Below average — CMS composite of the measures below.
A standard survey is most likely before around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mado Healthcare - Uptown during CMS and state inspections, most recent first.
Failure to complete timely smoking assessments affected all smoker residents in the facility. Several residents with diagnoses including COPD, dementia, schizophrenia, seizures, and mobility impairments were observed smoking in designated areas under staff supervision, with staff providing and lighting cigarettes. Records showed outdated or missing smoking-safety screens for multiple residents, and the ADM stated the facility had not yet implemented smoking assessments and had no assessments completed for smoker residents.
Improper Food Labeling, Storage, and Sanitizing Practices: Multiple opened or prepared food items in the kitchen and walk-in cooler were observed without proper use-by dating, and some items had only delivery or opened dates. Food was also stored too close to the floor and ceiling, including liquid eggs and cookies on low shelves and bread near the ceiling. In addition, dietary staff were observed briefly dipping blender parts and other equipment into the sanitizer sink for only a few seconds instead of fully submerging them for the required 60 seconds.
An LPN used the same glucometer for multiple residents without cleaning or disinfecting it between uses and did not perform proper hand hygiene before, during, or after resident care while giving insulin. The facility also lacked a completed Legionella water management program, and boiler room water temperatures were found below CDC guidance, with no temperature logs or documented control measures provided.
Medication administration errors exceeded the allowed rate when surveyors found 5 errors in 26 opportunities. An LPN gave an inhaler too close together between puffs, two residents received insulin after meals instead of before meals, another resident received 2 tablets of pseudoephedrine instead of 1, and one resident received insulin after lunch despite a pre-meal order. The DON stated nurses are expected to follow physician orders and the 5 rights, including giving insulin before meals and spacing inhaler puffs appropriately.
A resident with dementia and multiple chronic conditions was observed with food-stained clothing, long dirty fingernails with debris, and reddened, swollen thumbs, including a thickened brownish nail. The resident said she wanted her nails trimmed and cleaned and did not know when they were last done. Staff interviews confirmed that ADL care was supposed to include daily grooming, hygiene, and nail care, but the resident’s appearance showed those needs were not being met.
Failure to change oxygen tubing and humidifier bottles as ordered for two residents. A surveyor observed that the residents’ oxygen equipment was dated beyond the weekly change interval, and an LPN stated it should have been changed earlier. The DON confirmed respiratory tubing and humidifier bottles must be changed every 7 days, even for PRN oxygen use, and the facility policy required weekly replacement.
A facility failed to properly discard an opened multidose insulin glargine vial after the 28-day period and failed to refrigerate an unopened insulin pen for another resident. Surveyors found the outdated insulin still in a medication cart, along with another opened vial lacking proper dating, while the DON stated unopened insulin should be refrigerated and opened insulin discarded after 28 days.
A resident who fell and sprained his ankle was ordered WBAT in a gym shoe and PT/OT for ROM and gait mechanics, but the ordered rehab services were not provided. Staff said the resident had initially refused to walk and was referred to restorative, yet no clear rescreening or therapy follow-up occurred after the new MD order. The resident was later seen using a wheelchair and said he was unsure whether he was getting therapy.
A resident with dementia and a history of falls was forcefully and aggressively moved in his wheelchair by a housekeeper, despite the resident's attempts to resist. The incident, captured on surveillance footage, showed the staff member spinning and tilting the resident's wheelchair in a manner that disregarded the resident's nonverbal cues and right to be free from abuse.
A resident was found on the floor by a CNA, who lifted the resident without notifying the nurse or requesting assistance, contrary to facility policy. The nurse was only informed of the resident's pain after the resident was back in bed, and was not told about the fall until later. The resident was later diagnosed with a right shoulder fracture after being sent to the hospital.
A resident with a history of schizophrenia and hallucinations physically assaulted another resident by choking him during a group activity, stating he was compelled by auditory hallucinations. The incident was witnessed by a staff member who intervened, and the aggressor was later referred for psychiatric evaluation. The assaulted resident did not sustain injuries, but the event demonstrated a failure to protect a resident from physical abuse.
A resident with stage 2 and stage 3 pressure ulcers did not receive weekly wound assessments or consistent wound care as ordered by the wound NP. Nursing staff continued previous treatments instead of following updated orders, and required documentation was missing for several weeks, contrary to facility policy.
A resident with moderate cognitive impairment and a history of ambulating independently fell and sustained a hip fracture due to the facility's failure to update and follow the fall prevention care plan. The care plan, which required extensive assistance and use of a gait belt, had not been reviewed since 2022. The facility lacked a specific fall prevention policy, relying on post-fall protocols and staff training, contributing to the incident.
The facility failed to have a licensed nurse oversee its restorative nursing program, affecting 120 residents. A COTA was responsible for creating and supervising the program, contrary to CMS guidelines requiring a licensed nurse. The DON confirmed the absence of a restorative nurse and did not supervise the COTA due to unfamiliarity with restorative services.
The facility failed to maintain a homelike environment by not repairing broken window blinds in several residents' rooms, affecting their privacy and comfort. Observations showed missing slats in the blinds, with no replacements found. A CNA and the Maintenance Supervisor confirmed the issue, citing workload and staffing limitations as reasons for the delay. The DON acknowledged the impact on residents' privacy. Affected residents had various medical conditions, and some were cognitively intact while others were severely impaired.
The facility failed to follow proper protocols for oxygen therapy, affecting three residents and potentially impacting all residents on the 5th floor. Observations showed a lack of required signage for oxygen use and improper labeling and containment of oxygen tubing. An LPN was unsure about the signage requirement, and the DON confirmed that tubing should be changed daily and properly labeled for infection control.
The facility failed to ensure that controlled drugs-count records were not prematurely signed by nurses on multiple floors. An LPN admitted to signing for both incoming and outgoing shifts simultaneously due to the absence of medications. The DON confirmed that narcotic sheets should only be signed at the beginning and end of each shift, as per facility policy, even if no medications are present.
A facility failed to discard an expired medication, Breo Ellipta, intended for a resident with asthma, COPD, and congestive heart failure. The medication, labeled to be used by a past date, was found on the medication cart and documented as administered on subsequent days. An RN acknowledged missing the expired medication, and the DON confirmed that expired medications should be removed. Facility policy requires expired medications to be returned to the pharmacy and reordered as needed.
A facility failed to relocate an Enhanced Barrier Precaution (EBP) sign and PPE bin when a resident with a gastrostomy tube was temporarily moved to a different room for maintenance. The oversight resulted in a lapse in infection control measures, as the necessary precautions were not communicated to staff in the resident's new location.
The facility failed to provide functioning call devices for two residents, impacting their ability to request assistance. A CNA and the Maintenance Supervisor confirmed the call lights were not working. The DON emphasized the importance of the call device for resident safety. The affected residents required assistance with ADLs due to medical conditions, and their care plans highlighted the need for functioning call lights.
A facility failed to protect residents' funds, resulting in unauthorized transactions on two residents' bank accounts. One resident's wallet was mishandled, leading to fraudulent ATM withdrawals and online purchases. Another resident's debit card was misused by a staff member, depleting their account through unauthorized transactions. The facility's inadequate system for safeguarding funds and belongings contributed to these incidents.
The facility failed to conduct comprehensive background checks on several staff members before they began working with residents, as required by their policy. This oversight included missing checks against critical registries such as the Illinois Sex Offender and Health and Human Services Office of Inspector General registries. The HR Director admitted to not being fully trained on these checks, resulting in incomplete background screenings and potential risks to residents.
Failure to Complete Timely Smoking Assessments
Penalty
Summary
The facility failed to complete timely comprehensive smoking assessments for residents who smoke, including R6, R8, R9, R21, R39, R79, R89, and R110. The report states that this deficiency affected all 59 smoker residents in the facility. The administrator stated on 12/10/25 and again on 12/11/25 that smoking assessments had not yet been done in the facility, that the facility had just obtained a nursing advantage tool for smoking assessment, and that it would be implemented in January 2026. The administrator also stated that smoking rules and behavior were discussed during admission and that residents were expected to smoke in designated areas under staff supervision. R9 was admitted on 8/5/2025 with diagnoses including malignant neoplasm of the left bronchus or lung, COPD, type 2 diabetes mellitus, anemia, schizoaffective disorder, emphysema, osteoarthritis of the left knee, and peripheral vascular disease; his MDS dated 11/11/2025 showed intact cognition. R110 was admitted on 7/14/2022 with diagnoses including type 2 diabetes mellitus, unspecified dementia, COPD, asthma, epilepsy, chronic kidney disease, hypertension, chronic ischemic heart disease, and schizophrenia; her MDS showed moderate impairment. During observation, R9 was ambulatory, alert and oriented x3, and stated he was a smoker who did not carry cigarettes or a lighter because staff provided and lit cigarettes for him in the designated smoking area. R110 was observed in a wheelchair, alert and verbally responsive, and stated she was a smoker who did not keep smoking materials because staff lit her cigarette and supervised smoking in the designated area. Additional residents reviewed also had no updated smoking assessments in their records. R79 was observed smoking under staff supervision, and the last smoking safety screen in the record was dated 1/10/2024. R8 had diagnoses including COPD, nicotine dependence, difficulty walking, lack of coordination, and history of falling; his last smoking-safety assessment screen was dated 12/17/24. R21 had diagnoses including COPD, seizures, unspecified dementia, and bilateral primary open-angle glaucoma; his last smoking-safety assessment screen was dated 10/13/23. R39 had diagnoses including parkinsonism, extrapyramidal and movement disorder, history of falling, and mild intellectual disabilities; his last smoking-safety assessment screen was dated 11/12/24. R6, R89, and R110 were also identified as smokers in care plans, but no smoking assessment was found in their EHRs. The director of social services stated he did not know who was doing the smoking assessments and that his department did not deal with the smoking program or management of the program.
Improper Food Labeling, Storage, and Sanitizing Practices
Penalty
Summary
Food items were found improperly labeled and dated in the facility kitchen and walk-in cooler. During observation, multiple opened or prepared items had only a delivery date, only an opened date, or no use-by date at all, including barbeque sauce, chopped garlic, mustard, ranch dressing, salsa, Italian dressing, peanut butter, grape jelly, applesauce, pudding, and a wedge of bologna in a mini refrigerator with no label or dates. The Dietary Manager stated that opened or prepared food containers should be labeled with an opened date and a use-by or expiration date, and that items without appropriate dating should be discarded because they may no longer be safe to serve. Food storage practices were also observed to be out of compliance with the facility’s stated standards. In the walk-in cooler, six closed bags of liquid eggs were stored on the lowest shelf of a rack that measured 4.5 inches from the floor, and loaves of bread were stored on the highest shelf about 4 inches from the ceiling. In the dry storage room, two large boxes of cookies were stored on a lower rack that measured 4 inches from the floor, and the shelf was bowed in the middle, making it even closer to the floor. The Dietary Manager stated the food should be at least six inches off the floor and acknowledged the ceiling clearance was less than expected. Manual sanitizing of kitchen equipment in the three-compartment sink was observed to be incomplete. During pureed food preparation and other kitchen tasks, a dietary aide washed and rinsed blender parts, spoodles, containers, and a cutting board, then another dietary aide briefly dipped each item into the sanitizing sink for only a few seconds at a time. None of the items were fully submerged for the 60 seconds required by the facility policy and the manufacturer’s poster. The Dietary Manager stated the kitchen uses a Quat sanitizer and items must be fully submerged for one minute, and the consultant dietitian confirmed that equipment and utensils need to be fully submerged in sanitizing solution for 60 seconds.
Failure to disinfect shared equipment, perform hand hygiene, and maintain Legionella water controls
Penalty
Summary
The facility failed to clean and disinfect a reusable glucometer between resident uses and failed to ensure hand hygiene was performed between resident care during medication administration. During observation, an LPN checked blood sugars and administered insulin to multiple residents using the same glucometer without cleaning or disinfecting it between residents. The LPN also did not perform proper hand hygiene after removing gloves, before wearing gloves, or between resident care activities while providing insulin administration to several residents. The Infection Preventionist and the DON stated that glucometers are supposed to be cleaned after each use and that staff are expected to perform proper hand hygiene before and after care or medication administration. The facility's hand hygiene policy stated that hand hygiene is the most effective way of preventing transmission of healthcare-associated infection and must be performed before and after contact with a resident or the resident's environment. The facility's multi-equipment cleaning policy stated that shared resident-care equipment is to be cleaned and disinfected after each use to prevent infection. The facility also failed to maintain hot water temperatures within required parameters and did not have a completed water management program for Legionella. The Administrator stated the water management program was not complete, and the Maintenance Director was not familiar with it. The boiler room inspection showed water holding tanks, the water heater, and circulating pipes at temperatures of 105 degrees Fahrenheit and later 115 degrees Fahrenheit, and no temperature logs were provided. The binder provided did not show control measures, temperature management, disinfectant level control, visual inspections, or a risk analysis for the hot and cold water distribution system.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% for 5 of 16 residents reviewed for medication administration. Surveyors identified 5 errors in 26 opportunities, resulting in a 19.23% medication error rate. The residents involved were R28, R29, R46, R103, and R116, all of whom were documented as cognitively intact in the records reviewed. For R46, who was admitted with diagnoses including asthma, hypertension, type 2 diabetes, schizophrenia, and neuromuscular dysfunction of the bladder, a medication administration observation showed an LPN giving Symbicort inhaler and the resident inhaled a second puff after only 2 seconds instead of waiting 1 to 2 minutes between puffs. The MAR and POS ordered Symbicort 2 inhalations twice daily, and the medication audit showed it was documented as given at 8:36 AM, while the surveyor observed administration at 10:01 AM. For R28 and R29, both residents with diabetes, surveyors observed insulin aspart being administered after lunch even though the orders directed it to be given before meals. R28 received 6 units after the resident stated lunch had already been eaten, and R29 received 20 units after lunch as well. For R103, who had diagnoses including COPD, GERD, emphysema, hypertension, anxiety, and schizoaffective disorder, an LPN prepared and administered 2 tablets of pseudoephedrine even though the order was for 1 tablet by mouth as needed for congestion once daily. For R116, who had COPD, diabetes, hypertension, schizoaffective disorder, and asthma, an LPN administered 2 units of insulin aspart after the resident had already eaten lunch, despite the order for insulin to be given before meals based on sliding scale. The DON stated nurses are expected to follow physician orders and the 5 rights, and that insulin ordered before meals should be given prior to meals; he also stated inhaler puffs should be separated by at least 2 minutes.
Failure to Provide ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide ADL assistance and nail care for a resident with multiple diagnoses including type 2 diabetes mellitus, unspecified dementia, COPD, asthma, epilepsy, chronic kidney disease, hypertension, chronic ischemic heart disease, and schizophrenia. The resident’s MDS showed moderate cognitive impairment and need for assistance with dressing and personal hygiene. During observation, the resident was sitting in a wheelchair, alert and verbally responsive, with a sweater and pants stained with food, long and dirty fingernails with black debris under the nails, and both thumbs reddened and swollen; the left thumb was more reddened and swollen, and the nail was thickened and brownish. The resident stated she wanted her fingernails trimmed and cleaned and did not know when they were last cleaned or trimmed. Interviews confirmed that nail care and hygiene assistance were expected as part of daily ADL care. A CNA stated the resident needed assistance with lower dressing and personal hygiene, and that nail trimming was usually done during showers and as needed, with nails checked and cleaned as part of personal hygiene. The DON stated staff were supposed to assist with ADLs including grooming, dressing, and nail care, and that residents’ nails should be checked daily during care and trimmed and cleaned, while clothes should be free from food stains. The care plan identified an ADL self-care performance deficit in grooming and personal hygiene related to poor hygiene awareness and lack of motivation due to dementia, and included interventions to monitor daily ADLs including oral care, nail care, and grooming.
Failure to Change Oxygen Tubing and Humidifier Bottles as Ordered
Penalty
Summary
The facility failed to change oxygen nasal cannulas and humidifier bottles as ordered for two residents, R11 and R106, who used oxygen as needed. On 12/9/25 at 12:01 PM, a surveyor observed with V4, an LPN, that both residents were not in their rooms and that their oxygen concentrators were at bedside and not being used. Their oxygen tubing and humidifier bottles were dated 12/1/25, and V4 stated they should have been changed on 12/7/25. On 12/10/25 at 12:57 PM, V2, the DON, stated respiratory tubing and humidifier bottles are supposed to be changed every seven days and as needed, and that even PRN oxygen orders still require the equipment to be changed and labeled with the last change date. The residents’ order summaries printed on 12/9/25 directed weekly changes of the humidifier bottle and oxygen nasal cannula, and the facility policy stated oxygen supply use and storage items are to be replaced every 7 days, when visibly soiled, or per policy, with humidifier bottles changed weekly.
Improper insulin storage and outdated insulin left in medication cart
Penalty
Summary
The facility failed to properly discard a multidose insulin glargine vial for one resident after the 28-day opening period and failed to properly store unopened insulin that required refrigeration for another resident. On 12/9/2025, during inspection of the 4th floor medication cart with an RN, surveyors observed multidose insulin glargine for a resident with an open date of 11/4/25 and a discard date of 12/2/25 that had not been discarded and remained in the medication cart. Surveyors also observed another opened multidose insulin glargine vial for the same resident with no open date and discard date labeled. The pharmacy sticker indicated the insulin should be discarded 28 days after opening. On 12/9/2025, during inspection of the 3rd floor medication cart with an LPN, surveyors observed an unopened insulin pen for another resident inside the medication cart even though the pharmacy sticker indicated it should be refrigerated. The DON stated that nurses are expected to store unopened insulin in the refrigerator to follow pharmacy recommendations and maintain medication potency, and that insulin should be discarded after 28 days from opening. The facility policy stated that refrigerated items should be stored properly, outdated medications should be immediately removed, and opened containers or vials should be dated; the insulin administration policy stated unopened insulin should be refrigerated and opened insulin should be labeled with the date and discarded per manufacturer guidelines.
Failure to Provide Ordered PT/OT After Fall
Penalty
Summary
The facility failed to follow a physician order to provide specialized rehabilitative services for one resident after a fall. The resident had an unwitnessed fall in his room and was diagnosed with a sprained right ankle. After an orthopedic follow-up, the resident was ordered to be weight bearing as tolerated in a gym shoe and to receive PT/OT to work on range of motion and gait mechanics. The resident was observed sitting in a wheelchair in the dining room and stated he had used to walk with a walker before the fall but was now using a wheelchair because of the leg injury, and he did not know whether he was receiving therapy. Record review and staff interviews showed that therapy did not provide the ordered PT/OT services after the orthopedic recommendation. A PT screen had been completed earlier, when the resident reportedly refused to walk and said he was comfortable using a wheelchair, and he was referred to restorative. Staff stated that if a new physician order for PT/OT was received after that screen, the resident should have been rescreened and evaluated further, but the PT/OT services were not picked up and no one could confirm that a new screen or evaluation occurred. The restorative director stated restorative had not reassessed the resident since the fall because the resident had a physician order for PT/OT and restorative had not received new instructions from therapy. The resident’s MDS documented intact cognition, supervision/touching assistance for self-care and transfers, and the ability to walk 10 feet and 50 feet with two turns. The facility policy stated it was the policy to follow physician orders for resident care, including treatment plans. A handwritten screen dated after the orthopedic visit was later provided, but the facility did not identify the OTR who completed it, and the record still reflected that the ordered PT/OT services were not provided as ordered.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a housekeeper forcefully and unnecessarily moved a male resident with diagnoses including COPD, dementia, major depressive disorder, and a history of falls. The resident, who is care planned as being at risk for abuse/neglect and ambulates independently by wheelchair, was observed on facility surveillance footage being spun around aggressively by the housekeeper while attempting to resist by placing his feet on the floor. The housekeeper then tilted the wheelchair back and pushed the resident away from the area in an aggressive manner, despite the resident's nonverbal cues indicating he did not want to be moved. There were no other witnesses to the incident, and the event was captured on video during a routine review by corporate staff. The resident later confirmed the incident during an interview, recalling that the housekeeper spun his wheelchair and moved him from the area after he exited the elevator, and that he tried to stop the movement by putting his feet down. The housekeeper had previously attended an inservice on abuse and neglect. The facility's abuse prevention policy states that residents must be free from all forms of abuse, including physical and mental abuse. The incident demonstrated a failure to protect the resident's right to be free from physical abuse.
Failure to Notify Nurse and Assess Resident After Fall
Penalty
Summary
A deficiency occurred when facility staff failed to follow policy regarding the immediate assessment and notification of nursing staff after a resident fall. A certified nursing assistant (CNA) found a resident sitting on the floor in their room and, without notifying the nurse or requesting assistance, independently lifted the resident from the floor and assisted them back to bed. The CNA did not inform the nurse on duty about the fall at the time it was discovered, contrary to facility policy which requires immediate nurse notification and assessment before moving a resident post-fall. The resident involved was an older adult with a history of osteoarthritis and a recent diagnosis of a nondisplaced fracture of the right shoulder. The resident was cognitively intact and ambulatory, requiring stand-by assistance for showers. On the day of the incident, the resident was found on the floor by the CNA, who then lifted the resident without a nursing assessment. The resident subsequently complained of severe right arm pain and swelling, which was only communicated to the nurse after the resident was already back in bed. The nurse was not initially informed of the fall, but only of the resident's pain, and only learned of the fall and possible injury during the assessment prompted by the resident's complaints. Documentation and interviews confirm that the CNA acknowledged not following protocol, stating that the mistake was in transferring the resident post-fall without nurse notification or assessment. The nurse's assessment revealed a swollen, painful right arm, and the resident was sent to the hospital, where a closed fracture of the right shoulder was diagnosed. The failure to immediately notify the nurse and ensure a prompt assessment after the fall constituted a breach of facility policy and resulted in a delay in appropriate medical evaluation for the resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of schizophrenia, schizoaffective disorder, and audio hallucinations physically assaulted another resident by approaching from behind and placing his arm around the other resident's neck in a chokehold during a group activity in the dining room. The aggressor stated, through a translator, that he was compelled by auditory hallucinations, specifically that God told him to choke the other resident. The incident was witnessed by a staff member who intervened and separated the two residents. The aggressor was calm after the incident and did not display agitation. The assaulted resident, who has diagnoses including schizophrenia, chronic obstructive pulmonary disease, and hypertension, reported being surprised by the attack and did not recall any provocation or warning. He denied pain or injury following the incident, and a licensed practical nurse confirmed there were no visible signs of harm. The aggressor had a documented history of behavioral disturbances, hallucinations, and a felony history for aggravated stalking, and was known to be at risk for abuse/neglect according to his care plan. The facility's abuse policy and residents' rights documents state that all residents must be protected from abuse, neglect, and harm. Despite these policies, the incident occurred in a supervised setting with only one staff member present, who was required to physically intervene. The aggressor was subsequently referred for psychiatric evaluation due to his aggressive and psychotic behavior, but the event demonstrated a failure to protect a resident from physical abuse by another resident.
Failure to Provide Consistent Pressure Ulcer Care and Weekly Assessment
Penalty
Summary
The facility failed to assess and document pressure ulcer characteristics and measurements on a weekly basis and did not ensure that wound care orders provided by the wound nurse practitioner were followed for one resident. The resident was admitted with multiple diagnoses, including stage 2 and stage 3 pressure ulcers, and required substantial assistance with activities of daily living. Interviews with staff confirmed that wound treatments were performed by nurses on duty, but there were inconsistencies between the treatments ordered by the wound nurse practitioner and those actually administered, as documented in the treatment administration record (TAR). The wound nurse practitioner specified that Hydrofera should be used for both the sacrum and right heel wounds, but the TAR and order summary indicated that Santyl and Xeroform were still being used for these wounds during the same period. The nurse practitioner emphasized the importance of following current wound care orders to promote healing and prevent complications. Additionally, the nurse practitioner noted that wound assessments and documentation were missing for several weeks, which is necessary to monitor wound progress and determine if treatment changes are needed. The facility's own policies required weekly documentation of wound characteristics, measurements, and pain, as well as adherence to physician orders for wound care. However, the facility was unable to provide weekly wound assessment documentation for several specified dates, and the orders from the wound nurse practitioner were not consistently implemented as directed. This resulted in a failure to provide appropriate pressure ulcer care and to prevent the development or worsening of pressure ulcers for the resident involved.
Failure to Update Fall Prevention Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to follow and update the fall prevention care plan for a resident, leading to a fall incident that resulted in a right hip/pelvic fracture requiring surgery. The resident, who had been in the facility since 2020, was noted to have moderate cognitive impairment and a history of ambulating without assistance. However, the care plan indicated that the resident required extensive assistance during transfers, including the use of a gait belt and evaluation before transfers. Despite these requirements, the care plan had not been reviewed or updated since 2022, and the resident was allowed to ambulate independently without the necessary support. The incident occurred when the resident was observed limping in the hallway, and subsequent medical evaluation revealed a right hip fracture. The resident was transferred to the hospital, where surgery was performed. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's need for assistance and the use of mobility aids. The Director of Nursing and MDS Coordinator acknowledged that the care plan was outdated and not reflective of the resident's current needs, which contributed to the incident. The facility lacked a specific fall prevention policy, relying instead on post-fall protocols and staff training. This deficiency in proactive fall prevention measures, combined with the failure to update the resident's care plan, directly contributed to the resident's fall and subsequent injury. The absence of a restorative nurse and the lack of regular care plan reviews further exacerbated the situation, highlighting gaps in the facility's approach to resident safety and fall prevention.
Lack of Licensed Nurse Oversight in Restorative Nursing Program
Penalty
Summary
The facility failed to have a qualified licensed nurse oversee its restorative nursing program, which potentially affects all 120 residents receiving restorative programming. The Restorative Director, identified as a Certified Occupational Therapist Assistant (COTA), was responsible for creating, evaluating, and supervising the restorative programs. This individual also assessed residents for restorative needs and developed care plans, despite not being a licensed nurse. The Director of Nursing (DON) confirmed the absence of a restorative nurse and admitted to not providing supervision to the Restorative Director due to unfamiliarity with restorative nursing services. The facility's job description for the Restorative Director outlines responsibilities that include developing, implementing, and evaluating the restorative nursing program, as well as ensuring compliance with applicable laws and standards. However, the CMS's RAI Manual specifies that a registered nurse or licensed practical nurse must supervise restorative nursing activities. Despite the Restorative Director having taken a course in restorative nursing, the facility's reliance on a COTA for supervision does not meet the regulatory requirement for licensed nurse oversight.
Deficiency in Maintaining Homelike Environment Due to Broken Window Blinds
Penalty
Summary
The facility failed to ensure a homelike environment by not maintaining window blinds in several residents' rooms, affecting their privacy and comfort. Observations revealed missing panels or slats in the window blinds of five residents' rooms, with no replacement panels found on the floor. A Certified Nursing Assistant confirmed the lack of coverage and privacy due to the missing slats. The Maintenance Supervisor acknowledged awareness of the issue for about two months but cited a heavy workload and limited staffing as reasons for not addressing the problem. The Director of Nursing also recognized that the missing panels compromised the residents' privacy and the facility's obligation to provide a homelike environment. The affected residents included those with various medical conditions such as bipolar disorder, major depressive disorder, COPD, dysphagia, gastrostomy status, Type 2 Diabetes Mellitus, essential hypertension, obsessive-compulsive disorder, and epilepsy. Cognitive assessments indicated that some residents were cognitively intact, while others had severe impairments. The facility's policy mandates maintaining a safe, clean, and homelike environment, which was not upheld in this instance. The maintenance department's policy and job description for the Maintenance Director emphasize the responsibility for repairs, which were not fulfilled in this case, leading to the deficiency.
Failure to Ensure Proper Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, affecting three residents and potentially impacting all residents on the 5th floor. Observations revealed that a resident was using an oxygen concentrator without any signage indicating oxygen use on the door, which is against the facility's standard practice. An LPN confirmed the absence of the sign and expressed uncertainty about the requirement for such signage, despite acknowledging the flammable nature of oxygen. The facility's policy mandates that a sign should be posted on the resident's door when oxygen is in use. Additionally, the facility did not adhere to its policy regarding the labeling and containment of oxygen tubing. Two residents were observed with undated and uncontained oxygen tubing next to their beds. The Director of Nursing stated that oxygen tubing should be changed daily, dated, and placed in a plastic bag when not in use for infection control purposes. The facility's policy specifies that tubing must be discarded and replaced every 72 hours and labeled with the date and nurse's initials. These lapses in protocol could lead to potential safety and infection control issues.
Premature Signing of Controlled Drugs-Count Records
Penalty
Summary
The facility failed to ensure that the controlled drugs-count record form was not prematurely signed by both incoming and outgoing nurses. This issue was observed on multiple floors, including the second, fourth, fifth, and sixth floors, where the controlled drugs-count sheets were signed for the outgoing nurse before the end of the shift. During an inquiry, an LPN admitted to signing for both incoming and outgoing shifts simultaneously, citing the absence of medications as the reason for this practice. This practice was confirmed by the Director of Nursing (DON), who stated that the narcotic sheet should only be signed at the beginning and end of each shift, even if no medications are present. The facility's policies, dated February 21, 2024, and January 21, 2024, clearly state that narcotic counts must be conducted every shift with both incoming and outgoing nurses signing the records. Despite these policies, the premature signing of narcotic sheets was a common practice, as evidenced by the records reviewed by the surveyor. The DON acknowledged that the nurses should not sign the sheets before the end of their shifts, emphasizing the importance of verifying the count and confirming the absence of medications if applicable.
Expired Medication Not Discarded
Penalty
Summary
The facility failed to discard an expired medication, specifically Breo Ellipta (Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath), which was labeled to be used by 11/14/24. This medication was found on the third-floor medication cart on 11/17/24, and it was intended for a resident with a diagnosis that includes asthma, COPD, and congestive heart failure. The resident's active orders required the medication to be administered once daily for antiasthma purposes. Despite the expiration date, the medication was documented as administered on 11/15/24, 11/16/24, and 11/17/24, as indicated by check marks on the Medication Administration Record (MAR). During an interview, a registered nurse (RN) acknowledged missing the expired medication while cleaning the cart. The Director of Nursing (DON) confirmed that expired medications should not be present in the medication cart and should be removed by the nurse on duty. The facility's policy on Medication Discard and Labeling mandates that expired medications be removed and returned to the pharmacy, with reordering as necessary. The job descriptions for both registered nurses and licensed practical nurses include responsibilities for ordering prescribed medications and ensuring compliance with established policies.
Failure to Relocate EBP Signage and PPE Bin During Room Change
Penalty
Summary
The facility failed to ensure that an Enhanced Barrier Precaution (EBP) sign was posted and a personal protective equipment (PPE) bin was available for a resident on EBP. This deficiency was identified during an observation on the 3rd floor, where the EBP sign and PPE bin were found outside a room that was not occupied by the resident in question. The resident, who had a gastrostomy tube, was observed in a different room without the necessary EBP sign and PPE bin. The oversight occurred because the resident had been temporarily moved to another room for maintenance work, and the EBP sign and PPE bin were not relocated with the resident. The resident involved had a medical history that included dysphagia and gastrostomy status, requiring feeding formula via a gastrostomy tube. The resident's care plan indicated an increased risk for spreading multi-drug resistant organisms (MDRO) due to the indwelling medical device. The facility's policy required EBP signage and PPE to be present to inform staff of the necessary precautions. However, due to the room change, these precautions were not adequately communicated, leading to a lapse in infection control measures.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to provide functioning call devices for residents requiring assistance, affecting two residents in a sample of 57. On November 17, 2024, a Certified Nursing Assistant (CNA) identified that the call lights for two residents were not working, as the call light boxes were not lit. This observation was confirmed by the Maintenance Supervisor, who acknowledged the issue and emphasized the importance of a functioning call light system for resident safety and assistance. The Director of Nursing (DON) and the Administrator both acknowledged the deficiency, with the DON highlighting the critical nature of the call device as a lifeline for residents. The facility's policy requires immediate notification of maintenance and implementation of 30-minute rounds when the call light system is not working. The affected residents had various medical conditions, including epilepsy and movement disorders, and required assistance with activities of daily living (ADLs). Their care plans emphasized the need for functioning call lights to ensure their safety and prompt assistance.
Failure to Safeguard Residents' Funds Leads to Financial Exploitation
Penalty
Summary
The facility failed to establish a system of accounting for residents' funds and safeguarding them against theft, leading to fraudulent debit card transactions on the bank accounts of two residents. The facility did not follow its system for updating residents' belongings and failed to ensure that the shipping address for online purchases was directed to the facility. These failures resulted in an Immediate Jeopardy situation, which was identified when a family member of one of the residents reported unexplained activities on the resident's bank account. One resident, who had a history of bipolar disorder, essential hypertension, and depression, experienced unauthorized transactions on their bank account. The resident's wallet was kept in the business office manager's office without a proper log or inventory of its contents. The wallet was given to a psychiatric rehabilitation services coordinator (PRSC) when the resident needed to make withdrawals or purchases, but there was no verification of the wallet's contents upon return. Unauthorized transactions, including ATM withdrawals and online purchases, were made using the resident's debit card, with some items being shipped to a non-facility address. Another resident, diagnosed with chronic obstructive pulmonary disease and unspecified dementia, entrusted their debit card to the same PRSC, who promised to manage their finances. The resident later discovered that their account had been depleted, with unauthorized transactions made using a person-to-person mobile payment application. The resident had not consented to these transactions and was unaware of the extent of the financial abuse until it was brought to their attention. The facility's lack of a robust system for safeguarding residents' funds and belongings contributed to these incidents of financial exploitation.
Removal Plan
- Removed V5 from the facility, suspended without pay pending investigation as part of actions to mitigate risks to R1 and any other resident.
- Implemented a revised personal items log to account for resident personal items such as debit, credit, ID, and wallet.
- Revised the resident personal property policy to include language regarding investigating misappropriation of resident funds/property.
- Conducted in-services about abuse and resident belongings.
- Hired an outside team of Private Investigator to check on the situation, on anything that has to do with financial abuse.
- Revised personal property policy to require witnesses and receipts, and a detailed log of community visits including the staff members who accompanied the resident.
- Assisted residents in retrieving any loss of value owed to them once the investigation is complete.
Failure to Conduct Comprehensive Background Checks on Staff
Penalty
Summary
The facility failed to adhere to its own policy regarding conducting comprehensive background checks on employees before they begin working with residents. This deficiency was identified during interviews and record reviews, revealing that several employees, including a PRSC, CNA Supervisor, and multiple CNAs, were hired without complete background checks. The facility's policy mandates that background checks be conducted to ensure that staff are eligible to work in a nursing home and to prevent abuse. However, the Office Manager/HR Director admitted to not fully checking the backgrounds of employees against various registries, including the Illinois Sex Offender, Department of Corrections Sex Offender, and Health and Human Services Office of Inspector General registries. The personnel files of the employees in question showed that background checks were initiated, but results from critical registries were missing. For instance, the background check for one employee was initiated on a specific date, but there were no results provided for several important registries. This pattern was consistent across the files reviewed, indicating a systemic issue in the facility's hiring process. The HR Director acknowledged not being taught to check these registries, which resulted in incomplete background checks and potential risks to residents. The facility's abuse policy, dated earlier in the year, clearly outlines the requirement for screening employees before they work with residents, including conducting criminal background checks. The policy explicitly states that the facility will not hire individuals with findings of abuse, exploitation, or misappropriation of property. Despite this, the facility's failure to conduct thorough background checks as per their policy has left residents vulnerable to potential harm from staff with undisclosed backgrounds.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Sheriden Commons | 0.2 mi | ★★★★★ | 2 | 0 |
| Complete Care At Margate Park | 0.5 mi | ★★★★★ | 25 | 0 |
| Alden Lakeland Rehab & Hcc | 0.6 mi | ★★★★★ | 41 | 2 |
| Selfhelp Home Of Chicago | 0.6 mi | ★★★★★ | 0 | 0 |
| Carlton At The Lake, The | 0.7 mi | ★★★★★ | 25 | 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 October 2026) and official state health department websites.