Logan Square Rehabilitation and Healthcare Center

Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that toileting hygiene and assistance was provided for two of six residents reviewed (Resident R2 and R3).

Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide medications in accordance with physician orders and in a timely manner for one of six residents reviewed (Resident R2).

Inspectors wroteBased on observations, policy and interviews with staff, it was determined that the facility failed to ensure sanitary food handling practices were followed by dietary staff.

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility did not ensure posting of required State Survey Agency contact information was readily accessible on two of two nursing floors. (Second-Floor and Third-Floor Nursing Units) Findings Include: Review of facility policy titled, Resident Rights with a revised date of February 2011 states, Policy Statement- Employees shall treat residents with kindness, respect, and dignity. Further review of the policy states, Policy Interpretation and Implementation- 1. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to:.u. voice grievances to the facility, or other agency's that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; v. [...]

Inspectors wroteBased on a review of facility policies, medical records, observations, and interviews with residents and staff, it was determined that the facility failed to ensure proper infection prevention and control practices for three of five residents observed (Residents R31, R20, and R95). Specifically, the facility failed to implement Enhanced Barrier Precautions (EBPs) during wound care, medication administration via feeding tube, and personal care, placing residents at risk for transmission of multidrug-resistant organisms (MDROs).

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to ensure the resident and the residents representative received a written transfer notice that included all required details for one of three closed records reviewed (Resident R112).

Inspectors wroteBased on observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to medications found at bedside for one of thirty-three residents reviewed. (Resident R62)Findings Include: Review of facility policy titled, Administer Medications with a date of April 2019 states, Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. Further review of the facility policy revealed, 21. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. Review of Resident R62's record revealed the resident was admitted to the facility on [DATE]. The resident had the following medical diagnosis: [...]

Inspectors wroteBased on a review of facility policy and resident clinical records, it was determined that the facility failed to ensure timely and effective follow-up of consultant pharmacist medication regimen review (MRR) recommendations for two of four residents reviewed. (resident R 137, and R7) This failure had the potential to result in inappropriate medication use and medication errors.

Inspectors wroteBased on review on observations, interviews, review of clinical documentation, and review of facility policy it was determined that the failed did not ensure accurate documentation related to pharmacy reviews for one of 22 residents reviewed. (Resident R75)Review of Resident R75 Consultant Pharmacist MMR Recommendation to Prescriber, dated October 15, 2025, indicated Resident has two order(s) for the following: acetaminophen 500mg and Acetaminophen 325mg for mild pain. Please discontinue duplicate order, if appropriate. If both orders are to be given concurrently, please add the total mg dose to each order. Further review revealed a Physician/ Prescriber response to discontinue 325mg and continue with 500mg for scale 1-4 pain. Review of Resident R75 clinical record revealed a physician order for Acetaminophen 500mg discontinued on December 19, 2025. [...]

Inspectors wroteBased on observations, review of facility policies, review of facility grievances, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to administer medications in a timely manner for five of five residents reviewed (Residents R1, R2, R3, R4 and R5).

Inspectors wroteBased on the observation, review of facility policy and procedure, review of manufacturers guidelines, and interviews with staff, it was determined that the facility failed to properly label medications upon opening for ophthalmic solutions found on two of three medications carts observed. (third floor carts one and two)

Inspectors wroteBased on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for two of 30 residents reviewed (Resident R215 and R165). Findings Include: Review of Resident R215's clinical record revealed the resident was admitted to the facility on [DATE]. Height and weight measurements dated December 11, 2024, revealed Resident R215 was 6 feet 3 inches tall and weighed 225 pounds. Review of Resident R215's clinical record revealed a nursing note dated December 11, 2024, at 11:49 p.m. that a TELS (an electronic system used to enter, manage, and track maintenance requests) request was placed for a bed extender (increases the length and/or width of existing bed to provide more space and comfort). During an interview on January 12, 2025, at 11:35 a.m. [...]

Inspectors wroteBased on observation and review of facility policy, it was determined that the facility failed to ensure that the residents right to privacy was protected for two of 30 residents reviewed.

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative that included initial goals based on admission orders, physician orders, therapy services and social services for one of 22 residents reviewed (Resident R164).

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring and administering of medications) to meet the needs of each resident for one of 22 residents reviewed (Resident R34). Findings Include: Review of facility policy Unavailable Medication dated June 2021 revealed in conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interviews, it was determined the facility failed to provide adaptive equipment for 1 of 18 residents observed during dining on the third-floor dining room.

Inspectors wroteBased on review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Director of Nursing Services attended a quarterly Quality Assurance Process Improvement (QAPI) committee meeting for nine of nine QAPI meeting documentations reviewed (February 2024 through October 2024). Findings Include: A review of QAPI committee meeting attendees list for the month of February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, September 2024 and October 2024 revealed that it lacked Director of Nursing as attendee for the meetings. This information was confirmed by the facility Regional Staff during a meeting on January 15, 2025, at 1:13 p.m. Facility documentation provided at the time of the survey did not have evidence that the director of nursing attended the meetings. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that each resident was offered an influenza immunization for two of seven residents reviewed for immunizations (Resident R34 and R315). Findings Include: Review of Resident R34's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 21, 2024, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Interview on January 14, 2025, at 1:38 p.m. with Resident R34 the resident denied being offered the influenza immunization on admission but admitted being willing to accept the vaccine if suggested by the physician. [...]

Inspectors wroteBased on observations, review of clinical record, and staff and resident interviews it was determined that the facility failed to provide a sanitary and comfortable environment for two of 30 residents reviewed (Resident R220 and R164). Findings Include: Review of Resident R220's clinical record revealed a physician order dated January 1, 2024, for an antibiotic medication to be administered intravenously (medical technique that administers medications directly into the vein) one time per day. Observations on January 15, 2024, at 11:56 a.m. with Director of Nursing, Employee E2, revealed Resident R220's IV pole (a device that holds a bag of intravenous fluids or medications in place as it is being administered to a patient) was soiled at the base of the pole with what appeared to be old tube feeding formula. Interview with Resident R164 and with resident's family on January12, 2025 at 11: [...]

Inspectors wroteBased on a review of clinical records and facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for one of three residents sampled (Residents R1)

Inspectors wroteBased on review of facility documentation, review of policy and procedures, review of clinical records, review of hospital records, observation and interviews with staff, it was determined that the facility failed to provide adequate supervision to a resident with a history of over-the-counter medication usage. The facility failed to conduct a thorough assessment of the resident's environment to ensure that the resident was not in possession of over-the-counter medication for one of seven residents reviewed (Resident R31), which resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on review of facility policy, review of clinical record, and interviews with staff and residents, it was determined that the facility failed to ensure that one of 34 residents received showers. (Resident R6). Findings Include: Review of undated facility policy Resident Rights revealed federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the residents right to self-determination. Review of Resident R6's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2024, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Further review of the MDS revealed the resident was dependent on staff for shower/bathing. [...]

Inspectors wroteBased on review of facility policy, review of clinical record, observations, and interviews with staff and residents, it was determined that the facility failed to administer a resident's tube feeding per the physician orders for one of one resident with tube feeding reviewed (Resident R6). Findings Include: Review of undated facility policy Enteral Nutrition revealed adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete and include volume and rate of administration. [...]

Inspectors wroteBased on review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to ensure that residents were free from accidents related to self administration of medication. This failure placed Resident R31 at high risk for injury and was identified as an Immediate Jeopardy.

Inspectors wroteBased on review of facility policy, review of facility documents and resident clinical record and staff and resident interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of one residents reviewed (Resident R49). Findings Include: Review of facility policy Binding Arbitration Agreements dated October 2022, revealed binding arbitration agreements are explained to the resident or their representative in a language form, and manner that they can understand. Review of Resident R49's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 19, 2023, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of senile degeneration of brain (loss of intellectual ability). [...]

Inspectors wroteBased on observation, interviews with staff and review of facility policies and procedures, it was determined that the facility did not ensure an effective infection control program was maintained related to hand hygiene during wound care for one of one resident observed with wounds. (Resident R96)

Inspectors wroteBased on observation, review of clinical records, review of facility policy, and staff interviews, it was determined that the facility failed to provide a communication device to maintain optimal communication for two of seven residents reviewed. (Residents R1 and R7)

Inspectors wroteBased on observation, interview with resident and staff, review of resident records and facility policy, it was determined that the facility failed to ensure care and services was provided with dignity and respect related to one resident's dinning experience of two resident records reviewed (Resident R1).