Landmark of Cicero Rehabilitation and Nursing Cent

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its abuse prevention policy by: 1) failing to immediately protect R16 and all other residents after an allegation of staff-to-resident physical abuse was presented to facility administration; 2) failing to establish coordination between the facility's Quality Assurance and Performance Improvement (QAPI) program and the facility's abuse prevention program by tracking data of potential indicators of abuse; and 3) failing to develop plans of care for identified offenders that included recommendations made by the state police. These failures affect 3 residents (R16, R37, R63) in a sample of 68 residents. These failures have the potential to affect all 238 residents that reside in the facility and place all residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water temperatures for staff and visitors were at safe temperatures, failed to ensure dryer lint traps were clean to provide a safe environment for the residents and staff, and failed to provide clean homelike environment in the dining room and two community shower rooms on the fourth floor. These failures have the potential to affect all 238 residents residing at the facility and an indeterminate number of staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a linens for resident beds, failed to provide a safe environment, failed to ensure baseboards were free of holes and secured to the wall, failed to provide a clean environment in the resident's room that was free from debris, and failed to provide safe functioning air conditioners in resident rooms. These failures affected 11 residents (R2, R5, R12, R36, R38, R56, R65, R203, R218, R219, and R238) in a sample of 68 residents reviewed for home-like environment. Findings Include: 1. R12's Face sheet documents R12 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include Parkinsonism, Bipolar, Vascular dementia, and Personality Disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete assessments accurately and failed to complete the Minimum Data Set accurately in accordance with RAI guidelines. These failures affected four residents (R1, R2, R5, & R6) in a sample of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from verbal/mental abuse. This failure affected three residents (R49, R140, R204 ) in a sample of 68 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse to the State Survey Agency within regulatory reporting requirements and failed to report allegations of abuse to the Abuse Prevention Coordinator. These failures affected three residents (R16, R140, R204) in a sample of 68 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse. This failure affected one resident (R16) in a sample of 68 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one of six crash carts in the facility, with non-expired supplies and failed to stock the items in the crash cart checklist so the crash cart was complete and ready for emergency use. This failure has the potential to affect all forty residents on the eighth floor.

Inspectors wroteBased on interview and record review, to provide adequate supervision and interventions for a resident, R2, assessed as a smoker. This failure resulted in R2 sustaining a fall while unsupervised.

Inspectors wroteBased on interview and record review, the facility failed to ensure trauma screenings were documented as recommended and/or failed to conduct/document required abuse risk assessments per regulatory requirements for three of three residents (R1, R2, R3) reviewed for abuse/misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans include risk for abuse with preventive interventions for three of three residents (R1, R2, R3) reviewed for abuse/misappropriation of funds.

Inspectors wroteBased on interview and record review, the facility failed to provide a decision maker for a resident with severely impaired mental status. This failure affected one (R1) resident reviewed for residents' rights in the total sample of 4 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's refusal of medications was care planned. This failure affected one (R2) resident reviewed for care plan in the total sample of 10 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dish machine had the correct concentration of chlorine to sanitize dishes, trays, and utensils; failed to ensure the floor of the dry storage room was kept clean and free of visible debris, mice droppings, and spilled grits. These failures have the potential to affect all 266 residents that receive oral food from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 2 of 3 outside dumpsters garbage disposal were covered with the lids. This failure has the potential to harbor rodents which could cause infection and affect all 266 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility assessment was developed in accordance with all required information. This failure has the potential to affect all 266 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program to prevent and eliminate rodents/mice from the kitchen's dry storage area. This failure has the potential to affect all 266 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served timely and failed to ensure dining room seating was available for four of 59 residents (R102, R108, R213, R241) in the sample reviewed for resident rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify maintenance concerns, failed to document maintenance concerns/repairs, and failed to repair damaged ceilings/heater, for 54 (4th floor) residents reviewed for home-like environment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive, person-centered, and individualized fall care plans for four residents (R2, R8, R230, R253) with a history of falls. These failures have the potential to affect four residents (R2, R8, R230, and R253) reviewed for care plans in the total sample of 59 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities that are appropriate for the season. This failure affected one resident (R71) and has the potential to affect all 32 residents that reside within the 3rd floor dementia unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered within regulatory requirements and failed to document medication administration timely for 8 of 59 residents (R24, R30, R88, R159, R245, R267, R276, R286) in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not accessible to unauthorized individuals, failed to ensure medication room doors were locked, failed to store medications in locked cabinets/refrigerators, failed to maintain the medication refrigerator temperature between 36F (Fahrenheit) to 46F, and failed to store refrigerated medications within the required temperature range. These failures have the potential to affect a total of 94 residents residing on 5th and 6th floors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient plates were available, failed to provide meals timely, failed to ensure hamburgers appeared palatable, failed to ensure steam table lids fit properly, and failed to maintain food temperatures within requirements to prevent food borne illness. These failures affect 54 (4th floor) residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct hand hygiene prior to passing meal trays for four (R7, R57, R181, R211) of 59 residents reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the sixth-floor men's resident shower room and the eighth floor east wing community shower room were maintained in a clean and sanitary condition; and failed to cover an open electric wire on the wall of the eighth floor. These failures have the potential to affect 71 residents on the sixth floor and 37 residents on the east wing of the eighth floor, reviewed for sanitary and safe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure handrails within hallways used by residents. This failure has the potential to affect all 32 residents that reside on the 3rd floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code Minimum Data Sets (MDS) in accordance with the Resident Assessment Instrument (RAI). This failure affected three residents (R9, R11, R71) reviewed for assessment accuracy in a sample of 59 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal/hygiene care was provided to two of 59 dependent residents (R11, R40) in the sample reviewed for ADL care provided to dependent residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure alarms were functioning properly, failed to implement fall prevention interventions, and failed to provide supervision for two of 59 residents (R17, R230) in the sample reviewed for safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispense the correct medication and failed to dispense the correct medication dose. There were 2 medication errors out of 25 opportunities, resulting in a 8% medication error rate. 1 resident (R24) in the medication administration sample was affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate seating was available for one of 59 residents (R213) in the sample.

Inspectors wroteBased on interview and record review, the facility failed to update one resident's falls care plan with new interventions to prevent or reduce the risk of further falls. This affected one of three residents (R1) reviewed for plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively monitor/supervise residents in the dining room to prevent an avoidable accident. This affected one of three residents (R1) reviewed for supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable temperatures and failed to have a system in place to accurately take and record temperatures to ensure resident safety during extreme weather conditions. This failure has the potential to affect all 266 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve lunch to residents in the dining room at the same time as other residents seated at the same tables. This affected four of four residents (R192, R195, R258, and R260) reviewed for dignified dining experience in a sample of 63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and document consent for participation in a pharmacy program, which included taking medication (descovy) for human immunodeficiency virus (HIV) pre exposure prophylaxis for four (R117, R129, R256, R258) of four residents reviewed for resident rights.

Inspectors wroteDeficiencies at this level require more than one deficient practice statement. A. Based on interview and record review, the facility failed to conduct care plan meetings with residents and/or resident representatives quartely, and failed provide residents with an opportunity to participate in the development, review, and revision of their care plans. This failure affected six of seven residents (R9, R15, R149, R161, R211, and R255) reviewed for care planning in a sample of 63

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the lunch meal served from the steam table at a temperature of at least 125 degrees Fahrenheit. This failure affected the 10 of 10 ( R51, R79, R176, R186,R192,R195, R222, R256,R258, R260) residents on the eighth floor nursing unit.

Inspectors wroteBased on observation, interview, and record review, this facility failed to ensure there was a call light cord attached to the call light switch on the wall for a dependent resident. This affected one of three residents R161 reviewed for call light accessibility in a sample of 63.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident abuse to the State Agency. This affected one (R170) of three residents reviewed for abuse policy and procedure.

Inspectors wroteBased on record review and interview, facility staff failed to accurately code a Minimum Data Set (MDS) for residents. This affected three of three residents (R98, R46, R269) reviewed for accurate assessment in the total sample of 63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively monitor/supervise a resident with known history of wandering into other residents' rooms. This affected one of three residents (R255) reviewed for monitoring/supervision in a sample of 63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve double portions for one resident (R260) who was identified with a significant weight loss of 7.5 % in three months. This affected one of seven (R260) reviewed for significant unplanned weight loss This failure resulted in the R260 losing an additional unplanned five pounds in a month, and a total of 12.5% in six months.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was free from unnecessary medications and with a diagnosis for the use of an anticoagulant. This affected one of one resident (R120) reviewed for unnecessary medications in the total sample of 63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check a resident's food allergy prior to meal service. This affected one of one residents (R192) reviewed for food allergies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain separation between clean and soiled equipment, and failed to ensure staff and residents were not sharing drinks to prevent cross-contamination. This failure affected three residents ( R68, R161, and R178) out of four reviewed for infection control in a sample of 63.

Inspectors wroteBased on interview and record review, the facility failed to post Nurse Staffing Data available for residents and visitors. This failure has the potential to affect all 267 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report a physical abuse allegation to the State Agency. This failure applied to one (R1) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of resident to resident physical abuse. This failure applied to one (R1) of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform a blood glucose check on a diabetic resident that was reporting symptoms of a low blood sugar for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a cognitively impaired resident on an altered diet did not have access to a regular consistency sandwich. This failure resulted in R5 who was found choking and subsequently died. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 10/12/24 when R5 experienced a choking episode and dying at the hospital on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on 11/14/24 at 9:44 AM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 11/14/24; however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on interview and record review the facility failed to ensure the treatment plans from an infectious disease practitioner and a dermatologist were implemented for a resident with a rash for 1 of 3 residents (R3) reviewed for quality of care in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was served a no concentrated sweets diet as ordered by the physician for 1 of 3 residents (R3) reviewed for therapeutic diets in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to reassess a resident's right and privileges to go out on pass. This applies to 1 of 9 residents (R3) reviewed for resident rights in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure resident funds were refunded after discharge to 1 of 3 residents (R1) reviewed for personal funds in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and ensure residents received spiced peaches with the noon meal for all residents who receive meals in the facility.

Inspectors wroteBased on observations, interview, and record review the facility failed to maintain an effective pest control program to support a sanitary environment and to enhance each residents' quality of life due to the continued presence of pests throughout the facility. This failure has the potential to impact all residents served by the dietary department.

Inspectors wroteBased on observation, interview and record review the facility failed to utilize appropriate CPI technique by using excessive force while attempting to deescalate resident's behaviors and failed to prevent a resident-to-resident physical assault. This affected four of four residents (R1, R4, R3 R5) reviewed for abuse. This failure resulted in R1 being forced to the ground during CPI and R1 sustaining a right tibial plateau fracture. This failure also resulted in R5 being struck in the face by R3 with a closed fist unprovoked.

Inspectors wroteBased on interview and record review the facility failed to follow physician referral orders for unilateral inguinal hernia. Failed to follow orders and schedule gastroenterologist appointment for rectal bleeding for six months. Failed to complete a comprehensive assessment after complaint of rectal bleeding, failed to test for occult stool. This affected one of three residents (R2) reviewed for quality of care. This failure resulted in R2 having a delay in evaluation of rectal bleeding and hernia repair surgery, from 4.14.23 to 10.19.23. On 10.19.23 R2 was sent to the local hospital to be evaluated, treated for hernia repair. R2 secondary diagnosis was diagnosed with 5.0 cm rectal tumor with metastasis to the regional lymph nodes, liver, and lungs.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their abuse policy to report an alleged resident to resident physical assault. This affected two of four residents (R3, R5) reviewed for reporting abuse.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their abuse policy and investigate an alleged resident to resident physical assault. This affected two of four residents (R3, R5) reviewed for investigating physical abuse. Findings Include: R3 is [AGE] years old with diagnosis including but are not limited to Schizoaffect Disorder, Psychosis, and Anxiety. R5 is [AGE] years old with diagnosis including but are not limited to Schizoaffective Disorder, Bipolar type, Conduct Disorder, On 11/1/23 at 1:17PM V3, Security, said R3 was using both fists, throwing punches. V3 said R3 was hitting R5 on his face. V3 said R5 just said stop but didn't do anything else. V3 said I took R3 to the desk with the nurse. V3 said R3 got to swinging on the other guy. V3 said I saw R3 hit R5 like 4 hits before we intervened. V3 said V2 assisted him with R3. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their physician visits policy by not developing a treatment plan for a refusal of hernia surgery and the physician failed to document the resident refusal of treatment and services for a rectal bleed for approximately 8 months. This failure affected one of three residents (R2) reviewed for physician services. This failure resulted in R2 being sent to the hospital being diagnosed with 5.0 cm rectal tumor with metastasis to the regional lymph nodes, liver, and lungs.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their resident rights policy to provide safety and good care for 1 of 3 residents (R4) reviewed for dental care in a sample of 13.

Inspectors wroteBased on observation interview and record review the facility failed to follow its' policy and procedure for Activities of Daily Living (ADL) Care by not giving residents routine daily and night care by a certified nursing assistant (CNA) for 1 of 3 residents (R6) reviewed for ADL care in a sample of 13.

Inspectors wroteBased on observation, interviews and record review, the facility failed to prevent an incident of resident-to-resident physical assault that resulted in injury and psychosocial harm to R2, as the facility failed to follow their abuse policy by preventing physical abuse for one resident as a result of a physical attack by a peer (R1). This failure resulted in R2 sustaining swelling and bruising to his left upper lip and right eye, along with a cut to the bridge of his nose and caused psychosocial harm to R2 as he verbalized fear and feeling scared of another peer attacking him, which makes him not feel safe at the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to establish the rationale for transfers and discharges; failed to communicate and implement the discharge process accordingly for residents with mental illness and medical conditions. These failures affected 54 (R4, R7, R10 - R25, R28, R35 - R42, R45 - R54, R56 - R72) of 54 residents in the sample of 87 reviewed for transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to adequately notify the power of attorney and resident representative when transferring and/or discharging residents. This failure applied to eight (R11, R15, R16, R37, R54, R57, R58, and R61) of 87 residents reviewed for transfer and discharge.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide residents with sufficient preparation and orientation prior to transfer and/or discharge. This failure applied to eight (R10, R11, R15, R16, R18, R23, R36, and R37) of 54 residents in the sample of 87 reviewed for transfers and discharges.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide residents with required bed hold notice upon transfer to the hospital. This failure applied to nine (R31, R43, R73, R74, R75, R76, R78, R79 and R80) of 16 residents in the sample of 87 reviewed for bed-hold policy.

Inspectors wroteBased on interview and record review, the facility failed to provide a completed and accurate discharge summary for residents upon discharge from the facility. This failure applied to 50 (R4, R10, R11, R12, R13, R14, R15, R16, R17, R18, R21, R22, R28, R35, R36, R37, R38, R39, R40, R41, R42, R45, R46, R47, R48, R49, R50, R51, R52, R53, R54, R56, R57, R58, R59, R60, R61, R62, R63, R64, R65, R66, R67, R68, R69, R70, R71, R72, R85, R87) of 87 residents reviewed for proper discharge.