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 Harmony Park Ridge during CMS and state inspections, most recent first.
A cognitively intact, bedbound resident with paraplegia, a sacral pressure ulcer, and multiple comorbidities was provided a standard 35x80 inch bed and air mattress despite being 78 inches tall and spending most of his time in bed. The resident reported ongoing discomfort, stating he could not stretch his leg and wanted a longer bed with an air mattress that fit without extenders. Observation showed his foot touching the footboard with the head of the bed elevated, leaving no room to move. Record review confirmed the mismatch between the resident’s height and the bed dimensions, and staff, including the DON and wound nurse, acknowledged that the resident was too tall for the current bed and needed a longer one, resulting in a failure to uphold his dignity and comfort.
A resident with paraplegia, right BKA, neurogenic bladder with suprapubic catheter, sacral ulcer, and colostomy was assessed on the MDS as cognitively intact but dependent for personal and toileting hygiene, requiring all effort from staff or assistance of two or more helpers for rolling and bed mobility, and was on an air mattress. Despite the DON’s expectation that dependent residents and those on air mattresses receive two-person assistance for incontinence care and repositioning, a CNA provided incontinence and linen-change care alone while the resident was turned on the air mattress. During this one-person assist, the resident slid or rolled off the bed, striking his head and sustaining a left knee skin tear and right shoulder pain, later reporting additional pain in shoulders, chest, mid-back, and left leg to hospital staff. This sequence reflects a failure to follow the resident’s assessed need for two-person assistance during care.
A resident admitted with incontinence and slight sacral redness was assessed as at risk for skin breakdown, with care-planned interventions including daily skin inspections, frequent turning/repositioning, moisture-wicking incontinence products, and barrier creams, but the record lacked documentation that daily skin inspections were completed. The resident’s family reported finding the resident frequently saturated in urine and sometimes feces, with ill-fitting briefs that leaked, and stated the resident developed two large buttock wounds while in the facility. Although facility protocol called for early wound team involvement, there was no evidence of timely wound care consultation, and by later in the stay the resident had developed Stage 3 and Stage 4 pressure ulcers to both buttocks, with detailed wound measurements documented only after a delayed evaluation by the contracted wound care service.
A resident with encephalopathy, dementia with agitation, severe cognitive impairment (BIMS 5), and a documented high elopement risk was sent to a dermatology appointment without an escort, despite care plans and assessments noting wandering, confusion, and use of a wander alarm device. Staff, including the DON and social services, believed the resident was familiar with the clinic and did not require an escort, and the transportation coordinator reported this was at least the second unescorted visit. During the appointment, the transportation company could not locate the resident in the clinic lobby, and the resident was later found walking on a nearby residential street, stating he was going to see his mother and check his old house, which was located miles away and required crossing busy intersections. Facility documentation and interviews show inconsistent staff awareness and communication about the resident’s elopement risk, despite facility policies requiring assessment and care plan interventions for residents at risk of wandering/elopement and allowing for escorts based on medical, physical, and cognitive needs.
Two residents with respiratory disorders did not receive oxygen therapy as ordered by their physicians. One resident used a nasal cannula incorrectly and received inconsistent oxygen flow rates, with infrequent tubing changes and incomplete documentation in the MAR. Another resident received a lower oxygen flow rate than ordered, with tubing not changed as scheduled and no documentation of oxygen administration. Staff acknowledged these deviations from physician orders and facility policy.
A resident was not protected from employee-to-resident abuse when a CNA entered the room without knocking, leading to an altercation in which the CNA struck the resident in the face. The resident, who was alert and oriented, sustained facial bruising and scratches as a result of the incident, which was confirmed by staff, police, and hospital records.
A resident with multiple chronic conditions was found with unexplained bruising, but staff did not report the injury of unknown origin to the state agency as required by facility policy. Interviews confirmed that staff were aware of the reporting protocol, yet the incident was not reported in a timely manner, resulting in a deficiency for failure to follow abuse prevention and reporting procedures.
A resident with significant mobility and cognitive impairments, requiring a two-person assist for mechanical lift transfers, was transferred by a single CNA in violation of facility policy and the resident's care plan. During the transfer, the resident slid from the lift and sustained a left femoral neck fracture, necessitating hospitalization and surgery. Staff interviews confirmed awareness of the two-person assist requirement, but it was not followed due to staffing availability.
A resident with dementia and a significant fall risk was left unsupervised in a common area while a CNA attended to her cellphone, resulting in the resident being found on the floor by another resident. The care plan identified the need for close monitoring and specific interventions, but these were not followed, leading to a lapse in supervision.
A resident with multiple chronic conditions reported being physically and verbally abused by an agency CNA, including being punched and threatened. Facility staff failed to assess the resident for injuries, did not notify the family or physician, and did not document any follow-up. Additionally, the facility did not ensure agency staff were properly screened or trained in abuse prevention, contrary to facility policy.
A resident reported verbal and physical mistreatment by a CNA, but the facility failed to conduct a thorough investigation as required by policy. Key staff and the CNA involved were not interviewed, other potentially affected residents were not assessed, and there was no documented physical or psychosocial assessment of the resident after the incident. The DON was not informed or involved in the investigation, and required notifications and documentation were incomplete.
A resident reported verbal and physical mistreatment by a CNA, but the facility failed to conduct a comprehensive investigation as required by policy. Key staff and the CNA involved were not interviewed, other potentially affected residents were not assessed, and there was no documented psychosocial or thorough physical assessment of the resident after the incident.
The facility failed to follow its weight monitoring policy, leading to significant unplanned weight loss for three residents. One resident on a pureed diet was not assisted during meals, resulting in a 6.15% weight loss. Another resident with multiple health conditions lost 11.2% of their weight due to lack of documented weights and dietitian awareness. A third resident with a history of cancer experienced a 15.3% weight loss as their nutritional supplement was not implemented, and their food preferences were not accommodated.
The facility failed to follow its policies on oxygen administration and CPAP/BiPAP support, affecting four residents. Observations showed issues such as unlabeled humidifier bottles, lack of oxygen use signage, and deviations from physician orders. One resident used a CPAP machine without a physician's order for setup and flow, while another received oxygen at a rate higher than prescribed.
The facility failed to provide language support for a Bulgarian-speaking resident, leaving them unable to communicate effectively. Additionally, two residents with indwelling catheters were observed without privacy bags, compromising their dignity. These actions violate the facility's policies on resident rights and communication.
A facility failed to assess and manage the pain of a Bulgarian-speaking resident who reported daily headaches and migraines. The resident was unaware of receiving any pain medication and communicated their pain by pointing to their head. This was the first instance of using an interpreter since the resident's admission. The nursing supervisor was informed of the resident's migraine during the surveyor's visit, highlighting a lapse in following the facility's medication administration policy.
The facility failed to follow its infection control policy for enhanced barrier precautions, affecting two residents. Staff were observed not wearing appropriate PPE, such as gowns, while providing care to residents with enhanced barrier precautions. Interviews revealed inconsistencies in staff understanding of the policy, leading to non-compliance with infection prevention protocols.
The facility failed to report abuse allegations to the IDPH in a timely manner, affecting two residents. One resident reported being hit by another, leading to a police report, but the incident was not reported to the state due to communication lapses. Another incident was reported late due to the Administrator's focus on investigation and police contact, contrary to the facility's policy requiring immediate reporting.
A CNA failed to report a fall involving a resident who required substantial assistance for transfers. The resident attempted to get water during the night, fell, and was returned to bed by a male staff member without a nurse's assessment. This resulted in a delay of over 10 hours before medical evaluation, during which the resident sustained a laceration requiring sutures and broken ribs. The facility's protocol for reporting falls and observing residents post-fall was not followed.
A facility failed to investigate a resident's bruise of unknown origin and did not inform the family of the investigation's outcome. The resident, with severe cognitive impairment, was reported to have bruises allegedly caused by rough handling. The facility did not interview staff or collect statements as required by policy, and the Administrator admitted to the lack of documentation and communication with the family.
The facility failed to implement its fall prevention program, affecting three residents. A resident's call light was not within reach, leading to a fall and hip fracture. Another resident, identified as high risk, did not have the required fall star marking, and fall interventions were inconsistent with care plans. A third resident's bed was not in the lowest position, and their care card was outdated. The facility's policies on fall prevention and accident investigation were not adequately followed.
A resident with hemiplegia and other medical conditions experienced two falls due to inadequate supervision and equipment failure. The resident slid from a geriatric chair without footrests, resulting in a tibial fracture, and later fell from a bed that could not be lowered due to a malfunctioning remote. The facility's fall prevention policy was not followed, contributing to these incidents.
A resident with a history of falls and multiple medical conditions sustained a displaced nasal bone fracture due to inadequate supervision. Despite interventions in the fall care plan, the resident continued to fall when staff were not looking. The facility's fall policy and staffing levels were insufficient to prevent these incidents.
The facility failed to follow food service and sanitation policies, including improper hair net use, inadequate dishwasher temperature verification, and lack of hand hygiene by kitchen staff. These deficiencies affected all 98 residents receiving meals from the kitchen.
The facility failed to have a pest control policy and did not implement effective pest control treatments, affecting all 98 residents receiving meals from the kitchen. Observations revealed multiple gnats and roach-like insects in the kitchen area, with repeated pest control treatments documented from February to April 2024. Despite these treatments, the pest problem persisted, and the facility did not provide a pest control policy when requested.
The facility failed to follow its enhanced barrier precaution policy by not placing signage or making PPE available for residents with wounds, indwelling catheters, or G-tubes. This affected 26 residents and had the potential to impact all 104 residents. The interim ADON/IP admitted that in-services on enhanced barrier precautions had just started, despite policy requirements.
A resident reported an allegation of abuse by a CNA, but the facility failed to report the incident in accordance with its policies. The Administrator was not informed, and no Facility Reported Incident was filed at the time, leading to a significant delay in addressing the allegation.
The facility did not follow its abuse policy by failing to immediately suspend a staff member accused of hitting a resident on the head. The staff member continued to work the day after the allegation was reported before being suspended pending investigation.
The facility failed to provide restorative nursing services to two residents with limited range of motion. One resident reported not receiving any therapy for his contracted leg and experiencing discomfort from prolonged sitting. Another resident expressed frustration about being confined to a wheelchair since being discharged from therapy. Interviews confirmed the absence of a restorative program, despite facility policy requiring such services.
A resident at risk for weight loss and requiring extensive feeding assistance did not receive adequate help with meals. Staff members delivered meal trays but did not assist the resident with eating, leading to untouched meals. The facility's policy for feeding assistance was not followed, and the resident's nutritional needs were not met.
Failure to Provide Properly Sized Bed and Mattress for Tall Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a properly sized bed and mattress to meet the needs of a very tall, cognitively intact resident, affecting his comfort and dignity. The resident is a male with multiple medical conditions including hypertension, peripheral vascular disease, hyperlipidemia, chronic kidney disease, paraplegia, neurogenic bladder with suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, a sacral decubitus ulcer, and a colostomy. According to the MDS dated 2/12/2026, his BIMS score was 15/15, indicating he was cognitively intact, and he was totally dependent on staff for personal hygiene, toileting hygiene, and bed mobility tasks such as rolling and moving from sitting to lying and lying to sitting. The resident reported that since admission he had an air mattress and wanted a longer bed with an air mattress that fit the bed without any bed extender because of his wounds. He stated he was 6.6 feet tall and that the bed was not long enough for him to stretch his leg and be comfortable. Record review showed the resident’s height was 78 inches, while the bed’s sleeping surface, per the user manual, was 35x80 inches, leaving minimal space for movement and repositioning. The resident spent the majority of his time in bed and stated he was not comfortable and wanted a bed appropriate for his size. During observation, the surveyor noted the head of the bed elevated to approximately 40 degrees, with the resident’s foot touching the footboard and no room for him to move, while the resident expressed a desire to stretch his leg without touching the footboard. Facility staff, including the DON and the wound nurse, acknowledged that the resident was too tall for the current bed and would benefit from a longer bed so he could move better and prevent his foot from touching the footboard. The facility’s resident rights document stated that residents have the right to dignity, respect, and care that promotes quality of life, and the bed manufacturer’s manual confirmed the standard bed dimensions that did not adequately accommodate this resident’s height.
Failure to Provide Required Two-Person Assist During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide the level of assistance required by a resident during incontinence and repositioning care, as identified in the resident’s assessments and as expected by facility leadership. The resident is an adult male with multiple diagnoses including hypertension, peripheral vascular disease, chronic kidney disease, paraplegia, neurogenic bladder with suprapubic catheter, osteomyelitis status post right below-knee amputation, anemia, sacral decubitus ulcer, and colostomy. On the MDS dated 2/12/2026, the resident was documented as cognitively intact (BIMS 15/15) and dependent for personal hygiene and toileting hygiene, with the helper doing all the effort or requiring assistance of two or more helpers. Section GG further documented that rolling left and right, and moving between sitting and lying in bed, required the helper to do all the effort or assistance of two or more helpers. The DON stated that staff are expected to follow the plan of care and provide care with two staff members for residents who are dependent for incontinence care, personal hygiene, and repositioning, and specifically for residents on an air mattress because the surface is not stable. On the date of the incident, the resident reported that a CNA was assisting him alone with changing soiled linens and addressing a leaking colostomy while he was on an air mattress. The resident stated he was turned toward the door, held a bar on his right side, and then began to fall, ultimately falling on his face and striking his head on a refrigerator, as well as injuring his left knee and right shoulder. The CNA confirmed that he was providing care by himself, turned the resident toward the door to provide incontinence care, removed the dirty linen, and while picking up the linen, observed the resident turning and sliding out of bed from the air mattress; the CNA stated he was not able to stop the fall and that he routinely provided care to this resident as a one-assist, and did not know that two staff were required. A nurse reported hearing a noise, finding the resident already on the floor, cleansing a left knee skin tear, and calling 911, which the resident declined for immediate transport. Later hospital documentation recorded the resident’s report that the CNA moved him onto his side and he then rolled off the bed, with reported pain in both shoulders, chest, mid-back, and left leg, and a bleeding wound on the left shin. The facility’s fall policy describes a fall prevention program intended to ensure a safe environment and implementation of individualized plans of care, but in this case the assessed need for two-person assistance during care on an air mattress was not followed.
Failure to Prevent and Timely Manage Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary services and treatment to prevent the development and worsening of pressure injuries for one resident. The resident was admitted with incontinence and slight sacral redness documented on the admission nursing note, and an admission skin assessment the same day identified two pressure ulcers on the right and left buttocks with a Braden score of 14 (moderate risk). The initial care plan, created shortly after admission, identified the resident as at risk for impaired skin integrity and included interventions such as daily skin inspection, frequent turning and repositioning, use of moisture-wicking incontinence products, and application of moisture barrier per protocol. However, the clinical record lacked documentation that daily skin inspections were completed as care-planned, and staff were unable to provide any documentation of these daily assessments when requested. The resident’s family member reported visiting daily and finding the resident typically saturated in urine and sometimes feces, with incontinence briefs that were too large and leaked, resulting in the resident lying in wet briefs and sheets; the family member began supplying briefs from home. The family member also stated that nursing staff informed them the resident had developed two large wounds on the buttocks and that the resident did not have wounds prior to admission. The MDS completed shortly after admission did not indicate sacral/buttock redness, despite the admission note documenting slight sacral redness and the skin assessment identifying pressure ulcers on both buttocks. There was no documentation that the in-house wound care team evaluated the resident within 24–48 hours of admission, despite the DON’s statement that this was the facility’s protocol for all new admissions. Subsequent documentation showed that by mid- to late February, the resident had developed significant pressure injuries. Facility wound care documents dated 2/20/25 described Stage 3 pressure ulcers on both buttocks, and a care plan created 2/21/25 listed a Stage 4 pressure ulcer on the right buttock and a Stage 3 pressure ulcer on the left buttock, along with a skin tear on the right shin. Physician orders for wound care, repositioning every two hours, and later use of a low air loss mattress and specific topical treatments (Medi honey, calcium alginate, Santyl, hydro fiber, foam/dry dressings) were entered over the course of February. The contracted wound care company’s initial evaluation on 2/26/25 documented a Stage 4 wound on the right buttock measuring 7.9 cm x 4.5 cm x 0.3 cm and a Stage 3 wound on the left buttock measuring 6.7 cm x 8.6 cm x 0.3 cm. The wound care physician stated that new residents added to their service are to be seen within the same week, but the clinical record showed the initial wound care evaluation did not occur until 2/26/25, after the wounds had progressed to advanced stages.
High-Elopement-Risk Resident Sent Unescorted to Outside Appointment and Found Wandering in Street
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement appropriate interventions for a resident with severe cognitive impairment and a documented high risk for elopement when attending an outside medical appointment. The resident is an ambulatory male with diagnoses including encephalopathy and dementia with agitation, and an MDS BIMS score of 5 indicating severe cognitive impairment. An elopement risk evaluation completed shortly after admission scored the resident as high risk (score 9), noting that he roams or wanders throughout the facility, attempts to leave the facility unsupervised, does not respond favorably to redirection, is confused to time and place, and has the physical ability to leave the building. Interventions identified for this risk included a personal safety alarm device, exit and stairwell alarms, frequent monitoring, identification bracelets, a photo on a potential elopement list, and staff awareness of his wander/elopement risk. Despite these documented risks and interventions, the resident was sent to a dermatology appointment outside the facility without an escort. The Physician Order Sheet showed a scheduled dermatology appointment, and staff interviews confirmed that the resident went to this appointment alone. The Transportation Coordinator stated that this was the second time the resident had gone to that clinic without an escort and that nursing staff had indicated he was okay to go alone. The Administrator and Director of Nursing both reported that they understood the resident to be familiar with the clinic and environment and believed he did not require an escort at the time of the appointment, even though the resident’s care plans and elopement assessment documented dementia, confusion, wandering behavior, and high elopement risk. On the day of the appointment, the transportation company later reported to the facility that they could not locate the resident in the clinic lobby. The dermatology office reported that the resident had been seen and was in the waiting area, but the transportation company again reported he was not there. The Administrator subsequently located the resident walking on a residential side street near the clinic, where he stated he was going to see his mother and check his old house. The resident’s previous address was two miles from the clinic and required crossing busy streets and intersections. Facility documentation and staff interviews describe the resident as alert but confused, ambulatory, roaming from floor to floor in the facility, wearing a device that triggers alarms to prevent elopement, and at times believing he works at the facility and attempting to manage other residents. These documented behaviors and assessments, combined with the decision to send him unescorted to an outside appointment, led to the incident in which he left the medical building unsupervised and was found confused and wandering in the street. Additional documentation in the care plan and incident reports further supports the resident’s cognitive and behavioral status at the time of the deficiency. Care plans noted impaired cognitive function/dementia, altered thought processes, and movement behaviors interpreted as wandering, with interventions such as cueing, reorientation, supervision, direction, redirection, and staff monitoring. An incident report from two days before the appointment described the resident pulling another resident’s shirt because he believed he worked at the facility and was trying to get the other resident off a chair, leading to a care plan intervention for staff to monitor him as he stationed himself at the front door greeting others. Nursing staff and the CNA described him as alert, oriented to self, forgetful, confused, roaming, and wearing a wander device, with at least one nurse stating she was not aware he was an elopement risk and that there was no endorsement of this risk. The facility’s own policies on appointments/transportation and elopement state that residents will be assessed for wandering/elopement risk, that those identified will have these issues addressed in their care plans, and that depending on medical, physical, and cognitive needs, residents may require an escort for outside appointments if no family or representative is available. These documented assessments, behaviors, and policies contrast with the decision to allow the resident to attend the appointment without an escort, which directly preceded the resident leaving the clinic unsupervised and being found wandering in the street. The Medical Director, identified as the resident’s primary physician, stated that the resident is confused and has dementia and that, if he was assessed and documented as high risk for elopement, it would be preferable for him to be escorted during medical appointments. Social services staff and the DON, however, expressed the belief that the resident did not require an escort at that time because he was responsive, pleasant, agreeable, redirectable, and familiar with the clinic. The discrepancy between the documented high elopement risk and the staff’s decision-making regarding supervision for outside appointments, along with the lack of consistent staff awareness of his elopement risk, are central to the events that led to the resident leaving the medical building unsupervised and being found wandering in the community.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders regarding oxygen therapy for two residents with respiratory disorders. For one resident with COPD and chronic respiratory failure, surveyors observed the resident using a nasal cannula incorrectly by placing it in his mouth instead of his nose, and noted discrepancies in oxygen flow rates between the concentrator and portable tank. The resident reported infrequent changes of oxygen tubing and delays in replacing portable oxygen tanks. The oxygen concentrator and tank were set at different flow rates than ordered, and the resident's Medication Administration Record (MAR) did not accurately reflect the physician's order or document the amount of oxygen administered to maintain the required oxygen saturation. Additionally, the nebulizer mask was left exposed and the machine was placed on the floor, contrary to infection control practices. The Director of Nursing confirmed that the MAR and Treatment Administration Record (TAR) did not accurately reflect the physician's orders, and that tubing changes were not documented as required. For another resident with chronic respiratory failure and emphysema, surveyors found the resident receiving oxygen at a lower flow rate than ordered and using tubing that had not been changed according to the prescribed schedule. The MAR indicated the correct order, but there was no documentation of oxygen administration on the day of the survey. The resident's nebulizer masks were also left exposed, and staff acknowledged that the physician's orders for oxygen flow rate and tubing changes were not being followed. Facility policies require that physician orders be followed as written and that oxygen therapy be administered and documented according to those orders, but these procedures were not adhered to for the residents reviewed.
Failure to Protect Resident from Employee-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from employee-to-resident abuse, resulting in the resident sustaining redness, mild swelling, and facial bruising. The incident began when a Certified Nurse Aide (CNA) entered the resident's room without knocking or announcing herself, which upset the resident. The CNA retrieved the resident's urinal jug for the roommate, further agitating the resident, who then threw coffee at the CNA. In response, the CNA became aggressive, threw items in the room, and struck the resident in the face with a closed fist. The resident sustained visible injuries, including scratches and a bruise under the right eye, as confirmed by staff observations, police, and hospital records. The resident, who was alert and oriented with a BIMS score of 15, refused a full body assessment but was observed with new facial injuries not present during the previous shift. The incident was witnessed by staff who responded to the CNA's call for help and observed both the coffee stain on the CNA and the resident's injuries. The police and emergency medical services were called, and the resident was transported to the hospital for evaluation. Documentation from nursing progress notes, police, and hospital records corroborated the sequence of events and the resulting injuries.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prevention policy by not reporting an injury of unknown origin in a timely manner. On 6/18/25, a resident was assessed by the Restorative Nurse and the Director of Nursing, with the surveyor present, and was observed to have discoloration on both sides of the breasts. Staff interviews confirmed that any injury of unknown origin should be reported immediately to the Administrator for investigation and to the state agency, but this was not done. The Director of Nursing acknowledged that the incident was not reported to the Illinois Department of Public Health (IDPH) as required, and the Administrator admitted that the initial report was not sent in a timely manner, despite staff being aware of the reporting protocol. The resident involved had multiple diagnoses, including cerebral infarction, coronavirus, anemia, type 2 diabetes mellitus, hyperlipidemia, heart failure, and hypertension. A progress note indicated that bruising was observed on 6/13/25, but the incident was not reported to IDPH until 6/18/25. The facility's abuse prevention policy, revised in November 2023, requires prompt reporting of all injuries of unknown source to appropriate authorities, including the state licensing agency, the resident's representative, attending physician, and medical director. The failure to follow this policy resulted in a deficiency for not reporting the injury of unknown origin as required.
Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who required a two-person assist for transfers using a mechanical lift, was transferred by only one certified nurse aide (CNA). The resident had a complex medical history including a displaced fracture of the left femur, osteoarthritis, hemiplegia, dementia, and was identified as being at high risk for falls. The care plan and facility policy both specified that two staff members were required for mechanical lift transfers, and this was known to the CNA involved. During the transfer, the CNA noticed the resident's left foot was not positioned correctly on the lift and attempted to adjust it. At that moment, the resident let go of the grab bar and slid off the lift to the floor. The CNA, who was alone, assisted the resident back to bed. The incident was not immediately reported as a fall, and initial assessments did not reveal injury. However, the following day, the resident complained of hip pain, and an X-ray confirmed a left femoral neck fracture, requiring hospital transfer and surgical intervention. Interviews with staff, including the CNA, nurses, the DON, and the administrator, confirmed that the facility's policy and the resident's care plan required a two-person assist for mechanical lift transfers. The CNA stated she was aware of this requirement but proceeded alone because other staff were unavailable. Facility documentation and staff interviews consistently indicated that the standard of care was not followed, directly resulting in the resident's fall and injury.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to a resident with a significant risk for falls. The incident involved a resident with a history of multiple falls, dementia, impaired balance, and other co-morbidities, who was found sitting on the floor after being left unsupervised. At the time of the incident, a CNA assigned to supervise the resident in the dining room was observed attending to her cellphone and was unaware that the resident had slid off the wheelchair. The incident was reported by another resident, not by staff, indicating a lapse in direct supervision. The resident's care plan and fall risk assessment identified her as being at high risk for falls, with interventions in place such as offering toileting after dinner and monitoring due to impulsivity and unsteadiness. Despite these documented risks and interventions, the staff member responsible for supervision was distracted and did not notice the resident's fall. Facility policy requires staff to provide an environment free from accident hazards and to supervise residents to prevent avoidable accidents, but this was not followed in this instance.
Failure to Protect Resident from Abuse and Inadequate Response to Allegation
Penalty
Summary
A cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia reported being physically and verbally abused by an agency CNA during the night. The resident described being roughly handled, punched in the back multiple times, threatened, and intimidated by the staff member, who also instructed her not to use the call light. The resident was left feeling unsafe and distressed, ultimately leading her to discontinue her rehabilitation and request discharge home. The incident was not immediately reported to the resident's family or physician, and the resident's family only learned of the abuse when visiting later that day. Facility staff, including an RN and the LPN night supervisor, failed to conduct or document any physical or psychosocial assessment of the resident following the allegation of abuse. Both staff members acknowledged in interviews that no assessment was performed to determine if the resident had sustained injuries. Additionally, there was no documentation of efforts to notify the resident's family or physician about the incident, and no interdisciplinary notes reflected any follow-up assessment or intervention for the resident's well-being after the alleged abuse. The facility also failed to ensure proper screening and training of agency staff. The human resources director stated that agency staff records and training were not reviewed or maintained by the facility, and no documentation was provided to demonstrate that the agency CNA involved in the incident had been appropriately screened or trained in abuse prevention and reporting. The facility's own policy required prompt investigation, assessment, and reporting of abuse allegations, but these procedures were not followed in this case.
Failure to Thoroughly Investigate Alleged Abuse and Assess Resident
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving an alert and cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia. The resident reported to the night nurse that a CNA was verbally inappropriate, treated her roughly during incontinence care, and threatened her not to use the call light again. The CNA also refused to provide her name when asked. The nurse notified the administrator, who directed the CNA to leave the facility immediately. Although a body check was reportedly done with no injuries noted, there was no documented physical or psychosocial assessment of the resident after the incident, nor were efforts made or documented to reach the family, physician, or medical director at that time. The administrator did not interview or obtain statements from all relevant staff, including the night supervisor and the CNA involved in the incident. Other staff members who were working during the CNA's shift were not interviewed, and only residents from different units were interviewed as part of the internal review. The staffing agency manager confirmed that the CNA was simply blocked from future shifts but was not interviewed or reported to the CNA registry. The interim DON was not informed of the incident or involved in the investigation, despite being responsible for oversight of the nursing staff. Facility policy requires that all reports of abuse be thoroughly investigated, including interviews with all relevant staff, witnesses, and other residents who may have been affected, as well as a physical and psychosocial assessment of the alleged victim. The investigation did not meet these requirements, as key interviews and assessments were omitted, and documentation was incomplete regarding the resident's condition and notifications to appropriate parties.
Failure to Conduct Thorough Abuse Investigation and Resident Assessment
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving an alert and cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia. The resident reported to the night nurse that a CNA was verbally inappropriate, treated her roughly during incontinence care, and threatened her not to use the call light. The nurse notified the administrator, who directed the CNA to leave the facility and performed a body check, noting no visible injuries. However, there was no documented assessment of the resident's psychosocial well-being or further physical assessment after the incident. The internal investigation was incomplete, as the administrator did not obtain written statements or conduct interviews with all relevant staff, including the night supervisor and the CNA involved in the incident. Other staff members working during the CNA's shift were not interviewed, and the Director of Nursing was not informed or involved in the investigation. Additionally, the facility did not attempt to interview other residents who may have been affected by the alleged abuser, despite having access to a list of residents cared for by the CNA on the night of the incident and previous shifts. Facility policy requires a comprehensive investigation, including interviews with all relevant staff, witnesses, and potentially affected residents, as well as thorough documentation and assessment of the alleged victim. The investigation did not meet these requirements, as key interviews and assessments were omitted, and there was a lack of documentation regarding communication with the resident's family, physician, or medical director.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its weight monitoring policy, resulting in significant unplanned weight loss for three residents. One resident, on a pureed diet, experienced a 6.15% weight loss over a month. Despite being observed consuming only 20% of meals, staff did not assist or encourage eating, and the resident was not re-weighed as required by policy. The registered dietitian was unaware of the weight loss and no documentation indicated that the physician was notified. Another resident, with a history of muscle weakness, dementia, and other conditions, experienced an 11.2% weight loss over six months. The resident's weight was not documented as per the physician's orders, and the dietitian was only made aware of the appetite change after a significant period. The facility's policy required weekly weights to monitor stability and effectiveness of interventions, which was not followed. A third resident, diagnosed with malignant neoplasm of the endometrium and other conditions, experienced a 15.3% weight loss over six months. The resident's care plan included a nutritional supplement, but it was not implemented or documented in the medication administration record. The resident's family often brought food from home, and the resident expressed a preference for Polish food, which was not accommodated by the facility. The dietitian's recommendations were not followed, contributing to the resident's continued weight loss.
Failure to Follow Oxygen and CPAP/BiPAP Policies
Penalty
Summary
The facility failed to adhere to its policies on oxygen administration and CPAP/BiPAP support, affecting four residents. Observations revealed that a resident was receiving oxygen at 2 liters per minute via nasal cannula without appropriate signage on the door, which was later corrected. Another resident's oxygen concentrator machine had a humidifier bottle without a label or date, and there was no signage indicating oxygen use. This resident had been using a CPAP machine every night without a physician's order for its setup and flow, despite having a long history of CPAP use at home. Further observations showed another resident receiving oxygen at 4 liters per minute, contrary to the physician's order of 2-3 liters per minute, and the humidifier bottle was not labeled or dated. Additionally, a fourth resident was on 3 liters per minute of oxygen without a physician's order, and the humidifier bottle was also not labeled or dated. The Director of Nursing confirmed the need for proper signage, labeling, and adherence to physician orders as per the facility's policies.
Failure to Ensure Communication and Privacy for Residents
Penalty
Summary
The facility failed to ensure that residents could communicate with staff in their preferred language and did not maintain privacy and dignity for residents with medical devices. Specifically, a resident who only speaks Bulgarian reported that an interpreter was used for the first time during the surveyor's visit, despite the facility's policy requiring timely language access services. This lack of communication support left the resident feeling isolated and unable to express their needs effectively. Additionally, the facility did not maintain privacy for residents with indwelling catheters. Two residents were observed with catheter bags not placed in privacy bags, compromising their dignity. One resident had a catheter bag secured to the bed frame without a privacy bag, while another had a catheter bag dangling from the side of the bed. These observations indicate a failure to adhere to the facility's resident rights policy, which emphasizes treating residents with respect, kindness, and dignity.
Failure to Assess and Manage Pain for Non-English Speaking Resident
Penalty
Summary
The facility failed to accurately assess and manage the pain of a resident who only speaks Bulgarian. The resident reported experiencing daily headaches and migraines, which affected their sleep, but was unaware if any pain medication was being administered. The resident communicated their pain by pointing to their head, yet this was the first time an interpreter was used to facilitate communication since their admission. The nursing supervisor was informed of the resident's migraine during the surveyor's visit. The facility's medication administration policy requires staff to review the active medication list with residents, which was not effectively done in this case.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy regarding enhanced barrier precautions, which affected two residents out of a sample of 40. During an initial tour, signage indicating enhanced barrier precautions was observed outside the rooms of two residents. However, a registered nurse was seen providing gastrostomy tube care to one of these residents without wearing the appropriate personal protective equipment (PPE), specifically a gown. Additionally, a certified nurse aide was observed entering the room of the second resident to provide incontinence care without donning a gown, despite the enhanced barrier precautions in place. Interviews with facility staff revealed inconsistencies in understanding and implementing the infection control policy. The Infection Prevention Nurse stated that staff are expected to wear gowns and gloves when providing direct care to residents under enhanced barrier precautions. However, the registered nurse involved in the incident indicated that gowns should be worn only if there is a risk of spillage, which contradicts the facility's posted signage. This lack of compliance with the infection control policy highlights a deficiency in the facility's infection prevention and control program.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to adhere to its Abuse Investigation and Reporting policy by not submitting an initial report of an abuse allegation to the Illinois Department of Public Health (IDPH) in a timely manner. This deficiency affected two residents. One resident, who was alert and oriented, reported an incident where another resident hit him, causing him to spill coffee on himself. The police were called, and a report was filed. However, the Director of Nursing was not aware of the incident until the following day, and the Administrator was not fully informed, resulting in the failure to report the incident to the state. In another case, the facility did not report an abuse allegation involving another resident within the required timeframe. The incident occurred early in the morning, but the initial and final reports were only submitted three days later. The Administrator admitted to not reporting the incident immediately due to being occupied with the investigation and contacting the police. The facility's policy mandates that abuse or serious bodily harm should be reported immediately, but this was not followed, leading to a delay in reporting the incident to the appropriate authorities.
CNA Fails to Report Resident Fall, Resulting in Delayed Medical Attention
Penalty
Summary
Facility staff, specifically a Certified Nursing Assistant (CNA) identified as V3, failed to report a fall incident involving a resident, R2, to the nursing staff. This incident occurred when R2, who was admitted with diagnoses including Covid-19, urinary tract infection, Parkinson's, and overactive bladder, attempted to get water during the night and fell. R2, who required substantial assistance for transfers, was picked up by a male staff member and returned to bed without a nurse's assessment, resulting in a delay of over 10 hours before medical evaluation. The fall led to R2 sustaining a laceration on the left ear requiring eleven sutures and broken ribs. The facility's investigation revealed that V3 did not adhere to the protocol of reporting falls or changes in a resident's condition to a nurse. The Director of Nursing (DON) and the Administrator confirmed that the staff should have stayed with R2 and called for a nurse immediately after the fall. The facility's fall policy mandates that a licensed nurse should observe and document the clinical status of a resident for 72 hours following a fall. However, this protocol was not followed, leading to a significant delay in R2 receiving necessary medical attention.
Failure to Investigate Resident's Bruise and Notify Family
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's bruise of unknown origin and did not notify the family member of the investigation's outcome. The resident, a male with severe cognitive impairment and requiring maximal assistance for daily activities, was reported to have skin alterations on his left inner ear and cheekbone. The family member alleged that the bruises resulted from rough handling by a staff member and reported the incident to the police. Despite the facility's policy requiring interviews with all staff members in contact with the resident during the incident and the preceding 72 hours, no such interviews were conducted, and no statements were collected from the staff. The Quality Nursing Director and other staff members confirmed that the investigation was not conducted according to the facility's policy. The Administrator, responsible for the investigation, acknowledged the lack of documentation and communication with the family regarding the investigation's findings. The Director of Nursing also admitted to not participating in the investigation and failing to inform the family of the results. The facility's policy mandates thorough investigations and communication with the resident's representative, which were not adhered to in this case.
Failure to Implement Fall Prevention Program
Penalty
Summary
The facility failed to implement its fall prevention program policy, resulting in deficiencies affecting three residents. For Resident 1, the facility did not ensure that the call light was within reach, which contributed to a fall incident where the resident sustained a hip fracture. Despite being identified as high-risk for falls, the interventions from fall investigations were not consistently updated in the care plan. The resident had a history of multiple falls, and the fall risk assessment was inaccurately recorded as moderate instead of high risk. Resident 2 was identified as very high risk for falls and was supposed to be on the fall star program, which requires a star to be placed next to the resident's nameplate. However, this was not done, and the fall interventions developed from investigations were inconsistent with the care plan updates. The resident experienced seven falls in 2024, yet the fall risk assessments continued to indicate a moderate risk, contrary to the resident's history of multiple falls. For Resident 3, the facility did not maintain the bed in the lowest position, and the care card was not updated to reflect the resident's high fall risk. The resident had a fall incident resulting in a forehead laceration, but the fall risk assessment was inaccurately recorded as moderate. The facility's policies on fall prevention and accident investigation were not adequately followed, leading to these deficiencies.
Inadequate Supervision and Equipment Failure Lead to Resident Falls
Penalty
Summary
The facility failed to adequately supervise a resident at risk for falls, resulting in two separate incidents where the resident was injured. The resident, who is a total assist and dependent on staff for all activities of daily living, was left unsupervised in a dining area during an activity. The resident slid down from a high-back geriatric chair, bending and twisting his right leg, which led to a tibial fracture. The incident was not initially reported as a fall by the nurse on duty, as she did not consider it a fall since the resident did not hit the ground. The resident was later sent to the emergency department after swelling and pain were observed, where the fracture was diagnosed. In a second incident, the same resident was found on the floor beside his bed, which was not lowered to the ground due to a malfunctioning remote. The CNA on the previous shift had noticed the issue but did not take action to resolve it or report it to the appropriate personnel. The resident was again transferred to the emergency department after this fall. The facility's policy on fall prevention, which includes maintaining an environment free from accident hazards and providing supervision to prevent avoidable accidents, was not adhered to in these instances. The resident involved in these incidents is a male with a medical history that includes hemiplegia, diabetes, neoplasm of the prostate, and epilepsy. He is nonverbal, slightly confused, and requires a mechanical lift for transfers. The lack of supervision and failure to provide necessary assistive devices, such as footrests on the wheelchair and a functioning bed, contributed to the resident's falls and subsequent injuries.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to adequately supervise a resident with a history of falls, resulting in a displaced nasal bone fracture. The resident, who has multiple medical conditions including progressive supranuclear palsy and unsteadiness on feet, had three falls since January 2024. These falls were unwitnessed and occurred at the nursing station and activities room, leading to injuries including a minimally displaced nasal bone fracture. Despite interventions in the fall care plan, such as closely monitoring the resident and keeping her near the nurses' station, the resident continued to fall when staff were not looking. Observations revealed that the resident was often placed in a regular wheelchair instead of a broader chair, which her POA had requested for better safety. The POA expressed concerns about the resident's care, stating that the facility did not have enough staff to provide 1:1 supervision and often placed the resident in areas where she was not adequately monitored. The Director of Nursing (DON) acknowledged that the resident required constant supervision and that the facility's interventions were not effectively preventing falls. Staff interviews confirmed that the resident was a high fall risk and required constant supervision. On the day of the incident, the activity aide reported that she could not watch the resident due to the high number of residents in the activities room. The resident followed a nurse out of the room and fell face down from her wheelchair before the aide could reach her. The facility's fall policy emphasizes the need for fall risk assessments and close monitoring, but these measures were insufficient in preventing the resident's falls and subsequent injury.
Food Service and Sanitation Deficiencies
Penalty
Summary
The facility failed to follow their policy and procedures for food service and sanitation, affecting all 98 residents receiving meals from the kitchen. Observations revealed that a food service worker wore her hair net improperly, exposing her hair. The dietary manager ran temperature test strips through the high-temperature dishwasher, which did not change to the required orange color, indicating the final rinse temperature was not 180 degrees. The temperature gauge on the dishwasher was non-functional, and attempts to measure the temperature with an irreversible maximum registering thermometer were unsuccessful. Despite these issues, the kitchen staff continued to use the dishwasher for cleaning dishes instead of switching to disposable dishware. Additionally, a cook was observed not performing hand hygiene between tasks, and another food service worker touched his face and then handled clean utensils without washing his hands properly. The dietary manager acknowledged these lapses but did not take immediate corrective actions. The facility's policies for dish machine temperature, disposable glove use, and hand hygiene were not adhered to. The dishwasher temperature policy required the use of test strips or an irreversible maximum registering thermometer to verify the surface temperature of dishes, but neither method was effectively used. The disposable glove use policy mandated hand washing before and after glove use, which was not followed by the kitchen staff. The hand hygiene policy required washing hands before handling clean utensils and after touching skin or clothing, which was also not observed. The industrial blender's functionality was incorrectly attributed to the dishwasher's temperature, despite the manufacturer's instructions not mentioning such a feature. These deficiencies indicate a significant lapse in maintaining food service and sanitation standards in the facility's kitchen.
Failure to Implement Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to have a policy for pest control and did not implement effective pest control treatments and interventions, affecting all 98 residents receiving meals from the kitchen. Observations on 04/30/2024 revealed multiple gnats throughout the kitchen area, and the Dietary Manager acknowledged the presence of gnats, expressing concern about their potential contact with food. Additionally, the Maintenance/Housekeeping Director discovered multiple roach-like insects under the dishwashing machine, indicating a pest issue. The facility's pest control invoices from February to April 2024 documented repeated observations and treatments for fruit flies, gnats, and German roaches in the kitchen area, particularly around the dishwashing room. Despite these treatments, the pest problem persisted, with heavy German roach activity noted on multiple occasions. The local health inspector's visit on 04/23/2024 confirmed the presence of more than the allowed number of gnats, necessitating a follow-up inspection. The facility's Pest Control Invoice dated 05/01/2024 further documented multiple German roach nymphs around the dishwashing area. The facility did not provide a pest control policy when requested on 05/01/2024 and later reported on 05/03/2024 that they did not have one. This lack of a formal pest control policy and the ongoing pest issues in the kitchen area highlight the facility's failure to maintain a sanitary environment for food preparation and service, posing a potential risk to the residents' health and safety.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its enhanced barrier precaution policy by not placing any signage with informational material on residents' doors or making personal protective equipment (PPE) available inside or outside residents' rooms. This deficiency affected 9 residents on the first floor and 17 residents on the second floor who were receiving wound care, had an indwelling urinary catheter, IV line, or G-tube, and had the potential to affect all 104 residents at the facility. During a random observation, a unit scheduler was seen putting up enhanced barrier isolation signs without understanding their purpose, and a registered nurse (RN) was observed assisting a resident without using appropriate PPE. The RN mentioned that the facility had not completed any in-services on enhanced barrier precautions before, and the isolation bins were not properly stocked with necessary PPE. The interim Assistant Director of Nursing (ADON) and Infection Preventionist (IP) admitted that the in-services on enhanced barrier precautions had just started that day, despite the policy requiring full implementation in accordance with CMS regulatory requirements for F880. The ADON/IP acknowledged that the signs were posted and in-services initiated only after consulting with the corporate director of quality assurance. The facility's policy stated that enhanced barrier precautions should be implemented for residents with wounds, indwelling medical devices, or colonization with multi-drug resistant organisms (MDROs), but this was not followed, leading to the observed deficiencies.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in accordance with its policy and procedure. A resident, a [AGE] year old female with diagnoses including mixed anxiety, depressed mood, and dementia, reported to a registered nurse that an evening CNA had removed her clothes, grabbed her, and walked with her. Despite this report, the incident was not communicated to the abuse coordinator or the Administrator, and no Facility Reported Incident was filed for this allegation at the time it occurred. The Administrator only became aware of the incident when informed by the surveyor, and a Facility Reported Incident was subsequently filed with a significant delay. The facility's policies on Abuse Investigation and Reporting and Abuse Prevention require that all reports of resident abuse be promptly reported to local, state, and federal agencies and thoroughly investigated by community management. However, the staff failed to adhere to these policies, as evidenced by the lack of immediate reporting and investigation of the resident's allegation. The Director of Nursing confirmed that there were no Facility Reported Incidents of abuse for the resident over the last three months, indicating a lapse in following the established procedures for handling such reports.
Failure to Immediately Suspend Staff Accused of Abuse
Penalty
Summary
The facility failed to follow their abuse policy by not immediately suspending a staff member accused of physical abuse towards a resident. The incident involved a male resident with multiple fractures and a history of traumatic brain injury. The resident reported to his representative that a physical therapy assistant hit him on the head while providing care. The representative then informed the nurse on duty about the incident. Despite the facility's policy requiring immediate suspension of the accused staff member, the physical therapy assistant continued to work the day after the allegation was reported before being suspended pending investigation. The Director of Nursing received the abuse allegation and notified the Administrator. The Director instructed the nurse to conduct a physical assessment of the resident and interviewed the accused staff member the following day. However, the staff member was allowed to work a full shift before being suspended. The facility's policy clearly states that any employee accused of resident abuse should be immediately suspended pending the outcome of the investigation, which was not adhered to in this case.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to two residents who were assessed with limited range of motion. One resident, a [AGE] year old male with multiple diagnoses including anxiety, depression, hypertension, and seizure disorder, reported that he barely ever gets out of bed and never receives any restorative therapy for his contracted left leg. He expressed discomfort and pain from having to sit in his chair for upwards of eight hours due to insufficient staff to assist him back to bed. Another resident, a [AGE] year old male with diagnoses including hypertension, unsteady gait, developmental delay, and dysphagia, was observed sitting in a wheelchair and expressed frustration about not being able to walk since being discharged from therapy. He reported that he is always in his chair and wants to get out, but there is no restorative program to support his mobility needs. Interviews with the Director of Nursing, a Certified Nursing Assistant, and the Director of Rehab confirmed that the facility does not currently have a restorative program. The Director of Rehab mentioned that therapists typically recommend restorative services upon a resident's discharge from therapy, but the absence of a restorative program means that residents are not receiving the necessary support to maintain their functional status. The facility's policy on restorative nursing, last reviewed in December 2022, states that services should be provided per the resident's care plan to promote their highest practicable level of functioning, but this policy is not being implemented due to the lack of a restorative program.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident (R104) who was at risk for weight loss and required extensive feeding assistance. Observations revealed that staff members delivered meal trays to R104 but did not offer assistance with eating. On multiple occasions, R104's meal trays were left untouched, and no staff members attempted to help her with her meals. Family members also reported that staff did not offer meals or assistance to R104, and the resident herself expressed that she needed more help from the facility. Despite the resident's need for assistance, staff members did not follow the facility's policy and procedures for feeding assistance, which included sitting down with the resident, offering the meal again if initially declined, and providing supplements if necessary. On one occasion, a CNA delivered R104's breakfast tray but did not assist her with eating, and the tray was later collected untouched. During another observation, a CNA was more focused on preparing R104 for a chemotherapy appointment rather than ensuring she had eaten her meal. The CNA did not offer the meal again or provide any alternatives, and R104 left for her appointment without eating. The Director of Nursing (V2) confirmed that the facility's policy required CNAs to offer feeding assistance, reapproach residents if they initially declined, and notify the nurse if the resident continued to refuse food. However, these procedures were not followed in R104's case. R104's care plan and nutritional risk assessment documented her need for extensive feeding assistance and the importance of maintaining her weight due to her medical conditions, including malignant pancreatic cancer and protein-calorie malnutrition. Despite these documented needs, the facility did not ensure that R104 received the necessary feeding assistance, leading to her meals being left untouched and her nutritional needs not being met. The facility also failed to provide a protocol or procedure for feeding residents who require assistance during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,659 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Park Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Ridge Healthcare Center | 0.5 mi | ★★★★★ | 2 | 0 |
| Avantara Park Ridge | 0.8 mi | ★★★★★ | 0 | 0 |
| Rivaya Care Of Des Plaines | 1.5 mi | ★★★★★ | 9 | 0 |
| Elevate Care Regency | 1.8 mi | ★★★★★ | 2 | 2 |
| Elevate Care Niles | 2 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.