Wentworth Rehab & HCC

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent, identify, report and treat a new pressure ulcer wound for one resident (R1) who assessed at risk for developing pressure ulcers in the sample of 3 residents reviewed for pressure ulcer prevention.

Inspectors wroteBased on interviews and record review, the facility failed to have a policy in place to assess one cognitively impaired resident's (R14) ability to consent to sex; failed to create a plan of care after becoming aware of R14's sexual activity; and failed to properly document visitation restrictions for a visitor suspected of financially abusing R14. This failure has the potential to affect 191 residents that reside at the facility.

Inspectors wroteBased on interviews and record review, the facility failed to report allegations of sexual and financial abuse involving one resident R14. This failure has the potential to affect 191 residents that reside at the facility. Based on interviews and record review, the facility failed to report allegations of sexual and financial abuse involving one resident R14. This failure has the potential to affect 191 residents that reside at the facility.

Inspectors wroteBased on interviews and record review, the facility failed to conduct investigations for allegations of financial and sexual abuse for one resident R14 in a sample of five reviewed for abuse. This failure has the potential to affect 191 residents that reside at the facility.

Inspectors wroteBased on interviews and record review, the facility failed to prevent one resident (R14) with cognitive impairment from being sexually abused by a visitor suspected of possibly financially abusing R14. This failure has affected one of five residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to inform residents of their monthly personal funds amount and failed to distribute residents personal fund monies monthly. This failure affected three of three residents (R8, R9, R10) reviewed for personal funds.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their elopement policy to report an elopement that resulted in R1 eloping from the local emergency and not being located by the facility until a day later to Illinois Department of Public Health, for one [R1] of three residents reviewed for elopement in a total sample of three residents.

Inspectors wroteBased on interviews and record reviews the facility failed to provide adequate supervision for 1 [R1] of three residents who is an elopement risk. This failure resulted in R1 eloping from the emergency department and not being located by facility staff until 06/27/2025. Findings Include,R1's clinical record indicates in part: R1 was admitted on [DATE], with the following medical diagnoses but not limited to non-Hodgkin lymphoma, schizoaffective disorder, syncope and collapse, tremors, convulsions, major depression, essential hypertension, and anxiety disorder. R1's minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively intact, alert, and oriented x/times3. Facility's appointment book:R1 was scheduled for follow up appointment at a cancer clinic with V5 [Restorative Certified Nurse Aide/Escort]. [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their policy on weights and pressure ulcer measurements for one (R1) resident of three reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (R2) of three residents reviewed for quality of care received appropriate care and management for the diagnosis of diabetes, by failing to monitor R2's blood sugar levels upon admission and failing to provide continuity of care through medication administration in a total sample of six residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that fall risk assessments are accurate, failed to develop and/or implement preventive interventions, and failed to provide supervision to two of three residents (R2, R5) reviewed for falls. These failures resulted in the following: R5 sustained (12/31/24) fall resulting in intracranial hemorrhage and traumatic head injury requiring 4 staples. R1 sustained (1/10/25) fall resulting in left eyebrow laceration requiring 6 sutures.

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures and failed to develop a comprehensive care plan for one of three residents (R4) reviewed for abuse.

Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures and failed to review/revise comprehensive care plans for two of four residents (R1, R5) reviewed for falls and pass privileges.

Inspectors wroteBased on record review and interview the facility failed to follow their abuse policy for one resident (R1), out of three residents reviewed abuse. This failure resulted in R1 falling to the floor during a behavior episode when a staff member who was not appropriately trained on Crisis Prevention Interventions (CPI) attempted to assist with the behavior. Finding Include: R1's care plan reads: R1 has difficulties managing her anger/frustration as evidenced by verbal and physical aggression. During periods of increased agitation, move resident to a quiet location, and intervene as appropriate. 10/26/2024 08:40 R1 Behavior Note Text reads: Writer witness resident grab food rack from staff and shove and throw (it) down, at her, and other residents in facility. Writer responded asking resident to calm down, attempting to redirect. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) implement/revise the care plan interventions addressing the resident's required nutritional support for one (R4) resident b.) the facility's intermittent failure to provide required assistance/monitoring with eating resulted in poor intake for one (R4) resident out of three residents reviewed, in a total sample of three residents. This failure resulted in R4's significant, not severe, unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide special eating equipment and appropriate assistance for one (R3) resident out of three residents reviewed, in a total sample of three residents. This failure has the potential to affect the resident's ability to maintain or improve their ability to eat or drink independently.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records for one resident (R1) in accordance with its policy and accepted professional standards of practices that are complete and accurately documented. This failure affects one of three residents reviewed for records, in a total sample of three residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the fall prevention interventions as stated in the care plans for residents with Dementia who are also at risk for falls. This failure has the potential to affect 4 residents, R8, R9, R10, and R11, reviewed for proper footwear as a fall prevention intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the large community shower room on the fourth floor East-Wing is maintained in a sanitary manner free of drain/sewer back-up. This failure has the potential to affect all 37 residents on the fourth floor East-Wing.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide effective pest control for seven [R1, R2, R6, R7, R8, R9, R10] residents in the sample of 10. These failures have the potential to affect all 51 residents residing on the third floor.

Inspectors wroteBased on interview, and record review the facility failed to ensure a resident's mammogram, ultrasound appointment refusal was addressed and failed to ensure further attempts to reschedule the appointment for 1 (R2) of 3 residents reviewed for Quality of Care. Findings Include: R2 was admitted to the facility on [DATE] with diagnoses not limited to Chronic Sinusitis, Asthma, Constipation, Heartburn, Urinary Incontinence, Pain, Insomnia, Essential (Primary) Hypertension and Schizoaffective Disorder. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Transfer paperwork from previous facility dated 05/14/24 02:46 PM document in part: R2 complained of a lump under the left breast. Order given to do ultrasound of left breast. 9:01 PM performed ultrasound to left breast. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician and failed to document the reasons for not administering medications as ordered. These failures affected 5 residents (R1, R2, R3, R4, and R5) of 5 residents, reviewed for medication administration, missed medications, and documentation of medications not given.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure a safe environment that is free from accidents and hazards for one (R85) of 5 residents reviewed in a sample of 35. This failure resulted in R85 falling and sustaining a fracture of the 2nd left finger.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety and sanitation, failed to utilize measuring utensils when mixing ingredients, failed to follow the recommended portion size for the menu, and staff failed to wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. This has the potential to affect all 180 residents in the facility. On 5/28/2024 at 9:30AM surveyor arrived at facility. Conducted kitchen observation observed one cook, four dietary aides and a dietary manager. V17 observed without hair net while preparing food in food designated areas. Surveyor notified staff of inspection. V8 reminded V17 she needed a hair restraint on. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate staffing for one out of four floors of the facility. This failure affects all the residents that reside on the second floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer resident's prescribed medications in a timely manner according to the physician orders. This failure affects twelve (R63, R65, R68, R71, R83, R86, R107, R131, R134, R135, R143, R159) residents in a total sample of 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) ensure that multi-use blood pressure cuff devices and pulse oximeters were properly cleaned and disinfected in between resident use for ten (R12, R20, R27, R29, R83, R98, R124, R126, R159, R161) residents, b.) ensure that its staff follow the facility's policy to demonstrate proper hand hygiene while performing peri-care to one resident (R14), and c.) post a contact isolation precaution sign for one resident (R157) identified as having a physician order for contact isolation precautions in a total sample of 35 residents reviewed for infection control.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's call light device was within reach for two residents (R14, R17) reviewed for environment/accommodations of needs in a total sample of 35 residents. This failed practice placed the resident at risk for not being able to call for help, if needed.

Inspectors wroteBased on interview and record review, the facility failed to refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. This failure affects two of two residents (R58 and R88) reviewed for PASSR (Preadmission Screen and Resident Review) in a total sample of 35 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide showers to a resident who is unable to maintain good personal hygiene. This failure affects one of three residents (R174) reviewed for activities of daily living in a total sample of 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document catheter changes for a resident that requires an indwelling catheter. This failure affects one (R174) of three residents reviewed for catheters in a total sample of 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by the residents' physician for one (R83) resident in a total sample of 35 residents. Findings Include: On 05/28/2024 at 9:29AM, surveyor located on the first floor of the facility with V3 (Registered Nurse/RN). V3 states she is unable to locate R83's medications in the medication carts. V3 is observed opening and closing drawers and searching in both medication carts on the first floor. V3 states she will have to call the pharmacy to inquire about R83's medications. On 05/28/2024 at 10:21AM, V3 is observed calling the facility's contracted pharmacy and places the call on speaker. Pharmacy representative states to V3 that R83 has experienced a loss of insurance and R83's medications cannot be shipped to the facility due to insurance issues. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to follow their policy to ensure medications that are outdated are to be immediately removed or disposed, for 2 (R54 and R81) out of three residents reviewed for medication storage and labeling in the sample of 35.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to provide a meal to one (R85) of five residents reviewed in sample of 35. This failure resulted in R85 experiencing hunger.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement appropriate fall prevention interventions, and/or failed to provide supervision for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in R1 sustaining a fall that resulted in laceration and sutures to R1's left eyebrow.

Inspectors wroteBased upon record review and interview the facility failed to revise care plans with appropriate interventions for three of three residents (R1, R2, R3) reviewed for falls.

Inspectors wroteBased on interviews and records review the facility failed to ensure two (R5, R10) of three residents were free from abuse. This failure resulted in R5 being hit on the face and R10 being bitten on the arm by R6.

Inspectors wroteBased on interviews and records review the facility failed to supervise and monitor one (R3) of three residents reviewed for falls. This failure resulted in R3 falling and sustaining a right hip fracture.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment and maintain a sanitary, orderly, and comfortable interior for two residents (R7, R11) of 3 residents reviewed for clean, sanitary, and homelike environment.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to provide the necessary care and services to ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, oral and incontinent hygiene care affecting one resident (R8) out of three residents reviewed for incontinent care.

Inspectors wroteBased on interviews and record review, the facility failed to ensure 1 (R6) a totally dependent resident was free from Injuries of Unknown Origin in a sample of 11 residents. This failure resulted in R6 sustaining left upper extremity bruising, swelling and a fracture of the Left 2nd Metacarpal. Findings Include: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policies and procedures to (a) evaluate and monitor a high-risk resident's (R5) nutritional status, (b) obtain weights monitoring, and (c) implement nutritional interventions, monitor the effectiveness of interventions and revising them as necessary. These failures resulted in a severe weight loss [more than 9% over 2 months] for 1 (R5) of 5 residents reviewed for nutrition. Findings Include: R5's clinical records show an admission date of 5/20/23 with listed diagnoses not limited to abnormal weight loss, personal history of Malignant Neoplasm of Prostate, Hyperlipidemia, Essential Hypertension, Pulmonary Embolism, And Functional Dyspepsia. R5 was discharged to the hospital on 7/12/23 for complaint of rectal pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify physician of x-ray result revealing right hip fracture immediately. This failure affected one (R2) of 3 residents reviewed for resident injury.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure complete medical records by failing to have weights and wound treatments charted for two (R2, R3) out of a total sample of 11 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the residents' comprehensive care plan to ensure their call lights were within easy reach for 4 (R4, R16, R22, R317) of 4 residents reviewed for call lights in a total sample of 32 residents. Findings Include: On 6/13/23 at 10:54 AM, R16 was sitting on the side of R16's bed. R16 stated that R16 is legally blind and only see movements. R16's call light was observed on the floor by R16's bed and not within reach of R16. R16 stated that R16 goes up to the nurse's station when help is needed. R16 stated, I don't know where it is. At 11:21 AM, R317 lying in bed alert and able to verbalize needs. R317 stated that R317 is new to the facility and just came from an acute hospital for rehabilitation. R317 stated, I don't know. I don't have a call light, since I came here. I can't call for help. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow policy and procedures for advance directives by not addressing on the resident's care plan for one (R96) resident. The facility also failed to ensure in obtaining physician order for five (R1, R53, R96, R152, R155) of five residents. These failures can potentially affect 5 residents in a sample of 32 reviewed for advance directives.

Inspectors wroteBased on interview and record review, the facility failed to revise 4 (R1, R96, R155, R267) of 5 residents' comprehensive care plan to address their current psychotropic medications use in a sample of 32 reviewed for psychotropic medications. Findings Include: R1's clinical records show an admission date of 5/24/06 with listed dx not limited to schizoaffective disorder, type 2 diabetes mellitus, heart failure, and anxiety disorder. R1's physician order sheet (POS) shows R1 is taking scheduled psychotropic medications Haloperidol, Sertraline, and Quetiapine. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows R1 received antipsychotic, antianxiety, and antidepressant medications. R1's comprehensive psychotropic care plan date initiated on 6/9/22 does not address R1's current psychotropic medications use. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow smoking assessment and safety protocol policy and procedure by not developing a care plan for one (R72) resident and not evaluating residents who smoke on a quarterly basis for five (R30, R72, R113, R116, R152) residents. These failures can potentially affect five (R30, R72, R113, R116, R152) of five residents reviewed for smoking in the sample of 32.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy by not obtaining consents for psychotropic use prior to initiating the medications and failed to limit as needed psychotropic medications to 14 days for 4 (R96, R108, R133, R267) out of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure insulin pens were stored properly to prevent cross contamination in 2 of 4 medication carts reviewed for medication storage and labeling. Findings Include: On 06/14/23 at 12:15 PM the third-floor East medication cart was checked with V5 (Licensed Practical Nurse). Six Insulin pens were observed stored in a Styrofoam cup without bags in the medication cart drawer. R76 Order dated 04/24/23 document: Lantus Solostar Solution Pen-injector 100 UNIT/ML (Milliliters) (Insulin Glargine) Inject 53 unit subcutaneously at bedtime. Insulin pen observed in the medication cart reads: Lantus Solostar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 50 unit subcutaneously twice a day. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve foods under sanitary conditions by not ensuring serving utensils were sanitized before using to serve foods to the residents. This failure affected all 46 residents on the third floor receiving regular textured diet. Findings Include: On 6/13/23 at 12:19 PM, during dining observation on the 3rd floor for lunch, observed V9 (Dietary Aide) dropped three serving utensils on the floor. V9 picked them up and washed them briefly with soap and water at the nearby handwashing sink. V9 set the three wet serving utensils aside for approximately one minute and then placed one of the serving utensils in the plain pasta container and the other two serving utensils in the salad containers. V9 then started serving the residents the salads using the un-sanitized serving utensils. [...]

Inspectors wroteBased on observation, interview, and record review the facility. [A] the facility failed to follow their infection prevention and control policy when staff entered the room of one [R146] of two [R22] on transmission-based precautions without wearing the appropriate personal protective equipment (PPE) [B] failed to have Enhanced Barrier Precautions signage, have available and accessible Personal Protective Equipment (PPE), and wear PPE during high-contact resident care activities for one (R154) resident who had a urinary catheter and [C] failed to ensure the glucometer and reusable medical equipment was cleaned and disinfected between resident use. This failure has the potential to affect 6 (R22, R33, R67, R75, R91, R136) out of 7 (R97) residents reviewed during medication administration.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and provide discharge instructions to a resident (R166) who chose to discharge Against Medical Advice (AMA) who was reviewed for discharge in a sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an air mattress used for pressure reduction was on the correct settings, for 1 (R22) of 3 (R4, R85) residents reviewed for pressure ulcers, in a sample of 32. Findings Include: R22 has diagnosis not limited to Respiratory Failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Tachypnea, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant Side and Diaper Dermatitis. R22 weights dated 06/08/23 document: 120.0 Lbs. (pounds), 05/25/23 119.8 Lbs., 05/18/23 119.2 Lbs. and 05/11/23 120.8 Lbs. Care plan document in part: Actual alteration in skin integrity, sacrum, right buttock, right arm cast, Hx (history) of pressure ulcer R ischium, L Hip Date Initiated: 03/25/23. Interventions: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to perform appropriate hand hygiene practices when providing catheter care, handle the catheter bag and tubing in accordance with infection control standards of practice, and provide complete catheter care in a timely manner for 1 (R154) resident out of a total sample of 32 residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure oxygen tubing was labeled and stored to prevent contamination for 2 (R4, R67) of 2 residents and b.) ensure a resident received the correct oxygen flow rate for 1 (R67) resident in a sample of 32. Findings Include: R67 has diagnosis not limited to Type 2 Diabetes Mellitus, Pneumonia Due to Streptococcus Pneumoniae, Acute Respiratory Distress Syndrome, Acute Respiratory Failure with Hypoxia and Dependence on Supplemental Oxygen. Order Summary Report dated 06/14/23 document in part: Respiratory: Oxygen per nasal cannula @ 4 liters per minute continuous every shift for respiratory symptoms. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from a significant medication error related to insulin administration for 1 (R97) of 6 (R22, R33, R67, R75, R136) residents reviewed for medication administration. Findings Include: R97 has diagnosis not limited to Type 2 Diabetes Mellitus and Morbid Obesity On 06/14/23 at 12:00 PM V5 (Licensed Practical Nurse) stated R97 blood glucose was 350 and she will receive 10 units of insulin. V5 retrieved the Novolin R Injection Solution 100 UNIT/ML (Milliliters) (Insulin Regular (Human)) and applied a needle to the insulin pen. V5 proceeded to R97 room setting the insulin pen at 10 units. V5 injected the insulin into R97 right upper arm. V5 stated I prime the needle the first time using the insulin pen but when I use it again, I usually don't prime it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse Staffing information was posted daily and failed to ensure the Nurse Staffing information was accurate. These failures affected all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated, and stored; walk-in refrigerator clean; and failed to clean, sanitize, and air-dry cooking equipment after use to prevent food borne illness. These failures have the potential to affect all 158 residents receiving oral diets from the facility's kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to follow menu for residents on pureed diet. This failure affected 11 residents (R4, R9, R10, R25, R34, R71, R81, R87, R127, R135, and R141) reviewed for food and nutrition services in the sample of 64 residents. Findings Include: On 08/21/22, during lunch meal rounds the following observations were noted. Facility spreadsheets dated 8/21 list lunch meal as follows for general diets: Pork Roast, Garlic Mashed Potatoes, Mixed Vegetables, Dinner Roll or Bread, Margarine, [NAME] Cake with Chocolate Frosting, Beverage of Choice. Facility spreadsheets for lunch for pureed diets list items as follows: Pureed Pork Roast (#8 scoop), Garlic Mashed Potatoes (1/2 cup), Pureed Mixed Vegetables (#10 scoop), Pureed Cake (#10 scoop), pureed bread (#20 scoop), Margarine (1 each), Beverage of Choice. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that call lights were within reach of two residents (R414 and R415) reviewed for call lights in the sample of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who depend on staff assistance for their ADL's (Activities of Daily Living) receive shaving. This affects 3 residents (R30, R68 and R112) in the sample of 64 residents reviewed for ADL care and grooming.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure adaptive devices were applied to residents' hands to maintain and prevent further contracture for 3 (R71, R85, R141) residents reviewed for limited range of motion in the sample of 64 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 4 medication errors out of 36 medication opportunities, resulting in 11.11 percent medication error rate 3 residents (R122, R132, and R137) in the sample of 64 were affected when being reviewed for medications not administered as ordered.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that accommodates resident allergies and preference. This failure affected 2 residents (R85, R136) reviewed for food allergies and preference in the sample of 64 residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure required plate guard was provided to residents to facilitate self-feeding and promotion of dignity. This failure affected 2 residents (R71 and R85) reviewed for assistive device during mealtime in the sample of 64 residents.