any instruction or supervision from the nursing staff. The medications included inhalers, nasal sprays, eye drops, and various pills, all of which were not authorized to be kept at the bedside according to the residents' Physician Order Sheets (POS) and medical records. Additionally, the facility's policy on self-administration of medication was not followed, as no assessments were uploaded into the electronic medical record system for these residents. Interviews with the nursing staff, including an LPN and the Director of Nursing (DON), revealed that the facility did not consistently follow its own procedures for evaluating residents' ability to self-administer medications. The DON confirmed that nurses are required to obtain a physician's order and complete a self-administration assessment, which should be documented in the electronic medical record. However, these steps were not taken for the residents in question. The facility's policy mandates that the Interdisciplinary Team (IDT) evaluate the resident's capability to safely administer medication and obtain a physician's order for bedside storage, which was not adhered to in these cases.
Unqualified Staff Administering IV Medications
Penalty
Summary
The facility failed to ensure that intravenous medications were administered by qualified staff, specifically Licensed Practical Nurses (LPNs) who were not authorized to perform this task. This deficiency was observed in five residents (R24, R95, R476, R477, and R478) who were receiving intravenous therapy. On multiple occasions, an agency LPN (V24) reconstituted and administered intravenous medications to these residents without supervision. The Director of Nursing (DON) confirmed that LPNs should not be administering IV medications as it is outside their scope of practice, which is supported by the facility's job description and the Illinois Nurses Act. The medications administered included Micafungin, Meropenem, Cefepime, Cefiderocol, and Zyvox, all of which were given through midline catheters, a procedure that should only be performed by Registered Nurses (RNs). The facility's documentation and interviews with staff confirmed that these actions were not in compliance with professional standards of quality care. The report highlights specific instances where the LPN administered intravenous medications to residents without proper authorization. For example, R477 received Micafungin IV medication administered by V24, and R24 received Meropenem IV medication from the same LPN. Additionally, R95, R476, and R478 also received various intravenous medications from V24 and another agency LPN (V37). The facility's Director of Nursing acknowledged that these actions were outside the LPNs' scope of practice, and the facility's job description for LPNs did not include the administration of IV medications. This failure to adhere to professional standards of quality care was identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Provide Timely Incontinence Care and Respond to Call Lights
Penalty
Summary
The facility failed to provide timely incontinence care and respond to call lights, affecting eight residents. Observations revealed that residents were left in saturated disposable briefs, with some wearing two briefs at once, which is against facility policy. For instance, one resident was found with two urine-soaked briefs, and another had a wet bed sheet from urine. These incidents indicate that residents were not being changed frequently enough, leading to potential skin integrity issues. Several residents, including those with severe cognitive impairments and extensive care needs, were found in unsanitary conditions. One resident had dried stool on her buttocks, and another had a urine-soaked bed sheet. Interviews with CNAs revealed that they were not familiar with the residents and denied placing two briefs on them. The Director of Nursing confirmed that residents should not wear two briefs and emphasized the need for more frequent toileting or changing for heavy wetters. During a Resident Council Meeting, multiple residents expressed concerns about the slow response times from agency CNAs, particularly during the 3 PM - 11 PM shift. They reported that CNAs often took breaks simultaneously, leaving no staff to assist residents. One resident mentioned waiting 2.5 hours for toileting assistance. The Ombudsman and Resident Council Meeting minutes corroborated these complaints, highlighting ongoing issues with agency staff not performing ADL care adequately, especially during the night shift.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper hand hygiene and infection control practices for four residents. In one instance, a respiratory therapist (RT) did not change gloves or perform hand hygiene while performing multiple tasks, including handling soiled items and sterile equipment for a resident with a tracheostomy. The RT admitted to not following sterile technique and the Director of Respiratory Therapy confirmed the breach in protocol. The Director of Nursing (DON) acknowledged that such lapses increase the risk of infection for residents. In another instance, a Certified Nursing Assistant (CNA) was observed providing incontinence care to a resident and handling soiled briefs without changing gloves or performing hand hygiene. The CNA placed soiled items on the floor and on a roommate's overbed table, then continued to provide care without proper sanitation. The DON confirmed that these actions were against infection control policies and could spread contaminants. A third incident involved the same CNA providing care to another resident, where she again failed to follow proper hand hygiene and infection control practices. The CNA placed soiled linens and briefs on the floor and on surfaces used by residents, then continued care without changing gloves or performing hand hygiene. The DON reiterated that these actions violated the facility's infection control policies, which require hand hygiene before and after direct patient contact and after handling soiled items.
Failure to Utilize McGeer's Criteria for Antibiotic Use
Penalty
Summary
The facility failed to utilize a standardized tool, specifically McGeer's criteria, to determine the necessity of antibiotics prescribed to residents. This deficiency was identified for four residents who were prescribed antibiotics within the last three months. During the review of the infection control binder, it was found that there were no McGeer's criteria forms for these residents. The Infection Preventionist, who was covering for the previous infection preventionist, confirmed that the forms were not completed and stated that the facility had not been utilizing McGeer's criteria due to the presence of many agency nurses who were not performing this task. Additionally, the facility did not have a policy regarding the use of McGeer's criteria for antibiotics. The specific cases reviewed included a resident prescribed Levaquin for an infection, another resident prescribed Levofloxacin intravenously for leukocytosis, a third resident prescribed Amoxicillin-Potassium Clavulanate for a soft tissue infection, and a fourth resident prescribed Cefiderocol Sulfate Tosylate intravenously for an intra-abdominal infection. In all these cases, the required McGeer's criteria forms were not uploaded into the residents' medical records. The Infection Preventionist acknowledged the oversight and indicated that the facility was working on addressing the issue.
Failure to Ensure Call Lights Were Within Residents' Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to potential delays in care. On multiple occasions, surveyors observed that call lights were either on the floor or placed on a dresser, making them inaccessible to the residents. One resident, who requires assistance with incontinence care, stated that staff often forget to place the call light within reach. Another resident demonstrated that her call light was not within reach, and she expressed frustration about having to wait for staff to come to her room before she could receive help. The third resident also reported that staff do not always place the call light within reach, despite her need to use it for assistance. The residents involved had varying levels of cognitive impairment but no upper extremity impairments, indicating they were capable of using the call lights if they were accessible. The facility's Director of Nursing confirmed that call lights should always be within reach to ensure prompt care and prevent residents from attempting to do things on their own, which could lead to falls. The facility's Call Light Policy, revised in 2023, mandates that call lights be placed within reach of residents at all times, but this policy was not followed in these instances.
Failure to Document Pacemaker Details
Penalty
Summary
The facility failed to have the required documentation in the medical records of residents who had pacemakers. This deficiency was identified in two residents out of a sample of 30. For one resident, the Physician Order Sheet (POS) did not include an order for the pacemaker or parameters for checking it. The resident's admission assessment incorrectly indicated that the resident did not have a pacemaker, and the care plan lacked details such as the model, make, serial number, date of insertion, and the place it was inserted. The Director of Nursing confirmed that the nurse responsible for the admission should obtain this information from the Power of Attorney or the hospital and ensure it is included in the POS and care plan. However, this was not done for the resident in question, leading to incomplete documentation and care planning for the pacemaker management. Another resident's records showed that the pacemaker had only been checked once since admission, and the care plan did not specify the make, model, and serial number of the pacemaker. The facility's policy on pacemakers, which was reviewed recently, requires detailed documentation of the pacemaker, including the date of insertion, physician, place of insertion, make, model, serial number, and orders for how often the pacemaker should be checked and by whom. This policy was not followed, resulting in incomplete documentation and potential gaps in the monitoring and management of the resident's pacemaker.
Failure to Adhere to Midline Catheter Care Policy
Penalty
Summary
The facility failed to change a resident's midline catheter dressing, measure, and document the external length of the catheter and arm circumference as per facility policy. The resident, who was admitted with multiple diagnoses including an intra-abdominal infection, had a midline catheter with a transparent dressing dated 3/24/2024. Observations on 4/02/2024 and 4/04/2024 confirmed that the dressing had not been changed since 3/24/2024, despite the facility's policy requiring dressing changes every 7 days. Additionally, the resident's Treatment Administration Records for March and April 2024 did not show any documentation of the required dressing changes or measurements of the external catheter and arm circumference. The Infection Preventionist (IP) acknowledged that the midline catheter dressing should be changed every 7 days to prevent infection. The IP stated that the dressing change was missed because the resident had gone to the hospital and it was overlooked upon their return. The facility's Intravenous Therapy policy, revised on 8/07/2023, mandates weekly dressing changes and measurements to monitor for edema and catheter movement, which were not adhered to in this case.
Failure to Address Resident's Pain Promptly
Penalty
Summary
The facility failed to immediately address a resident's pain, as evidenced by the continuous screaming of a resident (R75) on the memory care unit. R75, who has diagnoses including congestive heart failure, anxiety, severe intellectual disabilities, schizoaffective disorder, and type 2 diabetes, was observed yelling and screaming from her room for over an hour. Despite the care plan indicating that R75 is at risk for pain and requires pain assessments every shift, the staff did not promptly respond to her distress. The resident pointed to a blue transfer sling under her, stating it was causing her pain. A CNA confirmed that the sling should not have been left under the resident, and the RN acknowledged that the last administration of Acetaminophen for pain was several days prior, on 3/24/24. The resident's pain was only addressed after the surveyor's intervention, and the resident felt better after receiving medication through her feeding tube. The Director of Nursing (DON) confirmed that staff should check on residents immediately if they hear screaming and that transfer slings should not be left under residents due to the risk of discomfort and potential injury. The facility's pain policy mandates that all residents be assessed for pain in situations where there is a potential for pain, which was not adhered to in this case. The failure to promptly address the resident's pain and discomfort constitutes a deficiency in providing appropriate pain management and care for the resident.
Failure to Dispose of Controlled Medications Properly
Penalty
Summary
The facility failed to dispose of controlled medications per its policy, as observed in three residents. For Resident 58, a lorazepam 0.5mg medication punch card was found with a pill slot punched open and taped over, despite no order for lorazepam in the resident's Order Review Report. Similarly, Resident 108's hydrocodone-APAP 5-325mg medication punch card had a pill slot punched open and covered with a band-aid, even though there was an active order for Norco Oral Tablet 5-325 MG. The Registered Nurse present during the observation acknowledged that the medications should have been wasted appropriately and not placed back into the punch cards. For Resident 4, a tramadol 50mg medication punch card was observed with a pill slot punched open and taped over. The Registered Nurse present confirmed that the medication should have been wasted and the medication log updated. The Director of Nursing stated that controlled medications should not be returned to the medication punch cards and should be discarded appropriately, witnessed by two nurses, and discontinued medications should be given to her for proper destruction. The facility's policy on Medication Storage, Labeling, and Disposal mandates that controlled medications be disposed of properly to prevent accidental exposure and diversion using Drug Buster or Rx Destroyer.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Elmhurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenora Elmhurst | 1.2 mi | ★★★★★ | 3 | 0 |
| Bridgeway Senior Living | 1.4 mi | ★★★★★ | 8 | 0 |
| Citadel At Casa Scalabrini | 2 mi | ★★★★★ | 0 | 0 |
| Park Place Christian Community | 4.2 mi | ★★★★★ | 0 | 0 |
| Landmark Of Itasca Rehabilitation And Nursing Cent | 4.4 mi | ★★★★★ | 28 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.