Inspection Reports for
Mayfield Care Rehab Center

F0686 - The facility failed to develop a plan of care and assure that one resident at high risk for skin breakdown received appropriate treatment and services to prevent the development and worsening of a pressure ulcer, resulting in hospitalization and surgical intervention.

F0689 - The facility failed to ensure the safety of a resident using a wheelchair with a broken right brake, which was unable to lock, posing a risk of falls and injury.

F0684 (295.6840 Provide appropriate treatment and care) - The facility failed to notify the physician of a resident's change in condition and delayed transfer to the hospital for evaluation of a contusion and bruised right eye in one resident of three reviewed.

F0550 (295.0550 Resident Rights) - The facility failed to maintain resident rights pertaining to dignity for three residents by not providing feeding assistance with dignity and failing to protect confidentiality of medical information.

F0554 (295.0554 Self-Administration of Drugs) - The facility failed to assess and monitor one resident for self-administration of medication without a physician order.

F0575 (295.0575 Resident Rights Program) - The facility failed to post required program information in a public and accessible location for twelve residents eligible for the program.

F0583 (295.0583 Confidentiality) - The facility failed to protect the privacy and confidentiality of personal information for one resident by allowing a hospital wristband with identifying information to remain visible.

F0645 (295.0645 PASARR Screening) - The facility failed to ensure Pre-admission Screening and Residential Review (PASARR) were completed for five residents prior to admission.

F0688 (295.0688 Range of Motion) - The facility failed to provide consistent restorative therapy and splint application for one resident, placing the resident at risk of losing mobility and independence.

F0725 (295.0725 Staffing) - The facility failed to provide enough nursing staff to meet the needs of residents, resulting in delayed response to call lights and insufficient CNA coverage on some shifts.

F0755 (295.0755 Pharmaceutical Services) - The facility failed to administer prescribed medications timely and maintain accurate narcotic counts for four residents.

F0759 (295.0759 Medication Error Rate) - The facility failed to maintain a medication error rate below 5%, with errors observed in medication administration for two residents.

F0761 (295.0761 Drug Labeling and Storage) - The facility failed to remove expired medications and enteral feedings, and failed to properly label medications in multiple medication carts and storage rooms.

F0809 (295.0809 Food Service) - The facility failed to ensure proper sanitation and food safety practices including dishwasher temperature, sanitizing procedures, hair net use, and labeling of opened food items.

F0812 (295.0812 Food Service) - The facility failed to ensure dishwasher temperatures met required standards for sanitization, risking cross contamination and foodborne illness.

F0842 (295.0842 Medical Records) - The facility failed to accurately classify psychotropic medication on consent forms for one resident, potentially affecting informed consent regarding medication side effects.

F0882 (295.0882 Infection Preventionist) - The facility failed to ensure the designated Infection Preventionist completed required specialized training for nursing homes.

F0883 (295.0883 Immunizations) - The facility failed to properly provide education, documentation, and administration of influenza and Covid-19 vaccinations for six residents.

F0600 (Abuse Prevention Program) - The facility failed to ensure resident R1 was free from verbal abuse by staff, substantiated by two separate investigations resulting in CNA terminations.

F0600 (295.6000 Resident Rights) - The facility failed to protect resident R2 from physical abuse by tying their wrists to bed rails with a pillowcase without consent or physician order, causing physical pain and mental anguish.

F0604 (295.6000 Physical Restraints) - The facility failed to ensure residents were free from unnecessary physical restraints, failing to obtain physician orders or medical justification for restraining R2 with a pillowcase.

F0609 (295.6000 Reporting) - The facility failed to timely report the alleged abuse of resident R2 to IDPH, reporting it 32 days after the incident.

F0689 (295.6000 Safety and Supervision) - The facility failed to ensure treatment carts and resident medication were secured, leaving an inhaler at bedside without order and an unlocked treatment cart unattended.

F0725 (295.6000 Staffing) - The facility failed to provide sufficient nursing staff to meet resident needs, resulting in inadequate supervision that contributed to the abuse of resident R2.

F0644 (No specific Illinois section cited) - The facility failed to refer five residents for required PASARR Level I and II screenings, resulting in residents not receiving timely assessments and necessary specialized services.

F0684 - The facility failed to provide wound treatment for two residents, including lack of treatment orders, missing weekly wound assessments, and inadequate care plans, resulting in actual harm including hospital admission for wound dehiscence.

F0600 (Abuse Prevention) - The facility failed to ensure residents were free from physical and verbal abuse, as evidenced by two residents being subjected to staff physical and verbal abuse incidents.

F0550 (295.6000 Resident Rights) - The facility failed to obtain a physician's order prior to administering a urine drug screen and failed to have a nurse conduct the screening for one resident.

F0558 (295.6000 Resident Rights) - The facility failed to reasonably accommodate the needs and preferences of one resident by not providing assistance in relocating to another facility.

F0658 (295.6000 Resident Rights) - The facility failed to ensure medications were administered within the facility's 2-hour window for medication administration for five residents.

F0689 (295.6000 Resident Rights) - The facility failed to ensure the appropriate assistive device was provided for one resident with a history of multiple falls, using a geriatric chair without proper assessment or physician order.

F0697 (295.6000 Resident Rights) - The facility failed to ensure timely ordering, sufficient supply, administration, and documentation of pain medication for one resident, resulting in multiple days without pain medication.

F0725 (295.6000 Resident Rights) - The facility failed to provide enough nursing staff daily to meet resident needs and have a licensed nurse in charge on each shift, resulting in delayed medication administration, incomplete ADL care, and resident complaints.

F0557 (295.2057 Resident Rights) - The facility failed to maintain resident privacy and dignity when a resident was seen without clothes on through an open door and staff did not immediately address the situation.

F0600 (295.2060 Abuse Prevention) - The facility failed to protect residents from physical and mental abuse by another resident and failed to establish a secure environment after the abuse was determined.

F0644 (295.2064 PASRR) - The facility failed to refer a resident to the state-designated authority for Level II PASRR evaluation after onset of possible serious mental disorder.

F0684 (295.2084 Treatment and Care) - The facility failed to provide proper positioning for a dependent resident during mealtime, increasing risk of aspiration.

F0686 (295.2086 Pressure Ulcers) - The facility failed to ensure low air loss mattresses were set correctly for dependent residents at risk for pressure ulcers.

F0688 (295.2088 Contractures) - The facility failed to follow physician's order and implement an individualized plan of care for a resident's left hand splint to prevent contracture progression.

F0693 (295.2093 Enteral Tube Feeding) - The facility failed to disconnect and flush a resident's gastric tube per physician order, risking tube clogging.

F0695 (295.2095 Respiratory Care) - The facility failed to provide safe and appropriate respiratory care including proper oxygen tubing labeling, storage, and tracheostomy care with appropriate PPE.

F0725 (295.2125 Staffing) - The facility failed to provide adequate nursing and CNA staffing to meet resident needs, resulting in late medication administration and incomplete care.

F0759 (295.2159 Medication Errors) - The facility had a medication error rate exceeding 5%, including omitted and late medications for residents.

F0760 (295.2160 Significant Medication Errors) - The facility failed to ensure medications were administered as prescribed for residents, including insulin and blood pressure medications.

F0761 (295.2161 Medication Storage and Labeling) - The facility failed to properly store and label medications and supplies, including expired medications and supplies, unrefrigerated insulin, and disorganized crash carts with expired items.

F0812 (295.2212 Food Safety) - The facility failed to discard expired food and failed to perform hand hygiene between handling dirty and clean dishes, risking cross contamination.

F0880 (295.2280 Infection Control) - The facility failed to implement an effective infection prevention program including failure to clean reusable medical equipment between residents, failure to wear proper PPE during tracheostomy care, lack of isolation care plans, and failure to update infection control policies.

F0883 (295.2283 Vaccinations) - The facility failed to properly offer, educate, and document influenza and pneumococcal vaccinations for residents.

F0887 (295.2287 COVID-19 Vaccinations) - The facility failed to properly offer, educate, and document COVID-19 vaccinations for residents and staff.

F0600 (Physical Abuse) - The facility failed to ensure a resident (R1) remained free from physical abuse when R2 aggressively grabbed R1 by the neck from behind, affecting one resident of three reviewed.

F0600 - The facility failed to protect residents from physical abuse by another resident, resulting in a left hip fracture for R5 and a periorbital contusion for R7.

F0600 (295.6000 Resident Rights) - The facility failed to protect resident R6 from abuse when a staff member sprayed a chemical agent in R6's face causing eye irritation and pain, and failed to remove the staff member from contact with R6 promptly.

F0684 (295.6840 Provide Appropriate Treatment and Care) - The facility failed to carry out physician orders timely, notify the physician of delayed services and family requests, and administered an incorrect dosage of medication for resident R5.

F0689 (295.6890 Accident Hazards and Supervision) - The facility failed to assess resident R1 immediately after a fall and notify the physician, resulting in delayed care for a displaced hip fracture requiring surgery.

F0689 - The facility failed to ensure adequate supervision to prevent accidents related to drug use, resulting in overdoses of two residents out of three reviewed.

F0600 (Protect each resident from all types of abuse) - The facility failed to maintain a safe environment and protect four residents from abuse by other residents, including physical hitting and altercations.

F0600 (Protect each resident from all types of abuse) - The facility failed to follow the abuse prevention policy and ensure two residents remained free from abuse, resulting in one resident sustaining injury.

F0622 (Not transfer or discharge a resident without an adequate reason) - The facility failed to meet discharge requirements for one resident, including lack of coordination of needed services and unclear transportation arrangements.

F0660 (Plan the resident's discharge to meet the resident's goals and needs) - The facility failed to document a discharge plan of care for one resident reviewed for discharge planning process.

F0600 - The facility failed to protect a resident from physical abuse by another resident, resulting in injury requiring hospital evaluation.

F0558 (Reasonably accommodate the needs and preferences of each resident) - The facility failed to ensure 2 of 2 residents' call lights were within reach in a sample of 26.

F0657 (Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals) - The facility failed to revise a resident's comprehensive care plan after significant weight loss for 1 of 26 residents reviewed.

F0677 (Provide care and assistance to perform activities of daily living for any resident who is unable) - The facility failed to follow a resident's comprehensive care plan and provide turning and repositioning every two hours or as needed for 1 of 26 residents reviewed.

F0684 (Provide appropriate treatment and care according to orders, resident’s preferences and goals) - The facility failed to identify presence of PICC or midline lines, provide needed care and services, follow policy for dressing changes, measuring, flushing, and cleaning of PICC or midline lines for multiple residents in a sample of 26.

F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to complete a fall risk assessment on 1 resident reviewed for falls, who subsequently fell and sustained a clavicle fracture.

F0693 (Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube) - The facility failed to ensure proper placement of the gastrostomy tube prior to medication administration and provide gastrostomy care per orders for 1 of 3 residents with gastrostomy tubes reviewed.

F0695 (Provide safe and appropriate respiratory care for a resident when needed) - The facility failed to follow policy and procedure on oxygen administration including checking physician orders and changing tubing and humidifier bottle for 1 resident reviewed for oxygen use.

F0697 (Provide safe, appropriate pain management for a resident who requires such services) - The facility failed to follow the comprehensive care plan to ensure a pain patch was applied as ordered by the physician for 1 resident reviewed for pain management.

F0755 (Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist) - The facility failed to ensure the system used for accountability of controlled medications was followed for 1 of 3 medication carts reviewed, resulting in a missed dose of Phenobarbital for 1 resident.

F0759 (Ensure medication error rates are not 5 percent or greater) - The facility failed to ensure a medication error rate of less than 5% for 2 residents reviewed for medication administration, resulting in a 6.9% error rate due to held medications without physician orders or notification.

F0761 (Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs) - The facility failed to ensure medications were not left unattended on top of medication carts, failed to ensure medications were properly labeled and stored, and failed to discard insulin open for more than 28 days in 2 of 3 medication carts reviewed.

F0812 (Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards) - The facility failed to prepare food under sanitary conditions, failed to ensure frozen meat was not thawed at room temperature, failed to date perishable items, failed to routinely monitor and log food temperatures, failed to maintain dishwasher drainage, and failed to maintain cold food at 41F or cooler.

F0814 (Dispose of garbage and refuse properly) - The facility failed to dispose of garbage properly in contained dumpsters and failed to keep the dumpster area clean and free of garbage or waste to prevent pest harborage.

F0880 (Provide and implement an infection prevention and control program) - The facility failed to perform hand hygiene during bedside care, failed to maintain linen bags off the floor, failed to clean reusable equipment between residents, and failed to implement a water management program to address Legionella risk.

F0883 (Develop and implement policies and procedures for flu and pneumonia vaccinations) - The facility failed to monitor and record influenza and pneumococcal vaccinations in the immunization log for 4 of 5 residents reviewed.

F0886 (Perform COVID19 testing on residents and staff) - The facility failed to follow policy for COVID-19 testing of residents and staff exposed to confirmed cases, including lack of documentation of testing and contact tracing.

F0887 (Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status) - The facility failed to monitor staff vaccination status including contractual staff, failed to document education provided to residents, and had incomplete vaccination records for multiple residents.

F0888 (Ensure staff are vaccinated for COVID-19) - The facility failed to monitor vaccination status of all staff including contractual and agency workers and failed to develop policy and procedure to ensure all staff are fully vaccinated for COVID-19.

F0689 (Fall Prevention) - The facility failed to provide adequate monitoring and fall prevention for one high fall risk resident, resulting in a fall and head injury.