South Shore Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to do a complete skin assessment and monitor a resident's (R1) skin issue, failed to have treatment orders in place, failed to have the wound physician evaluate R1's wound, and failed to identify a new skin issue for 1 (R1) out of 6 residents reviewed for Quality of Care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control protocol by not displaying the correct isolation sign for two residents (R66 and R143); failed to ensure that Enhanced Barrier Precaution (EBP) sign was visibly posted for three residents (R209, R210 and R211) who require EBP; and failed to ensure staff perform hand hygiene during dining for three residents (R125, R130 and R190). Theses failures affected eight residents (R66, R125, R130, R143, R190, R209, R210, and R211) reviewed for infection control and has the potential to place all 198 residents at risk for the spread of infection.

Inspectors wroteBased upon observation, interview and record review, the facility failed to empty the lint compartment and lint filter in an effort to provide safe environment to residents. This failure has the potential to affect all 198 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe homelike environment. This failure affected four residents (R3, R19, R20, and R158) reviewed for maintenance of a safe home like environment in a sample of 77.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident's (R36) care planned fall precaution intervention by maintaining the bed height in the lowest position and failed to perform a resident's (R36) fall risk assessment quarterly which affected one resident (R36); and failed to secure a resident's (R131) oxygen tank in a holder which affected R131 and has the potential to affect all 29 residents residing on the 1st floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to contain oxygen equipment (nebulizer masks) per facility's policy. This failure affected four residents (R11, R47, R113, R143) reviewed for oxygen equipment, in a total sample size of 77 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to lock the 3rd floor emergency crash cart and failed to double lock refrigerated controlled substances which affected R6, R8, R10 and R174 and has the potential to affect the 58 residents residing on the 3rd floor when reviewed for medication storage.

Inspectors wroteBased on interview and record review the facility failed to refer two residents (R14 and R17) to the appropriate state designated authority for PASARR (Preadmission Screening and Annual Resident Review) evaluation and determination and failed to perform additional screening for one resident (R17) diagnosed with a new mental disorder. This deficient practice affected two residents (R14 and R17) in a total sample size of 77 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medications were signed out when administered for one residents (R143). This failure affected one out of 77 residents in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide toenail care with trimming for a resident with lengthy and jagged toenails which affected one resident (R147) in the sample of 77 residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure ADL's (Activities of Daily Living) were completed for two residents (R202, R204) to allow the residents to maintain their dignity. This failure affected 2 residents out of a sample of 77.

Inspectors wroteBased on observation, interview, and record review the facility failed to redistribute pressure by maintaining the air mattress pump at the correct weight setting to prevent pressure wounds. This failure has the potential to effect one resident (R7) in a sample of 77. Findings Include: R7 was observed lying in bed on a low air mattress with an air mattress pump at the foot of the bed set on Firm which is one setting past 360lbs (pounds). On 8/4/2025 at 11:24 am, V17, RN (Registered Nurse/Agency) verified R7's air mattress pump was set past 360lbs (pounds) on firm. V17 stated she (V17) was not aware of the facilities protocol for the air mattress setting. V17 verified R7's current weight was 150.8lbs. On 8/4/2025 at 11:47 am, V8, WCT (Wound Care Technician) stated only a nurse, wound care coordinator, or the wound care tech can change the setting on a resident's air mattress pump. [...]

Inspectors wroteBased on interview and record review the facility failed to assess, monitor, identify and intervene promptly for one resident (R2) who was responsive but became unresponsive. This failure resulted in R2 being sent to the hospital and led the R2's death. Based on interview and record review the facility failed to assess, monitor, identify and intervene promptly for one resident (R2) who was responsive but became unresponsive. This failure resulted in R2 being sent to the hospital and led the R2's death.

Inspectors wroteBased on interview and record review, the facility failed to update resident care plans to accurately identify isolation needs. These failures have the potential to affect 4 residents (R1, R2, R4, and R5) reviewed for isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal protective equipment (PPE) was readily available for use for residents that require enhanced barrier precautions and transmission-based precautions; failed to ensure linen cart was covered. These failures have the potential to affect 6 residents (R1, R4, R5, R6, R8, R9) reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions as stated in the care plan for residents at risk for pressure ulcers. This failure has the potential to affect six residents (R2, R3, R4, R5, R6, and R7), reviewed for wheelchair cushions as a pressure ulcer prevention intervention for residents.

Inspectors wroteBased on interviews and record review, the facility failed to follow its policy and properly transfer a resident with a mechanical lift device during a transfer procedure for one (R1) resident out of three residents reviewed for resident safety. This failure resulted in R1 sustaining a fracture of the right knee while being transferred in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to supervise and use the appropriate shower equipment for one (R147) resident out of a total sample of 36 residents reviewed for falls. This failure resulted in R147 falling out of the shower chair and sustaining a closed nondisplaced fracture of the greater trochanter of the right femur.

Inspectors wroteBased on interview and record review, the facility failed to have a policy and procedure in place on how to provide beneficiary notifications such as NOMNC (Notice of Medicare Non-Coverage) and ABN (Advanced Beneficiary Notice) to its residents. This failure could potentially affect 182 Medicaid / Medicare eligible residents residing in the facility with 2 residents under private pay for a total census of 184 as of 7/23/24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a.) kitchen staff wearing facial hair covering b.) food items were properly labeled, dated, and stored, c.) refrigerator kept clean. These failures have the potential to affect all 180 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to update infection prevention and control policies at least annually resulting in current policies and procedures dating as far back as 2006. This failure has the potential to affect all residents at the facility. The facility also failed to ensure shared equipment was sanitized between each use for 3 [R62, R106, R129] of 4 [R127] residents reviewed for medication administration observation. Findings On 07/23/24 at 02:14 PM infection prevention and control policies were reviewed. Policy titled Infection Control Protocol for All Nursing Procedures was revised January 2019. Policy titled Blood and Body Fluids Exposure was revised August 2008. Policy titled Cleaning Spills or Splashes of Blood or Body Fluids was revised December 2006. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain effective pest control as evidenced by flying insects visualized both in resident rooms and common areas in the facility. This failure had the possibility of affecting the one hundred and eighty-four residents at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide physician generated diet orders. These failures affected 5 residents (R7, R15, R75, R110, R152) of 7 residents reviewed for nutrition in a total sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (a) follow standards of professional practice and facility policy by leaving medications at the bedside of one resident (R488); (b) ensure that one medication cart were locked during medication administration; (c) properly date opened multi-dose eye drops, insulin vials and pen; (d) properly discard expired house stock medication from 4 of 8 medication carts and 2 of 4 medication storage room inspected for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy and confidentiality for 3 [R62, R106, R129] of 4 residents personal medication administration record. Findings Include: On 7/23/24 at 9:25AM, Surveyor observed V11 [Licensed Practical Nurse] during medication administration. On 7/23/24 at 9:26 AM, V11 walked away from the medication cart and left the computer screen unlocked and displaying R129's personal medication information facing toward the hallway, visible to anyone walking pass. On 7/23/24 at 9:33 AM, V11 walked away from the medication cart and left the computer screen unlocked and displaying R106's personal medication information facing toward the hallway. On 7/23/24 at 9:46 AM, V11 walked away from the medication cart and left the computer screen unlocked and displaying R62's personal medication information facing toward the hallway. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' call lights were within reach for two (R43, R171) out of a total sample of 36 residents reviewed for accommodation of needs. Findings Include: 1. On 07/23/24 at 11:30 AM, surveyor observed R171 lying in bed. Surveyor observed R171's call light on the floor. R171 stated R171 cannot get out of bed without help, and R171 cannot find or reach for R171's call light. R171 must scream for help sometimes when the call light is on the floor. R171 stated the staff do not like when R171 screamed for help. R171 told staff to always keep R171's call light within R171's reach. On 07/23/24 at 11:46 AM, V23 (Certified Nursing Assistant/CNA) and surveyor observed R171's call light on the floor. V23 stated call light should not be on the floor, R171's call light should be within R171's reach. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain physician order for code status of 1 (R109) resident reviewed for advance directives in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 1 (R124) of 4 residents reviewed for resident assessment in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 3 (R99, R147, R167) of 4 residents reviewed for resident assessment in a sample of 36.

Inspectors wroteBased on interviews and record reviews, the facility failed to conduct a Preadmission Screening and Resident Review (PASRR) for one (R101) resident out of a total sample of 36 residents reviewed for PASRRs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure incontinence care was provided in a timely manner for 1 (R109) resident who needed assistance with toileting. This failure affected 1 (R109) resident reviewed for ADL (Activities of Daily Living) care in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered as ordered, failed to ensure oxygen masks and nebulizer masks and tubing were stored following professional standards of care and facility policy, and failed to ensure residents were provided humidity while on oxygen. These failures could potentially affect three (R18, R63, R80) residents out of a total of thirty-six residents reviewed for respiratory care. Findings On 07/23/24 at 10:25 AM R63 was observed lying in bed with oxygen running at four liters per minute per nasal cannula. An oxygen mask was observed on the bedside table not in a bag. On 7/23/2024 at 10:27 AM V32 (Certified Nurses Aide) stated, We store unused oxygen masks and cannulas wrapped in a plastic bag. V32 observed the oxygen mask on R63's bedside table and stated, It should be in a plastic bag. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to follow provider orders and provide speech evaluation for one resident (R176) out of a sample of seven residents (R31, R63, R106, R131, R133, R176, R488). Findings On 07/23/24 at 10:35 AM R176 stated I was expecting to get speech therapy on a regular basis, but I don't know if I should be expecting that. R176 stated that R176 has had multiple strokes. R176 stated I don't recall getting speech therapy. I have been to physical therapy. On 07/23/24 at 12:41 PM review of the orders for R176 includes Speech Therapy to Evaluate and Treat. Order was written on 5/22/2024. Order for Speech Therapy was signed by V53 (Physician) on 6/19/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow facility policy and standards of professional practice in the timely education and/or administration of pneumococcal vaccine for two residents (R176, R488) out of seven residents in the sample (R31, R63, R106, R131, R133, R176, R488). Findings On 07/23/24 11:20 AM V4 (Infection Prevention Nurse) stated that resident education, resident consent, resident declination, and resident vaccination of the pneumococcal and/or influenza vaccines will be documented under immunizations in the electronic health record. On 7/23/2024 at 12 PM, the electronic health record of R31, R63, R106, R131, R133, R176, R488 were reviewed. Under the immunization record in the electronic health record, there was observed to be no education, consent, or declination of the pneumococcal vaccine for R488. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and functional environment by not ensuring the shower room floor tiles had non-skid tape attached to prevent accidental hazards. This failure has the potential to affect 142 residents residing on the 1st, 2nd, and 3rd, floor out of 193 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that urine collection bag was placed appropriately where it is not visible from the hallway for two of two residents (R3 and R7) in the sample reviewed for nursing care in the sample. This failure affected R3 and R7 whose urine drainage bag was without privacy bag and was visible from the hallway to other resident and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that inhaler medication was labelled appropriately, was ordered by physician, and locked in a medication cart when not in visual proximity of the nurse and not in use to prevent tampering and hazard for two residents (R4 and R5) in the sample of 8 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their abuse policy by failing to ensure resident was safe from abuse by failing to immediately report an allegation of sexual abuse made by R4 regarding employee (V23/CNA); facility failed to protect R4 from additional abuse/trauma by allowing V23 to continue to work after R4 reported the allegation of sexual abuse to a staff member; failed to protect R4 from harm when she initially reported to CNA, prior to incident on 1/11/24 that she did not want V23 to provide care for her anymore. This affected one resident (R4) of 5 residents reviewed for physical abuse. These failures resulted in V23 re-entering resident's room after R4 made an allegation of sexual abuse against V23. R4 expressed amplified feelings of anguish and panic, in addition to the trauma R4 experienced during the alleged incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their elopement policy for monitoring a cognitively impaired resident (R2) with severe mental illness, who was assessed to have cognitive impairment, and assessed to be at risk of elopement, failed to have a physician order for unsupervised outside pass, and failed to obtain consent from state guardian to be discharged from facility. These failures resulted in R2 eloping from the facility on 10/10/23. R2 was located at a restaurant 4 miles away from the facility and refused to go back to the facility and facility discharged R2 AMA (Against Medical Advice). This was identified as an immediate jeopardy situation which began on 10/10/23 when R2 eloped from the facility. On 12/5/2023 at 11:45 am, V1 (Administrator) and V2 (Director of Nursing, DON) were notified of the Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review the facility failed to report an elopement of a cognitively impaired resident with an appointed state guardian to the Illinois Department of Public Health. This failure affected R2 wh0 eloped from the facility on 10/10/23.

Inspectors wroteBased on interview and record review, the facility failed to (a) ensure resident safety by allowing a resident (R6) with a history of alcohol dependence out on a community pass without a medical provider authorization/order and (b) failed to complete a community survival skills assessment for the same resident (R6) prior to allowing resident out on pass into the community. These failures affected one (R6) resident out of three residents reviewed. These failures resulted in R6 leaving the facility on an independent community pass and returning to the facility intoxicated. While intoxicated, R6 fell while inside the facility and sustained a right mandibular fracture and chin laceration. Findings Include: Face sheet dated 09/22/2023, documents R6 is a [AGE] year-old male with diagnoses not limited to: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served at a palatable temperature. This deficient practice has the potential to affect all 152 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a homelike environment to R3 by not providing privacy curtain in the shower stall. This failure resulted in R3 not being provided with a homelike environment at the facility.

Inspectors wroteBased on interview and record review, the facility failed to identify and provide medically related social services to address alcohol dependence when in the community for one (R6) of three residents reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent comingling of staff personal food items with facility food items in the kitchen's refrigerator. This failure has the potential to affect all resident receiving oral nutrition. On 6/11/2023 at 9:18am observed in the refrigerator a black plastic bag with food items, a lunch tote and a large bottle of coffee creamer. On 6/11/2023 at 9:20am V35 (Assistant Dietary Manager) stated those items (black plastic bag, lunch tote and large bottle of coffee creamer) belonged to the staff. On 6/12/2023 at 12:02pm V14 (Dietary Manager) stated, No it should not be stored refrigerator, it should be stored in the employee break room. Updated General Orientation Checklist and Acknowledgement documents, in part, during the facility tour-designated areas for lunch, breaks, personal item storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the fourth-floor bathroom wall tiles in good repair; failed to replace the missing shower knob in the community shower room; and failed to keep dryer lint compartments free of lint buildup. This failure has the potential to affect all 64 residents on the fourth floor and all 175 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess one resident (R26) for the ability to safely self-administer medication. This failure affected R26 and has the potential to affect all 45 residents residing on the 4th floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions as indicated in the facility's policy, for residents at risk for pressure ulcers. This failure has the potential to affect 9 residents (R2, R34, R40, R44, R69, R77, R82, R95, and R163), reviewed for pressure ulcer prevention interventions.

Inspectors wroteBased on interview and record review, the facility failed to maintain shift change accountability records for controlled substances for residents'-controlled medications. This failure has the potential to affect one of four medication carts reviewed, and all residents on the second floor that receive medications from the medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure handrails on the third floor were firmly affixed to the walls and failed to ensure the broken sharp edges of the handrails were fixed. This failure has the potential to affect all 64 residents on the third floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was within reach for a resident. This failure affected one resident (R106) reviewed for call lights, in a total sample of 66 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to document the code status for one resident, R337. This failure has the potential to affect one resident in the sample of 66. Finding including: R337's has a diagnosis of but not limited to Dementia, Diverticulosis of Intestine, Heart Failure, Hypertension, Chronic Kidney Disease, Stage 3 and Altered Mental Status. R337's Brief Interview of Mental Status is 06 which indicates severely impaired. On 6/13/2023 at approximately 12:00pm surveyor reviewed R337's profile and orders screen. There was no code status documented. Surveyor reviewed R337's face sheet and the response area for Advance Directive was blank. On 6/13/2023at 1:09pm V18 (RN/Case Manager) stated, code status should be on the profile screen and the orders screen. V18 stated, she would put R337's code status in the system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who depends on staff's assistance for ADL (Activities of Daily Living) care and grooming received nail care. This affects one resident (R4) in the total sample of 66 residents, reviewed for ADL care and grooming.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents' nasal cannulas and humidifier bottles were dated for 2 (R26 and R67) residents; failed to ensure the nasal cannula and humidifier bottle were not outdated for 1 (R53) resident; and failed to ensure humidifier bottles were filled with water for 2 (R26 and R53) residents. These failures affected 3 (R26, R53 and R67) residents reviewed for oxygen administration in the total sample of 66 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' expired eye drops were discarded; and failed to label opened multidose Insulin with the open date. This failure has the potential to affect 2 residents (R99 and R132), reviewed for medication storage, in a total sample of 66 residents.