Archer Heights Healthcare

Inspectors wroteBased on interviews and record reviews, the facility failed to follow policy and procedure to ensure one [R1] of four [R3, R4, R7] residents were dressed and ready for medical appointments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable environment by not maintaining resident room temperatures within the CMS (Centers for Medicare and Medicaid Services) required comfort range of 71 F (degrees Fahrenheit) to 81 F. This failure affected three (R4, R5, R6) of six residents reviewed for physical environment. Findings Include:On 7/5/26 between 9:55 AM and 10:37 AM, random temperature checks were conducted with V4 (Maintenance Director) in resident common areas and in randomly selected rooms across the first through fourth floors. All temperature readings were below 80 F except for R4's room, which measured 83.7 F. R4 was present in her room and was alert and oriented to person, place, and time. R4 was up and about with no observable signs or symptoms of feeling overheated or dehydrated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure proper food safety practices by permitting a dietary aide to continue working with an expired food handler certification. This failure has the potential to affect all 208 residents residing in the facility. On 4/27/2026 at 1:13 PM, V3 (Dietary Manager-Temporary) provided copies of V16 (Dietary Aide) state food and safety certificate issued on 10/31/2022 documents an expiration date of 3 years from the issue date (10/31/2025). On 4/28/2026 at 9:37 AM, Reviewed V16 (Dietary Aide) time cards dated for the 2 week time period of 3/29/2026 to 4/11/2026 which documents V16 worked 7:45 hours for eleven (11) shifts during that time period and V16 time cards dated for the 2 week period of 4/12/2026 to 4/26/2026 documents V16 worked eleven (11) shifts for seven hours and fifteen minutes to ten hours and thirty minutes. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that dietary staff followed the planned menu, therapeutic diets, or resident preferences. This failure has the potential to affect all 208 residents residing in the facility on an oral diet with one resident (R70) receiving a gastric tube and pleasure feed. On 4/27/2026 at 10:21 AM, R152 stated the food is terrible and he (R152) does not receive meat with every meal. On 4/28/2026 at 10:36 AM, V34 (Dietary Cook) stated the residents were fed eggs, toast, and oatmeal; some people get boiled eggs or no eggs depending on their ticket likes and dislikes; sausage didn't come in, so she (V34) did not make the egg casserole on the menu for today but made the other items on the menu; and the dietary supervisor tell us to cook what we have. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices by not monitoring and documenting refrigerator and freezer temperatures of stored foods daily. This failure affects all residents residing in the facility. On 4/27/2026 at 9:46 AM, surveyor observed the walk-in refrigerator cooler's thermometer reading was 41 degrees Fahrenheit with missing daily refrigerator tracking temperature entries on 4/19/2026, 4/24/2026, and 4/26/2026. On 4/27/2026 at 9:50 AM, walk-in freezer -3 degrees Fahrenheit. Observed missing daily refrigerator tracking temperature entries on 4/19/2026, 4/24/2026, and 4/26/2026. On 4/27/2026 at 9:53 AM, sandwich cooler temperature 36 degrees Fahrenheit with missing daily refrigerator tracking temperature entries and signatures for the following dates on 4/19/2026, 4/24/2026, and 4/26/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was visibly posted for a resident (R231) requiring Enhanced Barrier Precaution; and failed to maintain infection control practices to prevent the potential spread of infection (staff placed soiled linen on the floor for one resident (R53) and staff failed to separate clean and soiled linen in the laundry processing area). These failures affected two residents (R53 and R231) and has the potential to affect all 208 residents reviewed for infection control.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that disposable razors were not at bedside and failed to ensure proper disposal of razors in accordance with facility protocol which affected 4 residents (R72, R102, R162, R211) of 4 residents reviewed for hazards in a total sample of 70 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that psychotropic medication consents were obtained prior to the initiation/administration of medications and failed to ensure that the correct medical diagnosis was documented for the use of the psychotropic medications which affected 5 residents (R2, R5, R63, R163, R195) of five residents reviewed for unnecessary medications in a total sample of 70.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a treatment administration cart was kept locked; and failed to label and discard expired insulin for two residents (R4, R173). These failures affected two residents (R4, and R173) and has the potential to affect all 60 residents on the second-floor unit at the facility.

Inspectors wroteNumber of residents sampled: 70Number of residents cited: 3Based on observations, interviews and record reviews, the facility failed to provide feeding assistance for dependent residents receiving pleasure from eating and failed to clean and cut residents' nails. This failure affected three residents (R6, R54 and R70) out of 70 residents reviewed for ADL care.

Inspectors wroteBased on record review and interview, the facility failed to follow their abuse policy for two residents (R5,R6) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation where residents became abusive to each other. Staff did not intervene in time resulting in R5 and R6 engaging in a physical altercation that lead to R5 sustaining a facial laceration, laceration of the scalp, and a fracture of his nasal bone. Findings IncludeOn 3/31/26 at 11:30 am V10 CNA (Certified Nurse Aide) stated she was working on the floor doing rounds and heard someone say a fight. V10 stated she went into the room and saw R6 standing over R5 punching him. V10 stated she was able to separate R6 from R5 and escorted R6 down the hallway while calling for assistance. V10 stated the nurse came to R5 and R6's room and looked at R5. [...]

Inspectors wroteBased on interviews and reviews, the facility failed to maintain a safe, comfortable home-like environment for one [R1] of four [R5, R7, R8] residents reviewed for smoking.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection control policies and procedures for one of three residents (R3) in the sample of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a homelike environment due to uncleanliness of resident's rooms noted with paper, trash, and debris throughout residents' rooms. This failure affected 4 of 5 residents (R1, R2, R4, R6, and R7) reviewed for homelike environment. R1's Minimum Data Set Section C dated 11/3/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. R2's Minimum Data Set Section C dated 9/4/2025 documents a BIMS (Brief Interview Mental Status) Score of 6 which is indicative of a severely impaired cognition. R4's Minimum Data Set Section C dated 10/27/2025 documents a BIMS (Brief Interview Mental Status) Score of 15 which is indicative of an intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper administration of medication due to a resident standing at the medication cart taking medication without a nurse's observation to ensure the resident swallowed the medication. This failure affected 1 of 1 resident (R5).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, safe, and comfortable environment for all 196 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow their policy to ensure a call light was within reach for one (R4) out of three residents reviewed for call lights in a total sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the resident's physician for one (R8) out of three residents in a total sample of nine residents reviewed.

Inspectors wroteBased on interview and record review, facility failed to protect residents from physical abuse. This failure affected three residents (R2, R3, R5) of ten residents reviewed for abuse. This failure resulted in R1 slapping R2 on the smoking patio, R4 punching R3 in the face causing R3 to bleed from her mouth, R6 punching R5 in the face, and R6 pulling R5's hair resulting in R5 being pulled down to the ground by her hair.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide sanitary drinking water and ice by not maintaining their water and ice machines. This has the potential to affect all 199 residents that receive hydration orally.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a home-like environment by not having enough chairs in the first and second floor day/dining room, thoroughly cleaning and maintaining residents' rooms and common areas. This has the potential to affect 148 residents that reside in the first, second, and fourth floors.

Inspectors wroteFindings include: On 5/13/25, at 2:32 PM, observed R9 room; mats on both sides of the bed, a reacher/grabber tool on bed, no side rail(s) On 5/13/25, at 2:36 PM, observed R9 in day room sitting in a wheelchair watching television. R9 said he had two falls. The first fall R9 was sleeping in bed. R9 said he was dreaming he was swimming and rolled out of bed. R9 said he got a [NAME] on his head and a black eye. R9 said there were no side rails on the bed. R9 said They don't have those here. On 5/14/25, at 1:10 PM, V2 (Director of Nursing) stated I am familiar with R9. He has had two falls. The first fall was 4/27/25. The patient said he rolled out of bed. He hit his head and was sent out to the hospital. R9 is care planned for fall risk. According to the fall risk assessment, dated 3/20/25, he is moderate fall risk. The floor nurses do the assessments. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents do not have access to alcohol and other illicit drugs while at the facility. This failure affected one resident (R1) and has the potential to affect four other residents (R2, R5, R6, and R11) reviewed for adequate supervision and access so alcohol/illicit drugs at the facility. As a result, R1 got drunk and consented to sexual activity that she claimed happened while under the influence of alcohol and illicit drugs. R1 reported that the sexual activity caused emotional harm to her(R1) and R1 was sent to the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medication was locked up safely when not in visual proximity of the nurses and not in use to prevent tampering and accidental hazard. This failure affected R13, R15, R16, and R17 whose medications were left at the bedside having the potential to affect residents on the 3rd floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that personal hygiene including nail care is provided for one (R1) out of three residents in the sample who are dependent on staff for Activities of Daily Living (ADLs) personal hygiene. This failure affected R1 who did not receive appropriate personal hygiene care in a timely manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow to reconcile the hospital recommendation with the facility physician for BIPAP/CPAP treatment for one resident (R1) who has chronic hypercapnia and was supposed to wear BIPAP machine at night. This affected R1 who was not set up for BIPAP treatment as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician order in administering correct oxygen liter to one of three residents (R1) reviewed for oxygen administration. This failure affected R1 who was supposed to get three liters of oxygen per nasal cannula and was administered five liters per nasal cannula. Two liters over the ordered dosage.

Inspectors wroteBased on observation, interview, and record review the facility failed to manage a resident's pain and administer pain medication that was documented given. This failure affected one resident (R114) reviewed for medications in a sample of 128.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents' food items in the facility kitchen are properly labeled, dated when received and when opened; failed to follow proper food storage practices and labeling food to prevent food-borne illnesses; failed to ensure that staff store their food and drinks out of the facility kitchen used for residents; and failed to maintain the proper sanitation levels of the kitchen sanitation bucket. These failures have the potential to affect all 207 residents receiving an oral diet in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that housekeeping and maintenance services necessary to maintain a sanitary and comfortable environment were provided for four residents (R18, R27, R129, and R180). This failure affected the four residents reviewed for homelike environment in a total sample size of 128 residents.

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure medication refrigerators and medication carts with narcotic medications are secured and locked; failed to remove expired medications from a medication cart and the medication refrigerator to prevent them from being administered; failed to label multi dose vials and inhalers with opened date and expiration date and failed to accurately document count of narcotic medications. These failures affected six residents (R20, R,22, R23, R61, R134, R173) and have the potential to affect 16 residents on the fourth floor of the facility in a sample of 128.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor personal refrigerator temperatures and ensure that personal refrigerators had thermometers for four residents. These failures affected four residents (R47, R100, R110, R190) out of 128 residents in the total sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff don PPE (personal protective equipment) while performing wound care for a resident (R199); failed to visibly post Enhanced Barrier Precautions (EBP) signage outside a resident's room door for two residents (R96, R199); failed to place a PPE bin directly outside a resident's (R204) Contact Precautions door; failed to ensure that staff perform hand hygiene when passing meal trays; and failed to ensure that staff perform hand hygiene after touching staff's personal body then passing meal trays. These failures affected R25, R40, R96, R113, R118, R153, R177, R178, R199, R201, and R204 and had the potential to affect the 38 residents on the first floor of the facility.

Inspectors wroteBased on observation, interview,and record review the facility failed to ensure the call light device for two residents (R35, R41) were within reach of the residents. This failure affected two residents (R35, R41) and has the potential to affect all residents in the sample size of 128.

Inspectors wroteBased on interview and record review the facility failed to refer three residents R61, R104 and R141 to the appropriate state designated authority for a Level II PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination after new mental disorder diagnoses. This deficient practice affected three residents (R61, R104, and R141) in a total sample size of 128 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the completion of a new Pre-admission Screening and Resident Review (PASARR) when a new mental health diagnosis is identified. This failure affects 3 residents (R61, R104, and 141) out of a sample of 128. Findings Include: R61's face sheet has an initial admission date of 1/11/2023 and the following diagnosis: Major Depressive Disorder onset date 1/11/23. Unspecified Lack of Expected Normal Physiological Development in Childhood onset date 1/10/23. Unspecified Intellectual Disabilities onset date 12/22/2022. R61's Minimum Data Set (MDS) Section C dated January 9, 2025, has a Brief Interview of Mental Health score of 1 which indicates the resident is severely cognitively impaired. R61's MDS Section D (MOOD) dated January 9, 2025, documents a severity score of 10. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow wound care treatment orders. This failure affected one resident (R138) reviewed for wounds in a sample of 128.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to thoroughly investigate a fall incident and implement fall interventions listed on revised care plan; and failed to ensure adequate supervision to prevent a resident from smoking in a residential room. These failures affected two residents (R65 and R172) reviewed for accidents and hazards in a sample of 128 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the CPAP (Continuous Positive Airway Pressure) mask was contained, failed to change oxygen tubing, failed to label humidifier bottle with dates and failed to get an doctor's order for oxygen administration. This failure affected 2 residents (R73 and R98) reviewed for oxygen therapy in a sample of 128.

Inspectors wroteBased on observation, interview, and record review facility failed to obtain an informed consent before prescribing a psychotropic medication. This failure affected 1residents (R61) out of a sample of 128. Findings Include: R61's face Sheet has an initial admission date of 1/11/2023 and has a diagnosis of Major Depressive Disorder dated 1/11/23. R61's Minimum Data Set Section C dated January 9, 2025, has a Brief Interview of Mental Health score of 1 which indicates the resident is severely cognitively impaired. R61's Physician Order Sheet documents R61 is prescribed Remeron (Mirtazapine) for Situational Depression with a start date of 3/24/23. R61's Consent for Psychotropic Medications documents a verbal consent for the administration of a psychotropic medication dated 3/24/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to correctly administer antibiotics intravenous piggy bag via PICC line for one resident (R2). This failure resulted in V8 (Untrained LPN) observed administering improper treatment via PICC line to R2, putting R2 at risk of air embolism. This was identified as an immediate jeopardy which begin on 04/14/25 at 11:55am when V8 was noted in the medication room reconstituting IVPB, Ertapenem Sodium Solution Reconstituted 1GM (Gram) and proceeded to administer it via a peripherally inserted central catheter (PICC line). V1 (Administrator) was informed of the immediate jeopardy and a template was presented on 04/24/25 at 10:11am. On 04/28/25 an acceptable removal plan was received after revision from the original plan submitted on 04/24/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse and verbal abuse. This failure affects 2 residents (R8, R15) reviewed for abuse. This failure caused harm to R8, evidenced by R8 sustaining a laceration to the back of R8's head that required closure with staples and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that one resident (R1) with a surgical wound was provided the necessary treatment and services to promote wound healing and pain control. This failure resulted in R1's wound worsening and having avoidable pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the resident's right to a sanitary, clean environment throughout the facility. This has the potential to affect all 208 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility staff failed to notify the state survey agency within time reporting requirements of abuse; failed to report witnessed abuse to the abuse prevention coordinator. This failure affects 4 residents (R8, R12, R3 and R15) sampled for abuse reporting.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation after a fall with injury to substantiate if abuse occurred; failed to complete an abuse allegation after an allegation of verbal abuse was reported. This failure affects 4 residents (R8, R12, R3 and R15) sampled for abuse reporting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the community survival skills assessment was completed in a timely manner to determine if a resident could safely be out in the community independently. This affected one resident (R13)out of the three residents reviewed for timely completion of community survival skills assessments. As a result, on 3/11/2025 R13 left the facility without supervision for an appointment, did not return to the facility until 3/15/25 approximately at 8:30 pm. Facility and R13 ' s family were unaware of R13 ' s whereabouts and R13 ' s family were concerned for his safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow current standard of infection control practices, hand hygiene, during and following provision of care. This failure affected R2 who was administered IVPB medication via PICC without the nurse performing any hand hygiene and without use of gloves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the community shower room on the third floor was maintained in good repair and sanitary manner. This failure has the potential to affect all 52 residents on the third floor.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two residents (R2 and R7) were free from abuse from a resident (R3) with a known violent behavior by failing to perform R3's background checks and ensure fingerprint order was obtained for a new resident (R3) within the required time frames; failed to identify R3's known behaviors placing other residents at risk for abuse; failed to ensure a care plan was developed for R3's known violent behavior. These failures resulted in R3 physically assaulting 2 residents (R2 & R7) and causing multiple facial fractures to one resident (R7). This was identified as an immediate jeopardy began on 9/26/24. On 10/21/24 at 1:06 PM, the administrator was notified of the immediate jeopardy. The facility presented an abatement plan to remove the immediacy on 10/22/24 at 2:12pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete assessments that identify R3's aggressive behaviors and blindness. These failures resulted in R3 physically assaulting 2 residents (R2 & R7) and causing multiple facial fractures to one resident (R7). These failures caused harm and affected 3 residents (R2, R3, and R7) reviewed for assessment accuracy.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care to address R3's known aggressive behaviors and history of aggressive behaviors. These failures resulted in R3 physically assaulting 2 residents (R2 & R7) and causing multiple facial fractures to one resident (R7). These failures caused harm and affected 3 residents (R2, R3, and R7) reviewed for care planning.

Inspectors wroteBased on interview and record review, the facility failed to provide and ensure adequate supervision to a resident (R3) with a known violent behavior. These failures resulted to R3 physically assaulting 2 (R2 & R7) residents and causing multiple facial fractures to one resident (R7).

Inspectors wroteBased on interview and record review, the facility failed to conduct QAPI (Quality Assurance and Performance Improvement) meetings quarterly and ensure abuse data collection was implemented/coordinated within the QAPI meeting. These failures have the potential to affect all 200 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to submit a final investigation report regarding physical abuse to the state survey agency within 5 business days. This failure affects 2 residents (R2, R3) reviewed for reporting.

Inspectors wroteBased on interviews and record reviews, the facility failed to intervene and protect 4 residents (R2, R3, R4, R5) from verbal and physical abuse out of 4 residents reviewed for abuse. These failures resulted in; 1.) R2 attempting to run out the facility after an incident with another resident (R3). R2 then struck a window, resulting in a laceration to the right arm, R2 was sent to the local hospital and received sutures; 2.) R4 and R5 became verbally aggressive and then physically aggressive to one another. Findings Include: 1.) R2's clinical records show an admission date of 12/7/23 with diagnoses that included but not limited to schizoaffective disorder and bipolar disorder. R2's minimum data set (MDS) dated [DATE] shows R2 had moderately impaired cognition and required supervision with walking. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that necessary treatment and services consistent with professional standards of practice were adhered to for 1 resident (R7). The facility: 1.) Failed to assess, monitor, and document on R7 post fall. 2.) Failed to inform physician of R7's fall incident in a timely manner. 3.) Failed to send R7 who sustained head, injury while on anticoagulant, to the hospital in a timely manner. R7 fell on 7/28/24 and was subsequently sent to the hospital on 8/5/24 sustaining a subdural hematoma.

Inspectors wroteBased on interview and record review, the facility failed to monitor a diabetic resident's foot; failed to assess and report a new skin alteration on a diabetic resident's foot; and failed to provide activities of daily living (ADL) care as assessed for a diabetic resident which affected R2 in the sample of three residents reviewed for improper nursing care. These failures resulted in R2's nurse practitioner (V4) assessing for R2's right lower leg redness and swelling; removing R2's moist right sock to see multiple maggots crawling from R2's right foot wound (base of big toe); and R2 being transferred to the hospital for further evaluation of gangrene infection which required surgical amputation of R2's right big toe.

Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of abuse to the Illinois Department of Public Health (IDPH) within two hours of the allegation for one resident (R1) out of a total sample of five residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure coordination of outside services/appointments and have a complete medical record for R3 for one of five residents reviewed for appointments.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure accurate medical records for one resident (R1) out of a total sample of six residents.

Inspectors wroteBased on interview and record review, the facility failed to keep a resident (R5) free from abuse in a sample of 6 residents reviewed for abuse. This failure resulted in R4 running over R5's foot with a wheelchair, resulting in R5's foot swelling and pain with a score of 7-9 on a scale of 10.

Inspectors wroteBased on observation, interview, and record review. The facility failed to provide a clean and sanitary home-like environment for all 221 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to report allegation of abuse within 2 hours of the incident. This failure affected two (R4, R5) out of six residents reviewed for reporting.

Inspectors wroteBased on interviews and record reviews, the facility failed to properly monitor, supervise, and intervene for four residents (R1, R12, R14, R15) with known substance use disorder and history of using illicit substances/narcotics and overdose in the facility. These failures resulted in: 1. R1 testing positive for heroin use and suspected to be under the influence of an unknown substance. 2. R12 testing positive for cocaine and suspected to be under the influence of an unknown substance. 3. R15 being found unresponsive in the facility due to suspected drug use, admitting to drug use, testing positive for heroin, and having to be transferred to the hospital due to an overdose of drug use. 4. R14 was found unresponsive in the facility, transferred to the hospital, and expired with suspicion of drug overdose. This was identified as an Immediate Jeopardy began on [DATE]. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary and comfortable environment for two (R2, R4) out of three residents reviewed for sanitary physical environment.

Inspectors wroteBased on interview and record review, facility failed to affirm the right of the resident to be free from verbal abuse. This deficient practice has the potential to affect two (R2, R12) out of three residents reviewed for abuse. Findings Include: 1. On 07/30/2024 at 11:20AM, R2 stated on the day of the altercation he was sitting in the dining room talking to another resident. R2 stated a CNA staff member (identified as V20) did not like the nature of his conversation and told him to stop talking way and using the words he was using. R2 stated he used the N word and V20 did not like. R2 stated V20 then called him crippled. R2 stated V20 was holding a push broom and took the stick off the push brush and held it in his hand. R2 stated by this time they were located at the nurses station where a nurse (identified as V12) witnessed V20 called R2 crippled. [...]

Inspectors wroteBased on interview and record review, the facility failed to report and investigate verbal abuse for two (R2, R12) of three residents reviewed for verbal abuse.

Inspectors wroteBased on interview and record review the facility failed to provide resident with the bed hold notice for 1of 3 residents (R8) reviewed for transfer and discharges in a sample of three residents. On 8/1/2024 at 11:198 V27 (Hospital Social Worker) stated, I have made numerous attempts to send that resident (R8) back to the facility. I spoke to V25 (Care Coordinator) facility liaison 7/16/2024 and informed her (R8) will be returning to facility and will be ready for discharge 7/18/2024 or 7/19/2024. The MD put in the order for discharge 7/19/2024 and I sent over (R8) progress notes. An hour later they called informing me that no beds were available. On the tenth day they gave (R8) bed away. I also spoke to V26 (Director of Development), and he told me that they should have an available bed 7/23/2024 or 7/24/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to permit a resident to return to facility within the 10-day bed hold period for1 of 3 residents (R8) reviewed for transfer and discharges in a sample of three residents. On 8/1/2024 at 11:19AM V27 (Hospital Social Worker) stated, I have made numerous attempts to send resident (R8) back to the facility. I spoke to V25 (Care Coordinator) facility liaison 7/16/2024 and informed her (R8) will be returning to facility and will be ready for discharge 7/18/2024 or 7/19/2024. The MD put in the order for discharge 7/19/2024 and I sent over (R8) progress notes. An hour later they called informing me that no beds were available. On the tenth day they gave (R8)'s bed away. I also spoke to V26 (Director of Development), and he told me that they should have an available bed 7/23/2024 or 7/24/2024. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure medication ordered by physician to be administered was documented per their policy; failed to ensure all medications are being administered by license professional per their policy; and facility failed to ensure all medication administered to residents was ordered by physician per their policy. These failures apply to 2 out of 3 residents (R5, R6) in a total sample of 3 residents reviewed for pharmaceutical services. These failures have the potential to affect 2 residents (R5, R6) in not administering medication by trained professional, not receiving correct medication, and receiving medication not ordered by physician.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to ensure all medications are stored in an appropriate containers not exposed to unclean environment; failed to ensure medication in resident's possession has an order by the physician to be administered; failed to ensure all accessible medications are properly processed per facility policy. These failures apply to 1 out of 3 residents (R6) in a total sample of 3 residents reviewed for pharmaceutical services. These failures have the potential to affect 1 resident (R6) in receiving medication that are not stored in a clean environment, in not receiving correct medication, and receiving medication not ordered by physician.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the appropriate treatment to attain the highest practical mental and psychosocial well-being and ensure a resident received physician ordered medication timely for treatment of opioid dependence for 1 (R85) out of 1 resident reviewed in a sample of 35. This failure resulted in R85 feeling anxious and having trouble sleeping. Findings Include: R85's progress notes dated 5/24/24 at 7:09 PM documents R85 was re-admitted from acute hospital. R85's clinical records show a diagnosis not limited to Opioid Dependence. R85's Minimum Data Set (MDS) dated [DATE] shows R85 is cognitively intact. R85's physician orders dated 5/24/24 show an order of: Suboxone Sublingual Film 2-0.5 MG (Buprenorphine HCl-Naloxone HCl Dihydrate). Give 1 film sublingually one time a day related to Opioid Dependence. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate laundry services to ensure adequate clean linen and timely wash for resident clothing for all 220 residents residing in the facility. This failure resulted in substandard quality care resulting in an extended survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there were sufficient nursing staff in the facility to provide adequate care and assistance for residents, resulting in long call light response times, medications not being administered timely, activities of daily living (ADL) care not provided timely, and Resident Council concerns not addressed. This has the potential to affect all 220 residents residing in the facility. Findings Include: On 5/28/24 at 10:56 AM, R132 stated that the facility is short in nursing staff and sometimes R132 gets R132's medications late. R132's Minimum Data Set (MDS) dated [DATE] shows R132 is cognitively intact. At 11:01 AM, R85 stated that the facility is short in staff. R85 stated, I don't get my medications especially on weekends are really bad. If I could walk, I would walk out of here. Night shift is really bad. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: (a) Food is labeled, dated, and discarded after use by date. (b) Food and beverage were covered during transport or distributed to residents. (c) Meat was thawed or stored at appropriate temperature. (d) Kitchen staff wear beard restraint to prevent hair from contacting food. (e) Garbage bins were covered inside the kitchen preparation area. (f) Boxes with food were stored off the floor. These failures have the potential to affect 219 residents living in the facility with 1 resident on Nothing by Mouth (NPO) for a total facility's census of 220 dated 5/28/24.

Inspectors wroteBased on observation, interview, and record review the facility failed to (a) dispose of garbage properly in a contained dumpster; (b) keep the dumpster area clean and free of garbage or waste to maintain a sanitary condition and to prevent harborage and feeding of pest. These failures could potentially affect all 220 residents that reside in the facility as of census 5/28/24.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to keep flying insects out of the facility. This deficient practice has the potential to affect all 220 residents residing at the facility as of census 5/28/24.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to (a) ensure call lights were within reach for R50 and R81, (b) answer call lights in a timely manner and respond to R67's request, and (c) provide furniture and adequate lighting to accommodate needs/preferences for R414. There failures affected four out of a total sample of 35 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete the Non-Comprehensive Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 5 (R6, R38, R49, R110, R192) of 7 residents reviewed for resident assessment in a sample of 35.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to (a) obtain physician order for oxygen administration for R111, (b) follow oxygen liter flow as ordered for R88, (c) label/change oxygen tubing and bubbler per policy for R14, R88, and R111, (d) provide oxygen tubing extension for R14, and (e) store R81's positive airway pressure (CPAP) mask in a bag when not in use. These failures affected 4 out of a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate controlled substance documentation for four residents out of total of seventy-six residents in the sample. Findings On 5/28/2024 at 10:16 AM the Four North medication cart controlled substances were observed with V17 (LPN). Lorazepam 0.5 mg for R263 was documented as a quantity of one remaining. Lorazepam count for R263 by V17 was that two tablets were in stock. On 5/28/2024 at 10:16 AM the Four North medication cart controlled substances were observed with V17 (LPN). Hydrocodone for R52 has a count of twenty-six tablets, but twenty-five tablets were observed in stock. V17 stated that one tablet of Hydrocodone was administered to R52 at 9 AM on 5/28/2024 and not yet signed off. On 5/28/2024 at 10:16 AM the Four North medication cart controlled substances were observed with V17 (LPN). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store medications and medication administration supplies. This failure has the possibility of impacting 123 residents who are cared for using the medication cart on the first floor, second floor side B, third floor north and forth floor north. Findings On 5/28/2024 at 9:23 AM, V15 (LPN) was observed dispensing Readycare with a date of 5/24/2024 handwritten on the container. Just prior to administration, V15 was stopped and asked about the expiration date. V16 discarded the Readycare and left the medication cart to speak to another nurse. Upon return to the medication cart, V15 stated that he spoke with the Director of Nursing who said that Readycare was good for 24 hours after opening. Readycare container was observed to state, Store at room temperature. Do not freeze. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer consented pneumococcal vaccinations in a timely manner for four (R10, R48, R76, R90) of five residents reviewed for influenza and pneumococcal immunizations in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and procedure to ensure staff participated in a yearly abuse, neglect, and exploitation prevention training program and failed to have a process in place to track attendance. The facility's census on the first day of survey was 220. Findings Include: On 5/30/24 at approximately 10:30 AM, interviewed V1 (Administrator) about abuse in-services. V1 stated that abuse training and education should be provided to staff upon hiring and annually thereafter. The purpose of the abuse training is to educate staff on the facility's abuse prevention program policy and procedures. When asked to provide documented evidence that all staff received/participated in the abuse trainings/in-services within the last 12 months, V1 could not provide any documentation. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to maintain a resident's (R23) dignity and conceal R23's urine collection bag with a privacy bag for 1 out of a total sample of 35 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the code status documented in the care plan matched the physician order and POLST (Physician Order for Life Sustaining Treatment) form for 1 (R52) of 3 residents reviewed for Advance Directives in a sample of 35. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the comprehensive Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 1 (R166) of 7 residents reviewed for resident assessment in a sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards as indicated in their policy and procedure by giving medications outside of the timeframe and failing to check the blood pressure prior to administering blood pressure medication for 1 (R182) resident in a sample of 35.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure ADL (Activities of Daily Living) care were done in a timely manner for two dependent residents (R112 and R313), failed to follow policy and procedures for incontinence care for R112, and failed to provide adequate equipment to assist R313 out of bed. This failure affected two out of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow an order to apply a hand splint to prevent decreases in range of motion and update a resident's (R67) care plan for splint use for 1 out of a total sample of 35 residents.

Inspectors wroteBased on observation and interview the facility failed to (A) prevent urinary catheter bag from touching the floor, (B) obtain physician order for indwelling catheter, (C) develop a care plan for indwelling catheter for one (R171) out of 3 residents reviewed for urinary catheter in a sample of 35. Findings Include: On 05/28/24 at 12:42 PM, observed R171 lying in bed and R171's urinary catheter bag containing urine lying on the floor next to R171's bed. On 05/28/24 at 12:46 PM, V14 (Licensed Practical Nurse) observed R171's urinary catheter bag on the floor and stated it should not be on the floor due to infection control concerns. On 05/29/24 at 03:13 PM, review of R171's orders in R171's Electronic Health Record (EHR) indicate R171 does not have an order for indwelling urinary catheter and does not have a care plan for indwelling catheter. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dedicated covered garbage receptacles for used personal protective equipment inside a contact isolation room. These failures have the potential to affect one (R111) of eight residents reviewed for infection control in a total sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to assess eligibility, provide education on the COVID-19 vaccine, and offer COVID-19 vaccination to 1 (R413) of 5 residents reviewed for COVID-19 immunizations out of a sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standard of medication administration documentation after administration of medication in preventing medication error of double dosing residents for 21 of 21 (R5, R15, R16, R17, R18, R19, R20, R21, R22, R23, R23, R24, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, and R34) residents reviewed for medication pass in a timely manner. This failure affected (R5, R15, R16, R17, R18, R19, R20, R21, R22, R23, R23, R24, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, and R34) whose medications were not documented in a timely manner and has the potential to affect all residents on 1st and 2nd floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient dietary staff are provided to meet resident needs and services in meal preparation. This failure affected all residents eating from the facility kitchen. This affected R3, R6, R9, R10, R11, and R12 who were supposed to get double portions, but due to insufficient dietary staff to prepare the food and insufficient ingredients to prepare the menu, the resident needs were not met. This has the potential to affect all residents eating from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the sanitizing bucket has sanitizer solution; the food items are not stored on the bare floor; and the garbage cans have cover lids. This failure has the potential to cause food borne illnesses and has the potential to affect all 223 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow current standard of infection control practices and prevention, hand hygiene and failed to ensure that beverages were served in a sanitary way to prevent contamination and prevent spread of food borne illnesses. This failure has the potential to affect all 33 residents on the 1st floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's environment remains free of accidental hazard by leaving medication at resident's bed side table and not in visual proximity of nurse; and failed to ensure sharp items (scissors) in resident's room, visible from hallway without supervision for two residents (R3, R16) in the sample. This failure has the potential to affect R3 whose medication was left on the bed side table and R16 who had two pair of scissors and nail clippers stored on the side table and has the potential to affect all 66 residents residing on the 2nd floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure therapeutic diet orders for 2 of 2 (R3 and R11) were followed. This failure affected R3 and R11 who were supposed to receive mechanically altered diet but were served regular green beans, putting these residents at risk for choking and has the potential to affect all 223 residents residing in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure one resident (R3) was provided with a working television for 14 days after admission to the facility and the facility failed to ensure one resident (R3's) bed had linen on it for two of three days during investigation. This failure affected one of ten residents reviewed for Homelike Environment.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that proper incontinent care was rendered to one resident (R3) in a sample of ten residents reviewed for Improper Nursing Care.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's treatments for pressure ulcers were provided. This failure affected 1 resident (R1) reviewed for pressure ulcer/injury treatment. Findings Include: R1's admission record documents, in part, R1's diagnoses include dysphagia, quadriplegia, cervical spine fracture, substance abuse, depression, respiratory failure, tracheostomy, and pressure ulcers. R1's admission date to the facility is documented as 11/16/23. R1's (11/22/23) Minimum Data Set, documents, in part, Brief interview for Mental Status (BIMS) score is 15, which indicates R1 is cognitively intact. Section M- Skin Condition documents R1 has one stage 1 pressure ulcer. R1 has one stage 3 pressure ulcer that was present upon admission. R1 has one unstageable deep tissue injury noted at time of admission. [...]

Inspectors wroteBased on interview and record review, facility failed to follow their policy to ensure vaccinations were administered to prevent disease for 1 (R1) out of three residents reviewed influenza immunizations.

Inspectors wroteBased on observations, interviews and records review, the facility failed to provide proper pain management to one(R2) of three residents reviewed for pain management. This failure caused R2 pain and suffering.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow infection control policy by failing to clean IV (Intravenous) site as required for one (R2) of one resident reviewed for IV care.

Inspectors wroteBased on review of records and interview, the facility failed to provide PBJ (payroll-based journal) information in a uniform format which excludes information to determine category of data to review and verify for accuracy. These failures have the potential to affect determination of staffing needs that may affect residents' care.

Inspectors wroteBased on interviews and records review the facility failed to ensure sufficient nursing staff on a 24-hour basis to care for 4 (R3, R4, R5 and R8) residents' needs, out of 7 residents (R1, R2, R3, R4, R5, R7and R8) reviewed. This failure resulted on R3, R4, R5 and R8 not receiving their night medications.

Inspectors wroteBased on interviews and records review the facility failed to follow policy to account for narcotics for 1 resident (R2) and failed to document medications administration as per ordered by physician for 6 residents (R2, R3, R4, R5, R7, R8) out of 7 residents (R1, R2, R3, R4, R5, R7, R8) reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to maintain medical records that were accurately documented, complete and readily accessible for 1 (R2) of 2 residents reviewed for documentation by failing to a.) provide a signature on a resident's Controlled Drug Receipt/Record/Disposition Form for 3 of 30 entries; b.) failing to document narcotic administration on the Medication Administration Record and c.) failing to provide Controlled Drug Receipt/Record/Disposition Form for the dates of 09/10/23 -10/03/23. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that call lights are within reach for six of six residents (R2, R13, R14, R15, R16, and R21) reviewed for call light. Findings Include: On 09/18/23 at 11:27am, R2 noted sitting on the bed with call light not within reach. On 09/18/23 at 11:49am, R13, R14, and R15 observed in the same room with their call lights not within reach and on the floor under their beds. R13 was verbally calling for help to urinate in the urinal. R13 asked the surveyor for help to locate the urinal which was observed under R13's bed. R13 was unable to locate call light and did not understand what the surveyor meant by call light. On 09/18/23 at 11:50am, R16 noted in bed with call light not within reach under the bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient nursing staff are provided to meet residents needs and services. This failure affected R4, R13, R14, R15, and R21 in the sample reviewed for ADLs (Activities of Daily Living).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current standards of infection control practices during incontinent care and following the provision of care for three residents (R11, R21, R22) in the sample reviewed for infection control and prevention. This failure affected R11, R21 and R22 and has the potential to affect all resident residing on the 2nd and 4th floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sanitary environment free of urine odor; failed to ensure that the facility temperature did not exceed 81 degrees Fahrenheit; and failed to ensure a functional environment free of accidental hazard. This failure affected has the potential to affect all the resident's residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to report an injury to IDPH (Illinois Department of Public Health) within regulatory requirements for one resident (R1) reviewed for incident and incident with injury. This failure affected R1 who had an injury while toileting self which resulted in R1 having an acute fracture of the distal phalanx.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personal hygiene care and incontinent care was provided for R4, R13 and R21 in the sample of residents dependent on staff assistance for ADLs (Activities of Daily Living). This failure affected R4, R13 and R21 who did not receive appropriate personal hygiene and incontinent care in a timely manner.