Aspyre of Bronzeville

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure temperatures were comfortable and offer room changes to residents whose room temperatures exceeded 81 F due to air cooling units not working. This affected five (R6, R7, R8, R9, and R10) residents of 20 reviewed for physical environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) provide treatment or services, equipment or device and (b) develop comprehensive care plan to address contractures for two (R4 and R34) of two residents reviewed for limited range of motion in sample of 29. This failure resulted to left hand contracture of one (R34) resident admitted with full range of motion and / or mobility status.

Inspectors wroteBased on observation, review of records and interviews facility failed to provide supervision, assistance, assessments and interventions to maintain the right of every resident to be free from accidents, hazards and injuries for 1 out of 1 resident (R6) for a total sample of 29 residents. These failures affected 1 resident (R6) who sustained multiple falls resulting to right arm fracture on 05/21/2025 and right hand/finger fracture on 06/14/2025.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure for preventing foodborne illnesses to ensure dairy in the main cooler was discarded by the best by date, and to ensure staff was wearing hair restraint while in the kitchen. These failures have the potential to affect all 143 residents in the facility who are receiving oral diet. Findings Include: On 9/2/25 at 9:54 AM, during the initial tour in the kitchen with V4 (Dietary Manager), surveyor found a carton of 2% milk labeled with best by date of 6/11/25. V4 stated it should have been discarded and not be stored in the main cooler. On 9/3/25 at 11:07 AM, surveyor observed V25 (Director of Rehab) entered the kitchen with no hair restraint on. V4 stated that everyone entering the kitchen should wear hair restraint to prevent hair contaminating the food. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dumpsters and garbage bins were properly covered and not overflowing to prevent the harborage and feeding of pests. This deficient sanitation practice has the potential to affect all 144 residents residing in the facility. Findings Include: On 9/2/25 at approximately 10:00 AM, V4 (Dietary Manager) brought surveyor outside to inspect the facility's dumpsters. Surveyor observed two dumpsters with the lid not fully closed due to overflowing of garbage. V4 stated that all dumpsters should be fully closed to prevent rodents and other pests' infestation. V4 stated, They did not pick up the garbage this morning. V4 stated that pest will be all over the overflowing garbage and residents will be at risk to get sick. V4 stated, They called me yesterday saying garbage was overflowing. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to label/date medications when opened and remove expired medications from the medication carts and medication room during review of medication storage and labeling. Findings Include:On 09/02/25 at 12:52PM the third floor A medication cart was reviewed with V7 (Registered Nurse) R100's Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 inhalation inhale orally one time a day dispensed 08/15/25 was observed in the medication cart with no label/open date. V7 said when the inhalers are opened, they are supposed to be dated. One multi dose vial of Lantus insulin 100/units/ml was observed in the medication cart drawer open with no date with a label indicating discard after 28 days. Surveyor asked V7 what could potentially happen if the Lantus insulin was used passed the 28 days. [...]

Inspectors wroteThe facility failed to ensure reusable medical equipment (blood pressure monitor) was cleaned and sanitized between residents use and failed to ensure proper PPE (Personal Protective Equipment) was worn during care of one (R1) resident on Enhanced Barrier Precautions with a Nephrostomy tube. The facility also failed to perform hand hygiene during and after performing direct care and catheter care for 1 (R41) resident on Enhanced Barrier Precautions. This failure has the potential to affect all residents residing on the second and third floors of the facility. Findings Include:

Inspectors wroteBased on observation and interviews facility failed to ensure 3rd floor corridor handrails used by residents are firmly secured. These failures have the potential to affect 63 residents' safety when using handrails for support.

Inspectors wroteBased on interviews and review of records the facility failed to maintain resident rights to access personal funds in timely manner for 1 out of 1 resident (R41). These failures affected 1 resident (R41) in his ability to support his wants and/or needs due to lack of financial funds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed within 48 hours - 72 hours of admission for 3 (R11, R103, R125) of 3 residents reviewed for baseline care plans in a sample of 29. Finding Include:R11 was admitted to the facility on [DATE] with diagnosis not limited to Hypertensive Heart Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Gastro-Esophageal Reflux Disease, Primary Open-Angle Glaucoma, Bilateral, Stage, Polyosteoarthritis, Schizophrenia, Hyperlipidemia and Major Depressive Disorder, Recurrent. R11's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R11's Care Plan Report document No Data Found. R11's Care Plan Report presented to the surveyor areas of Focus/Goals/ Interventions/Tasks document Cancelled and/or resolved. [...]

Inspectors wroteBased on observation, interview, and record review the facility staff failed to follow professional standards of practice with regards to medication administration by storing medication outside of its original packaging for administration. The facility also failed to ensure the physician was notified when blood pressure medications were not administered for 2 (R92, R109) of 3 (R96) residents during medication administration. Findings Include: On [DATE] at 09:37 AM V5 (Registered Nurse) entered R109's room and said to R109, come out and take your blood pressure. At 09:40 AM V5 placed the blood pressure cuff on R109's right arm while standing at the medication cart with a blood pressure reading of 81/54 pulse 100. V5 placed the blood pressure cuff on R109 left arm to recheck R109's blood pressure with a reading of 104/75 pulse 101. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow a physician's plan of care for a resident (R71) with history of significant weight loss for one resident out of a total sample of 29 residents.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to provide care and services for a catheter bag for one resident. Observations of R1 revealed the attached urinary drainage leg bag was wrapped in a brief with the closure cap not in place for a resident at risk for urinary tract infections in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) follow oxygen liter flow as ordered by physician, (b) provide humidification for oxygen use, (c) properly stored oxygen tubing when not in use and (d) develop care plan for oxygen use for 1 (R33) of 2 residents reviewed for respiratory care in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to reconcile and account for controlled medications accurately in 1 of 3 medication carts reviewed for medication labeling and storage. Findings Include:On 09/02/25 at 12:52PM the third floor A medication cart was reviewed with V7 (Registered Nurse). When checking the controlled substances with V7 said R100 has 25 Vimpat Oral Tablet 100 MG (Lacosamide) Twice a day for Seizure. The Controlled Drug Receipt/Record/Disposition Form document dated dispensed 08/30/25, Lacosamide Tab 100 MG take 1 tablet by mouth twice daily. Quantity dispensed, 30 amount left 26. R100's Lacosamide 100 MG medication punch card has a remaining count of 25 pills. V7 said I did not sign for the Lacosamide, 26 is documented on the sheet. It was given at 9am. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5%, by making 9 errors out of 30 opportunities with an error rate of 30%.Findings Include:On 09/02/2025 at 09:37 AM V5 (Registered Nurse) entered R109's room and said to R109, come out and take your blood pressure. At 09:40 AM V5 placed the blood pressure cuff on R109's right arm while standing at the medication cart with a blood pressure reading of 81/54 pulse 100. V5 placed the blood pressure cuff on R109 left arm to recheck R109's blood pressure with a reading of 104/75 pulse 101. V5 said let me look to see if you have some blood pressure medications because your blood pressure is a little too low. I am not giving Amlodipine; I am going to hold it because the blood pressure is a little low. R109 gets three blood pressure medications that I am going to hold. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered as ordered by the residents' Physicians orders resulting in significant medication errors for 2 (R92, R109) of 3 (R96) residents reviewed during medication administration. Findings Include:R109 has diagnosis not limited to Cerebrovascular Disease, Hypertensive Heart Disease with Heart Failure and Hyperlipidemia.0n [DATE] at 09:37 AM V5 (Registered Nurse) entered R109 room and said to R109, come out and take your blood pressure. At 09:40 AM V5 placed the blood pressure cuff on R109's right arm while standing at the medication cart with a blood pressure reading of 81/54 pulse 100. V5 placed the blood pressure cuff on R109 left arm and rechecked R109's blood pressure with a reading of 104/75 pulse 101. [...]

Inspectors wroteBased on interviews and record reviews, facility failed to follow their abuse policy to protect the resident's right to be free from physical abuse for one [R1] of [R2, R3] three residents. This failure resulted in R1 sustaining a bruised right eye, facial areas, and pain.

Inspectors wroteBased on interviews and record reviews, the facility [A] failed to follow their Abuse Prevention Program Policy and report an allegation of abuse within 2 hours of the incident to IDPH (Illinois Department of Public Health) and [B] failed to submit the final report to IDPH within five business days for two 2 (R1 and R2) of three [R3] residents reviewed for abuse.

Inspectors wroteBased on interviews and records review, the facility failed to assist one resident (R1) of three reviewed in a sample of three with communication and access to services inside and outside the facility. This failure resulted in R1 not getting his social security card.

Inspectors wroteBased on interviews and record reviews, facility failed to follow their abuse policy to protect the resident's right to be free from [A] physical abuse and mental abuse for one [R2] of [R1, R3] three residents. This failure resulted in R2 experiencing pain and feeling humiliated, crying, depressed and fearful of retaliation. Findings Include: Facility reported incident dated 3/27/25 documents in part: R1 and R2 were observed in alleged physical altercation. R1 clinical record indicates in part; R1 is a seventy-four-year-old male with medical diagnosis include but not limited to violent behavior, schizoaffective disorder, and hypertensive heart disease. Minimum data set [MDS] section C indicates R1 is cognitively intact, able to make his needs known. R1's Progress Notes documented in part: 3/28/2025 08:38 Daily Note Note Text: R1 admitted to the hospital diagnosis of aggressive behavior. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain hot water at comfortable level in one resident's hand sink for one of four residents (R1) in a total sample of 5.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that there was no ice build-up in their walk-in freezer, separate the prep area from the sanitization area, and air-dry their blender container and pans prior to use. This has the potential to affect all 59 residents receiving nutritional needs from the kitchen.

Inspectors wrote2. R6's admission Record documents in part medical diagnoses of overactive bladder, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, disorder of male genital organs, retention of urine, and presence of urogenital implants. R6's Order Summary Report documents in part orders for an indwelling urinary catheter. It does not include orders for Enhanced Barrier Precautions. R6's comprehensive care plan documents in part that R6 has an indwelling urinary catheter related to diagnosis of obstructive uropathy and benign prostatic hyperplasia (initiated 3/11/2024). R6's care plan does not document in part Enhanced Barrier Precautions. On 7/30/2024 at 10:41 AM, surveyor observed an isolation bin outside R6's bedroom. There was no isolation sign inside the bin or on R6's bedroom door. V26 was cleaning the room. [...]

Inspectors wroteBased on interview and record review the facility failed to follow its policy by not obtaining code status order from a prescriber for 1 (R45) resident reviewed for advance directives in a sample of 19.

Inspectors wroteBased on interviews and records reviews, the facility failed to follow fall care plan intervention for a resident with history of falls and failed to update care plan fall interventions after fall had occurred. These failures affected 1 (R204) of 4 residents reviewed for falls out of a sample of 19. Findings Include: R204 admitted to the facility on [DATE] with diagnosis not limited to Seizures, Epilepsy, Repeated Falls, Major Depressive Disorder, Unspecified Hearing Loss, Dementia, Bipolar Disorder with Psychotic Features, Schizophrenia, Psychotic Disturbance, Mood Disturbance, Drug Induced Subacute Dyskinesia, Legal Blindness, As Defined In USA, Parkinson's Disease, Restlessness and Agitation, Chronic Obstructive Pulmonary Disease. R204's MDS (Minimum Data Set) dated 06/14/24 documents BIMS (Brief Interview of Mental Status) score of 03/15 indicating severely impaired cognition. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy by not performing a nutritional evaluation on readmission for 1 (R45) resident with significant weight loss. This failure affected 1 (R45) of 2 residents reviewed for nutrition in a sample of 19.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to date and store nebulizer mask inside a plastic bag when not in use for 1 (R103) resident in a sample of 19. Findings Include: From 07/30/24 to 08/02/24, surveyor observed R103's nebulizer mask by the window, undated and not inside a plastic bag when not in use. On 07/30/24 at 11:10 AM, V6 (Registered Nurse/RN) stated the Nebulizer mask should be dated and kept in a plastic bag when not in use to prevent contamination which could potentially cause infection for R103. V6 stated the nebulizer was administered by previous shift, V6 then discarded the undated nebulizer mask and replaced with a new dated mask in a plastic bag. On 07/30/24 at 12:07 PM, V2 (Director of Nursing) V2 stated it is V2's expectation that nurses will date and keep nebulizer mask inside the plastic bag when not in use to prevent infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of professional practice by leaving medications at the bedside of one resident (R19), failed to date insulin for one resident (R25) and failed to store insulin inside the refrigerator for one resident (R49) in a sample of 19. Findings Include: 1. On [DATE] at 11:25 AM, 1 of 2 medication carts and 1 of 1 medication storage room inspected for medication storage and labeling. Surveyor observed R25's multi-dose vial of Humulin R Injection solution (Insulin Regular Human) inside the medication cart, opened and undated. V9 (Licensed Practical Nurse/LPN) stated the multi-dose vial of Humulin R Insulin is opened and should have been dated per the facility's policy. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to provide dental care services to one resident (R20) in a sample of 19 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow physician's orders for nectar-thick liquids for one resident (R353) out of a total sample of 19 residents.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their Antibiotic Stewardship Program, [A] failed to develop a report for the number of residents on antibiotics that did not meet criteria for active infection, and [B] failed to keep an accurate report for surveillance tracking for 4 [R1, R6, R10, R17,] out of 5 residents reviewed for antibiotic stewardship in a sample of 19. Findings Include: On 7/31/24, surveyor and V3 [Infection Preventionist (IP)/Licensed Practical Nurse] reviewed the following facility antibiotic stewardship record-Infection Control Log dated 1/1/24 thru 7/23/24: R1 was admitted on [DATE], and his urine was collected for testing, no signs or symptoms documented on the log. On 1/26/24, R1's urine resulted in bacterial growth, the organism was not documented on the log. On 1/27/24, R1 was ordered Cipro 500mg twice daily for ten days. [...]

Inspectors wroteBased on interview and record reviews the facility failed to follow their Influenza and Pneumococcal Immunization policy and administer immunizations for 3 [R5, R11, R46] of 5 residents reviewed for immunizations in the sample of 19. Findings Include: On 7/31/24, surveyor and V3 [Infection Preventionist (IP)/Licensed Practical Nurse] reviewed the following facility immunization records dated 1/1/24 thru 7/28/24: R5 consented on 1/17/24 for pneumococcal and influenza vaccine on 1/17/24. V3 stated, R5 originally consented on 1/17/24 according to his electric clinical record under misc. documents both consents were effective dated on 1/17/24 and scanned into R5's chart on 1/17/24. I was not aware R5 consented on 1/17/24. I received his consents again on 5/15/24 for pneumococcal and influenza vaccines. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that resident' call light is functioning for one (R22) out of a total sample of 59 residents reviewed for resident call system. Findings Include: On 07/30/24 at 11:15 AM, surveyor observed R22 lying in bed. Surveyor observed R22's call light not functioning. R22 stated R22's call light is not working since last storm 2 Mondays ago (7/15/24). R22 stated the staff are aware of the broken call light. R22 stated R22 cannot get out of bed independently, and R22 stated R22 must wait until staff come in to help R22 when staff feel like. R22 stated R22 is wet and sad that the call light is not working. R22 stated the staff come to check on R22 sometimes. On 07/30/24 at 11:25 AM, V13 (Registered Nurse/RN) and surveyor observed R22's call light not working. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and acquire medications as ordered by the doctor to meet the needs of each resident. These failures could potentially affect 2 (R1 and R5) of 5 residents reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, the facility failed to complete an elopement risk assessment, develop and implement an elopement care plan, and provide a secure physical environment to minimize the risk of unwitnessed elopement for a resident with a known history of successful elopement for one of three residents (R1) reviewed for supervision. These failures resulted in an incident of successful elopement that the facility staff were not aware of until the resident had already left the facility. R1 was located two days later at his mother's home.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and home like environment by not maintaining comfortable and safe temperature levels in the entire premises of the facility and the facility failed to follow their policy to take and record temperature levels every hour during an event of extremely hot weather. These failures resulted in an immediate jeopardy to the health and safety of all 132 residents residing in the facility who were subjected to hazardous temperatures above 80F (Fahrenheit) on 8/23/23 requiring evacuation and transfer of all 132 residents to different facilities. On 8/23/23, R1 sustained nausea, vomiting and weakness secondary to heat. This was identified as an Immediate Jeopardy which began on 8/23/23 at 9:35am per (8/23/23) facility temperature log which documents a temperature of 81.2F (Fahrenheit) in resident's room. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain safe and comfortable temperatures in the facility, failed to monitor residents for heat exhaustion, failed to provide adequate hydration during hazardous temperature, and failed to assess and supervise one resident (R21) with a change in condition related to heat exhaustion. These failures affected R21 who was sent to the hospital exhibiting heat related signs and symptoms and has the potential to affect all 132 residents. This was identified as an Immediate Jeopardy which began on 8/23/23 at 9:35 am per (8/23/23) facility temperature log which documents a temperature of 81.2F (Fahrenheit) in resident room. On 8/30/23 at 2:22 pm, V9 (RDO/Regional Director of Operations), V17 (Corporate Administrator), V18 (Chief Financial Officer) and V19 (Attorney) were notified of the immediate jeopardy. [...]

Inspectors wroteBased upon observation, interview, and record review the facility failed to administer medications as ordered and failed to ensure that three of three residents (R21, R51, R52) reviewed for medication administration remained free from significant medication errors. These failures resulted in R21 sustaining a high blood glucose level of 249 on 8/23/23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a safe and orderly transfer for all 132 residents residing in the facility who were subjected to hazardous temperatures above 80F (Fahrenheit) on 8/23/23 requiring evacuation and transfer to different facilities. This failure affected all 132 residents residing in the facility. This failure also resulted in an unnecessary hospital transfer for R50 due to the receiving facility not being able to accommodate R50's physical needs.

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure the menu was followed, failed to post alternate menu, failed to provide meal options, and failed to provide meals timely. This failure has the potential to affect 130 residents receiving meals from facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resources in a safe, effective, and efficient manner, and failed to provide adequate supervision, direction and instruction during the evacuation and discharge of facility residents. These failures have the potential to affect all 132 residents residing in the facility.

Inspectors wroteBased upon observation, interview and record review the facility failed to document AC (Air Conditioner) concerns on a maintenance log/worksheet, failed to repair malfunctioning AC, failed to ensure that the AC remained operable, and failed to maintain facility air temperature below 80F (Fahrenheit). These failures affected 132 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill set to carry out the functions of the food and nutrition service. The failure has the potential to affect all residents receiving oral nutrition residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to discard food items from the walk-in cooler by the use by date. This failure has the potential to affect all resident receiving oral nutrition from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly clean the dryer lint screen to provide a safe environment for the residents. This failure has the potential to affect all 128 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a homelike environment for eight residents (R10, R23, R25, R32, R39, R51, R68, R91) in the sample of 59 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall prevention interventions for 4 (R26, R84, R96, R103) residents reviewed for fall prevention in the sample of 59 residents.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure staff did not pre pour medications, failed to keep medications in original packaging, failed to monitor vaccine refrigerator twice a day, failed to ensure staff did not keep food item inside the medication room, failed to ensure unopened insulin vial was kept in the refrigerator, failed to ensure medication refrigerator temperature kept at appropriate temperature, failed to ensure insulin was labeled with open and discard dates, and failed to ensure medication carts were free of loose pills. These failures affected 5 (R24, R75, R85, R88, R131) residents reviewed for medication storage and labeling and have the potential to affect the 3rd floor Team B residents, all the resident in 1st and 2nd floors.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's indwelling catheter drainage bag was covered for dignity. This failure affected 1 (R103) resident reviewed for dignity in the total sample of 59 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure the call light was within reach for 2 residents (R87, R91) out of 59 residents reviewed for call lights.

Inspectors wroteBased on interview and record review the facility failed to list the code status for one resident (R40) on the electronic medical record. This failure has the potential to affect one resident (R40) in a sample of 59 residents.

Inspectors wroteBased on interview and record review the facility failed to provide two residents (R64, R138) Medicare end of coverage notice. This failure has the potential to affect all 59 residents in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the piston syringe was changed daily for 1 (R84) resident reviewed for tube feeding in the total sample of 59 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses reconciled the controlled medications during shift change and failed to ensure administration of controlled medication was documented. These failures affected 3 residents (R47, R61 and R76) reviewed for pharmacy services and records in a total sample of 59 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (R28) mattress was the correct size for R28's bed frame. This has the potential to affect one (R28) of 59 residents in the sample reviewed for home-like environment.