Atrium Health Care Center

Inspectors wroteBased on interview, and record review, the facility failed to protect residents from physical abuse when resident-to-resident altercations occurred, resulting in R2 slapping R1 in the face; and R4 slapping R3 in the face. This failure affected four out of six residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely assessment, treatment, monitoring, and physician follow-up for a resident with a persistent lice infestation. This failure resulted in the resident (R5) experiencing ongoing symptoms, including scratching, and placed the resident and other residents at risk for continued infestation. This failure affected one out four residents reviewed for resident assessment, treatment, skin conditions, and infestations.

Inspectors wroteBased on interview and record review the facility failed to ensure adequate supervision and monitoring of residents during a scheduled smoking break. This failure affected one resident (R3) resulting in resident-to-resident altercation occurring (R4 slapped R3) and has the potential to affect all 37 residents who smoke on the patio area in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (R1) was free from physical abuse when R2 struck R1 during an altercation in their shared room. This affected two of three residents (R1/R2) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow a care plan and provide a safe environment for a resident at risk for falls by failing to ensure items were away from a residents bed/space for one (R1) of three residents reviewed for falls.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from abuse by a resident. This failure affected two (R1 & R2) residents out of 13 residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident (R2) was free from abuse. This failure has affected one of four residents reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled and dated, b.) food items were stored according to manufacturer recommendations, c.) discard expired food based on use by date and guidelines, d.) sanitize kitchen equipment based on manufacturers' procedure directions. These failures have the potential to affect all 150 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly date opened multi-dose inhaler for 1 (R27) resident, ensure that multi-dose insulins and antibiotic medication were stored properly at appropriate temperature for 4 (R12, R33, R57, R205) residents and discard expired multi-dose vial injection reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare pureed food in appropriate diet consistency form based on recipe and spreadsheet. This failure has the potential to affect four residents on pureed diets (R9, R15, R68, R75) prepared in the facility kitchen. Findings Include: On 04/30/25 at 11:06 PM, observed lunch tray line in progress. Desserts were already portioned out and on resident's meal trays. Observed regularly prepared gelatin without canned fruit on R9, R15, R68, R75's lunch trays. The regularly prepared gelatin without canned fruit was not pureed and the gelatin appeared firm and stiff, holding its shape in large, spooned portions in the bowl. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wear proper PPE (Personal Protective Equipment) during high contact resident care activities for 1 (R1) resident on Enhanced Barrier Precautions (EBP) reviewed for infection control on the total sample of 61.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times for two residents (R7, R41) reviewed for dignity in the total sample of 61.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide podiatry services for one (R355) of six residents reviewed for foot care in a sample of 61.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to ensure controlled medication that require refrigeration are stored within a locked box within the refrigerator to decrease the possibility of loss or diversion for 1 (R68) resident reviewed for medication storage and labeling in a sample of 61.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a medication error rate of less than 5% for 3 (R73, R125, R149) of 9 residents observed during medication administration. Surveyor observed 4 errors during 28 medication administration opportunities. This resulted in a medication error rate of 12.49%.

Inspectors wroteBased on interview, and record review, the facility failed to follow their policy of requesting a fingerprint-based background check within 72 hours of receiving the residents' name based criminal history background check for two of two residents (R9, R10) reviewed for Abuse Prevention.

Inspectors wroteBased on interview and record review the facility failed to ensure that staff are aware of the requirements for involuntary (psychiatric) admission, failed to provide resident a petition for involuntary admission and failed to explain the rights of admittee for one of four residents (R1) reviewed for transfer/discharge.

Inspectors wroteBased on interview and record review the facility failed to follow policy procedures, failed to ensure that osteomyelitis was included in diagnoses, failed to schedule medication as directed, and failed to administer medications as ordered for one of four residents (R3) reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to follow policy procedures, failed to assess/document skin integrity impairments, failed to ensure that the facility wound report was accurate, failed to obtain descriptive treatment orders (including wound locations/medication/type of dressing), and failed to follow physician orders for one of four residents (R3) reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two (R1, R2) residents were free from abuse. This failure resulted in R1 and R2 verbally and physically abusing each other in a total sample of four residents reviewed for abuse.

Inspectors wroteBased on interview and document review the facility failed to ensure the residents right to be free of abuse in for two (R1 and R4) out of five residents included in the resident sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to ensure the initial reportable for the allegation of sexual assault was sent to the State Agency within the mandated timeframe for one (R2) resident reviewed for abuse in the total sample of 6 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of sexual assault was thoroughly investigated. This failure affected 1 (R2) resident reviewed for abuse in the total sample of 6 residents.

Inspectors wroteF689 Based on interview and record review, the facility failed to uodate a plan of care and provide assistance to one resident (R1) who required supervision assistance when ambulating. This failure affected one resident (R1) in a total sample of three residents reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects one (R1) resident out of eight residents reviewed for abuse. As a result of this failure, R2 pushed R1 to the floor.

Inspectors wroteBased on interview and record review, failed to follow their policy to report any allegation of abuse to the administrator or administrator's designee and to Illinois Department of Public Health for one resident (R5) out of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, failed to follow their policy to investigate allegations of abuse by the administrator or administrator's designee for one resident (R5) out of three residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to keep two (R8, R10) of six residents free from abuse. This failure resulted in R8 and R10 sustaining a swollen and bruised eye.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe practices when turning a resident in bed during resident care for 1 (R7) of three residents reviewed for falls. The facility also failed to ensure fall preventions were added to the care plan after R7's fall. This failure resulted in R7 falling out of bed and sustaining a laceration to the scalp. Findings Include: R7 has diagnosis not limited to Quadriplegia, Osteomyelitis, Hyperlipidemia, Muscle Spasm, Constipation, Postherpetic Polyneuropathy, Type 2 Diabetes Mellitus, Angina, Anxiety Disorder, Thiamine Deficiency, Vitamin D Deficiency, Bipolar Disorder, Schizophrenia, Chronic Pain, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Buttock, Stage 4 and Essential (Primary) Hypertension. [...]

Inspectors wroteBased on interview and records review, the facility failed to provide safe and adequate care for a resident (R1) of 3 residents reviewed for incontinence care and bed mobility, who requires two person-assist for incontinence care and bed mobility. This failure resulted in R1 falling out of bed, hitting his head on the bedside dresser, being transferred to the hospital on 2 different occasions post fall, and being diagnosed with post-concussion syndrome.

Inspectors wroteBased on interview and record review the facility failed to ensure the right of resident to be free of abuse for two (R4, R8) of six residents reviewed for abuse in the sample. This failure resulted in R4 being hit in the mouth sustaining facial trauma and R8 being hit in the nose resulting in bleeding and pain.

Inspectors wroteBased on observation, interview and document review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This affects all 149 residents in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to maintain an effective pest control program so that the facility is free of insect pests in the dietary area. This has the potential to affect all 149 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly disinfect multi-use equipment used on 4 residents (R58, R61, R92 and R135). The failures affected R58, R61, R92 and R135 reviewed for infection control in the sample of 60.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the first floor shower room was clean and sanitary. This has the potential to affect the 45 residents residing on the first floor.

Inspectors wroteBased on observation, interview and record review the facility failed to empty one resident's (R59) urinal located on the resident's (R59) bedside dresser and failed to ensure that the call light was within reach for one resident (R133). This failure had the potential to affect 2 residents out of a sample of 60 residents.

Inspectors wroteBased on interview and record review the facility failed to update the advance directive status in the medical records for one resident (R77) reviewed for advance directives in a sample of 60.

Inspectors wroteBased on observation, interview and record review the facility failed to document that a medication was not received by one resident (R92) and failed to follow a physician's order to take a blood pressure prior to administering medication to one resident (R119). This failure had the potential to affect 2 residents out of a sample of 60 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 2 residents (R95 and R147) receiving controlled substances from the third floor, team 1 medication cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide thermometers for resident's personal refrigerators for 2 residents (R84 and R133), failed to properly log refrigerator temperatures for 2 residents (R60 and R133) and failed to discard expired food from 1 resident's personal refrigerator (R133). These failures have the potential to affect all 3 residents reviewed for safety of personal food items, in a total sample of 60 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly secure and protect the resident's money for six (R2, R4, R5, R6, R7, R8) out of eight residents reviewed for resident's rights.

Inspectors wroteBased on observation, interview and record review the facility failed to accommodate a resident's preference to aid in providing a comfortable and homelike setting for one (R1) resident out of eight residents reviewed for resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to affirm the right of the resident to be free from misappropriation of resident property. This failure affects one (R2) out of three residents reviewed for misappropriation of resident property.

Inspectors wroteBased on interview and record review, the facility failed to report and investigate misappropriation of property for one (R2) of three residents reviewed for misappropriation of resident property.

Inspectors wroteBased on observation, interview and record review the facility failed to acquire a physician ordered medication and accurately document the administration of medication for one (R1) of three residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to that ensure that a resident was free from physical abuse. These failures affected R2 who was physically scratched in the face by R1 and affected R6 who was physically kicked and scratched on the neck by R7 when reviewed for resident to resident physical assault, for four (R1, R2, R6, R7) of six residents reviewed in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to supervise residents in the facility day room which affected two residents (R6 and R7) involved in a physical assault, resident to resident, in the sample of 6 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to keep one resident free from physical abuse. This failure affected one (R3) out of the three residents reviewed for physical abuse. This failure resulted in R2 physically assaulting R3, who experienced an abrasion to the right cheek.

Inspectors wroteBased on interview and record review, the facility failed to monitor a cognitively impaired resident (R1), who was assessed to be at high risk for elopement and who had an electronic monitoring safety device on the right ankle; the facility staff failed to respond to alarms which may have sounded as R1 exited the building; and the facility failed to follow their elopement risk policy and procedures to prevent elopement. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident's mail was delivered unopened which affected one (R2) of six residents (R2, R3, R4, R5, R6 and R8) reviewed for resident rights.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor, supervise, and assist one resident (R109) with history of multiple falls with injuries resulting in left arm fracture, acute nasal fracture, and acute intracranial hemorrhage with a hematoma; the facility also failed to provide 2-person assistance during bedside care for 1 resident (R129) who required total assist. This failure resulted in R109 falling off the bed during bedside care. These failures apply to 2 out of 4 residents (R109 and R129) from a total sample of 30 residents reviewed for accidents and supervision. R109 was hospitalized and treated for injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy related to unintended weight loss and failed to follow care plan interventions for weight loss. The facility also failed to follow its policy for providing resident with double portion during meals for 1 (R60) out of 11 residents reviewed for nutrition status. These failures resulted in (R60) having continuous significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy on safe food handling practices. This failure has the to potential to affect all 53 residents residing on the 3rd floor.

Inspectors wroteBased in interview and record review, the facility failed to follow their immunization policy for 5 residents (R94, R48, R69, R137, R17) of 8 residents reviewed.

Inspectors wroteBased on observation, interview and record review, facility failed to follow their policy to ensure substitute meals were provided for three (R42, R79, R36) out of seven residents reviewed for dining in a sample of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the Infection Preventionist (IP) requirement guidelines by failing to have an infection control preventionist certification. This failure has the potential to affect all 150 residents residing at the facility.