Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Warren Park Health & Living Ctr during CMS and state inspections, most recent first.
Failure to transmit IDPH reportable incident forms correctly resulted in multiple reportables not being received for several residents. The Administrator stated the facility had been using an outdated fax number and relied on the fax result sheet as confirmation, without realizing the reports were not going through. The facility policy required allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to be reported to IDPH by phone or fax, followed by a final investigation report.
Ineffective Pest Control Program: Surveyors observed flying insects in resident rooms and the basement dining room, and residents reported ongoing flies, roaches, spiders, and mice in bedrooms, hallways, and common areas. Housekeeping, the Ombudsman, and the DON all acknowledged continued pest activity despite weekly pest control services, and service reports documented mice and roaches in kitchen and resident areas.
Unsafe shower room fixtures were observed when the toilet rails in the second-floor shower area were found loose, rusted, and missing screws, with the Maintenance Director stating they had likely been that way for a while. A missing shower head and a torn shower curtain were also observed, preventing full coverage of the shower area. The Administrator said she was not aware of the rail issue, and the Maintenance Director stated he had no record of maintaining or checking shower areas.
Unrepaired wall and flooring damage left three residents in visibly damaged rooms, including large holes in the drywall and missing floor tiles near beds. Residents reported the issues had been present since move-in or since a prior roommate caused them, and that they had asked staff to fix them without success. The Maintenance Director said he was not aware of the problems, and the DON stated staff are supposed to report maintenance issues through the electronic communication dashboard.
Failure to complete a current PASARR review for a resident with SMI. The resident had bipolar disorder, unspecified mood disorder, depression, and was receiving psychotropic meds including citalopram, lorazepam, and trazodone. The care plan identified a need for supportive counseling and psychotherapeutic services, but the EMR showed no current PASARR. Staff gave conflicting statements about PASARR responsibility and whether a new review was needed when the resident’s mood disorder diagnosis was added.
Failure to promptly notify the physician of resident skin rashes led to delayed treatment for multiple residents. A CNA reported noticing rashes on several residents over the past month and said the nurse had been informed, but the nurse and NP notification timing was unclear. Residents described persistent itching and widespread rashes, and surveyors observed red and black bumps, some crusted or with central openings, on the feet, legs, buttocks, stomach, back, arms, and under the breasts. An LPN believed skin cream had been ordered for one resident, while a nurse stated she was new to the facility and was not aware of another resident's rash.
Improper Administration of G-Tube Bolus Feeding: A resident with a G-tube, NPO status, and orders for Jevity 1.2 bolus feedings received the feeding using an incorrect syringe and plunger method instead of gravity administration. During observation, the RN used a short-tip 60 mL syringe that leaked feeding onto a blanket, and the DON stated the plunger should not be used for bolus feedings.
A resident on continuous O2 was repeatedly observed without oxygen in use, had no oxygen-in-use sign posted, and had unlabeled tubing and a wheelchair-stored cannula kept without protective storage. The resident reported her oxygen was broken and that she had no portable O2 for an upcoming appointment; staff acknowledged the resident was supposed to be on continuous oxygen and that portable tanks were not available. A second resident’s nebulizer mask was also observed on the bedside table without a bag to prevent contamination.
Controlled substance accounting was not completed correctly for multiple residents. An LPN could not identify or locate a Lorazepam Intensol order, an RN found extra Lorazepam vials for one resident that were not included in the count, and another resident’s Lorazepam tablets were undercounted because 60 tablets were not recorded. The DON stated controlled meds must be verified, documented, and counted by both nurses at shift change.
Expired and discontinued medications were found in medication storage, including an eye drop in a med cart that had been opened beyond the pharmacy’s discard timeframe and multiple vials of Lorazepam stored in the med room after the order had been discontinued. An LPN said she was unsure when the eye drop would expire, and an RN found the controlled medication in two labeled bags in the refrigerator with the controlled substance sheet folded inside.
Failure to Administer COVID-19 Vaccine After Consent: Three residents consented to receive the COVID vaccine, but the vaccine was not administered. The IPC stated the residents did not receive it because an in-house vaccine clinic was not set up. The DON stated residents who consent should have the physician contacted for an order and the vaccine administered timely.
Staff failed to prevent and address incidents of unwanted sexual contact between residents and between staff and residents. A resident with a history of mental illness was reported to have groped a female resident who had expressed her discomfort, and a staff member was observed patting the same resident on the rear. The care plan lacked updated interventions, and staff minimized or failed to recognize the seriousness of the behaviors, contrary to facility policy.
The facility's pest control program was ineffective, as evidenced by mouse droppings found in multiple rooms on the 2nd and 3rd floors. Residents confirmed the presence of mice, with one resident reporting having killed a mouse. The Maintenance Director was unaware of the issue, despite regular pest control services, and facility policy requires the environment to be pest-free.
The facility failed to discard expired food, label food items with use-by dates, and sanitize cooking equipment per manufacturer's directions. A container of tuna salad was found past its discard date, and sliced deli turkey lacked a use-by date. Additionally, the Quaternary solution used for sanitizing was below the recommended concentration, indicating improper disinfection of kitchen items. These deficiencies could affect the safety of food served to 123 residents.
The facility failed to ensure reusable cloth incontinence briefs were in good condition, as observed by a surveyor who found a stained brief on a linen cart. The Laundry Aide assumed it was acceptable for use since it was not torn, despite washing it twice. The Housekeeping Director confirmed the stains were from urine and feces, and stated the aide is responsible for discarding such linens. This failure potentially affects 40 incontinent residents.
The facility did not refer four residents with serious mental illness for a PASARR Level II evaluation, despite their diagnoses indicating a need for further assessment. The facility's policy requires such referrals when a Level I screen suggests potential mental disorders, but the Social Service Director stated that the facility only conducts PASARR screenings when instructed by an outside agency.
A medication cart was found unlocked and unattended in an LTC facility, with keys left inside the lock. An RN responsible for the cart admitted to forgetting to secure it due to being busy. The cart contained medications for residents on the 1st and 3rd floors, posing a risk of unauthorized access and potential adverse reactions. The DON confirmed the danger and the facility's policy requires medications to be locked when not in use.
A registered nurse in an LTC facility failed to sanitize a wrist blood pressure cuff device between uses on multiple residents during medication administration. The nurse admitted to forgetting to clean the device due to nervousness. The DON confirmed that all shared equipment must be sanitized to prevent infection spread, as per facility policy.
Two residents were found without appropriate clothing or incontinence briefs, compromising their dignity. One resident was left exposed due to a lack of properly sized briefs, while another was found completely naked under a blanket. Staff acknowledged the dignity issue, and facility policies emphasize treating residents with respect, yet these standards were not upheld.
A resident's air loss mattress was incorrectly set for a weight range of 240-320 pounds, despite the resident weighing between 100-110 pounds. This error resulted in a firm mattress, unsuitable for pressure distribution, potentially worsening the resident's stage IV pressure wound. The resident, with a high risk for pressure wounds due to multiple health conditions, requires proper mattress settings to prevent further skin breakdown.
Two high fall risk residents experienced falls due to inadequate supervision in a facility. One resident fell in the bathroom without assistance, while another fell in the dining room with no staff present. Both residents had high Morse Fall Scale scores and required supervision, but staff were unaware of the incidents, indicating a lapse in communication and adherence to care plans.
The facility failed to offer pneumonia vaccines to three residents upon admission, as required by its policy. Despite consent being obtained, the vaccines were not administered, and there was no documentation in the residents' electronic health records. The Infection Preventionist and Director of Nursing acknowledged the oversight, which affected residents with chronic health conditions, increasing their risk for pneumonia.
A resident with a history of falls and complex medical conditions was not properly assessed or monitored, leading to a significant injury. Despite being a high fall risk, the facility did not conduct necessary fall risk assessments or update the care plan after previous falls. The resident was eventually hospitalized with a cervical vertebrae fracture and subdural hematoma, highlighting a failure in implementing adequate fall prevention measures.
A resident with a complex medical history was found with a new hematoma on her head, which was not reported to the state agency as required by the facility's policy. Despite the facility's protocol for reporting injuries of unknown origin, the administrator was unaware of the injury, and it was not documented or reported within the mandated 24-hour period.
Failure to Transmit IDPH Reportable Incident Forms
Penalty
Summary
The facility failed to ensure its IDPH reportable initial and final Incident Report Forms were transmitted correctly for 7 residents identified on four Facility Reportable documents. During review of the facility Reportable Fax Transmittal Form, the transmittal sheet showed a result of “No answer,” and IDPH did not receive reportables dated 09/18/25, 10/27/25 regarding R20 and R28, 10/28/25 regarding R121, 11/19/25 regarding R28 and R86, and 09/19/25 regarding R50, R45, and R82. The report states this failure had the potential to affect 123 residents residing in the facility. During interview, the Administrator stated the facility had been submitting reportables to the fax number shown on the result report for about 2 years and believed the fax confirmation was the receipt of transmission. The Administrator stated being unaware that the reportables were not being transmitted correctly and acknowledged not going further after seeing the result. The facility policy titled Abuse Prevention Program required allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to be reported to the Illinois Department of Public Health immediately by telephone or fax, with a five-day final investigation report sent afterward.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. During observations, surveyors saw a black flying insect in R7’s room while the resident was lying in bed, and another black flying insect in R113’s room while the resident was lying in bed. R113 stated flies were seen at least once a week and also reported seeing roaches and spiders in the bedroom. In the basement dining room, surveyors observed a black flying insect and a brown bug crawling on the floor, and R121 stated roaches were around the vending machines. In another room, a rodent glue trap was present under a heater vent, but R11 stated a small mouse had been seen the night before and that the trap did not work. Additional interviews reflected ongoing pest activity throughout the facility. R27 stated seeing a cockroach in the third-floor hallway a couple of weeks earlier. Housekeeping staff reported roaches in residents’ bedrooms, bathrooms, the women’s locker room, and the basement activity room, and stated a mouse had been seen in R120’s room the prior week. R41 stated seeing mice, water bugs, and roaches in the bedroom. The Ombudsman stated residents had complained about cockroaches in the past and that it was an ongoing issue. The Maintenance and Housekeeping Director and the DON stated the facility had a pest control company that came weekly and as needed, but staff and residents continued to see pests and rodents. Service inspection reports from the pest control company documented a mouse in kitchen dry storage, a resident room attracting flies and roaches, and German roaches in the kitchen dish room.
Unsafe Shower Room Fixtures and Missing Shower Equipment
Penalty
Summary
The facility failed to maintain the toilet rails inside the second-floor shower room in safe working condition and failed to ensure that a shower head and shower curtain were present to fully cover the shower area for all residents on the second floor. During observation on 12/09/2025 at 12:11 PM with the State Ombudsman present, the left and right toilet rails in the shower room were observed not to be properly attached to the floor and to wobble when pressure was applied. Screws on both rails were missing and the metal showed heavy rust. A missing shower head was also found inside one of the shower areas, and the shower curtain had a tear where it attached to three rings, preventing it from fully covering the shower area when expanded. At 12:25 PM the Maintenance Director entered the shower room and stated that the toilet rails were not properly attached to the floor, that many screws were missing, and that the rails wobbled widely when moved. He stated it appeared to have been that way for a while because of the rust on the metal parts. He also stated that residents were at risk for fall if the rails detached while being used. On 12/10/2025 at 10:00 AM, the Administrator was informed about the toilet rails inside the shower room and stated she was not aware of the problem. On 12/11/2025 at 12:33 PM, the Maintenance Director stated he had no record of maintaining or checking shower areas and that this was the first time he knew about the rail problem in the second-floor shower room.
Unrepaired Room Damage Left Residents Without a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents by leaving visible damage in their shared rooms unrepaired. R9, who was oriented to self, place, and year, stated there was a hole in the wall behind the bed that had been there since moving into the room and that the facility had not fixed it despite requests. Survey observation confirmed a large break in the wall greater than R9’s breakfast plate, with multiple pieces of drywall caved in and smaller pieces on the floor below the hole. R134, who was oriented to self, place, and date, stated a previous roommate made a hole in the wall behind the bedroom door and that the facility had not repaired it despite requests. Survey observation found a crescent-shaped hole in the drywall about a foot long and eight inches high. R133, R134’s current roommate, stated the hole was present when R133 moved in and also reported holes in the floor near the bed that had not been fixed; survey observation confirmed missing flooring tile near both sides of the bed. The Maintenance Director stated he was not aware of the wall holes or the holes near the bed, and the DON stated staff are supposed to report maintenance issues on the communication dashboard in the electronic system.
Failure to Complete Current PASARR Review for Resident With Severe Mental Illness
Penalty
Summary
The facility failed to ensure that a Level II PASARR yearly review was completed for 1 of 2 residents reviewed for PASARR in a sample of 26. The resident had multiple diagnoses, including bipolar disorder, unspecified mood disorder, depression, and several medical conditions such as COPD with exacerbation, ulcerative colitis, morbid obesity, gait and mobility abnormalities, insomnia, overactive bladder, osteoporosis, osteoarthritis, pulmonary embolism and infarction, heart failure, coronary artery disease, hyperlipidemia, and hypertension. The resident’s MDS BIMS score was 15, indicating intact cognitive response, and the medication review listed psychotropic medications including citalopram, lorazepam, and trazodone for mood-related diagnoses. The resident’s care plan included a focus on severe mental illness and documented the need for supportive counseling and/or psychotherapeutic services related to bipolar disorder, signs and symptoms of clinical depression, and other medical/psychiatric/cognitive conditions. Review of the electronic medical record showed the resident did not have a current PASRR. The resident’s OBRA screen dated 07/21/1992 documented a reasonable basis for suspecting developmental disability or severe mental illness, and records showed diagnoses of bipolar disorder in 2015 and unspecified mood disorder in 2017. During interviews, the Social Service Director stated the department was responsible for PASARR, later stated the resident had never left the facility and that she only had to submit PASARR if residents were going to a different facility, and also stated the resident did not have a PASARR because she was here prior to 2022. A psychotropic nurse/care plan coordinator stated she was not the one who normally did the PASARR. An undated typed document later provided by the facility stated the resident was admitted in 2010 with bipolar disorder and that no new PASARR was completed when unspecified mood disorder was added after a hospital stay in 2017.
Failure to Promptly Notify Physician of Resident Skin Rashes
Penalty
Summary
The facility failed to follow its Change in Condition policy to promptly notify the physician of skin rashes for three residents, resulting in a delay of treatment. During the tour, several residents voiced concern about body rashes. A CNA stated that she had noticed body rashes on multiple residents over the past month and that the nurse had been made aware. The DON stated that when CNAs note a change in a resident's skin, they must report it to the nurse immediately, and the nurse must document the change in condition and notify the physician or nurse practitioner timely. R23 stated that she had been itching for a month and described a rash that started on her feet and between her toes and spread to her lower legs, stomach, back, and under her breasts. The surveyor observed red and black bumps, some with crust on top and others with a tiny hole in the middle, across multiple areas of her body. V14 stated that a nurse practitioner had been notified but could not remember who was told or when. R97 stated that his feet, legs, and buttocks would not stop itching and that he had been itching for a long time; surveyors observed similar bumps with crusting and central openings on his feet, lower legs, buttocks, stomach, and arms. A CNA stated she noticed the rash about two weeks earlier and had notified the nurse, while an LPN stated she thought skin cream had been ordered and that the rash appeared to have spread. R113 stated that he had a rash on his left hip for the past two weeks that itched, and he believed it came from the facility linens. A nurse observed dry, scaly skin with multiple raised bumps from the hip down both legs, and stated she was new to the facility and was not aware of the rash.
Improper Administration of G-Tube Bolus Feeding
Penalty
Summary
The facility failed to ensure an enteral bolus feeding was administered per physician orders for one resident with a gastrostomy tube and an order for NPO status. The resident had diagnoses including chronic systolic congestive heart failure, chronic obstructive pulmonary disease, asthma, gastrostomy, essential hypertension, and hyperlipidemia. The resident’s record showed an order for Jevity 1.2 cal bolus feedings via G-tube four times daily, with 120 mL of water before and after each bolus feed, and the care plan noted the resident required tube feeding related to dysphagia. During observation, a registered nurse administered the bolus feeding using a 60 mL syringe with a short tip, which allowed some of the feeding to leak onto a blanket covering the resident’s abdomen. The nurse aspirated the feeding into the syringe from a plastic cup, inserted the short tip into the gastric tube, and pushed the feeding into the tube using the plunger. The nurse stated this was not the right kind of syringe. The DON stated bolus feedings are done by gravity, the nurse must verify the order, check placement and proper position, and that the syringe plunger should not be used to give a bolus feeding. The DON also stated that if the bolus feeding is leaking, there is a potential the resident is not receiving enough feeding according to the order.
Failure to Follow Oxygen Orders and Protect Respiratory Equipment
Penalty
Summary
The facility failed to follow physician orders for a resident on continuous oxygen, failed to post oxygen-in-use signage at the entrance of the resident’s room, and failed to label and store oxygen tubing and a nebulizer set-up to prevent contamination for two residents receiving respiratory care. One resident had diagnoses including COPD with acute exacerbation, heart failure, pulmonary embolism and infarction, morbid obesity, and other chronic conditions, and had a BIMS score of 15. Her orders included continuous oxygen via nasal cannula or mask at 2 liters per minute, pulse oximetry every shift and as needed, and notification of the MD if oxygen saturation was below 90%. The resident was observed multiple times without oxygen in use while away from her room and near the nurse station. She stated her oxygen was broken, that she had no oxygen tank for an upcoming medical appointment, and that she felt like a prisoner in her room. A small rectangular bag attached to the back of her wheelchair contained a nasal cannula, but it was observed without a bag to prevent contamination. When the resident later returned to her room, staff observed her oxygen concentrator at the bedside and her oxygen saturation was 82% before increasing after oxygen and Ventolin were administered. The RN stated the resident was supposed to be on continuous oxygen, that the portable oxygen was faulty, and that the facility did not have portable oxygen tanks available at that time. The second resident had diagnoses including CHF, COPD, asthma, and other chronic conditions, and had an order for ipratropium-albuterol nebulizer solution every 4 hours as needed for shortness of breath. The resident’s nebulizer set-up mask was observed on the bedside table with no bag to prevent contamination. Staff stated the nebulizer set-up mask should be in a bag to protect it from bacteria and germs. The DON stated oxygen tubing should be labeled and stored in a bag when not in use, oxygen tubing and humidification bottles should be changed weekly, and oxygen-in-use signage should be posted at the room entrance and bedside, but these measures were not in place for the resident observed.
Controlled Substance Counts Not Properly Documented
Penalty
Summary
The facility failed to follow its policy for accounting for controlled substances for residents on the 2nd floor. During review of the medication cart and medication room, a LPN found a controlled substance record sheet for Lorazepam Intensol that did not identify the resident it belonged to, and the medication could not be located in the refrigerator or elsewhere in the medication room. The LPN stated the medication had not been accounted for during the shift change review with the night nurse. A RN reviewing controlled medications for one resident found two separate plastic bags labeled with that resident’s name in the refrigerator, each containing four vials of Lorazepam 2 mg/mL, but only one set of four vials had been included in the controlled substance count. The RN stated the additional four vials were not accounted for during shift change. For another resident, the controlled substance sheet for Lorazepam 0.5 mg tablets documented 28 remaining tablets, but the actual bingo cards contained 88 tablets; the RN stated she made a mistake and that 60 tablets were not recorded, so they were not included in the shift count. The DON stated controlled medications must be verified, received with signatures and amounts documented, and counted by the oncoming and offgoing nurses.
Expired and Discontinued Medications Found in Medication Storage
Penalty
Summary
Medication storage was not maintained free from expired and discontinued medications in 1 of 4 medication carts and 1 of 2 medication rooms. During observation, an LPN was seen in the medication cart for one resident and the resident’s Latanoprost 0.005% eye drop was labeled as opened on a date when, according to the pharmacy instruction submitted by the facility, the medication was to be discarded 6 weeks after opening. The LPN stated she did not know when it would expire and was not sure when it would expire. During review of controlled medications, an RN found four vials of Lorazepam 2 mL/mL in a plastic bag in the refrigerator in the medication room under one resident’s name, and another plastic bag with the same resident’s name containing four more vials of Lorazepam 2 mL/mL with the controlled substance sheet folded inside. The resident’s physician order showed that Lorazepam 2 mL/mL had already been discontinued on a prior date. The DON stated that nurses are supposed to give all expired and discontinued medication to her, and that expired or discontinued medications have the risk of being given or administered even if they are already expired or discontinued.
Failure to Administer COVID-19 Vaccine After Resident Consent
Penalty
Summary
The facility failed to follow its Vaccination of Resident Policy by not administering the COVID-19 vaccine to three residents who had consented to receive it. A review of the facility’s immunization report showed that R23 consented on 2/6/25, R46 consented on 4/4/25, and R113 consented on 5/8/25, but none of the three residents received the vaccine as documented by the Infection Control Preventionist. During interviews, R23 stated that they had asked for the COVID vaccine months earlier and had not received it. R46 stated they wanted the COVID vaccine but were not given it, and R113 stated they told the nurse they wanted the COVID vaccine but it was never given. The Infection Control Preventionist stated the residents did not receive the vaccine because an in-house vaccine clinic was not set up. The DON stated residents are offered the COVID vaccine upon admission and annually, and if a resident consents, the nurse should call the physician for an order and administer the vaccine timely.
Failure to Protect Residents from Sexual Abuse and Inappropriate Contact
Penalty
Summary
The facility failed to follow its policy to ensure residents are free from sexual abuse, as evidenced by multiple observations and interviews involving inappropriate sexual contact between residents and between staff and residents. One resident, a man with schizoaffective and bipolar disorder who is moderately cognitively intact, was reported by another resident to have groped a female resident, who is cognitively intact, despite her expressing that she did not like the behavior and had told him to stop. Another resident and a staff member confirmed witnessing or hearing about these inappropriate interactions, with the staff member indicating that such behavior was sometimes consensual and sometimes not. The staff member also minimized the seriousness of the behavior, attributing it to typical male conduct rather than recognizing it as potentially abusive. Additionally, the surveyor observed a staff member, an activity aide, patting the same female resident on the rear in a playful manner, which the Director of Nursing acknowledged as inappropriate and unprofessional. The care plan for the male resident included counseling on appropriate sexual behavior and the need for consent, but interventions such as redirection were not documented in the care plan. The facility's abuse policy affirms residents' rights to be free from abuse, including sexual abuse, but the policy was not effectively implemented in these cases, resulting in residents being subjected to unwanted physical contact.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice on the 2nd and 3rd floors. Mouse droppings were observed in multiple rooms, including the toilet room floor of one resident's room on the 2nd floor and near the wardrobe dresser of another resident's room on the same floor. On the 3rd floor, over 100 mouse droppings were found next to a wardrobe cabinet in a resident's room. Interviews with residents confirmed the presence of mice, with one resident stating they had killed a mouse in their room. The Maintenance Director acknowledged the issue, despite pest control reports indicating no mouse activity, and stated that a pest control company regularly services the facility. The facility's policy mandates that it should be free of pests and rodents.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety protocols, which included not discarding expired food, not labeling food items with use-by dates, and not sanitizing cooking equipment according to the manufacturer's directions. During a kitchen inspection, a container of tuna salad was found with a preparation date indicating it should have been discarded, yet it remained in the refrigerator. Additionally, sliced deli turkey was observed without a use-by date, which is against the facility's policy. These oversights in food labeling and discarding practices have the potential to compromise the safety of food served to the 123 residents receiving meals from the facility's kitchen. Furthermore, the facility did not ensure proper sanitization of kitchen equipment. The concentration of the Quaternary solution used for sanitizing was found to be below the manufacturer's recommended level, indicating that the items were not being disinfected properly. The dietary manager acknowledged that the concentration should be checked before cleaning items, but it was revealed that the dishwasher did not check the concentration that morning. This lapse in following sanitization procedures could lead to cross-contamination and foodborne illnesses among residents.
Facility Fails to Maintain Clean Incontinence Briefs
Penalty
Summary
The facility failed to ensure that reusable cloth incontinence briefs intended for resident use were in good condition. During a tour of the laundry room, a surveyor observed a cloth incontinence brief with multiple, permanent dark colored stains on a linen cart intended for resident use. The Laundry Aide, identified as V13, acknowledged awareness that stained incontinence briefs should be discarded when new ones are received. However, V13 assumed it was acceptable for residents to continue using the brief since it was not ripped or torn, despite washing it twice. The Housekeeping Director, identified as V14, confirmed the presence of permanent stains on the incontinence brief, attributing them to urine and feces. V14 stated that V13 is responsible for notifying him when incontinence briefs and other linens need to be reordered and for discarding old, stained, and worn linens. The facility's policies emphasize the importance of providing a safe, clean, comfortable, and homelike environment, with linens in good condition. The failure to adhere to these policies potentially affects 40 incontinent residents residing in the facility.
Failure to Refer Residents for PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer four residents with serious mental illness to the appropriate state-designated authority for a PASARR Level II evaluation and determination. The residents involved had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, schizoaffective disorder, panic disorder, and major depressive disorder. Despite the PASARR screenings indicating a reasonable basis to suspect mental illness, there was no documentation showing that these residents were referred for the necessary Level II evaluations. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASARR process. If a Level I screen indicates potential criteria for these conditions, a referral to the state PASARR representative for a Level II evaluation is mandated. However, interviews with the Social Service Director revealed that the facility does not conduct or repeat PASARR screenings unless instructed by the outside agency responsible for PASARR screenings, leading to the oversight in referring the residents for further evaluation.
Medication Security Lapse in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were locked and secured while unattended, as observed by a surveyor. On the first floor, a medication cart was found unlocked and unattended with the keys left inside the lock. A registered nurse (RN) acknowledged responsibility for the cart, which contained medications for residents on both the 1st and 3rd floors. The RN admitted to forgetting to lock the cart and retrieve the keys due to being busy with other tasks. This oversight left the medications accessible to residents, posing a risk of overdose, adverse reactions, or other life-threatening complications. The Director of Nursing (DON) confirmed the danger of leaving medication carts unlocked and unattended, acknowledging the potential for residents to self-administer the wrong medications and suffer adverse reactions. The facility's policy, dated April 2021, mandates that compartments containing drugs and biologicals must be locked when not in use and that unlocked medication carts should not be left unattended unless under visible supervision. The facility census indicated that 68 residents resided on the 1st and 3rd floors, all potentially affected by this deficiency.
Failure to Sanitize Shared Medical Equipment
Penalty
Summary
The facility failed to ensure that shared medical equipment, specifically a wrist blood pressure cuff device, was cleaned and decontaminated between uses for four residents during medication administration observation. On multiple occasions, a registered nurse used the same blood pressure device on different residents without sanitizing it before or after each use. This occurred during a medication pass observation where the nurse measured the blood pressure and heart rate of several residents consecutively without cleaning the device, which was then stored in the medication cart or placed on top of it without disinfection. The registered nurse acknowledged the oversight, attributing it to nervousness and forgetting to clean the device. The Director of Nursing confirmed that all shared medical equipment must be sanitized before and after each use to prevent the spread of infection. The facility's policy mandates that reusable resident care equipment be decontaminated between residents according to CDC recommendations and the manufacturer's instructions. The failure to adhere to these protocols was observed and documented by the surveyors.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide dignity for two residents, R226 and R41, as observed during a survey. R226 was found lying in bed with his buttocks exposed, wearing only a shirt and a blanket partially covering him. He reported that a staff member removed his incontinence briefs because they were too small, and the facility did not have any briefs in his size. R226, who is cognitively intact with a BIMS score of 13/15, has multiple diagnoses including unspecified dementia and chronic kidney disease. The CNA, V4, confirmed the lack of appropriate incontinence briefs and mentioned that the facility uses reusable briefs for mostly bed-bound residents, while some residents have disposable briefs purchased by their families. R41 was observed completely naked under a blanket, without a gown or incontinence briefs, and was not alert to make his needs known. R41 has a BIMS score of 09/15, indicating cognitive impairment, and requires moderate assistance with ADLs. The CNA, V7, acknowledged the dignity issue and stated she was instructed to use reusable briefs for R41. The Director of Nursing confirmed that leaving residents without clothing or briefs is a dignity issue. Facility policies emphasize treating residents with dignity and respect, yet these incidents demonstrate a failure to uphold these standards.
Improper Air Loss Mattress Setting for Resident
Penalty
Summary
The facility failed to correctly set the air loss mattress for a resident, identified as R75, based on their weight, which is crucial for pressure wound treatment services. During an observation, the air loss mattress was set for a weight range of 240-320 pounds, while R75 actually weighed between 100-110 pounds. This incorrect setting made the mattress hard and firm, which is not suitable for pressure distribution and could potentially worsen the resident's stage IV pressure wound on the sacrum. The Director of Nursing initially assumed the setting was correct based on the displayed weight range, but it was later confirmed by the Restorative Nurse that the setting was inappropriate for R75's actual weight. R75 has a medical history that includes dementia, adult failure to thrive, muscle weakness, and other conditions that contribute to a high risk for pressure wounds, as indicated by a Braden Score of 10. The resident is dependent on staff for most self-care activities and has a facility-acquired pressure ulcer on the coccyx. The facility's policy and the mattress owner's manual both emphasize the importance of setting the mattress according to the resident's weight to prevent skin breakdown and promote comfort, which was not adhered to in this case.
Inadequate Supervision Leads to Falls for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate assistance and supervision to two high fall risk residents, leading to incidents where both residents experienced falls. One resident, identified as R50, reported slipping and hitting their head on the sink while in the bathroom alone, despite being at high risk for falls and requiring staff assistance for toileting and transfers. The incident was not immediately reported to the nursing staff, and the resident was able to return to bed without assistance. The staff, including a registered nurse and a certified nursing assistant, were unaware of the incident until informed by the surveyor, indicating a lapse in communication and supervision. Another resident, R84, also at high risk for falls due to impulsive behaviors and impaired cognitive function, fell in the dining room without any staff present to supervise. The fall was unwitnessed by staff, although other residents were present and called for help. The facility's fall coordinator confirmed that R84 requires supervision and touch assistance for mobility and that staff should be within eye distance to monitor and intervene as needed. The absence of staff in the dining room at the time of the fall suggests a failure to adhere to the facility's policy of providing adequate supervision for high-risk residents. Both residents had documented high fall risk scores on the Morse Fall Scale, and their care plans indicated the need for supervision and assistance to prevent falls. The facility's policies emphasize the importance of resident safety and supervision, yet the incidents involving R50 and R84 highlight deficiencies in implementing these policies effectively. The lack of staff presence and communication regarding the incidents contributed to the failure to prevent these falls, which could have been avoided with proper supervision and adherence to care plans.
Failure to Administer Pneumonia Vaccines Upon Admission
Penalty
Summary
The facility failed to adhere to its policy of offering pneumonia vaccines to residents prior to or upon admission. This deficiency was identified during a review of records and interviews, affecting three residents out of a sample of 25. The residents involved were an elderly male with chronic obstructive pulmonary disease, anemia, and other conditions; an elderly female with stage 4 chronic kidney disease, diabetes, and other health issues; and another elderly male with adult failure to thrive, muscle wasting, and dementia. None of these residents had documentation in their electronic health records indicating that they had been offered or administered the pneumonia vaccine upon admission. Interviews with facility staff revealed that the Infection Preventionist acknowledged the residents had consented to the vaccine but had not yet received it. The Director of Nursing stated that the facility's procedure is to offer the vaccine upon admission, obtain consent, and then order the vaccine from a contracted pharmacy, which should arrive within three days. However, the vaccines had not been administered as expected. The facility's policy, dated October 2022, mandates that all residents be assessed for eligibility and offered the pneumococcal vaccine series upon admission unless contraindicated or previously vaccinated, with detailed documentation required for those who receive the vaccine.
Failure to Assess and Prevent Falls in High-Risk Resident
Penalty
Summary
The facility failed to appropriately assess and evaluate a resident who was at high risk for falls, leading to a significant injury. The resident, a female with a complex medical history including schizophrenia, bipolar disorder, and seizures, had previously fallen on two occasions. Despite these incidents, the facility did not conduct fall risk assessments after the falls on February 19th and April 18th, 2024, nor did they update the resident's care plan with new interventions to prevent further falls. On May 21st, 2024, the resident was sent to the hospital with a diagnosis of a fracture of the cervical vertebrae and an acute subdural hematoma. Prior to this, the resident had refused to go to the hospital after a fall in April, despite sustaining a head injury. The facility's nurse practitioner noted a new hematoma on the resident's head on the day she was sent to the hospital, but no one knew how the injury occurred. The resident was described as impulsive and not adhering to fall precautions, yet no additional measures were implemented to address these behaviors. Interviews with facility staff revealed that the resident was considered a high fall risk upon admission, but the necessary assessments and interventions were not completed following her falls. The Director of Nursing acknowledged that more specific interventions could have been added after the resident's fall in April. The facility's policy on falls and fall risk management requires re-evaluation and potential changes to interventions if a resident continues to fall, which was not adhered to in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy for reporting injuries of unknown origin, as evidenced by the case of a resident who sustained a new hematoma on her head. The resident, who has a complex medical history including schizophrenia, bipolar disorder, and seizures, was found with a new hematoma on her forehead by a nurse practitioner and a licensed practical nurse during an assessment. Despite the facility's policy requiring immediate reporting of suspicious bruises or injuries of unknown origin, the administrator was not informed of the new injury, and it was not reported to the state agency within the required 24-hour timeframe. The resident had a history of falls, with documented incidents occurring earlier in the year. On the day the new hematoma was discovered, the resident was sent to the hospital due to altered mental status and low oxygen saturation, where she was diagnosed with a fracture of the cervical vertebrae. The facility's abuse prevention program mandates that any injury of unknown source be reported and documented, but this protocol was not followed in this instance, leading to a deficiency in the facility's compliance with its own policies and state regulations.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,492 citations issued within 25 miles in the last 12 months — including the 28 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.
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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.
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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) |
|---|---|---|---|---|
| Ryze At The Ridge | 0.3 mi | ★★★★★ | 1 | 0 |
| Elevate Care Chicago North | 0.9 mi | ★★★★★ | 6 | 0 |
| Westwood Vlge Nrsg And Rhb Ctr | 0.9 mi | ★★★★★ | 3 | 0 |
| Atrium Health Care Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Clark Manor | 1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.