Morgan Park Healthcare

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident (R6) who depends on staff's assistance for their ADL (Activities of Daily Living) care received incontinence care. This failure affected one residents R6 out of six residents reviewed for ADL care.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician-ordered physical therapy, occupational therapy and speech therapy screening upon admission was completed for one resident (R2). This failure affected one of six residents reviewed for specialized rehabilitative services.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable, homelike environment by ensuring that the toilets in residents' rooms were functioning for four residents (R4, R11, R21 & R24) and ensuring that one resident's (R4) dresser drawer was not broken with exposed nails. These failures have affected four residents from the sample of 4 residents reviewed for homelike environment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that: a Fall Risk Assessment was completed for one resident (R12) who sustained a fall in the facility that resulted in a fracture; failed to ensure that an Incident Report was completed for two residents (R12 and R9) post falls; and failed to ensure that Fall Interventions were updated on the Care Plan for (R8, R9 and R12). These failures have affected three of four residents reviewed for falls.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that prescribed medication was administered to four residents (R7, R10, R11 and R12) within an hour of the scheduled time, and the facility failed to ensure that an IV (Intravenous) medication hanging at R10's bedside was labeled with the date and time it was administered. These failures affected four residents (R7, R10, R11 and R12) reviewed for nursing care in a total sample of twelve residents.

Inspectors wroteBased on interview and record review the facility failed to update the care plan for one (R1) of 6 (R1, R3, R4, R5, R6, R7) residents reviewed for falls. Findings Include:R1 was admitted to the facility on [DATE] with diagnosis not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and With Stage 5 Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, End Stage Renal Disease, Dependence on Renal Dialysis, Dementia, Epilepsy, Acute Pain, Presence of Automatic (Implantable) Cardiac Defibrillator, Seizures, Alzheimer's Disease and Diabetic Retinopathy with Macular Edema. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 07 indicating severe cognitive impact. R1's Initial reportable dated 03/23/26 document in part: R1 was observed on the floor next to the bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor, supervise, and intervene for seven residents (R1, R3, R7, R19, R20, R21, R22) with known substance use disorders. This failure resulted in the residents engaging in activities suspected of drug use and overdose. R1, R7, R19, and R21 were found unresponsive in the facility. R3 was found unresponsive in the facility and expired with suspicion of drug overdose. The facility also failed to provide supervision and monitoring for residents. As a result of these failures, R4 fell on the floor on [DATE], while located inside the facility and sustained a left femur fracture. The facility also failed to update a fall care plan and follow assessments to prevent 1 out of three residents (R6) from falling. These residents were reviewed for accidents and supervision in a sample of 22. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy to protect two residents (R13, R14) from abuse in a sample of 22 residents reviewed for abuse. This failure resulted in psychosocial harm to R13 and R14.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to follow their employee handbook policy related to employee cell phone use. This failure has the potential to affect 115 residents residing in the unit.

Inspectors wroteBased on interview and record review, the facility failed to treat a resident's personal belongings with respect and ensure the resident has access to their personal belongings. This failure affects one (R4) resident out of three residents reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and revise a care plan to ensure that the resident's care plan addressed each fall and interventions were changed with each fall for one (R4) out of three residents reviewed for care plans following a fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper indwelling catheter care for two residents (R7, R9) of 22 residents reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, clean and comfortable environment. This failure affects all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow sanitation and food handling practices while preparing resident meals. Failed to record temperatures of food before serving residents. Failed to maintain temperatures of food before serving food to residents. This failure affected 20 residents reviewed for food safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain clean kitchen and food storage room floors and walls, compromising safe and sanitary dietary conditions. This failure has the potential to affect 213 residents residing in the facility. On 2/13/2026 at 11:29, V22 (Dietary Manager) stated the dietary aides and cooks are responsible for cleaning the floors in their assigned stations; she (V22) is in the process of revising job descriptions; has not received complaints of bugs in food; has not observed bugs in the kitchen; and there is not a staffing issue in the kitchen. V22 stated the purpose of clean and sanitation in the kitchen practice good cleaning practices for the health of the residents. V22 verified the kitchen contained dirty floors with trash on the floors and debris along the walls throughout the kitchen. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that the dumpster was closed and free from trash. These failures have the potential to affect all 213 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, clean and comfortable environment. This failure affects all 213 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control that eliminated roaches and mice in the facility. This failure has the potential to affect all 213 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable environment for seven residents (R3, R4, R5, R9, R19, R21, R22). Failed to provide functional furniture to store clothes for two residents R3 and R5. Failed to provide adequate window coverings for one resident (R3). Failed to ensure there were no holes in the walls of resident living areas for three (R4, R5, and R9). Failed to ensure the floors were clean and no garbage was on the floor for two residents (R3 and R19). This failure affected seven residents out of 22 residents reviewed for homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free from physical abuse. This failure affected two residents (R14 and R15) of Four residents reviewed for resident-to-resident abuse. Findings Include:R2's admission record includes diagnoses of bipolar, depression, hypertension, delusional disorder, schizophrenia, heart failure, seizures and unspecified psychosis. R2's (2/3/26) Brief Interview Mental Status (BIMS) score is 12 which indicates that R12 has moderate impairment. R14's admission record includes diagnoses of chronic respiratory failure, COPD, congestive heart failure, pulmonary embolism, hemiplegia and hemiparesis. R14's (1-12-26) Brief Interview of Mental Status (BIMS) score is 12 which indicates that R12 has moderate impairment. [...]

Inspectors wroteBased on interviews and record review, the facility failed to investigate and report an allegation of resident-to-resident physical abuse to IDPH (Illinois Department of Public Heath) within the regulatory time requirement. This failure affected 2 residents (R14 and R15) in a sample of 3 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to assure that one resident (R9) had ceiling suspended curtains to create full visual privacy. This failure affected one resident out of 22 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate peri care supplies were available for two of three residents (R2, R4) reviewed for dignity in the sample of 11.

Inspectors wroteBased on interviews and review of records the facility failed to follow policy on providing Community Survival Skill Assessment. Failed to follow policy to involve responsible party/family to resident discharged against medical advice ([NAME]). Failed to follow policy in procuring physician order for independent pass and failed to follow community pass and care plan intervention on restriction of resident related to independent pass for 5 out of 11 residents (R1, R2, R3, R4, R11) reviewed for resident safety during community pass. These failures apply to 2 residents (R1 and R11) who was on independent pass and did not return to facility and applies to 3 residents (R2, R3 and R4) that were allowed to go out on independent community pass without physician orders and/or has care plan for restricted pass.

Inspectors wroteBased on interviews and review of records the facility failed to follow their policy to ensure notification of proper parties are done related to discharging 1 out of 5 residents. These failures affected 1 resident (R1) who was discharged after going out of the facility on community pass without required documentation and notification to the proper parties.

Inspectors wroteBased on interviews and review of records the facility failed to coordinate with law enforcement agency in providing information related to 1 out of 5 residents (R1) reviewed for independent out on pass. These failures affected 1 resident (R1) who left the facility during community pass did and not return. The facility is unable to report R1's whereabouts and status. Law enforcement agency unable to proceed in finding or knowing resident (R1) status due to lack of cooperation by facility.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow their policy to accommodate resident's needs by ensuring call light is within reach for 4 (R2, R127, R156, R203) out of 8 residents reviewed for call lights as well as provide an adequately sized wheelchair for 1 (R92) resident out of 8 reviewed for appropriate wheelchairs in a sample of 37. R203 has diagnosis not limited to Unspecified Dementia, Severe Protein-Calorie Malnutrition, Encephalopathy, Adult Failure to Thrive, Alcohol Dependence with Unspecified Alcohol-Induced Disorder, Essential (Primary) Hypertension, Anemia, Muscle Wasting and Atrophy, Vitamin D Deficiency, Polyneuropathy, Abnormal Weight Gain, Restlessness and Agitation and Gastro-Esophageal Reflux Disease. R203’s MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a resident's tube feeding in accordance with the physician's order for 1 of 1 resident (R44) reviewed for tube feeding in a sample of 37. Findings Include:R44 has diagnosis not limited to Gastrostomy, Asthma, Essential (Primary) Hypertension, Seizures, Encephalopathy, Chronic Pain, Tachycardia, Dysphagia, Cognitive Social or Emotional Deficit Following Unspecified Cerebrovascular Disease and Abdominal Pain, Vascular Dementia. MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 03 indicating severe cognitive impact. Care Plan document in part: Focus: The resident is receiving a tube feeding and it has been determined medically necessary. Focus: The resident may be at risk for weight loss related to NPO (Nothing by Mouth) diet. Interventions: [...]

Inspectors wroteBased on interview and record review, the facility failed to keep a resident free of sexual abuse from a resident. This failure affects two of three residents (R1 and R2) in a total sample of three residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure for reporting an allegation of resident-to-resident abuse.

Inspectors wroteBased on interview, and record review the facility failed to investigate an incident involving a verbal argument and physical contact between a resident and employee to rule out abuse. This failure affected one resident (R1) of three residents reviewed for abuse in a total sample of five residents.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that two residents (R5 and R6) that receive supplemental oxygen in the facility had active Doctor's orders. This failure has the potential to affect 31 residents currently receiving oxygen in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the environment remains free of hazards and was a homelike environment. The facility failed ensure the wall paint in residents' rooms was not chipped and damaged exposing the drywall and failed to ensure ceiling and wall tiles in the shower room were repaired or replaced. This failure has the potential to affect 101 residents residing on the second floor.

Inspectors wroteBased on record review and interview the facility failed to follow their abuse policy for two residents (R1, R2,) out of four residents reviewed for abuse. This failure resulted in staff members not immediately intervening in a situation before residents became abusive to each other. Staff did not intervene in time thus allowing R1 and R2 to put scratches on each other's face, neck and arms. Finding Include: Facility's abuse policy denotes residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure a resident was transferred as per assessment, care plan, and proper procedure/use of equipment (Hoyer lift) for 1 (R1) out of 3 residents reviewed for the right of every resident to be safe and free of accidents. These failures affected 1 resident (R1) resulting in R1 sustaining a fractured left leg and undergoing surgery on the left leg (left leg nailing procedure) with three (3) separate incisions with staples.

Inspectors wroteBased on interviews and record reviews, the facility failed to accurately record the fall incident of 1 (R1) out of 3 residents reviewed for incident record. This failure affected the accuracy of 1 resident's (R1) record, with inaccurate documentation of the chronological occurrence of the incident, impacting the credibility of facility staff documentation on resident's record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide all 205 residents residing in the facility with needed supplies for activities of daily living such as towels and linen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) ensure medications were administered as ordered by the residents' physician, b.) ensure medications were locked and secured while unattended, c.) provide sufficient nursing coverage to ensure adequate resident care and support, and d.) provide care and services that meet professional standards. These failures have the potential to affect 103 residents residing in the facility. The facility also failed to provide timely incontinence brief changing to a resident due to not providing linen to staff. This failure affects one of three residents (R17) reviewed for ADL care in a total sample of 17 residents.

Inspectors wroteOn 1/28/25, at 2:03 PM, R7 said a CNA (Certified Nursing Assistant), V9, took R7 to the toilet. R7 said R7 had a incontience brief on and asked to get the brief off so R7 could go to the toilet. R7 said V9 was taking too long and R7 started peeing before R7 got onto the toilet. R7 said the pee got on V9's shoe. R7 said V9 slammed R7's back and R7's back hit the back of the toilet. R7 said this happened in the evening about a month ago. R7 said R7 was sent to the hospital. R7 told the hospital that R7 was abused. The hospital called the police. V9 has not worked with R7 since then. R7 has seen V9 in the building. On 1/28/25, at 2:20 PM, R5 said R5 pushed another resident (R6). R5 said R6 kept coming into R5's room. R6 is blind. R6 was in the room next to mine. R5 said R5 lost their temper. R5 was going into their room. R6 was blocking the way. R5 said R5 pushed R6 pretty hard. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) provide adequate supervision and monitoring for residents, and b.) revise a care plan for one (R8) out of three residents reviewed for resident injuries. These failures have the potential to affect 45 residents residing in the facility.

Inspectors wroteOn 1/28/25, at 2:03 PM, R7 said a CNA (Certified Nursing Assistant), V9, took R7 to the toilet. R7 said R7 had a brief on and asked to get the brief off so R7 could go to the toilet. R7 said V9 was taking too long and R7 started peeing before R7 got onto the toilet. R7 said the pee got on V9's shoe. R7 said V9 slammed R7 back and R7s back hit the back of the toilet. R7 said this happened in the evening about a month ago. R7 said R7 was sent to the hospital. R7 told the hospital that R7 was abused. The hospital called the police. V9 has not worked with R7 since then. R7 has seen V9 in the building. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that a brown substance was not on the bathroom wall of three residents (R4, R5, and R10). This failure has affected three of four residents reviewed for homelike environment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that one dependent resident (R7) received timely incontinent care. This failure resulted in R7 waiting an hour, sitting in her feces before being cleaned.

Inspectors wroteBased on interviews and record review the facility failed to ensure that one resident (R11) was free from abuse from another resident (R4.) This failure affected 2 residents (R4 and R11.)

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that indwelling urinary catheters/urine drainage bags are monitored, and failed to document when indwelling urinary catheters are inserted and/or urine drainage bags are changed for three of three residents (R2, R3, R4) reviewed for catheters. These failures resulted in R2 sustaining (10/14/24) abdominal pain and UTI (Urinary Tract Infection). R3 and R4 sustained Purple Urine Bag Syndrome which is a rare phenomenon where the urine drainage bag turns purple due to a chemical reaction between bacteria in the urine and the plastic of the bag often associated with UTI's in patients using long-term catheters.

Inspectors wroteBased on record review and interview the facility failed ensure that fall risk assessments were accurate for two of four residents (R2, R3) reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the community shower room on the third floor North-Wing is maintained in good repair and a sanitary manner. This failure has the potential to affect all 53 residents on the third floor North-Wing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the doctor's wound care order and keep a wound clean and dry for one resident (R442) and failed to follow policies for proper handling of garbage for 7 residents reviewed in a sample of 35. This failure caused harm to R442, who was admitted with a diagnosed surgical wound and hospital discharge orders for IV (Intravenous therapy) antibiotics for skin and soft tissue infection. R442's wounds were not cleaned, and wounds' dressings changed as ordered, causing the resident's wound dressing and wound to appear uncleaned increasing the risk of further infection/delaying the healing progress.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an adequate amount of linen and towels to provide for resident care needs. This failure affects all 197 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure Soiled Utility rooms that contained sharps and infectious waste materials. These deficient practices have the potential to affect all residents that reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain all fans and portable air conditioners used that circulate air in the kitchen in clean and sanitary condition; failed to ensure that testing strips were available to be used in the three-compartment sink that sanitizes equipment used for food preparation are not expired; failed to maintain the kitchen areas without stagnant water that attracts insects; failed to maintain all areas in the kitchen in a clean and hygienic status free from dirt and food wrappers including below the shelves, stoves, dishwasher, and three-sink compartment. These failures have the potential to affect all 196 residents with 1 resident not taking food by mouth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have functional and comfortable hot water for four (R90, R141, R154, R162,) residents and failed to have a safe environment for one (R443) resident. These deficient practices have the potential to affect all residents that reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an effective pest control program, failed to follow the pest control policy in maintaining the kitchen environment clean to prevent harborage of pests and failed to maintain areas free from pests for 2 residents (R8 and R94) rooms. These failures have the potential to affect all the facility residents.

Inspectors wroteBased on interview and record reviews the facility failed to refer six (R21, R79, R97, R120, R127, R135) out of six residents reviewed with newly evident or a possible serious mental disorder to the appropriate state-designated authority for review, in a total sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care for three (R56, R62, R94) residents and failed to provide scheduled showers for one (R87) resident. These failures affect four residents who are dependent for Activities of Daily Living/ADL care in a total sample of 35 residents reviewed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow the tracheostomy care policy for maintaining a clean environment around a tracheostomy opening for 1 out of 1 resident (R49) and failed to label and date oxygen tubing for 3 out of 7 residents (R8, R96, R124) for a total sample of 35 residents reviewed for respiratory care. These failures have the potential to affect 4 residents (R8, R49, R96, R124) in avoiding respiratory health risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor its call light system and answer call lights within a timely manner for two (R62, R182) residents in a total sample of 35 residents reviewed.

Inspectors wroteBased on record reviews and interview the facility failed to follow the Pre-admission Screening and Resident Review (PASRR) policy for 2 of 8 residents (R12 and R49) in a total sample of 35 residents reviewed for PASRR assessment requirements. This failure has the potential to affect 2 residents (R12 and R49) in the correct determination of placement based on proper PASRR assessment.

Inspectors wroteBased on observation, interviews, and records review the facility failed to provide an individualized care plan to include an identified hygiene concern related to a tracheostomy of 1 (R49) of 35 residents in a total sample of 35 residents reviewed for planning of care. This failure has the potential to affect 1 resident (R49) in maintaining hygiene of the tracheostomy area.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate count of narcotic medication for two residents (R3 and R141) in a sample of 35 reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the potency of insulin medications by not labeling the medications with the dates they were opened and the dates they were to be discarded for three residents (R21, R80 and R169) of 35 residents reviewed for medication storage.

Inspectors wroteBased on record review and interview the facility failed to implement care plan interventions, failed to conduct a physical assessment, failed to obtain vital signs, failed to contact the Physician/Nurse Practitioner, failed to ensure that a Nurse was on the unit when EMS (Emergency Medical Services) arrived, failed to follow Physician orders, and/or failed to provide timely care to three of three residents (R2, R3, R4) reviewed for change in condition. These failures resulted in: R2 sustaining abdominal pain secondary to small bowel obstruction and death caused by septic shock with multi organ failure likely from ischemic bowel. In addition, R3 sustained excruciating pain due to pulmonary embolism.

Inspectors wroteBased on record review and interview the facility failed to ensure that residents and staff are aware of the grievance process and failed to ensure that a grievance form and/or resolutions were provided to one of four residents (R1) in the sample. These failures have the potential to affect 198 residents.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R3) from physical abuse from staff which affected one resident (R3) out of three residents reviewed for abuse. This failure caused R3 to suffer bilateral mandibular fractures to R3's face requiring oral and maxillofacial surgery.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to conduct a thorough assessment, failed to implement care plan interventions, failed to timely notify the Physician/Nurse Practitioner of resident change in condition, failed to document orders received, failed to request appropriate orders, and failed to determine the root cause of pain for one of four residents (R1) reviewed for change in condition. These failures resulted in R1 sustaining pain rated 50 (on a 1-10 scale), emotional distress (crying), WBC (White Blood Cell) count 17.4 (High), UTI (Urinary Tract Infection), and fecal impaction. The facility also failed to ensure that R1's (3/29/24) referral for Neurosurgery consult was transcribed in the physician orders and failed to ensure that orders for R1's GI (Gastrointestinal) consult were obtained prior to surveyor inquiry.

Inspectors wroteBased on record review and interview the facility failed to acknowledge resident rights and failed to comply with hospital transfer request (timely) for one of four residents (R1) in the sample.

Inspectors wroteBased on record review and interview the facility failed to follow policy procedures, failed to notify family of resident change in condition, and failed to document communication with the Nurse Practitioner regarding change in condition for one of four residents (R1) in the sample.

Inspectors wroteBased on interviews and records reviews, the facility failed to provide proper nursing care to one (R1) resident by failing to provide Indwelling Urinary Catheter care and Activities of Daily Living (ADL) Care in a sample of three reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise and monitor two residents (R1 and R3) of 6 residents reviewed for supervision. These failures resulted in R3 eloping from the facility without staff knowing that R3 eloped and R1 having a fall after being left in the shower room unattended and sustaining a forehead laceration which required sutures and sustaining a non-displaced linear fracture of the right distal radius.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that one resident's (R4's) pain was managed as per facility policy. This failure has affected one of four residents reviewed for pain management and caused R4 to endure pain consistently at a level of 8 out of 10 on the pain scale.

Inspectors wroteBased on observation, interviews and record review that facility failed to ensure that one bedbound resident (R5), (with current deep tissue damage) had interventions in place to prevent further skin breakdown. This failure has affected one resident (R5) and has the potential to affect 14 other residents in the facility with pressure wounds.

Inspectors wroteBased on observations, interviews and record review that facility failed to ensure that one resident (R4), received scheduled medication as prescribed by the doctor. This failure has affected one of four residents reviewed for medication.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident (R4), who requires hemodialysis three times per week, received his scheduled hemodialysis treatment on two different occasions. This failure has the potential to affect fifteen other residents who reside at the facility and receive dialysis.

Inspectors wroteBased on interview and record review the facility failed to ensure that necessary treatment and services consistent with professional standards of practice to prevent wound infection were implemented for 1 (R1) resident with a surgical wound due to left above the knee amputation. The facility failed to: 1. Failed to sign TAR (treatment administration record) that treatment was provided. 2. Failed to assess and monitor surgical wound upon admission and on weekly basis. 3. Failed to complete nutritional consultation / assessment. 4. Failed to complete Braden scale on a weekly basis. These failures resulted to 1 (R1) resident admitted to the hospital with diagnosis of wound infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement necessary treatment and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing for a resident identified at risk. The facility failed to: 1. Failed to initial or sign on the electronic treatment administration record (eTAR) after each treatment for 3 (R1, R4 and R5) residents with pressure ulcers. 2. Failed to revise care plan to reflect alteration of skin integrity, approaches, and goals for care for 1 (R5) resident with multiple facility acquired pressure ulcers. 3. Failed to do weekly wound assessment for 3 (R1, R4 and R5) residents with pressure ulcers. 4. Failed to complete Braden scale assessment upon admission for a total of four consecutive weeks for 1 (R1) resident with multiple pressure ulcers. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were enough clean under pads and pillowcases readily available for residents use. This failure has the potential to affect all 199 residents residing in the facility. Findings Include: On 2/13/24 at 12:07 PM, V9 (Certified Nursing Assistant) stated sometimes the staff does not get enough under pads for the residents. At 12:54 PM, a phone interview conducted with V30 (Certified Nursing Assistant). V30 stated, They distribute linens to every floor each shift, but we don't get enough. We don't get any pillowcases for our residents. Some days they would only send two under pads and four bed sheets on our unit. We have around 50 residents on my unit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen floor was clean and equipment was in working order. These deficient practices have the potential to affect all 197 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect R7, R8, and R10' s right to be free from abuse by a resident (R2). This failure resulted in R2 becoming physically aggressive by slapping and spitting on the face of R10, and R2 inappropriately touching R7 and R8. Findings Include: R2' s clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer' s Disease. R2' s Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and independent with walking. R2' s progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) revealed that R2 was noted attacking other residents pulling (R2' s) own hair out, biting and scratching self. It also documents that emergency ambulance was called and transferred R2 to the acute hospital. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedure to report an abuse immediately and no later than two hours to the State Survey Agency (SA) for 3 (R7, R8, R10) out of 7 residents reviewed for abuse. Findings Include: R2's clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and independent with walking. R2's progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) shows that R2 was noted attacking other residents and pulling (R2's) own hair out, biting and scratching self. It also documents that an emergency ambulance was called and transferred R2 to the acute hospital. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate an incident of abuse for 3 (R7, R8, R10) out of 7 residents reviewed for abuse. Findings Include: R2's clinical records show R2 was initially admitted to the facility on [DATE] with listed diagnoses not limited to Schizophrenia and Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] shows R2 had moderately impaired cognition and is independent with walking. R2's progress notes dated 1/26/24 at 3:18 PM documented by V5 (Restorative Nurse Manager) shows that R2 was noted attacking other residents and pulling (R2's) own hair out, biting and scratching self. It also documents that an emergency ambulance was called and transferred R2 to the acute hospital. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies and procedures to administer a medication per physician's order for 1 (R6) out of 3 residents reviewed for pharmaceutical services with behavioral symptoms and who received an antipsychotic medication. R6's Medication Administration Record (MAR) was reviewed, it reflected that the medication had been unavailable for administration on multiple occasions. Findings Include: R6's Minimum Data Set, dated [DATE] shows R6 is cognitively intact. R6 Physician order Sheet (POS) with active orders as of 2/13/24 shows an order for Clonazepam 1 mg tablet, give 1 mg by mouth every 12 hours for anxiety related to anxiety disorder. Medication Administration Record (MAR) shows Clonazepam 1 mg tablet was not administered for ten days of admission. Note text dated 2/13/24 by V20 (LPN) reads in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized fall prevention interventions as indicated in a residents' care plan for a cognitively impaired resident who had repeated falls; and failed to properly assess the fall risk of a resident. These failures affected two residents (R11 and R16) of three residents reviewed for falls. As a result, R11 fell, sustained a left hip fracture, and was sent to the hospital.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a cognitively impaired resident who was assessed to be in pain receives pain management as stated in the pain assessment and care plan. This failure affected one resident(R19) of two residents reviewed for pain management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of four residents (R5) reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of three residents (R5) reviewed for ADL care.

Inspectors wroteBased on interview and record review, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day for five of eight days reviewed for October 2023 (10.8, 10.21, 10.22, 10.28, 10.29) and two of eight days (11.5, 11.26) reviewed for November 2023.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one resident (R22) was free from severe physical abuse and emotional trauma caused by three staff members. This failure resulted in R22 sustaining a right black eye, scratches under the eye and a scratch on top of R22's head after being repeatedly punched by staff members. The staff failed to recognize abusive behavior towards R22. Staff continued to work in the facility; facility staff failed to assess and monitor R22 for injuries. This was identified as an immediate jeopardy which began on 10/12/23 when R22 was attacked by three facility staff members. On 10/19/23 at 2:06 PM the Administrator and Nurse Consultant were notified and presented with the immediate jeopardy template. The immediate jeopardy began on 10/12/23. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that resident's rooms were free from peeling drywall and leaking water from the ceiling or bathroom sink. This failure has affected 5 residents (R10, R15, R16, R17 and R18) of 21 reviewed for homelike environment.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that residents had clean linen available. This deficiency has the potential to affect all 218 residents that reside in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that the kitchen was free from pests and failed to ensure that food was covered in a storage container. This failure has the potential to affect 217 residents that receive meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a treatment cart was locked when not in visual proximity of the nurse and not in use to prevent tampering. This failure has the potential to affect all residents residing on the 1st and 2nd floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow current standards of infection control and prevention in storing soiled linen after residents' care. This failure has the potential to affect all 45 residents residing on the 3rd floor.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the facility was free from urine and feces odor. The facility also failed to ensure that 2 elevators were in working condition. This failure has the ability to affect all 218 residents that reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to report to IDPH (Illinois Department of Public Health) incidents of illicit drug overdose for one resident (R3) in the sample reviewed for opiates overdose; and failed to report to IDPH within the required regulation time an allegation of abuse of R22 by facility staff members.

Inspectors wroteBased on interview and record review the facility failed to conduct a thorough investigation for one resident (R3) reviewed for substance abuse and failed to immediately initiate an investigation into the physical abuse of one resident (R22). These failures resulted in the alleged perpetrators continuing to have access to R22 and exposing R22 to the potential of further abuse and R3 to additional substance abuse.

Inspectors wroteBased on interviews and record reviews the facility failed to revise and initiate a plan of care for one resident R3 reviewed for opiate overdose. This failure affected R3 who was found unresponsive on 09/27/23. R3 was transferred to the local hospital and was admitted with a diagnosis that includes R3 was intubated and admitted with diagnosis that include but not limited to Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose and opiate abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide supervision and interventions for two residents (R10 and R13) with substance abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility policy to conduct resident criminal history background checks within 24 hours after admission of a new resident which affected R213, R216, R222, R223 and R225 in the total sample of 74 residents and has the potential to affect all 215 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was posted in a prominent place readily accessible to residents and visitors and failed to ensure the Daily Nurse Staffing was complete with the required information. This failure affected all 215 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper labeling and dating of food items in the refrigerator and freezer and maintain sanitary conditions in the food preparation areas. This failure has the potential to affect all residents receiving oral nutrition. On 9/10/2023 at 9:40am surveyor observed in the refrigerator ½ loaf of yellow cheese with no label or date, 1/2 bag of shredded cheese with a sticker with no name of product name or dates, a long steel pan of Alfredo, written on the foil, that was not dated or covered properly. Surveyor further observed in the refrigerator a medium size steel container with 8 boiled eggs in it with no label or date, a medium size steel pan of peanut butter and jelly mixed with a date of 9/08/2023 and a medium sized steel pan of turkey slices with a date of 9/03/2023. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to secure the lid on the outside garbage dumpster in an effort to prevent pest and rodents from entering into the facility. This failure has the potential to affect all residents residing in the facility. On 9/10/2023 at 8:31am surveyor observed the lid to one of the garbage dumpsters open from overflowing garbage bags. On 9/10/2023 at about 9:30am surveyor observed the lid to one of the garbage dumpsters open from overflowing garbage bags. On 9/13/2023 at 10:43am via email V21 (Maintenance Director) stated, dumpster lids should be closed when not in use to prevent and deter rodent activity. Housekeeping is responsible for ensuring the dumpster lids are closed after use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment by providing linens or pillows for resident beds; by ensuring that water was not leaking from the ceiling onto resident beds in room; by maintaining integrity of resident room walls, closet doors, baseboards, drawer covers, overhead lights, and wall air conditioner units; and by repairing or replacing damaged furniture. These failures affected R19, R31, R49, R50, R112, R126, R132, R134, R163, R165, R180, R181, R182 and R197 and has the potential to affect all 215 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment by correcting hazards from damaged furniture with an exposed nail and electrical outlets not covered. These failures affected R9, R64 and R112 and has the potential to affect the 47 residents residing on 2 South.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete the controlled drug count sheet which is utilized to count controlled substances for two residents (R67 and 216); and failed to complete a controlled drug receipt/record disposition form for three residents (R112, R149 and R204). This has the potential to affect all 47 residents on the 2-south unit and all 60 residents on the 2-north unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the call light was within a resident's reach for use to call for staff assistance and failed to promptly respond to a resident's call light which affected one resident (R182) in the total sample of 74 residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to acknowledge and comply with one resident's (R40's) meal preference. This failure has the potential to affect all residents in the sample of 74.

Inspectors wroteBased on interview and record review, the facility failed to obtain an advance directive for two residents (R9, R105) in the resident's electronic medical record (EMR). This failure affected two residents (R9 and 105) in a sample of 74 residents reviewed for advance directives.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a care plan for advance directive is updated for one (R126) resident reviewed for care planning in the total sample of 74 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care for a dependent resident which affected one resident (R182) in the total sample of 74 residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a resident's head of the bed elevated to at least 30 degrees when the resident is receiving enteral feedings (tube feedings) via a gastrostomy tube (G-tube) which affected one resident (R182) in the total sample of 74 residents reviewed for tube feedings.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen tubing and a tracheostomy mask. This failure affected two residents (R143 and R151) reviewed for oxygen equipment, in a total sample of 74 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were five medication errors out of 31 medication opportunities, resulting in a 16.13% medication error rate and affected six (R94 and R213) residents observed for medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that an eye drop medication was labeled with an open date and expiration date after opening the solution. This has the potential to affect one resident (R5) out of 74 residents in the sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to check and document the temperatures of residents' personal refrigerators daily and failed to maintain an appropriate refrigerator temperature inside a residents' personal refrigerator which affected R21 and R47 in the total sample of 74 residents reviewed.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that residents' call devices are functioning to allow residents to call for staff assistance. This failure affected 2 residents (R126 and R165) reviewed for functioning resident call devices in a total sample of 74 residents.

Inspectors wroteBased on interview and records review, the facility failed to provide adequate and sufficient care for one resident (R1) of 3 reviewed for two person-assist for bed mobility. This failure resulted in R1 falling out of bed and sustaining a subdural hematoma.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable home like environment. This failure has the potential to affect all 215 residents in the facility. Findings Include: On 08/29/2023 at 9:50 am, R6 stated, The drawer from my dresser is missing and it has always been this way. Nothing was done about it. The paint in my room is old and chipped and the trim from the base boards is gone. It is like that in the entire facility. This place needs to be renovated. On 08/29/2023 at 10:01am, R8 stated, The facility is old looking and it really needs a lot of work. The residents feel depressed living in an old run-down building. On 08/30/2023 at 11:06pm, R9 stated, This place looks terrible. This place is so run down that it is depressing. On 08/31/2023 at 10:40am, R4 stated, The facility is very run down. It's a shame that we have to live like that. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate staffing for the 3-south unit of the facility on 08/20/2023. This failure resulted in R1 falling of the bed and sustaining a subdural hematoma as a result of the facility not having adequate staffing to provide resident care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated and stored; failed to practice safe hand washing and use of gloves; failed to clean kitchen equipment and failed to ensure that cook/service ware are sanitized. These deficient food sanitation practices have the potential to affect all 216 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 8 residents (R45, R54, R56, R73, R76, R95, R163, R215) reviewed during dining in a total sample of 104 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a clean and homelike environment by having loose or missing baseboards, walls damaged and not intact, broken or missing cabinets, window curtain not attached to curtain rod, and torn window screen. These failures affected residents (R5, R11, R21, R22, R25, R53, R56, R65, R74, R95, R104, R105, R122, R131, R157, R158, R162, R167, R186, R201, R210, R305) when reviewed for environment in the sample of 104 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that assistive devices were properly maintained for two residents (R121 and R306) in the sample of 104 residents and failed to remove clutter from a restorative storage closet and ensure that the storage closet was locked, which has the potential to affect all 57 residents on the 3 North unit.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide oral supplements as recommended. This failure has the potential to affect 4 residents (R91, R95, R98, R162) reviewed for nutrition status in a total sample of 104.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff donned the appropriate PPE (personal protective equipment) for PUI (persons under investigation) residents on contact and droplet isolation and failed to label and date oxygen equipment to prevent the spread of microorganisms including COVID-19 which affected R179, R205, R207, R211, R213, R558, R559, and R560 and had the potential to affect the 17 residents on the 1st floor of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the call light was within a dependent resident's reach which affected one (R51) of 104 residents reviewed for accommodation of needs. Findings Include: R51's admission Record, documents, in part, that R51's diagnoses include schizophrenia, depression, muscle wasting and atrophy, idiopathic gout, osteoarthritis and cellulitis of left lower limb. R51's Minimum Data Set (MDS), dated [DATE], documents, in part, Section C. Brief Interview for Mental Status (BIMS) score: 15. which indicates that R51 is cognitively intact. Section G. Functional Status: self-performance for personal hygiene, and toilet use is coded as requiring extensive assistance, and support is coded as one-person physical assist. On 8/1/22 at 10:35 am R51's call light was observed not within R51's reach and was on the floor under R51's bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident's low air loss mattress was placed at the recommended setting. This failure affected one resident (R39) of the four residents reviewed for pressure ulcer prevention interventions in a total sample of 104 residents.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide a specialized adaptive drinking cup for a resident (R98); failed to follow a physician order for a specialized adaptive drinking cup for a resident (R98); and failed to follow a physician order for specific feeding guidelines related to swallowing (R98). These failures have the potential to affect 1 (R98) of 6 residents reviewed for adaptive equipment usage in a total sample of 104.