Illinois Department of Public Health: Nursing Home Violations 1Q 2018

The Illinois Department of Public Health (IDPH) conducts regular investigations, surveys and inspections of Nursing Facilities, Assisted Living Homes and Rehabilitation Centers statewide throughout the year. The efforts of the surveyors and inspectors can quickly identify any violation of regulations as outlined by the Nursing Home Care Act. When surveyors identify a deficiency or violation, state and federal nursing home regulators can take quick action to impose severe penalties in monetary fines.

The Public Health Department routinely publishes their publicly available findings online through Quarterly Nursing Home Reports with detailed descriptions of serious problems, violations, and deficiencies. During the first quarter of 2018, surveyors found numerous serious deficiency and violations at the facility’s listed below. Each one was cited for multiple Type A (severe violations) and Type AA (extreme violations) that resulted in fines that ranged from $12,500-$50,000. These facilities include:

Aperion Care Oak Lawn
9401 South Ridgeland Avenue
Oak Lawn, IL 60453

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145197&SURVEYDATE=02/02/2018&INSPTYPE=CMPL&profTab=1&Distn=2.4&loc=60453&lat=41.7087701&lng=-87.7468071

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145197&SURVEYDATE=12/12/2017&INSPTYPE=CMPL&profTab=1&Distn=2.4&loc=60453&lat=41.7087701&lng=-87.7468071

Fine:
The State surveyor fined the 134-certified bed Medicare/Medicaid-participating facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated December 12, 2017, the state surveyor noted the facility’s:

  • Failure to Provide Adequate Treatment and Care According to Physician Orders, Resident’s Preferences and Goals

The state investigators documented the facility’s failure “to follow the resident care standards for [one resident] by failing to monitor [the resident’s] vital signs, resulting in [the resident] not getting better management of her vital signs.”

The surveyor documented that the “facility’s resident care standards denote following standards are to be practiced by all nursing employees in the performance of direct and indirect care procedures for or with the resident, whether using equipment for technical procedures or when assisting residents to carry out self-care activities. The standards will not be repeated again in the individual procedures unless significance warrants repetition.”

A review of the resident’s extensive Care Plan noted “activity intolerance secondary to cardiac arrhythmia. Interventions, medications as ordered and monitor for changes in the ability to tolerate activities, increase in symptoms of arrhythmia, shortness of breath, dizziness, etc., and report to the doctor.”

However, the surveyor reviewed the facility’s camera video noting that a member of the nursing staff “arrived in the unit at 10:45 PM… for the night shift, and entered the resident’s room with no blood pressure cuff or stethoscope in her hand, only a piece of paper” and exited the room one minute later. The actions of the nurse were repeated multiple times during the evening.

  • Failure to Provide Care and Assistance to Perform Activities of Daily Living for Any Resident Who is Unable

In a separate summary statement of deficiencies dated February 2, 2018, the state investigator documented that the facility’s failure “to ensure all showers are given on shower days.” There was also a failure to “inform residents of their designated shower days [and failure to] provide shaving and nailed grooming/hygiene services to dependent residents.” The deficient practice by the nursing staff affected three residents “reviewed for Activities of Daily Living.”

The state investigator documented that there were multiple residents who “voiced concerns about cold and hot water and the lack of regular showers.” One resident “complained that she had not received a regular shower in two months.” The resident “complained of the hot water in towels are cold, and staff [did not] provide bed baths.” The resident also noted that they have “had a slight body odor and have to dry oatmeal on her left side of the neck. [The resident] is total to extensive care for her Activities of Daily Living and require the assistance of two staff members for bathing and personal hygiene, and one staff member for feeding.”

Avantara Long Grove
1666 RDF (Checker Road)
Long Grove, IL 60047

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145868&SURVEYDATE=01/04/2018&INSPTYPE=CMPL&profTab=1&Distn=6.4&loc=60047&lat=42.1970343&lng=-88.0935013&dist=25

Fine:
The State surveyor fined the Medicaid/Medicare-participating facility $25,000 for Type A violations. Currently, Avantara Long Grove maintains a two out of five-star rating on staffing, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated January 4, 2018, state surveyors documented that the facility’s failure “to ensure necessary care and services for a resident who was experiencing a decline in her condition.

  • Failure to Provide Appropriate Treatment and Care According to Orders, Resident’s Goals Preferences and Goals That led to Death

The state investigator noted that the facility “failed to complete and document ongoing assessments and failed to monitor a resident urine output who was receiving intravenous fluids.” It was also noted the facility had failed to “assess a resident after they became unresponsive. These failures contributed to the resident deteriorating and developing septic shock.” The resident “was admitted to the hospital for septic shock” and expired two days after admission to the hospital.

During an interview with the Medical Director, it was noted that “it is the standard of care and protocols to monitor a resident’s intake and output who is receiving IV fluids.” The Director also stated that “a white blood cell count of 31 is pretty high, indicating an infection. That high of a count could [indicate a medical condition]. If the resident is showing clinical symptoms (change in mental status, low blood pressure, and critically high white blood cell count) with elevated white blood cell count, they should be sent to the hospital immediately.”

Big Meadows
1000 Longmoor
Savanna, IL 61074

http://dph.illinois.gov/sites/default/files/publications/NH18-S0049-01-17-18-BigMeadows.pdf

Fine:
The State surveyor fined the 83-certified bed Medicaid-participating facility $25,000 for Type A violations. Currently, Big Meadows maintains an overall two out of five-stars rating compared to all other facilities in the United States, which is significantly below the national average.

Violations:
In a summary statement of deficiencies dated January 17, 2017, the state investigator documented that the facility’s failure to “immediately notify the physician of a significant change in condition when [a resident’s] oxygen saturation was 81% on room air and became unresponsive.”

  • Failure to Immediately Notify the Resident’s Doctor and Family Member of a Change in the Resident’s Condition

The state investigator documented that these failures resulted in the resident “becoming unresponsive, restless, and hypoxic [deprived of adequate oxygen supply] for over 14 hours before being sent to the hospital for medical treatment.”

The state investigator reviewed November 10, 2017, at 5:42 PM Nurses Notes that revealed that the resident “was sitting in his wheelchair at the nurse’s station ready for supper and was noticed a grayish color with his head back. The other nurse could not feel a pulse, and then he turned red in color.” The document stated that “I was walking over to him“ and the resident “was not responding, and he was put to bed where he still remains comfortable.”

The nurses documented that they had left a message with the resident’s POA (Power of Attorney) “to call back and give her an update on his condition. Blood pressure just an hour before was 148/80. The next entry in the Nurses Notes [was documented the following morning on] Saturday, November 11, 2017, at 10:30 AM (over 14 hours later).” The resident “presents with an oxygen saturation of 72% on room air, dusty gray appearance and nonresponsive and with restlessness.”

The Licensed Practical Nurse (LPN) providing care stated during an interview two months later that “she did not recall the incident of November 11, 2017, with [that resident].” The LPN recalled that “the physician is notified via electronic communication system for change with a resident with the exception of emergencies, then the physician is called.” The LPN stated that “emergencies would include shortness of breath, episodes of unresponsiveness, residents not having a pulse or residents that are difficult to arouse.”

  • Failure to Protect Every Resident from All Types of Abuse Such as Physical, Mental, Sexual Assault, Physical Punishment, and Neglect by Anybody

In the same summary statement of deficiencies dated January 17, 2018, the state investigator documented that the facility had failed to “immediately call the physician when [a resident] had a significant change in condition. The facility neglected to follow its physician standing orders for a resident experiencing respiratory distress. These failures resulted in [the resident] having an episode of unresponsiveness, restlessness, and hypoxia for over 14 hours before being assessed and sent out for medical treatment.”

During an interview with the resident’s physician, it was stated that “he should have been called or the on-call position should have been called for a resident having an episode of unresponsiveness, gray and ashen in color, difficulty finding a pulse and oxygen saturation of 81% on room air and restlessness. The resident was in apparent distress and needed to be evaluated.” The state investigators interviewed the facility’s Corporate Nurse Consultant who stated that “they have no specific policies for monitoring and assessments for a change in a resident’s condition.”

Cedar Ridge Health & Rehabilitation Center
One Perryman Street
Lebanon, IL 62254

http://dph.illinois.gov/sites/default/files/publications/NH18-S0047-01-05-18-CedarRidge-HealthRehabCenter.pdf

Fine:
The State surveyor fined the 116-certified bed Medicare/Medicaid-approved facility $27,200 for Type A and Type B violations.

Violations:
In a summary statement of deficiencies dated January 5, 2018, investigators documented numerous violations after reviewing records, making observations and interviewing staff members.

  • Failure to Provide Timely Reassessment, Monitoring, and Services to Maintain or Improve Ambulation

The facility’s failure to provide timely reassessment, provide services and monitoring to improve or maintain ambulation resulted in the resident’s “decline in ambulation from 200 feet to barely making steps.” The investigators reviewed the Extended Program Sheet dated May 15, 2017, that documented that then the resident “was ambulating 200 feet with a wheeled walker at that time with two restorative aides.”

Upon observation of the resident during a lunch meal and December 26, 2017, the resident “was propelled out of his room to the dining room by [the resident’s] wife, while the resident] remained in his wheelchair for lunch.” A Certified Nursing Aide (CNA) documented that morning that the resident “usually propels his own wheelchair, but now they have to propel him, so he needs to have the pedals on.”

In an interview with the resident’s wife on January 3, 2018, she stated that she visits the facility “daily from morning to late afternoon.” The wife stated that the resident “does not walk anymore to the dining room, adding that [the CNA] tries to get them to walk into the bathroom from the dining room from bed.” A review of the resident’s “Progress Notes [revealed] documented falls on November 23, 2017, and December 11, 2017.”

However, during a tour with the facility’s MDS Coordinators and Licensed Practical Nurses, it stated that the resident “was on a walk-to-dine program daily at the lunch meal and also on an ambulation program to walk daily.” Both coordinators “were not aware that [the resident] was no longer walked into the dining room ambulating with the restorative person. No one could explain why the programs were documented as being done when they were not. Both stated that “the resident] had not been reassessed since his decline.”

  • Failure to Provide Adequate Supervision, and Develop and Implement Effective Interventions to Prevent Falls

The surveyors also identified a deficiency where the Health and Rehabilitation Center “failed to provide adequate supervision, develop and implement effective treatment to prevent a fall for one resident reviewed for falls.” This failure resulted in the resident “receiving a head injury that required sutures from two subsequent falls, and [another resident] receiving a left hip fracture requiring hospitalization after the fall.”

With the first resident, “there was no documentation the facility determined causative factors in each of the falls for [that resident] or if there was a pattern since two of the falls occurred at bedtime and another in the bathroom. The current Care Plan did not address [the resident apposite as] need for added supervision given the discontinuation of the alarm, possible toileting needs, or [the resident’s] cognitive impairment and inability to use the call light or involved [the resident’s] self in activities.”

DeKalb County Rehabilitation & Nursing Center
2600 North Annie Glidden Road
DeKalb, IL 60115

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145547&SURVEYDATE=02/07/2018&INSPTYPE=STD&profTab=1&Distn=5.5&loc=60115&lat=41.89322&lng=-88.7686382&dist=25

Fine:
State and federal regulators fined the 190-certified bed Medicaid/Medicare-approved facility $25,000 for Type A violations. Currently, DeKalb County Rehabilitation & Nursing Center maintains a two out of five-stars rating for health inspections, which is significantly below the national average.

Violations:
In a summary statement of deficiencies dated February 7, 2018, the state investigator documented the facility’s failure to “treat a resident in a dignified manner.

  • Failure to Honor Resident’s Right to a Dignified Existence, Self-Determination, Communication and Exercise His or Her Rights

The state surveyor noted that on February 5, 2018, at 10:44 AM, a Certified Nursing Assistant (CNA), and a Licensed Practical Nurse (LPN) transferred the resident “from his wheelchair to the toilet using a mechanical stand lift. With his incontinence brief removed and his buttocks exposed, [the resident] was placed on the toilet with the bathroom door and the door to [the resident’s] room open.”

Approximately 20 minutes later during an interview, the LPN stated that “we should have closed the door [before] putting [the resident] on the toilet.” The state investigator interviewed the resident who stated “yes, it bothers me that the left the doors open while I was going to the bathroom. I want my privacy.”

A review of the facility’s Resident Right Staff In-Service Education Form (undated) revealed that:

“The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of his or her quality of life, physical and mental health, sense of satisfaction, recognizing each resident’s individuality, and protect the rights of the resident, including access to quality care.”

  • Failure to Honor a Resident’s Right to Request, Refuse or Discontinue Treatment, and Formulate an Advance Directive

In the same summary statement of deficiencies dated February 7, 2018, the state investigator documented that the facility “failed to ensure a resident’s code status was updated.” Included in the findings was a “Do Not Resuscitate (DNR) practitioner orders for life-sustaining treatment (POLST) Form [for a resident that] shows a Physician signed the DNR on September 5, 2017. However, a review of the resident’s physician’s order sheet from September 2017 through February 2018 show that the resident had a “full code status.” The investigator documented that “there was no order for the assigned DNR/POLST Form.”

Dixon Rehabilitation and Health Care Center
800 Division Street
Dixon, IL 61021

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145906&SURVEYDATE=01/31/2018&INSPTYPE=CMPL&profTab=1&Distn=2.0&loc=61021&lat=41.8192126&lng=-89.4931176&dist=25

Fine:
The State surveyor fined the Medicaid/Medicare-approved 97-certified bed facility $25,000 for Type A violations. Currently, Dixon Rehabilitation & Healthcare Center maintains a two out of five-star rating compared to other facilities in the United States, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated January 31, 2018, a state investigator documented that the facility had failed to ensure a resident “was transferred in a safe manner using a mechanical lift.”

  • Failure to Ensure That Every Resident Is Provided an Environment Free of Accident Hazards and Provided Adequate Supervision to Prevent Accidents

The deficient practice by the nursing staff resulted in the resident sustaining injury. The incident involved a resident who “was totally dependent on staff for transfers [and] required a mechanical lift with the assistance of two persons for transfers and to ensure this method was used.

The Illinois Department of Public Health received the facility’s initial report that revealed “during a mechanical lift transfer with two Certified Nursing Assistants present, [the resident] slid out of her mechanical lift sling. The staff attempted to intervene and lower her to the floor but were unsuccessful in doing so, and which [the resident] landed on the floor under buttocks. The skin assessment was performed immediately and range of motion was noted to be within normal limits.”

The document also stated that the resident “did complain of pain in her left hip, the physician was notified, and orders were given to send [the resident] to the hospital for x-rays. The hospital called {the nursing home] to notify the facility that [the resident] has an acute comminuted intertrochanter hip fracture.

The final report sent to the IDPH from the facility revealed that “through interview and investigation, the right bottom loop on the mechanical lift sling was not secured and detached from the mechanical lift which resulted in the resident sliding out of the sling. The staff was unsuccessful in their attempt to intervene, and the resident landed on her buttocks/left hip. The Director of Nursing inspected the sling and found the sling in good working condition. The Maintenance Director inspected the mechanical lift and found no deficiency.”

Glenlake Terrace Nursing and Rehabilitation Center
2222 West 14th Street
Waukegan, IL 60085

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145669&SURVEYDATE=01/18/2018&INSPTYPE=CMPL&profTab=1&Distn=2.6&loc=60085&lat=42.3641878&lng=-87.8647961&dist=25

Fine:
The State surveyor fined Medicare/Medicaid-approved 265-certified bed facility $25,000 for Type A violations. Currently, Glenlake Terrace Nursing and Rehabilitation Center maintains a two out of five-star rating on staffing compared to all other in the United States, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated November 29, 2017, the state investigators documented that the facility “failed to conduct a thorough investigation of an allegation of physical abuse.”

  • Failure to Respond Appropriately to All Alleged Violations

The facility’s Administrator/Abuse Coordinator stated that “she received a call on January 2, 2018, at 8:30 PM from [a Registered Nurse who stated that] she was informed by the resident’s family that the respiratory therapist had allegedly slapped [the resident] during routine care.”

Surveyors also documented that on January 12, 2018, “the facility provided the surveyor a third-floor census [the resident’s floor] indicating three interviewable residents. The facility also provided a list of third-floor residents requiring [respiratory] care which show three additional interviewable residents based on MDS (Minimum Data Set) assessments.”

However, the investigator documented that “none of these residents had been interviewed regarding the potential for abuse by [the respiratory therapist].” Additionally, the resident’s “abuse investigation file was reviewed by the surveyor with [the Administrator] present. The resident’s investigation file did not contain any resident interviews to address the care by the [respiratory therapist.”

  • Failure to Develop, Implement and Enforce Policies and Procedures That Prevent or Abuse

In a summary statement of deficiencies dated January 18, 2018, the state investigator documented that the facility’s failure “to follow its abuse policy by not thoroughly investigating an allegation of physical abuse.” The state investigator interviewed the facility Administrator/Abuse Coordinator who discussed an allegation of physical abuse of the Respiratory Therapist slapping a resident while providing care.

As a part of the investigation, the alleged perpetrator was sent home “pending an investigation.” The Abuse Coordinator stated that the investigation “was completed on January 4, 2018, and all interviews were in the investigation file.” The resident’s “abuse investigation file was reviewed by the surveyor” in the presence of the Administrator. However, the resident’s Incident File “did not contain any resident interviews to address care by [the respiratory therapist]. The facility’s Abuse Policy dated February 7, 2017 states under the investigation section that “residents to whom the accused has regularly provided care will be interviewed.”

Glenshire Nursing & Rehabilitation Centre
22660 South Cicero Avenue
Richton Park, IL 60471

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145424&SURVEYDATE=12/22/2017&INSPTYPE=CMPL&profTab=1&Distn=0.0&loc=60471&lat=41.4841903&lng=-87.7418842&dist=25

Fine:
The State nursing home regulators fined the 294-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Currently, Glenshire Nursing and Rehabilitation Centre maintains an overall one out of five-star rating compared to all other facilities nationwide. This rating includes three out of five stars for quality measures and one out of five stars for both staffing and health inspections.

Violations:
In a summary statement of deficiencies dated December 22, 2017, the state investigators documented that the facility had “failed to ensure that incontinent care was provided in a timely manner for [three residents].”

  • Failure to Provide Care and Assistance to Perform Activities of Daily Living for Any Resident Who is Unable

The state surveyor noted that upon a facility tour at 4:45 AM on December 20, 2017, a resident was observed “in bed. The back of the resident was soaked with urine. [The resident] did not have a disposable brief on, and a disposable and cloth incontinent pad were used. The disposable pad was completely saturated with feces and urine. The cloth pad was saturated from top to bottom with urine, a dark ring was noted. [The resident’s] sheet was wet.”

“The dressing to [the resident’s] stage IV sacral pressure ulcer was not clean/dry/intact. The dressing fell during incontinent care performed by the [Wound Nurse and] the wound packing fell out of the wound.” During an interview with the Certified Nursing Assistant will providing the resident care, it was revealed that “she last changed the resident around 2:30 AM.”

  • Failure to Provide Adequate Staff to Meet Every Resident’s Need Every Day and Have a Licensed Nurse in Charge on Every Shift

In a summary statement of deficiencies dated December 22, 2017, the state investigator documented that the facility’s failure “to provide required direct care staffing to ensure personal care was provided according to the resident’s needs.” The deficient practice by the nursing staff involved three residents reviewed for personal care needs. The facility documents reveal that on the third shift in December 2017, there were 46 residents on the third floor. At that time, “there were three Nurses and two Certified Nursing Aides.

During an interview with the Director of Nursing, it was revealed that “staffing is getting better. The Staff Coordinator was hired two weeks ago. [Before] her hire, the Assistant Director of Nursing and I were doing the staffing, [and the] staff (nurses, CNAs) were doing their own thing, coming and later not at all. A couple of people did not show (Third Shift, Third Floor). I was told by the night supervisor that staffing was okay.”

Grasmere Place
4621 North Sheridan
Chicago, IL 60640

http://dph.illinois.gov/sites/default/files/publications/NH18-C0010-11-01-17-GrasmerePlace.pdf

Fine:
The State surveyor fined the facility $12,500 for Type A violations.

Violations:
In a summary statement of deficiencies dated November 1, 2017, based on interviews and record reviews the facility “failed to follow their drug test policy and conducted a drug test.”

  • Failure to Follow Established Procedures and Protocols

The state investigator documented that the facility’s failure “to carry out a physician’s orders regarding care, medications and an appointment with a high-risk obstetrician.” The nursing staff also “failed to follow their Cardiopulmonary ‘Resuscitation (CPR) policy and failed to follow the standards of care and provide effective CPR.” Additional failures included the failure to “provide psychiatric rehabilitation services, the facility’s Director of Nursing failed to review the physician’s orders” regarding a resident at Grasmere Place.

The surveyor documented that the failure to assess the resident’s needs “potentially contributed to the fetal demise of the resident’s unborn child and the overdose of the resident.” The failure also resulted in the resident “not receiving prenatal care from February 21, 2017 [upon admission at Grasmere Place] until May 31, 2017.” Investigators also documented that the facility failed to “provide effective CPR that has the potential to affect one of all 178 resident’s living in the facility.”

When the resident was admitted to the facility on February 21, 2017, the resident was admitted to the hospital the following day for “benzodiazepine and opioid withdrawal. [The resident] was discharged and sent back to the facility on February 24, 2017. The hospital discharge instruction stated February 24, 2017, showed opioid withdrawal, insulin treatment for diabetic ketoacidosis and smoking cessation.”

Approximately three weeks after the resident was admitted to the facility the Certified Addiction Drug Counselor completed an initial MISA Note that revealed the resident “should meet for one-on-ones [counseling] once a month. The facility’s substance abuse history document that is part of the assessment was never completed in the five months [that the resident] was in the facility.” The counselor also “failed to complete the assessment at the time of the admission per the facility’s policy and failed to meet with [the resident] as an addiction counselor upon [the resident’s] admission.

Helia Healthcare of Champaign
1915 South Mattis Street
Champaign, IL 61821

http://dph.illinois.gov/sites/default/files/publications/NH18-C0057-01-09-18-Helia-HealthcareofChampaign.pdf

Fine:
The State surveyor fined the facility $50,000 for multiple Type AA (extreme) violations.

Violations:
In a summary statement of deficiencies dated January 9, 2018, the state investigator identified a facility’s failure “to effectively monitor the whereabouts of one of five residents with known wandering behaviors.” The deficient practice by the nursing staff resulted in the resident’s death by freezing outside in the cold.

  • Failure to Provide Every Resident Adequate Supervision to Prevent Elopement (Wandering Away)

The incident in question involved an 89-year-old resident diagnosed with Alzheimer’s disease and dementia with behaviors. State investigators reviewed the resident’s MDS (Minimum Data Set) dated October 17, 2017, that indicates that the resident “exhibited wandering behavior that ‘places a resident at significant risk of going to potentially dangerous places.’” The investigator noted that the “assessment also documents that [the resident] was independent with ambulation.”

The investigator reviewed the resident’s October 17, 2017 Elopement Risk Assessment that documents the resident “as severely cognitively impaired, independent with locomotion, and exhibiting the following behaviors: ‘History of leaving the facility’ and ‘wandering in the past 60 days.’”

The facility’s Progress Notes documents the Licensed Practical Nurse stated that the resident “is resistant to being redirected.” The resident is continually “wandering in and out of resident’s room.” On the same day during the evening hours, a Registered Nurse at the facility documented that the resident “has a personal alarm on their leg for security. [The resident] does not need help to get up from the bed. [The resident] wanders in the facility all day.”

A review of the facility’s Incident Report dated December 30, 2017, approximately 11:00 PM, [notes that the resident] was found ‘laying on the ground near the North second door of the kitchen.’” The facility Charge Nurse that evening verified that she “was the one to discover the resident” after the resident eloped from the facility. “I was the only nurse on nights.” The Charge Nurse was notified by the Certified Nurse’s Aide (CNA) who stated that the resident “was missing.” The Charge Nurse said “we did room checks, I asked [the Licensed Practical Nurse (LPN)] when the resident was last seen.”

The Charge Nurse stated that “the kitchen door was wide open [and] the lights were on. The North West kitchen door was cracked [open], and I saw a body lying there.” The Certified Nursing Aides (CNA) “screamed.” The Licensed Practical Nurse “went to call 911.” The Charge Nurse found the resident “as cold as ice [with] no pulse.”

On January 3, 2018, the County Deputy Coroner stated that “there is no final cause of death in this case (the death of [the resident]), pending toxicology results. At this point, we can say that there was no obvious trauma or physical cause of death at the scene.” By the time the coroner arrived, the resident “had been in the cold for approximately an hour. The Emergency Medical Technicians (EMTs) could not obtain a core temperature, but [the coroner] did measure a surface temperature” of “8°F. “The resident’s hands and forearms were still frozen solid. The resident was wearing a light blouse and pants, and a pair of White Sox. One of the socks was dirty on the bottom as if the resident had walked on it without issue and one was not. Only one shoe could be located. There was no other clothing located.

The investigator reviewed historical temperature data around the time the resident “was discovered.” The temperature at that location was “-8°F with northwesterly winds at 10.4 mph at 9:53 PM.

Integrity Health Care of Wood River
393 Edwardsville Road
Wood River, IL 62095

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145655&SURVEYDATE=01/30/2018&INSPTYPE=CMPL&profTab=1&Distn=0.0&state=IL&name=INTEGRITY%20HC%20OF%20WOOD%20RIVER&lat=38.8675607&lng=-90.0886948

Fine:
The State surveyor fined the 106-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Currently, Integrity Health Care of Wood River maintains an overall two out of five-star rating compared to all other facilities in the United States, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated January 30, 2018, the state investigator documented a deficiency at the facility and their failure “to notify the physician and responsible party of a change of condition.” The deficient practice by the nursing staff resulted in the resident’s death.

  • Failure to Immediately Notify the Resident’s Doctor or Family Member of a Change in the Resident’s Condition

The state surveyor reviewed the facility’s Fire Department Incident Report dated December 25, 2017, at 12:55 PM that documents the nurse “arrived in stated that this was not her patient and she was not familiar with them. The nurse remarked the patient had been in this condition ‘since Wednesday.’” The report also remarked that “the nurse was asked to clarify told that Wednesday would have been five days ago. She again stated that this was not her patient, but that the aides on this hall all agreed no one has seen him awake since Wednesday of last week. She also advised that his normal mental status was alert and responsive but occasionally combative.”

A Certified Nursing Aide (CNA) stated that on December 20, 2017, the resident “was sleeping in the hall [and] he was not responding by waking up, so we laid him back down. A week before Christmas he was very sleepy, which was a change because he would propel himself in the wheelchair, be combative and try to get up.”

The CNA stated that on Thursday, December 21, 2017, during the day shift, they “did not see him the dining room. Normally he would propel himself and feed himself. At this stage [he] had to be pushed in his wheelchair and I assisted him with feeding. I came back, and I worked with [the resident during the] midnight shift, and he slept all night. I changed him three times. He would tense up, but never fully aroused or spoke to me. He did not respond to me during incontinent care. I thought he was in a deep sleep. This sleeping at night was abnormal for him. Usually, he would be up all night.”

A Registered Nurse providing the resident care on December 22, 2017, stated that the resident “was not responsible enough to give them his medication safely [and…] Was sleepy/lethargic.” The following day on December 23, 2017, the Certified Nursing Assistant stated that during the day shift the resident “was asleep and snoring and he was not responding.” The CNA stated that “this is because he usually is up and dozing in his chair.”

The Licensed Practical Nurse stated that on December 24, 2017, the resident “slept through breakfast. At approximately 11:00 AM/12:00 PM, [the resident’s] family came in and we try to get him up, but he was sleeping. The family requested I laid him back down. He has a history of staying up all night. I work the midnight shift, and he is up. He was sleeping through breakfast or [will] get up and go back to sleep.”

The resident’s daughter-in-law stated “my husband and I went down to see the resident on Christmas Eve around lunchtime. He was in bed with the door shut. The resident was in a gown and a diaper. There were half dissolved pills in his mouth.” The daughter-in-law also stated that after they went to the “emergency room, the next day he still had on the same shirt he [was wearing] on Christmas Eve because it had the applesauce stain in the same place.”

An interview with the resident’s physician revealed that the doctor “did not know that [the resident] does refuse medications all the time. From a respiratory standpoint with wet respirations, the man sounded like a very sick man. He at least deserved a phone call to notify me of a change of condition. A change in sleeping patterns is also a change in condition that I should have been notified of. A delay to notify me of this change of condition contributed to his death because it delayed his treatment.”

In a separate summary statement of deficiencies dated February 14, 2018, an additional failure was identified to immediately notify the resident’s Doctor and family member of a change in the resident’s condition. The state investigator reviewed the resident’s progress note dated January 19, 2018, at 4:50 AM the documents that a nurse “heard someone yelling out and found [a resident] lying face down. The Progress Notes document that the nurse called 911 and started chest compressions. Progress Notes document [the resident] was transported to the hospital. However, the Progress Notes “failed to document that the family was notified of a change in the [resident’s] condition and transferred to the hospital.”

The facility Director of Nursing stated that “she would expect staff to notify the family of a change of condition and transferred to the hospital.” The facility Policy Change in A resident’s Condition or Status dated revised December 2016 revealed that “unless otherwise instructed by the resident, the nurse will notify the resident’s representative when it is necessary to transfer the resident to a hospital/treatment center.”

  • Failed to Honor a Resident’s Right to a Dignified Existence, Self-Determination, Communication, and the Right to Exercise His or Her Rights

In a summary statement of deficiencies dated February 14, 2018, the state investigator identified the facility’s failure “to answer call lights timely for [two residents].” The deficient practice by the nursing staff was identified by the resident who stated that “when he pushes his call light, the staff does not answer it.”

The state investigator interviewed the facility’s Director of Nursing on the morning of February 8, 2018, who stated that “she was aware there had been an issue [regarding] call lights being answered from the resident council meeting.” The Director also stated that “she would expect staff to answer call lights and that she had provided staff training.

Lexington of LaGrange
4735 Willow Springs Road
LaGrange, IL 60525

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145737&SURVEYDATE=12/14/2017&INSPTYPE=CMPL&profTab=1&Distn=1.9&loc=60525&lat=41.7906113&lng=-87.8647961&dist=25

Fine:
The State surveyor fined the 120-certified bed Medicaid/Medicare-participating facility $25,000 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated December 14, 2017, the state investigators identified a facility’s failure “to develop a plan to reduce and prevent the risk of constipation.” The failure by the nursing staff resulted in the resident “being transported to the local hospital” for treatment. The incident involved a resident who is admitted to the facility for rehabilitation therapy “following left hip surgery due to a fracture.”

  • Failure to Provide Appropriate Treatment and Care According to Orders, Resident’s Preferences and Goals

The state investigator reviewed the resident’s MAR (Medication Administration Record) and Nursing Notes that revealed that the resident “did not complain or get medicated for abdominal pain or constipation during the course of her stay at the facility.”

At the time of the problem, the Certified Nursing Aide (CNA) providing the resident care stated that in the early afternoon “she helped care for the resident [during] the 7:00 AM through 3:00 PM shift. In the early afternoon, the resident was not as alert as she normally was and moaned a little when repositioned. [The resident’s] abdomen was distended, and tender to touch. The resident had urinated that day yet.” The CNA took the resident’s “vital signs and reported these findings immediately to [the nurse in charge].”

The surveyor documented that according to “hospital records” the resident “arrived at the hospital emergency room at 2:49 PM… With the heart rate of 107 … mouth appeared dry, and her abdomen was soft, with normal bowel sounds and diffused abdominal tenderness with guarding. The resident was sleepy, but arousable by voice. The resident began vomiting after arrival in the emergency room.” The hospital surgeon stated that “dehydration could be driving her colonic wall thickening. The resident did not have a small bowel obstruction or any definite signs of perforation.” The surgeon determined that the resident “was not in need of surgery at the time.”

Hospital documents reveal that the “patient expired peacefully. Hospital records obtained by the surveyor did not indicate the details surrounding the resident’s death [and the resident’s] Death Certificate signed by the Medical Examiner [listed the cause of death] as possible large bowel obstruction. An autopsy was not performed.”

The state investigator interviewed the facility’s Director of Nursing who stated that Nurses and Certified Nursing Aides are responsible for documenting each resident’s bowel movement. It is the nurse’s responsibility to monitor these records to ensure residents are moving their bowels regularly, by information shared and verbal report, as well as a review of the resident’s continents record. If the nurse finds a resident has moved his/her bowels, the nurse should interview the resident [if possible] regarding his/her normal bowel pattern or interviewed the resident’s family when appropriate.”

Manor Court of Peoria
6900 North Stalworth Drive
Peoria, IL 61615

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146108&SURVEYDATE=11/20/2017&INSPTYPE=CMPL&profTab=1&Distn=4.0&loc=61615&lat=40.8064627&lng=-89.6345796&dist=25

Fine:
The State surveyor fined the 50-certified bed Medicare/Medicaid-approved facility $25,000 for multiple Type A violations. Currently, Manor Court of Peoria maintains a one out of five-star rating compared to all other facilities in the United States, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated November 20, 2017, the state investigators identified the facility’s failure to “ensure two residents were not abused.”

  • Failure to Protect Every Resident from All Abuse, Physical Punishment and Being Separated from Others

The reported incident involved a member of the nursing staff forcefully restraining two residents “during cares, resulting in skin tears for [one resident] and causing bruising on the [other resident’s] wrists, eye, and upper arms and also causing fear for [that resident].” Observations were made of the first resident sitting in a wheelchair at 1:00 PM on November 14, 2017, who “had a 5 cm dark purple V-shaped area to the left upper arm and a 3 cm dark purple scabbed area to the left wrist.”

A Certified Nursing Assistant (CNA) stated at 9:40 AM on November 14, 2017, that they had witnessed another CNA hold the resident’s “wrists down on October 31, 2017, at 7:00 AM.” The reporting CNA stated that while holding [the resident] down, the other CNA caused skin tears to [the resident’s] left wrist and left arm and that [the aggressive CNA and the resident] both had blood on them.” The reporting CNA stated that the resident “is a tough man and [the allegedly aggressive CNA held the resident] down entirely by the wrists and arms while providing cares.”

The reporting CNA stated that both residents did not like the aggressive CNA “and would swing at the [aggressive CNA].” The reporting Certified Nursing Assistant stated that “I would see [the allegedly aggressive CNA hold the resident’s’] wrists down. The amount of strength [they] would use to hold the resident’s wrists down would depend on how strong the resident is.”

It was documented that one of the residents had a “3 cm round dark purple bruise under the left eye, four brown with yellow discolored 7 cm bruises with a 2 cm round bruise below those bruises to the bilateral upper arms and bilateral wrists. These four bruises resembled the fingers and thumb of a handprint.” The resident’s “left rib area had a 5 cm round brown bruise.” The resident’s “left elbow had a 5 cm yellow/brownish bruise [and the resident’s] left outer breast had an 8 cm light purple bruise.”

The reporting Certified Nursing Assistant stated at 2:40 PM on November 14, 2017, that the resident “has good days and bad days [and] will say ‘Look at my bruises. Somebody hit me.’ [The resident] is way more on edge and scared since the incident on November 3, 2017. It takes a lot more time to take care of her and [she] is always afraid she will get hurt. There is a big difference with [that resident] feeling safe [because she] always feels unsafe. The female victim stated at 1:15 PM on November 13, 2017, by pointing “to the bruise under her left eye and wrists, ‘I got hit. I am scared I will get hurt again.’”

  • Failure to Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents

In a separate notation dated November 20, 2017, the state investigators identified the facility’s failure “to ensure staff reported an act of physical abuse immediately to the Administrator.” A notation was made of the facility’s failure “to protect two residents from physical abuse, and [a failure] to remove the alleged perpetrator [a Certified Nursing Assistant] from the facility immediately after a witnessed abuse for two residents.”

These failures by the nursing staff and administration resulted in the allegedly aggressive Certified Nursing Assistant (CNA) “having continued access to residents after physically restraining [one resident] causing skin tears to [their] upper left arm and left wrist, and later restraining [another resident’s] wrists and arms, resulting in a handprint bruising to both the resident’s upper arms and wrists, and causing fear and mental anguish.”

Niles Nursing & Rehabilitation Center
9777 Greenwood Avenue
Niles, IL 60714

Fine:
The State surveyor fined the Medicare/Medicaid-participating 304-certified bed facility $25,000 for multiple Type A violations. Currently, Niles Nursing and Rehabilitation Center maintains a two out of five-stars rating for health inspections compared to other facilities nationwide, which is significantly lower than average.

Violations:
In a summary statement of deficiencies dated January 22, 2018, the state investigators identified a deficiency at the nursing facility in their failure “to obtain Physician orders, care instructions, and assess a resident skin following application of a controlled ankle motion boot.”

  • Failure to Ensure That Every Resident Receives a High Standard of Quality Care According to Professional Standards

The failure by the nursing staff resulted in the resident “sustaining a pressure ulcer and wound infection requiring hospitalization and the removal of surgically implanted hardware.” A review of the resident’s October 12, 2017, Nursing Progress Note revealed the resident “fell outside of the facility when [a family member] transferred [the resident] from the wheelchair to a car. [The resident] was sent to the local hospital and returned the same day with a right ankle fracture.”

The facility’s Nursing Progress Note dated November 6, 2017, revealed that the resident “had surgery at the local hospital and returned to the facility on November 8, 2017.” A follow-up examination with the surgeon on November 21, 2017, showed “minimal edema present to the right ankle.” The surgeon ordered that the resident be given a walker on December 5, 2017, and “may begin applying weight for a transfer to bed and chairs. [The resident] is not to be ambulatory at this time.” The resident was to follow-up with the surgeon in 2 to 4 weeks.

However, documentation dated November 28, 2017, revealed that the resident “came back to the doctor’s appointment with orders to send out the resident to the local hospital for right ankle ulcer [treatment], hardware exposed…” An ambulance was called, the family was called, and the resident was sent to the hospital at 2:00 p.m. The hospital noted “opened an ulceration with infected hardware, right ankle.”

A review of the facility’s Medication Review Report for December 2017 revealed “no orders for the management of [the resident’s] CAM boot, including data for the removal of the boot for circulation check, skin inspection, washing and to remove the boot while sleeping.” The Director of Nursing stated during an interview on January 18, 2018 that “when a resident comes back from a doctor’s appointment, physician’s orders and documentation should be checked. The nurse should call the physician if they need clarification on orders.”

The Director of Nursing also stated that “there is no documentation in the medical record to show the resident’s POA [power of attorney] or physician was notified of the resident’s repeated refusals for staff to touch [their] boot and assess [their] right ankle.” The Director also stated that “the order to have the resident seen by the wound care nursing to wrap the resident’s right leg with gauze never made it to the [resident’s medical records] so it was never done.”

Norridge Gardens
7001 West Cullom
Norridge, IL 60706

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145329&SURVEYDATE=02/28/2018&INSPTYPE=STD&profTab=1&Distn=0.5&loc=60706&lat=41.9633064&lng=-87.8107561&dist=25

Fine:
The State surveyor fined the Medicare/Medicaid-approved 292-certified bed facility $25,000 for multiple Type A violations. Currently, Norridge Gardens maintains a two out of five stars rating for staffing compared to all other facilities in the United States, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated February 28, 2018, the state investigators identified deficiency practices including the:

  • Failure to Provide Appropriate Pressure Ulcer Care and Prevent the Development of New Ulcers

The state investigators identified the facility’s failure to “ensure that an air mattress was functioning properly and failed to ensure that a resident with a stage IV pressure ulcer maintained proper positioning.” The deficient practice by the nursing staff affected one resident “reviewed for pressure ulcers.” The failure “contributed to the increase in the size of [the resident’s] sacral pressure sore.”

During an interview with the resident on February 25, 2018, the resident stated that “My bed is lopsided and there is no one to pull me over.” The resident stated that “she [nursing help] was coming back and never came back.” The resident stated that “he had been in the same position for more than two hours and that he has a sore on his buttocks area.” The resident “began to cry and stated it hurts him to stay in bed in the same position [and] was positioned on his back on the right side of his bed with one pillow between his right side and the rail.”

The investigator interviewed the Certified Nursing Assistant (CNA) providing the resident care who stated at 11:44 AM that the resident “was turned at 9:00 AM and he would be turned every two hours.” The CNA stated that “he asked to be pulled over. His bed is kinda messed up so keys lopsided.” The CNA also said that the resident “slides to the right. I know it is uncomfortable too.” The Certified Nursing Assistant also said that “the air mattress was not inflated properly [and believes] the bed frame is too small for the mattress. So, it dips to the right.” The resident’s “air mattress extended approximately 5 inches past the edge of the bed frame on the left side.”

The state investigator reviewed the resident’s Wound Care Assessments that “document that the sacral pressure sore declined and increased in size from January 25, 2018, through February 8, 2018. The measurements were as follows:

  • “January 25, 2018: 4.5 cm x 2.5 cm x 2.0 cm
  • February 1, 2018: 5.5 cm x 2.5 cm x 1.5 cm
  • February 8, 2018: 6.5 cm x 2.5 cm x 1.5 cm”

The resident’s “Care Plan documents: Interventions: Turn and reposition every two hours while lying.”

  • Failure to Provide Every Resident Environment Free of Hazards and Provide Adequate Supervision to Prevent Accidents

In a summary statement of deficiencies dated December 14, 2017, the state investigators documented a facility’s failure “to ensure residents were properly transferred using the assessed mechanical lift and proper technique.” The deficient practice by the nursing staff “resulted in a fall for one” resident. In an interview with the resident, it was revealed that “she was dropped by the Certified Nursing Assistants when being put back to bed about a month ago.”

The incident was documented in the Facility Incident Report dated January 5, 2018, at 7:06 PM that indicates “during transfer, the resident was assisted to the floor one resident became weak.” A Certified Nursing Assistant who was providing the resident care stated that “on that day, [while transferring the resident] with the help of [another Certified Nursing Assistant, they] did not utilize a mechanical lift for the transfer.”

The resident “started to slip during the transfer and had to be lowered to the floor. Once [the resident was] on the floor, [two more CNAs] were called in to assist in transferring a resident from the floor to the bed.” This action was performed again “without using a mechanical lift, [but by] lifting the resident up by grabbing the resident by her arms and legs to place her back in bed.”

All four Certified Nursing Assistants “were disciplined for improperly transferring the resident following this incident, with [one Certified Nursing Assistant] receiving a suspension, while [the remaining] received written warnings.” The suspended Certified Nursing Assistant “also stated she failed to notify the nurse to come and address the resident after falling, [before putting the resident] back in bed.”

Parents and Friends of the Specialized Living Center
1450 Caseyville Avenue
Swansea, IL 62226

http://dph.illinois.gov/sites/default/files/publications/NH18-C0037-12-14-17-Parents&Friends-oftheSLC.pdf

Fine:
The State surveyor fined the facility $12,500 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated December 14, 2017, the state investigators identified a deficiency at the facility that included a:

  • Failure to Maintain Necessary Oversight to Ensure the Health and Safety of Residents

According to interviews, record reviews and observations, the state investigators determined that the facility’s Governing Body “failed to maintain necessary oversight over the facility to ensure the health and safety of the individual at the facility.” Multiple incidents involved two individuals “who were a full code and did not have a Do Not Resuscitate (DNR) order at the time of their death.

In one incident, a resident “was admitted to the facility on September 6, 2017 as a Full Code and after his admission to the facility was found on September 23, 2017 without a pulse or respirations.” However, cardiopulmonary resuscitation (CPR) “was not performed by facility staff nor by the contract nurse even though the resident was a Full Code.” After his death, the facility investigated but failed to:

  • “Update their policies and procedures for the Emergency Crash Cart/Box and necessary emergency medical equipment needed during a Code Blue.”
  • “Ensure that the nursing staff was trained and demonstrate competencies in their knowledge of oxygen tank locations and how to open the Emergency Crash Box to prevent a potential delay in emergency medical treatment.”
  • “Update and provide training for utilization of the Emergency Crash Box and necessary emergency medical equipment needed during a Code Blue.”

In a separate incident, a resident sustained a head injury caused by a fall and “was sent to the emergency room on February 15, 2017.” However, “the facility sent the wrong Advance Directive Orders resulting in life-sustaining treatment, not being provided to him as indicated on his Uniform Practitioner Orders for Life Sustaining Treatment (POLST) form dated December 15, 2016.” The resident “expired at the hospital on February 15, 2017 and after his death the facility failed to:

  • “Investigate whether the wrong Advance Directive form was sent with the resident at the time of this transfer [to the hospital].”
  • “Establish a system to ensure that each individual’s Advance Directive orders are current to prevent future recurrence.”

The failures by the nursing staff and administration “posed a potential threat to the health and safety of all 62 residents at the facility.”

Pleasant View Lutheran Home
505 College Avenue
Ottawa, IL 61350

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145801&SURVEYDATE=12/08/2017&INSPTYPE=STD&profTab=1&Distn=3.8&loc=61350&lat=41.375388&lng=-88.8455037&dist=25

Fine:
The State surveyor fined the 90-certified bed Medicare/Medicaid-approved facility $25,000 for multiple Type A violations. Currently, Pleasant View Lutheran Home maintains an overall two out of five stars rating compared to all other facilities in the United States, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated December 8, 2017, the state investigators identified a deficiency at the facility that included a:

  • Failure to Provide Appropriate Pressure Ulcer Care and Prevent New Ulcers from Developing

The state surveyors noted the facility’s failure “to identify and prevent worsening of a pressure ulcer [for one resident].” The failure by the nursing staff “resulted in the development, decline and increase in the size of the Stage III pressure ulcer.” The deficient practice was in direct violation of a facility policy and procedure revised December 4, 2017, that reads in part:

“Any resident admitted without a pressure ulcer/injury will not develop a pressure ulcer [bedsore] or a resident who has a pressure ulcer/injury will receive care, services to promote healing and prevention of additional pressure ulcer/injury. Prevention of pressure ulcers/injury will be thoroughly assessed, care plans, evaluation and monitoring of the resident. Pressure injury present as intact skin may be painful. Pressure ulcer will present as an open ulcer, as a result of intense, prolonged pressure or presence the tolerance for soft tissue for pressure and sheer may also be affected by skin temperatures and moisture, nutrition and comorbidities…”

The state investigator noted that according to the physician’s orders, no coccyx pressure ulcer issues or treatments are documented.” The resident’s Current Care Plan dated October 20, 2017 “documents incontinence care, assessment of skin and perineal area and change padding/toilet or give proper hygiene… [the resident] requires limited to extensive assistance with Activities of Daily Living. No coccyx pressure ulcer issues or interventions are documented.”

The resident’s Nursing Note dated October 12, 2017 documents that the resident “was admitted to the facility with no complaints of pain and that [the resident] ambulates with standby-assistance with one staff member.” The resident’s Scale for Predicting Pressure Ulcer Risk dated October 12, 2017 documents that the resident “was a mild risk for skin breakdown.”

Other documentation reveals that the resident “had pain in the last five days and received/or was offered pain medication.” However, the resident’s MDS (Minimum Data Set) assessments document that the resident “had no pressure ulcers but was at risk for pressure ulcers.”

But, seven days later the resident’s MDS (Minimum Data Set) dated October 26, 2017, documented “an unhealed Stage III or IV pressure ulcer measuring 2.5 cm x 1.2 cm with no depth.” By October 24, 2017, the resident now “complained of pain on the coccyx and the staff identified a new Stage III wound measuring 2.5 cm x 1.2 cm x 0.5 cm. The wound presented with maceration, swollen edges, no drainage, and’ slough in the wound bed.”

By November 2, 2017, the wound measured “4.0 cm x 3.0 cm with redness” requiring surgical debridement [cutting away dead tissue] procedure scheduled for November 13, 2017. By November 8, 2017, the MDS Assessment Notes documented that the resident “had pain rated at an 8, on a scale of 1 to 10.” The resident’s records document an “unhealed Stage III or IV pressure ulcer measuring 4.4 cm x 4.2 cm x 2.8 cm [noting that the pressure ulcer had increased in size].”

Providence Downers Grove
3450 Saratoga
Downers Grove, IL 60515

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145657&SURVEYDATE=01/12/2018&INSPTYPE=STD&profTab=1&Distn=1.1&loc=60515&lat=41.8132909&lng=-88.0216334&dist=25

Fine:
The State surveyor fined the Medicare/Medicaid-participating 145-certified bed facility $25,000 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated January 12, 2018, the state investigators identified the deficient practice of the facility for the failure “to monitor, assess and provide treatment” for a resident’s medical condition.

  • Failure to Provide Appropriate Treatment and Care According to Orders, Resident’s Preferences and Goals

The state investigator documented the facility’s failure applied to five residents “reviewed for skin care, infections, position, medications, and changes in condition.” An observation was made of one resident at 11:17 AM on January 9, 2018 while the resident “was sitting in the dining room with her head leaning to the left and hip protruding to the right to the wheelchair that was low, [and] poorly position.” The resident “could not reach the table which she was seated.” Nearly an hour later, the same resident “was sitting in a wheelchair rocking back and forward, with her head leaning to the left side in her hip protruding to the right side, [and] again poorly position.”

The resident “ate her lunch … and had to propel forward to the table and reach him to grapple with the food from the low seated wheelchair.” The resident was then again observed at 9:53 AM on January 10, 2018 while “sleeping slumped forward on her lap in a seated position in a wheelchair during a church activity, again her hip was protruding to the right, and she was poorly positioned.” The facility’s Assistant Director of Nursing observed the resident about 15 minutes later stating that the resident “looks very uncomfortable in that position.”

The state investigator documented that there was “no Plan of Care to address [the resident’s] mobility/poor position. There was no assessment for any type of positioning or seated device to aid [the resident’s] positioning.”

  • In a separate incident, a resident was observed lying in bed in isolation at 10:52 AM on January 9, 2018. A family member “was in the room visiting the resident at the time [stating that the resident] takes, eats and smears own feces and is on contact isolation” for their medical condition.

The family member was told by the facility that “they cannot provide a device to prevent digging because it is a restraint.” The family member said that “she was upset because the resident was cleared of isolation about a week ago and had to be placed back on contact isolation because [the resident] re-infected herself with [her contagious medical condition]. The family member also stated that “the facility could have provided some mittens to prevent this from recurring.”

The state investigator reviewed the resident’s Progress Notes dated December 21, 2017, throughout January 11, 2018. The document notes “behaviors of smearing and eating feces contaminated with Clostridium difficile (C-diff) on December 23, 2017, continued on a regular basis.” The resident’s Infectious Disease Note dated January 9, 2018, documented that the resident did have a relapse of their medical condition.

The facility’s Assistant Director of Nursing said they were working as the unit nurse manager providing care to the resident and that they “were not aware of the resident eating her feces.” The Assistant Director also stated that “restraints were not provided in the facility and she was not aware that the resident re-infected herself due to digging and eating her feces.”

Ridgeview Rehabilitation and Nursing Center
6450 North Ridge Boulevard
Chicago, IL 60626

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145832&SURVEYDATE=11/27/2017&INSPTYPE=CMPL&profTab=1&Distn=1.3&loc=60626&lat=42.0099321&lng=-87.663045&dist=25

Fine:
The State surveyor fined the Medicare/Medicaid-participating 136-certified bed facility $25,000 for multiple Type A violations. Currently, Ridgeview Rehabilitation and Nursing Center maintains a two out of five-star rating and health inspections and one out of five-star rating in staffing issues, which are significantly lower than the national averages

Violations:
In a summary statement of deficiencies dated November 27, 2017, the state investigator documented deficient practices at the facility including a:

  • Failure to Immediately Notify the Resident’s Doctor or Family Member of a Change in the Resident’s Condition

The state investigator documented that the facility’s failed “to inform the legal representative of [one resident’s] discharge.” In an interview with a state guardian representative on the morning of November 15, 2017, it was revealed that the resident “cannot make decisions on his/her own. We (the Guardian Office) should have been contacted first, before [the resident] was discharged. We make all decisions on their behalf [and] if they have a state guardian, they are unable to make decisions. They (the facility) did not contact us before discharging [the resident].”

A review of the resident’s Progress Notes dated July 31, 2017 document that the resident “has a history of having multiple visits to the emergency room, severe alcohol intoxication and [other medical conditions].” The document also reveals that the resident “has been homeless and [is] unable to care for self.”

The Social Worker stated on the morning of November 16, 2017, that they were unaware of “any behaviors [of the resident] until August 2, 2017”. The Social Worker first conducted an initial counseling session on September 11, 2017 “because of the medication. We offer the resident a substance abuse group; we encourage activities, the resident refused them all.”

The resident “was sent to the hospital […for] behaviors.” The resident “would throw feces at the staff, smear it on the walls and floor, and food trays.” The resident “would not allow the nurses to take care of [their medical condition]. On September 20, 2017, the resident was given a 30-day notice for discharge.” The resident’s Progress Note dated October 18, 2017 documents that the resident “was reminded of his/her 30-day notice that would go into effect on October 20.” The resident “stated that [they] did not want to wait until 20 October and wanted to lead today to go back to Joliet, Illinois.”

  • Failure to Ensure That the Nursing Home Area Remains Safe, Easy to Use, Clean and Comfortable for Residents

Based on observations, the investigator documented the facility’s failure “to maintain the facility in a comfortable environment for 112 residents … by not maintaining interior temperatures at comfortable levels.” The findings included observations of multiple rooms on January 1, 2018 “during an initial tour the facility with the Maintenance Staff using a facility thermometer.” Twelve rooms, three corridors, and the third-floor dining room registered temperatures ranging from 51°F to 65°F. Numerous residents complained of the cold by stating:

  • “It is too cold in the facility.
  • It is too cold that night.
  • It is very cold in the building.
  • The heat has been out at the facility for 4 to 5 days. It is very cold in my room.”

The facility Administrator stated on January 1, 2018, that they had received a call from the medical staff saying that “the blower was not blowing heat.” The staff member “callback one hour later stating it was now working.” However, the staff member “call me again and said it stopped working again.

Rochelle Gardens Rehabilitation and Health Care Center
1021 Caron Road
Rochelle, IL 61068

http://dph.illinois.gov/sites/default/files/publications/NH18-C0012-11-17-17-Rochelle-Gardens-CareCenter.pdf

Fine:
The State surveyor fined the 50-certified bed facility $25,000 for Type A violations. Currently, Rochelle Gardens Rehabilitation and Healthcare Center maintains a two out of five-stars rating for quality measures, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated November 17, 2017, the state investigators identified a deficient practice by the nursing staff and their failure “to provide cardiopulmonary resuscitation (CPR) services according to the standards of practice.”

  • Failure to Ensure That Every Resident Receives the Highest Level of Quality Care That Resulted in the Resident’s Death

According to observations, interviews and records review, the investigator’s documented that the facility “failed to establish an open airway and initiate artificial respirations immediately when they began CPR. No respirations were administered to the resident for a period of approximately ten minutes. The resident later expired at the hospital due to cardiac arrest.”

The state surveyor reviewed the facility’s Advance Directive Policy dated September 27, 2017, that revealed “it is the policy of the facility to honor the resident’s wishes as expressed in advance directives. If cardiopulmonary resuscitation (CPR) is indicated, personnel shall administer CPR.” The facility’s incident timelines revealed that the resident’s roommate found the resident “hanging from her scarf on November 7, 2017, at 5:50 PM.” The facility “was unable to provide a policy for CPR when requested. An emergency care policy dated September 7, 2009, was provided.”

Investigators reviewed the resident’s Nurse’s Notes dated November 7, 2017, at 7:00 PM, which revealed that approximately one hour earlier, a Registered Nurse (RN) was notified by the resident’s roommate “that she wanted to show her something in her room. When [the Registered Nurse and another RN] got to the room, [the resident] was found hanging from a pipe in the ceiling by her scarf.” The resident’s face “was white and she was warm to the touch.”

Both RNs found the resident with her “eyes closed, her face was white, lips were white, and she was not breathing.” One Registered Nurse attempted to lift the resident as the other RN “called 911 and attempted to cut the scarf to release the resident from the pipe.” The nurses lower the resident to a chair and then to the floor and started “chest compressions while [one RN] went to get an Ambu bag.” One documentation revealed that “the scarf was tied around the resident’s neck very tight.”

One Registered Nurse stated that “I attempted ventilations with the Ambu bag with the air leaking out the sides. I moved her head and neck to try to get a good seal in the air was coming out the sides of the mask. I do not think we ever got the scarf off from around her neck.” The local fire Chief stated during an interview that the “scarf was still around the resident’s neck when he arrived at the scene…” The Fire Chief stated that “the facility was not attempting to remove the scarf. We called it to their attention, that if the scarf was removed it would help ventilation. The facility removed the scarf. We did not have any problems ventilating the resident. Of course, the scarf was not tied around her neck at that time.”

Records from the local emergency room dated November 7, 2017, revealed the resident was “presented to the hospital at 6:21 PM and was pronounced dead at 6:24 PM.”

Rosewood Care Center of Alton
3490 Humbert Road
Alton, IL 62002

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145651&SURVEYDATE=12/14/2017&INSPTYPE=CMPL&profTab=1&Distn=1.1&loc=62002&lat=38.9354092&lng=-90.1401381&dist=25

Fine:
The State surveyor fined the Medicare/Medicaid-participating 137-certified bed facility $25,000 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated December 14, 2017, the state investigators identified a deficient practice at the facility that included a:

  • Failure to Ensure Every Resident Remains Free of Accident Hazards and Is Provided Adequate Supervision to Prevent Accidents

According to interviews, observations and record reviews, investigators identified the facility’s failure “to ensure safety measures were in place for [one resident] reviewed for falls.” The deficient practice by the nursing staff resulted in the resident’s “fall sustaining a subdural hematoma.”

A review of the resident’s Fall Risk Assessment dated December 4, 2017, it was determined that the resident is “at risk for falls. The fall risk assessment documents fall prevention measures were initiated on December 3, 2017, that included using a low bed, and ensuring the resident had a floormat surrounding the bed. The nursing staff was to “monitor frequently” and “keep the call light within reach” reminding the resident “to call for assistance.”

The resident’s Narrative Nurses Progress Note dated December 4, 2017 documents of the resident was “found out of bed on the floor during the 2:40 PM Hall check. The resident was lying “in bed [before] being found on the floor. He was lying on his left side. He denies pain and denies hitting his head.” An additional Nurses Progress Note dated December 5, 2017, at 3:30 AM documented by a Registered Nurse revealed that the resident was “restless and attempting to get out of bed.”

The resident’s Narrative Nurses Progress Notes dated December 6, 2017, at 1:10 AM revealed that a Certified Nursing Assistant (CNA) found the resident “lying partially on the right-side … with active bleeding.” The resident’s Hospital Report dated December 6, 2017 documents the results of a CT scan to the head revealing “an acute and chronic right frontal/parietal subdermal hematoma…”

The state investigator interviewed the resident’s physician on the morning of December 14, 2017, stated that the “head injury was due to a fall and the subdermal hematoma could be due to the height of the bed and the mat not being placed next to the bed.” The physician stated that “the bed should have been in the lowest position in the mat should have been next to the bed before [the nursing staff walked] away from the bed.”

A review of the facility’s Fall Risk Assessment Policy dated October 2003 revealed that “once significant potential for falls is noted via the assessments, appropriated fall prevention measures will be implemented.”

Rosewood Care Center of Rockford
1660 South Mulford Road
Rockford, IL 61108

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145891&SURVEYDATE=01/02/2018&INSPTYPE=CMPL&profTab=1&Distn=3.1&loc=61108&lat=42.2610481&lng=-88.9509626&dist=25

Fine:
The State surveyor fined the 116-certified bed Medicaid/Medicare-participating facility $25,000 for multiple Type A violations. Currently, Rosewood Care Center of Rockford maintains an overall one out of five stars rating compared to the national average. This ranking includes two out of five stars for health inspections and one out of five stars for staffing.

Violations:
In a summary statement of deficiencies dated January 2, 2018, the state investigators identified deficient practices at the nursing fill facility that included a:

  • Failure to Provide Appropriate Treatment and Care According to Orders, Resident’s Preferences and Goals

Based on the record reviews, interviews and observations, the investigators documented the facility’s failure “to ensure treatment orders were in place for a resident with a new surgical incision.” An observation of the resident at 9:10 AM on December 15, 2017, revealed the resident was lying on his/her back on his/her bed. The resident “had a pillow behind [their] and a regular mattress on the bed.” The resident “heels were lying flat against the mattress.”

The surveyor spoke to the resident who stated that they are “in the facility for rehabilitation and to receive intravenous antibiotics for an infection in the left hip.” The resident stated that they “had a hip replacement in their left hip that was removed due to acquiring a severe infection, which was causing the resident’s kidneys to fail.” The surveyor observed a dressing change the same morning at 10:40 AM. “During the dressing change, it was noted that there was also a dressing in place to the left hip area from surgical procedures done on December 4, 2017. The dressing to the left hip was rolled up along the top edge and stuck to the resident’s pants. There were dried blood and drainage that had soaked into the left hip dressing.”

The Licensed Practical Nurse performing the dressing change stated that the resident “has an appointment scheduled for December 22, 2017, for a follow-up on their left hip incision.” The LPN also stated that “there are no instructions for the dressing to the left hip incision dressing on the Treatment Administration Record.”

The state investigator interviewed the Director of Nursing who reviewed nurse reports and handwritten reports and verified that “the dressing should have been removed on December 11, 2017 (four days prior). And that “the dressing to the left hip incision should be removed seven days after surgery unless saturated before then.”

  • Failure to Provide Appropriate Pressure Ulcer Care to Prevent New Ulcers from Developing

In a summary statement of deficiencies dated January 2, 2018, the state surveyor identified the facility’s failure to “document initial skin assessments upon admission.” There was also a failure to “measure identified wounds upon admission, [a failure to] conduct weekly measurements and assessments of pressure ulcers [and a failure to] document dressing changes on the treatment record.” The record also stated that the facility had failed to “implement preventative measures for a resident admitted with pressure ulcers and failed to obtain physician’s orders for a new admission with a Stage II pressure ulcer.”

The investigator also documented the facility’s failure “to develop and implement individualized care plans for residents with known pressure ulcers and” a failure “to identify a new pressure ulcer [before degrading to] a stage IV.” The deficient practice by the nursing staff “resulted in an Immediate Jeopardy” when the resident “was found to have a stage IV pressure ulcer under a leg immobilizer. The facility failed to perform an initial assessment of the wound when it was reported to the Nurse Practitioner including obtaining measurements and a description of the wound.”

The investigator documented that the resident’s Pressure Ulcer Risk Assessment was completed on June 16, 2016 (over one year ago).” The resident’s “Care Plan does not indicate the use of the leg immobilizer or interventions to prevent pressure ulcers. The Care Plan interventions for stage IV pressure ulcer were not implemented.”

South Elgin Rehabilitation and Health Care Center
746 West Spring Street
South Elgin, IL 60177

http://dph.illinois.gov/sites/default/files/publications/NH18-C0034-01-04-18-South-Elgin-Rehab&HCC.pdf

Fine:
The State surveyor fined the 90-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Currently, South Elgin Rehabilitation & Healthcare Center maintains a two out of five stars rating for health inspections, compared to all other facilities in the United States. This ranking is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated January 4, 2018, state surveyors initiated an investigation that resulted in a resident experiencing acute hypoxic respiratory failure and death.

  • Failure to Provide Cares and Services at a Level That Meets Professional Standards

Based on interviews and record reviews, the state investigator determined the facility had failed to “provide supervision and cueing to a resident who required supervision with eating. The failure of supervision by the nursing staff resulted in the resident “choking on food, causing acute hypoxic respiratory failure” that ended in death.

According to the emergency medical services report “an ambulance was called to the facility on December 24, 2017, at 12:20 PM” for a resident “who was unresponsive and barely breathing.” The facility staff members had “initiated chest compressions,” and the “paramedics initiated cardiopulmonary resuscitation (CPR).”

Upon inspection of the resident’s throat, “a foreign body was noted in the airway. Forceps were used to extract a significant amount of what appeared to be chicken from the resident’s throat. The resident was transferred to the hospital.”

Reports from the hospital emergency room by the physician stated that the resident arrived at the facility “in full cardiac arrest. [The resident] was eating at the facility when he became unresponsive.” The physician at the hospital stated that the resident “most likely will not survive this illness. The physician’s impressions on the resident’s “status post-cardiac arrest, [was] most likely related to choking episode, with acute respiratory failure from the upper airway asphyxiation and severe encephalopathy post-cardiac arrest.” The resident’s hospital discharge summary list stated that the resident “expired on December 27, 2017, at 8:50 AM.”

The investigator interviewed a nurse providing the resident care on that day who stated that beginning around 6:30 AM the resident “had no problems with breathing or pain.” A Certified Nursing Assistant (CNA) was attempting to put the resident “to bed around 11:00 AM because the resident was trying to self-transfer to bed and he was a fall risk.” The resident “was in bed in an upright position” when the CNA left the room. When asked by a different CNA to return to the room, both Certified Nursing Assistants found the resident with “no pulse, his chest was not moving, and he was not breathing.” A finger’s swipe/scoop in the resident’s mouth found nothing.

The state investigator reviewed the resident’s diet card was last updated on October 16, 2017, that the states of the resident “has difficulty cueing or swallowing related to the condition of missing teeth.” The resident “will chew and swallow food per recommendations that each meal. Regular diet [with] small bites, give [the resident] verbal cues to stimulate cueing or swelling, stroke throat lightly at Adam’s apple to stimulate swallowing. Give [the resident] verbal cues or limit amounts available to take small bites and prevent fast-paced eating. Observe for indicators of aspiration-coughing, choking, gagging, gurgling in the throat. These approaches were started on September 29, 2015.

The United Methodist Village
1616 Cedar
Lawrenceville, IL 62439

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145417&SURVEYDATE=01/17/2018&INSPTYPE=CMPL&profTab=1&Distn=1.0&loc=62439&lat=38.7282652&lng=-87.6814198&dist=25

Fine:
The State surveyor fined the 143-certified bed Medicare/Medicaid-approved facility $25,000 for multiple Type A violations. Currently, the United Methodist Village maintains a two out of five-stars rating for health inspections, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated December 12, 2017, the state investigators identified deficiency practices at the facility that included a:

  • Failure to Ensure That Every Resident Remains Free from Accident Hazards and Is Provided Adequate Supervision to Prevent Accidents

Based on the investigator’s observations, record reviews, and interviews, it was determined that the facility had failed to “identify fall hazards, analyze the cause of multiple falls, and failed to implement, monitor and modify interventions to prevent further falls and injuries for three [residents].” The deficient practice by the nursing staff “led to multiple falls resulting in a right proximal humerus fracture with displacement, worsening of the fracture, pain and subsequent surgery.”

A review of the resident’s medical records revealed the resident “is a high risk for falls, due to gait/balance problems and a history of frequent falls.” Documents reveal that at 1:44 PM on 12 for 2017 the resident “was in her room, seated in a wheelchair with her right arm in a sling.” The resident “indicated that she had a fall in the dining room several weeks ago that led to a fracture and surgical repair.”

A review of the resident’s Nursing Progress Notes from November 18, 2017, at 4:48 PM documents the resident “falling in the dining room.” The resident “had increase pain to the right-side drooping, was sent to the emergency room and found to have a proximal humerus fracture with displacement.” The notes described further falls that occurred “on November 23, 2017, at 12:30 PM and November 24, 2017, at 4:13 PM.” The resident underwent surgical repair and returned to the facility. On November 19, 2017, at 8:10 PM, notation reveals that the resident “is crying in pain. The November 22, 2017, at 6:45 AM note states that the resident is crying and saying ‘hurry,’ due to pain.”

The state investigator reviewed the resident’s Incident Report Records and Care Planning for the resident that documents “seven falls occurred between August 12, 2017, and November 24, 2017.” The investigator noted that some falls “were not Care Planned.”

On September 9, 2017, at 10:07 AM, the resident “was found on the dining room floor, face down and slightly to the left.” The resident was reported in the Care Plan “to have bruising on the left face/eye and knee.” However, “no interventions were added to the incident report after this fall.” The investigator also noted that “there was no evaluation to determine the cause of the fall that was documented” and the Nursing Progress Note dated September 9, 2017, 4:43 PM read that the resident “remembers falling but is not sure why.”

On October 11, 2017, at 1:02 PM the resident “was found in her room on her back.” The resident “had attempted to sit on a rolling walker and missed.” The resident “was soiled with a bowel movement at the time. The incident report does not denote any interventions for this fall.” An interview with the Director of Nurses revealed that the facility “went to a new computerized record system and [the Director] is not aware of where the fall interventions are documented.”

Villa Health Care East
100 Marian Parkway
Sherman, IL 62684

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145721&SURVEYDATE=12/21/2017&INSPTYPE=CMPL&profTab=1&Distn=1.4&loc=62684&lat=39.9086291&lng=-89.596906&dist=25

Fine:
The State surveyor fined the Medicaid/Medicare-approved 99-certified bed facility $25,000 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated December 21, 2017, the state investigators identified deficient practices at the facility including a:

  • Failure to Provide Appropriate Treatment and Care According to Orders, Resident’s Preferences and Goals That Resulted in the Resident’s Death

Based on record reviews, interviews and observations, investigators determined the facility “failed to identify, monitor and treat a significant change of condition for [one resident].” The deficient practice by the nursing staff “resulted in the delay of treatment.” Revealed on the day in question, the resident was noted to be “lethargic during the evening meal time.” Other records show that there was “no intake of the evening meal.” The resident was “able to [consumed] honey-thick liquids offered by the wife without difficulty. No changes noted with urination or bowel movements. Remains incontinent the both.” The resident’s “wife does not want to be sent to the hospital for testing.

An additional note documents that the resident’s Power of Attorney (POA) arrived to take the resident to the emergency room. The nurse asked why the POA “felt he needed to go to the emergency room.” The resident’s power of attorney stated that “she has a gut feeling that something was off.” The LPN stated that the resident physician would need to be “notified and updated as to why the resident needed to go [to the hospital] and an order would be needed to be given.”

However, the resident’s power of attorney stated that “regardless of the medical director gives an order or not, [the resident] is going even if she has to call 911.” The medical director was notified of the power of attorney’s wishes. However, “there is no documentation in the resident’s medical record that the nursing staff monitored or assessed the resident for a further decline after he was identified as being lethargic.”

The CNA stated that the resident “was a little more lethargic than what he normally was and ate/drink very little.” However, the evening in question, the Certified Nursing Aides providing the resident care “did not report anything unusual for him that night.”

The resident’s Hospital History and Physical documented that the resident “is critically ill with organ impairment, with a high probability of life-threatening complications.” The resident’s Discharge Summary at the emergency room revealed that the resident “was found to be in septic shock with lactic acidosis, acute kidney injuries,” right-sided pneumonia and other medical conditions. The family opted “for Comfort Care only. The summary documents that the resident was discharged to hospice services.

The resident’s Death Certificate states a cause of death listed as “septic shock and pneumonia.” The CNA during the day shift stated that the resident “did not respond normally that day and had a color about him.”

The investigator reviewed the facility’s policy/procedure titled Condition Change Documentation that revealed in part:

“The purpose as being to maintain a medical record which is reflective of documentation of the care provided to residents to include, but not limited, nursing assessment and notifications related to the change of the resident’s condition. The procedure documented [that] nursing will assess the resident’s complaints and complete a nursing assessment of the resident, document the complaints and nurse assessment into the clinical record, notify the physician of condition change, report to oncoming shift and implement a hot rack or condition change flowsheet charting for each shift use to monitor the resident’s health status. Continue charting on the resident’s condition change into the resident is free of clinical abnormal or is symptoms-free for three consecutive shifts (24 hours.)”

Warren Barr Lincoln Park
2732 North Hampden Court
Chicago, IL 60614

http://dph.illinois.gov/sites/default/files/publications/NH18-C0023-12-07-17-WarrenBarr-LincolnPark.pdf

Fine:
The State surveyor fined the 109-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Currently, Warren Barr Lincoln Park Nursing Facility maintains a two out of five-star rating for staffing issues, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated December 7, 2017, the state investigators identified deficient practice is by the nursing staff including a:

  • Failure to Develop and Implement a Complete Care Plan That Meets All the Resident’s Needs That Led to the Resident’s Death

Based on record reviews and interviews, the state investigators determined that the facility had failed to “develop and implement care plans with measures to address the behavior of [one resident].” The incident involved an 86-year-old severely impaired resident who “had a history of pulling out medical tubes.” The failure by the nursing staff resulted in the resident “pulling out a trach tube and being hospitalized for lack of oxygen to the brain.”

The nurse providing the resident care on the night of October 27, 2017, stated that the resident “was on 15-minute checks and she had just checked the resident at 12:30 AM. Shortly after the time she went back of the resident’s room due to the bed alarm sound. She said she noticed the resident was still moving around in bed and waving hands as per normal.” However, the resident’s “trach was out of place, and she tried to reinsert the trach and cannula but was unsuccessful and administered oxygen to the resident while 911 was called.”

The Director of Nursing stated that the facility is a restraint-free nursing home and the use of mittens to prevent pulling out the trach tube is not done. But, the Medical Director stated that “he did not know the resident, however, a patient who was cognitively impaired with the behavior of pulling out tubes like trachea, he would have ordered a mitten. He said he as the medical director would never order psychotropic medications but left that up to the psychiatrist.”

The investigators reviewed the resident’s MDS (Minimum Data Set) dated October 23, 2017, that noted “her condition was severely impaired. She also has a tracheostomy tube attached to 35% oxygen.” A review of the facility’s unusual occurrence report dated October 27, 2017, at 12:33 AM revealed that the resident’s bed alarm “sounded and upon investigation, the entire trach tube was noted on the bed and out of place. Records also noted that” the nursing staff “attempted to reinsert the cannula [but] failed. 911 was called, and the resident was sent to the community hospital.”

The resident’s Hospital Discharge Summaries dated November 28, 2017, at 6:10 AM documented by the physician revealed that the resident arrived at the hospital with “cardiac arrest provoked by pulling out her tracheostomy and subsequent anoxic encephalopathy and unresponsiveness.” The resident was “placed under hospice care [and] expired on November 28, 2017, at 6:10 AM at the community hospital.”

The facility’s policy on Tracheostomy Decannulation dated February 20, 2017, revealed that “unplanned removal of the tracheostomy needs to be dealt with in a safe manner which minimizes risk to the patient.”

Additional Information

The CDC (Centers for Disease Control and Prevention) routinely updates their quarterly rating system on every Illinois Nursing Facilities, Assisted Living Homes and Rehabilitation Centers. Family members use this information to determine the best facilities that protect the health and well-being of their residents. The grading system and detailed data help to quickly identify the level of skilled nursing care and hygiene assistance and identify facilities that are providing substandard care.

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