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 West Chicago Living And Rehab Center during CMS and state inspections, most recent first.
A resident with schizophrenia, major depressive disorder, and generalized anxiety disorder, who was cognitively intact, was in the dining room with peers when another cognitively intact resident with schizoaffective disorder, bipolar type, began loudly singing, running, and was non-redirectable. After the disruptive resident placed a phone on the first resident’s table, the first resident moved the phone to another table and used a curse word, prompting the disruptive resident to grab him from behind and push him to the floor, causing elbow redness and later-reported bruising and pain. Staff and leadership acknowledged that this was physical abuse and that it was their responsibility to prevent such abuse, despite an existing abuse prevention policy stating the facility’s commitment to protect residents from abuse and to do all within its control to prevent it.
Two cognitively intact residents, both with mental health diagnoses, were involved in an incident where one resident purchased an object grabber for another resident experiencing difficulty bending. Facility leadership, including psych social services and the former administrator, confiscated the grabber, citing concern it could be used as a weapon and stating a physician order was required, but did not provide the purchasing resident with written policy justification or return of the item. Despite memos and verbal complaints from the resident describing arbitrary denial of rights, lack of professionalism, and discourtesy, documentation shows only that staff offered to help return the item and later obtained a physician order for a different grabber for the intended recipient. The original grabber’s location was unknown, and there was no evidence that a physician had deemed it medically inappropriate or that the restriction was documented as required by the facility’s resident rights policy.
A resident with schizoaffective disorder, intact cognition, and a documented history of physical and verbal aggression, including prior liquid-throwing behavior and felony convictions for aggravated battery, was able to obtain coffee during lunch and throw it on another cognitively intact resident with multiple serious medical conditions after becoming annoyed by her talking. An activity aide witnessed the incident, and the aggressive resident admitted he threw the coffee because he found the other resident annoying. Despite existing care plans identifying him as an offender requiring monitoring and supervision, the facility’s incident investigation inaccurately stated he had no history of verbal aggression toward peers and deemed the abuse allegation unfounded.
A resident reported that another resident approached her in the dining room, grabbed her walker, made explicit verbal threats to harm and kill her, and caused her to feel scared. Staff interviews and written statements corroborated that the aggressor resident grabbed and pushed the walker toward the victim while making these threats, and video review confirmed the physical interaction with the walker. Although the facility’s abuse policy requires immediate reporting of abuse allegations to the state health department, the incident was only investigated internally and there is no evidence that the allegation was reported to the Illinois Department of Public Health.
Multiple residents experienced uncomfortably high room temperatures and humidity due to repeated air conditioning failures. Despite maintenance efforts and offers to relocate residents, the cooling systems remained unreliable, leading to sustained periods of discomfort as confirmed by temperature readings and resident complaints.
A staff member disclosed a resident's personal information, including her name and housing situation, to another resident during a discussion about discharge planning. This action violated the facility's privacy policies and the resident's right to confidentiality, as confirmed by staff interviews and facility records.
Surveyors found that dishes were not properly sanitized due to a malfunctioning dish machine that failed to dispense chlorine sanitizer, and staff did not test the machine before use. Additionally, dented cans were stored with other canned goods instead of being separated. These failures affected all residents receiving food from the kitchen.
The facility did not fully implement or document its water management program for Legionella, as the plan lacked identification of building water systems needing control measures, risk assessments, and a complete water distribution diagram. The Maintenance Director performed some flushing and cleaning tasks, but these were not included as control measures in the official plan, and the plan was not updated to reflect current practices or facility needs. A resident had previously tested positive for Legionella pneumonia, but the water management program remained incomplete.
The facility did not use a standardized tool, such as McGeer's or Loeb's criteria, to identify infections before starting antibiotics, as required by its own antibiotic stewardship policy. Instead, staff relied on the EMR Infection Control Module, which does not indicate whether infection criteria are met, affecting all residents receiving antibiotics.
Six residents who selected a substitute meal at lunch received turkey sandwiches that did not provide the same protein content as the main entrée of baked chicken. The sandwiches were prepared with less turkey than required and did not include cheese as specified in the recipe, resulting in a lower protein portion than intended.
A resident with a history of endocarditis and a cardiac valve prosthesis was prescribed daily Doxycycline Hyclate with instructions for continued use until evaluated by an Infectious Disease (ID) specialist. The facility failed to ensure the resident was seen by an ID practitioner, resulting in ongoing antibiotic therapy without the required specialist assessment.
A resident with chronic kidney disease, hypertensive heart disease, and diabetes reported swelling in the hands, feet, and face and requested a diuretic. Lab tests were ordered, and an antibiotic was prescribed and administered before urine culture results were available. The culture later showed no infection, and the NP confirmed the antibiotic should not have been given, resulting in unnecessary drug administration.
Two residents on mechanical soft diets were served chopped baked chicken in varying sizes instead of the required ground consistency, contrary to dietary orders and facility policy. The cook manually chopped the chicken and added gravy, rather than following the recipe for ground deboned chicken, and the dietitian confirmed that proper recipe guidance was not followed.
A resident with mental health diagnoses and intact cognition was physically abused by another resident, who threw coffee and struck her in a common area. Multiple staff and video evidence confirmed the incident, and facility leadership acknowledged the failure to provide a safe environment as required by policy.
A facility failed to have policies in place to address the intimacy rights of mentally ill female residents, leading to a resident becoming pregnant and experiencing psycho-social harm. The facility did not adequately assess her ability to engage in safe sex practices, and there was no tracking of intimate relationships or distribution of contraceptives. The resident's care plan was not updated to address her desire to become pregnant and her engagement in unprotected sex.
A resident was physically abused by another resident who became aggressive after being told to stop being rude. The aggressor shoved and punched the victim, resulting in an injury. Staff intervened, and the aggressor was later discharged. Both residents had mental health diagnoses, and the facility's abuse policy was not effectively enforced.
The facility failed to provide adequate documentation for the involuntary discharge of two residents, one due to safety concerns after an altercation and another after leaving unsupervised. The facility did not document the specific needs they could not meet or follow up on the residents' conditions, violating state and federal regulations.
A resident with schizophrenia and other conditions was not notified of her involuntary discharge after leaving the facility AMA following an emotional crisis related to her pregnancy. The facility did not provide the required AMA form or IVD notice, violating its own policies and federal guidelines.
A pregnant resident with schizophrenia and a history of elopement was allowed to leave a facility unsupervised, despite known risks and previous incidents requiring emergency intervention. The facility failed to follow established protocols, such as contacting emergency personnel or having the resident sign an AMA form, leading to her unauthorized departure. The resident was later found by family members and police, highlighting a deficiency in supervision and safety measures.
A resident, assessed as cognitively intact, requested to manage her own Social Security payments, which were initially handled by the facility as her representative payee. Despite the resident's request and a psychiatrist's agreement to sign a letter confirming her capability, the facility delayed providing the necessary documentation, citing the need for a discharge plan. This delay violated the resident's right to manage her own financial affairs.
The facility failed to implement proper infection control practices for three COVID-19 positive residents, including inadequate PPE use and disposal, and improper hand hygiene. Additionally, the facility lacked a system to monitor and prevent the growth of Legionella and other waterborne pathogens, as they did not test the water. Soiled linen was also improperly stored, potentially affecting all residents.
The facility did not provide education on the benefits, risks, and side effects of the COVID-19 vaccine to staff, despite offering the vaccine. Interviews with staff, including an Activities Aide and a Psych Rehab Social Assistant, confirmed the lack of education. The Assistant Director of Nursing/Infection Control Nurse and the Director of Nursing admitted to not providing or documenting any educational efforts regarding the vaccine.
The facility failed to maintain a safe and comfortable environment for residents due to unresolved temperature control issues and maintenance deficiencies. Residents experienced discomfort from high room temperatures, and one resident faced inconvenience and distress due to a leaking bathroom that had not been repaired since May. The absence of a maintenance director contributed to these ongoing issues.
The facility failed to invite residents to quarterly care plan meetings and maintain active care plans for specific medical diagnoses. Several residents reported not attending or being invited to these meetings, and there was no documentation of invitations or attendance. Additionally, a resident with alcohol dependence did not have a care plan addressing this condition, despite the facility's policy requiring it.
The facility failed to properly label and manage medications, leading to potential safety risks for residents. An RN was unaware of the expiration date for an insulin pen, and a haloperidol pill was not discarded after a resident left. Additionally, tramadol and lorazepam medications were improperly stored, with compromised pills not being wasted as required. The facility's policies on medication control and storage were not followed, risking contamination and adverse effects.
A facility failed to document a resident's DNR status in the EMR, despite having a paper POLST. The resident, with multiple diagnoses, was considered a full code due to the absence of a physician's order in the EMR. Staff interviews revealed that the nurse is responsible for entering the code status, while the psychosocial team scans the POLST, and the DON updates the profile. The facility's policy presumes consent to CPR unless a DNR order is documented.
A resident with an enlarged prostate experienced a delay in receiving a urology appointment due to scheduling errors and insurance issues. Despite a physician's order and insurance approval, the appointment was not made, leading to worsening symptoms. The facility's policy to confirm and arrange outside appointments was not followed.
A resident was observed with long, jagged toenails and dirty feet, indicating a lack of appropriate foot care. The resident reported wearing socks due to a bunion and sore, and stated that the foot doctor was too busy to see her. A CNA confirmed that she is not allowed to cut toenails, and the scheduler could not provide documentation of the last podiatrist visit. The facility lacked a policy on foot care.
A resident with multiple health conditions did not receive timely visits from her primary care physician, as required by facility policy. Instead, she was only seen by a nurse practitioner and medical students. The facility's administrator confirmed the physician's absence and lack of documentation in the resident's medical record, highlighting a failure to comply with federal regulations and facility policy.
The facility failed to provide necessary behavioral health services for two residents. One resident with alcohol dependence did not receive promised AA meetings or substance abuse support, while another resident with mental health issues experienced frequent cancellations of scheduled therapy sessions. Staff confirmed the lack of services and documentation, highlighting a gap in the facility's behavioral health care provision.
The facility did not post the daily staffing information on time, affecting all 85 residents. The staffing sheet for a specific day was not posted at the reception desk, with the last update being from the previous day. The administrator and receptionist acknowledged the oversight, with the receptionist responsible for posting the sheet unable to explain the delay. The facility's policy requires staffing numbers to be posted within two hours of each shift's start, which was not followed.
A resident with multiple diagnoses did not receive her scheduled 9 PM medications due to the LPN's failure to bring the medications to her when she was unable to get out of bed due to pain. The LPN incorrectly documented the medications as refused, leading to a deficiency in medication administration services and quality of care.
The facility failed to maintain a safe, clean, and comfortable environment for its 90 residents. Observations revealed dirty and damaged walls, broken furniture, and hazardous flooring. Residents reported these issues, but they were not addressed promptly due to insufficient maintenance staff. The administrator acknowledged the ongoing hazards and delays in repairs.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident (R1) from physical abuse by another resident (R2). On the evening of 3/6/26, R2 was observed by staff to be singing loudly, running back and forth in the dining area, and was described as non-redirectable, with residents complaining about the noise. R1, who has diagnoses of schizophrenia, major depressive disorder (recurrent, moderate), and generalized anxiety disorder and was assessed as cognitively intact, was in the dining room with other residents attempting to talk and watch a movie. R2 placed his phone on the table where R1 was sitting; R1 moved the phone to another table and told R2 he did not want the phone on his table, and also called R2 a curse word. R2 then grabbed R1 from behind, pushed him to the floor, and stood over him until staff separated them. R1 initially reported feeling okay and not hurt, with staff documentation noting no injury other than slight redness to an elbow at the time of assessment. During the investigation, R1 later reported bruising and pain to his right elbow and lower back, stating that the elbow injury occurred when he landed on the floor. Staff accounts, including the RN assigned to both residents and the DON, confirmed that R2 had been running around, talking or singing loudly, and was not redirectable prior to the incident, and that R2 physically grabbed and pushed R1 to the ground after R1 moved his phone. R2’s face sheet shows a diagnosis of schizoaffective disorder, bipolar type, and his MDS indicated he was cognitively intact, with no prior history of aggression at the facility. The facility’s Abuse Prevention Policy states that physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that the facility is committed to protecting residents from abuse and doing all that is within its control to prevent occurrences of abuse. The final incident investigation concluded that physical abuse was founded, determining that R2’s act of grabbing and pushing R1 to the ground constituted physical abuse. Both the Administrator and the DON acknowledged in interviews that the event was physical abuse and that it is the facility’s job to prevent abuse, indicating that the facility did not keep R1 free from abuse as required by its policy and regulatory standards.
Failure to Honor Residents’ Rights to Personal Property and Explanation of Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to retain personal property and to receive explanations and justification when such property is restricted. One resident (R4), with intact cognition and a diagnosis including major depressive disorder, purchased an object grabber for another cognitively intact resident (R5), who had multiple mental health diagnoses. When the grabber arrived, the receptionist directed R4 to take it to psychiatric social services and then to the administrator. The Psychiatric Rehabilitation Services Director (V3) and the former Administrator (V5) determined the grabber could potentially be used as a weapon and confiscated it, telling R4 that R5 would need a physician order to use such a device. Despite R4’s request, the facility did not provide a policy or written justification supporting the confiscation or the requirement for a physician order for the grabber. R4 reported feeling disrespected, dismissed, and that his rights and R5’s rights were being arbitrarily denied. He wrote at least two memos documenting his displeasure with what he described as lack of professionalism, arbitrary denial of resident rights, and discourtesy toward himself and R5. These memos stated that he followed procedures, that his item was confiscated, that he was told the administrator would not allow the object in the facility, and that he requested but did not receive a policy explaining why the grabber was not allowed. Social services notes show staff told R4 the shape of the grabber could render it usable as a weapon and offered to help him return it for a refund, and later documented that his concerns did not rise to the level of abuse, that he was allowed to vent, and that he remained dissatisfied and felt he was not being listened to. R5 separately approached psych social services stating he wanted to use the grabber purchased for him by another resident, and was informed, per the administrator, that he was not allowed to have it due to facility regulations. Subsequently, R5 obtained a physician order for a grabber and the facility provided a different grabber, but the original grabber purchased by R4 was not returned to him and its whereabouts were unknown to the Assistant Administrator (V2), the Director of Nursing (V7), or V3. The facility’s Resident Rights Policy states that residents have the right to retain and use personal property in their immediate living quarters unless deemed medically inappropriate by a physician and documented in the clinical record, and the facility’s dignity document states staff will not speak in a manner that could be interpreted as condescending, critical, or argumentative. The record and interviews do not show that a physician deemed the original grabber medically inappropriate or that the decision to confiscate and withhold it from R4 and R5 was documented in the clinical record, nor that R4 received the requested written policy justification or the return of his personal item.
Failure to Prevent Resident-on-Resident Abuse by Known Aggressive Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident threw hot coffee on another resident. The resident who committed the act had intact cognition, a diagnosis of schizoaffective disorder, and a documented history of physical and verbal aggression, including throwing liquid at a peer and calling a roommate an “idiot.” His background check and an identified offender care plan showed felony convictions for aggravated battery and battery with bodily harm, and he was to be monitored and supervised. Despite this known history and care plan directives, he was able to obtain coffee during lunch service and throw it on another cognitively intact resident during an interaction in which he reported being annoyed by her talking. The resident who was the target of the coffee-throwing incident had diagnoses including malignant neoplasm of the colon, liver, and intrahepatic bile duct, schizophrenia, epilepsy, and low back pain, with intact cognition. An activity aide witnessed the incident, reporting that the aggressive resident threw coffee at the other resident after they had been speaking and she got up. Progress notes documented that the aggressive resident admitted throwing coffee because he found the other resident annoying. The facility’s Final Incident Investigation Report inaccurately stated that the aggressive resident had no history of verbal aggression with peers and concluded the allegation of abuse was unfounded, despite documentation of prior verbal abuse and the resident’s own admission to throwing the beverage.
Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the Illinois Department of Public Health (IDPH) as required by its Abuse Prevention Policy. A resident (R1) reported that another resident (R2) threatened her, including threats to hit her with a walker, shove the walker up her anus, and kill her. Staff interviews and written witness statements confirm that R1 told the Psychiatric Rehabilitation Services Counselor and the Assistant Administrator that R2 approached her in the dining room, grabbed her walker, made explicit verbal threats of physical harm and death, and that R1 stated she was scared and did not know what R2 was going to do. An investigation assessment and investigation document completed by the former Administrator describe the incident, including review of video footage showing R2 walking up to R1, speaking toward her, placing both hands on R1’s walker, lifting it slightly off the ground, and pushing it toward R1. The facility’s Abuse Prevention Policy requires employees to report any incident, allegation, or suspicion of abuse to the Administrator immediately and requires the Administrator or designee to notify the Department of Public Health’s regional office immediately by telephone or fax when an allegation of abuse has been made. While the Assistant Administrator reported the allegation internally to the former Administrator and an internal investigation was conducted, the investigation documentation does not show that the allegation was reported to IDPH. The current Administrator reviewed the investigation report and stated that, based on the threats made toward R1, the incident should have been reported to IDPH and that she had no evidence that such a report was made by the facility.
Failure to Maintain Comfortable Room Temperatures Due to Air Conditioning Malfunctions
Penalty
Summary
The facility failed to maintain cool and comfortable room environments for residents, as evidenced by multiple reports of excessive heat and humidity in resident rooms over several days. Several residents, all cognitively intact except for one with moderate cognitive impairment, reported their rooms being uncomfortably hot, with some describing the conditions as unbearable. Temperature and humidity readings taken in various rooms confirmed elevated levels, with temperatures frequently reaching 78-82 degrees Fahrenheit and humidity levels between 54-64%. Residents attempted to alleviate discomfort by opening windows, but this was discouraged by staff due to high outside temperatures. Facility staff, including the Administrator and Maintenance personnel, acknowledged ongoing issues with the air conditioning units across multiple resident halls. Maintenance staff described repeated breakdowns, intermittent functioning, and difficulties in sourcing necessary repair materials such as freon. Despite efforts to monitor and repair the units, some air conditioners remained nonfunctional for extended periods, and staff were not always aware of the elevated temperatures in resident rooms at the time they occurred. Documentation, including grievances and progress notes, showed that residents had formally complained about the heat, and while alternative rooms were offered, residents declined due to the perception that all rooms were affected. The facility's Emergency Operations Plan required maintenance checks of all AC units, but the persistent failures and delayed repairs resulted in sustained periods where residents were exposed to uncomfortable and potentially unsafe room temperatures.
Failure to Protect Resident Privacy During Discharge Planning Discussion
Penalty
Summary
A deficiency occurred when a staff member, specifically a Psychiatric Rehabilitation Services Coordinator (PRSC), disclosed a resident's personal information to another resident during a discussion about discharge planning and housing. The PRSC used the resident's name and specific details about her housing situation as an example while speaking to another resident, rather than using a generalized or anonymous example. This disclosure was confirmed by interviews with the resident involved, the PRSC, the Director of Nursing (DON), and other staff, all of whom acknowledged that the resident's name and situation were inappropriately shared. The resident whose information was disclosed was cognitively intact and had a diagnosis of schizophrenia. She reported the incident to the facility administrator, expressing that her privacy rights had been violated. Facility records and progress notes corroborated that the resident did not want her name mentioned in conversations with other residents. The facility's policies on resident rights and privacy require the protection of personal and medical information, which was not upheld in this instance.
Failure to Sanitize Dishes and Store Food Safely
Penalty
Summary
The facility failed to ensure proper food safety practices in two key areas: dish sanitization and canned food storage. During an initial kitchen tour, three dented cans of Salsa Para Enchiladas were found stored alongside other canned goods in the dry storage area. The dents were located at the seams, and the Dietary Manager acknowledged that staff had missed these defects during storage. Additionally, the dishwashing process was observed to be deficient. The dish machine, which uses chlorine as a chemical sanitizer, was not dispensing sanitizer as required. When tested with a chlorine test strip, no sanitizer was detected, and dietary staff admitted they had not tested the machine prior to washing dishes after breakfast. The dish machine log confirmed that required checks for wash temperature and chlorine concentration were not completed for that meal service. The posted requirements on the dish machine specified a minimum chlorine concentration of 50 parts per million (ppm), but this standard was not met during the observed cycle. The operation manual for the dish machine also emphasized the importance of proper sanitizer concentration and regular testing. The facility census at the time was 88 residents, all of whom received food prepared in the kitchen. No residents were on NPO status. The failure to properly sanitize dishes and to separate dented cans from usable stock directly affected all residents receiving meals from the facility kitchen.
Failure to Implement Comprehensive Water Management Program for Legionella
Penalty
Summary
The facility failed to follow its water management program for Legionella, affecting all 88 residents. The Maintenance Director reported that he flushes water in empty resident rooms and soiled utility rooms, documenting these tasks in an electronic system. However, the Administrator confirmed that the facility's water management plan does not include flushing as a control measure, nor does it identify specific building water systems requiring control measures or assess the level of risk in those areas. The plan also lacks a diagram showing how water is distributed throughout the facility, only including a diagram of water flow out of the building. Additionally, the plan was already in place before the current Maintenance Director started and he did not participate in its development. A resident previously tested positive for Legionella pneumonia, prompting water testing that returned negative results. The facility has an eyewash station in the laundry room, which the Maintenance Director checks for functionality, and another station is planned for the kitchen. The Water Management Program document does not identify building water systems needing Legionella control measures or assess the risk of hazardous conditions in those systems, and it lacks a comprehensive diagram of the facility's water system. These omissions indicate the facility did not fully implement or document required elements of its infection prevention and control program related to water management.
Failure to Use Standardized Tool for Infection Identification in Antibiotic Stewardship
Penalty
Summary
The facility failed to follow its policy for antibiotic stewardship by not utilizing a standardized tool to identify infections in residents when antibiotics were prescribed. Interviews with the Infection Preventionist Nurse revealed that while information about antibiotic use was logged into the EMR Infection Control Module, McGeer's criteria or any other standardized tool was not used to determine if a resident had an infection. The Director of Nursing confirmed that the facility does not use McGeer's criteria, citing a copyright issue, and relies solely on the EMR infection module, which does not indicate whether infection criteria are met before starting antibiotics. The Regional Nurse Consultant also acknowledged the absence of a standardized tool for infection identification in the EMR. A review of infection tracking records from November 2024 to the present showed no evidence that a standardized tool was used when residents were started on antibiotics. The facility's own Antimicrobial/Antibiotic Stewardship Program policy requires the use of McGeer Criteria or the EMR Infection Control Module for infection information collection, but the EMR module does not provide a standardized method to determine infection status. This deficiency applied to all 88 residents in the facility, as the process for monitoring and identifying infections prior to antibiotic use was not standardized as required by policy.
Failure to Provide Nutritionally Equivalent Substitute Meal Options
Penalty
Summary
The facility failed to provide a substitute meal option with nutritional content equivalent to the main entrée for six residents who chose the substitute meal during lunch. The main entrée, baked chicken, was specified to provide 3 oz of protein per portion. However, the substitute turkey sandwich was prepared with approximately 3.5 slices of deli turkey, which, when weighed, amounted to only 2.7 oz, and did not include cheese as specified in the recipe. The cook did not weigh the turkey slices or include cheese, and the dietary manager confirmed the protein portion was less than required. The dietitian stated that substitute menu items should match the protein serving portions of the main entrée and follow recipe specifications.
Failure to Follow Physician Order for Infectious Disease Consultation
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for an Infectious Disease (ID) consultation for a resident with a history of unspecified valve endocarditis and infection related to a cardiac valve prosthesis. The resident, who was cognitively intact, had an active order for Doxycycline Hyclate to be administered daily until evaluated by an ID practitioner. Despite this order, there was no evidence in the electronic medical record or progress notes that the resident was ever seen by an ID specialist to assess the continued need for the antibiotic. Staff interviews confirmed that the facility was unaware that the ID consultation had not been scheduled since the initial order was made. The MDS Coordinator and the Assistant Director of Nursing/Infection Preventionist both acknowledged that the required follow-up for the ID evaluation was not completed, and the facility's own guidelines require that verbal orders be followed through as required. This lapse resulted in the resident continuing antibiotic therapy without the intended specialist evaluation.
Unnecessary Antibiotic Administration Due to Incomplete Assessment
Penalty
Summary
A resident with multiple diagnoses, including chronic kidney disease, hypertensive heart disease, and type 2 diabetes mellitus, was admitted to the facility and later complained of swelling in the hands, feet, and face. The resident requested a diuretic, and laboratory tests were ordered. Despite the absence of infection indicated by the urine culture results, an antibiotic (nitrofurantoin) was prescribed and administered for five days based on the initial symptoms and urinalysis results. The electronic medical record and progress notes confirm that the antibiotic was given before the urine culture results were available, which later showed only mixed urogenital flora not indicative of infection. The nurse practitioner acknowledged that, based on the resident's symptoms and the laboratory findings, the antibiotic should not have been administered. This sequence of actions resulted in the resident receiving an unnecessary medication.
Failure to Provide Properly Prepared Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food in the appropriate form for residents on mechanical soft diets, as required by their dietary orders and facility policy. During tray line service, the cook prepared mechanical soft diet meals by manually chopping baked chicken and adding gravy, resulting in pieces of varying sizes rather than the required ground consistency. Two residents on mechanical soft diets were served this improperly prepared chicken, despite the menu and recipe specifying ground deboned chicken with gravy. The dietitian confirmed that the recipe guidance for mechanically altered diets should be followed, and facility policy requires adherence to prescribed texture modifications for therapeutic diets.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of mental illness and intact cognition was subjected to physical abuse by another resident while waiting in line. The incident involved one resident throwing coffee on and striking the other, as confirmed by video evidence, multiple staff witness statements, and the aggressor's own admission. The abused resident reported being hit in the mouth and having coffee thrown on her, and her care plan identified her as being at risk for abuse due to her mental health diagnosis. The facility's incident report and risk management documentation corroborated the occurrence of physical abuse. Despite the facility's policy to maintain a safe and secure environment free from abuse, the event occurred in a common area with staff present. Staff and administrative interviews acknowledged that the actions were willful and deliberate, and that the facility failed to provide a safe environment for the resident. The facility's abuse policy defines abuse as the willful infliction of injury or harm, and the incident met this definition according to both the administrator and the assistant director of nursing.
Failure to Address Intimacy Rights and Safe Sex Practices
Penalty
Summary
The facility failed to have a system or policies in place to address the intimacy rights of mentally ill female residents of child-bearing age, leading to a significant deficiency. This deficiency resulted in a female resident becoming pregnant by another resident, which caused her psycho-social harm and led to her hospitalization. The resident, who has schizophrenia, anxiety disorder, epilepsy, and asthma, was unable to care for a child due to her need for 24-hour custodial care. The facility did not adequately assess her ability to engage in safe sex practices, and she refused condoms and other forms of birth control. The facility's lack of policies and processes to monitor menstruation cycles, perform pregnancy testing, distribute contraceptives, and complete intimacy assessments and consents contributed to the deficiency. Staff interviews revealed that there was no tracking of residents engaging in intimate relationships or the distribution of condoms. The facility did not have a process to monitor residents in intimate relationships, and there was no policy regarding contraceptives. The resident's care plan was not updated to address her desire to become pregnant and her engagement in unprotected sex. The facility's failure to address these issues resulted in an Immediate Jeopardy situation, as the resident's pregnancy placed her in a catastrophic situation. The facility was aware of the resident's intimate activity and her refusal of contraceptives but did not take appropriate actions to prevent the pregnancy. The facility's policies did not address how to care for residents who become pregnant while residing at the facility, and there was no process to track intimate relationships or the distribution of condoms.
Removal Plan
- Policies have been developed for Contraception Policy, Menstrual Cycle Monitoring Policy, Intimate Relationship Assessment and Education Form Policy.
- Nursing and PRSD/PRSC staff have been training regarding Contraception Policy, Menstrual Cycle Monitoring Policy, Intimate Relationship Assessment and Education Form Policy and responsibilities regarding all policies.
- Residents of childbearing age and who engage in sex are offered contraceptives by PRSC/PRSD staff. If resident chooses medicine-based contraceptive, they will be referred to nursing who will contact MD for orders.
- New admissions will have admission assessment completed and placed on menstrual cycle tracking as indicated.
- New admissions will have Intimacy assessment and Education Form completed upon admission assessment and will have contraceptives offered. If resident chooses medicine based contraception, MD will be contacted per nursing.
- The facility has developed new policies on Contraception use, Intimate Relationship assessment and education form, and Menstrual Cycle Monitoring. Policies reviewed with Medical Director.
- The facility will ensure that Nursing Staff and psych social staff are educated on responsibilities regarding the following policies: Contraception policy, Menstrual Cycle Monitoring Policy, and Intimate Relationship Assessment and Education Form Policy. Employees that are on vacation will be educated prior to returning to the facility.
- The facility will audit residents medical record to identify female residents of childbearing age, these residents will have menstrual cycle tracking by nursing staff and will be offered contraception and education regarding contraception. If resident chooses medicine-based contraception, MD will be contacted for orders per nursing. Facility audit initiated by the PRSD.
- The facility PRSD and the PRSCs educated on intimacy assessment and education form policy, including review of intimacy assessment and education form, review of need to educate residents regarding contraception and safe sex practices, review of educating residents regarding risks of pregnancy which include an understanding that they will not be able to continue to reside in facility. Education provided by Regional Director of Behavioral Health.
- A QA tool developed to monitor menstrual tracking. During facility rounds, the DON or designee will ensure that menstrual tracking is completed. New admissions will be added to the QA tool.
- A QA tool developed to review status of contraceptive use for biological female residents of childbearing age. DON or designee will review orders to ensure that biological female residents of childbearing age have orders for medicine-based contraceptives or have documented refusal of medicine-based contraceptives. New admissions will be added to the QA tool.
- A QA tool has been developed to review status of intimate relationship assessments and education form. PRSD or designee will review completed intimate relationship assessments and education form for completion and intimacy care plan. New admissions will be added to the QA tool.
- The results of the monitoring completed under this plan are submitted to the QA/QAPI Committee for review and follow-up and reviewed with Medical Director.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. One resident, identified as R9, reported that another resident, R7, became upset and physically aggressive after being told to stop being rude to others. R7 shoved R9 against a bookcase and later punched her in the face while she was in line for her medications. This altercation resulted in R9 sustaining a linear abrasion on her forearm and a punch to her left eye, although no bruise was reported. Staff members, including an LPN and a Psychiatric Rehab Social Counselor, witnessed the incident and intervened by calling a Code Orange due to the combative situation. The facility's records show that R9 is cognitively intact and has a history of mental health issues, including bipolar disorder and anxiety disorder. R7, who was involuntarily discharged from the facility following the incident, also had multiple mental health diagnoses and exhibited verbal and physical behaviors towards others. The facility's policy on abuse, effective since March 2022, prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. Despite this policy, the incident occurred, highlighting a failure in protecting residents from abuse.
Inadequate Documentation for Involuntary Discharges
Penalty
Summary
The facility failed to provide adequate physician documentation for the involuntary discharge of two residents, R1 and R7, which is a violation of state and federal regulations. R7 was discharged to a behavioral hospital due to safety concerns after an altercation with another resident. However, the facility did not document the specific needs they could not meet, the efforts made to meet those needs, or the services the receiving facility would provide. This lack of documentation is a critical oversight in the discharge process. R1, a long-term resident with a history of mental health issues, left the facility unsupervised and was later found by her family and police. The facility considered her departure as leaving Against Medical Advice (AMA) but did not provide her with an AMA form or an Involuntary Discharge (IVD) notice. Despite completing a petition for R1's involuntary transfer to a hospital due to a mental health crisis, the facility did not follow up on her condition or consider her for readmission, citing her as permanently discharged. The facility's policies on AMA and involuntary discharge require specific documentation and communication, which were not adhered to in these cases. The lack of proper documentation and follow-up for both residents highlights significant deficiencies in the facility's discharge procedures, potentially impacting the residents' care and safety.
Failure to Notify Resident of Involuntary Discharge
Penalty
Summary
The facility failed to provide a resident with a notification of involuntary discharge, which is a violation of regulatory requirements. The resident, who had been diagnosed with schizophrenia, epilepsy, anxiety, myopia, astigmatism, and hyperlipidemia, was confirmed to be pregnant while residing at the facility. On the day following the pregnancy confirmation, the resident left the facility against medical advice (AMA) after experiencing an emotional crisis. The facility staff, including the Psychiatric Rehab Social Director and the Director of Nursing, acknowledged that the resident was not given an AMA form or an involuntary discharge (IVD) notice before leaving the facility. The facility's administrator confirmed that the resident was permanently discharged without being notified or given an IVD notice, despite the facility's awareness of the resident's mental health condition and pregnancy. The facility's policy requires that residents be informed and provided with documentation when leaving AMA or being involuntarily discharged. However, in this case, the facility did not adhere to its own policies or federal guidelines, which mandate that notice of involuntary transfer or discharge and the opportunity for a hearing must be provided at least 30 days prior to discharge, or as soon as practicable. The facility completed a petition for the resident's involuntary transfer to an emergency inpatient facility due to acute mental illness symptoms, but failed to provide the necessary documentation and notification to the resident, her representative, or the ombudsman, as required by law.
Failure to Supervise Resident with Elopement Risk
Penalty
Summary
The facility failed to adequately supervise a pregnant resident with schizophrenia, who had a known history of elopement, leading to her unauthorized departure from the facility. The resident, who had been residing at the facility for mental health care, was confirmed to be pregnant and was not administered her antipsychotic medications as instructed. On the morning of the incident, the resident was observed to be calm in the dining room before a code green was called, indicating a resident elopement. Despite the presence of the Administrator, Director of Nursing, and other staff, the resident was allowed to leave the facility without signing an Against Medical Advice (AMA) form or contacting emergency personnel. The resident's history included multiple instances of elopement attempts and behaviors indicating a risk for self-harm, including suicidal and homicidal ideations without a plan. Previous incidents had resulted in the facility contacting emergency services and petitioning for the resident's hospitalization. However, on this occasion, the facility did not follow the same protocol, and it was the resident's family who contacted the police after finding her approximately half a mile from the facility. The facility's response to the resident's elopement was inconsistent with their previous actions, and no clear explanation was provided for this deviation. The resident's care plan included interventions for her history of unauthorized departures and paranoid delusional statements. Despite these measures, the facility did not effectively prevent the resident's elopement or ensure her safety. The facility's elopement policy defined elopement as the unplanned, unauthorized leaving of the facility by a resident unable to understand the risks, which was applicable in this case. The lack of supervision and failure to adhere to established protocols contributed to the deficiency in providing a safe environment for the resident.
Failure to Relinquish Financial Control to Resident
Penalty
Summary
The facility failed to honor a resident's right to manage her own financial affairs, as required by federal and state laws. The resident, who was assessed as cognitively intact, had initially authorized the facility to act as her representative payee for her Social Security payments upon admission. However, she later requested to manage her own finances and sought a letter from the facility to provide to the Social Security office, which was necessary for her to receive her payments directly. Despite the resident's request and the psychiatrist's agreement to sign such a letter, the facility's social services representative delayed writing the letter, citing the need for a discharge plan before proceeding. The resident expressed her desire to manage her finances to facilitate her discharge and search for an apartment. The facility's administrator and medical records staff confirmed the resident's cognitive ability to make such decisions. However, the social services representative had not yet provided the necessary documentation to the resident, resulting in a failure to comply with the resident's rights. The facility's own documents affirm the resident's right to manage personal funds, yet the delay in providing the letter impeded the resident's ability to exercise this right.
Infection Control Deficiencies in COVID-19 Precautions and Water Management
Penalty
Summary
The facility failed to adhere to appropriate infection control practices for three COVID-19 positive residents, identified as R15, R54, and R60. Observations revealed that outside R15's room, there was a sign indicating the need for droplet precautions, including eye protection, but no eye protection was available. Additionally, a housekeeping staff member, V9, entered R15's room without wearing eye protection. Similarly, outside R60's room, there was a sign for droplet precautions, but no PPE supplies were available, leading V9 to retrieve PPE from another room. V9 entered R60's room without eye protection and improperly disposed of PPE in an open box in the hallway. After visiting R54's room, V9 failed to remove her N95 mask before leaving the room and did not perform hand hygiene afterward. The facility also lacked a system to monitor measures to prevent the growth of Legionella and other waterborne pathogens in the building's water systems. The Assistant Director of Nursing/Infection Preventionist (ADON/IP), V10, acknowledged the absence of closed containers for disposing of contaminated PPE and the lack of water testing. The facility's water management plan was not effectively implemented, as it did not include testing the water for pathogens. Additionally, soiled linen was improperly stored in open bins, which could contribute to the transmission of infections. The facility's infection control hand hygiene policy required hand hygiene before and after entering isolation settings, which was not consistently followed by staff.
Failure to Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to provide education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine, which has the potential to affect all residents. Observations and interviews revealed that staff members, including an Activities Aide and a Psych Rehab Social Assistant, were offered the COVID-19 vaccine but did not receive any education about it. The Assistant Director of Nursing/Infection Control Nurse admitted to not offering any education or having documentation to show that information about COVID-19 vaccinations was provided to staff. The Director of Nursing acknowledged the need for staff education on the current COVID-19 vaccination, as some staff might not be aware, and education could potentially change their minds. However, there was no documentation to show that such education had been provided.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for three residents due to issues with room temperature and maintenance. On July 9, 2024, it was observed that the shared room of two residents was very warm, with temperatures recorded at 82°F, exceeding the facility's standard range of 70-81°F. The residents reported that the air conditioning was not functioning properly, causing discomfort, especially in the afternoons. The Housekeeping Director confirmed the temperature issues and noted the absence of a maintenance director since spring, which contributed to the unresolved problem. Additionally, another resident reported similar temperature issues in her room, which had persisted for about a month. Further observations revealed maintenance deficiencies in one resident's bathroom, where a blanket was used to collect water leaking from behind the wall. The bathroom had missing tiles, exposed plaster, and a leaking faucet, which forced the resident to shower in another room, causing inconvenience and distress. The facility's maintenance records showed an open work order for these issues dating back to May 15, 2024, which had not been addressed. The Sister Facility's Maintenance Director, who was not informed of the need for repairs, confirmed the severity of the bathroom's condition and the necessity for repairs. The facility administrator acknowledged the potential safety hazards and the impact on residents' mental health due to these unresolved issues.
Failure to Invite Residents to Care Plan Meetings and Maintain Active Care Plans
Penalty
Summary
The facility failed to invite residents to their quarterly care plan meetings and maintain active care plans for specific medical diagnoses. This deficiency was observed in six residents who were reviewed for care plans. One resident expressed that he had not attended any care plan meetings this year and was not invited to the meetings scheduled earlier in the year. The facility's policy requires that residents be notified and invited to these meetings, but there was no documentation to show that this resident was invited or refused to attend. The resident, who is cognitively intact, has multiple diagnoses including schizoaffective disorder and hypertensive heart disease, and his care plans were updated without his participation. Additionally, other residents who were alert and oriented reported not attending or being invited to care plan meetings. The facility lacked documentation of invitations or attendance for these residents. Furthermore, a resident with a diagnosis of alcohol dependence did not have a care plan addressing this condition, despite the facility's acknowledgment that such a care plan should have been established upon admission. This resident also has a history of residential instability due to alcohol and depression, highlighting the importance of addressing this diagnosis in their care plan.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and manage medications for four residents, leading to potential safety risks. During an inspection, it was observed that a Basaglar insulin Kwik Pen for one resident did not have an 'opened on' or 'use by' date, despite the label indicating it expires 28 days after opening. The RN responsible was unaware of the expiration date, acknowledging that using expired insulin could have adverse effects, including the risk of the resident going into shock. Additionally, a green pill identified as haloperidol was left in a medicine cup for a resident who had already left for an outside program, with the RN admitting it should have been discarded to prevent potential administration errors. Further issues were identified with medication storage and handling. A medication card for another resident containing tramadol had pills taped and others open, which the RN acknowledged should have been wasted with two nurses present due to it being a controlled substance. Similarly, a lorazepam medication card for another resident had an open blister, which the LPN stated should be wasted as it could be contaminated. The facility's administrator confirmed that compromised blister packs should be discarded to prevent contamination and potential risks to residents, including allergic reactions or negative interactions with other medications. The facility's policies on medication control and storage were not adhered to, as medications were not routinely checked for expiration dates, and compromised medications were not properly destroyed.
Failure to Document Resident's DNR Status in EMR
Penalty
Summary
The facility failed to enter a physician's order reflecting a resident's chosen code status of Do Not Resuscitate (DNR). This deficiency was identified for one resident, who was part of a sample size of 21 residents reviewed for advanced directives. The resident, who has multiple diagnoses including schizophrenia, asthma, bipolar disorder, major depressive disorder, osteoarthritis, fibromyalgia, and osteoporosis, did not have a physician's order for code status in their Electronic Medical Record (EMR). Although a paper copy of the resident's POLST (Physicians Order for Life Sustaining Treatment) was available in the facility binder, it was not reflected in the EMR. Interviews with facility staff revealed that the administrator acknowledged the absence of a physician's order for the resident's code status in the EMR, and stated that the nurse is responsible for obtaining and entering this information. The psychosocial team is tasked with scanning the POLST into the EMR, and the Director of Nursing (DON) is responsible for updating the resident's profile. Without a physician's order, the resident is considered a full code. Both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) indicated they would look for the code status in the EMR or the resident's profile during an emergency. The facility's policy on Advanced Directives states that all residents are presumed to have consented to CPR unless there is documentation specifying a DNR order, which should be supported by a physician's order obtained by nursing personnel.
Failure to Schedule Timely Urology Appointment for Resident
Penalty
Summary
The facility failed to make a timely appointment for a resident experiencing urinary urgency symptoms, despite having a physician's order for a urology referral. The resident, who was cognitively intact and had a history of an enlarged prostate, had been waiting for three months to see a specialist. The initial referral was sent on April 1, 2024, but the first urology office did not accept new patients. A subsequent appointment was scheduled for June 20, 2024, but was canceled because the office did not accept the resident's insurance. Although the insurance had approved a second urologist, the appointment was not made, and the resident's symptoms worsened. The Director of Nursing (DON) indicated that once insurance approval is obtained, appointments should be scheduled promptly. However, the Medical Records/Scheduler admitted that the urology appointment fell through the cracks due to the resident having several other appointments. The facility's policy requires confirmation and arrangement of all outside appointments, but this was not adhered to in this case. The resident expressed frustration over the delay, as his urinary symptoms were worsening, and he had already been tested and ruled out for bladder and urinary tract infections.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as R51, in a sample of 21 residents. On July 9, 2024, a staff member informed R51 that she could not go out to smoke without shoes, prompting R51 to remove her sock and reveal her right foot. Her toenails were observed to be very long and jagged, with a black spot on her right toe. Later that day, R51 showed the surveyor her long, claw-like toenails on both feet, and the bottoms of her feet were filthy and black. R51 mentioned wearing socks due to a bunion and sore on her foot and stated that the foot doctor was too busy to see her. On July 11, 2024, a CNA, identified as V17, stated that she is not allowed to cut residents' toenails as they are seen by a foot doctor. However, the scheduler, identified as V4, could not provide documentation of when the podiatrist last saw R51. The facility did not provide a policy on Activities of Daily Living or foot care.
Failure to Provide Timely Physician Visits
Penalty
Summary
The facility failed to provide timely physician visits for a resident, identified as R6, who was part of a sample of 21 residents. R6, who was admitted to the facility with multiple diagnoses including major depressive disorder, diabetes, and chronic kidney disease, reported not having seen her primary care physician, V20, in over four months. Instead, she was only seen by a nurse practitioner and medical students. This lack of direct physician visits was confirmed by the facility's administrator, who acknowledged that the physician should be rounding in person monthly but had not done so for R6. The facility's policy requires residents to be seen by a physician or extender at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. The policy allows for alternating visits between the physician and a nurse practitioner after the initial visit. However, there was no documentation of V20, who is also the facility's Medical Director, having conducted any personal visits for R6. The administrator admitted to the absence of such documentation in R6's electronic medical record, indicating a failure to adhere to the facility's policy and federal regulations regarding physician visits.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for two residents with specific needs. One resident, identified as R83, who has a history of alcohol dependence, reported that the facility did not offer Alcoholics Anonymous (AA) meetings or any substance abuse support groups, despite being informed that such services would be available. The resident expressed difficulty in managing alcoholism without support and noted that the facility had purchased AA books but had not initiated any group sessions. Interviews with staff confirmed the absence of AA meetings and a lack of documentation for any substance abuse groups being held. The Director of Nursing acknowledged that if AA meetings were needed, the facility should either provide them on-site or arrange for residents to attend external meetings. Another resident, R52, who has multiple mental health diagnoses, including schizoaffective disorder and PTSD, was scheduled for weekly video therapy sessions with a contracted therapist. However, these sessions were frequently canceled, with the last documented session occurring nearly a month prior. The Psych Rehabilitation Services Coordinator and the Administrator confirmed the cancellations and the lack of alternative one-on-one sessions by the assigned PRSC, as required when the therapist was unavailable. The importance of these sessions for R52 was emphasized, given her preference for individual therapy over group sessions.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the daily staffing information, affecting all 85 residents. On July 9, 2024, at 9:38 AM, the daily staffing sheet was not posted at the reception desk for the current date, with the last posting dated July 8, 2024. The administrator, identified as V1, acknowledged on July 11, 2024, that the daily census sheet for July 9, 2024, was not completed by the expected time of 9:30 AM. The receptionist, identified as V12, who was responsible for posting the daily staffing sheet, admitted to not having it posted on time and was unsure why it was not done. The facility's policy, effective since April 2020, requires the posting of staffing numbers within two hours of each shift's start, indicating a lapse in adherence to this guideline.
Failure to Administer Scheduled Medications as Ordered
Penalty
Summary
The facility failed to administer scheduled medications as ordered for one resident, leading to a deficiency in medication administration services and quality of care. The resident, who had multiple diagnoses including schizoaffective disorder, multiple sclerosis, and chronic pain, did not receive her scheduled 9 PM medications on the specified date. Despite the resident's inability to get out of bed due to nerve pain, the LPN on duty did not bring the medications to her and incorrectly documented the medications as refused in the Medication Administration Record (MAR). The Assistant Director of Nursing confirmed that the LPN should have returned to the resident to assess the situation and administer the medications as ordered. The resident's Electronic Medical Record (EMR) and Minimum Data Set (MDS) indicated that she was cognitively intact and had a complex medical history. On the night in question, the LPN made multiple attempts to have the resident come to the nurses' station for her medications but did not take appropriate action when the resident reported being in pain and unable to get up. The facility's Medication Administration policy requires that medications be administered within a specific time frame and that nurses return to the resident if they are not available initially. The LPN's failure to follow these guidelines resulted in the resident missing her scheduled medications for anxiety, depression, multiple sclerosis, and pain management.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure maintenance and housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment for all 90 residents. During an environmental tour, it was observed that a resident's room had dirty and scraped walls with a red-stained mark, a broken nightstand, and a broken floor area. Another resident's overhead light fixture was broken, and the bulb was dirty. The main dining room had broken walkway tiles and an uneven floor. Interviews with the residents revealed that these issues had been reported but not addressed in a timely manner. The housekeeping manager was unaware of some of the issues, and the maintenance manager indicated that the facility lacked sufficient maintenance staff to address the concerns promptly. The administrator acknowledged the ongoing issues and the tripping hazard posed by the broken tiles. The facility's work order log showed ongoing painting and plumbing issues, and the facility policy emphasized maintaining the building in good repair and free from hazards. Despite these policies, the facility failed to address the maintenance concerns effectively. The housekeeping manager stated that she rounds the facility daily and reports concerns, but some issues remained unresolved. The maintenance manager confirmed that he was covering for the lack of maintenance staff and was unable to complete all work orders. The administrator mentioned efforts to hire maintenance staff but acknowledged the existing hazards and delays in addressing them.
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What surveyors actually found near you
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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 West Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ahva Care Of Winfield | 2.8 mi | ★★★★★ | 0 | 0 |
| Aperion Care West Chicago | 3 mi | ★★★★★ | 22 | 0 |
| Dupage Care Center | 3.3 mi | ★★★★★ | 13 | 0 |
| Wynscape Health & Rehab | 3.3 mi | ★★★★★ | 3 | 0 |
| Springs At Monarch Landing, The | 4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.