Inspection Reports for Mayfield Care Rehab Center

The inspection was conducted to evaluate the facility's compliance with care standards, specifically regarding pressure ulcer care and prevention.

The facility failed to develop and implement an adequate plan of care for a resident at high risk for skin breakdown, resulting in the development and worsening of an unstageable pressure ulcer that required hospitalization and surgical intervention. Staff did not consistently reposition the resident as ordered, and the care plan was incomplete and not individualized.

The inspection was conducted due to a complaint investigation regarding the safety of a resident using a mobility device, specifically a wheelchair with a broken brake.

The facility failed to ensure the safety of one resident (R2) by allowing the use of a wheelchair with a broken right brake, which posed a fall risk. Staff were unaware or delayed in addressing the repair, and the resident refused removal of the broken wheelchair, creating a safety hazard.

The complaint investigation found that one resident (R2) was using a wheelchair with a broken right brake that staff were unaware of or did not promptly repair. The resident refused removal of the wheelchair, and social services were not notified of the refusal as required.

The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the physician of a resident's change in condition following a fall, which delayed hospital transfer and evaluation.

The facility failed to notify the physician of a change in condition for one resident (R1) after a fall, resulting in delayed hospital transfer for evaluation of a contusion and bruised right eye. Several staff members were terminated for not following facility policies on reporting falls and changes in condition. The resident sustained head edema, hematoma, and contusion requiring hospital admission.

The investigation found that staff members V8 (Licensed Practical Nurse), V9 and V10 (Certified Nursing Assistants) failed to report the resident's fall and change in condition to the nurse or physician, resulting in delayed care. These staff were terminated for gross misconduct and failure to follow facility policies. The resident was admitted to the hospital with serious head injuries and was on blood thinner medications, increasing risk of death.

Routine inspection of Complete Care at the Boulevard nursing home to assess compliance with resident rights, medication administration, staffing, infection control, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to maintain resident dignity, improper medication administration and documentation, inadequate staffing levels, failure to ensure infection preventionist certification, improper food safety practices, failure to provide consistent restorative therapy, and incomplete immunization documentation and administration.

The inspection was conducted following complaints of verbal abuse by Certified Nursing Assistants (CNAs) towards resident R1. The investigation focused on substantiating allegations of verbal abuse and ensuring resident safety.

The facility substantiated two separate incidents of verbal abuse towards resident R1 by CNAs, resulting in the termination of the involved staff. The facility's abuse prevention program and policies were reviewed and followed, with no new physician orders other than monitoring.

The complaint investigation was substantiated based on interviews with resident R1, other residents, and staff. Two CNAs were found to have verbally abused R1, and both were terminated. The facility administrator investigated and confirmed the allegations on 11/28/24 and 12/18/24.

The inspection was conducted due to a complaint investigation regarding alleged abuse and improper use of restraints on resident R2, who was tied to bed rails with a pillowcase by a nurse without physician order or consent.

The facility failed to protect resident R2 from physical abuse and mental anguish by tying R2's wrists to bed rails with a pillowcase without physician order or consent. The facility also failed to report the abuse timely to the Illinois Department of Public Health and had staffing shortages contributing to the incident. The immediate jeopardy was removed after corrective actions including staff training and resident reassessments.

The complaint investigation was triggered by an incident on 10/12/2024 where resident R2 was tied to bed rails with a pillowcase by nurse V6 due to staffing shortages. The facility delayed reporting the abuse to IDPH by 32 days. Interviews with staff and physicians confirmed the abuse and lack of physician orders or consent. The facility implemented corrective actions including staff training and resident reassessments.

The inspection was conducted due to a complaint regarding the facility's failure to properly refer five residents for Preadmission Screening and Resident Review (PASRR) Level I and II assessments as required.

The facility failed to refer five residents (R2, R3, R4, R5, R6) for timely PASRR Level II assessments, resulting in residents not receiving necessary specialized programs and treatment. The social services department had a transition period without a director, causing delays in entering resident information into the assessment tool and failure to notify the appointed screening agency.

The complaint investigation found that the facility did not complete required PASRR Level II screenings for residents with serious mental illness, intellectual disability, or developmental disability, leading to delays in specialized care and treatment. The social services director was new and unaware of the requirements until the surveyor interview.

The inspection was conducted due to complaints regarding the facility's failure to provide appropriate wound care treatment for residents with surgical and pressure wounds.

The facility failed to provide wound treatment for two residents (R1 and R4), including lack of treatment orders, incomplete wound assessments, missing care plan interventions, and failure to change wound dressings as ordered. These failures resulted in actual harm, including hospitalization of R1 due to wound dehiscence and inadequate wound care for R4.

The investigation was complaint-driven, focusing on wound care deficiencies for residents R1 and R4. The complaint was substantiated as the facility failed to provide ordered wound treatments, complete required assessments, and maintain proper documentation, resulting in actual harm to residents.

The inspection was conducted due to allegations of physical and verbal abuse involving residents and staff at the facility.

The facility failed to ensure residents were free from physical and verbal abuse. Two residents (R1 and R2) were involved in incidents where staff members physically slapped or verbally abused them. Staff members involved were terminated following investigations.

The complaint investigation substantiated physical abuse of resident R1 by staff member V3 and verbal abuse of resident R2 by staff member V6. Both staff members were terminated. The facility followed its Abuse Prevention Policy and monitored affected residents.

The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, medication administration, resident relocation assistance, accident prevention, pain management, and staffing adequacy at Complete Care at the Boulevard nursing home.

The facility was found deficient in multiple areas including failure to obtain physician orders and have nurses conduct urine drug screens, failure to assist a resident with relocation, medication administration delays beyond the facility's 2-hour window, inappropriate use of a geriatric chair without assessment, inadequate pain management with delays and missed doses, and insufficient nursing and CNA staffing leading to delayed medication administration and incomplete care.

The inspection was conducted to assess compliance with regulatory requirements including resident rights, abuse prevention, PASRR assessments, care and treatment, medication administration, infection control, staffing, and vaccination policies.

The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, protect residents from abuse, coordinate PASRR assessments, provide proper positioning and pressure ulcer care, ensure use of splints, administer enteral feedings properly, provide safe respiratory care, maintain adequate staffing, prevent medication errors, properly store and label medications, implement infection control practices, and follow vaccination policies.

The inspection was conducted following a complaint investigation regarding an incident where one resident (R2) aggressively grabbed another resident (R1) by the neck without apparent reason.

The facility failed to ensure a resident (R1) remained free from physical abuse by another resident (R2). The investigation confirmed the incident of physical abuse with no injuries sustained by either resident. The facility has policies prohibiting abuse and monitors residents exhibiting harmful behaviors.

The complaint investigation was triggered by an incident on 02/13/24 where R2 aggressively grabbed R1 by the neck. The facility's investigation concluded the abuse occurred with no injuries to either resident. The incident was reported to the local state agency and involved multiple staff interviews.

The inspection was conducted due to allegations of resident-to-resident physical abuse involving residents R1, R5, and R7, including an incident where R1 pushed R5 causing a hip fracture and another where R1 punched R7 in the face.

The facility failed to protect residents from physical abuse by another resident. Resident R5 was pushed by R1 resulting in a left hip fracture requiring surgery and hospital transfer. Resident R7 was punched in the face by R1 causing a periorbital contusion. The abuse allegations were substantiated by interviews and record reviews.

The complaint investigation substantiated that resident R1 physically abused residents R5 and R7. R1 pushed R5 causing a fall and hip fracture on 2/17/24, and punched R7 in the face in November 2023. The facility investigation confirmed these incidents.

The inspection was conducted due to a complaint investigation regarding an incident where a staff member sprayed a chemical agent at a resident (R6), causing injury and failure to protect the resident from abuse.

The facility failed to protect resident R6 from abuse when a staff member sprayed pepper spray at R6's face, causing eye irritation and pain requiring emergency treatment. The staff member was allowed to continue working with R6 after the incident. The facility also failed to timely carry out physician orders and notify physicians of delayed services for resident R5, and failed to properly assess and notify physicians after a fall involving resident R1, resulting in delayed care and injury.

The complaint investigation was triggered by an incident on 11/15/2023 where a staff member (V26) sprayed pepper spray at resident R6's face, causing injury. The investigation included interviews, witness statements, video surveillance review, and medical record review. Immediate jeopardy was identified and removed after the facility implemented a removal plan including staff suspension and termination, in-services, and policy reinforcement.

The inspection was conducted due to concerns about inadequate supervision and use of illicit substances by residents, specifically following incidents of overdose involving two residents (R1 and R2).

The facility failed to develop and implement appropriate measures to ensure adequate supervision for residents with a history of drug use, resulting in multiple overdoses. Despite monitoring and interventions, the source of drugs within the facility was not identified, and residents continued to have access to illicit substances.

The investigation was complaint-related, focusing on supervision and illicit drug use by residents. The report notes that two residents overdosed, and the facility was unable to determine how drugs were brought into the facility. The complaint was substantiated by findings of inadequate supervision and failure to prevent drug use.

The inspection was conducted due to complaints of abuse involving four residents (R1, R2, R3, and R4) at the facility. The investigation focused on incidents of physical abuse between residents.

The facility failed to protect residents from abuse, with documented incidents of physical altercations between residents R1 and R2, and between R3 and R4. Staff intervened and placed residents on 1:1 observation, but abuse incidents occurred multiple times, indicating a failure to maintain a safe environment.

The complaint investigation substantiated abuse incidents involving residents R1, R2, R3, and R4. Multiple physical altercations were documented, including hitting and punching between residents. Staff responses and observations were recorded, and residents were placed on 1:1 observation. Police were notified in one incident.

The inspection was conducted following allegations of abuse and improper discharge practices involving residents R4, R5, and R1. The investigation focused on abuse prevention failures and discharge planning deficiencies.

The facility failed to prevent abuse between residents R4 and R5, resulting in actual harm to R4. Additionally, the facility failed to meet discharge requirements and did not document a discharge plan for resident R1, who was discharged without adequate coordination of services.

The complaint investigation was triggered by allegations that resident R4 was physically abused by resident R5, and that resident R1 was discharged without proper coordination of housing, medications, and social security assistance. The investigation confirmed abuse occurred and deficiencies in discharge planning.

The inspection was conducted due to a complaint investigation regarding an incident of physical abuse between two residents (R3 and R4) at the facility.

The facility failed to protect a resident (R3) from physical abuse by another resident (R4), who struck R3 in the face during an altercation in the main dining room. The incident was witnessed by staff, resulted in R3 being sent to the hospital for evaluation, and both residents were subsequently separated.

The complaint investigation found that R4 physically abused R3 by hitting him in the face during an altercation in the main dining room. The abuse was substantiated based on witness statements and staff reports.

Routine inspection of Complete Care at the Boulevard nursing home to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility safety.

The facility was found deficient in multiple areas including call light accessibility, care plan updates, turning and repositioning, PICC line care, fall risk assessments, gastrostomy tube medication administration, oxygen therapy orders, pain management, medication cart security and accuracy, medication error rates, medication storage and labeling, food safety and sanitation, garbage disposal, infection prevention practices, COVID-19 testing and vaccination documentation, and staff vaccination monitoring.

The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate monitoring and fall prevention for a high-risk resident, resulting in a fall and head injury.

The facility failed to follow its fall prevention policy by not adequately monitoring a high fall-risk resident (R2), who fell in the hallway and sustained a head injury requiring hospital admission. Staff interviews and records confirmed multiple prior falls and insufficient supervision.

The complaint investigation found that the facility did not properly monitor resident R2, a high fall risk with a history of multiple falls, leading to a fall on 2/18/2023 that caused a head injury and intracerebral hemorrhage. The fall was witnessed by staff who reported inadequate supervision and failure to follow fall prevention policies.