13 CMS Surveys
Inspection Report — May 29, 2025
Date: May 29, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to ensure a medication administration error rate below 5%, with errors found in medication administration for two residents.
Deficiencies (1)
F0759 - The facility failed to ensure a medication administration error rate below 5%, with errors involving incorrect medications given to two residents out of four reviewed.
Report Facts
Residents affected: 2
Residents reviewed: 4
Medication administration opportunities: 33
Medication administration errors: 3
Inspection Report — Apr 18, 2025
Complaint Investigation
Date: Apr 18, 2025
Visit Reason
This complaint investigation was conducted due to an allegation that the facility failed to timely report suspected abuse involving one resident (R1).
Complaint Details
Complaint # not explicitly stated in the text; complaint investigation of abuse allegation for one resident (R1).
Findings
The facility failed to report an abuse allegation to the Illinois Department of Public Health for one resident. The investigation found that the resident reported the injury was accidental and not intentional, and the facility did not submit the report to the state agency.
Deficiencies (1)
F0609 - The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for one resident.
Report Facts
Residents affected: 1
Residents reviewed: 4
Inspection Report — Mar 14, 2025
Annual Inspection
Date: Mar 14, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including medication administration errors, failure to follow dietary orders, improper infection control practices, and issues with resident care such as nail care and pressure ulcer prevention. The facility failed to maintain proper food safety and storage practices and did not consistently follow resident care plans and physician orders.
Deficiencies (14)
F0554 (77 Ill. Adm. Code Part 295) - The facility failed to obtain a physician order and to determine if self-administration of medication was appropriate for one resident observed with medications at bedside.
F0644 (77 Ill. Adm. Code Part 295) - The facility failed to refer a resident to the appropriate state-designated authority for PASRR re-evaluation after new psychiatric diagnoses.
F0677 (77 Ill. Adm. Code Part 295) - The facility failed to ensure nail care was provided for three residents dependent in grooming.
F0686 (77 Ill. Adm. Code Part 295) - The facility failed to ensure low air loss mattress devices were on the correct weight settings for residents with pressure ulcers or at risk for pressure ulcers.
F0689 (77 Ill. Adm. Code Part 295) - The facility failed to follow a resident's fall care plan intervention and physician recommendation to ensure a soft head helmet was applied while in bed, resulting in a subdural hematoma after a fall.
F0695 (77 Ill. Adm. Code Part 295) - The facility failed to ensure oxygen and nebulization tubing were dated/changed, BiPAP and CPAP masks and tubing were properly stored, and physician orders were obtained for BiPAP and CPAP use for four residents.
F0700 (77 Ill. Adm. Code Part 295) - The facility failed to ensure appropriate side rails were used, evaluate side rail use quarterly, and develop care plans for four residents.
F0758 (77 Ill. Adm. Code Part 295) - The facility failed to update a resident's care plan and limit PRN psychotropic medication to 14 days for one resident.
F0759 (77 Ill. Adm. Code Part 295) - The facility failed to maintain a medication error rate below 5%, with a 6.25% error rate observed for one resident.
F0803 (77 Ill. Adm. Code Part 295) - The facility failed to follow the menu and cooking instructions, including improper preparation of pureed mashed potatoes and failure to serve planned desserts.
F0805 (77 Ill. Adm. Code Part 295) - The facility failed to follow physician orders for nectar-thick liquids for one resident.
F0808 (77 Ill. Adm. Code Part 295) - The facility failed to provide oral supplements as part of therapeutic diets for five residents.
F0812 (77 Ill. Adm. Code Part 295) - The facility failed to follow policies regarding disposal of expired food, labeling opened food, storing food away from cleaning solutions, hand hygiene during dishwashing, and covering prepared food to prevent contamination.
F0880 (77 Ill. Adm. Code Part 295) - The facility failed to implement infection prevention and control program requirements including failure to don PPE for residents on Enhanced Barrier Precautions and Contact Isolation, and failure to post appropriate signage.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 4
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 108
Residents affected: 1
Residents affected: 5
Residents affected: 4
Inspection Report — Nov 14, 2024
Date: Nov 14, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to ensure that one resident with a known history of falls did not have nine repeated falls, resulting in minimal harm or potential for actual harm to a few residents.
Deficiencies (1)
F0689 - The facility failed to ensure that one resident (R1) with a known history of falls did not have nine repeated falls, despite interventions including a 1:1 aide.
Report Facts
Residents affected: 1
Fall incidents: 9
Inspection Report — Aug 12, 2024
Date: Aug 12, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to use a gait belt during resident transfer for one resident, resulting in a fall and a left femur fracture. Multiple staff interviews and records confirm the incident and the failure to provide adequate supervision during transfer.
Deficiencies (1)
F0689 - The facility failed to utilize a gait belt during transfer of one resident, resulting in a fall and a left femur fracture.
Report Facts
Residents affected: 1
Inspection Report — Jun 3, 2024
Complaint Investigation
Date: Jun 3, 2024
Visit Reason
Complaint investigation regarding failure to monitor call light system, provide incontinence care, administer medications as ordered, and ensure sufficient nursing coverage.
Findings
The facility failed to timely answer call lights, provide incontinence care for dependent residents, administer medications as ordered, and maintain adequate nursing coverage. These failures potentially affected 20 residents on the three north unit.
Deficiencies (1)
F0684 (295.2040) - The facility failed to monitor the call light system and answer call lights timely for four residents, failed to provide incontinence care for five dependent residents, failed to administer medications as ordered for one resident, and failed to provide sufficient nursing coverage to ensure adequate resident care.
Report Facts
Residents affected: 20
Residents affected: 5
Residents affected: 4
Residents affected: 1
Inspection Report — Apr 19, 2024
Annual Inspection
Date: Apr 19, 2024
Visit Reason
Annual Licensure Survey. For this survey, the establishment was found not in compliance with Part 295 due to failures in providing adequate assistance with activities of daily living including grooming, showers, personal hygiene, and feeding assistance.
Findings
The facility failed to ensure residents dependent on staff assistance for ADLs received proper grooming, showers, personal hygiene, and feeding assistance. Three residents were affected by these deficiencies.
Deficiencies (1)
F0677 (Activities of Daily Living) - The facility failed to provide adequate care and assistance with grooming, showers, personal hygiene, and feeding for three residents dependent on staff assistance.
Report Facts
Residents affected: 3
Inspection Report — Apr 12, 2024
Annual Inspection
Date: Apr 12, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility failed to ensure menus met residents' nutritional needs, were followed, and communicated properly, resulting in minimal harm or potential for actual harm to some residents. Issues included lack of coffee availability, repetitive menus, uncommunicated menu substitutions, and failure to follow individual food plans.
Deficiencies (1)
F0803 (295.2040 Food and Nutrition Services) - The facility failed to ensure resident menus, individual food plans, and preferences were followed, provide variety in entrees, and communicate menu changes or food substitutions to residents, affecting multiple residents.
Report Facts
Residents affected: 7
Residents affected: 4
Residents affected: 3
Residents affected: 1
Inspection Report — Apr 12, 2024
Annual Inspection
Date: Apr 12, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide timely meals and supervision, inadequate language support, improper care for residents with compression wraps and pressure ulcers, insufficient staffing, medication management issues, food safety and quality concerns, and lapses in infection control practices.
Deficiencies (15)
F0550 - The facility failed to treat five residents with respect and dignity by not serving all residents sitting at the same table at the same time during dining observations.
F0676 - The facility failed to provide language support to non-English-speaking residents in accordance with professional standards and facility policy, impacting seven residents.
F0684 - The facility failed to provide needed care by not ensuring compression stockings or wraps were applied properly, midline dressings were dated, and care plans developed for three residents reviewed for quality of care.
F0686 - The facility failed to ensure the low air loss mattress was set correctly and left heel boot protector was applied for two residents reviewed for pressure wound prevention.
F0689 - The facility failed to ensure adequate supervision in the dining room to prevent accidents for multiple residents, with staff shortages and lack of assigned monitors.
F0692 - The facility failed to provide thickened liquids as prescribed, physician ordered nutritional supplements, and to assess and adjust nutrition interventions for residents with significant weight loss.
F0693 - The facility failed to ensure a resident receiving enteral feeding received appropriate care and services, including administering feeding as ordered and changing g-tube dressings daily.
F0695 - The facility failed to ensure oxygen tubing and bubbler were dated, changed weekly, and tubing stored properly for two residents reviewed for respiratory care.
F0725 - The facility failed to provide adequate nursing staffing to ensure timely medication administration, supervision in dining rooms, and resident care needs.
F0758 - The facility failed to obtain consents prior to administering psychotropic medications, complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months, and document attempts or contraindications for gradual dose reductions for residents on psychotropic medications.
F0761 - The facility failed to properly discard expired multi-dose inhalers and insulins, date opened insulin vials and pens, and secure medication carts, risking medication safety for residents.
F0803 - The facility failed to ensure menus met residents' nutritional needs, were followed, updated, and communicated, resulting in residents not receiving requested foods or beverages and repetitive menus.
F0804 - The facility failed to serve food at palatable temperatures and appearance, with cold and mushy foods, and improper handling of pureed foods and bread, affecting all residents receiving food prepared in the kitchen.
F0812 - The facility failed to properly label and date food items, discard expired or rotten foods, follow manufacturer storage guidelines, maintain clean food storage areas and ice machine, and practice proper hygiene during food preparation.
F0880 - The facility failed to implement an effective infection prevention and control program, including inconsistent use of enhanced barrier precautions, inadequate hand hygiene, lack of hand sanitizer availability, and incomplete staff education and compliance monitoring.
Report Facts
Residents affected: 5
Residents affected: 7
Residents affected: 3
Residents affected: 2
Residents affected: 12
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 107
Residents affected: 107
Residents affected: 109
Inspection Report — Nov 17, 2023
Complaint Investigation
Date: Nov 17, 2023
Visit Reason
Complaint Investigation regarding a resident fall resulting in injury.
Complaint Details
Complaint #145844: Resident fall with injury resulting in emergency room visit.
Findings
The facility failed to ensure resident safety for one resident who fell and sustained a laceration requiring emergency care. The facility assessed and educated staff on bed mobility and fall prevention following the incident.
Deficiencies (1)
F0689 - The facility failed to ensure resident safety, resulting in a resident falling and sustaining a laceration to the right lower leg that required emergency room treatment.
Report Facts
Residents affected: 1
Inspection Report — Sep 10, 2023
Annual Inspection
Date: Sep 10, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights to choose their food menu, failure to implement involuntary transfer and discharge policies properly, failure to provide bed hold policy upon discharge, failure to permit a resident to return after hospitalization, and failure to follow infection prevention and control policies related to COVID-19 cohorting.
Deficiencies (5)
F0550 (295.6000 Resident Rights) - The facility failed to assert residents' rights by not ensuring residents were afforded the opportunity to choose their own food menu items, potentially affecting 96 residents.
F0622 (295.6220 Transfer and Discharge) - The facility failed to implement their involuntary transfer and discharge process policy and failed to provide their bed hold policy upon discharge to hospital for one resident reviewed.
F0625 (295.6250 Bed Hold Policy) - The facility failed to notify the resident or representative in writing about how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave for one resident reviewed.
F0626 (295.6260 Return from Hospitalization) - The facility failed to permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeded the bed-hold policy for one resident reviewed.
F0880 (295.8800 Infection Prevention and Control) - The facility failed to follow its infection control policy by cohorting COVID positive residents with persons under investigation, potentially affecting two residents.
Report Facts
Residents affected: 96
Residents affected: 1
Residents affected: 2
Inspection Report — May 5, 2023
Annual Inspection
Date: May 5, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to protect residents from abuse, failure to report and investigate abuse allegations properly, failure to ensure safe respiratory care, failure to properly manage psychotropic medications, failure to maintain kitchen cleanliness and food safety, failure to properly dispose of garbage, failure to implement infection prevention and control programs including Legionella water management and COVID-19 protocols, and failure to properly offer and document vaccinations for influenza, pneumococcal, and COVID-19 for residents and staff.
Deficiencies (12)
F0600 (295.6000 Resident Rights) - The facility failed to protect residents from physical and mental abuse for three residents, including rough handling causing pain and rude behavior causing mental anguish.
F0609 (295.6000 Resident Rights) - The facility failed to timely report suspected abuse incidents involving two residents to the Illinois Department of Public Health.
F0610 (295.6000 Resident Rights) - The facility failed to conduct thorough investigations of abuse allegations for two residents.
F0695 (295.6900 Respiratory Care) - The facility failed to label oxygen nasal cannula tubing and humidifier bottle with dates for one resident, risking infection.
F0758 (295.7500 Psychotropic Medications) - The facility failed to discontinue a PRN psychotropic medication after 14 days for one resident.
F0812 (295.8100 Food Service) - The facility failed to ensure disposal of expired food items, maintain kitchen cleanliness, and follow proper sanitation practices, risking contamination for many residents.
F0814 (295.8100 Food Service) - The facility failed to properly dispose of garbage and refuse, leaving heavy uncovered garbage bins outside, risking contamination.
F0880 (295.8800 Infection Control) - The facility failed to implement infection prevention and control programs including weekly domestic water temperature and chlorine testing, sanitizing blood pressure cuffs between residents, and labeling oxygen tubing, risking infection for many residents.
F0883 (295.8800 Infection Control) - The facility failed to offer, educate, and document influenza and pneumococcal vaccinations for four residents.
F0886 (295.8800 Infection Control) - The facility failed to perform COVID-19 testing on residents and staff exposed to a positive case during an outbreak, risking spread of infection.
F0887 (295.8800 Infection Control) - The facility failed to offer, educate, and document COVID-19 vaccinations for four residents.
F0888 (295.8800 Infection Control) - The facility failed to monitor COVID-19 vaccination status of healthcare workers including contracted/agency staff and failed to ensure contracted/agency nursing staff were fully vaccinated.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 78
Residents affected: 80
Residents affected: 80
Residents affected: 4
Residents affected: 80
Residents affected: 4
Residents affected: 80
Inspection Report — Apr 12, 2023
Complaint Investigation
Date: Apr 12, 2023
Visit Reason
Complaint investigation regarding medication errors and resident transfer safety.
Findings
The facility failed to ensure that only ordered medication was administered to one resident, resulting in an unprescribed medication and unnecessary lab draw. The facility also failed to transfer a resident using a total body lift and maintain a safe environment, causing a laceration requiring hospital treatment.
Deficiencies (2)
F0684 - The facility failed to ensure only ordered medication was administered and failed to follow doctor's orders for lab draws for one resident, resulting in medication errors and unnecessary blood work.
F0689 - The facility failed to transfer a resident using a total body lift and failed to ensure the resident's environment was free of hazards, resulting in a laceration requiring hospital transfer and sutures.
Report Facts
Residents affected: 1
Residents affected: 1
Number of sutures: 25
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