Amoroso Healthcare and Rehabilitation Woodridge

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of six residents reviewed (Resident 2). Findings Include: Review of facility policy, titled Activities of Daily Living (ADL), Supporting, last revised April 2025, read, in part, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for one of six residents reviewed (Resident 1).

Inspectors wroteBased on employee file review, facility labor report, and staff interviews, it was determined that the facility failed to ensure an individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, has completed a competency evaluation program approved by the state, for one of four employee files reviewed (Employee 1).

Inspectors wroteBased on observations, facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement (Resident 1). Resident 1 exited the building through an unlocked door and was found in the facility's parking lot. This failure placed eight additional residents in an Immediate Jeopardy situation who were identified as an elopement risk (Residents 2, 3, 4, 5, 6, 7, 8 and 9). Findings Include: Review of facility policy, titled Wandering and Elopements, revised March 2019, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner that enhances his or her quality of life for one of four residents reviewed (Resident 2). Findings Include: Review of the facility's policy, titled Dignity, dated 2001, read, Residents are treated with dignity and respect at all times. Also, Resident goals, choices, preferences, values, and beliefs, are respected and honored. This begins at initial admission and continues throughout the resident's stay. Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). [...]

Inspectors wroteBased on policy review, document review, and staff interview, it was determined that the facility failed to ensure that the services provided met professional standards of quality for two of four resident records reviewed (Residents 1 and 4). Findings Include: Review of the facility's policy, titled Administering Medications, revised April 2019, read, Medications are administered in a safe and timely manner, as prescribed. The policy continued, The individual administering medications verifies the resident's identity before giving the resident his/her medications. Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive, incurable, but treatable inflammatory lung disease causing obstructed airflow) and hypotension (abnormally low blood pressure). [...]

Inspectors wroteBased on a review of clinical records and a staff interview, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice and the comprehensive plan of care for one of four residents reviewed (Resident 2). Findings Include: Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). Review of Resident 2's clinical record revealed a recent hospitalization resulting in surgery to the spine. According to documentation, Resident 2's wound/incision required staples, and the care to the site should be open to air. [...]

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide routine drugs to its residents and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of the four residents reviewed (Resident 2). Findings Include: Review of the facility's policy, titled' Policy Services Overview, revised April 2019, reads, in part, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The policy continued, Pharmacy services are available to residents 24 hours a day, seven days a week. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident condition for six of 19 residents reviewed (Residents 2, 4, 5, 7, 15, and 32).

Inspectors wroteBased on policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for two out of 19 residents reviewed (Residents 4 and 83).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for two of 19 residents reviewed (Residents 4 and 85).

Inspectors wroteBased on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and three of three pantry areas.

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 9).

Inspectors wroteBased on facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received a transfer notice with required included information upon transfer/discharge; failed to provide residents with a copy of the facility's bed hold policy for three of four residents reviewed for hospitalization (Residents 8, 12, and 85).

Inspectors wroteBased on policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 19 residents reviewed (Residents 18 and 83).

Inspectors wroteBased on facility policy review, observation, manufacturer product information, and staff interviews, it was determined that the facility failed to discard expired medications in a timely manner in one of three medication carts reviewed (Unit 2 Cart 4).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of 19 residents observed (Resident 74).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide and document sufficient preparation to residents to ensure a safe and orderly discharge from the facility; and failed to provide a discharge summary that included a post-discharge plan of care, including post-discharge services, for one of two discharged residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide sufficient and timely social services related to the admission and discharge planning process for one of two residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed (Resident 5).

Inspectors wroteBased on employee file review, policy review, and staff interviews, it was determined that the facility failed to conduct timely, complete, and accurate background investigations for four of five employee files reviewed (Employee 7, 8, 9, and 11).

Inspectors wroteBased on observation, record review, and staff interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders for two of 23 residents reviewed (Residents 22 and 72).

Inspectors wroteBased on facility document review and staff interviews, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for five of five employees reviewed (Employees 1, 2, 3, 4, and 5). Findings Include: Review of select facility documentation revealed that Employee 1 was hired on November 16, 1999; Employee 2 was hired on January 4, 2019; Employee 3 was hired on March 27, 2007; Employee 4 was hired on September 12, 2011; and Employee 5 was hired on May 1, 2006. On October 16, 2024, at approximately 8:45 AM, the surveyor was provided with performance evaluations for Employees 2, 3, and 5. Review of the performance evaluations revealed they were all dated as being completed on October 15, 2024. No performance evaluations were provided for Employees 1 and 4. [...]

Inspectors wroteBased on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain a safe and sanitary environment that supports infection prevention and control for seven of 25 residents reviewed (Residents 40, 49, 60, 66, 80, 83, and 86); and failed to maintain an accurate data collection system of infection surveillance from January 2024 through August 2024. Findings Include: Review of facility policy, titled Enhanced Barrier Precautions, with a revision date of March 2024, revealed Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Further review of the policy revealed: 2. [...]

Inspectors wroteBased on observations, facility policy review, manufacturer label review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of three residents with tube feedings reviewed (Resident 19).

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined that the facility failed to ensure drugs are stored in locked compartments and only accessible by authorized personnel for two of three resident areas observed (100 Hall and 200 Hall). Findings Include: Review of facility provided policy, Disposal of Medications and Medication-Related Supplies, effective July 1, 2023, revealed, all discontinued and unused medications may be disposed of by the facility, and medications to returned to the pharmacy should be secured until the time of pick-up. An observation on October 15, 2024, at 10:11 AM revealed a round, white object on the floor in a resident's room in the 100 Hall. An immediate interview with Employee 6 (Registered Nurse), confirmed the round, white object to be a medication (pill) and stated she would attempt to determine the type of medication. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of three residents reviewed for pressure ulcers (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness). [...]

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of three residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents pharmacy reviews are acted upon appropriately by the attending physician for four of five residents reviewed for unnecessary medication (Residents 19, 45, 49, and 63)

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the faciliy failed to ensure the resident assessment was accurate for two of 21 residents reviewed (Residents 10 and 49).

Inspectors wroteBased on observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure services provided meet professional standards of quality and practice for one of 21 residents reviewed (Resident 28). Findings Include: Review of the facility's policy, titled Self -Administration of Medications, revised December 2016, read Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Review of the facility's policy, titled Medication Administration-Preparation and General Guidelines, read Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. [...]

Inspectors wroteBased on clinical record review, observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 21 residents reviewed (Resident 9).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the faciliy failed to ensure that the resident enviornment was free of accident hazards two of three residents reviewed for falls (Residents 14 and 35).