Citations in Illinois N

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a cognitively intact resident from resident-to-resident physical abuse. Late in the evening, one resident was suddenly attacked by another male resident who approached from behind while the victim was standing at the ice machine holding a cup. The aggressor placed both arms around the resident’s upper torso and neck area, putting him in a headlock. Staff and another resident intervened to separate them. Multiple staff, including an RN and a CNA, as well as the resident’s roommate, described the event as an unprovoked physical attack or physical abuse. The Administrator, who serves as the Abuse Coordinator, reviewed security camera footage and confirmed that the aggressor made physical contact and had his arms around the resident from behind. Following the incident, the resident reported new, severe left shoulder pain that began after the attack, distinct from his pre-existing chronic cervical and back pain from a decades-old accident. He consistently rated his shoulder pain as 8–10/10, described it as severe and unbearable, and reported that it was not relieved by his current pain medications. Nursing documentation reflected ongoing high pain scores and limited range of motion in the left shoulder. An X-ray later showed an acute or subacute inferior glenoid fracture fragment of the left shoulder, and the resident continued to experience significant pain with shoulder movement. The resident stated he had repeatedly requested an X-ray and to be sent to the hospital to assess the injury. The resident also experienced psychosocial distress after the assault. He reported feeling on edge, anxious, fearful of encountering the aggressor again, and hesitant to use common areas where the abuse occurred. He described intrusive recollection of the aggressor’s statement, “I’m here for murder,” which he heard during the altercation and which replayed in his mind, causing fear and distress. He reported difficulty sleeping, frequent nighttime awakenings, feeling more depressed and withdrawn, and no longer feeling safe in the facility. A psychiatric NP noted that the resident’s reported symptoms of heightened anxiety, hypervigilance, disrupted sleep, and worsening mood were not consistent with his baseline and were characteristic of an acute traumatic response. Both the in-house NP and psychiatric NP emphasized that pain and psychological distress are subjective experiences that must be taken seriously regardless of mental or psychiatric status. The facility’s own abuse policy affirms residents’ rights to be free from abuse and defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food and drink were served at palatable and safe temperatures for all residents receiving meals from the kitchen. Multiple residents reported that their meals were not served hot, with one resident stating the food is not always served hot, another stating the food is usually barely warm, and another stating the meals are usually not served hot. One resident reported that when she requested staff to reheat her food, she was told they could not do so and would not obtain a new tray from the kitchen, leaving her to eat the food cold. The DON confirmed that all residents in the facility at the time of the survey received services from the Dietary department. During a meal service observation with the Dietary Director and a cook, several hot food items were found to be held below the facility’s stated standard of 135°F, including broccoli at 100°F, sweet and sour pork (carbohydrate-controlled, low concentrated sweets) at 95°F, plain rice at 100°F, and grilled cheese sandwiches at 90°F, while some pureed items and carrots were at 120°F. A test tray contained chili, carrots, crumbly cornbread, and cookies served on a Styrofoam plate. The Dietary Director stated that due to budget constraints, the facility uses Styrofoam instead of real plates, acknowledged that Styrofoam affects the maintenance of food temperatures, and reported there is no plate warmer and the delivery carts are not insulated. He also stated that there have been occasions when meal trays remained unpassed on the units for up to 20 minutes after leaving the kitchen. The facility’s undated policy stated that foods meant to be held for a long time require elevated temperatures and should be held at 135°F or above.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a functioning call light system for all residents on one hall, affecting 28 residents whose rooms were connected to a faulty call light panel. Multiple residents reported that their call lights had not worked since the previous day and that this was a recurrent problem over the past month. One cognitively intact resident who required moderate to maximal assistance with ADLs demonstrated that pressing his call light did not activate a signal outside his door or at the nurses’ station and stated he had no way to get assistance or help in an emergency. Another cognitively intact resident who required touch to substantial assistance with ADLs reported significant difficulty obtaining toileting assistance due to the nonfunctioning call light and described having to yell or bang on the wall to get staff attention. A visually impaired resident with cognitive impairment and needing moderate to maximal ADL assistance was observed yelling repeatedly for help with hydration without staff response. Staff interviews confirmed that the call lights for the unit had stopped working the previous afternoon and that this had occurred multiple times in the prior month. A CNA assigned to the affected hall stated that when she started her morning shift, the room call lights were not working and that she had not been given instructions on how residents would be monitored while the system was down. Maintenance staff reported that the main call light panel at the nurses’ station had a missing wiring connection, that they had just rewired it, and that the wiring problem had recurred at least three times in the past month. The Maintenance Director acknowledged that some rooms’ call lights had stopped working, that an outside vendor had been called previously, and that there were no work order logs for the call light issues. An untitled facility document showed 30‑minute rounding for a limited time period on one date but did not specify which residents were rounded on, what type of rounds were done, or any entries covering the time from when the call lights again stopped working through the following morning, despite the facility’s policy requiring prompt reporting of call bell system defects and room checks until repair.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to identify, investigate, protect, and report an incident of resident-to-resident abuse, and to implement care plan interventions afterward. One resident reported severe left shoulder pain that began after another resident suddenly charged at him, grabbed him from behind, and placed both arms around his upper torso in a headlock. During observation, the resident was seen in bed holding his left shoulder and wincing in pain, and later verbalized psychosocial distress related to the incident. The Administrator/Abuse Coordinator acknowledged reviewing security camera footage the night of the incident, which showed the aggressor resident approaching from behind and placing both arms around the other resident’s upper torso. Despite this, the Administrator did not consider the event to meet the facility’s definition of abuse at that time and did not report it to the state agency until nine days later, contrary to the facility’s policy requiring immediate or timely reporting of allegations and incidents. The facility did not conduct an internal investigation of the incident in a timely manner and was unable to provide staff statements, interviews, incident reports, or other related documentation during the survey. Review of the injured resident’s EMR showed no new care plan interventions or protective measures were initiated following the incident to address his severe shoulder pain or psychosocial distress, and his care plan was not updated until during the survey. The other resident involved had diagnoses including anxiety disorder, insomnia, schizophrenia, and schizoaffective disorder, yet his care plan was also not updated after the incident. Care plan sections addressing abuse, behaviors, mood triggers, and physical and verbal aggression for both residents were only added during the survey, indicating that the facility did not promptly implement or document interventions or protections following the reported abuse, as required by its Abuse and Retaliation Prevention and Reporting policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to promptly report and thoroughly investigate an allegation of physical abuse between two residents. On 1/27/2026 at 10:37 AM, one resident (R131) was observed sitting in bed, holding his left shoulder and wincing in pain, and reported experiencing severe left shoulder pain that began on 1/18/2026 after being physically attacked by another resident (R200). R131 stated that R200 suddenly charged at him, grabbed him, and placed both arms around his upper torso, putting him in a headlock. The facility’s Administrator/Abuse Coordinator (V1) acknowledged that he had reviewed security camera footage from 1/18/2026 and was aware of the incident that same night. Despite this awareness, V1 stated he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the definition of abuse, citing the absence of serious injury, bodily harm, or psychosocial effects. The incident was not reported to IDPH until 1/27/2026, as confirmed by a fax confirmation sheet showing the initial report was sent at 2:59 PM with a documented occurrence date of 1/18/2026 and categorized as resident abuse. The report also indicated that a thorough investigation was to be conducted, demonstrating that the investigation was initiated nine days after the incident. This delay and failure to immediately initiate an investigation conflicted with the facility’s Abuse and Retaliation Prevention and Reporting policy, which requires that all incidents be documented and that any incident or allegation involving abuse result in an investigation initiated by the administrator or designee upon learning of the report, including interviews of the reporter, individuals with direct knowledge, and the resident, as well as review of written statements and pertinent medical records or documents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide appropriate assessment and management for a resident’s new onset of severe left shoulder pain following a physical altercation with another resident. The resident, who had previously reported only mild, occasional pain that did not affect sleep and had intact cognition and no upper extremity ROM limitations per the MDS, began experiencing sharp, non-radiating left anterior shoulder pain rated 8–10/10 after the incident. The N Adv – Long Term Care Evaluation identified this as a new issue, with documented severe pain and facial expressions consistent with pain. Despite this, the resident reported that his existing pain medication regimen, which predated the incident, was not relieving the new shoulder pain, and he repeatedly requested an X-ray and hospital evaluation. Medication records showed that after the incident, the resident received PRN Acetaminophen-Codeine 300-30 mg and Tylenol Extra Strength 500 mg on multiple occasions, yet pain assessments documented ongoing moderate to severe pain levels (4–10/10) on numerous days. The resident consistently reported severe, unrelieved left shoulder pain, including during surveyor interviews, and described worsening pain with shoulder movement. Nursing documentation and interviews confirmed that the resident’s pain remained severe and that his left shoulder ROM was compromised, indicating a change in condition and ineffective pain control. However, there was no evidence that the pain management plan was promptly reassessed or modified in response to the resident’s persistent high pain scores and reports of inadequate relief. The facility’s own Pain Management Program policy required initiation of a pain assessment protocol whenever there is a change in condition requiring pain control or a change in the identification of pain, recognition of pain as the fifth vital sign, ongoing monitoring, and review and updating of care plans when pain management is ineffective. Interviews with the in-house NP and psychiatric NP emphasized that pain is subjective and must be taken seriously regardless of psychiatric status, and that uncontrolled pain can exacerbate psychological symptoms. Despite these expectations and the DON’s stated requirement that pain rated above 6/10 necessitates immediate action, the resident’s severe, ongoing pain after the new injury was not adequately assessed or managed in a timely manner, and the pain management plan was not effectively adjusted in accordance with facility policy until much later, when imaging ultimately revealed a left glenoid fracture.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to prevent an elopement of a resident identified as high risk for wandering and elopement, and the failure to ensure mechanical lift equipment and slings were in proper working order during transfers, resulting in two separate resident falls. One resident with severe cognitive impairment, dementia, poor decision-making skills, and a history of wandering and exit-seeking behaviors eloped from the building without staff awareness. This resident had a wander management system in place and was care planned and assessed as at risk for elopement. On the day of the incident, door alarms sounded and staff performed head counts on the halls, but they did not identify that this resident was missing. Staff statements indicate that alarms sounded, staff checked their assigned halls, and all residents on those halls were believed to be present, yet the eloping resident was not accounted for. The facility later learned of the elopement only after being contacted by staff from a nearby assisted living facility, who had been alerted by a community member who found the resident wandering in a ditch and then observed her walking down the road, confused and unable to state her name. Multiple interviews and written statements describe confusion among staff and residents about how the elopement occurred and how long the resident had been outside. A CNA reported taking two residents out for a smoke break and later learning from those residents that the eloping resident had been pushing on their wheelchairs trying to get out the door and that she had gotten out. Another resident reported that the eloping resident tried to push her and another resident toward the door and that she notified a nurse, who removed the eloping resident from the area; this resident later saw the eloping resident come through the door to the outside but did not see her afterward. A different resident recalled the eloping resident trying to push her and another resident to get outside and stated she went to get the nurse because the eloping resident was not supposed to go out without staff. Nursing staff, including the former ADON and an LPN, described hearing door alarms, going to the front desk, and conducting head counts when the cause of the alarm was not witnessed, but they did not determine who had set off the alarm and believed all residents were present. The facility’s own investigation notes reference a family member of another resident who knew the patio door code and used it to take her husband outside, and who was unsure whether the eloping resident may have followed her out, while also noting that this family member had memory loss and became more confused throughout the day. The second part of the deficiency concerns two separate incidents in which mechanical lift slings failed during transfers, causing residents to fall. One resident with paraplegia due to spina bifida, scoliosis, morbid obesity, and neurogenic bladder required total assist with a mechanical lift for transfers and was cognitively intact. This resident reported that during a transfer from a shower chair to bed, while suspended in the air by the lift, the sling straps broke and she fell, striking her face on the base of the lift. Progress notes and hospital records document that staff found her on the floor with her legs partially under the bed and the sling snapped and hanging from the lift, with a large amount of blood from a facial laceration, bruising and swelling around the right eye, and subsequent diagnosis of an acute nondisplaced fracture of the anterior right iliac wing. CNAs involved in the transfer stated that the sling was already under the resident, they did not inspect or test the straps before use, and that the sling loops or stitching came undone while the resident was in the air, causing her to fall. Another resident, severely cognitively impaired and dependent on staff for transfers, experienced a similar sling failure during a transfer from bed to wheelchair. Progress notes and a CNA witness statement describe that the resident was in a sling that appeared properly fitted, with straps and hooks intact and without noted fraying or breaks, when two of the sling straps on one side snapped as the resident was being lowered into the wheelchair, causing the resident to fall backward to the floor. The nurse assisting with the transfer eased the resident to the floor, and the resident sustained three skin tears to the left arm, discoloration, and a red spot on the left cheek from contact with the nurse’s knee. Staff interviews confirm that this earlier sling break occurred and that the same type of equipment was involved. The laundry supervisor stated that laundry staff were supposed to inspect every sling, discard damaged ones, and document inspections, but acknowledged that they were not documenting in the log as required and that she had been written up for this. The administrator confirmed that after the first sling-related fall, management checked with laundry about inspecting slings and not using bleach, and that after the second fall, staff were re-educated, indicating that prior to these incidents, sling inspection and maintenance practices were not being reliably documented or verified.

Removal Plan

• Resident returned to facility safely; skin assessment and vital signs completed upon return
• Resident placed on checks
• Wander management system checked for proper functioning
• Code to patio door changed
• All door alarms checked for proper functioning
• Staff education/in-service regarding elopement policy (resident supervision, redirecting exit-seeking residents, alarm response, and no sharing of door codes with non-staff members)
• DON/ADON to audit wander management system documentation on MAR/TAR
• Review and update care plans for residents at risk for elopement as needed
• Social Service Director to review the Code Yellow book to ensure completeness
• Code Yellow drills performed on each shift
• Administrator to review audits to ensure compliance
• Report trends to the QA committee and implement further corrective action as needed

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide timely ADL and incontinence care to residents who were dependent on staff assistance. One resident with diagnoses including lack of coordination, cauda equina syndrome, osteoarthritis, and major depressive disorder was cognitively intact and care planned as dependent for toileting hygiene and bed mobility. On the morning in question, this resident reported having a bowel movement after breakfast and stated they had just turned on the call light. A strong fecal odor was noted in the room. Despite the call light sounding, the assigned LPN remained at the medication cart nearby and a CNA walked past the room multiple times over a 14‑minute period without entering. The resident’s assigned CNA had been sent out of the facility around 8:30 a.m. to accompany another resident to a medical appointment, and coverage was to be provided by other CNAs on the unit. At 10:00 a.m., a covering CNA entered the resident’s room only to turn off the call light and then left without providing care. When the surveyor re-entered the room at 10:15 a.m., the resident was crying and reported that the CNA had said they were busy and would return in a few minutes, which did not occur. Continuous surveillance from 9:00 a.m. to 11:50 a.m. showed that the CNA did not return. The resident reactivated the call light at 11:45 a.m., and another CNA responded at 11:50 a.m., returning with supplies and initiating incontinence care around noon, resulting in the resident remaining soiled with feces for approximately three hours while reporting itching, burning, pain, humiliation, and feeling “like a dog” lying in feces. A second resident, with medical conditions including spinal stenosis, weakness, a gastrostomy, a sacral pressure ulcer, and polyosteoarthritis, was moderately cognitively impaired and care planned as dependent for toileting hygiene and bed mobility. During the same surveillance period, this resident was heard calling out for help and reported being wet for a long time. The surveyor activated the call light, which the LPN answered by entering the room, turning off the call light, and then leaving to return to the nursing station. The LPN later stated that the resident needed to be cleaned up and that she had told one of the aides but did not recall which one, noting she was occupied with an admission. The resident remained wet until a CNA who had been out on a medical escort returned to the unit and, at the surveyor’s request, provided incontinence care, resulting in the resident being left wet for approximately two hours. Staff interviews referenced ongoing staffing issues and working short, with only two CNAs on the floor for about forty residents and the reassignment of a primary CNA to an outside appointment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse between two cognitively intact residents, R1 and R2, during access to the smoking patio. Both residents have multiple medical diagnoses, including nicotine dependence and other chronic conditions, and both have BIMS scores of 15, indicating intact cognition. On the date of the incident, R1 and R2 were proceeding to the smoking area via a ramp and vestibule with a noted blind spot. R2 stopped in the walkway to light a cigarette, which partially blocked the path. R1 attempted to pass and there was physical contact between them, after which a physical altercation occurred resulting in R2 being struck and falling to the ground. Multiple interviews and notes describe differing accounts of who initiated the physical contact, but consistently confirm that R1 hit R2 in the face. R1 reported that while attempting to pass R2 on the ramp, he felt a blow to the left side of his own face, then grabbed R2’s jacket collar, pulled him down, and punched him in the face multiple times before another resident intervened. R2 stated that he was attacked in the vestibule on the way to the smoking tent, reporting that R1 rammed him from behind with a wheelchair, hit him in the right temple area, and threatened to beat him into a coma, and that he did not feel safe. Witnesses, including residents and staff, gave varying accounts: some stated R2 hit or pushed R1 first and R1 hit back, while others stated R2 put his hand in R1’s face and R1 then struck R2, or that R1 grabbed R2, threw him to the ground, and hit him in the face. Clinical documentation and staff observations confirm that R2 sustained visible injury as a result of the altercation. An abuse report noted redness on R2’s upper cheek immediately after the incident, and subsequent nursing and wound care notes described a bruise, black eye, and maroon discoloration on the upper right cheek and around the right eye. R2 was sent to the hospital and admitted with diagnoses including hypotension, facial contusion, dehydration, and lactic acidosis, and later readmitted to the facility with a documented black eye. The facility’s abuse and neglect policy states that physical abuse includes infliction of injury that occurs other than by accidental means and requires medical attention. The survey finding concludes that the facility failed to protect residents from physical abuse, resulting in R2 sustaining an injury near the right eye and requiring hospital evaluation, and that a reasonable person would have experienced psychosocial harm from being injured in this manner.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and monitoring to prevent accidents for three residents, including one who sustained a left femoral fracture. One resident had multiple diagnoses including essential hypertension, type 2 diabetes with neuropathy, cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, muscle wasting, weakness, unsteadiness on feet, and unspecified convulsions. This resident’s MDS showed significant cognitive impairment with a BIMS score of 6/15 and documented need for supervision with ADLs and mobility. The resident’s care plan stated that a safe environment was to be maintained and that staff should anticipate and meet needs and provide a safe environment. A community survival skills assessment documented that the resident did not appear capable of unsupervised outside pass privileges. On 12/11/2025, staff identified a change in this resident’s condition related to mobility and gait. The restorative nurse received a report that the resident was experiencing increased unsteadiness in gait. Upon assessment, the resident reported that his left knee sometimes gave out. A wheelchair and urinal were provided, and the resident was educated on safe wheelchair use and encouraged to request staff assistance. A change in condition note by an LPN the same day documented that the resident needed two-person assistance to bed due to left leg weakness, later proceeded to walk without staff after resting, and that his gait was not at baseline, though it showed some improvement. Another note documented that the resident was later seen leaning on the bathroom door, unable to use his left leg during transfer, and that he walked into the dining area for dinner with a shuffled gait that was not baseline. The care plan and progress notes from 12/11/2025 to 12/16/2025 did not document any ongoing non-compliance with wheelchair use or additional interventions related to his increased unsteadiness. On 12/16/2025, the LPN documented that the resident complained of left leg pain starting at the groin and radiating down the thigh, with pain on movement but not on light touch, and the resident was sent to the hospital for evaluation. Hospital records showed a left basicervical femoral neck fracture, and the resident was described as a very poor historian, alert and oriented x1, unable to explain why he was brought to the ED, and unable to recall the mechanism or timing of injury. The hospital record noted that no information was provided from the nursing home and that family could not be reached. The social services director stated that the resident did not go into the community independently and that any community pass would be documented; review of progress notes and the Resident Community Access Tracking Tool for December 2025 showed no documentation that the resident went out on community pass. Despite the resident’s impaired cognition, unsteady gait, and documented change in condition, there was no clear documentation of how the fracture occurred while the resident was in the facility. The deficiency also includes inadequate supervision of two additional residents who were both assessed as high fall risk. On observation, two residents were seen sitting in geri-chairs in the second-floor dining room unsupervised and unattended. Their fall risk assessments documented high fall risk scores (13 and 12), and their care plans included impaired cognition, history of falls, muscle weakness, dementia, impaired decision-making, and the need for cueing, reorientation, supervision, fall precautions, and maintenance of a safe environment with fall interventions in place. An LPN stated that CNAs take turns monitoring residents in the dining room at 30-minute intervals to ensure residents do not fall, injure themselves, choke, or get into physical altercations, and that a specific CNA was assigned to monitor the dining room during the time of observation. Despite this assignment and the facility’s policies on standard supervision and incidents/accidents/falls, the two high-risk residents were left in the dining room without staff present, demonstrating a failure to provide the supervision and monitoring required by their assessed needs and care plans.