Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to implement interventions to prevent a resident's fall.
Complaint Details
The investigation was triggered by a complaint about a fall incident involving resident R1. The complaint was substantiated as the facility failed to meet fall prevention standards.
Findings
The facility failed to implement appropriate fall prevention interventions for one resident at risk, resulting in a fall with minimal harm. Staff did not promptly attend to the resident's needs, contributing to the incident.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent falls, resulting in a resident sustaining a fall without significant injury.
Report Facts
Residents reviewed for quality of care: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Described the circumstances of the resident's fall | |
| Registered Nurse | Provided information on resident's condition and fall prevention interventions | |
| Director of Nursing | Commented on the importance of attending to resident needs and the fall incident |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 29, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate personal care, nursing needs, and supervision of residents, including failure to provide appropriate treatment and care to residents and failure to prevent accidents related to wandering residents.
Complaint Details
The complaint investigation found substantiated failures in personal care and nursing needs for resident R1, including neglect in feeding, wound care, and hygiene. It also found failure in supervision of resident R2, a wanderer who entered another resident's room unsupervised, posing safety risks.
Findings
The facility failed to provide appropriate treatment and care for one resident (R1), including feeding assistance, wound care, and hygiene. Additionally, the facility failed to provide adequate supervision for a wandering resident (R2), which affected resident safety and had the potential to affect all residents on the 3rd floor.
Deficiencies (2)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in neglect of one resident's (R1) personal care, feeding assistance, and wound care.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents involving a wandering resident (R2).
Report Facts
Brief Interview for Mental Status (BIMS) score: 9
Brief Interview for Mental Status (BIMS) score: 4
Date of survey completion: Aug 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Certified Nursing Assistant (CNA) | Named in neglect of resident R1's care and supervision of resident R2 |
| V3 | Registered Nurse (RN) | Named in wound care and supervision findings |
| V2 | Assistant Director of Nursing (ADON) | Provided statements on facility expectations for nursing communication and supervision |
| V12 | Family Member of Resident R1 | Reported observations of neglect and wandering resident incidents |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 3
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with state regulations including quality improvement, employee orientation and training, and Alzheimer's and dementia program requirements.
Findings
The facility failed to provide evidence of a resident satisfaction survey and Quality Improvement Program, did not ensure completion of required employee orientation for 2 of 5 employees reviewed, and failed to document 16 hours of on-the-job training in memory care for 5 caregivers.
Deficiencies (3)
Failure to present evidence of resident satisfaction survey and Quality Improvement Program affecting all 31 residents.
Failure to ensure completion of employee orientation as required for 2 employees (E8, E9) out of 5 reviewed.
Failure to ensure completion of 16 hours of on-the-job training in memory care for 5 caregivers (E6, E7, E8, E9, E10).
Report Facts
Resident census: 31
Employees missing orientation training: 2
Caregivers missing memory care training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Involved in receiving requests and acknowledging missing documentation |
| E2 | Director of Nursing | Presented with written request for documentation |
| E3 | Assistant Director of Nursing | Presented with written request for documentation |
| E8 | Certified Nursing Assistant | Missing documentation of orientation and disaster preparedness training |
| E9 | Certified Nursing Assistant | Missing documentation of orientation, resident rights, HIPAA, disaster preparedness, and abuse training |
| E11 | Human Resources | Responsible for employee files and training documentation; acknowledged missing training |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 14, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations, focusing on resident care, safety, and facility procedures.
Findings
The facility was found to have actual harm deficiencies related to pressure ulcer care and fall prevention. Two residents suffered harm due to inadequate interventions and supervision, resulting in stage 3 pressure ulcers and a femoral fracture from falls.
Deficiencies (2)
F 0686: The facility failed to implement interventions for a newly admitted resident, resulting in progression from skin redness to stage 3 pressure ulcers on the buttock and heel.
F 0689: The facility failed to provide adequate supervision and monitoring to prevent falls for a resident needing maximal assistance, resulting in two falls and a left femoral fracture.
Report Facts
Residents affected: 12
Residents affected: 1
Residents affected: 1
Wound size: 1.7
Wound size: 3.1
Wound size: 1.5
Wound size: 1.7
Fall incidents: 2
Length of stay: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V17 | Wound Care Nurse | Provided statements about wound care treatments and observations for resident R199 |
| V28 | Wound Care Physician | Provided statements regarding wound evaluation and treatment for resident R199 |
| V10 | Licensed Practical Nurse | Reported on falls and pain management for resident R49 |
| V2 | Acting Director of Nursing/Infection Control Preventionist/Restorative | Provided statements about fall incidents and care plan for resident R49 |
| V11 | Licensed Practical Nurse | Documented fall incidents and resident mobility status for resident R49 |
| V20 | Minimum Data Set Coordinator / Registered Nurse | Provided statements about resident R49's medical diagnosis and care plan |
| V4 | Medical Doctor | Provided statements about pain management and collaboration with hospice for resident R49 |
| V26 | Certified Nursing Assistant | Documented observations of resident R49 found on the floor |
| V25 | Verified handwritten notes regarding resident R49's fall and condition |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 14, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding PASARR screening, pharmaceutical services, medication labeling and storage, and food safety in the nursing home.
Findings
The facility failed to initiate required PASARR Level I screening for a resident with known mental illness, did not properly reconcile controlled medications leading to discrepancies, failed to secure medication carts and remove expired medications, and improperly stored and labeled food items in the walk-in cooler and freezer.
Deficiencies (4)
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities was not initiated for one resident with known mental illness, lacking a required Level II PASARR screening.
F 0755 The facility failed to reconcile controlled medications properly, with discrepancies in pill counts and incomplete documentation of nurse initials on controlled substance logs.
F 0761 Medication carts were left unlocked and unattended with medications left on top, and expired medications were not removed, posing potential harm to residents.
F 0812 Food items in the walk-in cooler and freezer were improperly stored and labeled, including undated produce and unsealed frozen burger patties, risking contamination for all residents consuming food by mouth.
Report Facts
Residents reviewed for PASARR screening: 12
Residents affected by PASARR deficiency: 1
Residents affected by medication reconciliation deficiency: 2
Residents affected by medication storage deficiency: 2
Residents affected by food storage deficiency: 42
Inspection Report
Routine
Deficiencies: 7
Date: May 26, 2023
Visit Reason
Routine inspection to assess compliance with care standards including nursing care, nutrition, respiratory care, medication management, food safety, and resident environment.
Findings
The facility was found deficient in multiple areas including failure to provide proper turning and repositioning for a dependent resident, failure to administer enteral feedings as prescribed, failure to ensure oxygen administration under physician orders, failure to discard expired medications, failure to follow meal ticket menus, failure to discard expired food and dairy products, and failure to provide a sanitary elevated toilet seat.
Deficiencies (7)
F 0677: Facility failed to provide turning and repositioning for a dependent resident (R28) as required by care plan and policies.
F 0692: Facility failed to provide enteral feedings as prescribed by physician for resident R40, resulting in inadequate nutrition delivery.
F 0695: Facility failed to follow policy ensuring oxygen administration under physician orders for resident R245 using oxygen without a physician order.
F 0761: Facility failed to discard expired medications from medication carts for residents R9, R29, and R30, risking adverse effects.
F 0803: Facility failed to follow meal ticket menus for resident R22, providing incorrect food items inconsistent with dietary needs and allergies.
F 0812: Facility failed to discard expired food and dairy products in the main cooler, risking illness for 42 residents.
F 0921: Facility failed to provide a sanitary elevated toilet seat for resident R95, who refused to use a rusted seat that was not replaced.
Report Facts
Residents reviewed: 20
Residents reviewed for nutrition: 22
Residents affected by expired food storage: 42
Tube feeding rate: 50
Tube feeding total volume: 1000
Oxygen flow rate: 2
Expired medication open dates: Feb 10, 2023
Facility roster residents: 44
Residents NPO: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Interviewed regarding tube feeding and oxygen administration policies and practices |
| V5 | Registered Nurse | Interviewed regarding tube feeding and medication cart observations |
| V10 | Nurse | Observed medication cart and resident care |
| V13 | Registered Dietitian | Interviewed regarding nutrition assessments and meal ticket compliance |
| V15 | Central Supply | Interviewed regarding maintenance and replacement of raised toilet seats |
| V17 | Dietary Aide | Interviewed regarding meal ticket and food preparation |
| V4 | Dining Services Director | Interviewed regarding food service and expired food handling |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure that a resident with an indwelling urinary catheter had a care plan reflecting the current status.
Complaint Details
The complaint investigation found that the facility did not have a care plan for the resident's indwelling urinary catheter despite the resident being admitted with one. The Daily Skilled assessment incorrectly documented bladder elimination status. The Care Plan Coordinator and Assistant Director of Nursing acknowledged the oversight and planned to update the care plan immediately.
Findings
The facility failed to develop and maintain an updated care plan for a resident with an indwelling urinary catheter. Documentation and assessments did not accurately reflect the resident's catheter status, and staff acknowledged errors in care plan updates and assessments.
Deficiencies (1)
F 0657: The facility failed to develop the complete care plan within 7 days of the comprehensive assessment; the care plan did not reflect the current status of a resident with an indwelling urinary catheter.
Report Facts
Residents Affected: 1
Catheter size: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 | Care Plan Coordinator | Acknowledged no care plan for the resident's indwelling urinary catheter and responsibility for updating care plans. |
| V2 | Assistant Director of Nursing | Confirmed resident admission with indwelling urinary catheter and noted errors in Daily Skilled assessment documentation. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 29, 2022
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with healthcare regulations and facility policies.
Findings
The facility was found deficient in multiple areas including failure to properly label enteral feeding equipment, inadequate infection control practices related to blood glucose monitoring and insulin pen use, and failure to provide or document influenza and pneumonia vaccinations for several residents.
Deficiencies (3)
F 0693: Facility failed to follow protocol for labeling enteral tube feeding set-ups and related equipment for resident R30, risking potential complications.
F 0880: Facility failed to prevent potential cross contamination during blood glucose monitoring and did not clean insulin pen stoppers prior to use for residents R24, R26, R34, and R39.
F 0883: Facility failed to provide and document pneumonia vaccines for three residents and influenza vaccine for one resident, not following immunization policy.
Report Facts
Residents reviewed for enteral feeding labeling: 12
Residents affected by blood glucose monitoring deficiency: 4
Residents reviewed for immunizations: 12
Residents missing pneumonia vaccine documentation: 3
Residents missing influenza vaccine documentation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Named in infection control deficiency related to blood glucose monitoring and insulin pen use |
| V2 | Nurse Supervisor Clinical Service | Provided statements on infection control practices and policy expectations |
| V1 | Administrator / Executive Director | Provided statements regarding immunization policies and facility practices |
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