The Villa at Parkridge

Inspectors wroteBased on observation, interview, and record review the facility failed to address and prevent repeated intrusive behaviors by one resident toward another resident in one (Resident #11) out of three reviewed for resident rights.

Inspectors wroteThis citation pertains to intake #3039625 and 3039655 Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident. Findings Include:Resident #1 (R1) Review of the face sheet reflected R1 was admitted to the facility on [DATE], with diagnoses that included auditory hallucinations, delusional disorders, adjustment disorder with anxiety, and paranoid schizophrenia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/25/26, reflected R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the face sheet reflected R2 was admitted to the facility on [DATE], with diagnoses that included dementia, post-traumatic stress disorder, and adjustment disorder with anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the timely reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings Include:Resident #1 (R1) Review of the face sheet reflected R1 was admitted to the facility on [DATE], with diagnoses that included auditory hallucinations, delusional disorders, adjustment disorder with anxiety, and paranoid schizophrenia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/25/26, reflected R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the face sheet reflected R2 was admitted to the facility on [DATE], with diagnoses that included dementia, post-traumatic stress disorder, and adjustment disorder with anxiety. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, assess, document, and initiate appropriate treatment for a wound in one (Resident #11) out of three reviewed for wound care.

Inspectors wroteBased on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify residents of where to find grievance forms and how to file a grievance as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate nursing staff to ensure that the needs of their residents were met for 11 residents (R7, R41, and R64) and 8 residents identified through confidential group interviews, resulting in insufficient and unmet resident care needs, feelings of frustration, and complaints about not enough staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat all residents with dignity for one (Resident #7) of two reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had a call system adapted to their physical limitations in one (Resident #98) out of two reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment for one (Resident #72) of two reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R135) of four reviewed. Findings Include: Review of the medical record revealed R135 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes. Review of the Social Services Comprehensive Evaluation dated 3/4/26 revealed R135 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Order dated 3/3/26 revealed Wound Care (L [left] posterior leg): cleanse [with] normal saline, apply Medihoney (Activon) to wound bed, cover with foam dressing. The wound care was ordered to be completed every evening shift, every other day. On 03/08/2026 at 10:13 AM, R135 was observed sitting on the edge of his bed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent misappropriation of resident property for one (Resident #34) of one reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comprehensive care plans were developed and implemented for three out of 24 residents (Resident #'s 12, 41, & 98). Findings Included: Resident #12: Per the facility face sheet R12 was admitted to the facility on [DATE]. Record review of R12's care plans revealed an active care plan that was in place with a Focus of .antidepressant medication r/t (related to) bipolar, depression. There was an intervention on R12's care plan to, Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective and consistent means of communication in one (Resident #98) out of two reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activities of daily living, including showers, shaving, grooming, and nail care, were being completed in one (Resident #98) out of two residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure consistent availability of water at the bedside, failed to ensure hydration was offered, and failed to document fluid intake in one (resident 98) of 2 reviewed for hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive necessary respiratory care and services that was in accordance with professional standards of practice for 1 (Resident #41) of 1 resident reviewed for respiratory care resulting in the potential for respiratory distress and exacerbation of respiratory conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were accurate and not falsified for one (R135) of 24.

Inspectors wroteBased on observation and interview, the facility failed to provide a functional window for one (Resident #98) out of 2 reviewed for environment.

Inspectors wroteThis citation pertains to Intake # 2589332. Based on interview and record review the facility failed to immediately assess and notify the physician and responsible party of a fall with major injury for one Resident (#3) of three reviewed.

Inspectors wroteThis citation pertains to Intake MI00146710 Based on interview and record review, the facility failed to address and respond to a repeated concerns related to food palatability, satisfactory resolutions to grievances, being offered and provided an evening snack, and call light response, brought forth by Resident Council.

Inspectors wroteResident #374 (R374) Review of the clinical record, including the Minimum Data Set (MDS) with an assessment reference dated of 7/29/24 reflected Resident # 374 was admitted to the facility on [DATE] with a readmission date of 7/22/24, diagnoses that included nontraumatic intracerebral hemorrhage, multiple localized, muscle wasting and atrophy, anxiety, major depression. Of note, R374 was transferred to the hospital on 9/11/24 and did not return to the facility. Review of R374's weight record revealed R374 weighed 105.6 pounds on 7/23/2024. On 6/11/24 R374 weighed 117.4 pounds revealing an 11.7% weight loss in one month. Review of R374's 7/29/24 MDS section K queried for weight if there was a 5% or more in the last month or loss of 10% or more in 6 months. This question was coded as 0 meaning No or unknown. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for four (R25, R48, R75, and R109) of 25 reviewed.

Inspectors wroteThis citation pertains to Intakes MI00146664, MI000146710 Based on observation, interview, and record review the facility failed to maintain sufficient staff to meet residents' needs timely for three (R41, R65, R109) and Resident Council of ten reviewed for staffing.

Inspectors wroteThis citation pertains to intakes MI00148581, MI00147352. Based on observations, interviews, record reviews, 7 of 8 from the confidential group meeting, 3 (#65, #94, #103) of 25 sampled residents, and 1 (#105) non-sampled resident, the facility failed to provide palatable food products effecting 125 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline.

Inspectors wroteThis citation pertains to Intake MI00146710 Based on observation, interview, and record review, the facility failed to make prompt efforts to resolve grievances for one (R88) of 2 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess bed bolsters as potential restraints for two (Resident #25 and #63) of three reviewed.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment timely for one (R68) of 25 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the Care Plan for two residents (Resident #79 and 374) of 25 reviewed.

Inspectors wroteThis citation pertains to Intakes MI00146664, MI00146710 Based on observation, interview, and record review the facility failed to provide necessary care to assist two of five residents reviewed for grooming (R#29 and R#49) with necessary activities of daily living (ADLs), resulting in these residents not receiving the care needed to maintain their highest practicable well-being and potential for embarrassment and humiliation of residents. Findings Include: Resident #29 (R29) Review of the medical record reflected R29 was an initial admission to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful, individualized activities to one resident (#29) of two reviewed for activities, from a total sample of 25 residents, resulting in the potential for depression, boredom and feelings of lack of self-worth.

Inspectors wroteThis citation pertains to Intake MI00146664. Based on observation, interview and record review, the facility failed to honor preferences for weight management for one (Resident #79) and prevent weight loss for one (Resident #374) of six reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessment and monitoring of a dialysis access site and updated Care Plans for one (Resident #75) of one reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to provide medically related Social Services for one resident (#375) of two reviewed for Social Services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage and administration of medications, in one of five residents (R#5) reviewed for sample of 25 resulting in unsafe medication administration, unsafe medication access, and the potential for lost medications/medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately honor food preferences for one resident (#94) of six resident reviewed for food preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure collaboration of care and communication with the hospice provider for one (Resident #112) of one reviewed.

Inspectors wroteBased on interview and record review, the facility failed to administer a pneumococcal immunization per consent for one (R48) of five reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hot liquid/food was served at a safe and appropriate temperature for one (Resident #101) of three reviewed for accident hazards, resulting in second-degree thermal burn (damage to outer and second layer of skin, causing blisters, pain and discoloration) on R101 abdomen, groin and right inner thigh, open wounds and increased risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of a change in condition for 1 of 3 sampled residents (R101) reviewed for physician notification, from a total sample of 3 residents, resulting in R101 having a delay in treatment of a burn and increased risk for pain and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary care and services to maintain the highest practical physical level of well being (adequate care after a burn) in 1 of 3 sampled residents (R101) reviewed for accidents, resulting in second degree burns to R101 after spilling hot soup in his lap.

Inspectors wroteThis citation pertains to intake MI00145665 Based on observation, interview, an record review the facility failed to notify one Resident (#2) out of three Resident reviewed of grievance investigation and resolution of grievances. Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 09/13/2023 with diagnoses that included cirrhosis of liver (scarring and liver failure), constipation, anxiety, alcohol abuse, anemia (low red blood cells), hepatic encephalopathy (loss of brain function because liver damage does not remove toxins) , hypertension, gastro-esophageal reflux, chronic pancreatitis (inflammation of pancreas), low back pain, depression, and cognitive communication deficit. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 123 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced illumination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for the entire resident council members, resulting in anger, frustration and feelings of being ignored and ongoing unresolved concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate coding on the Minimum Data Set (MDS) assessment for three (Resident #41, #72 and #370) of 24 reviewed, resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to follow-up with OBRA for one (Resident #110) of two reviewed, resulting in the potential for mismanaged mental health services.

Inspectors wroteBased on interview and record review the facility failed to ensure for one out of 24 residents (Resident #39) resident preferences were included in the plan of care, resulting in the potential for anxiety and resident preferences not being met. Findings Included: Per Resident 39's (R39) electronic medical record (EMR) R39 was initially admitted to the facility on [DATE]. In an interview on 1/30/2024 at 11:13 AM, R39 stated that he wanted to get up every morning at 6:15 AM. R39 said staff were aware of his preference, however stated that there had been a few days when it was after 7:00 AM and around 10:00 AM before the staff assisted him with getting up out of bed. In an interview on 2/01/2024 at 10:48 AM, Registered Nurse (RN) J stated that R39 would always be up when she would arrive to work at 7:00 AM. RN J said the third shift staff would get R39 up out of bed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure for one out of 24 residents (Resident #5) fall care plan was revised, resulting in the potential for additional falls to occur. Findings Included: Per the Resident #5's (R5) electronic medical record (EMR) R5 had resided at the facility since 6/16/2023. Review of a Post-Fall Evaluation dated 8/29/2023, revealed R5 had a fall on 8/29/2023. An immediate intervention put into place was. bed in low position, call light within reach, frequent rounding on resident (R5). However, the intervention of frequent rounding on resident was not added to R5's care plan, and the interventions of bed in low position and call light within reach were already interventions in place, but were both dated 2/27/2018, and did not have any revisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prime an insulin pen per manufacturer guidelines for one (Resident #74) of one reviewed, resulting in the potential for medication errors and adverse effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly assess and follow podiatry services orders for one resident (R40) reviewed for foot care, resulting in resident frustration, the development of long thick brittle toenails, pain, skin breakdown and delay in needed treatment.