Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sheridan Village Nrsg & Rhb during CMS and state inspections, most recent first.
A resident with multiple chronic diagnoses developed an itchy, scattered rash that was documented in nursing notes and wound records, but the chart did not consistently reflect the dermatology diagnosis. The dermatologist assessed scabies and ordered permethrin and ivermectin, yet a progress note was edited from scabies to skin rash. Staff interviews showed the RN had originally documented scabies but was told by the DON and ADON to change it, and the DON acknowledged documentation problems and said staff were looking for symptoms for the charting.
Surveyors observed multiple failures in food safety and sanitation, including improper storage and handling of food, spoiled produce left in the cooler, unsanitary food carts, and staff not following hand hygiene or equipment sanitization protocols. The cooler was found above the required temperature, and food items were not properly labeled or discarded, increasing the risk of contamination.
The facility did not complete new Level I PASARR screenings for several residents with known mental illnesses, despite documentation of diagnoses such as schizophrenia and bipolar disorder. PASARR records were incomplete or incorrectly indicated that no further screening was needed. Staff interviews revealed confusion about PASARR requirements and inconsistent practices regarding which residents required updated screenings.
Surveyors found expired medications and enteral feeding containers stored in medication carts and storage rooms, and also observed a medication cart left unlocked and unattended by an RN. Staff confirmed these items should have been discarded and that medication carts must be locked when unattended, in accordance with facility policy.
A resident who is totally dependent and requires assistance for transfers was unable to access her call light, which was found on the floor at the foot of her bed. Despite the resident's repeated requests for staff to place the call light within reach, it remained inaccessible. Both a RN and the DON confirmed that call lights are required to be within reach according to facility policy and the resident's care plan.
The facility failed to ensure timely refills and availability of controlled substances for two residents, resulting in unmanaged pain and sleep disruption. Additionally, there were discrepancies in narcotic medication counts due to lack of documentation by an LPN, and required shift-to-shift controlled substance counts were not consistently performed or recorded, as evidenced by missing signatures on check forms.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was given psychotropic medications without discontinuing or renewing PRN orders after 14 days, and without obtaining consent from the POA as required. The resident personally signed consent forms despite documented cognitive impairment and the presence of a POA, and there was no documentation that the POA was notified or provided consent for the medications.
A medication error rate above 5% was identified when an LPN administered the incorrect dose of Acetaminophen to a resident and failed to give a scheduled dose of Bactrim DS during a medication pass. The LPN later realized the omission after reviewing the MAR and administered the missed medication at a later time, contrary to facility policy requiring verification of medication orders and adherence to the five rights of medication administration.
A resident was not offered, educated about, or given the opportunity to consent to influenza and pneumococcal vaccines, and there was no documentation of these actions in the medical record. The Infection Preventionist and DON confirmed that the required education and consent were not documented or provided, contrary to facility policy.
A resident was not offered or educated about the COVID-19 vaccine, and there was no documentation of consent or administration. The Infection Preventionist could not confirm if the vaccine was offered or given, and the DON stated that all education and consent should be documented, but the resident's record lacked this information, contrary to facility policy.
A resident with a history of delusions and false accusations made several allegations of abuse against staff members. Despite the facility's policy requiring immediate reporting of all allegations, staff failed to report these incidents to the administrator or IDPH. The registered nurse involved did not report the allegations, believing them to be false, which was against the facility's policy. This inaction led to a deficiency in handling abuse allegations.
A resident with cerebral palsy and schizoaffective disorder reported being injured during a mechanical lift transfer, alleging intentional harm by staff. Despite the resident's report and call to emergency services, the RN did not assess the injury or notify the physician and administration, violating the facility's abuse prevention policy.
The facility failed to label and date food items in the walk-in cooler, as observed with a package of chopped spinach and a box of non-dairy whipped topping. The Dietary Supervisor confirmed that labeling is essential for monitoring food usage, with a 30-day storage limit. The facility's policy mandates proper labeling and storage, which was not followed in this instance.
The facility failed to properly implement Enhanced Barrier Precautions (EBP) for residents, affecting four individuals and potentially impacting all 174 residents. Observations showed staff not using PPE when required, missing EBP signs on doors, and inadequately stocked PPE bins. The facility's policies mandate clear signage and PPE availability for high-contact care, but lapses were noted, with staff relying on in-services and verbal communication for EBP implementation.
A resident's indwelling catheter drainage bag was left uncovered, compromising their dignity. The resident, who is cognitively intact and has a history of cancer and diabetes, was observed with the drainage bag hanging from the bed frame facing the hallway. Facility staff, including an LPN, DON, and ADON, acknowledged the need for the bag to be covered for privacy. The facility's policies and Residents Rights documentation emphasize the importance of maintaining resident dignity and privacy.
A facility failed to rescreen a resident with bipolar disorder for PASRR requirements within the mandated 60-day period. The resident's PASRR Level I Screen Outcome indicated a need for rescreening if the stay exceeded 60 days, but the facility did not comply, resulting in a lapse in required evaluation. The oversight was acknowledged by the Psychiatric Rehabilitation Services Director, who confirmed the rescreening was submitted only after the deficiency was identified.
A resident's personal refrigerator was not properly cleaned or monitored for temperature, with missing log entries and a black substance found on the thermometer. The resident, with moderately impaired cognition and multiple medical conditions, reported infrequent cleaning and temperature checks, contrary to facility policy. Staff interviews revealed a lack of adherence to daily maintenance expectations.
A resident with cervical disc degeneration and quadriplegia was found using a wheelchair with broken brakes, compromising their safety and mobility. The facility's restorative staff was responsible for daily checks, but it was unclear how long the resident had been using the malfunctioning wheelchair. The facility's policy required equipment evaluation prior to use, which was not followed in this instance.
A resident with multiple diagnoses and high fall risk fell from his bed during incontinence care due to inadequate supervision. The CNA was providing care alone, contrary to the resident's care plan, resulting in a laceration that required stitches.
A resident with memory problems and a high risk for falls was inadequately supervised, resulting in a fall and a laceration to the right eyebrow that required one suture. The resident was known to wander and had a history of frequent falls, yet staff did not know the resident's whereabouts at the time of the fall. The RN on duty admitted to being preoccupied with other tasks, and the DON confirmed the need for frequent observation and assistance, which was not adequately provided.
Incomplete and Inaccurate Diagnosis Documentation for Resident Skin Condition
Penalty
Summary
The facility failed to maintain complete medical records that were readily accessible and contained a complete and accurately documented diagnosis for one resident. The cited resident had multiple diagnoses, including quadriplegia, acute neurologic condition, mood disorder due to known physiological condition, neuromuscular dysfunction of the bladder, major depressive disorder, elevated prostate specific antigen, and aphasia. The deficiency centered on the resident’s skin condition documentation, where the record reflected ongoing rash and itching but did not consistently or accurately identify the diagnosis associated with the dermatology findings and treatment. The resident’s wound management record documented a red, scattered, itchy rash on the right lower back with comments that weekly skin observation showed skin rashes and that treatment was ongoing because the resident continued to complain of itching. A dermatology office visit documented a one-month history of itchy body eruption involving the upper and lower extremities, abdomen, chest, and back, with excoriated papules on examination. The dermatologist assessed scabies and ordered permethrin cream to the total body from the neck down, washed off in 8 hours and repeated weekly for 4 weeks, along with ivermectin 200 mcg/kg weekly for 4 weeks. After the dermatology visit, the resident’s progress note was edited so that the diagnosis changed from scabies to skin rash. Subsequent nursing notes continued to describe scattered erythematous papular rash, generalized rash, itching, and contact isolation for skin rash, while later notes stated the rash was subsiding and the resident completed treatment. During interviews, the RN stated she originally documented scabies but was told by the DON and ADON to document skin rash, and the DON stated the facility was not great with documentation and was looking for symptoms for documentation. The former infection control coordinator stated she did not see documentation of scabies and wrote skin rash because that was the conclusion reached after reviewing the paperwork.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices, as observed during a kitchen tour and interviews with dietary staff. Two silver baking pans containing meat loaf were found in the cooler with a pool of spilled milk on top of the foil wrapping, which the Dietary Manager acknowledged could cause contamination and pose a risk to residents with milk allergies. In the same cooler, cartons of cabbage and oranges were found with spoiled produce, including yellowing and brownish cabbages with liquid dripping out and moldy, squishy oranges. The Dietary Manager confirmed these items should have been discarded to prevent illness and cross-contamination. The cooler temperature was recorded at 51°F, above the required 41°F, and an open box of waffles in the freezer was not labeled with the date it was opened, contrary to facility policy. Additionally, unsanitary conditions were noted with two food carts that had whitish substances and black stains from food spills, which the Dietary Manager admitted had not been cleaned due to staff shortages. During dishwashing, a dietary aide was observed handling clean dishes without washing hands or wearing gloves after handling dirty dishes, which the Dietary Manager stated was not in accordance with sanitary procedures. Furthermore, the cook was seen rinsing, but not sanitizing, the puree machine between uses, despite facility policy requiring thorough washing and sanitizing. These actions and inactions contributed to the facility's failure to maintain proper food safety and sanitation standards.
Failure to Complete Required PASARR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to initiate new Level I PASARR screenings for four residents with known mental illnesses, as required for Pre-admission Screening and Resident Review (PASARR). Documentation for these residents showed diagnoses such as schizoaffective disorder, bipolar disorder, schizophrenia, major depressive disorder, and delusional disorders. However, their PASARR records were either incomplete, did not indicate a reasonable basis for suspecting mental illness or developmental delay, or incorrectly stated that no Level II PASARR was required despite the presence of qualifying diagnoses. There was no documentation to show that appropriate Level II PASARR screenings had been completed for these residents. Interviews with facility staff revealed confusion and inconsistent understanding of PASARR requirements, particularly regarding which residents required new screenings and the process for updating expired screenings. The Social Services Director and Admissions Director each described different responsibilities and procedures for ensuring PASARR compliance, with both referencing a belief that residents admitted prior to a certain date were "grandfathered" and did not require new screenings. Facility policy required compliance with federal and state PASARR standards and obtaining complete PASARR documentation from referral sources, but the observed practice did not align with these requirements.
Expired Medications and Unsecured Medication Cart Identified
Penalty
Summary
Surveyors observed that expired medications and enteral feeding containers were not removed and discarded as required. Specifically, an open bottle of Meclizine with an expiration date of 02/2025 was found in a medication cart on the third floor, and four containers of Glucerna enteral feeding with an expiration date of 04/01/2025 were found in the medication storage room. Staff confirmed that these items should have been discarded after expiration and acknowledged that expired medications and feedings should not be available for resident use. Additionally, a medication cart on the second floor was found unlocked and unattended while the responsible RN was out of sight. The RN admitted that the cart should have been locked when unattended and stated that she may have been rushing at the time. Facility policy requires that all medication storage areas be locked when not attended by authorized personnel and that expired medications be immediately removed and destroyed.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. During observation, the resident was found unable to access the call light, which was hanging on the floor at the foot of the bed. The resident, who is totally dependent and requires assistance for transfers, reported being unable to find the call light and stated that she had repeatedly asked staff to place it within reach. A registered nurse confirmed the call light was not accessible and acknowledged the importance of keeping it within reach for residents to communicate their needs. The Director of Nursing also stated that call lights should always be within reach of residents. Documentation in the resident's care plan and facility policy both specify that call lights must be placed within easy reach of residents.
Failure to Refill Medications and Maintain Accurate Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that medications were refilled and readily available for two residents who required controlled substances for pain management and sleep. One resident, with diagnoses including lymphedema and chronic pain, reported not receiving Tylenol with Codeine for several days due to the medication running out and not being reordered in time. The resident expressed significant pain and discomfort, stating that regular Tylenol was not sufficient. Another resident, with a history of hemiplegia and psychiatric disorders, reported repeated instances of not receiving Lunesta for sleep because the medication was not refilled before running out, resulting in sleepless nights and frustration. Inspection of the medication cart confirmed that both medications were not available at the time of the survey, and the nurse acknowledged the medications had run out and were awaiting delivery from the pharmacy. Additionally, the facility failed to maintain accurate counts of narcotic medications for two residents. During a controlled substance count, discrepancies were found between the number of pills present in the medication bingo cards and the amounts documented in the controlled drug receipt records. The LPN responsible admitted to administering the medications but forgetting to document the administration, leading to inaccurate records. The facility also did not ensure that controlled substances were counted and documented at the beginning and end of each shift as required. Review of the Controlled Substances Check Forms for multiple medication carts revealed missing signatures for several shifts, indicating that the required shift-to-shift controlled substance counts were not consistently performed or documented. Facility policy requires these counts to be conducted by two licensed nurses at each shift change, but this procedure was not followed for a number of shifts.
Failure to Discontinue PRN Psychotropics and Obtain POA Consent for Severely Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not discontinuing or obtaining an order to continue as needed (PRN) psychotropic medications after the required 14-day period. Additionally, the facility did not obtain proper psychotropic medication consent from the resident’s Power of Attorney (POA), despite the resident having severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3/15. The resident, who has diagnoses including major depressive disorder, schizophrenia, schizoaffective disorder, and anxiety disorder, was observed to be oriented to person and place but confused about time and situation, and unable to answer most questions. The review of records showed that the resident personally signed consent forms for psychotropic medications, even though the face sheet documented a POA for health and there was no documentation that the POA was notified or provided consent for these medications. The DON acknowledged that there was no documentation of POA notification or consent for the psychotropic medications. Furthermore, PRN psychotropic medication orders were found to be open-ended and not discontinued or renewed after 14 days as required by facility policy and CMS regulations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a medication administration observation. During a medication pass, an LPN administered Acetaminophen 500 mg (2 tablets) to a resident, despite the resident's medication administration record (MAR) specifying Acetaminophen 325 mg (2 tablets) every 6 hours as needed. Additionally, the resident was scheduled to receive Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg at 9:00 AM, but this medication was not administered during the observed medication pass. The LPN confirmed that she had completed the morning medication administration for the resident without giving the scheduled Bactrim dose. Upon later review, the LPN stated she did not initially see the Bactrim order in the MAR and only noticed it after checking the facility's 24-hour communication report. She then administered the Bactrim at approximately 10:30 AM, after the surveyor had left the area. Facility policy requires medications to be administered as prescribed, with verification of the five rights (right resident, drug, dose, route, and time) at multiple steps, and comparison of the MAR with medication labels prior to administration. The failure to follow these procedures led to the medication errors identified during the survey.
Failure to Offer, Educate, and Document Consent for Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to follow its policy regarding the offering, education, and documentation of consent for influenza and pneumococcal vaccinations for one resident. During interviews and record reviews, it was found that the resident did not recall being offered the influenza or pneumococcal vaccines. The Infection Preventionist was unable to locate any documentation of consent, education, or administration of these vaccines for the resident. The Infection Preventionist stated she was unsure why the resident had not received the vaccines or the required education, and confirmed that there was no record of these actions in the resident's file. Further review with the Director of Nursing revealed that the facility's process is to review immunizations upon admission, provide education on the importance and benefits of the vaccines, and obtain informed consent before administration. The Director of Nursing emphasized that all education and decisions regarding immunizations should be documented in the clinical record, and if not documented, it is considered not done. The resident's immunization record showed no evidence of the vaccines being offered, administered, or any education or consent being documented for the year in question, which is inconsistent with the facility's stated policy.
Failure to Offer, Educate, and Document COVID-19 Vaccination for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy regarding COVID-19 vaccination for one resident out of five reviewed for immunizations. The resident reported not recalling being offered or educated about the COVID-19 vaccine. Upon review, the Infection Preventionist was unable to locate documentation of consent, education, or administration of the COVID-19 vaccine for this resident. The Infection Preventionist stated uncertainty about whether the vaccine was offered or administered and acknowledged the absence of required documentation. Further, the Director of Nursing confirmed that the facility's process includes reviewing immunizations upon admission, providing education on the importance and benefits of the COVID-19 vaccine, and obtaining informed consent, all of which should be documented. However, the resident's immunization record lacked any indication that the COVID-19 vaccine was offered, administered, or that education and consent were provided. The facility's policy requires notification, education, and documentation of acceptance or declination of the vaccine, which was not followed in this instance.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report alleged abuse allegations to the proper authorities within the prescribed time frame for one resident. The resident, a 39-year-old with a complex medical history including cerebral palsy, schizoaffective disorder, and other conditions, made several allegations of abuse against staff members. Despite the resident's history of delusions and false accusations, the facility's policy requires all allegations to be reported to the administrator and the Illinois Department of Public Health (IDPH) within two hours. On two occasions, the resident made allegations against certified nurse assistants, claiming physical abuse and inappropriate behavior. These incidents were documented by the staff but were not reported to the administrator or IDPH as required. The registered nurse involved in these incidents did not report them, believing the allegations to be false due to the resident's history of delusional behavior. This inaction was contrary to the facility's policy, which mandates reporting all allegations regardless of their perceived validity. Interviews with staff revealed a lack of adherence to the reporting policy, with some staff assuming others would report the incidents. The administrator, who is also the abuse coordinator, was not informed of these allegations until much later. The facility's policy clearly states that it is not the responsibility of the staff to determine the truth of an allegation, but rather to report it immediately for proper investigation. This failure to report in a timely manner constitutes a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Allegation of Abuse During Transfer
Penalty
Summary
The facility failed to assess and investigate an allegation of physical abuse involving a resident with multiple medical diagnoses, including cerebral palsy and schizoaffective disorder. The resident, who has intact cognitive abilities and requires substantial assistance for daily activities, reported that during a mechanical lift transfer, staff injured her knee intentionally. Despite the resident's report to a registered nurse and her call to emergency services, the nurse did not assess the resident for injuries, notify the physician, or inform the facility's administration, as required by the facility's abuse prevention policy. The Director of Nursing and the Administrator both acknowledged that the nurse should have conducted an assessment and notified the appropriate parties to investigate the allegation. The facility's policy mandates immediate reporting and investigation of any incidents or allegations of abuse, but this protocol was not followed. The failure to document and investigate the resident's report of injury during a mechanical lift transfer represents a deficiency in the facility's response to potential abuse allegations.
Failure to Label and Date Food Items in Walk-in Cooler
Penalty
Summary
The facility failed to ensure that food items stored in the walk-in cooler and freezer were labeled with the date they were placed there. During an observation, a 48-ounce package of chopped spinach and an opened box containing ten cans of non-dairy whipped topping were found in the walk-in cooler without any date labels. This lack of labeling prevents staff from monitoring the duration for which the food items have been stored, which is crucial for maintaining food safety and quality. The Dietary Supervisor (V5) confirmed that the purpose of labeling and dating food containers is to track when the food should be used, with a 30-day limit for items in the cooler and freezer. The responsibility for labeling lies with the cooks and dietary aides. The facility's policy, as outlined in the Health Technologies, Inc. Guideline & Procedure Manual, requires all stored foods to be properly labeled and dated, using a first in-first out method. The Dietary Aid Job Description also emphasizes the importance of maintaining safe food handling procedures, including proper labeling and storage.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for residents requiring such measures, affecting four residents and potentially impacting all 174 residents in the facility. Observations revealed that staff were not consistently using Personal Protective Equipment (PPE) when providing care to residents on EBP, and there were instances where EBP signs were not posted on resident doors. For example, a Certified Nursing Assistant (CNA) was observed adjusting a resident's diaper without wearing gloves or a gown, and there was no EBP sign on the resident's door, despite the resident having an indwelling Foley catheter and a pressure ulcer. Further observations indicated that PPE bins were either missing or inadequately stocked outside the rooms of residents on EBP. In one instance, a resident's room had an EBP sign, but there was no PPE bin available either inside or outside the room. The Director of Nursing confirmed the absence of PPE bins and acknowledged that EBP should be in place for residents with certain medical conditions, such as wounds or indwelling devices, to prevent infection transmission. The facility's policies on infection control and EBP require clear signage and the availability of PPE for high-contact resident care activities. However, the report highlights lapses in adherence to these policies, as evidenced by the lack of signage and PPE availability. Staff interviews revealed a reliance on in-services and verbal communication for EBP implementation, which may have contributed to the inconsistencies observed during the survey.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering the indwelling catheter drainage bag with a privacy bag. This deficiency was observed during a survey when the drainage bag of a resident, who is cognitively intact and has a history of malignant neoplasm of the colon, colorectal cancer, and diabetes, was found hanging from the bed frame facing the hallway without a privacy cover. The resident's care plan indicated the need for a urinary catheter due to the presence of urogenital implants. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), confirmed that the urinary drainage bag should be covered with a privacy bag to maintain the resident's dignity. The facility's job descriptions for LPNs and CNAs emphasize the importance of complying with policies and procedures, including ensuring resident privacy and dignity. The facility's Residents Rights documentation also highlights the right to dignity, respect, privacy, and confidentiality in medical and personal care.
Failure to Rescreen Resident for PASRR Requirements
Penalty
Summary
The facility failed to rescreen a resident, identified as R153, to determine if specialized services under the Preadmission Screening and Resident Review (PASRR) requirements were necessary. R153 had a PASRR Level I Screen Outcome that indicated a convalescence categorical approval for a 60-day stay due to a suspected or confirmed mental health disability, specifically bipolar disorder. The PASRR Level I screen stated that if the resident needed to stay beyond the approved 60 days, a new Level I screen must be submitted. However, the facility did not conduct the required rescreening within the 60-day period, as confirmed by the Psychiatric Rehabilitation Services Director (V26), who acknowledged the oversight and stated that the rescreening was only submitted after the 60-day period had expired. R153's medical records indicated a diagnosis of bipolar disorder and the use of antipsychotic medications, suggesting the need for ongoing assessment and potential specialized services. Despite the clear requirement for rescreening outlined in the PASRR documentation, the facility staff, including the Admissions Director and the Psychiatric Rehabilitation Services Director, failed to ensure that the necessary procedures were followed in a timely manner. This oversight resulted in the resident remaining in the facility without the required updated PASRR evaluation, which was only addressed after the deficiency was identified by the surveyor.
Failure to Maintain Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain proper cleaning and temperature logging for a resident's personal refrigerator. Observations revealed that the temperature log on the refrigerator was missing entries for specific dates, and a black substance was found on the thermometer inside the refrigerator. The resident stated that the staff cleaned the refrigerator and checked its temperature only once a month, which contradicts the facility's policy and the expectations set by the Maintenance Director. The resident involved has a BIMS score indicating moderately impaired cognition and has multiple medical diagnoses, including multiple sclerosis and schizoaffective disorder. Interviews with the housekeeper and Maintenance Director revealed a lack of clarity and adherence to the facility's policy, which requires daily cleaning and temperature checks of personal refrigerators. The housekeeping staff was unaware of the black substance on the thermometer and did not consistently log the refrigerator's temperature, leading to the deficiency.
Failure to Maintain Functional Wheelchair for Resident
Penalty
Summary
The facility failed to ensure that a resident's adaptive equipment, specifically a wheelchair, was functional and safe for use. On observation, the resident reported that the brakes on their wheelchair were broken, with the right brake not touching the rear wheel and the left brake being loose. This issue was confirmed when the wheelchair moved despite the brakes being engaged. The Assistant Director of Nursing acknowledged the problem and stated that the facility would provide a new wheelchair immediately. The responsibility for checking the wheelchair daily was assigned to the restorative staff, but it was unclear how long the resident had been using the malfunctioning wheelchair. The resident involved had a diagnosis of cervical disc degeneration and quadriplegia, and their mental status was documented as cognitively intact. The resident's care plan highlighted a risk for deterioration in mobility and activities of daily living, emphasizing the importance of functional mobility devices. The facility's policy required all medical equipment to be evaluated prior to use, but this was not adhered to in this case, leading to the deficiency. The failure to maintain the wheelchair could potentially limit the resident's mobility and increase the risk of falls, as noted by the Director of Nursing.
Inadequate Supervision During Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall during incontinence care for a resident (R1). R1, a male resident with multiple diagnoses including COPD, paranoid schizophrenia, heart failure, diabetes, anxiety disorder, severe depressive disorder with psychotic features, and obesity, fell from his bed while being changed by a CNA. R1's care plan indicated he required extensive or total staff assistance and was at high risk for falls due to weakness and poor safety awareness. During the incident, the CNA was providing care alone, and the resident rolled out of bed, resulting in a laceration on his forehead that required 13 stitches. The CNA reported that the mattress shifted off the edge of the bed frame, contributing to the fall. The resident had previously mentioned that the mattress on the original bed often fell off the edge, and he had almost fallen before because of that. The incident report and interviews with staff revealed that the CNA was aware that R1 typically required two-person assistance for transfers but was performing the incontinence care alone. The Assistant DON and the physician both acknowledged that while one person might be sufficient for this type of care, two people would have been better. The facility's Fall Reduction Program policy emphasizes the need for appropriate interventions and supervision to ensure resident safety, which was not adequately provided in this case. The failure to follow the care plan and provide the necessary supervision led to the resident's fall and subsequent injury.
Inadequate Supervision of High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise a resident (R3) who has memory problems and is at high risk for falls. On the day of the incident, R3 was found on the floor with a laceration to the right eyebrow, which required one suture. The resident was sent to the local hospital for evaluation and returned to the facility the same day. The incident report and staff interviews indicate that R3 was known to wander and had a history of frequent falls, yet the staff did not know R3's whereabouts at the time of the fall. The RN on duty admitted to being preoccupied with other tasks and not being able to supervise R3 adequately, despite knowing R3's high fall risk status. The Director of Nursing (DON) and R3's physician both confirmed that R3 requires supervision due to dementia and confusion. The physician was not surprised by the fall, given R3's history, and emphasized the importance of staff supervision to prevent injuries. The DON stated that staff should be answering call lights promptly and conducting hourly rounds to check on residents, but it was unclear how long R3's call device had been alarming before staff responded. R3's care plan and progress notes highlighted the resident's high fall risk and the need for frequent observation and assistance with transfers. Despite these documented needs, the facility's failure to provide adequate supervision led to R3 sustaining a laceration from a fall. The facility's records show that R3 had multiple falls in the past 120 days, indicating a pattern of insufficient supervision and fall prevention measures for this high-risk resident.
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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) |
|---|---|---|---|---|
| All American Vlge Nrsg & Rhb | 0.6 mi | ★★★★★ | 1 | 0 |
| Park View Rehab Center | 0.7 mi | ★★★★★ | 25 | 0 |
| Admiral At The Lake, The | 0.8 mi | ★★★★★ | 10 | 0 |
| Aperion Care Wesley | 1 mi | ★★★★★ | 5 | 0 |
| Selfhelp Home Of Chicago | 1 mi | ★★★★★ | 0 | 0 |
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