Bria of Elmwood Park

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R1) from physical abuse by R2, with a known documented history of verbal altercations between R1 and R2, who were roommates, yet R1 and R2 remained assigned to the same room despite these ongoing altercations. These failures affected one (R1) of four residents reviewed for abuse. These failures resulted in R1 being struck in the face with a glass vase by R2. R1 sustained pain, bruising, and swelling to the left side of the face and was transferred to the hospital for evaluation and treatment where R1 was admitted with a diagnosis of assault related to the injuries sustained during the incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy procedures, failed to follow physician orders, failed to follow the facility assessment tool, failed to schedule required nursing staff, and failed to ensure that sufficient nursing staff were available to meet the needs for four of four residents (R2, R3, R8, R9) reviewed for medication administration. These failures have the potential to affect 174 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to follow policy procedures, failed to follow physician orders, failed to administer medication as prescribed, and failed to ensure that four of four residents (R2, R3, R8, R9) reviewed for medication administration remained free from significant medication errors.

Inspectors wroteBased on interview and record review the facility failed to follow policy procedures and failed to submit a facility reported incident to IDPH (Illinois Department of Public Health) within regulatory requirements for one of three residents (R6) reviewed for abuse.

Inspectors wroteBased upon interview and record review, the facility failed to follow policy procedures and failed to conduct a thorough investigation for two of three residents (R4, R5) reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to follow policy procedures and failed to develop a baseline care plan within 48 hours of admission for three of four residents (R1, R4, R6) reviewed for abuse and falls.

Inspectors wroteBased on interview and record review the facility failed to follow policy procedures, failed to timely reorder medication, and failed to ensure that prescribed medication was available for one of four residents (R3) reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (R6) was free from unnecessary restraint use, failed to ensure restraints were applied in a manner that allowed for easy release, failed to obtain informed consent prior to restraint use, failed to release restraints in accordance with the facility's restraint program/policy and professional standards, failed to exhaust all required interventions prior to initiation of restraint use, failed to follow the facility's restraint protocol/policy. This failure affected one resident (R6) in a sample of 82 residents reviewed for restraints. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide R1 enteral nutrition as ordered by the physician/dietician, failed to follow the facility's tube feeding management policy, failed to provide nutrition and hydration to R11 as indicated in his Illinois Department of Public health Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form, failed to notify the dietician of changes in resident's diet order, and failed to document those changes in resident's medical record. Applying the reasonable person concept due to R1's severe cognitive impairment and inability to make needs known, a reasonable person would have suffered unnecessary psychosocial harm by the delay of feeding and not abiding by resident's last wishes by feelings of hunger, pain, and headaches. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's abuse policy, failed to establish coordination with the facility's QAA/QAPI program and the abuse prevention program, and failed to ensure agency staff were educated/competent on the facility's abuse policy upon hire. These failures affect all 107 residents that reside within the facility and place all residents at risk for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure certified nursing assistants received a performance review annually and received training based on areas identified in the performance review. These failures have the potential to affect all 170 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to comply with proper food storage and sanitation protocols; failed to ensure that residents' food items in the facility kitchen are dated when removed from original box and when opened; failed to ensure that residents' food items in the facility kitchen are properly stored; and failed to ensure the scoops for bulk food items are stored appropriately. These failures have the potential to affect all 156 residents receiving an oral diet in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the outside dumpsters were closed. These failures have the potential to affect all 170 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to employ a Registered Nurse (RN) to serve as the facility's assistant director of nursing (ADON) according to state regulations, failed to ensure the staff member covering/responsible for the ADON's duties was an RN as required by state regulations. This failure has the potential to affect all 170 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to disclose their quality assurance performance improvement plan when requested by the state survey agency. This failure has the potential to affect all 170 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility's quality assurance and performance improvement (QAPI) committee failed to complete a performance improvement project annually. This failure has the potential to affect all 170 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical director was invited and attended quality assurance and performance improvement (QAPI) committee meetings. This failure has the potential to affect all 170 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wore appropriate PPE (personal protective equipment) when providing care for residents on isolation, failed to ensure EBP (enhanced barrier precautions) sign was posted for a resident on EBP, failed to ensure staff doffed isolation gown appropriately, failed to ensure staff kept personal item outside of resident's room, and failed to ensure hand sanitizers were available. These failures affected three (R46, R87, and R139) residents reviewed for infection control and have the potential to affect all 47 residents on the second floor.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of staff screening, education, offering and current COVID-19 vaccination status of all staff. This failure has the potential to affect all 170 residents currently residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure agency staff were trained on the abuse prevention program/policy as indicated within the facility abuse policy and facility assessment. This failure has the potential to affect all 170 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct mandatory training of all staff on the facility's QAPI program that includes the goals and elements of the QAPI program. This failure has the potential to affect all 170 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promotes the resident's right to dignity by failing to cover urinary catheter drainage bags for three residents (R7, R8, and R183); and failed to ensure residents were provided privacy during blood glucose monitoring and insulin administration for two (R96 and R149) residents who were seated at a table in the dining room during the lunch meal with multiple other residents present. These failures affected five residents (R7, R8, R96, R149 and R183) of 82 residents reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to submit a new PASRR (Preadmission Screening and Resident Review) level I screening for residents who have new diagnosis of mental illness (R21 and R49), and failed to ensure that two residents are screened for PASRR level 1 (R46 and R61) as indicated in their level 1 PASRR outcome. This failure affected four (R21, R46, R49, and R61) residents reviewed for PASRR screening in the total sample of 82 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff documented changes in resident's diet orders and failed to notify the dietician of those changes for one resident (R11), failed to maintain professional standards of medication storage, labeling and pharmacy services failed to ensure expired insulin was removed from the active medications in the medication cart for eight (R14, R35, R78, R100, R149, R160, R186, and R187) residents, failed to ensure multi-dose insulin vials and insulin pens were dated upon opening and first use while stored on the medication cart for six (R33, R78, R129, R185, R186, and R189) residents, failed to ensure insulin and an albuterol inhaler without a pharmacy label with the resident's name was removed from the active medications in the medication cart, failed to remove expired stock medication from the medication cart, [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that emergency medical equipment stored to be used in emergency basic life support was checked daily. This deficient practice has the potential to affect all 35 residents that reside on the 3rd floor of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that four residents (R61, R87, R134, and R191) low air loss (LAL) mattress were not layered with multiple linen layers and failed to have the low air loss mattress (LAL) at the correct weight settings for one resident (R87). These failures affected four residents (R61, R87, R134, and R191) at risk for developing pressure ulcers in the sample of 82 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the respiratory equipment was contained for two residents (R8 and R68); failed to ensure the respiratory equipment was changed for two residents (R5 and R68); and failed to ensure the respiratory equipment was dated for two residents (R68 and R184). These failures have the potential to affect four residents (R5, R8, R68, and R184) reviewed for respiratory care in a total sample of 84 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure there was sufficient staffing for the respiratory (ventilator) unit to meet the resident's needs. This failure affects all 32 residents that reside in the respiratory unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure staff properly documented medication administration on the controlled substance record for three (R100, R167, and R175) residents and failed to ensure a resident's Oxycodone controlled medication was initially documented on an individual controlled substance form for one (R188) resident. These failures affected four (R100, R167, R175, and R188) of four residents reviewed for pharmacy services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that five residents (R1, R11, R12, R39, and R172) reviewed for medication administration, remained free from significant medication errors in a sample of 82 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure expired insulin was removed from the active medications in the medication cart for eight (R14, R35, R78, R100, R149, R160, R186, and R187) residents, failed to ensure multidose insulin vials and insulin pens were dated upon opening and first use while stored on the medication cart for six (R33, R78, R129, R185, R186, and R189) residents, failed to ensure insulin and an albuterol inhaler without a pharmacy label with the resident's name was removed from the active medications in the medication cart, failed to remove expired stock medication from the medication cart, and failed to ensure the cleanliness of the medication cart by failing to remove 24 loose pills. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident's (R183) call light was readily accessible and within reach to call for staff assistance and failed to ensure resident (R183) was able to effectively utilize the call system. These failures affect one resident (R183) in a sample of 82 residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident's advance directive was followed when determining the type of life sustaining measures provided to the resident. This failure affected one resident (R11) of one resident reviewed for advance directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's information was protected. This failure affected one (R21) resident reviewed for confidentiality of records in the total sample of 82 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to code Minimum Data Set (MDS) assessments accurately. This failure affected one resident (R6) in a sample of 82 residents reviewed for assessment accuracy.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program by failing to refer one (R102) resident for a level one screening to determine the presence of a serious mental illness, intellectual or developmental disability and to ensure the best setting for the resident and any services needed. This failure affected one (R102) of 11 residents reviewed for PASRR screening.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise one (R6) resident care plan after restraints were initiated. This failure affected one resident (R6) reviewed for care planning in a total sample of 82.

Inspectors wroteBased on interviews and record review, the facility failed to implement care plan interventions for a resident identified at risk for falls. This deficient practice statement affected one resident (R2) out of five reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standards of nursing practice by failing to ensure effective communication of clinical information during the resident's transfer to the acute care hospital. This failure applied to two (R3, R5) of three residents reviewed for hospital transfer procedures.

Inspectors wroteBased on interviews and record review, the facility failed to follow its fall prevention policy as evidenced by:Failure to complete fall risk evaluations/assessments prior to and following resident falls. Failure to document a resident's fall. This deficient practice affected two residents (R2 and R4) out of five residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination and integration of hospice services into the resident's plan of care by not incorporating resident request for hospice enrollment into the resident's active physician orders, failing to ensure nursing staff were aware of the resident's hospice status, and failing to communicate hospice enrollment during a hospital transfer. This failure applied to one (R3) of three residents reviewed for hospice services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were able to receive visitors of their choosing at the time of their choosing by limiting visitors after 8pm. This failure applied to two (R1, R5) of three residents reviewed for resident rights and has the potential to affect other residents in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to maintain adequate nutrition independently received enteral nutrition as ordered and failed to maintain accurate records of daily enteral intake for residents. This failure affected three of three (R1, R4, R5) residents reviewed for enteral feeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received care and services in accordance with professional standards of practice by failing to monitor potassium levels after initiation and continuation of potassium supplementation and by failing to recognize and act upon a critically abnormal laboratory value. The facility did not ensure timely laboratory monitoring for a resident receiving potassium and failed to notify the provider or initiate emergent medical intervention when a critically high potassium level of 8.4 mEq/L (normal range 3.5-5.1) was identified. These failures applied to one (R1) of three residents reviewed for nursing care and resulted in R1 not receiving medical intervention for critically high potassium level; R1 subsequently experienced cardiac arrest in the facility and expired four days after the laboratory result was obtained. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that laboratory results were communicated to the ordering provider in accordance with facility policy and procedures for notification. This failure applied to one (R1) of three residents reviewed for notification of laboratory results and resulted in no provider being notified that R1 had a critical potassium level of 8.4 mEq/L (normal range 3.5-5.1), putting R1 at risk of cardiac arrythmia (irregular or abnormal heart rhythm). R1 subsequently experienced cardiac arrest in the facility and expired four days after the laboratory result was obtained. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was provided with continued assessment and monitoring while receiving potassium supplementation. This failure applied to one resident (R1) who was being treated for low potassium of 2.5 mEq/L and then continued to receive the potassium supplement with no plan for monitoring or follow up labs scheduled, in order to confirm the continued need for treatment. As a result, R1 was found to have a critically high potassium level of 8.4 mEq/L (normal range 3.5-5.1) when labs were re-checked 13 days later.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standard infection prevention and control regarding hand hygiene and use of gloves during care for two residents (R12 and R13) in the sample reviewed for infection control. As a result, R12 ADLs (Activities of Daily Living) bed bath was done with staff assistance with gloved hands not performing any hand hygiene or removing soiled gloves and touching R13 belongings and the clean linen cart with soiled gloves. This failure affected R12, R13 and has the potential to affect all 37-residents residing on the 1st floor.

Inspectors wroteBased on interview and record review, the facility failed to follow their discharge policy and Against Medical Advice (AMA) policy when discharging a resident. This failure affected one resident (R4) of three residents reviewed for discharge. R4 was discharged from the facility to an unknown location and the facility does not know resident's current location or condition.

Inspectors wroteBased on interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to obtain vital signs, failed to conduct a thorough assessment, failed to fill out an SBAR (Situation Background Assessment Recommendation) form, and failed to ensure that EMS (Emergency Medical Services) was made aware of resident status/vital signs prior to arrival for one of three residents (R2) reviewed for change in condition. These failures contributed to R2's [DATE] death.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff report/document maintenance issues/broken equipment, and failed to ensure that broken equipment was not in use. These failures have the potential to affect 169 residents.

Inspectors wroteBased on record review and interview the facility failed to follow policy procedures, failed to document a grievance form, failed to investigate reported theft of funds, and failed to report a theft allegation to IDPH (Illinois Department of Public Health) for one of three residents (R4) reviewed for misappropriation of funds.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate staffing of certified nursing aides and implement an effective system in place for call-offs on the night shift. This failure has the potential to affect all residents residing on the first floor. Findings Include:Based on Facility Census Report dated 9/30/2025, there were 38 residents residing on the first floor. Facility Assessment Tool dated 8/1/2025 with review date of 10/1/2025 shows the facility will staff 10 CNAs in total on the night shift. Facility Staffing Sheets dated 9/9/2025-9/28/2025, showed 6 night shifts out of 20 reviewed, were staffed with less than 10 CNA's. On 9/29/2025 at 11:45AM, R3 said at nighttime he has to wait a long time for his call light to be answered. At 11:50AM, V5 (Registered Nurse) said she works both night and day shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent multiple fall incidents for a resident assessed to be high risk for fall. Facility also failed to follow proper post fall procedure and transferred resident back to bed who complained of right leg pain upon ROM (Range of Motion) assessment. This deficient practice affects one resident (R1) of three residents reviewed for fall incidents. R1 was sent out to the hospital and admitted with Right Closed Hip Fracture. Findings Include:R1 is a [AGE] year-old female resident with diagnoses of but not limited to: Muscle Weakness, Abnormal Posture, Depression, Profound Intellectual Disabilities, Seizure, Atherosclerotic Heart Disease, Dementia without Behavioral Disturbance, Anemia, Anxiety, and Generalized Osteoarthritis. admitted in the facility on 4/12/2010. R1 had a fall incident on 3/25/25 and 7/5/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Activities of Daily Living (ADL) policy by not providing ADL care assistance to dependent residents. This applies to 2 of 3 residents (R4 and R5) reviewed for ADL care in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately transcribe hospital nutrition support orders for one resident (R1) who readmitted to the facility on [DATE] and failed to follow physician orders for three residents (R2, R3, and R4) who require nutrition support. This failure resulted in R3 having a severe weight loss of 11.7% in six months and R1 who was severely underweight with multiple pressure ulcers to not receive adequate nutrition. Findings Include: R1 is a [AGE] year-old male who originally admitted to the facility on [DATE]. R1 was hospitalized on [DATE], readmitted to the facility on [DATE], and sent to the hospital again on 6/2/2025. R1 remains in the hospital at the time of this survey. R1 has multiple diagnoses including but not limited to the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to one (R1) out of three residents reviewed for falls (R1, R2, and R3) and failed to follow their fall policy and procedure after R1 experienced a fall on 5/14/2025.

Inspectors wroteBased on interview and record review the facility failed to revise and update Abuse/Neglect Care Plan affecting 1 of 3 (R1) residents reviewed for Abuse Care Plan. Findings Include: On 4/24/2025 at 9:27 AM, V6 (Social Service Director) stated Social Service Department is responsible for updating resident Abuse Comprehensive Care plan. Care plan is updated quarterly, annual, and significant change such as grievance/concern related to allegation. V6 said sexual abuse allegation is considered a concern. V6 stated R1's abuse/neglect comprehensive care plan was last updated/revised on 3/28/2024. V6's abuse care plan should have been updated on 4/22/2025 when a sexual abuse allegation was reported to IDPH. On 4/24/2025 at 10:24 AM, V9 (MDS Coordinator) said she oversee the overall care plan like a gate keeper. [...]

Inspectors wroteBased on interview and record review the facility failed to report immediately resident to resident sexual abuse allegation to Illinois Department of Public Health and Local Law Enforcement affecting 1 of 3 (R1) residents reviewed for Abuse. Findings Include: On 4/22/2025 at 9:15 AM during initial interview, V1 (Administrator) stated that the facility was aware of the sexual assault allegation by R1. V1 stated R1 was upset because of room change and allegation about roommate was told to V11 (Licensed Practical Nurse/LPN) who was the nurse on duty. V1 stated the sexual allegation that R1 stated was he was touched inappropriately and penetrated by his roommate. V1 stated R1's roommate has been discharged from facility. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a credentialed certified respiratory staff, as required by state law, to perform respiratory assessment, treatment, and monitoring for residents requiring respiratory care for 3 of 19 (R67, R79, R149) residents reviewed for respiratory care in the sample of 58. The Immediate Jeopardy began on 01/27/2025 at 12:07 PM when V5 (Respiratory Technician/Student) was observed independently providing tracheostomy care to R149. V1 (Administrator) was notified on 01/29/2025 at 03:12 PM of the Immediate Jeopardy. The facility presented an acceptable removal plan, and the immediacy was removed on 02/03/2025 The surveyor conducted onsite investigation on 02/03/2025 to confirm the removal plan was implemented. V1 (Administrator) was informed that the Immediate Jeopardy was removed on 02/03/2025.

Inspectors wroteBased on interviews and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for a resident who was experiencing a change in condition for 4 of 4 (R61, R67, R79, R149) of residents reviewed for services provided to meet professional standards in the sample of 58. This failure resulted in R61's unnecessarily prolonged physical distress and anxiety lasting until the resident made arrangements to be taken to the hospital, where she was diagnosed with pneumonia and influenza A

Inspectors wroteBased on interview and record review, the facility failed to timely assess and respond to a significant change in condition for 1 (R61) of 1 resident reviewed for acute medical changes from the sample of 58. This failure resulted in the delay of care to send the resident to the emergency department, failure to assess the resident's medical condition after pleas for hospitalization, resulting in prolonged physical distress, pain, and anxiety for nineteen hours, after which she was admitted for pneumonia and influenza.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a grievance council that addresses residents' complaints to voice and resolve concerns of food quality. This failure affected four residents (R71, R81, R99 and R107) out of a total sample size of 30 and has the potential to affect 128 of 150 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a credentialed certified respiratory staff, as required by state law, to perform respiratory assessment, treatment, and monitoring for residents requiring respiratory care. This failure has a potential to affect all residents requiring respiratory care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to adequately protect its residents by failing to supply individuals entering the facility with appropriate masks during an influenza outbreak. This failure had the potential to adversely affect the facility's entire resident population of 150.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy by 1. Failing to ensure staff properly document medication administration of medication on the controlled substance record for three (R14, R17, and R256) residents, and 2. Failed to follow their policy by failing to ensure a newly admitted resident's Oxycodone controlled medication was initially documented on an individual controlled substance form for one (R257) resident. These failures affected four (R14, R17, R256, and R257) residents reviewed for pharmacy services.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure licensed staff administered medicated breathing treatment for 1 of 6 (R67) residents reviewed for medication administration in the final sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy by 1. Failing to ensure medication without a resident name and medication discontinued by the physician was removed from the active medications in the medication cart for one (R15) resident, 2. Failed to follow their policy by failing to ensure expired insulin and insulin without a resident's name was removed from the active medications in the medication cart for one (R75) resident, 3. Failed to follow their policy by failing to ensure new unopened insulin was refrigerated per the facility policy to retain purity and potency for one (R256) resident. These failures affected three (R15, R75, and R256) residents reviewed during medication storage and labeling. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their mechanical lift policy by not keeping the base in the widest/opened position when lowering/transferring a resident with the mechanical lift. This affected one of three residents (R3) reviewed for safety when using the mechanical lift for transfers. This failure resulted in R3 hitting his head hard on the floor sustaining an acute subdural hematoma .

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect a resident (R1) from resident-to-resident physical abuse. This failure affected one (R1) resident out of four residents reviewed for abuse. As a result of this failure, R2 hit R1 in the face with a remote control resulting in R1 sustaining facial lacerations with bleeding, requiring medical attention.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of physical abuse for one (R1) resident out of three residents reviewed for physical abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident recieved the correct dose of medication as prescribed, Oxycodone 5 milligrams every eight hours as needed. This affected one of three residents (R1) reviewed for professional standards of care for medication administration.

Inspectors wroteBased on interview and record review the facility failed to follow their narcotic medication policy to ensure control medication Oxycodone 5 milligrams are documented and accounted for. This affected one of three resident (R1) reviewed for controlled medications.

Inspectors wroteBased on interview and record review the facility failed to serve palatable resident meals. This failure affects six ( R3, R6, R7, R8, R9 and R10) residents reviewed for food palatability.

Inspectors wroteBased on interview and record review the facility failed to provide residents with dinner meal at the facility's designated mealtimes. This failure affected 14 (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) residents review for frequency of meals.

Inspectors wroteBased on interview and record review, the facility failed to make transportation arrangements that took into account the resident's physical and mental needs, in order to avoid a missed appointment with the resident's oncologist. This failure applied to one (R1) of four residents reviewed for assistance with transportation arrangements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their narcotic and medication administration policy by not documenting in the electronic medical record (EMR), that narcotic medication was administered. This failure applied to one (R11) of four residents reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to prevent an incident of staff to resident mental abuse. This affected one of three residents (R5) reviewed for mental abuse. This resulted in V9 (Activity Aide) pulling a wig off R5's head after a disagreement. R5 said she felt humiliated and embarrassed.

Inspectors wroteBased on interview and record review the facility failed to ensure that all healthcare personnel have current basic life support cardiopulmonary resuscitation training and certification. Ten certified Nursing Aides 10 of 10 (V27, V28, V29, V30, V31, V32, V33, V34, V35, V36) reviewed for current CPR.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a licensed respiratory therapist on duty on 8/8/24 for the entire duration of the shift. This affected 11 of 11 residents (R13-R23) reviewed for respiratory care.

Inspectors wroteBased on interviews and records reviewed the facility failed to notify the attending physician of an acute change in condition to include loose stools and weakness. This affected one of three residents (R1) reviewed for notification of a change.

Inspectors wroteBased on interviews and records reviewed the facility failed to conduct a comprehensive assessment of one resident who developed new loose stools. This affected one of three residents (R1) reviewed for quality of nursing care and assessments. This failure resulted in R1's loose stools being left untreated.

Inspectors wroteBased on interview and record review, the facility nursing staff failed to provide timely respiratory care to a resident with a tracheostomy and failed to provide documentation of monitoring for an agitated resident for an hour after suctioning. These failures affected one (R2) of three residents reviewed for respiratory care in the sample of four. This failure resulted in R2 left being agitated with no follow up for one hour after trach care from RT, found with this trach out and in respiratory arrest. The Immediate Jeopardy began on [DATE] when R2 gestured and pointed to his trach, was not immediately suctioned by nursing staff, but later was by respiratory who admitted R2 was agitated before, during, and after trach care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of quality by 1. Failing to provide timely respiratory tracheostomy care; 2. Failed to respond to request from resident for respiratory suctioning to clear airway; 3. Failed to have staff who had the necessary skills to adequately meet the needs of the resident in respiratory distress; 4. Failed to provide adequate supervision and monitoring of tracheostomy patients to avoid life-threatening situations. These failures affect 1 (R2) of 3 residents reviewed for respiratory care in the sample of 4 and have the potential to affect 12 residents in the facility.

Inspectors wroteBased on interview and record review, the facility nursing staff failed to respond to a resident requiring respiratory care and the nursing staff failed to provide needed suctioning for a resident in potential hypoxia (lack of oxygen); for one (R2) of three residents reviewed for respiratory care in the sample of four.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow the facility abuse policy to conduct criminal background checks within 24 hours after admission of a new resident for 11 (R14, R35, R45, R48, R52, R56, R68, R70, R95, R106, R122) of 11 residents reviewed for criminal background check. This failure has the potential to affect the 153 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two resident shower rooms on the first floor were in working order. This failure affected R25 and has the potential to affect all 28 residents residing on the first floor. Findings Include: On 3/11/24 at 11:40AM, R25 stated, I do not like receiving showers because the water temperature in the shower is too cold. The CNA's will turn the hot water all the way up and it is still freezing cold. I request for bed baths instead of showers because the hot water in the shower does not work. On 3/11/2024 at 12:35PM, this surveyor observed two shower rooms on the first floor. One of the shower rooms was observed to be missing a handle and not in working order. The second shower room temperature was noted to not reach an acceptable hot water temperature. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ADL (Activities of Daily Living) care to 4 (R89, R92, R95, R154) of 8 residents reviewed for residents dependent on staff to provide ADLs in the sample of 74.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 25 medication opportunities resulting in a 12% medication error rate. This failure affected one resident (R43) and has the potential to affect all 53 residents on the 4th floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff accommodate a resident's need to utilize a wheelchair for mobility as assessed and according to resident's care plan. This failure affected one resident (R89) of 3 residents review for mobility/limited range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one resident (R54) with existing pressure ulcers with necessary treatment and services consistent with professional standards of practice to promote wound healing and prevent infection and failed to provide psychological services for a resident with a history of refusing pressure ulcer treatments. These failures affected one resident (R54) of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall interventions for one (R112) of 5 residents reviewed for falls in the sample of 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practice during incontinence care. This failure affected 1 (R124) of 9 residents reviewed for bowel and bladder care.

Inspectors wroteBased on interview and record review the facility failed to protect a resident from sexual abuse from another resident when both residents were found engaging in inappropriate behavior in bed earlier that same day. This failure resulted in R13 found with her breast exposed and R6 poking R13's genitals through R13's clothes. This failure affected 1 resident (R13) of 2 residents reviewed for sexual abuse in a total sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not ensuring one resident (R11) social security checks were returned to the office of social security after being discharged from the facility for four months. This affected one of three residents (R11) reviewed for misappropriation of funds. This failure resulted in R11's family not receiving two months of social security payments for daily expenses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement effective pressure prevention interventions. This affected one of three residents (R7) reviewed for pressure sores. This failure resulted in R7 stage 4 pressure ulcer progressing to develop osteomyelitis (an inflammation or swelling of bone tissue this is usually the result of an infection.)

Inspectors wroteBased on interview and record review the facility failed to monitor and supervise a resident with a diagnosis of dementia and a history of wandering. This failure affected two of three residents (R6, R13) reviewed for supervision. This failure resulted in R13 being able to wander into R6 room, and being found by facility staff with R6 inappropriately touching and groping R13 while exposing R13's breast.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the physician of abnormal laboratory test results for one resident (R7) out of three reviewed for physician notification in a sample of 18. R7's elevated sodium level (sodium 151, normal range is 135-145) was reported to this facility on 1/17/24 at 4:02pm and not reviewed by nursing staff until 1/18/24 at 2:54 AM. This result was not communicated to R7's physician prior to R7 being admitted to the hospital on [DATE] at 9:20pm with diagnoses including dehydration and elevated sodium level (sodium 158).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their facility assessment tool for staffing by not having two nurses on the first floor morning shift on 2/2/24. This failure resulted in R2, R14, R15 and R16 receiving their medication over one hour late. In addition, the facility failed to have enough staff to provide direct care on the night shift for 12/05/23. This failure resulted in R2 not being provided incontinence care and R3 who was diagnosed as dependence on renal dialysis missing her scheduled in-house dialysis treatment as prescribed. This failure affects five of five residents reviewed for staffing.

Inspectors wroteBased on interviews and record reviews, the facility failed to report and investigate an allegation of injury of unknown origin. This deficient practice affects one resident (R5) of three residents reviewed for abuse. R5 was noted to have bruising on right shoulder, reported to the facility by a family member on 12/24/23. Findings Include: Facility Reportable Incidents reported to IDPH in December 2023, there is no report filed for R5's allegation of injury of unknown origin On 2/7/24 at 2:45PM, V1 was asked if there was reportable done to R5 on December of 2023. V1 stated nothing was reported to V1 about abuse and bruising. Stated that the DON and the wound care team looked at it on the 12/29/23 when it was reported to them, it was not bruising it is skin pigmentation. Facility unable to provide state reportable and investigation of injury of unknown source for R5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their weight management policy and the recommendation of the dietician by not monitoring weekly weights for one of three (R12) residents. This failure resulted in R12 sustaining an unplanned 24.5% weight loss over three months.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow physician's order and failed to administer medication for pain. This deficient practice affect one resident (R8) of three residents reviewed for medication administration and fall incident. R8 had a fall, and complaint of right hip pain. Staff received an order for right hip and femur STAT x-ray and to give 650mg of acetaminophen for the pain. Findings Include: R8 had a fall incident on 2/7/24 upon record reviewed. Nursing notes reviewed and on 2/7/2024, Nurses Notes reads in part: R8 found on floor, full assessment completed, no signs and symptoms (s/s) of injury noted, no s/s of pain noted. Placed back in bed. Bed in lowest position. R8 had no pain after fall incident, however on the 2/7/23 (day shift), R8 complaint of right hip pain. Nurse received an order for STAT hip and femur x-ray and to give Tylenol for pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow a resident who was diagnosed with End Stage Renal Disease and dependence on renal dialysis plan of care by not transporting 1 of 3 (R3) to their scheduled dialysis treatment. This failure resulted in R3 missing one three hour treatment. Findings Include: R3 was diagnosed with End Stage Renal Disease and dependence on renal dialysis. Brief interview for mental status dated 01/08/24 documents a score of thirteen which indicate cognitively intact. Section GG (functional abilities) documents: R3 had impaired lower extremity (hip, knee, ankle, foot) on both sides and required a wheelchair. On 2/7/23 at 10:42AM, V16 (Dialysis Nurse) said, R3 was scheduled for 6:00am dialysis treatment on 12/6/23. V16 said, she called R3's nursing station to inquire about R3 who was not in dialysis. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow physician orders and obtain a stat x-ray of the right hip and femur within 4-6 hours. This affected one of three residents R8 reviewed for radiology. This failure resulted in delay in R8 being x-rayed post fall for over 24 hours. Findings Include: R8 had a fall incident on 2/7/24 upon record reviewed. Nursing notes reviewed and on 2/7/2024, Nurses Notes reads in part: R8 found on floor, full assessment completed, no signs and symptoms (s/s) of injury noted, no s/s of pain noted. Placed back in bed. Bed in lowest position. R8 had no pain after fall incident, however on the 2/7/23 (day shift), R8 complaint of right hip pain. Nurse received an order for STAT hip and femur x-ray and to give Tylenol for pain. On 2/7/2024 11:04 Nurses Notes reads in part: Writer informed NP that resident is complaining of right hip pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their abuse prevention policy and procedures by failing to protect 1 of 3 residents (R1) in the sample from abuse by a staff member. This failure resulted in R1 being pushed to the bed, forcibly restrained, and roughly suctioned by a respiratory therapist (V3) after a physical struggle. This failure also led to R1 expressing fear, anger, and frustration with facility for not preventing further contact with this staff member after the resident reported the incident to his nurse and family member. This resulted in an Immediate Jeopardy (IJ). The Immediate Jeopardy began on 12/25/2023 when V3 (Respiratory Therapist) physically abused R1 and satisfied interventions were not implemented to prevent it from happening again. The immediacy was removed on 01/07/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their abuse prevention investigation procedures by failing to conduct a thorough investigation of an alleged abuse by a staff member; Failed to remove access by the alleged perpetrator to the victim; and failed to provide ongoing assurances of protection after appeals from the resident and family member to disallow alleged staff member access to the resident. This failure affects 1 of 3 residents (R1) in the sample and led to R1 being physically abused, restrained, and roughly suctioned by a staff person, and continued fearfulness of staff person's return.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy for tracheotomy suctioning, failed to follow physician orders to provide adequate and appropriate respiratory and tracheal suctioning consistent with professional standards of practice for 1 of 3 residents (R1) in the sample. This failure resulted in R1 not receiving sufficient suctioning to maintain tracheal airway free from mucus/phlegm and failed to conduct tracheal suctioning care by being forcibly suctioned in a harsh and non-gentle manner by the respiratory therapist who caused pain and fear to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to take appropriate action to ensure the safety of 1 of 3 residents (R1) in the sample. The facility administration failed to protect a resident from harmful actions inflicted by staff, failed to conduct a thorough investigation of an allegation of abuse, and failed to honor the requests of the resident to remain safe and free from harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and implement a treatment plan for one resident who was at moderate risk for skin breakdown and readmitted to the facility with a stage two pressure sore. This affected one of three residents (R11) reviewed for pressure sore prevention. This failure resulted in R11's wound worsening and progressing to a stage 4.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected two of three residents (R1, R2) reviewed for investigation of an allegation of sexual assault. This failure resulted in R2 not being physically assessed by facility after an allegation of sexual assault was made by R1.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide appropriate and sufficient supervision to prevent avoidable accidents for two residents (R2 and R19) out of three residents reviewed for falls in a sample of 34. This failure resulted in R19 sustaining a right pelvic fracture.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor a gastrostomy stoma site for placement and signs/symptoms of infection. This affected one of three residents (R14) reviewed for Gastrostomy tube care. This failure resulted in R14's gastrostomy tube requiring hospitalization and requiring abdominal surgery.

Inspectors wroteBased on interview and record review the facility failed to follow their antibiotic stewardship policy to ensure one resident was receiving the correct treatment for a urinary tract infection and wound infection, and failed to track the duration of antibiotic therapy, in order to monitor the effectiveness of antibiotic therapy. This affected two of three residents (R9, R12) reviewed for antibiotic therapies. This failure resulted in R9 being hospitalized with a white blood count of 79.1(normal range 3.5-10.5) and diagnosed with septic shock related to sacrococcygeal osteomyelitis and urinary tract infection/cystitis.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies to include bathing and incontinence care for residents reliant on staff for care needs. This affected six of six residents ( R1, R2, R3, R4, R15, R16) all reviewed for assistance with activities of daily living.

Inspectors wroteBased on observations, interviews, and record review this facility failed to properly prevent and/or contain the spread of Covid-19 by not following their infection control protocol to include donning and doffing the appropriate personal protective equipment prior to entering and exiting a Covid-19 isolation room, and following hand hygiene policy and procedures. This affected four of four residents (R12, R25, R29, and R30) reviewed for infection control.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify residents' family members of positive Covid-19 infection by 5:00 pm the next calendar day following confirmed infection of Covid-19. This failure affected 9 residents (R4, R25, R26, R29, R30, R31, R32, R33, and R34) out of 20 residents positive for Covid-19 infection in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's family representative with changes in sacral pressure ulcer and treatments. This failure affected one resident (R14) out of three residents reviewed for notification of change and treatments.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse policy and conduct a thorough investigation for an allegation of physical abuse involving two residents (R23 and R24) out of 3 reviewed for abuse in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician orders to restart glaucoma eye drops for one of three residents (R12) reviewed for readmission orders after hospitalization. Findings Include: On 9/6/23 at 4:55 pm, V2 (Director of Nurses) said, R12 had multiple hospitalizations. R12's Latanprost eye drop was not reinstated as a mistake. At that time we had a lot of agency nurses working. R12's eye drops should not have been discontinued nor should they have been stopped without a doctor's orders. On 9/1/23 at 10:30 am, V31 (Pharmacy Personnel) said, R12 did not have Latanprost eye drops for three months. R12 did not have any billing issues. Every time, R12's eye drops were requested we sent them. Nurse Practitioner note dated 6/6/23 documents: [...]

Inspectors wroteBased on interview and record reviews, the facility failed to review and revise the falls care plan to prevent or reduce the risk of falling. This affected one of three residents (R19) reviewed for plan of care review and revisions.

Inspectors wroteBased on interviews and record reviews, the facility failed to consistently monitor and implement pressure relieving interventions to prevent the development of a facility acquired pressure ulcer for one resident (R13). This failure resulted in R13 developing a stage 3 sacral pressure ulcer on 2/27/23 which worsened to a stage 4 pressure ulcer during R13's stay at this facility. In addition, the facility failed to prevent one resident (R20) who was identified as very high risk for pressure injuries from developing a facility acquired deep tissue injury for two of three residents reviewed for wound care.

Inspectors wrote1. Based on interview and record review, the facility failed to follow physician orders by not ensuring an urgent abdominal x-ray was completed as ordered on 7/3/23 for one resident (R14). This failure resulted in R14 having an abdominal ultrasound, not an x-ray as ordered, 48 hours later on 7/5/23. In addition, the facility failed to follow physician orders to obtain a stat doppler for one resident (R9) who was displaying signs of cyanosis in lower bilateral lower extremities for two of three reviewed for diagnostic testing.