Avantara Chicago Ridge

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to return to the facility following hospitalization. This failure applied to one (R1) of three residents reviewed for discharge procedures.

Inspectors wroteBased on interview and record review, the facility failed to ensure required physician visits occurred within the federally mandated timeframe. This deficient practice affected one (R1) of three residents reviewed for physician visits.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of care by failing to follow physician orders for one (R1) of four residents reviewed for professional standards.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy, failed to ensure g-tube site was clean, dressing applied and failed to administer g-tube feeding at the ordered rate. This failure affected one of four (R1) residents reviewed for quality of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement interventions per resident's care plans and care assessment in preventing falls; and failed to follow policy related to fall investigation for two (R1 and R5) of five residents reviewed for accidents and falls. These deficiencies resulted in R1 sustaining a fall that resulted in bruising to the left side of the head and R1 being transferred to the local hospital for treatment after being found sitting on the floor with left arm hanging on the left bedrail with head slouched over to the left side. R5 who is confused with unsteady gait; had a fall requiring emergent transfer to the hospital and was diagnosed with acute nondisplaced fracture to the left parietal calvarium.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of resident property and/or exploitation. This failure affected one (R1) of three residents reviewed for misappropriation and/or exploitation as a result of R1's credit card being stolen by facility staff, who made unauthorized charges of more than $1000.00 on R1's account.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provide shower/bed bath and grooming as scheduled for residents who are dependent on staff for Activities of Daily Living (ADLs). This failure affected four (R1, R2, R3, and R4) of five residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure preventive measures are in place to prevent developing of new skin impairment and deteriorating of current pressure ulcer to resident who is at high risk. This deficiency affects one (R139) of three resident in the sample of 32 reviewed for Pressure Ulcer Prevention management. This failure resulted in R139 developing a new moisture associated skin disorder (MASD) to bilateral buttocks and deteriorating pressure ulcer on sacrum area to unstageable.

Inspectors wroteBased on observation, interview and record review, the facility failed to label insulin and inhalers with open date and follow pharmacy/manufacturer's recommendation on discarding for two of five medication carts (2nd floor East-West and 2nd floor [NAME] medication carts), and one of two medication room storage (3rd floor medication room) observed for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review the facility failed to fill the sanitation kitchen rags bucket with appropriate amount of sanitizer per manufacturer's recommendation to prevent foodborne illness. This deficiency has a potential to affect 158 residents who received oral food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects 4 (R3, R15, R150, R416) of 4 residents in the sample of 32 reviewed for Accommodation of needs.

Inspectors wroteOn 1/7/25 at 10:50AM, V9 RN (Registered Nurse) taking Blood Pressure (BP) and Oxygen saturation of R113 using BP apparatus and pulse oximeter. After taking the vital signs, V9 proceeds to R217 without disinfecting the medical equipment used. After taking vital signs of R217 V9 used hand sanitizer but did not disinfect the medical equipment used. V9 stated that R113's BP is 107/57 and oxygen saturation is 92% and R217 's BP is 132/60 and oxygen saturation is 97%. On 1/7/25 at 11:00AM, V9 RN proceeds to R416 and took R416's BP and oxygen saturation. V9 used hand sanitizer but did not disinfect the medical equipment used. V9 stated that R416's BP is 114/59 and oxygen saturation is 92%. [...]

Inspectors wroteBased on interview and record review the facility failed to refer a resident to the appropriate state-designated authority for a PASRR/Preadmission Screening and Resident Review level 2 screening for evaluation and determination of newly evident serious mental illness related condition, for one of one resident (R111) reviewed for a PASRR level 2 screening in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to ensure safety interventions were in place for a resident who is at high risk and has history of falls. This deficiency affects two (R27 and R216) of three residents in the sample of 32 reviewed for fall prevention program. This failure resulted in R216 falling and sustaining a laceration to his right eyebrow that required a visit to the hospital for suturing.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise residents while taking medications during medication administration for two of four residents (R53, R100) observed for medication administration. The facility also failed to account for the usage, disposition, and reconciliation of controlled medications for one of five medication carts (2nd floor [NAME] medication cart) observed for medication storage affecting all seven residents (R3, R11, R29, R73, R76, R86, R149) on controlled medications on 2nd floor [NAME] medication cart.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that coordinated care services was provided to a resident who had a fractured hip from a fall at the facility. The facility failed to provide skilled therapy services as ordered by physician in a timely manner. This deficiency affects one (R74) of three residents in the sample of 32 reviewed for Quality of care.

Inspectors wroteBased on interview and record review the facility failed to document incontinence care every shift per facility policy. This failure applied to two (R1 and R2) of three residents reviewed for incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to prevent a new pressure ulcer from developing for a resident who was assessed to be at risk for developing pressure ulcers while in the facility. This failure applied to one (R1) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to replace a damaged call light cord in a resident's room. This failure applied to one (R2) of three residents reviewed for accidents and hazards.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for fall prevention by not providing toileting assistance as needed in a timely manner and by not ensuring fall risk assessments were completed quarterly and annually. This failure applied to one of three residents (R2) reviewed for falls and resulted in R2 sustaining a left foot fracture.

Inspectors wroteBased on interview and record review the facility failed to ensure dialysis services were provided in a manner consistent with professional standards for 1 of 3 residents (R1) reviewed for dialysis in the sample of 3. This failure resulted in R1 being transferred to the acute care hospital on 3/17/24, treated for peritonitis, sepsis, and R1's abdominal dialysis catheter had to be removed requiring R1's mode of dialysis to change.

Inspectors wroteOn 1/3/24 at 9:17 AM V19 (Registered Nurse) retrieved a gown from the PPE (Personal Protective Equipment) cart. V19 dropped a gown on the floor and picked it up and returned it to the cart on top of the clean gown and closed the drawer. Surveyor asked if that was acceptable, she said I don't know what I was thinking. She removed the dropped gown and the clean gown from the cart. V19 then measured the vital signs for R134. V19 cleaned the blood pressure cuff and the pulse oximeter with a bleach wipe and removed her gloves. She did not perform hand hygiene and proceeded to pour and administer medications to R134. Surveyor asked V19 why hand hygiene wasn't performed after removing her gloves. V19 stated I should have done that. On 1/3/24 at 1:20 PM V2 (Director of Nursing) stated it (gown) should be discarded. It is no longer clean. [...]

Inspectors wroteBased on observation interview and record the facility failed to ensure a dignity pouch was provided for a urine collection bag for one of three residents' (R94) reviewed for dignity in a sample of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the necessary follow up is done and that the pacemakers are in good working condition. This deficiency affects one (R97) of one resident in the sample of 28 reviewed for Professional Standards of Practice.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a means of communication for resident who has language barrier. This deficiency affects one (R97) of two residents in the sample of 28 reviewed for Communication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for one of three residents' (R91) reviewed for falls in a sample of 28. Findings Include: On 1/3/2024 at 12:10pm R91 was observed up in wheelchair in the dining room with chair alarm not turned on. On 1/3/2024 at 12:15pm V23(Licensed Practical Nurse-LPN) stated R91 is a fall risk and the chair alarm should be on whenever the resident is up in the chair. On 1/3/2024 at 12:17pm V24(Certified Nursing Assistant-CNA) state the alarm should be turned on and then proceeded to turn on the chair alarm. On 1/3/2024 at 12:30pm V2(Director of Nursing-DON) said R91 is a fall risk, and the chair alarm should be turned on if she is in the chair. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician order of checking bladder scan every shift for resident who has urinary retention. This deficiency affects one (R72) of one resident in the sample of 28 reviewed Bladder Management program.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician order in providing enteral feeding and enteral stoma care. This deficiency affects two (R12 and R246) of three residents in the sample of 28 reviewed for Enteral Tube Feeding Management.

Inspectors wroteBased on observation, interview, and record review the facility failed to accompany a resident to an appointment for 1 of 3 residents (R2) reviewed for appointments in the sample of 8

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free of significant medication errors to 1 of 3 residents (R6) reviewed for medications in the sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to provide oral nutritional supplements, and accurately document monthly weights to identify weight loss triggers. This resulted in a significant weight loss (>5% change over a span of 1 month and >10% change over a span of 6-month period) for 1 (R134) of 6 residents reviewed for nutrition in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) ensure food items were properly labeled, dated, and stored; 2.) discard food products on or before the expiration date; 3.) practice appropriate hand hygiene; 4.) keep kitchen walk-in refrigerator clean 5.) allow equipment to air-dry before use. These failures have the potential to affect all 141 residents receiving oral diets from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate below 5% as evidenced by 4 medication errors out of 35 opportunities, resulting in a medication error rate of 11.43% for four (R30, R135, R62, R18) of seven residents observed during medication administration. Findings Include: On 10/26/22 at 08:14am V12 (Registered Nurse) prepared R30s' medications at the medication cart. V12 then entered R30s' room to administer the medication. R30 received: Aspirin chewable 81mg 1 tablet by mouth Apixaban 5mg 1 tablet by mouth Ferrous Sulfate Tablet 325mg 1 tablet by mouth Metoprolol Tartrate Tablet 12.5 mg 1 tab by mouth Amlodipine Besylate 5 mg 1 tablet by mouth Probiotic Capsule 250 mg 1 capsule by mouth R30's Physician order dated 08/12/2022 documents in part, Aspirin EC Low Dose Delayed Release 81mg- Give 1 tablet by mouth one time a day. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications and 1 of 6 medication carts were secure while not in use or in view. These deficient practices have the potential to affect 60 residents residing on the third floor of the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide care according to professional standards for two (R131, R135) residents out of a sample of 26 residents reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure air mattresses were at the appropriate settings for 2 (R12, R26) residents reviewed for pressure ulcer prevention in a sample of 29. Findings Include: R12 has diagnoses (Dx) not limited to senile degeneration of brain, peripheral vascular disease, dementia, quadriplegia, chronic kidney disease, uninhibited neuropathic bladder, major depressive disorder R12's Order Summary Report document in part: Pressure reduction mattress, order date 10/25/22. R12's Care Plan document in part: R12 has (stage 4 pressure ulcer present on sacrum) related to impaired mobility, incontinence, cognitive deficit, Dx: quadriplegia, history of CVA, dementia, depression, terminal illness, at risk for malnutrition, weight loss, date initiated 8/24/2021. R12's Braden Scale dated 09/30/22 document in part: Braden Risk Levels: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label oxygen tubing for one (R55) resident reviewed for oxygen therapy in a sample of 29 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain medications from the pharmacy and administer medications as prescribed for one (R135) resident out of a sample of 26 residents reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their infection prevention and control policy when staff entered the rooms of 1 residents (R392) on transmission-based precautions without wearing the appropriate personal protective equipment (PPE). Findings Include: On 10/25/2022 at 12:03pm, R392's room observed with a droplet and contact precaution signage posted on the outside of the room door. Isolation signage instructs individuals entering R392's room, to put on a face mask, face shield or goggles, gloves, and isolation gown before entering the room. V39 (Certified Nursing Assistant) observed in R392's room not wearing gloves or an isolation gown. On 10/25/2022 at 12:03pm, V39 stated, I have been working here for 4 weeks, and I have never seen an isolation sign posted on R392's door. These signs are new, and I did not see them posted. [...]