Claridge Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R2) did not physically abuse other residents for three of nine residents (R1, R2, R3) reviewed for abuse in the sample of nine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a history of elopement and identified as high risk for elopement was provided adequate supervision to prevent elopement and failed to ensure an exit door alarm was alarmed. This failure resulted in R1 eloping from the facility without being witnessed on 3/11/26 being found about 1.6 miles away having crossed three busy heavily traveled roads. This applies to 1 of 3 residents (R1) reviewed for safety supervision in the sample of 3. This failure resulted in immediate jeopardy. The Immediate Jeopardy began on 3/11/26 when staff were unable to locate R1. V1 (Administrator) was notified of Immediate Jeopardy on 3/17/26 at 3:15 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to treat a resident with dignity and respect for1 of 4 residents (R1) reviewed for dignity in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident went to her outpatient medical appointment for 1 of 3 residents (R1) reviewed for medical appointments in the sample of 4.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident did not elope from the facility's locked unit, failed to update the list of residents at risk for elopement, and failed to update a resident's care plan after an elopement for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions for a resident at risk for elopement to elope from the facility. These failures resulted in R1 eloping from the facility and being found walking in the road of a heavily traveled highway. This applies to one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/7/25 when staff were unable to locate R1 inside the facility. V2 (Director of Nurses) was notified of the Immediate Jeopardy on 9/12/25 at 9:50 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 9/12/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from resident-to-resident physical abuse for 1 of 7 residents (R4) reviewed for abuse in the sample of 7. Findings Include:On 9/2/25 at 12:50 PM, V3 (Assistant Director of Nursing) said there was an altercation that had just occurred between two residents {R4 and R5} and one of the residents was punched in the face and was just sent to the hospital because he had a small laceration on the side of his eye. R4's face sheet shows he has diagnoses including Alzheimer's disease, muscle weakness and abnormality of gait and mobility. R4's active care plan last revised on 7/8/25 shows he is alert but confused and forgetful, uses a wheelchair for mobility and his primary language is Spanish. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from misappropriation of resident property for 1 of 4 residents (R1) reviewed for misappropriation in the sample of 7. Findings Include:An Illinois Department of Public Health Investigation Report completed by V3 (Assistant Director of Nursing) on 8/21/25 shows that R1 had reported that $300 was missing from her wallet. The report shows that R1 had taken a nap between 1:30-5:00 PM and when she woke up to take her medication, she noticed her wallet was not secured and the envelope she had inside it with her money was gone. The report shows that R1 is alert and oriented x 4 and cooperative. A Nursing Progress Note completed by V17 (Registered Nurse) on 8/20/25 at 10:30 PM for R1 states, Resident reported to nursing assistant that she lost $300.00 between 1 PM and 5 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the abuse coordinator was immediately notified of an allegation of misappropriation of resident property for 1 of 5 residents (R1) reviewed for abuse reporting in the sample of 7. Findings Include:An Illinois Department of Public Health Investigation Report completed by V3 (Assistant Director of Nursing) on 8/21/25 shows that R1 had reported that $300 was missing from her wallet. A Nursing Progress Note completed by V17 (Registered Nurse) on 8/20/25 at 10:30 PM for R1 states, Resident reported to nursing assistant that she lost $300.00 between 1 PM and 5 PM. On 9/2/25 at 3:10 PM, V19 said R1 did report to her that she had money missing from her wallet. V19 said she went and told her nurse (V17) that evening about the missing money. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have a system in place for monitoring resident room temperatures during hot weather. This applies to 4 of 5 residents (R1-R4) reviewed for comfortable room temperatures in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident (R1) from physical abuse by another resident (R2). This applies to 2 of 5 residents (R1, R2) reviewed for physical abuse in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident which applies to 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for abuse in a sample of 7. This failure resulted in R1 sustaining a right hip fracture.

Inspectors wroteBased on interview and record review the facility failed to notify law enforcement when an allegation of physical abuse occurred which applies to 4 of 4 residents (R1, R2, R4, R5) reviewed for abuse notification in a sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were supervised and trained by a qualified dietary manager resulting in R6, R53, R21, and R65 receiving incorrect physician prescribed diets and resulted in R6 choking, requiring the Heimlich maneuver. R6 required hospitalization for aspiration pneumonia and remains at risk for further episodes of choking and aspiration due to continuing receiving the incorrect diet. This failure applies to 4 of 4 residents (R6, R53, R21, and R65) reviewed for mechanical soft diets in the sample of 20. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/22/24, when the facility failed to ensure residents were served a mechanically soft diet as prescribed by their physician. V1 (Administrator) was notified of the Immediate Jeopardy on 6/4/24 at 2:30 PM. [...]

Inspectors wroteI. Based on observation, interview, and record review the facility failed to ensure residents with a history for choking and at risk for choking were served the correct physician prescribed diets. This failure resulted in R6 choking, requiring the Heimlich maneuver, going to the hospital, and being treated for aspiration pneumonia. R6 returned to the facility and continued to be served the incorrect diet putting him at risk to choke again. The facility also failed to ensure R21, R53, and R65 were served the correct physician prescribed diets putting them at risk to choke. This applies to 4 of 20 residents (R6, R21, R53, R65) reviewed for menus in the sample of 20. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/22/24 when the facility failed to ensure residents were served a mechanically soft diet as prescribed by their physician. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Registered Dietician was immediately notified of a significant weight loss for a resident receiving enteral feedings. This failure resulted in a delay in a resident (R24) being assessed by the dietician to implement interventions to prevent further weight loss. The facility failed to ensure weekly weights were completed for a resident (R1) on enteral feedings with insidious weight loss. This applies to 2 of 3 residents (R24, R1) reviewed for enteral feedings in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a qualified, full time activity director. This failure applies to all 84 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient nursing staff to meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide medically related social services to meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a serving spoon was sanitized and air dried to prevent foodborne illness. This has the potential to affect all 82 residents in the facility receiving food from the kitchen.

Inspectors wroteBased on observation, interview and record review facility administration failed to manage the facility in manner to effectively meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide/employ a qualified, full-time social worker. This failure has the potential to affect all 84 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure nursing staff received dementia care training and education, annually, as required. This failure has the potential to affect all 84 residents in the facility.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure the residents were provided activities. This applies to 3 of 20 residents (R48, R65, R74) reviewed for activities in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure opened, multi-dose bottles of medication, inhalers, and insulin pens were labeled with expiration dates for 4 of 4 residents (R64, R20, R45, R82) reviewed for medication storage in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident with a multi-drug resistant urinary infection was placed on contact isolation. The facility failed to initiate enhanced barrier precautions on residents with a catheter, tube feeding, and/or wounds. These failures apply to 5 of 20 residents (R51, R4, R84, R1, R24) reviewed for infection control in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident, dependent upon staff for cares, had a call light system in place to meet the needs of the resident. This applies to 1 of 20 residents (R4) reviewed for accommodation of needs in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was provided privacy during wound dressing changes. This applies to 1 of 20 residents (R6) reviewed for privacy in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff-dependent residents were bathed, their nails were cut, and facial hair was groomed for 3 of 20 residents (R1, R24, R64) reviewed for activities of daily living (ADL's) in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a skin rash was assessed and failed to ensure a skin treatment was applied according to standards of practice, for 1 of 20 residents (R17) reviewed for quality of care in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a sacral pressure injury was assessed, reported to the physician, and a treatment for the injury was in place. The facility also failed to follow physician orders for pressure injuries. This applies to 1 of 3 residents (R6) reviewed for pressure injuries in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to provide restorative services to 2 of 5 residents (R24, R64) reviewed for restorative cares in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents at risk for falls were supervised and interventions were in place to prevent falls. The facility also failed to ensure residents were transferred in a safe manner. These failures apply to 2 of 20 residents (R21, R65) reviewed for safety/supervision in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was dated and failed to change humidifier containers on the oxygen concentrator for 2 of 4 residents (R23, R61) reviewed for oxygen administration in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor behaviors and provide stimulation for residents with a diagnosis of dementia. This applies to 3 of 3 residents (R21, R53, R138) reviewed for dementia in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were dispensed according to standards of practice for 1 of 20 residents (R26) reviewed for pharmacy services in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident admitted for therapy services received therapy services. This applies to 1 of 4 residents (R84) reviewed for therapy services in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were screened for and received all recommended doses of the pneumococcal (pneumonia) vaccine for 2 of 5 residents (R388, R38) reviewed for the vaccine in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of sexual abuse was immediately reported to the Administrator for 1 of 1 resident (R1) reviewed for abuse reporting in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were not verbally abused by R2 for 3 of 4 residents (R1, R3, R4) reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure a thorough investigation of an abuse allegation was conducted for 1 of 3 abuse investigations reviewed involving 2 of 4 residents (R1, R2) in the sample of 4.

Inspectors wroteBased on observation, interview and record review the facility failed to set up a urology appointment for a resident with a suprapubic urinary catheter for (R46) 1 of 4 residents reviewed for urinary catheters in the sample of 20. This failure resulted in R46 suffering from catheter pain, leaking, urinary blockages and infections requiring emergency treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dishes were sanitized after washing in the 3-compartment sink. This has the potential to affect all 88 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a facility wide assessment was reviewed and updated at least every year. This failure has the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to have a written QAPI plan and failed to show evidence of an ongoing QAPI Program. This has the potential to affect all 88 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and maintain an Enhanced Barrier Precautions Policy and Procedure, failed to develop, and maintain a Water Management Plan to detect and prevent water borne pathogens, and failed to have a system in place for tracking and trending any infections in the facility. The facility also failed to ensure that staff change their gloves and wash their hands while providing care to residents to prevent cross contamination. This has the potential to affect all 88 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was administered in a manner to prevent infection for 4 of 4 residents (R58, R26, R1, R338) reviewed for oxygen in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications at the ordered time and ordered dosages. There were 28 opportunities with three errors resulting in a 10.71% error rate. This applies to 2 of 3 residents (R41 and R43) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a resident in a dignified manner for two of 20 residents (R48, R51) reviewed for dignity in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy by not investigating and reporting an injury of unknown origin and verbal abuse allegation for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin and an allegation of verbal abuse to the abuse coordinator for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to investigate injuries of unknown origin and allegation of verbal abuse for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to ensure residents who require extensive assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 20 residents (R41 and R16) reviewed for ADLs in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure necessary care and treatment was performed for a resident with leg ulcers and failed to ensure compression stockings were applied for a resident with edema. This applies to 2 of 20 residents (R4, R16) reviewed for quality of care in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to arrange for a resident to see the eye doctor upon resident complaints of being unable to see. This applies to 1 of 20 resident (R62) reviewed for vision and hearing in a sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure ulcer treatment orders were followed and in place for a resident with pressure injuries for 1 of 3 residents (R26) in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have fall prevention interventions in place and failed to safely transfer residents for two of 20 residents (R73, R76) reviewed for safety in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed notify the physician of a significant weight loss, failed to ensure residents with a significant weight loss were assessed by a dietitian, and weight loss prevention interventions were implemented for 2 of 9 residents (R3 and R4) reviewed for weight loss in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure diet orders were followed for a resident on a tube feeding for 1 of 2 residents (R1) reviewed for tube feeding in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure controlled drugs were reconciled and failed to ensure medications were administered for 2 of 2 residents (R11, R41) reviewed for medication administration in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's liquid Morphine (Schedule II Controlled Substance) was stored in a separately locked, permanently affixed compartment for storage of controlled drugs for 1 of 1 resident (R5) reviewed for medication storage in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to assist a resident who is having mouth pain in making a dental appointment for 1 of 20 residents (R41) reviewed for dental services in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received all recommended doses of the Pneumonia Vaccine. This applies to 2 of 5 residents (R13, R66) reviewed for vaccinations in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff removed PPE (personal protective equipment) when exiting the COVID-19 unit, failed to ensure a COVID-19 positive resident remained isolated, failed to ensure staff wore a N95 mask when cleaning a COVID-19 positive room, and failed to prevent cross contamination by cleaning a COVID-19 positive room then a COVID-19 negative room. This has the potential to effect all 84 residents at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a resident from eloping off of a locked memory unit, failed to supervise a resident at risk for aspiration while eating, and failed to transfer a resident in a safe manner after a fall. This applies to 4 of 22 residents (R10, R62, R38, R48) reviewed for safety in a sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to puree bread for 4 of 4 residents (R21, R285, R42, and R84) reviewed for following the menu in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nail care and personal hygiene were completed for 1 of 22 residents (R72) reviewed for Activities of Daily Living (ADL's) in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure ulcer. This apples to 1 of 5 residents reviewed for pressure injuries in a sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure restorative care was being completed, and failed to ensure assistive devices were implemented for a resident with contractures, for 1of 8 residents (R52) reviewed for restorative services in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident was offered and assisted with eating to maintain weight and adequate nutritional intake. This applies to 1 of 4 residents (R48) reviewed for weight loss in a sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication ordered for a particular resident was not administered to another resident for 2 of 2 residents (R61 and R285) reviewed for pharmacy services in the sample of 22.