Citations in Illinois
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Illinois.
Statistics for Illinois (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Illinois
A resident with multiple stage 2 pressure injuries was not provided with a low air loss mattress as ordered by the wound physician and outlined in the care plan. Despite facility policy and active orders, the resident was found on a regular mattress after a room change, and wound deterioration was observed by the wound care nurse.
A resident with cognitive impairment had a designated POA for healthcare decisions, but facility staff facilitated the completion and release of guardianship paperwork to a non-POA family member without informing or obtaining consent from the POA, contrary to facility policy.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
The facility did not ensure 8 hours of daily RN coverage on multiple occasions, as confirmed by review of nursing schedules and staff interviews. This affected all 35 residents and was acknowledged by the DON, a regional specialist, and the administrator, who also noted the absence of a staffing policy.
Several residents were not provided with admission contract packets at the time of admission, with some waiting over a year to receive them. One resident with intact cognition reported being asked to sign a contract recently, expressing concerns about missing information and lack of time for review. Staff confirmed the facility was years behind in issuing these contracts, and an audit revealed multiple residents without them. The facility's policy did not address timely provision of admission packets.
Two residents were found living in rooms with significant maintenance issues, including water leaks, holes in walls and ceilings, musty odors, and exposed rusty metal. Despite being reported to maintenance staff, these problems remained unaddressed for over a month, resulting in unsafe and non-homelike living conditions.
Two residents experienced significant delays in call light response, with one developing a pressure ulcer and another falling while attempting to self-transfer due to long wait times. Ongoing concerns about call light response were documented in resident council meetings, and the facility's policy requires timely responses.
A resident experienced a decline in range of motion or mobility because the facility did not provide appropriate care to maintain or improve ROM, and there was no documented medical reason for the decline.
A resident with a history of amputation, spinal stenosis, anxiety, and depression did not have pain assessments documented before or after receiving scheduled pain medications, contrary to facility policy. The DON confirmed that pain assessments were not performed or recorded, and the resident reported experiencing pain and delays in medication administration.
Failure to Provide Ordered Pressure Redistribution Mattress for Resident with Pressure Injuries
Penalty
Summary
The facility failed to implement ordered wound care interventions for a resident with multiple pressure injuries. Upon observation, the resident was found in bed on a regular mattress, despite an active physician order and care plan intervention for a low air loss mattress to aid in pressure redistribution. The wound care nurse and technician confirmed that the resident had stage 2 pressure injuries on both buttocks, which were present on admission and required daily dressing changes. The nurse expressed concern about wound deterioration, noting an increase in wound size and peri-wound irritation with minor bleeding. The nurse also stated uncertainty regarding why the resident was not provided with the specialized mattress after a recent room change. Record review showed that the resident's wounds had been measured and documented by the wound physician, with a consistent order for a low air loss mattress since admission. The care plan identified the resident as being at risk for further skin breakdown and included interventions for pressure redistribution. Facility policy required implementation of individualized care plans and provision of low air loss mattresses for residents assessed as needing them. Despite these orders and policies, the resident was not provided with the required mattress, and wound deterioration was observed.
Failure to Notify POA Before Facilitating Guardianship Paperwork
Penalty
Summary
The facility failed to inform and involve a resident's designated Power of Attorney (POA) before facilitating the completion of guardianship paperwork for another family member. The POA, who was listed in the resident's records as the healthcare agent, responsible party, surrogate decision maker, and emergency contact, was not notified or consulted when a non-POA family member requested and received a completed guardianship evaluation report from the facility. The Social Services Director received a legal guardianship form from the non-POA family member and, without seeking authorization from the POA, passed it to the Administrator, who then facilitated its completion by the resident's physician. The completed form was subsequently provided to the non-POA family member. The resident involved was cognitively impaired, as documented by a SLUMS assessment and care plan indicating impaired judgment. Despite this, there was no documentation or expression from the resident regarding a desire to change guardianship. Both the Social Services Director and Administrator acknowledged that they should have honored the wishes of the designated POA and notified her for consent, as required by facility policy, but failed to do so.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of daily Registered Nurse (RN) coverage as required, affecting all 35 residents in the facility. Review of the nursing schedules for June and July showed that there was no RN on shift for 8 consecutive hours on five specific dates. The Director of Nursing confirmed that there were no RN hours documented on those days, and both the Regional Reimbursement Specialist and the Administrator acknowledged the lack of required RN coverage. The Administrator also stated that the facility does not have a staffing policy, although it follows federal and state staffing regulations.
Failure to Provide Timely Admission Contracts to Residents
Penalty
Summary
The facility failed to provide admission contract/agreement packets in a timely manner to five residents, as evidenced by observations, interviews, and record reviews. One resident, who had been living in the facility for over two years and had an intact cognitive status, reported only recently being asked to sign a contract for services. The resident expressed dissatisfaction with the process, noting that the contract contained blank areas, missing pages, and insufficient time was given for review. The resident also described being called to a meeting by the administrator, who accused him of discouraging others from signing the contract, which the resident denied. The resident was concerned that the contract could alter his living arrangements and expressed reluctance to sign it. Staff interviews confirmed that the facility was three years behind in providing admission contracts to residents already in the facility, prompting the hiring of a consultant to address the issue. The Director of Social Services acknowledged that the admission contract, which outlines policies, regulations, resident rights, and payment terms, should be provided at the time of admission. An audit conducted by the administrator revealed that several residents had not been offered admission contracts, with most affected residents lacking these documents for over a year after admission. The facility's admission policy, dated January 2025, did not include procedures for providing the admission packet or contract during or at the time of admission.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's room had a hole in the ceiling, chipped paint, a musty odor, and a blue blanket placed on the floor to collect water from a leak that occurred when it rained. The resident reported having informed the Maintenance Director about the issue, but no repairs had been made. The Maintenance Director confirmed being aware of the water leak for approximately one and a half months and had notified the Regional Maintenance Director, but no vendors had come to address the problem. The Maintenance Director also stated that no residents should be living in the room under these conditions and that a room change was necessary. In another case, a different resident's room had a large hole in the wall with exposed rusty metal and chipped paint throughout the ceiling. The resident stated that someone had started repairs but did not return to complete the work. The Maintenance Director explained that the painter responsible for the repairs was let go and no one else had been assigned to finish the job. The Regional Maintenance Director was aware of the ongoing issues and had attempted to patch the roof without success. Both maintenance staff confirmed that the rooms were not safe for occupancy until repairs were completed. The facility's policy requires a safe, clean, and homelike environment, which was not maintained in these instances.
Delayed Call Light Response Leads to Resident Harm and Complaints
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for two out of three residents reviewed for accommodation of needs. One resident, who is dependent on staff for toileting and has a stage 2 pressure ulcer, reported having to press her call light multiple times and waiting over two hours for assistance, which she attributed to the development of her bedsore. This resident also attends dialysis three times a week and requires prompt assistance upon return due to fatigue. Another resident, with a history of stroke and left-sided hemiparesis, reported waiting one to two hours for call light responses, leading her to attempt self-transfer, resulting in a fall. She also reported delays in assistance after incontinence episodes. Resident Council minutes from multiple months documented ongoing concerns about long call light wait times, including staff walking by active call lights without responding and call lights being turned off without providing assistance. The facility's policy requires call lights to be answered within a reasonable amount of time. The administrator acknowledged that complaints about call light response times have been raised in resident council meetings, and audits and education have been conducted in response.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care was provided unless a decline was for a documented medical reason. This resulted in a resident experiencing a decline in ROM or mobility without evidence that the decline was medically unavoidable.
Failure to Assess and Document Pain Management for Resident Receiving Scheduled Pain Medications
Penalty
Summary
Facility staff failed to assess the pain of a resident who was receiving scheduled pain medications, as required by the facility's pain management policy. The policy mandates that pain management must be provided in accordance with professional standards, the resident's care plan, and their goals and preferences, including regular reassessment for effectiveness and adverse effects. However, review of the medical record for a resident with a history of left below the knee amputation, spinal stenosis, anxiety, and depression revealed no documentation of pain assessment before or after administration of scheduled pain medications, which included hydrocodone, pregabalin, and tizanidine. During an interview, the resident reported being in pain and noted delays in receiving morning medication, particularly when agency nurses were on duty. The Director of Nursing confirmed that pain assessments were not performed or documented prior to or after medication administration, acknowledging that the pain scale was missing from the record. This lack of assessment and documentation represents a failure to follow the facility's own pain management policy and to ensure appropriate pain management for the resident.
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