Inspection Reports for
Symphony Bronzeville

The facility failed to ensure that missing ceiling tiles were replaced in a hallway and residents' room, affecting residents R3, R21, and R22, with potential impact on 36 residents on the first floor. The issue was linked to leaks from cracked cast iron pipes and an air conditioning unit, with ongoing repairs and tile replacements.

The complaint investigation found substantiated failures related to blood glucose monitoring and pressure ulcer care, affecting three residents (R67, R7, and R77) in a sample of 66 residents.

The facility failed to ensure proper blood glucose monitoring and documentation for one resident, and failed to provide adequate pressure ulcer prevention and treatment for two residents, resulting in actual harm including hospitalization and surgical intervention for one resident's pressure ulcer.

The facility failed to ensure that medications were securely stored for one resident, as medications were left unattended at the bedside, posing a risk of medication errors or unauthorized access.

The complaint investigation found that resident R4's call light was not answered promptly, with an observed wait time of 11 minutes. Staff were seen walking past call lights without responding. The Director of Nursing and Administrator acknowledged the issue and stated expectations for timely response, with plans for staff in-service training.

The facility failed to ensure call lights were answered in a timely manner for resident R4, who waited 11 minutes for assistance. Staff were observed walking past call lights without responding, which is against facility policy.

The complaint investigation involved allegations of physical abuse between residents R2, R4, and R6 by their roommates R5, R1, and R7 respectively. The abuse included attacks with scissors, hitting with a call light, wrestling, and kicking. The incidents were substantiated with interviews, care plan documentation, police reports, and staff statements.

The facility failed to protect three residents (R2, R4, and R6) from physical abuse by their roommates, resulting in actual harm. Multiple incidents of resident-to-resident altercations involving weapons and physical attacks were documented, with staff interventions and subsequent resident relocations.

The complaint investigation found that the facility failed to assure that a resident with pressure ulcers received necessary treatment and services to promote wound healing, causing wound decline, infection, and hospitalization. Staff interviews confirmed delays in wound care assessment and orders, and lack of wound care nurse coverage for about one week.

The facility failed to provide timely wound care and treatment for a resident with pressure ulcers, resulting in wound deterioration, infection, and hospitalization. The resident did not have wound care orders from admission on 02/06/25 until 02/14/25, and the facility lacked a wound care nurse for approximately one week. Multiple staff acknowledged the failure to obtain timely wound care orders and the potential impact on the resident's condition.

The complaint investigation revealed that the facility failed to properly inventory personal belongings of resident R3, resulting in loss of items. It also found that the facility failed to assess and manage fall risk for resident R1, who fell twice resulting in serious injuries including an epidural brain bleed and a laceration to the head.

The facility failed to ensure proper inventory of personal belongings for one resident, resulting in loss of items. Additionally, the facility failed to accurately assess fall risk, provide appropriate fall prevention care plans, and adequately supervise a resident at high risk for falls, leading to two falls with injuries.

The complaint investigation found substantiated failures including lack of timely notification to family of resident's change in condition, failure to prevent resident-to-resident abuse causing injury, inadequate supervision in the dining room, and failure to monitor residents on fall precautions and wandering behavior.

The facility failed to notify a resident's family of a change in condition, failed to prevent resident-to-resident abuse resulting in injury, failed to provide adequate supervision in the dining room, and failed to properly monitor residents on fall precautions and those with wandering behavior. These failures affected multiple residents and posed risks of harm.

The complaint was substantiated as the resident (R10) reported the call light never worked, and maintenance failed to repair it despite multiple visits. The resident had to use a roommate's call light, which was inconvenient and caused distress.

The facility failed to ensure that the call light for one resident (R10) was functioning properly. Despite maintenance visits, the call light remained non-functional, forcing the resident to use a roommate's call light, which caused inconvenience and potential safety risks.

The complaint investigation focused on incidents of physical abuse among residents R2, R3, R5, and R6 involving verbal altercations escalating to physical hitting. The investigation included interviews with residents, staff, and review of medical records and facility policies. The facility confirmed the incidents and acknowledged failures in preventing abuse. Additional concerns about IV fluid administration and medication cart security were also investigated.

The facility failed to protect residents from physical abuse in multiple resident-to-resident altercations involving residents R2, R3, R5, and R6. Additionally, the facility failed to ensure safe administration of IV fluids for five residents, with IV infusions not following physician orders for drip rates. The medication cart was also found unlocked and unattended, posing a risk of tampering or accidental hazard.

The complaint investigation revealed that resident R1 fell from bed on 12/15/24 while receiving care from a CNA alone, resulting in a left femur intertrochanteric fracture. The fall was attributed to inadequate assistance during bed mobility and failure to use side rails as per care plan. The facility did not complete the required fall risk evaluation in October 2024. Root Cause Analysis identified that R1 was unable to self-stabilize during bed mobility with one-person assist. Staff interviews confirmed the incident and deficiencies in care.

The facility failed to provide appropriate assistance during ADL care and did not follow the ADL care plan intervention for side rails. Additionally, the facility failed to complete a fall risk evaluation in a timely manner. These failures resulted in a resident (R1) sustaining a left hip fracture after a fall from bed while receiving care.

The facility failed to provide individualized, person-centered care plans for pressure ulcers and hospice care, failed to address and document abnormal vital signs for a hospice resident, failed to follow physician orders for pressure ulcer monitoring and documentation, and failed to provide a working call light for a resident.

The complaint involved an allegation of physical abuse where Resident 1 placed a pillow and blanket over Resident 2's face. Resident 2 was non-verbal with severe cognitive impairment. Staff intervened promptly, and no physical harm was observed. The family was notified and planned to file a police report. Interviews with staff confirmed the incident and the facility's response included separating the residents and monitoring. The investigation found failures in abuse prevention policies. Additionally, concerns were raised about inadequate pressure ulcer care and documentation for Resident 3.

The facility failed to protect a resident from abuse by not affirming the resident's right to be free from abuse, resulting in an incident where one resident placed a pillow and blanket over another resident's face. Additionally, the facility failed to properly assess, monitor, document, and revise care plans for multiple facility-acquired pressure ulcers for a high-risk resident, including missing wound assessments and treatment documentation.

The complaint involved resident R3 alleging that V5, a former Certified Nursing Assistant, used profane language and verbal abuse towards R3 on 10/07/2024 at around 7:35 AM. Multiple staff and witnesses confirmed the use of profanity and verbal abuse. The facility reported the incident to the state surveying agency more than two hours after the incident, violating timely reporting requirements.

The facility failed to protect resident R3 from verbal and emotional abuse by a staff member, resulting in psychosocial harm. Additionally, the facility failed to report the abuse allegation to the state surveying agency within the required two-hour timeframe.

The complaint involved an incident where resident R3 hit resident R2 with a walker during a disagreement. The facility investigated but was unable to substantiate verbal abuse. R3 was removed from the room and transferred to another facility. The police were called and the resident's family was notified. The complaint was substantiated for physical abuse but not for verbal abuse.

The facility failed to affirm the right of a resident to be free from verbal abuse and failed to prevent physical abuse when R3 hit R2 with a walker. The facility was unable to substantiate verbal abuse but confirmed the physical altercation and took corrective actions including separating the residents and transferring R3. Additionally, the facility failed to administer scheduled pain medication on time for a hospice resident (R1) with prostate and bone cancer.

The facility was found deficient in multiple areas including failure to assess resident ability to self-administer medications, inadequate accommodation of resident needs such as call light accessibility and linen provision, lack of public availability of survey results, failure to document code status, involuntary seclusion of a resident, incomplete PASARR screenings by qualified staff, lack of resident participation in care plan development, failure to follow physician orders for infectious disease consult, inadequate wound care, unsafe environment due to unsecured laundry chute and resident possession of a weapon, failure to change indwelling catheter bags timely, unlabeled respiratory equipment and missing physician orders for oxygen therapy, improper storage of controlled substances, failure to maintain personal refrigerator safety, and failure to implement infection prevention and control measures.

The complaint investigation found that the fall was substantiated. Resident R2, who was severely cognitively impaired and dependent on staff for bed mobility, rolled out of bed when only one staff member was present during care. The incident was witnessed and documented, with medical and family notification.

The facility failed to ensure two staff members were present during ADL care for resident R2, resulting in R2 rolling out of bed and sustaining a hematoma. Interviews and record reviews confirmed the fall and inadequate supervision during care.

The visit was complaint-related, triggered by allegations of inadequate call light response, insufficient incontinent care, inadequate feeding assistance, inadequate cooling, and staffing shortages. Substantiation is implied by the findings documented.

The facility failed to respond timely to call lights for dependent residents, ensure call lights were within reach, provide timely incontinent care, maintain a comfortable environment due to broken air conditioners, adequately feed a resident with a 1:1 feeding order, and maintain sufficient nursing staff to meet resident needs. These failures affected multiple residents and had the potential to impact all 210 residents.

The facility failed to provide the nutritional supplement as ordered by the physician to one resident (R7). Observations and interviews confirmed that the resident did not receive the supplement at lunch despite physician orders and meal tickets indicating it should be given.

The visit was complaint-related due to repeated falls among residents R1, R6, and R7. The complaint was substantiated by observations, interviews, and record reviews showing inadequate supervision and failure to implement fall prevention interventions.

The facility failed to ensure supervision in the dining room and did not consistently provide non-skid footwear to residents at risk for falls. Multiple residents (R1, R6, and R7) experienced repeated falls, some resulting in injury, despite documented care plans and fall prevention policies.

The facility failed to ensure proper maintenance and housekeeping services were provided, resulting in dirty air vents with thick black substances, water stains, and ceiling tile damage due to leaks. These conditions have the potential to affect all 189 residents and may contribute to mold growth and poor air quality.

The facility failed to ensure residents received bathing or showering at least once a week as per policy, failed to complete fall risk evaluations and update care plans after falls for a resident with multiple falls, and failed to serve food at a palatable and safe temperature affecting many residents.

The complaint involved failure to maintain a safe and homelike environment and failure to timely report and investigate an injury of unknown origin for resident R3. The injury was a bruise to the resident's face and head, with unclear cause. The facility did not report the injury within required timeframes and did not conduct a thorough investigation as per policy.

The facility failed to maintain a comfortable and homelike environment on the second and third floors, with issues such as mold, stained ceiling covers, broken shower stalls, and missing vent covers. Additionally, the facility failed to timely report and properly investigate an injury of unknown origin (bruising) for one resident (R3), and did not follow its own policies for reporting and investigating such incidents.

The facility failed to provide a homelike environment to 15 residents reviewed, with issues including water staining on ceiling tiles, non-functioning exhaust vents in multiple residents' restrooms, and lack of window coverings in some rooms. These deficiencies have the potential to affect all residents on the second and third floors.

The complaint investigation found that the facility failed to prevent accident hazards related to wheelchair maintenance. The incident involved resident R3 who was injured by exposed metal on a wheelchair armrest. The complaint was substantiated with findings of missing foam on the wheelchair and other wheelchairs with safety issues. Multiple staff interviews and audits confirmed the deficiencies.

The facility failed to provide an environment free from accident hazards, resulting in actual harm to residents. Specifically, a wheelchair with missing foam on the armrest exposed sharp metal, causing a resident to suffer a laceration requiring 14 sutures. Additional wheelchairs were found with safety issues such as missing arm cushions and non-functional brakes, posing risks to residents.

The complaint investigation substantiated that the facility failed to provide R2 with monthly trust fund allowances and failed to provide R1 and R3 with routine access to warm/hot water. The facility acknowledged issues with trust fund disbursement due to staff emergencies and transition to a new company, and maintenance confirmed hot water temperature issues with incomplete log documentation.

The facility failed to provide a resident (R2) with monthly trust fund allowances totaling $270 over 9 months and failed to ensure routine access to warm/hot water for two residents (R1 and R3). Water temperature checks revealed water temperatures below the required minimum, and documentation of temperature logs was incomplete.

The visit was complaint-related due to reports of a resident fall resulting in injury and multiple complaints about the call light system not functioning for over a month, affecting resident safety and staff response.

The facility failed to follow its fall prevention policy resulting in a resident sustaining a fall with a head injury requiring stitches. Additionally, the call light system was found to be malfunctioning for about three months, affecting all 173 residents' ability to call for staff assistance, posing a safety risk.

The facility was found deficient in multiple areas including failure to ensure accurate code status orders in the EMR, timely reporting of serious injury, pressure ulcer prevention, respiratory care, sufficient nursing staff, medication administration accuracy, narcotics accountability, medication storage, and food safety practices.

The complaint involved a resident (R2) whose wallet containing a debit card was stolen, resulting in unauthorized transactions totaling $60 transferred to a former CNA (V20). The facility reported the abuse to police and state agency. The resident also reported missing smoking materials worth $20, and a reimbursement request for $80 was submitted to corporate office. The former CNA did not return to work and could not be contacted.

The facility failed to prevent misappropriation of property involving a resident's bank account by a former CNA, failed to provide a resident with double meal portions and milk as ordered, and failed to maintain complete and accurate medication administration records for a resident.

The complaint investigation found that the resident (R6) fell during a mechanical lift transfer due to only one staff member being present instead of the required two. The fall caused serious injuries including a right intertrochanteric hip fracture and a right fibular fracture. The investigation included interviews with staff and review of incident reports and facility policies.

The facility failed to use two staff members during a mechanical lift transfer for one resident, resulting in the resident falling from the lift and sustaining a right hip fracture and a right fibular fracture. Interviews and record reviews confirmed the improper transfer and the facility's policy requiring two or more caregivers for such transfers.

The complaint investigation was triggered by an incident on 02/26/2023 where resident R3 physically attacked resident R2, causing a nasal fracture. The facility reported the incident to the state agency and police. Both residents were sent to local hospitals for evaluation and returned to the facility on different floors. The facility implemented one-to-one monitoring for both residents.

The facility failed to protect residents from resident-to-resident physical abuse resulting in a nasal fracture for one resident. Additionally, the facility failed to provide appropriate wound care and incontinence care to residents, including failure to apply physician-ordered dressings and timely incontinence care.

The complaint investigation found that resident R4 was left unsupervised while operating a motorized wheelchair, which was against therapy orders, leading to a fracture injury. Resident R9, identified as high fall risk, did not have fall mats in place as required, contributing to multiple falls.

The facility failed to provide adequate supervision and fall prevention measures, resulting in resident R4 sustaining an acute fracture to the right great toe while operating a motorized wheelchair unsupervised, and resident R9 not having fall mats in place despite being identified as high fall risk and having multiple falls.

The facility was found deficient in multiple areas including failure to develop baseline care plans within 48 hours of admission, improper labeling of peripheral intravenous catheters, unsecured medication carts and expired medications, improper food storage and thawing practices, and failure to enforce transmission-based precautions for visitors.