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 Irving Park Living & Rehab Ctr during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe cognitive and physical impairments was injured during a mechanical lift transfer when two CNAs failed to adequately monitor and respond to the resident's agitation, resulting in the resident's foot striking the bed and sustaining a laceration that required sutures. Staff interviews and documentation confirmed that proper supervision and intervention were not provided during the transfer.
The facility failed to follow proper food safety and sanitation practices, affecting all 75 residents receiving food from the kitchen. Cooking equipment was not sanitized for the required 60 seconds, and several food items lacked proper labeling and were past their use-by dates, including deli meats, cheese, and cucumbers. Mold was found on Parmesan cheese, and incorrect labeling was noted on pudding and lemon-flavored water nectar. These deficiencies could lead to foodborne illnesses.
The facility failed to maintain proper sanitation by not keeping dumpster lids closed, potentially attracting pests. A smaller dumpster was overfilled, leaving its lid open, while a larger dumpster's lid was propped open due to improper arrangement of contents. The Cook and Maintenance Director acknowledged the issue, noting the importance of closed lids to prevent rodent attraction. Facility policy mandates timely garbage pick-up and proper containment to prevent pests.
A facility was found deficient in infection control practices, including inadequate hand hygiene by an RN during medication administration and improper PPE use during a gastric tube flush. Additionally, clean linens were left uncovered, and soiled linens were not properly bagged, violating the facility's infection prevention policies.
The facility failed to provide a $60 monthly allowance to eligible residents receiving SSA benefits, despite an increase from $30 to $60 effective January 2024. This affected 16 residents, including one who confirmed receiving only $30. The BOM was aware of the increase but it was not implemented due to staffing issues, violating residents' rights to the correct allowance.
The facility failed to maintain adequate hot water temperatures in several residents' rooms and a third-floor shower room, with temperatures significantly below the required 110 degrees Fahrenheit. Residents resorted to using microwaved water for bed baths. Additionally, the facility did not ensure a safe smoking patio environment, as snow and ice were not removed, posing a fall risk. The Maintenance Director was preoccupied with the annual survey and failed to clear the area.
The facility failed to securely store and properly label medications. A nurse left Aspirin pills unattended on a medication cart, and expired medications were found in storage areas. Additionally, a Breztri aerosphere lacked an open date label. The DON confirmed the need for proper medication disposal and secure storage.
The facility failed to follow standardized pureed recipes, affecting residents on pureed diets. Observations revealed that pureed bread and noodles were not served, and oatmeal was not pureed, contrary to dietary guidelines. The cook cited time constraints, while the Dietary Manager believed oatmeal was soft enough. The Speech Language Pathologist and Consultant Dietitian stressed the importance of adhering to recipes to ensure safety and nutritional adequacy.
The facility failed to provide fortified supplements as prescribed for six residents. The cook prepared oatmeal instead of the prescribed super cereal, mistakenly believing it was equivalent. The dietary manager and consultant dietitian confirmed that super cereal is a fortified food ordered by the physician for residents needing to gain weight. Documentation showed that super cereal was listed on meal tickets and physician orders, but it was not prepared according to the specified recipe.
The facility failed to provide education and assess eligibility for pneumococcal vaccinations for several residents, as required by their policy and CDC guidelines. Despite having chronic conditions and cognitive impairments, these residents did not receive the necessary information or documentation in their medical records, leading to a deficiency in care.
The facility failed to include and update advance directives in the care plans of three residents, leading to discrepancies between care plans and physician orders. One resident's care plan incorrectly indicated a full code status despite having a DNR order, while two others lacked any care plan for advance directives despite having full code orders. This oversight contravenes the facility's policy requiring advance directives to be part of the care plan and reviewed quarterly.
A resident with a PICC line for IV antibiotic therapy did not have their dressing changed as per facility policy, which requires changes every 5-7 days. Observations showed the dressing was overdue for a change, confirmed by both the resident and nursing staff. This failure to adhere to professional standards could lead to infection risks.
A facility failed to ensure a resident with a tracheostomy had the required emergency equipment at the bedside. The resident, with chronic respiratory failure, was observed without an emergency step-down tracheostomy tube readily available. A nurse had to retrieve the tube from the supply room, indicating it was not immediately accessible. The facility's policy requires such equipment to be at the bedside to prevent airway closure if the tracheostomy becomes dislodged.
The facility failed to ensure accurate accountability for controlled substances, leading to discrepancies in medication counts for Clonazepam and Tramadol. Missing nurse initials on the Shift Change Accountability Record indicated incomplete narcotic counts. An LPN confirmed the procedure for counting and signing off on narcotics, while the DON emphasized the importance of accurate records. The facility's policy requires two licensed nurses to verify narcotic log sheets, but failure to follow procedures resulted in unaccounted controlled substances.
A resident with Type 2 Diabetes Mellitus did not receive the prescribed insulin dose due to a nurse's failure to perform a blood glucose check and prime the insulin pen. The nurse administered 15 units of Basaglar insulin without priming the needle, potentially resulting in an incorrect dose. The facility's policies require priming to ensure accurate dosing and prevent air injection.
A resident's personal refrigerator was found to be improperly managed, with a temperature of 58°F and containing expired and undated food items. The facility's policies for maintaining refrigerator temperatures and discarding expired food were not followed, posing a potential health risk to the resident.
A resident with mild dementia and anxiety was verbally and physically abused by her roommate, who also has dementia and a major depressive disorder. The incident involved verbal aggression and physical actions, resulting in a skin tear. Facility staff were aware but failed to immediately report the incident to the administrator, violating the facility's abuse prevention policy.
A facility failed to notify a resident's family about a hospitalization due to suicidal ideation, as required by their policy. The resident's POA requested a report but did not receive an update. The Director of Nursing claimed to have contacted the POA, but there was no documentation in the electronic health record to confirm this communication.
A facility failed to protect residents from sexual abuse, as a male resident with cognitive impairments allegedly assaulted another male resident. Despite a history of inappropriate behavior, the facility did not update interventions in the resident's care plan, leading to repeated incidents. The facility's abuse prevention policy was not effectively implemented, and the investigation into the incident remained inconclusive.
A facility failed to promptly investigate an alleged incident of staff-to-resident abuse when a resident reported being struck in the groin by a CNA during care. The incident was reported by the resident's family, but the facility delayed initiating a formal investigation, contrary to its abuse prevention policy. The resident, who had a urinary catheter, experienced pain and reported the CNA's rough handling, but the facility initially treated the report as a concern rather than potential abuse.
A resident in a LTC facility experienced repeated unwanted touching by another resident, leading to psychosocial harm. Despite the resident's complaints and evidence provided to staff, the behavior persisted, indicating a failure in the facility's abuse prevention measures.
A resident with chronic pain did not receive PRN Oxycodone for breakthrough pain as ordered by their physician. Despite the resident's request and the physician's instructions, the nursing staff failed to administer the medication, citing a misunderstanding of the timing between scheduled and PRN doses. The facility's documentation confirmed the resident's claim, highlighting a deficiency in pain management practices.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Injury During Mechanical Lift Transfer Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, neuroleptic-induced parkinsonism, and significant functional limitations was being transferred using a mechanical lift by two CNAs. During the transfer from a specialized chair to the bed, the resident became agitated and moved around, resulting in his right foot striking the footboard of the bed. This incident caused a laceration to the resident's right fifth toe, which required hospital treatment and sutures. Staff interviews revealed that two CNAs were present during the transfer, with one operating the mechanical lift and the other guiding the resident. Both staff members acknowledged the need for careful monitoring during mechanical lift transfers, especially for residents who are dependent and may become anxious or impulsive. The DON stated that the staff should have stopped the transfer and notified the nurse when the resident became agitated, but this did not occur, leading to the injury. Documentation confirmed that the resident was dependent for all ADLs and required substantial/maximal assistance, with a care plan specifying the use of a mechanical lift and two-person assist for transfers. The facility's policy also required two staff for safe mechanical lift operation. Despite these protocols, the resident sustained an injury during the transfer due to inadequate supervision and failure to appropriately respond to the resident's agitation.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in its kitchen, which could potentially affect all 75 residents receiving food prepared there. During a kitchen tour, it was observed that cooking equipment was not being sanitized according to the manufacturer's directions. Specifically, the equipment was dipped in the sanitizing solution for less than 10 seconds, whereas it should have been submerged for at least 60 seconds to ensure proper sanitation. This improper sanitization process was acknowledged by the Dietary Manager, who confirmed that inadequate sanitization could lead to foodborne illnesses. Additionally, the facility did not adhere to proper food labeling and storage practices. Several food items in the reach-in coolers were found without proper labeling, including opened packages of deli ham, turkey, and Swiss cheese, which lacked open or use-by dates. An unopened bag of grated Parmesan cheese was found with visible mold, and cucumbers showed signs of spoilage. Furthermore, a container of butterscotch pudding and a container of lemon-flavored water nectar were labeled with incorrect use-by dates, indicating they were past their safe consumption period. The facility's policies require all food items to be labeled with a prepared or opened date and a use-by date to prevent serving expired items, but these practices were not followed, posing a risk of foodborne illness to residents.
Improper Dumpster Management Leads to Sanitation Deficiency
Penalty
Summary
The facility failed to ensure proper sanitation practices by not keeping the dumpster lids closed, which could lead to the harborage and feeding of pests, insects, and rodents. During an observation, a smaller dumpster near the back door was found overfilled with garbage bags, leaving the lid open. A larger dumpster in the parking lot was also observed with its lid propped open due to an old refrigerator and empty cardboard boxes inside, preventing the lid from closing. The Cook (V12) acknowledged the issue, stating that the smaller dumpster was too full to close the lid and that the larger dumpster had room for more garbage but was not properly arranged to allow the lid to close. The Maintenance Director (V6) confirmed that the lids should be closed to prevent rodent attraction, noting that the facility uses a pest control company with rat houses set up around the building. The facility's policy requires timely garbage pick-up and proper containment to prevent pests, with the maintenance director or designee responsible for ensuring dumpsters are covered at all times.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as observed during a survey. A Registered Nurse (RN) was seen administering medications to residents without performing hand hygiene between resident contacts. Specifically, the RN did not wash hands after handling medication cups and before preparing medications for another resident. This lapse in hand hygiene occurred despite the presence of Enhanced Barrier Precautions for residents with specific medical conditions, such as a PICC line, Foley catheter, and Klebsiella Pneumoniae, which require strict infection control measures. Additionally, the RN failed to wear appropriate Personal Protective Equipment (PPE) during a high-contact resident care activity. While flushing a gastric tube for a resident, the RN did not don a gown, which is required under Enhanced Barrier Precautions. This oversight was acknowledged by the RN, who admitted the potential for infection spread due to not wearing a gown during the procedure. The facility also demonstrated deficiencies in the handling and storage of linens. Clean linens were observed uncovered and exposed to potential contaminants in the basement hallway, contrary to the facility's policy requiring linens to be covered when not in use. Soiled linens were not properly bagged before being placed in the laundry chute, increasing the risk of contamination. These practices were inconsistent with the facility's infection prevention and control program, which mandates annual review and adherence to established guidelines.
Failure to Implement Increased Monthly Allowance for SSA Residents
Penalty
Summary
The facility failed to provide a $60 monthly allowance to eligible residents receiving Social Security Administration (SSA) benefits, despite an increase from $30 to $60 that took effect in January 2024. This deficiency affected 16 eligible residents, including one resident who was alert and oriented, and who confirmed during a resident council meeting that he had been receiving only $30 per month. The Business Office Manager (BOM) acknowledged awareness of the increase but stated that the facility had not yet implemented it. The Administrator confirmed that the resident should have been receiving the increased allowance and verified the oversight with corporate staff. The facility's Trust Fund Policy, effective January 2024, stipulated that residents receiving SSA benefits should receive a $60 monthly allowance. However, due to staffing issues, the increase was not implemented, and residents continued to receive the outdated amount. The facility's failure to adjust the allowance in accordance with the updated policy resulted in a violation of residents' rights to receive the correct personal needs allowance.
Deficiencies in Hot Water Supply and Smoking Patio Safety
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not ensuring adequate hot water temperatures in several residents' rooms and a third-floor shower room. Residents reported that the water in their rooms was not warm enough for bathing, with some having to resort to using microwaved water for bed baths. The water temperatures in the affected areas were measured significantly below the required 110 degrees Fahrenheit, with readings ranging from 63 to 72 degrees Fahrenheit. The issue arose after one of the facility's hot water tanks rusted and failed, and a replacement was ordered but not yet delivered. Additionally, the facility did not maintain a safe smoking patio environment, as snow and ice were not removed, posing a potential fall risk to residents. On one occasion, six residents were observed smoking on a patio covered with snow and ice. The Maintenance Director was responsible for snow removal but was preoccupied with the annual survey and failed to clear the area. The Social Service Director acknowledged the oversight and intended to address it. The report highlights the residents' dissatisfaction and discomfort due to the lack of hot water, with some residents unable to shower or bathe adequately. The facility's policies on water temperature, smoking safety, and fall prevention were not adhered to, contributing to the deficiencies observed by the surveyors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications, as observed during a survey. A registered nurse left a clear cup containing Aspirin 325 mg pills unattended on top of a medication cart while administering medications to residents. This occurred multiple times, leaving the medication accessible to anyone passing by. The nurse acknowledged the oversight when questioned by the surveyor, admitting that someone could have taken the pills. Additionally, the survey revealed expired medications in the facility's storage areas. In the second-floor medication storage room, a bottle of Liquid Pain Relief Acetaminophen was found with an expiration date of 12/24. Similarly, a medication cart contained expired bottles of B complex and docusate sodium liquid, both with expiration dates of 10/24. Furthermore, a Breztri aerosphere was found without an open date label, contrary to the facility's policy requiring opened medications to be dated. The Director of Nursing confirmed that expired medications should be removed and properly disposed of, and that medications should not be left unattended on medication carts.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to adhere to standardized pureed recipes during food preparation, affecting seven residents on pureed diets. During a dining tour, it was observed that residents on regular diets received roast turkey, egg noodles, mixed vegetables, fruit cup, and bread with margarine, while those on pureed diets received pureed turkey, mashed potatoes, pureed vegetables, and pureed dessert. Notably, pureed bread and pureed buttered noodles were not served to residents on pureed diets. The cook, V12, admitted to substituting mashed potatoes for pureed egg noodles and not preparing pureed bread due to time constraints. Additionally, during breakfast, oatmeal was served to both regular and pureed diet residents without being pureed, as V12 and the Dietary Manager, V11, believed it was soft enough. The Speech Language Pathologist, V21, emphasized the importance of pureeing foods like oatmeal to prevent choking and aspiration risks for residents with mastication difficulties. The Consultant Registered Dietitian, V19, highlighted the necessity of following diet spreadsheets and recipes to ensure meals meet dietary requirements and maintain the correct texture and consistency. The facility's documentation, including physician order sheets, meal tickets, diet spreadsheets, and recipes, indicated that pureed buttered noodles and bread should have been served, and oatmeal should have been pureed. The failure to follow these guidelines could potentially lead to nutritional deficiencies and compromised safety for residents on pureed diets.
Failure to Provide Prescribed Fortified Supplements
Penalty
Summary
The facility failed to provide fortified supplements as prescribed by the physician for six residents. During an observation of the breakfast tray line, it was noted that the cook prepared only one type of hot cereal, oatmeal, instead of the prescribed super cereal. The cook mistakenly believed that adding brown sugar and cinnamon to oatmeal made it equivalent to super cereal, which is incorrect. The dietary manager confirmed that super cereal is a fortified food specifically recommended by the registered dietitian and ordered by the physician for residents needing to gain weight. The super cereal is listed on the residents' meal tickets to be served at breakfast daily, and there is a specific recipe that should be followed. The consultant registered dietitian explained that fortified foods like super cereal are used to add extra calories and protein to a resident's diet, particularly for those losing weight. If super cereal is ordered by the physician, it should be provided to the resident to ensure the planned or desired weight gain occurs. The facility provided documentation showing that the residents' breakfast meal tickets and physician orders included super cereal. However, the cook did not prepare it according to the specified recipe, which includes ingredients such as non-fat dried milk, evaporated milk, margarine, brown sugar, and granulated sugar. This failure to provide the prescribed fortified supplement could potentially impact the residents' nutritional status and weight gain goals.
Failure to Provide Pneumococcal Vaccination Education and Assessment
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of pneumococcal vaccinations to eligible residents or their representatives. This deficiency was identified through interviews and record reviews, which revealed that several residents, including those with severe cognitive impairments and chronic conditions, did not receive the necessary education or assessment for pneumococcal vaccination eligibility. The facility's policy mandates that residents or their representatives be informed about the significant risks and benefits of vaccines, but this was not documented in the residents' medical records. The surveyor's findings highlighted that five residents, among a sample of 48, were not assessed for pneumococcal vaccination eligibility, nor were they offered the vaccine. These residents had various medical conditions, such as Alzheimer's disease, dementia, hypertension, diabetes, and chronic kidney disease, which could increase their risk of complications from pneumococcal infections. Despite the facility's policy and CDC guidelines, there was no documentation of education or assessment in the records of these residents, indicating a lapse in following the established procedures. Interviews with the facility's Infection Preventionist and Director of Nursing confirmed that the facility was supposed to follow CDC guidelines for pneumococcal immunization, which includes providing education and documenting it in the residents' health records. However, the records reviewed showed a lack of documentation for education and assessment, and some residents had outdated or missing immunization records. This failure to adhere to the facility's policy and CDC guidelines resulted in a deficiency in the care provided to the residents.
Failure to Update and Include Advance Directives in Care Plans
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the inclusion and updating of advance directives in residents' comprehensive care plans. This deficiency was identified for three residents out of a sample of 48. For one resident, there was a discrepancy between the care plan, which indicated a full code status, and the physician's orders and POLST form, which both indicated a Do Not Resuscitate (DNR) status. The Social Service Director acknowledged this inconsistency and emphasized the importance of having the care plan reflect the resident's wishes to ensure appropriate action during emergencies. Another resident had a physician's order for full code status but lacked a corresponding care plan for advance directives. Similarly, a third resident, who had intact cognition and a physician's order for full code status, also did not have a care plan for advance directives. The facility's policy mandates that advance directives be included in the care plan and reviewed quarterly, but this was not followed, leading to a lack of clear guidance for staff on how to proceed in emergency situations.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to adhere to professional standards for the maintenance of a PICC line for a resident, identified as R130, who required intravenous antibiotic therapy due to osteomyelitis. The resident's care plan specified the need for IV antibiotic therapy with ceftriaxone and indicated that the IV site should remain free of infection signs. However, observations revealed that the PICC line dressing, dated 01/07/25, was not changed by the required date of 01/14/25, as per the facility's policy. This oversight was confirmed by the resident, who mentioned that the dressing change was pending, and by the Registered Nurse, who acknowledged the dressing should be changed every seven days. The Director of Nursing further confirmed that the PICC line dressings are to be changed weekly or as needed, and failure to do so could lead to infection control issues and hinder the assessment of the site. The facility's policy mandates that PICC line dressings be changed every 5-7 days or sooner if compromised. The lack of timely dressing change for R130's PICC line, as documented in the Medication Administration Record, highlights a deficiency in maintaining the standard of care required for intravenous access devices, potentially exposing the resident to infection risks.
Failure to Provide Emergency Tracheostomy Equipment at Bedside
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy had the required emergency equipment at the bedside. The resident, who has multiple diagnoses including chronic respiratory failure and a tracheostomy, was observed without the necessary emergency step-down tracheostomy tube readily available. During an observation, a registered nurse was unable to locate the emergency step-down tracheostomy tube at the resident's bedside and had to retrieve it from the supply room. This indicates that the emergency equipment was not immediately accessible in the event of a tracheostomy dislodgement. The Director of Nursing confirmed that the emergency tracheostomy supplies should be easily accessible at the head of the bed to prevent potential airway closure if the tracheostomy becomes dislodged. The facility's policy on tracheostomy care requires that an emergency tracheostomy tube replacement, either the same size or one size smaller, should be kept at the bedside. The failure to adhere to this policy and ensure the availability of emergency equipment at the bedside represents a deficiency in the facility's respiratory care for the resident.
Controlled Substance Accountability Deficiency
Penalty
Summary
The facility failed to ensure accurate shift change reconciliation and accountability for controlled substances, specifically Clonazepam and Tramadol, leading to discrepancies in medication counts. This issue was identified in one of the three medication carts used for storing controlled narcotics. The Shift Change Accountability Record for Controlled Substances was found to have missing nurse initials for specific shifts, indicating that the narcotic count was not completed as required. Additionally, discrepancies were noted in the medication counts for two residents: one Tramadol tablet was missing from a resident's medication card, and two Clonazepam tablets were missing from another resident's medication card. During the review, a Licensed Practical Nurse (LPN) confirmed the procedure for counting and signing off on narcotics at the beginning and end of each shift, and the Director of Nursing (DON) explained the importance of the Shift Change Accountability Record in ensuring accurate narcotic counts. The facility's policy requires two licensed nurses to verify the narcotic log sheets, and any discrepancies should be reported to the DON or administrative nursing staff for investigation. However, the failure to adhere to these procedures resulted in unaccounted controlled substances, raising concerns about potential medication mismanagement.
Failure to Administer Correct Insulin Dose
Penalty
Summary
The facility failed to ensure that a resident received the prescribed amount of insulin, resulting in a significant medication error. The resident, identified as R25, has multiple diagnoses including Type 2 Diabetes Mellitus, which requires careful management of blood glucose levels. The physician's order specified that R25 should receive 15 units of Basaglar insulin twice a day, with blood sugar monitoring before meals and at bedtime. However, on the day of the incident, the registered nurse (V4) did not perform the required blood glucose check before administering the insulin. Additionally, the nurse failed to prime the insulin Kwik pen, which is necessary to ensure the correct dose is delivered and to prevent air from being injected. The Director of Nursing (V18) confirmed that the proper procedure for insulin administration includes priming the needle to avoid air injection and ensure the correct dose is given. The facility's policies on medication and insulin administration emphasize the importance of monitoring and priming to prevent medication errors. The nurse's failure to follow these procedures resulted in the potential for R25 not receiving the full prescribed dose of insulin, constituting a significant medication error as per the facility's standards and policies.
Improper Management of Resident's Personal Refrigerator
Penalty
Summary
The facility failed to properly manage and maintain the personal refrigerator of a resident, identified as R53, which led to potential health risks. Upon inspection, the refrigerator was found to be warm, with a thermometer reading of 58 degrees Fahrenheit, indicating it was not functioning correctly. Several food items inside the refrigerator were either expired or not dated, including smoked ham, a defrosted beef pot pie, strawberry creme parfait, and rice pudding. The Certified Nursing Assistant (CNA) and Maintenance Director confirmed the refrigerator's inadequate temperature and the presence of expired food items, acknowledging the risk of food spoilage and potential illness if consumed by the resident. The facility's policies require maintenance and housekeeping staff to ensure refrigerators are in proper working order and for CNAs to check and discard expired food items. However, these procedures were not followed, as evidenced by the undated and expired food items found in R53's refrigerator. The Maintenance Director and Dietary Manager both emphasized the importance of maintaining refrigerator temperatures at 40 degrees Fahrenheit or below to prevent foodborne illnesses. Despite these guidelines, the facility's failure to adhere to its policies resulted in a deficiency that could affect the health and safety of the resident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. One resident, with a diagnosis of mild dementia and anxiety, reported being verbally and physically abused by her roommate, who also has dementia and a major depressive disorder. The incident involved the roommate throwing tissues and a cup of water on the floor and poking the resident's hand, resulting in a skin tear. The facility's incident report confirmed the abuse, and the social services notes documented the roommate's verbal aggression and physical actions. The facility's staff, including the Assistant Director of Social Services and several Licensed Practical Nurses, were aware of the incident but failed to immediately report it to the administrator as required by the facility's abuse prevention policy. The administrator was only informed the day after the incident occurred. The facility's policy mandates immediate reporting of any abuse allegations to the administrator, which was not adhered to in this case. The failure to promptly report and address the incident contributed to the deficiency in protecting the resident from abuse.
Failure to Notify Family of Resident's Hospitalization
Penalty
Summary
The facility failed to adhere to its policy of notifying family members about a resident's change in condition. This deficiency was identified for one resident out of a sample of three. The resident, referred to as R1, was sent to the hospital on October 31, 2024, due to suicidal ideation. The resident's Power of Attorney (POA), V3, requested a report on November 5, 2024, regarding the incident, but did not receive an update. The facility's Director of Nursing (V2) acknowledged that although she was informed of the request and claimed to have contacted V3, there was no documentation in the resident's electronic health record to confirm this communication. The facility's policy requires that any notification to the family about a resident's condition be documented in the electronic health record, including details of who was notified, the date, time, and the response. However, the documentation provided by the facility was incomplete and did not include the resident's name or signatures. The lack of proper documentation in the electronic health record indicates that the facility did not fulfill its obligation to notify the family as per its policy.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two male residents. Resident R4, who has a history of dementia with behavioral disturbances and other cognitive impairments, was involved in an incident where he allegedly sexually assaulted resident R3, who is cognitively intact. R3 reported that R4 put his hands down R3's diaper, prompting R3 to push R4's hand away and call for assistance. A CNA responded to the call light and found R4 sitting on his bed. The CNA reported the incident to the nurse, and R4 was moved to a different room. This incident was not isolated, as R4 had a previous report of inappropriate touching on another resident earlier in the year. The facility's failure to implement effective interventions following R4's previous inappropriate behavior contributed to the recurrence of such incidents. Despite R4's documented history of sexually inappropriate behavior, there were no changes in interventions in his care plan after the initial incident. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, yet the lack of adequate measures to prevent further incidents indicates a failure to adhere to this policy. The final incident investigation report did not conclusively determine the outcome of the abuse allegation, leaving the situation unresolved.
Failure to Timely Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an alleged incident of potential staff-to-resident abuse involving a resident who reported being struck in the groin area by a CNA during patient care. The incident was initially reported by the resident's family on 8/7/2024, but the facility did not begin a formal investigation until 8/15/2024, after the ombudsman was informed by the family. The resident, who had a urinary catheter, reported that the CNA was rough and caused pain while checking the resident's diaper, leading to the resident's sister contacting the facility to express her concerns. Despite the family reporting the incident to the facility on 8/7/2024, the initial response was to view it as a concern rather than a potential abuse case, and the CNA was not immediately removed from duty. The facility's policy requires immediate reporting of any allegations of abuse to the administrator, but this protocol was not followed. The lack of documentation in the medical record regarding the allegations and the delay in starting the investigation contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in psychosocial harm. The incident involved a resident, who had been in the facility for about two years, experiencing unwanted touching by another resident. The affected resident, who was cognitively intact but physically dependent due to medical conditions, reported that the other resident repeatedly attempted to touch them inappropriately. Despite the resident's complaints to staff, the unwanted behavior continued, leading the resident to record a video of the incident as evidence. The report details that the resident showed the video to the facility's Social Services Director and Administrator, as well as to the police and hospital staff. The video depicted the other resident approaching the bed and attempting to touch the resident under the covers. The resident expressed feeling violated and unsafe, and despite informing staff multiple times, the behavior persisted. Another resident corroborated the account, stating they had also experienced similar unwanted advances from the same individual. The facility's staff, including CNAs and nurses, were aware of the situation, with several staff members witnessing or being informed of the inappropriate behavior. However, the facility's response was inadequate, as there was no documented care plan addressing the risk of abuse for the affected resident. The facility's policy on abuse prevention and reporting was not effectively implemented, as the resident continued to experience unwanted contact despite raising concerns with multiple staff members.
Failure to Administer PRN Pain Medication as Ordered
Penalty
Summary
The facility failed to administer a PRN dose of pain medication to a resident, identified as R3, for breakthrough pain, despite the resident's request and the physician's instructions. R3, who has a history of chronic pain syndrome and other medical conditions, reported that the nurses were not administering the PRN medication as needed, particularly when it was requested less than four hours after a scheduled dose of Oxycontin. The physician's order clearly stated that the PRN Oxycodone should be administered based on the last PRN dose, not the scheduled dose, allowing for up to four doses per day. During the survey, it was revealed that the nurse, identified as V5, did not administer the PRN Oxycodone when R3 requested it on a specific date, despite R3's complaint of pain. V5 admitted to asking R3 to wait for the PRN medication, believing that the scheduled Oxycontin had not yet taken full effect. The facility's EMAR and narcotic log showed no documentation of the PRN Oxycodone being administered during the shifts V5 worked, supporting R3's claim of not receiving the medication. The Director of Nursing, V2, acknowledged the issue, stating that agency nurses were not following the physician's orders correctly, leading to R3 not receiving the PRN medication as needed. The facility's pain management policy emphasizes the importance of providing comfort and administering medications as ordered, yet the documentation and actions of the nursing staff did not align with these guidelines, resulting in a deficiency in pain management for R3.
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 1,660 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 Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Rehab At Fairmont | 0.9 mi | ★★★★★ | 27 | 0 |
| Ambassador Nursing & Rehab Center | 1 mi | ★★★★★ | 5 | 0 |
| Harmony Healthcare & Rehab Ctr | 1.1 mi | ★★★★★ | 2 | 0 |
| St Joseph Village Of Chicago | 1.5 mi | ★★★★★ | 0 | 0 |
| Paul House & Health Cr Ctr | 1.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.