The Illinois Department of Public Health April – June 2018 Quarterly Nursing Home Report

The Illinois Department of Public Health (IDPH) conduct routine inspections, investigations, and surveys of all nursing homes, rehabilitation centers, and assisted-living facilities throughout the year across the state. The inspectors typically arrive at the facility unannounced to determine the level of care every resident is being provided and identify any violation of regulations as outlined by the Nursing Home Care Act. When surveyors find a deficiency or violation, federal and state nursing home regulators usually take quick action to enforce regulations and impose severe penalties in monetary fines.

The dedicated nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC remains committed to posting publicly available information so families can make a fully decision about where to place a loved one who requires the highest level of skilled nursing care. If you suspect that your loved one was abused, mistreated or neglected in an Illinois nursing home, we encourage you to contact us today to schedule a free, initial consultation with our experienced attorneys to discuss your legal options and rights. We provide every client a “No Win/No-Fee” Guarantee, meaning you pay us only when, and if, our law firm is successful in resolving your case.

The Public Health Department makes their findings publicly available online through Quarterly Nursing Home Reports. These reports include detailed descriptions of serious deficiencies, violations, and problems. During the second quarter of 2018, surveyors found numerous serious violations and deficiencies at the nursing homes listed below. Each of these nursing centers were cited for multiple Type A (severe violations) or Type AA (extreme violations) that resulted in fines that ranged from $25,000-$50,000. These nursing homes include:

Accolade Healthcare of Pontiac
300 W. Lowell
Pontiac, IL 61764

http://dph.illinois.gov/sites/default/files/publications/NH18-S0235-04-25-18-Accolade-Healthcare-ofPontiac.pdf

Fine:

The State surveyor fined the 97-certified bed Medicare/Medicaid-approved nursing home $25,000 for multiple Type A violations. Currently, Accolade Healthcare of Pontiac Nursing Facility maintains a one out of five stars rating for health inspections and staffing, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated April 25, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure That Every Resident Receives Appropriate Treatment and Care According to Orders, Resident’s Preferences, and Goals

Based on observation, interview, and record review, oxalate Health Care of Pontiac failed to “ensure physician’s orders related to diuretic use were implemented for [one resident at the facility] review for hospitalizations…” The resident had “return the facility from being hospitalized for Acute Kidney Injury due to Dehydration with orders to discontinue Lasix, a diabetic medication, which was not transcribed or carried out at the facility.” The state inspector also stated that the facility “failed to ensure foods were within reach and encourage for hydration of the resident. This failure resulted in [the resident] receiving 45 doses of Lasix in error and [the resident] to develop an ongoing, worsening Acute Kidney Injury (AKI) due to dehydration from continued Lasix use and a urinary tract infection.”

According to the hospital discharge summary record dated March 27, 2018, the resident “was sent to the emergency room on March 26, 2018, was found to be ‘clinically dehydrated.’” The document also reported that the resident’s “computed tomography (CT) of the head showed ‘questionable’ subacute ischemic changes in the right caudate an internal capsule besides multiple old infarcts but no bleed.” The document also revealed that “following overnight hydration, the patient is more awake and oriented this morning.” The summary also documented [that the resident] had an acute kidney injury…”

The state investigator interviewed the facility’s Director of Nursing just after noon on April 19, 2018, who stated that the “Licensed Practical Nurse (LPN) who stated [a member of the staff] overlook the order to stop the Lasix.” The Director also stated that “the orders to discontinue the Lasix were overlooked and not transcribed or carried out by the facility and that they should have been.” In an interview with the facility License Practical Nurse at 2:30 PM on April 24, 2018, it was revealed that “a nurse puts the orders in from the hospital and a 2nd nurse from another ship double check the orders.”

‘The LPN also stated that “when a resident comes back from the hospital, the nurses or to compare the orders from the hospital with what the resident was on at the facility prior to the hospital and update the orders at the facility with the new orders.” A review of the resident ‘s Progress Notes dated March 28, 2018, by the nurse practitioner documented that “Lasix therapy was discontinued at discharge (March 27, 2018).” However, the resident’s MAR (Medication Administration Record from 2 of March 2018 documents that the resident “received Lasix 40 mg by mouth twice daily from March 28, 2018, through March 31, 2018.”

Aledo Rehabilitation & Healthcare Center
304 SW. 12th St.
Alito, IL 61231

http://dph.illinois.gov/sites/default/files/publications/NH18-S0236-05-03-18-Aledo-Rehab%26HealthCareCtr.pdf

Fine:

The State surveyor fined the 80 certified bed Medicare/Medicaid-participating nursing home $50,000 for serious Type AA violations. Currently, Aledo Rehab & Health Care Center maintains a three out of five stars rating for health inspections compared to the national average.

Violations:

In a summary statement of deficiencies dated May 3, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Generate Timely Reports of Suspected Abuse, Neglect or Self and Report the Results of the Investigation to Proper Authorities

Based on observations and a review of records and interviews, the investigators documented that the facility “failed to investigate and report an injury of unknown origin, as required by the facility’s Abuse Policy.” The deficient practice by the nursing staff involved one resident. The surveyor noted that the facility’s Abuse Prevention Program policy revised on October 14, 2016 documents that:

“The facility affirms the rights of our residents to be free from abuse, neglect, and misappropriation of resident property, corporal punishment, and involuntary seclusion. This will be done by identifying occurrences own patterns of potential mistreatment, neglect, and abuse of residents, implementing systems to investigate all reports of allegation of mistreatment, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively. And filing accurate and timely investigated reports.”

The surveyor documented that at 12:45 PM on May 1, 2018, two Certified Nursing Assistants (CNAs) “prepared to perform an incontinence care for [a resident while transferring the resident from their wheelchair to bed].” One Certified Nursing Assistant removed the resident’s pants which revealed a “five cm purple, yellow bruise present under [the resident’s] right knee.” At that time, that CNA stated that “I noticed that bruise when I came back to work a couple of days ago. I did not report it to the nurse.” The facility Director of Nursing stated at 12:51 PM on May 2, 2018, that “I do not have a report of the bruise on [the resident’s] right leg. I did not do an abuse investigation. The facility Administrator stated a few minutes later that “any bruise of unknown origin should be reported to the nurse, who fills out an incident report. I did an investigation and reported to the State Agency as possible abuse. I did not receive an incident report for the bruise on the resident’s leg. I did not report the bruise to the State Agency.”

  • Failure to Develop a Complete Care Plan within 7 Days of the Comprehensive Assessment That Is Prepared, Reviewed, and Revised by Team of Health Professionals

Patient observation, interview and record review, surveyors noted that the facility had “failed to revise and update a fall and a skin condition Care Plan for [2 residents at the facility].” The surveyor’s reviewed an April 2007 document title Skin Care/Wound Care/Teaching Protocols that the nursing staff should ensure that a “Care Plan is completed for presence of wound a new interventions including treatment [and] ensure all interventions and use are listed on the care plan.”

However, surveyors observed a Certified Nursing Assistant at 10:00 AM on May 1, 2018, who “was providing indwelling catheter care for [a resident whose] inner thighs, abdomen, and perineal area were red and excoriated. The resident’s May 2018 TAR (Treatment Administration Record) documented on December 27, 2018 “Read Abdominal Fold, Groin Area and bilateral buttocks – Apply [medication] powder three times a day; Groin/Upper thighs, apply [medication] cream three times daily.” A review of the resident’s Current Pressure Ulcer Care Plan failed to document the resident’s “excoriated areas for treatment.”

Surveyors interviewed the facility Care Plan Coordinator on the afternoon of May 2, 2018, who verified that the resident’s “excoriation of her groin and abdomen as well as treatments for those areas are not on [the resident’s] current Care Plan.”

  • Failure to Ensure That Every Resident Remains Free from the Use of Physical Restraints Unless Required for Medical Treatment

Based on observation, record reviews, and interviews, Aledo Rehab “failed to document appropriate medical symptoms to warrant the use of a restraint and follow a restraint reduction plan for [one resident at the facility].” As a part of the investigation, surveyors found that the facility’s “Physical Restraint/Enabler Policy (undated)” documents the following:

To allow residents to be free of physical restraints which are not required to treat the resident’s medical symptoms are as a therapeutic intervention. Physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident’s body, which the individual cannot remove easily, and which restricts freedom of movement or normal access to one’s body. They include but are not limited to laptop cushions.

The state surveyor reviewed the resident’s April 15, 2016, Physical Restraint/Enabler Consent form that documents that the resident “is to have a wheelchair with a (laptop cushion). This same form documents the reason for the restraint is safety. The same form documents release every 2 hours with activities, at meals, and as needed.” The investigator also reviewed the resident’s March 16, 2018, Physical Restraints/Enabler Assessment the documents that the resident “rocks back and forth in a wheelchair. The (laptop cushion) keeps the resident sitting in the wheelchair and does not restrict [the resident’s] movement.” However, the observation was made of the resident on April 30, 2018, at 11:45 AM and May 1, 2018, at 11:30 AM when the resident “was sitting in the facility’s dining room feeding herself lunch.” The resident “was sitting upright in [her] wheelchair with correct posture [… and the resident’s] laptop cushion was positioned across [her] lap during these times. On May 1, 2018, 11:30 AM, a Licensed Practical Nurse verified that the resident’s “laptop cushion was positioned across [her] lap while she was eating lunch.” The LPN verified “that this laptop cushion should have been removed before the lunch meal.” On May 1, 2018, at 12:45 PM, the LPN “attempted to have [the resident] remove [her] laptop cushion from [her lap, but she] was unable to remove [the] laptop cushion.

Aperion Care Capitol
555 W. Carpenter Rd.
Springfield, IL 62702

http://dph.illinois.gov/sites/default/files/publications/NH18-C0110-03-07-18-Aperion-Care-Capitol.pdf

Fine:

The State surveyor fined the 251 certified bed Medicare/Medicaid-participating facility $25,000 for multiple Type A violations. Currently, Aperion Care Capitol Nursing Facility maintains a one out of five stars rating for staffing issues, which is significantly than the national average.

Violations:

In a summary statement of deficiencies dated March 7, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure Services Provided by the Nursing Facility Meet Professional Standards of Quality

Based on observation, interview and record review, the facility failed to “ensure appropriately train competent staff performed reinsertion of a gastronomy tube for [a resident at the facility.” The investigator stated that this failure resulted in a resident “sustaining a bowel obstruction and perforation secondary to insertion of a urinary catheter for gastronomy tube.”

The investigator’s findings included a review of the resident’s January 30, 2018, Electronic Health Record (EA chart) that states “Enteral feeding, Jevity 1.5 mL per hour.” The feeding was to occur “via Percutaneous Endoscopic Gastrostomy (PEG) tube, continuous 6:00 PM to 6:00 AM.” However, a review of the January 28, 2018 Electronic Nurse’s Notes revealed that it 6 3:30 PM, Licensed Practical Nurse documented in the resident’s record that a Certified Nursing Assistant (CNA) “reported to the nurse that the resident PEG/G-2 (gastronomy) came out of the resident’s abdomen. The Nurse Practitioner (NP) and the Director of Nursing aware of the tube coming out. Urinary catheter… inserted.” The document also states that the new orders by the nurse practitioner include holding “flushes and feeding until the appropriate tube is re-inserted and position verified. Will address tomorrow in the a.m.” The document also revealed that the resident’s power of attorney (POA) was aware of the problem.”

A Licensed Practical Nurse providing the resident care stated that on January 29, 2018, when she came to work “she was told that the resident’s peg/Jeep tube had come out and because [the resident] was eating and everything was fine, the facility was trying to get him sent out to get a G-tube placement. She stated [the resident] was eating by mouth, and she would crush his pills, and he was taken by mouth. She further stated [the resident] was on thickened fluids.” The LPN stated that “she called the hospital to see when [the resident] could get a G-tube placement schedule, [… and was told that the resident] had to go to the hospital where his initial peg/G-tube was placed.” The Licensed Practical Nurse also stated that “she has not had any training on replacing a peg/G-tube with a (urinary catheter) nor any training on enteral feedings.”

A review of the resident ‘s January 30, 2018, Electronic Nurses Notes at 3:15 PM documents in part that a new order was received from the Nurse Practitioner that states “in the resident to Memorial Medical Center (ER) Emergency Room for PEG tube placement.” The resident’s H & P electronically signed on February 6, 2018, revealed that radiology identified a balloon measuring 4.0 centimeters was “blocking the jejunum.” The document also revealed that the resident was complaining of “increasing abdominal distention, constipation for one week and general feeding of malaise and diaphoresis.” The document states that the resident “has not had a bowel movement in over one week [… And that the resident] states he has been sweating since his abdomen was noted to get bigger.” The document also states in part “Abdominal pain: All quadrants. The severity is moderate.”

The resident’s H & P signed on February 5, 2018 documents that on January 28, 2018, the resident’s “PEG tube became dislodged and was replaced at Nursing Home. However, the tip was placed into the jejunum and with inflation created small bowel obstruction was caused by diaphoresis when eating. The patient was brought to the emergency department on January 30, 2018, and had the PEG tube replace.” The resident “was also found to be significantly constipated and was given fleets and am a and suppositories with minimal response. Surgery would G-tube placement. He underwent secondary exploratory laparotomy on February 2, 2018, to look for a perforated viscus and EGD (esophagogastroduodenoscopy) which showed a gastric perforation from prior PEG tube.”

Aperion Care Morton Villa
190 E. Queenwood Rd.
Morton, IL 61550

http://dph.illinois.gov/sites/default/files/publications/NH18-C0109-03-13-18-Aperion-Care-Morton-Villa.pdf

Fine:

The State surveyor fined the 166 certified bed Medicaid/Medicare-participating facility $25,000 for multiple Type A violations. Currently, Aperion Care Morton Villa Nursing Facility maintains an overall two out of five stars rating including two out of five stars for staff issues, and one out of five stars for health inspections and quality measures, which are substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated March 13, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Develop a Complete Care Plan within 7 Days of the Comprehensive Assessment; and Have It Prepared, Reviewed, and Revised by a Team of Health Professionals

Based on interviews and record reviews, the state investigators documented that the facility had “failed to revise a resident’s Care Plan to address each of the resident‘s falls and to include fall interventions for [one resident at the facility].” A review of the resident’s January 1, 2018 (6:58 PM) Nurse’s Notes revealed that “a nurse was called to the dining room at a proximally 6:30 PM to observe the resident sitting on the floor.” An incident investigation worksheet document at the same day list fall interventions of a tilt wheelchair. The resident’s Report of Incident form that was documented and sent to the local state agency on January 14, 2018, reveals that the 80-year-old resident fell “on January 13, 2018, at 6:10 PM [and was] sent to the emergency room for further evaluation and treatment.” An updated Report of Incident form documented on January 22, 2018, that the resident “return to the facility [with] a sling to [their] left arm to be worn daily and can be removed for cares. (Anti-slip mat) was placed in her wheelchair. Per family request, the chair alarm has been added as well and patient care has been updated.” The resident’s current Care Plan does not document the new fall interventions put into place after the resident’s fall on January 1, 2018, or on January 13, 2018.”

The state investigator conducted an interview with the minimum data sets/MDS coordinator on the afternoon of March 7, 2018, who verified that the resident’s “current Care Plan was not updated with new fall interventions after each of [their] falls.” The coordinator stated that “I even went back and checked our old Care Plan system and it was not there. The intervention should have been listed.”

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

The state investigator’s findings included a resident’s 9:00 PM January 16, 2018 Nurse’s Notes that revealed the resident “fell out of bed while a CNA (Certified Nursing Assistant) was providing care. A skin tear was noted on the left elbow. The resident was complaining of pain (8/10) on the hips and chest around the ribs. The resident was transported to the local area hospital for further evaluation.” Early reports documented in the January 23, 2018 Report of Incident Form and sent to the local agency stated that the incident occurred when the resident “began slighting out of bed away from the [caretaker].” X-rays performed on the resident identified an impression of acute mildly displaced intertrochanteric [fractured] femur.”

A Certified Nursing Assistant will (CNA) admitted to the state investigator that “I was cleaning the resident by myself. I had someone help me [because the resident is a] mechanical lift from the wheelchair to the bed, but then the CNA left the room and I rolled [the resident to their] left side by myself. Normally when we rolled [the resident] side to side, we would have two staff members. We are supposed to roll a resident with two people when they are a (mechanical lift). If we are rolling a resident buyer sells, we should roll the resident orders.” The resident “was turned away from me [and that there were] no side rails can use on the [resident’s] bed.”.

The state investigator interviewed the Director of Nursing on the afternoon of March 6, 2018, who stated that the resident “should have had to CNAs when being rolled on to their side in bed.” The resident “was a mechanical lift transfer. All mechanical lift transfers are automatically to assist with cares regarding bed mobility and transfers.” The Director also stated that the resident had conditions that would provide even more reasons to have “two staff members” assisting during transfers. The Director stated that “there were 10 CNAs on the shift the night [the resident] fell. There was no reason to have used only one CNA. The use of two CNAs could have prevented this fall. Even if the resident only requires one CNA for cares, the resident should always be turned toward the staff member, not away from them.” The resident “was turned away from” the CNA.

Bria of Westmont
6501 S. Cass Ave.
Westmont, IL 60559

http://dph.illinois.gov/sites/default/files/publications/NH18-C0168-03-09-18-Bria-ofWestmont.pdf

Fine:

The State surveyor fined the 215 certified bed Medicare/Medicaid-approved facility $25,000 for Type A violations. Currently, Bria of Westmont Nursing Facility maintains a two out of five stars rating for staffing issues, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated March 9, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure That Every Resident Is Free from Abuse and Neglect

After a review of observations, records, and interviews, the state surveyor’s documented that the nursing home had “failed to follow their policy for medication administration and failed to ensure that ophthalmic eye drops were re-ordered as needed. This failure led to [the resident] receiving the incorrect medication resulting in an overdose of medication with resulting lethargy, decreased blood pressure and hospitalization.”

The incident involved an 89-year-old resident who was admitted to the facility on December 4, 2017, with “acute kidney failure, heart failure, muscle weakness, diabetes mellitus typed to, peripheral vascular disease, hypothyroidism, hyperlipidemia, dementia, coronary artery disease, and diabetic neuropathy.”

The state investigator reviewed a facility Registered Nurse (RN) Nurse’s Notes who stated that on December 8, 2017, they “entered the resident’s room to administer medication. After administration of medication, [the nurse noted that they had administered the medication to the wrong resident and notified the Director of Nursing and the Nurse Practitioner. At that time, the resident’s daughter was at the resident’s bedside. The nurse received orders to “monitor the resident and take vitals every 15 minutes for the remainder of the shift.” Within an hour, the resident “was noted with low blood pressure and [the resident] was discharged from the hospital for treatment.”

The surveyor interviewed the facility Director of Nursing on the morning of March 7, 2018 who stated that the registered nurse “had given the wrong medication to a resident [and stated that] the medication error was identified because the family of [the resident] had asked about” why their parent (the resident) was receiving aspirin. The Director of Nursing stated that there the facility policy involves verifying the patient’s five rights including “right patient, the right route, right dose, the right drug, and the right time before administering the medication. The Director also stated that “if the family is there, the policy is to identify the resident’s name” and stated that “we have pictures on the MAR [Medication Administration Record]. All MARs have pictures.” The Director of Nursing “then pointed to the printed MAR showing the picture.”

The facility Medical Director stated that the resident “was hospitalized because [the resident] was given the wrong medication and [the resident ‘s] blood pressure did not come up. We sent [the resident] to the hospital. The medication definitely caused [the resident’s] blood pressure to drop and required hospital treatment. You have to be very careful.” The Director also stated that the resident “was admitted to the hospital.”

  • Failure to Provide a Resident Safe Transfer Using Two-Person Assist to Prevent Falls

Based on observations, record reviews, and interviews, the state investigator documented that the facility had “failed to safely transfer a resident using two staff members and as a result, [the resident] sustained a fracture injury during an improper transfer.” The deficient practice by the nursing staff involved a 93-year-old resident at the facility diagnosed with “hyperlipidemia, hypertension, gastroesophageal reflux disease (GERD), muscle weakness, osteoarthritis, Alzheimer’s disease, generalized anxiety disorder, and a fractured left fibula.” The resident’s MDS (Minimum Data Set) documents of the resident “requires extensive physical assistance for transfers by two staff members. Moving from ceded to standing position in service to service transfer (transferred to bed and chair or wheelchair) – not steady, only able to stabilize was staff assistance. Lower extremity – impairment on both sides. Mobility device – wheelchair.”

The facility’s December 15, 2017 Nursing Notes revealed that a nurse was called into the resident’s “room by the nurse’s aide to check [the resident’s] knee.” The nurse noted that “the right knee was swollen and warm to the touch.” The resident “was also noted with pain to the area. The physician was notified in order was obtained for an x-ray.” The facility December 15, 2017 Occurrence Report documents that that resident “express pain when the staff member touch the right lower extremity.” The facility Incident Report dated December 16, 2017 document at the resident “was observed was swelling, bruising to the right lower leg. The doctor was contacted, and an order was received for a right to be a/fibula x-ray. X-ray completed, and results revealed fracture of the distal tibia and neck of the fibula. The doctor was notified, and orders were [given to send the resident] to the ER for further evaluation.” The diagnostic report from the hospital noted “impression: fractures of the distal tibia and neck of the fibula.”

The state investigator interviewed the Licensed Practical Nurse who said that the resident “is a high risk for falls [and stated that] the resident’s transfer status is documented on care cards, printed and put in the resident’s room.” The LPN also stated that CNAs and nurses are made aware of the resident’s transfer status [and] added there is also a code about the resident’s bed.” The LPN stated that the resident “was changed to a two-person assist on November 20, 2017 [because they cannot] pivot safely with one person.”

The facility Director Nursing stated on the afternoon of March 7, 2018 that “she was present when [the resident] was transferred to the hospital” and that the resident “had a bruise and their right leg was swollen from the need to the ankle and was warm, with the bruise by the ankle.” The Director also said that the resident “was exhibiting expressions of pain.” The Director also stated that the CNA providing the resident care had attempted to transfer the resident “by herself. She did not transfer the resident the way [the resident] was supposed to be transferred, and the care card was right in front of her.” The facility Medical Director stated that same day that “he was informed the resident had a fall, not a transfer. However, the Director stated, ‘it caused the resident harm.’ [The resident] had to go to the hospital. There was deformity in the leg. It looked like a fracture.”

Bridge Care Suites
3089 Old Jacksonville Rd.
Springfield, IL 62704

http://dph.illinois.gov/sites/default/files/publications/NH18-C0195-04-05-18-Bridge-Care-Suites-The.pdf

Fine:

The State surveyor fined the 75-certified bed Medicare/Medicaid-participating nursing home $25,000 for Type A violations. Currently, Bridge Care Suites Nursing Facility maintains a two out of five stars rating for quality measures, which is significantly lower significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated April 5, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure the Nursing Home Areas Free from Accident Hazards and Provide Every Resident Adequate Supervision to Prevent Accidents

After making observations, reviewing records and conducting interviews, the state investigators documented the facility’s failure “to ensure the safety measures including secured side rails, adequate supervision, safe positioning in bed and assistance for an implement to prevent falls from bed.” The deficient practice by the nursing staff involved six residents who were “reviewed for fall prevention.” This failure resulted in a resident “falling from bed sustaining bilateral subdermal hematomas.” One incident involved a female resident with short/long-term memory loss and severe cognitive impairment.” The resident’s MDS (Minimum Data Set) documents of the resident “requires extensive assist of two staff for bed mobility and transfer.”

The state investigator reviewed the resident’s Medical Records that stated on 11:45 AM on April 4, 2018, the resident “was in bed with her side rails in a position. She had a scoop mattress, but her bed was not in low position.” The resident “was lying flat. She had bilateral blackened eyes and bruising down the right side of her face.” The resident “spoke slowly but was cooperative as she was rolled to the right by [two] Certified Nursing Aides (CNAs) with no problem.” A review of the resident’s electronic health record (PHR) dated March 22, 2018 revealed that a Registered Nurse found the resident “on the floor – left side of the bed – with her head toward the head of the bed, range of motion (ROM) within normal limits, noting that [the resident] was already flaccid on the left side. The note documents [the resident] to have a hematoma [on the] right side of the forehead [and] after contacting the physician, was sent to the emergency room (ER) for evaluation due to her being on anticoagulants. The Progress Note documents [the resident] returned to the facility… with negative x-rays noted.”

The facility Event Report documents that after an evaluation of the resident’s fall on March 22, 2018, it concluded that the resident “slid off the bed onto the floor on her left side and a high sided mattress with bed in the low position when occupied being implemented as a result. There is no explanation as to how [the resident] slid off the bed given that she required extensive assist of two staff for bed and transfer mobility and the investigation fails to reflect where in the bed [a resident] was just prior to the fall or if the handrails were up and functional.”

Bridgeway Senior Living
111 E. Washington St.
Bensenville, IL 60106

http://dph.illinois.gov/sites/default/files/publications/NH18-S0152-03-01-18-Bridgeway-Senior-Living.pdf

Fine:

The State surveyor fined the 226-certified bed Medicare/Medicaid-participating nursing home $25,000 for Type A violations. Currently, Bridgeway Senior Living Nursing Facility maintains a one out of five stars rating for health inspection issues, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated March 1, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After review reviewing records and conducting interviews, the state investigators documented that the facility had failed to “provide supervision and ambulation assistance to a resident identified as at high risk for fall and failed to keep common areas free of accident hazards.” The deficient practice by the nursing staff resulted in one resident “sustaining an intertrochanteric fracture of the right hip and [another resident] sustaining a partial acute non-angulated distal radial fracture of the left elbow/hand.”

The observation was made of one resident at 10:45 AM on February 26, 2018, sitting in the “D Wing” dining area. At that time, “there was no staff around supervising [the resident who] was dozing on and off, rubbing her right arm and right thigh area.” The resident “was alert and oriented to only her name.” The resident “stated she could not recall her fall but knew there his pain in the right thigh area aware she was intermittently rubbing.” The resident stated “I fell, but I can’t remember what happened to me. The resident was also observed in her wheelchair were to family members. One family member stated that the resident “has not been eating or drinking and has refused to do anything. The family member also stated that they had flown and “from another state when she heard [a resident] was not responding well [stating] it was difficult to even get [the resident] to take her medications and applesauce [because she] has refused to take even drinks from her.” The family member stated that “he is concerned [the resident] is not eating or hydrating since after her fall and surgery.”

The family member stated on the morning of March 1, 2018, that “nothing has changed regarding [the resident’s] condition since hospitalization. That [the resident] has continued not to eat but drank little.” The family member also stated that the resident “was very agitated at the facility on February 28, 2018.” Both family members spoke with the facility Nurse practitioner about the resident’s “decline of physical and mental status and reduced appetite since the fall.” The Nurse Practitioner stated that the resident’s “blood will be drawn the next day” and because of the new development of not eating, she recommends additional testing.

A facility Incident Report dated February 18, 2018, show that the resident “had a fall on the way to the main dining room while ambulating with the CNA. The report also showed, ‘the nurse immediately assessed [the resident who] complained of pain in the right hip. Vitals taken and stable. The doctor notified with new orders to send [the resident] to the ER for evaluation and treatment. 911 call. Power of attorney made aware.” The resident was admitted to the hospital with an intertrochanteric fracture of the right hip.

Brookdale Plaza Lisle Skilled Nursing Facility
1800 Robbins Ln.
Lisle, IL 60532

http://dph.illinois.gov/sites/default/files/publications/NH18-C0173-04-05-18-Brookdale-Plaza-Lisle-SNF.pdf

Fine:

The State surveyor fined the 55-certified bed Medicare-approved facility $25,000 for Type A violations. Currently, Brookdale Plaza Lisle Skilled Nursing Facility maintains a one out of five stars rating for health inspections issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated April 5, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After investigators reviewed records, made observations and conducted interviews, was determined that the facility had “failed to supervise residents at increased risk for falls, failed to avoid resident falls, and failed to revised interventions to prevent further falls when necessary.” The deficient practice by the nursing staff required a resident being “transferred to the hospital after an unwitnessed fall.” Facility admittance documents reveal that “have a history of falls but was scored “at risk for falls and recommended initiation of fall risk interventions.” The severely cognitive impaired resident required extensive assistance of two or more persons for bed mobility and toileting and was also assessed as non-ambulatory. Other documentation revealed that the resident “is confused and unable to follow staff instructions on the use of call lights, is unable to understand being encouraged to participate in activities” but was encouraged to “wear non-skip footwear when ambulating or mobilizing in a wheelchair.”

A hospital report identified that the resident “fell in their room and was witnessed by [the resident’s] roommate was not witnessed by staff. According to the incident report, [the resident] was observed on the floor and said [that the resident] had been trying to go find help. No injury was noted. The only documentation of [the resident’s fall was documented in the Progress Notes that] mentions a low bed and staff encouraging [the resident] asked for help and to lock the wheelchair. The call light was placed within reach.” At a different time, the resident had another unwitnessed fall in their room. The documentation in the Incident Report revealed that the resident had fallen when they were reaching “for the door handle and loss balance.” The surveyors interviewed a Certified Nursing Aide (CNA) who had provided the resident care and stated that they had “just returned from lunch and did not find [the resident] on the floor and was unsure what the staff did.” That CNA help get the resident “off the floor and the resident complained of shoulder pain but did not say how [they] fell.” The resident “could not remember to call staff even if the call light was within reach.”

The state surveyor interviewed the facility Director of Nursing who “admitted having residents who had falls with fractures and later provided a list of residents with falls.” This resident, along with others “were listed and identified as having fractures.” The Director stated that “Care Plans are to be updated after each fall as are the fall risk assessments” and also stated that “new interventions such as urine cultures and culture and sensitivity post fall were put into place to prevent [this resident] from having further falls.

Christian Nursing Home
1507 7th St.
Lincoln, IL 62656

http://dph.illinois.gov/sites/default/files/publications/NH18-C0131-03-07-18-Chrisitan-Nursing-Home.pdf

Fine:

The State surveyor fined the 124-certified bed Medicare/Medicaid-approved nursing home $50,000 for multiple Type AA violations. Currently, Christian Nursing Home maintains a two out of five stars rating for health inspections and staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated March 7, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Immediately Notify the Resident, the Resident’s Doctor, and Family Members of Situations Including a Decline in Health

After reviewing records and conducting interviews, the state investigators documented that the facility had “failed to notify the physician of a resident’s decline respiratory status.” The resident had “complained of shortness of breath… and continue to decline [in health].” The documentation revealed that the resident’s “physician was not notified until the resident was emergently sent to the local hospital… where the resident subsequently died.”

The state investigator reviewed the facility’s Change in Condition Policy that states:

“It is the policy of this facility that a license staff member will notify the attending physician and responsible party of charge in the resident’s condition. The physician/responsible party will be notified when: a. The change is sudden in onset, or b. Represents a marked change in relation to unusual signs and symptoms, or c. The signs of signs and symptoms are relieved by measures already prescribed. The nurse will document in the clinical record. Documentation assessment will be ongoing until condition has stabilized.”

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

After reviewing records and conducting interviews, the state investigators documented that the facility “neglected to follow their policy on change of condition for [one resident].” The deficient practice by the nursing staff resulted in a resident “being found unresponsive after verbalizing continued complaints of respiratory distress for three days.” The resident was sent to the emergency room where they subsequently died.

  • Failure to Develop and Implement a Care Plan That Meets All the Resident’s Needs with Measurable Timetables and Actions

Based on interviews and record reviews, the state investigator document at the facility “failed to develop a Sleep Apnea Care Plan for [a resident].” The facility also “failed to assess and treat a resident with a compromised respiratory status” who had been complaining “of shortness of breath” and later died at the hospital after being found unresponsive at Christian Nursing Home.

Country Health
2304 C R 3000 N.
Gifford, IL 61847

http://dph.illinois.gov/sites/default/files/publications/NH18-C0105-03-28-18-Country-Health.pdf

Fine:

The State surveyor fined the 89-certified bed Medicaid/Medicare-participating nursing home $25,000 for multiple Type A violations. Currently, Country Health Nursing Facility maintains a three out of five stars rating for staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated February 15, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Immediately Notify the Resident, the Resident’s Doctor, and Family Members of Situations Including a Decline in Health

After conducting interviews and reviewing records, the state investigators identified the facility’s failure “to notify [the resident’s] physician of a significant weight gain. This failure resulted in the decline and fluid overload with subsequent hospitalization of [the resident].” This facility had recorded the resident’s weight and 309.0 pounds on December 6, 2017, 316.6 pounds on December 13, 2017, 315.4 pounds on December 27, 2017, 319.8 pounds, on January 3, 2018, 324.6 pounds on January 10, 2018, 327.6 pounds, on January 17, 2018, 336.0 pounds on January 24, 2018, 337.6 pounds on January 31, 2018. This significant weight gain was documented as a .5% (28.6 pounds) weight gain between December 6, 2017, and January 31, 2018.

A review of the facility Nurse’s Notes dated February 3, 2018 documents of the resident “was admitted to the hospital into the critical care unit” for treatment and “appears to be in respiratory distress with expiratory wheezing, tachypnea, accessory muscle usage.” Hospital records from the intensive care unit documents that the resident has read, indurated, hot, small skin openings” with serosanguineous fluid coming from the area on bilateral arms and knees. The doctors also noted that lower extremity pulsations were absent and that “blood cultures growing Gram-positive cocci resemble staphylococcus scene in two of two bottles.”

The resident returned to the facility after discharge from the hospital weighing “285.0 pounds (39 pounds less than on hospital admit on February 3, 2018).” The state investigator documented that the Medical Director and Primary Care Physician for the resident stated that they “did not recall being notified of the resident’s 8.4-pound weight gain in the week of January 17, 2018, through January 24, 2018.” The Director also stated that they “had notification of the resident’s weight gain being reported… [and] would have initiated assessments and interventions of fluid overload” given the resident’s medical history.

Failure to Employ Sufficient Staff with Appropriate Competencies and Skills Sets to Carry out the Functions of Food and Nutrition Service Including a Qualified Dietitian

The state investigators conducted interviews and reviewed records before noting the facility’s failure “to obtain a Registered Dietitian’s assessment for a resident concerning a significant weight gain over a 7-day period. The facility was reminded of their Dietary Manager Tasks in Preparing for Dietitian document that says:

“Complete the Nutritional Tracking Form or RD (Registered Dietitian Referral Form), keep the form out every month and add to it as new residents are admitted or readmitted, significant weight losses or gains (Weight Exception Report from Electronic Medical Record). Meet with dietitian briefly to update at the beginning of each visit.”

The state investigator interviewed the Food Service Supervisor on the afternoon of February 15, 2018, who “acknowledged that the Registered Dietitian should have seen [the resident] due to [the resident’s] weight gain.” The Food Service Supervisor dated that the resident “did trigger for weight gain and was referred for the Registered Dietitian to see but there was no assessment in the resident’s chart since April 14, 2017.”

Covenant Health Care Center – Batavia
831 N. Batavia Ave.
Batavia, IL 60510

http://dph.illinois.gov/sites/default/files/publications/NH18-C0175-NH18-S0176-03-22-18-Courtyard-Healthcare-Center.pdf

Fine:

The State surveyor fined the 99-certified bed Medicare/Medicaid-approved $25,000 for multiple Type A violations. Currently, covenant healthcare Center – Batavia maintains a three out of five stars rating for health inspection issues, which is nearly identical to the national average.

Violations:

In a summary statement of deficiencies dated March 29, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

Based on record reviews, interviews and observations, the state investigators documented that the facility had “failed to provide supervision from a resident with a history of wandering. This failure resulted in the resident sustaining a hematoma with hospitalization that required evacuation of the hematoma.”

The facility March 11, 2018 Incident Report revealed through interviews with the resident’s physician and the facility Medical Director that “it is conceivable that [another resident] sitting down on [the injured resident] could result in a hematoma due to [the injured resident’s] use of Xarelto and [the injured resident’s] structure (thin and bony).” A family member stated that the resident had to be hospitalized and had emergency surgery on her legs and was being sent to a wound specialist. The family member said that the resident “had told her that the hematoma developed because [another resident] had come into her room with a wooden box and slammed it on her legs.” Two Certified Nursing Assistants (CNAs) that provided the resident care stated the resident “had nothing in her hands and was redirected back into her room” but stated, “they were aware of the resident’s wandering into other residents’ rooms.”

Fair Oaks Rehabilitation and Healthcare Center
1515 Blackhawk
South Beloit, IL 61080

http://dph.illinois.gov/sites/default/files/publications/NH18-C0189-04-11-18-FairOaks-Rehab%26Helathcare.pdf

Fine:

The State surveyor fined the 78-certified bed Medicare/Medicaid-approved nursing home $25,000 for multiple Type A violations. Currently, Fair Oaks Rehab & Health Care Center maintains a two out of five stars rating for health inspections and staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated April 11, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Immediately Notify the Resident, the Resident’s Doctor, or Family Member of a Change in the Resident’s Condition Including a Decline in Health or Injury

After reviewing records, conducting interviews and making observations, the state surveyor identified the facility’s failure “to notify a resident’s power of attorney and position after a fall.” The facility’s Occurrence Report indicated that the resident’s “family her physician [was] not notified of the fall at the time of the incident.” The facility’s Progress Notes indicated that a Registered Nurse said that the resident “fell in the bathroom at the facility in the facility staff did not call her.” The Communication Form indicated that a family member was notified, but there was “no date or time entered for notification.” The RN stated that the resident “fell while taking himself to the bathroom.”

The facility Wound Nurse arrived at work at 4:00 AM and stated “I forgot to do a fall report. I did not call the resident’s family or medical doctor with his fall. I don’t remember if [the Wound Nurse] called the family or medical doctor.” The Wound Nurse said that “she did not know that the resident fell, and she did not notify the family or the Medical Doctor.” The state investigator interviewed the Director of Nursing who said that “staff should notify the medical doctor and family of the resident has a fall.” The facility’s Significant Condition Change and Notification Policy reads:

“The resident’s family and medical practitioner are notified of an accident or incident, with or without injury, that has the potential for needed medical practitioner intervention.”

Friendship Skilled Nursing and Rehabilitation Center
826 N. High St.
Carlinville, IL 62626

http://dph.illinois.gov/sites/default/files/publications/NH18-C0154-03-12-18-Friendship-Skilled-Nsg%26Rehab.pdf

Fine:

The State surveyor fined the 49-certified bed Medicare/Medicaid-approved nursing facility $25,000 for multiple Type A violations. Currently, Friendship Skilled Nursing and Rehab Facility maintains a two out of five stars rating for staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated March 12, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

The state investigator reviewed records and interviewed staff members before identifying a facility’s failure “to provide supervision to prevent falls of [two residents at the facility].” The failure of the nursing staff resulted in the resident “falling and receiving multiple facial fractures and a subdermal hemorrhage.” The injured resident’s documents reveal that they “require extensive assistance and 2+ physical assistance for bed mobility, transfers, and toileting.” The resident’s fall risk assessment indicates a higher risk for falls and the resident a positive Care Plan shows a history of falls.

The facility’s February 17, 2017 Fall Report indicates that the resident “fell out of their wheelchair and received a skin tear to the right hand, left side of the face bruising, and a hematoma to the left face and eye.” A subsequent Fall Report dated February 28, 2018, revealed that the resident “fell out of the wheelchair during transport. The report documented [that the resident] receive laceration and bruising.” The Verification of Incident Investigation/Administrative Summary dated the same day documented that the resident “was being transferred from bed to wheelchair by a CNA (Certified Nursing Assistant).” The resident’s POA (Power of Attorney) was made aware and arrived at the facility at 11:15 AM and requested that the resident “be sent to the emergency room (ER). Transport arranged. Residents and to ER at 12:01 PM.”

The state investigator interviewed the Director of Nurses on March 2, 2018, who documented that the resident “loss balance was sitting on the toilet and fell onto the floor. The summary documented the resident was escorted back from therapy stating she needed to go to the toilet. The resident was assisted per 2 staff assist and gait belt onto the toilet in the shower room. The resident stated to the CNA that she needed to have a bowel movement but could not get it to come out. The CNA stepped the door that was far from the toilet where the resident was sitting. The CNA stated she open the bathroom door just a fraction to maintain privacy to tell the nurse [that the resident had requested] a laxative.” The Documentation stated that “the resident sustained a laceration to her left forehead.” After the resident arrived at the emergency room, the physician closed the resident’s wound using seven sutures.

As a part of the investigation, the surveyor interviewed the resident’s physician who stated that the resident “recently had a stroke… and should never have been a left alone on the toilet.” The physician stated that “this fall and injury could have been prevented had the staff not left the [resident] alone in the bathroom.”

Glenlake Terrace Nursing and Rehabilitation Center
2222 W. 14th St.
Waukegan, Illinois 60085

http://dph.illinois.gov/sites/default/files/publications/NH18-S0119-03-08-18-Glenlake-Terrace-Nursing%26Reh.pdf

Fine:

The State surveyor fined the 265-certified bed Medicaid/Medicare-approved nursing home $25,000 for multiple Type A violations. Currently, Glenlake Terrace Nursing and Rehab Center maintains a two out of five stars rating for staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated March 8, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After a comprehensive record review, interviews and observation, the state surveyors identified the facility’s failure “to ensure a mechanical lift sling was the correct size to accommodate the resident’s weight and in good repair before transferring a resident.” The deficient practice by the nursing staff “resulted in two of the sling attachment straps to rip apart, resulting in [the resident] falling to the floor.” The incident left the resident with a sustained “fractured right leg requiring surgical repair. These failures contributed to [the resident’s] fear and anxiety about using the mechanical lift device again.”

The fall incident report documented by the facility staff members indicated that “staff were transferring the resident from her bed to her chair when two of the mechanical lift slings (attachment loose) snapped during the transfer process.” The resident said that she “was being transferred with a mechanical lift and the top right Loop and bottom right Loop of the sling broke during her transfer [making her fall] to the floor and broke her right leg and had to have surgery.” The resident stated that “she got back from the hospital two days ago (March 5) and has not gotten up out of bed yet because she is too nervous and scared that it will happen again.” The resident said that the pain in her leg is sometimes a ten on a pain scale of 0 – 10.”

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

Based on interviews, observations and record reviews, state investigators documented that the aides did not “ensure residents who require extensive assistance received personal hygiene care.” The deficient practice by the nursing staff involved with residents at the facility. One resident was observed “sitting in her wheelchair in her room.” The resident’s “gown was dirty with old dried food spots throughout her down [and the resident’s] hair was disheveled.” The observer noted that the resident “smelled of a musty body odor.” During an interview with the resident, it was revealed that “staff does not give her showers on a weekly basis [and that she said] her last shower was two weeks ago.”

The state investigator reviewed another resident’s MDS (Minimum Data Set) that the revealed that the second resident’s “cognition is intact and requires extensive assist with bathing.” The investigator interviewed that resident who stated that “he is supposed to get a shower on Tuesday, Thursday and Saturdays.” The resident stated that “some staff are lazy and do not give him showers [saying] he had a shower sometime last week.” The Certified Nursing Assistant providing the resident care stated that all residents “should receive a shower three times a week.” The facility Activities of Daily Living Policy dated 2000 indicated resident should receive a bath or shower at least once a week.

Glenview Terrace Nursing Center
1511 Greenwood Rd.
Glenview, IL 60025

http://dph.illinois.gov/sites/default/files/publications/NH18-C0126-02-16-18-Glenview-Terrace-NursingCtr.pdf

Fine:

The State surveyor fined the 314 certified bed Medicare/Medicaid-participating nursing home $25,000 for multiple Type A violations. Currently, Glenview Terrace Nursing Center maintains a three out of five stars rating for staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated February 16, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure That the Nursing Staff Does Not Use Feeding Tubes Unless There Is a Medical Reason and Only after the Resident Agrees

After reviewing records, conducting interviews and making observations, the state surveyor noted that the facility “failed to meet professional standards of quality for [a resident] reviewed for an acute change in condition and timeliness of transport” to receive immediate care. The failure by the nursing staff “resulted in a delay in [the resident] receiving intensive monitoring and hospital-level treatment…”

A Licensed Practical Nurse (LPN) stated on February 15, 2018, at 1:45 PM that “the resident’s gastronomy tube should be checked by auscultation with a stethoscope for correct placement and also for gastric residual volume before administering any feeding, water, or medication.” The LPN also said that “residents with gastronomy tube should be monitored for nausea, vomiting, abdominal distention, abdominal pain, and aspiration of feeding tubes.” A Registered Nurse (RN) stated at 6:50 AM on February 16, 2018 “that residents that receive intermittent feeding via gastronomy tube, the gastronomy tube should be checked for any gastric residual volume at the beginning of each shift and before each use.”

The resident’s medical records dated August 8, 2017, revealed that on that afternoon the resident “complained of the abdominal pain/tenderness which is revealed by the resident’s reaction to touch upon abdominal palpation. Pain medication given [but] with no relief.” The nurse practitioner assessed the resident and “ordered abdominal x-ray immediately and bladder scan… due to poor urine output.” The outside diagnostic company notified the nursing home of the resident’s “need for urgent abdominal x-ray.” The resident had difficulty all evening and complained of abdominal pain measuring 5/10 at 10:35 PM when their heart rate was 105 bpm and their blood pressure was 85/61 with 30 respirations every minute. By 11:05 PM the nursing staff determines to transport the resident to the hospital. The resident’s x-ray results of the abdomen noted that the “gastronomy tube overlies the region of the stomach, proper positioning within the stomach of the gastronomy tube cannot be positively confirm without installation of positive contrast material followed by x-rays and should be considered prior to gastronomy tube utilization.” The state surveyor noted that there was “no documentation found that the resident’s feeding was held at any time at August 8, 2017” between the time when the resident was complaining of unrelieved abdominal pain.

The state investigator reviewed the resident’s Hospital Medical Record dated August 8, 2017. The record revealed peritonitis last septic shock likely secondary to tube feeding contents seeping into intra-abdominal cavity. CT (computerized tomography) scan of the resident’s abdomen/pelvis demonstrating displays gastronomy tube with a large amount of intra-abdominal fluids.” The state investigator noted that the facility’s Enteral Tube Feeding Via Continuous Pump Policy dated July 2016 states “report complications (gastric distention, respiratory distress) promptly to the supervisor and the attending physician.”

Golfview Developmental Center
9555 W. Golf Rd.
Des Plaines, IL 60016

http://dph.illinois.gov/sites/default/files/publications/NH18-C0143-03-01-18-Golfview-Developmental-Center.pdf

Fine:

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

Violations:

In a summary statement of deficiencies dated March 1, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure the Nursing Staff Provides Every Resident Appropriate Care According to Acceptable Professional Care

After reviewing records and conducting interviews, the state surveyors noted the facility’s failure “to ensure nursing met the health needs of [one resident] who was diagnosed with a stroke and expired five days later in the hospital.” The incident involved a resident “who developed cellulitis, an open wound of her left lower extremity, and sepsis.”

The state investigator reviewed the facility Incident Report involving the resident documented at 1:45 AM on January 19, 2018. The incident revealed that the resident “was found lying on the floor in his room by the agency staff on his right side, next to his roommate’s bed.” The resident’s “fall was unwitnessed. The care rendered was an abrasion noted to his right buttock [that] was cleaned and bandaged. The resident “was to be monitored by the direct care staff member.” A subsequent Incident Report dated January 19, 2018, at 9:50 AM concerning the resident was reviewed by the investigators. “This report indicates that the resident was being transferred to the emergency room via 911. Care rendered indicated that after speaking with the Assistant Director of Nursing, that [the resident] appears to be worse, with no pupil reaction, although [the nursing staff] contract to voice with his eyes, therefore, 911 was called.” A review of the Public Health Notification on the same date and time revealed that the resident “was transferred to the Emergency Room via 911 for hypertension, hypoglycemia, and tachycardia, but the Incident Report does not indicate any of those findings.”

As a part of the investigation, the surveyor’s reviewed the resident’s Nursing Quarterly Assessment dated November 22, 2017, indicating that the resident “was verbal, alert, and oriented to person and place, with baseline vital signs of 120/72 blood pressure, and an 83 heart rate.” The resident is “independent with his mobility, does not use an assistive device, and once ambulating has a steady gate.” The resident’s POS (Physician Order Sheet) dated December 20, 2017, revealed the diagnosis of “moderate intellectual disability, hypertension, agitation, type II diabetes, secondary Parkinsonism, and hypothyroidism.” However, by January 18, 2018, the resident’s nurse’s notes states at 8:00 PM that the resident “had an emesis, and they will continue to monitor him. The entry from 10:00 PM states that the resident has an unsteady gait but denies pain. Entry from 11:30 PM states that the resident was awake to go to the bathroom but needed assistance due to his unsteady gait. Vital signs were assessed, and the resident’s blood pressure and heart rate were 130/89 and 113.”

An entry dated at 1:45 AM on January 19, 2018, revealed that the resident “was found on the floor in his bedroom, next to his roommate’s bed, lying on his right side, with his body up off the floor. An abrasion to his right buttock was noted and was cleaned and bandaged.” The document states that “this was an unwitnessed fall” but there was no neurological assessment documented nor were there any assessments regarding the movement of his extremities. The nursing staff placed the resident back in bed and did not know of any other injuries. The nursing team contacted the resident’s physician, but there was no return call. By 6:30 AM, the nurses note that the resident upon assessment was “now lethargic, but responsive.… His blood sugar is elevated to 320. An attempt was made to contact the physician, but they were unable to reach him.” By a 50 a.m., the Assistant Director Nursing received a report from the physician’s office nurse informing to send the resident to the Emergency Room for evaluation.

The nursing staff contacted the resident’s guardian saying her brother had fallen at 5:00 AM and was “found on the floor in his room, and the staff put them back to bed” the guardian wanted to speak to the brother of the nursing staff would not allow that. At 9:45 AM, the guardian was informed that the brother was being transported to the emergency room. The resident’s Hospital report dated January 19, 2018, shows a diagnosis of “MCA (middle cerebral artery) ischemic stroke with right hemiparesis with left-sided gays deviation… acute respiratory failure… and hypernatremia [electrolyte issues].” Surveyor’s reviewed the resident’s death certificate that showed the “cause of death was hemorrhagic stroke.”

Heartland of Decatur
444 W. Harrison St.
Decatur, IL 62526

http://dph.illinois.gov/sites/default/files/publications/NH18-C0124-02-01-18-Heartland-ofDecartur.pdf

Fine:

The State surveyor fined the 117 certified bed Medicaid/Medicare-participating nursing home $25,000 for multiple Type A violations. Currently, Heartland of Decatur Nursing Facility maintains a one out of five stars rating for health inspection issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated February 1, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Develop and Implement Policies and Procedures That Prevent Abuse, Neglect, and Theft

After a comprehensive review of medical records and conducted interviews, the state surveyor noted the facility’s failure “to operationalize or abuse prevention policy by failing to identify, investigate, and report abuse allegations and to protect [a resident] from potential further abuse.” As a part of the investigation, the surveyor also reviewed the facility’s Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation Prevention Practice Guide… [That uses] the seven key components of an abuse prevention program to identify and prevent risk of abuse, neglect, exploitation, mistreatment, and misappropriation. The document was implemented to “ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of resident property are reported immediately but not later than 2 hours after the allegation is made.”

The care plan for a resident at the facility documents of the resident “is at risk for pain and to administer medications as per the medical doctor’s orders. These care plans document [that the resident] is receiving hospice care due to a terminal illness with the goal to be comfortable.” However, the resident’s incident report documents that the resident’s medication was due to be changed “but was out of patches due to an expired prescription.” The report also documents that a family member approached the Registered Nurse to notify the nurse that the resident did not have the medication in place. The report also contains a witness statement from the Registered Nurse verifying that the resident “did not have a patch on.” The surveyor notes that there was no documentation of an investigation into why the patch was missing.

The hospital’s Director of Nursing stated that they should have been notified that the “patches missing from a resident’s body due to an incident being considered an abuse allegation from misappropriation/drug diversion.” The Director also stated that “she would expect an incident report be completed and that the State Survey Agency should be notified of the missing [medication] do to them being allegations of misappropriation/drug diversion.” The Director also said that “a fall investigation should have been completed for [the resident’s missing medication].”

  • Failure to Respond Appropriately to All Alleged Violations

The state surveyor’s reviewed records and conducted interviews and identified a failure the facility “to investigate and protect a resident from further potential abuse after abuse allegations were reported.” This failure involved the resident above who was receiving hospice care when the nursing staff failed to change their pain medication patch because they were “out of patches due to an expired prescription.” The facility Director of Nursing stated that there “was no investigation completed into these missing [medications, and] sought since it was a hospice’s fault for the [medication] incident that hospice was responsible for the investigation.” The Director also stated that “she was unsure of what days the CNA [Certify Nursing Assistant] had worked since the incident [occurred].” The Director stated that the CNA continued to work at the facility and she did not “have an answer as to why she was allowed to come to work after the allegation [of abuse] was reported to the facility by the hospice staff.”

Heartland of Normal
510 Broadway
Normal, IL 61761

http://dph.illinois.gov/sites/default/files/publications/NH18-S0240-04-25-18-Heartland-ofNormal.pdf

Fine:

The State surveyor fined the 116 certified bed Medicare/Medicaid-approved nursing home $25,000 for multiple Type A violations. Currently, heartland of Normal Nursing Facility maintains a one out of five stars rating for health inspection issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated April 25, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After a comprehensive review of medical records, conducting interviews and making observations, the state surveyors identified the facility’s failure “to ensure two staff members were present for repositioning a patient in bed” who requires repositioning. The failure by the nursing staff resulted in a Certify Nursing Assistant pulling the resident up in bed by their “right arm/shoulder causing an anterior dislocation of the right shoulder requiring multiple internal reductions and eventual surgical repair.”

The January 2, 2018 State Report documents that the day earlier the resident “was attempting to push himself up in bed. The CNA was walking by, and the resident called out for assistance. The CNA states that the resident had their need bed and was using the leg to move up in the bed and was stuck on his shoulder. The CNA attempted to lift the resident under the right shoulder and heard a ‘pop.’ The nurse on duty was called to the room for assessment [that] revealed mild pain in the right shoulder with range of motion, hand grasp strong, and no redness or bruise of the shoulder.” The nursing staff sent the residents of the emergency department for evaluation that diagnose the resident with a “dislocation of the right shoulder.”

The state surveyor interviewed the facility Assistant Director of Nursing who revealed that “he was the nurse on shift when [the resident’s] January 1, 2018 injury occurred.” The Assistant Director stated that the CNA “had reported he was trying to pull [the resident] up in the bed, and on the count of three, when [the CNA told the resident, the CNA] heard a pop from [the resident’s] shoulder.” The Assistant Director of Nursing assessed the resident’s condition and noticed “an obvious deformity of the right shoulder.” The Assistant interviewed the CNA “for the investigation into the resident’s injury but did not question the CNA about exactly how he was repositioning [the resident]” but assumed that the injury was the result of the CNA cooking “his arm under [the resident’s] arm to pull him up into the bed, which is an improper method for repositioning a patient.”

Heddington Oaks
2223 W. Heading Ave.
Peoria, IL 61604

http://dph.illinois.gov/sites/default/files/publications/NH18-C0130-02-27-18-Heddington-Oaks.pdf

Fine:

The State surveyor fined the 214-certified bed Medicaid/Medicare-participating $25,000 for multiple Type A violations. Currently, Heddington Oaks Nursing Facility maintains a one out of five stars rating for health inspection problems, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated February 27, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Provide Every Resident an Environment Free of Accident Hazards Involving an Incident That Led to the Death of the Resident

The state investigators reviewed records and conducted interviews to identify the facility’s failure “to properly transfer” one resident at the facility. The deficient practice by the nursing staff resulted in the resident “being lowered to the floor resulting in hospitalization for a bilateral distal femur fracture.”

The facility Event Report documents that the nursing staff was called to the resident shower room by a Certify Nursing Assistant and observed the resident sitting on the floor. The CNA reported that “during a transfer from the wheelchair to the shower chair, [the resident] went to sit down before the shower chair was under her.” The CNA gently lower the resident to the floor who was observed to be alert but confused. The nursing staff called 9114 ambulance transport to the hospital. The staff related that the resident was “able to move her upper extremities freely but did not move lower extremities.” The nursing staff transferred the resident to a cart using a sheet from the Nursing Home bed. The resident was transferred to the hospital in the bedsheet yelling “both times she was transferred.” The hospital radiology report documents of the x-ray of the left femur revealed “displaced distal femur fracture.” The resident “yelled when repositioned and moved. Patient screams when legs or touched her repositioned.”

The facility’s Progress Notes document that the resident returned to the facility with “bilateral leg immobilizers in place and is totally non-weightbearing, has numerous staples in place to both legs, has foot protectors in place.” The report also documents of the resident “is comfort measures only.” Other documents reveal that the “resident noted without respiration or pulse, cyanotic, and unresponsive. The local County coroner physician report documents [that the resident died] and documents the cause of death [as] Bilateral Femur Fractures, Impact/contact resulting from a fall. The same form documents the approximate interval between onset and death was immediate. This form also documents cause of death [per the resident’s medical condition] with the appropriate interval between onset and death as weeks.”

Helia Health Care of Champaign (SFF)
1915 S. Mattis St.
Champaign, IL 61821

http://dph.illinois.gov/sites/default/files/publications/NH18-S0125-03-06-18-Helia-Healthcare-ofChampaign.pdf

http://dph.illinois.gov/sites/default/files/publications/NH18-C0165-03-28-18-Helia-Healthcare-ofChampaign.pdf

Medicare identifies this nursing facility as having “a history of persistent poor quality of care, as indicated by the findings of state and federal inspection teams, it can be determined a Special Focus Facility (SFS). This means the facility is subjected to more frequent inspections, escalating penalties, and potential termination for Medicare and Medicaid.”

Fine:

The State surveyor fined the 118 certified bed Medicare/Medicaid-participating nursing home $25,000 for multiple Type A violations. Currently, Helia Healthcare of Champaign (SFF) Nursing Facility maintains a one out of five stars rating for health inspections and staffing problems, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated March 6, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Safeguard a Resident-Identifiable Information or Maintain Medical Records and Each Resident That Are in Accordance with Accepted Professional Standards

Based on record reviews and interviews, the state investigators identified the facility’s failure “to completely and accurately transcribe an order” that eventually led to the resident’s death. During an interview with the facility Speech Therapists it was noted that during her evaluation of the resident on February for 2018 “he was pocketing a lot of Food in his left cheek and because of the lack of sensation due to his tongue resection, she felt [the resident] needed cueing and supervision while eating.” The Speech Therapists stated that “she wrote the order for the diet change and 1:1 supervision while the resident was eating and gave the telephone order to the Licensed Practical Nurse (LPN), so it would be entered into the resident’s Electronic Medical Record (EMR).”

The resident’s physician’s telephone order dated February 6, 2018 documents at the speech therapists did order the resident’s diet “to be changed from a regular consistency to a mechanical softwood puréed needs, nectar thick liquids, and for the resident to have 1:1 supervision. The LPN stated that “she did receive the telephone order for the resident’s diet change and 1:1 supervision from the speech therapists. However, when she entered it into the EMR system, she must have missed the order that the resident required 1:1 supervision.”

  • Failure to Provide Every Resident and Environment Free of Accident Hazards Involving an Incident That Led to the Death of Two Residents

Based on interviews and record reviews, the state investigators identified the facility’s failure “to transcribe an order” by a doctor which resulted in the resident choking “and was subsequently hospitalized where he expired. These failures resulted in an Immediate Jeopardy.” The surveyors noted that they removed the immediacy “the facility remains out of compliance at severity level II. The facility is in the process of educating and in servicing nurses on proper transcription of telephone orders and on assuring physician’s orders [are met]. Managers will continue to complete daily meal rounds and discuss the findings of those rounds in daily meetings to discuss trends and patterns of noncompliance.”

The state surveyor reviewed the resident’s Baseline Care Plan the documents of the resident “was at risk for swallowing problems.” The Admission Assessment – Oral Cavity Observation revealed that the resident “had mouth dryness and difficulty moving his tongue in swallowing.” The Facility Incident Report revealed that the resident “was eating dinner in his room with his mother present at a proximally 5:00 PM.” His mother “came to get the nurse and stated [that the resident] is not right.” A Licensed Practical Nurse assess the resident “and found residual Food in his mouth. Abdominal threats were performed an endless was called.” The resident “had labored breathing and a pulse when leaving the facility.” The resident’s mother notified the facility that the resident “passed away the next day.” The state investigator interviewed the facility Nurse Practitioner who “agreed that [the resident] did not receive the safest care when at the facility because the order for 1:1 supervision while eating was not followed and [the resident] ended up choking.”

  • In a separate summary statement of deficiencies dated March 28, 2018, the state surveyor identified a failure to “ensure that a mechanical lift sling was safe for use prior to transferring” one resident. The deficient practice by the nursing staff resulted in the resident “falling from the mechanical lift on two separate occasions, the second time sustaining a subarachnoid hemorrhage (brain bleed), and a subdermal hemorrhage (brain bleed).” The resident was subsequently “hospitalized when transferred to another long-term care facility where [the resident] expired.” The state investigators documented that this failure “had the potential to affect 17 additional residents who share the same supply of poorly maintained mechanical lift slings. These failures resulted in an Immediate Jeopardy.”

Helia Health Care of Onley
410 E. Mack
Olney, IL 62450

http://dph.illinois.gov/sites/default/files/publications/NH18-C0210-04-05-18-Helia-Healthcare-ofOlney.pdf

Fine:

The State surveyor fined the 118 certified bed for-profit Medicare/Medicaid-participating $25,000 for multiple Type A violations. Currently, Helia Health Care of Olney Nursing Facility maintains a two out of five stars rating for health inspections and staffing problems, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated April 5, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After reviewing records and conducting interviews, the state surveyor identified the facility’s failure to “identify and implement and preventative treatment and services for pressure ulcer risks and timely identified an area of compromised skin and pressure ulcer.” The deficient practice by the nursing staff resulted in a resident “developing an unstageable pressure ulcer, resulting in hospitalization and Comfort Care measures.” The state investigator documented that this “past noncompliance occurred from February 15, 2018, through March 12, 2018.”

The state investigator reviewed the resident’s Clinical Health Status Form and Baseline Care Plan dated February 15, 2018. “Under-skin tears, skin intact was checked. Skin break risk was blank/not check, and the resident’s skin integrity goal was blank/not checked. Under skin break interventions, a specialty mattress was checked, but other skin break interventions such as turn and reposition, cushion for chair in wheelchair, and skin and wound treatments were left blank. This same document has for blank areas that could be used to document or write in any other conditions with possible documentation of risk, goal, and interventions. These areas were also left blank.”

The resident’s March 6, 2018 Nurse’s Notes document a “noted area to the resident’s coccyx. Noted unstageable 5.0 cm x 2.0 cm area. Area open and draining moderate amount of serosanguineous drainage.” The document also reveals the wound has “an area of necrosis in Center. The doctor notified with treatment requests per facility treatment protocol” which included a prescription for calcium alginate. A Certified Nursing Assistant providing the resident care stated that on the days she helped the resident with toileting, she “noted the sore area on the resident’s coccyx that was smaller than a quarter, very red, and thought it was starting to open.” The CNA stated that “she wrote it on the CNA report sheet but did not reported to the nurse.”

The investigator interviewed the resident’s physician who stated that the resident “was highly prone to a pressure ulcer and ‘yes, this [unstageable bedsore] was preventable” saying that the resident “was at risk to develop a pressure ulcer because of his mental state, physical state, and being malnourished. However, [the doctor] also clarified that if the facility would have put hydration, nutritional and preventative measures in place for pressure ulcers, [the resident] would have been alive for a few weeks to a few months more, but not long-term.”

Heritage Health – Staunton
215 W. Pennsylvania Ave.
Staunton, IL 62088

http://dph.illinois.gov/sites/default/files/publications/NH18-S0162-03-02-18-Heritage-Health-Staunton.pdf

Fine:

The State surveyor fined the 90 certified bed for-profit Medicaid/Medicare-participating $25,000 for multiple Type A violations. Currently, Heritage Health – Staunton Nursing Facility maintains a three out of five stars rating for staffing and quality measure issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated March 2, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After reviewing records and conducting interviews, the state surveyor noted the facility’s failure to “identify and assess, timely treatment, and turn and reposition to prevent pressure ulcers.” The deficient practice by the nursing staff involved four residents at the facility who were “reviewed for pressure ulcers.”

During one observation and 9:15 AM on February 20, 2018, a resident was seen “sitting in her wheelchair in her room. At 10:25 AM, [two Certified Nurses’ Aides (CNAs) transfer the resident] to bed using a mechanical lift. When the resident was rolled to the right side, the resident’s buttocks near her coccyx was observed to be deeply read and/purple. There were four open pressure ulcers with varying stages of healing. There was an opened denuded area observed to the left buttock with serosanguineous drainage noted. There were deep purple areas noted in surrounding tissue. There were no dressings on the open pressure ulcers. Also, the left second toe had an open area that was dark brown in color, bleeding and had multiple areas of skin that was scabbed. There was no bandage or treatment done.” Both Certify Nursing Aides “denied having seen this open area before.” The state investigator had the bed linens checked for dressing, “but none were found. [The resident] stated she had not had a dressing on since yesterday [and] complained that her bottom was hurting. She said that her bottom hurts a lot when she is up in the wheelchair too long.”

A separate resident was observed at 11:08 AM on February 20, 2018, when certified nursing assistants were transferring the resident onto the toilet. The resident’s “DuoDERM dressing was curled on his coccyx [and the resident] had red open areas on his buttock.” One certified nursing assistant stated that they were treating the resident’s bottom. However, that CNA “applied no barrier cream after completion of [the resident’s] incontinent care.” Later that day at 1:55 PM, the same Certified Nursing Assistant will transfer the resident “from a wheelchair to the bed using a sit-to-stand [device]. While suspended above the bed, [the resident] stated the pants were ‘awfully wet. I need a diaper’.” The CNA lower the resident “onto the dry incontinent briefs” while the DuoDERM was curled upon the resident’s coccyx area. The CNA then lifted the resident’s legs “up onto the bed and cover him up at the blanket [but] did not wash [the resident’s] perineal area or apply barrier cream to [the resident’s] buttocks.”

  • Failure to Provide Enough Food or Fluids to Maintain the Resident’s Health

Based on record reviews, interviews and observations, the state investigators documented that the facility failed to “assess and provide service to maintain nutritional status and offer sufficient fluids to maintain proper hydration.” The deficient practice by the nursing staff involved three residents at the facility.

In one incident, and observation was made of a resident on February 20, 2018, at 1:11 PM while the resident “was feeding herself in the assist dining room. Each food item was in individual bowls, and she was reaching for other bowls as she was eating from one.” A member of the nursing staff “was assisting at her table and would hand her another ball when she finished one.” The resident “would spill food from the bowls onto her lap and tray [when] she fed herself.” After the resident “are 100% of her food (except what was left on her tray and lap), she continued to check her empty bowls for more food.” The nursing staff told the resident that the bowls “were empty and made no attempt at getting her more food.” The resident continued “to check her bowls for more food as [the nursing staff] wash her hands and removed the protective cloth.” A subsequent observation of the same resident on the following day at 12:40 PM notice of the resident after completing all their food “continue to scrape and look for empty bowls.” The surveyor observed that “no additional food or second helpings were offered before [the resident] was taken from the table.”

The investigator reviewed the resident’s Minimum Data Set (MDS) and Care Plan dated December 18, 2017, the documents of the resident “to be at risk for nutritional problems related to her [medical conditions].” The Care Plan also documented that the resident had “been moved to the assist dining room due to gradual weight loss was staff to encourage and assist with adequate fluid intake, Monitor for signs and symptoms of urinary tract infections or dehydration, monitor labs as ordered, monitor intakes and fluids with meals per nutritional flowsheet, provide fluids throughout the day at bedside, obtain weight per schedule, diet order is mechanical texture within liquids.”

Jennings Terrace
275 S. LaSalle Street
Aurora, IL 60505

http://dph.illinois.gov/sites/default/files/publications/NH18-C0239-05-16-18-Jennings-Terrace.pdf

Fine:

The State surveyor fined the 12 certified bed nonprofit Medicaid-participating $25,000 for multiple Type A violations. Currently, Jennings Terrace Nursing Facility maintains a one out of five stars rating for staffing issues, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated May 16, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Provide Every Resident and Environment Free of Abuse, Mistreatment or Neglect

After reviewing records and conducting interviews, the state investigators identified the facility’s failure “to complete a comprehensive pain assessment and identify new onset of pain.” The investigator also stated the facility “failed to notify the physician of the resident’s change in condition and failed to transfer a resident in accordance with the plan of care.” The deficient practice by the nursing staff led to the resident “receiving a delay in treatment for a fractured femur [that the resident] sustained in the facility.” The incident involved a resident with “severely impaired cognitive skills who requires “extensive physical assistance of two staff for transfers and toilet use.”

A review of the resident’s July 27, 2017 Care Plan for Pain directed the nursing staff to “observe for nonverbal signs of pain or discomfort, including increase restlessness, crying, moaning, guarding/protecting of an area, flushed appearance, increased swelling, pale color, etc.; Utilized proper assistive devices [light] wheelchair, as indicated. [The resident] is non-ambulatory.” The State Surveying Agency Report provided on May 2, 2018, revealed that the resident “complained of right leg pain, x-ray showed right femoral fracture. Received reduction surgery at a local hospital.” However, the Nurses Notes concerning the resident revealed that a member of the nursing staff noticed a bruise on the resident’s upper right arm on April 29, 2018, measuring 2.8 centimeters by 3.2 cm, although the resident denies pain. By May 1, 2018, the resident is noted to be “still complaining of pain in the right leg. The resident is unable to verbally scale his pain, but when you move the resident in bed, the resident cries out, so I assume the resident’s pain is 8/10. Tylenol was given. Resident cannot [place weight] on the leg without discomfort.”

That same afternoon, an x-ray as ordered by the doctor. Later that evening, the doctor receives an email regarding the x-ray results showing “an acute transfer’s fracture through the right femoral neck…” The doctor orders that the resident being sent to the emergency room for “evaluation and treatment” which occurs at 8:56 PM that day. The state investigator interviewed the Director of Nursing who stated that “she did all the staff interviews related to the resident’s fractured leg.” The Director also stated that “staff is really good about reporting everything.” However, “when asked if she was aware that the resident was complaining of pain, [the Director] replied ‘no.’ When asked about the interview process, [the Director] replied ‘I interviewed the ones who worked on the unit” but when asked to provide the interview of the nursing staff in charge of providing resident care at the time the resident was injured, the Director “looked at the documented interviews and stated “she is not on their’” The state investigator noted that there was “no event/incident report on the resident’s medical record related to the pain/fracture. There was also no comprehensive pain assessment.” The Director of Nursing stated that “the facility did not complete an event/incident report.”

Jerseyville Nursing and Rehabilitation Center
1001 S. State Street
Jerseyville, IL 62052

http://dph.illinois.gov/sites/default/files/publications/NH18-S0160-03-26-18-Jerseyville-Nsg&Rehab.pdf

Fine:

The State surveyor fined the 111 certified bed for profit Medicare/-participating nursing home $25,000 for multiple Type A violations. Currently, Jerseyville Nursing and Rehabilitation Center maintains a two out of five stars rating for health inspections and staffing problems, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated March 26, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After the state investigators reviewed records and interviews, a noted the facility’s failure “to prevent residents from physical abuse. The deficient practice by the nursing staff involved one resident at the facility. A review of the Abuse Investigation on one resident, the Administrator provided documentation from a Certified Nursing Assistant who stated that the resident “was crying at the time [they were being transferred into their chair.” The CNA stated “after I help with the transfer, [another CNA] was taking [the resident] out of the room. As I was walking out of the room, I heard [the other CNA] call the resident a crybaby.” An interview was conducted with the resident who stated: “yes, it would upset me if someone called me a crybaby.” The Administrator said that “We investigated the allegation and it was substantiated.”

The investigator reviewed the December 28, 2017, Employee Disciplinary Action Report that revealed “based off of resident and staff interviews; we were able to substantiate that [the verbally abusive CNA] did call a resident a cry baby. This behavior is considered unacceptable towards a resident, therefore, employment is terminated effective immediately.” The investigator added the documentation of the facility’s Abuse Prevention Program Policy and Procedure dated December 2016 that read:

“Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with result in physical harm, pain, or mental anguish. It includes verbal abuse.”

  • Failure to Ensure That Every Resident Remains Free from Physical Restraints Unless Needed for Medical Treatment

After reviewing observations, interviews, and records, state investigator documented that the facility had “failed to obtain an order, provide an assessment, consent or medical symptoms for the use of restraint.” The deficient practice by the nursing staff involved one resident at the facility.

An observation was made of a resident at 8:16 AM on March 20, 2018, who “was in the assisted dining room sitting in [their] wheelchair with the seatbelt on and secured.” Later that morning at 9:55 AM, the resident was in their room sitting in their wheelchair “with the seatbelt on. When asked if [the resident] could remove [their] seatbelt, a Certified Nurse Aide (CNA), stated ‘I don’t know.’” The CNA then asked the resident to release the seat belt, and the resident “was not able to release the seat belt.” The following morning and 9:13 AM, when the Assistant Director of nurses was informed of the resident could not release the seat belt, the Assistant Director stated, “Oh, yes [the resident] can.” The Assistant Director then asked the resident to release their seatbelt “to separate times, and [the resident] was not able to release [their] seatbelt either time.” On March 22, 2018, at 10:00 AM, the registered nurse told the investigator “there are no restraint assessments for [that resident].” The investigator reviewed the resident’s monthly physician ordered and found “no assessment or medical symptom was documented for the restraint. No consent was documented for the restraint.”

The investigator reviewed the facility’s Restraint Use Guide Policy and Procedure from 2012 the documents in part:

“Symptoms: Restraint use may constitute an accident hazards, and professional standards of practice have eliminated the need for physical restraints except under limited medical circumstances. Therefore, medical symptoms that would warrant the use of restraints should be reflected in the comprehensive assessment and care planning.”

Lexington of Streamwood
815 E. Irving Park Rd.
Streamwood, IL 60107

http://dph.illinois.gov/sites/default/files/publications/NH18-S0237-NH18-C0238-05-02-18-Lexington-ofStreamwood.pdf

Fine:

The State surveyor fined the 214 certified bed for-profit Medicaid/Medicare-participating nursing facility $25,000 for multiple Type A violations. Currently, Lexington of Streamwood Nursing Facility maintains a two out of five stars rating for staffing problems, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated May 2, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Follow Policies When Transferring Residents and a Failure to Use Transfer Slings Appropriately

After conducting record reviews and interviews, the state investigator document at the facility’s failure “to follow its policy for transferring residents and failed to use the recommended slings size and tactics for mechanical lift transfer.” The deficient practice by the nursing staff resulted in the resident “falling to the floor during a mechanical lift transfer and sustaining intracranial hemorrhage that required hospitalization.” The incident involved a resident who “was admitted to the facility on July 17, 2010, with the diagnoses including dementia, generalized muscle weakness, anxiety, and psychosis.” The resident’s April for 2018 Fall Risk Assessment documented that the resident was “at high risk for falls.” The resident’s care plan for falls indicated that the resident “had balance problems and problems with strength… cognitive impairment and impaired safety awareness… reaches out for things that are not there.” The documentation also showed that the resident’s care plan for Activities of Daily Living revealed that the resident is “dependent on two staff members for transfers.”

During an interview of the Restorative Nurse, it was revealed that “she performed an assessment on the resident on April 13, 2018 [stating that] she recommended that [the resident] be transfer using a mechanical lift using a medium [red] sling because [the resident’s] weight was 150 pounds.” On April 23, 2018, a Certified Nursing Assistant (CNA) providing the resident care was “transferring the resident from the bed to the wheelchair with assistance of another CNA. The first CNA stated that “she placed a blue sling under the resident while the resident was on the bed… and held the resident at the feet as [the other CNA] operated the mechanical lift at the back of the machine.” While raising the resident off the bed, she saw the resident “lean forward towards the right side and fell over on the right side of the sling to the floor.” The CNA stated that she was not sure if the resident “hit her head on the leg of the mechanical lift, but [the resident] was bleeding from the back of her head.” The CNA stated that “she did not check the resident’s care card for the appropriate slings size for the resident when she transferred the resident. The CNA stated that the correct sling for the resident was medium (red) [not blue].”

Meadowbrook Manor – Naperville
720 Raymond Dr.
Naperville, IL 60563

http://dph.illinois.gov/sites/default/files/publications/NH18-C0164-03-29-18-Meadowbrook-Manor-Naperville.pdf

Fine:

The State surveyor fined the 245 certified bed for-profit Medicaid/Medicare-participating nursing home $25,000 for multiple Type A violations. Currently, Meadowbrook Manor – Naperville Nursing Facility maintains a one out of five stars rating for health inspection problems, and two out of five stars for staffing issues, which are significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated March 29, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Provide Every Resident an Environment Free of Accident Hazards

After reviewing records and interviews, the state investigators noted that the facility had “failed to ensure staff properly care for a resident was severe contractures.” The deficient practice by the nursing staff resulted in the resident “sustaining an acute, severely anterolaterally displaced [fracture] of the left femur.” The physical therapist’s evaluation revealed that the resident has “severe multiple contractures of bilateral lower extremity joints as well as upper extremity joints, increased muscle tone, impaired muscle strain, decreased cognition and impaired sitting balance/trunk control which affects all Activities of Daily Living/mobility and sitting/bed positioning. Patient is at high risk for falls, developing further skin breakdown and joint contractures. Skilled physical therapy is medically necessary on a trial basis to address above-stated problems, focusing on contracture management, proper positioning, with appropriate positioning devices and caregiver training to prevent further skin breakdown and joint tightness/contractures.”

The state investigator reviewed a nursing note written by a Licensed Practical Nurse that revealed they were “called to the room because a Certified Nursing Assistant noticed when he removed the blanket that the residents left leg was in a different position than usual. Upon a valuation [there was] no swelling, redness or tenderness to touch. The resident showed no signs of pain but when asked, stated he had pain but unable to rate.” The medical doctor prescribed pain medication and paged the nurse practitioner who sent the resident “to the emergency room for further evaluation.”

During an interview, the physical therapist “stated she performed physical therapy on the resident and provided training to the staff regarding the resident’s positioning and use of pillows between his legs.” The physical therapist stated that the resident “had had contractures for some time and had severe tone [stating that] his tone and his legs buried between relaxed… To increased tone when the resident would become more contracted.” The physical therapist stated that “during the staff training, she instructed the staff how to safely incorrectly placed the pillow between the resident’s legs – including telling the resident to relax his legs, instructing staff not to push the resident’s legs, and how to gently place the pillow between the resident’s legs where the legs meet.” The physical therapist stated that “the staff who attended the training were expected to endorse the information to the following ships’ staff [and stated that if the resident’s] contracted legs were forced to straighten; the force would cause a fracture or dislocation.”

Mooring of Arlington Heights
761 Old Barn Ln.
Arlington Heights, IL 60005

http://dph.illinois.gov/sites/default/files/publications/NH18-S0150-03-06-18-Moorings-ofArlingtonHeights.pdf

Fine:

The State surveyor fined the 84 certified bed non-profit Medicaid/Medicare-participating nursing home $25,000 for multiple Type A violations. Currently, Mooring of Arlington Heights Nursing Facility maintains a three out of five stars rating for health inspections and staffing issues, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated March 6, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After the investigators conducted record reviews and interviews, they determine the facility had “failed to ensure the resident was safely positioned and supported during the process of transfer from a recliner chair to the bed.” The deficient practice by the nursing staff resulted in the resident “sustaining a fracture.”

The incident report documented by the nursing staff revealed that approximately 10:45 AM on January 26, 2018, a Certified Nursing Assistant (CNA) assigned to providing the resident care asked another CNA to help transfer the resident from “the tilt recliner chair to the bed. As [the first CNA] was trying to straighten the bed [before transferring the resident, the second CNA] was trying to prepare the resident on the tilt recliner chair, position the tilt recliner chair in the upright position.” However, the resident’s “poor trunk control because the resident to fall forward, and out of the chair [sustaining] a bump on the forehead, it was showing signs of pain on the right hip area.” The nursing staff sent the resident “to the emergency room for further evaluations.”

The state surveyor interviewed the facility Assistant Director of Nursing on February 27, 2018 who stated that the resident “had poor cut trunk control, needs total assistance in all transfers and mobility, needs assist in turning and repositioning on the bed and chair, has episodes of involuntary jerking movements, not able to follow instructions and has poor strength and balance.” The Assistant Director also stated that they “conducted the investigation of the fall and concluded that the root cause was staff attentiveness and focus during the transfer which caused the fall.”

  • Failure to Provide the Appropriate Pain Management Every Resident Who Requires Such Services

The state investigator reviewed interviews and records and determined that the facility had failed to “ensure that the pain and comfort care management plan for a resident who was at the end of life, was carried out by failing to administer and ordered scheduled pain medication.” The deficient practice by the nursing staff affected one resident.

Niles Nursing and Rehabilitation Center
9777 Greenwood Ave.
Niles, IL 60714

http://dph.illinois.gov/sites/default/files/publications/NH18-C0218-04-16-18-Niles-Nsg%26RehabCtr.pdf

Fine:

The State surveyor fined the 304 certified bed for-profit Medicaid/Medicare-participating nursing home $25,000 for multiple Type A violations. Currently, Niles Nursing and Rehabilitation Center maintains a two out of five stars rating for health inspections and staffing issues, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated April 16, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Develop, Implement and Enforce an Infection Prevention and Control Program That Led to the Death of a Resident

After conducting a review of interviews, medical records, and observations, the state investigators noted that the facility “failed to establish and maintain an infection control and prevention program designed to provide an environment for its residents which was free from potential exposure to Legionella bacteria. The facility failed to have a water management program based on industry standards of practice.” As a result of the deficient actions of the nursing staff, one resident “tested positive for Legionella pneumophila and subsequently expired due to bilateral pneumonia.” As a part of the inspector’s findings, the Director of Nursing stated that the Hospital Infection Control Staff called the facility, informing the facility that [the resident] died at the hospital and had tested positive for Legionella.” According to the Director, the resident “was sent to the hospital due to an abnormal ultrasound report.” The Director stated that the resident “did not have respiratory symptoms at the time of transfer. During the same interview, [the Director of Nursing] stated that the County Health Department also called to inform the facility of [the resident’s] death and the positive lab results of Legionella.” The resident’s Death Certificate documents the “immediate cause of death (final disease or cause resulting in death) as Bilateral Pneumonia.”

The state investigators tour the facility with the former maintenance Director and the Administrator. The resident’s room before being transferred to the acute care Hospital “was a three-bedroom ward with the bathroom in a sink which was shared by three residents occupying the room.” When the tour was conducted, the “room was closed and not occupied by the residents. Clinical records [for the other two residents revealed that they] resided in this room until they were transferred out… when the bathroom sink fossa tested positive for Legionella.” The Administrator stated that “medical filters were installed on the 5th-floor shower stalls and in the faucet on [the deceased resident’s] faucet… five days after the facility received notification that the resident tested positive for Legionella.”

Documentation from the local Health Department provided instructions to in-service the staff and residents “regarding Legionella to heighten awareness related to any respiratory illness.” The Director of Nursing indicated that “in services were provided to staff related to legionnaires infection based on the CDC (Centers for Disease Control and Prevention) guidelines. At that time, the Director confirmed that the decedent’s “roommates remain in the same room with no restrictions related to the use of the sink in the bathroom.” The Director also said that one of the resident’s “has dementia and is amatory and [the other resident] needs extensive to total assistance with Activities of Daily Living.”

The Parc of Joliet
222 N. Hammes Ave.
Joliet, IL 60435

http://dph.illinois.gov/sites/default/files/publications/NH18-C0153-03-15-18-Parc-atJoliet-The.pdf

Fine:

The State surveyor fined the 203 certified bed for-profit Medicare/Medicaid-participating nursing facility $25,000 for multiple Type A violations. Currently, The Parc at Joliet Nursing Facility maintains a two out of five stars rating for health inspections and staffing problems, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated March 15, 2018, the state investigators identified deficient practices by the nursing staff including a:

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

After the state investigators review records, interviews and made observations, it was determined that the facility “failed to ensure transfer [of a resident] with two assistance and failed to provide supervision for [another resident] at risk for falls while ambulating.” The deficient practice by the nursing staff affected to residents at the facility “reviewed for falls.” This failure resulted in one resident fracturing the right femur.”

The state investigator reviewed the incident report that had been sent to the IDPH (Illinois Department of Health) that revealed that the resident “was toilet by staff members. The report showed that during the transfer, [the resident’s] knee buckled and [the resident] was assisted to the floor.” The report also indicated that the resident “lost his balance. The report showed [the resident] was not crying so he was returned to his wheelchair.” The facility Fall Event Report indicated that the “fall was witnessed by staff and that [the resident] lost his balance [and that the resident] had no injury and had range of motion to all four extremities. The report showed that [the resident] had no pain and that no medical care was required after the fall. The report showed that interventions put in place where to increase supervision and monitoring.”

The report also indicated that in the nursing notes, the resident “complained of pain in the right knee. The report showed an x-ray was ordered [and that] results were obtained at 10:02 PM and the nurse practitioner was notified.” The resident was admitted, “to the community hospital with a fracture to the right femur.”

Rosewood Care Center of Moline
7300 34th Ave.
Moline, IL 61265

http://dph.illinois.gov/sites/default/files/publications/NH18-C0113-02-22-18-Rosewood-CareCenter-ofMoline.pdf

Fine:

The State surveyor fined the 116 certified bed for-profit Medicaid/Medicare-participating nursing home $25,000 for multiple Type A violations. Currently, Rosewood Care Center of Moline Nursing Facility maintains a one out of five stars rating for quality measures and staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated February 22, 2018, the state investigators identified deficient practice is by the nursing staff including a:

  • Failure to Immediately Notify the Resident, the Resident’s Doctor, or Family Member of a Change in the Resident’s Condition Including a Decline in Their Health or Injury

After the state investigators conducted a review of the records and interviews, it was determined that the facility had “failed to notify the physician of a change in the [resident’s] condition, obtain a STAT lab draw, report abnormal laboratory results, and to transfer to the emergency room.” The deficient practice by the nursing staff affected one resident “being hospitalized.” The state investigator reviewed the facility’s Change of Condition Reporting Policy dated February 2013, the Obtaining Labs Specimen Policy dated November 1998 and the Laboratory Agreement dated April 8, 2015, that read in part:

“The facility will notify the resident’s physician and resident’s representative whenever: There is a significant change in the resident’s health, mental or psychosocial status, there is a change in the resident’s condition that although not significant is prudent to report using good nursing judgment; the resident is to be transferred or discharged.”
“The laboratory company will provide STAT (life-threatening situation) service for clinical lab services 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within 5 hours of laboratory notification.”
“The collection of the specimen and the resulting findings in the Nurse’s Notes, as well as the physician and family notification of any abnormal results.”

The surveyor’s reviewed the resident’s nurse’s notes dated February 9, 2018, at 2:00 AM that show that the resident “has been shaky and weak the past couple of nights. Full color. Strong smelling urine and seems increasingly confused.” A subsequent Nurse’s Notes dated the same day at 6:45 AM reveals that the resident’s “son requested and STAT hemoglobin and hematocrit [tests]. Doctor notified. Orders written. STAT lab called into laboratory company.”

Two Certified Nursing Assistants reported to the Licensed Practical Nurse (LPN) on duty at 9:45 AM on February 9, 2018, that the resident “was not acting herself before breakfast, then three additional times.” The LPN kept telling us that the resident probably needs a blood transfusion. After breakfast [the resident] had very Black tarry stool. We reported that to [the LPN]. Later that morning, [the resident] was dry heaving when we took her to the bathroom, and we reported that to the LPN.” Later that day at 12:05 PM, the certified nurse assistant reported that the resident “is normally pretty independent and she could stand or barely set up on her own. We assisted her to the toilet and cleaned her up. I reported this to the LPN in the LPN said ‘yeah, the 3rd shift nurse told me she needs a transfusion. She spine.” A little later, [the resident] call light was on, and I smelled something. So, I told [the resident] we needed to go to the restroom. Her skin was yellow, and she was incontinent of Black tarry stools all over her clothing. She is never incontinent. I reported this to the LPN again; the LPN told me, ‘yeah, she needs a transfusion single can. [The resident] was weak all day and did not want to come out of her room. She is normally out and about social with activities and meals, and she was not herself.” At 12:55 PM, the Certified Nursing Assistant stated that the resident “was not feeling well. She did not look good, and she had black tarry stools.” After repeatedly telling the LPN on duty, the LPN “never would do anything.”

At 8:45 PM, the same day, the Nurse’s Notes revealed that they had received “a call from the laboratory.” The resident’s test results showed a “hemoglobin of 3.7; at 8:55 PM, 911 call, and 9:04 PM, [the resident] left the facility by ambulance.” The facility received the laboratory results by fax at 9:43 PM. However, the state investigator noted that according to the Nurse’s Notes dated February 9, 2018, there is no “documentation of the resident’s physician being notified after 6:45 and a.m., with the resident’s change in condition symptoms, the delay in STAT lab draw, the abnormal lab results, nor when the resident was transferred to the emergency room.”

The state investigator interviewed the Medical Director who stated “I was notified at 2:00 AM, and 6:45 AM, regarding the resident’s change in condition, and I ordered the STAT Hemoglobin and hematocrit with the last phone call at 6:45 AM. A STAT lab should be drawn within a few hours, not almost 12 hours later. If a STAT lab draw is delayed, I would have them transfer [the resident] to the emergency room to have the lab drawn. I should be notified that the laboratory is delayed, and I was not. If the nurse would have notified me of the new symptoms of black tarry stools, I would have insisted the resident be transferred to the emergency room much earlier than 9:00 PM. I should have been notified of these changes, and again I was not. I also was not notified of her critical laboratory value or that she was sent to the emergency room.”

South Elgin Rehabilitation and Healthcare Center
746 W. Spring St.
South Elgin, IL 60177

http://dph.illinois.gov/sites/default/files/publications/NH18-C0117-02-22-18-South-Elgin-Rehab%26HCC.pdf

Fine:

The State surveyor fined the 90 certified bed for-profit Medicare/Medicaid-participating nursing home $25,000 for multiple Type A violations. Currently, South Elgin Rehabilitation and Healthcare Center maintains a two out of five stars rating for health inspection problems, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated February 22, 2018, the state investigators identified deficient practices by the nursing staff

  • Failure to Protect Every Resident from All Kinds of Abuse Including Physical, Mental, Sexual Abuse, Physical Punishment, and Neglect by Anybody

After state investigators conducted a review of medical records and interviews, the team determined that the facility “neglected to file the facility’s policy and procedure for advanced Directors regarding initiating CPR (cardiopulmonary resuscitation) on a resident designated as a full code and delayed providing CPR to a resident designated as a full code.” The deficient practice by the nursing staff “resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin… when the facility staff failed to initiate CPR on a resident.” The surveyor’s reviewed the facility’s updated Advance Directive that reads in part:

“Policy: The Patient Self-Determination Act states that individuals have the right to make their own decisions and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor the resident’s wishes as expressed in advance directives regarding medically indicated treatments whenever possible. This facility shall take all steps necessary to comply with the state of federal legislation relating to advance directives. Implementation of a code is as follows: Direct and non-direct care staff upon finding a person non-responsive shall remain with that resident as is possible while signaling for assistance. The nurse shall be summoned to respond, and upon review of chart, documents determine code status. The nurse shall evaluate the code status and note notify appropriate staff are tasked assignment. If CPR is indicated only certified personnel shall administer CPR. Activation of the Emergency Medical System shall be initiated, or the ambulance service notified. The physician shall also be notified to inform him/her of the resident condition. Upon completion of notification and necessary paperwork, the nurse shall relieve those performing CPR. The appropriate certified staff will continue until emergency medical team arrives and takes over. The facility shall provide education to all employees regarding advance directives and the implementation of such. In-servicing of advance directive policy and procedure shall be conducted annually.”

The investigators reviewed the facility’s Nursing Notes that showed that the resident “sustained a fall at the facility” was administered a sedative because due to the resident “screaming and agitation.” A Registered Nurse was summoned to the room after it was determined that the “resident was noted to be called.” The register nurse “then called 911 and other staff stayed with [the resident. The RN] continue to document that CPR was done by the 911 responders and [the resident] was noted dead at 8:15 AM.”

A review of the resident’s Illinois Statutory Short Form Power of Attorney for Health Care was signed by the resident and reveal that the resident “initiated the following statement: I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the procedures.” The registered nurse stated that other nursing staff reported to them that the resident “had a fall during the night that there were no problems.” The RN “checked her after the report and she was okay. They gave her [a sedative] during the night. She was sleeping when [the RN] saw her. “At 7:40 AM, [a Certified Nursing Assistant] deliver the room tray to [the resident]. They called [the RN] to go to the room because she was cold on her lower extremities and they tried to booster. She moaned when they boosted her, but [the RN] went and called 911 because something did not seem right.”

The registered nurse called “911 and told him she is cold but still responsive.” The RN “did not Checker vitals at 7:40 AM when [the RN] went in the room [nor did the RN] checked a blood pressure or a pulse oximeter, [nor] document a pulse rate. Another nurse (RN) came about 10 minutes after.” The first RN “never started CPR (cardiopulmonary resuscitation). Right before [the ambulance arrived] she deteriorated, but we did not start CPR. She was full code. The paramedic started CPR when they got here.” The registered nurse stated that “I did a sternal rub on [the resident]. I thought she was still alive. I did not apply oxygen to her. We are supposed to start oxygen.”

Warren Barr Lincolnshire
150 Jamestown Ln.
Lincolnshire, IL 60069

http://dph.illinois.gov/sites/default/files/publications/NH18-S0229-04-19-18-Warren-Barr-Lincolnshire.pdf

Fine:

The State surveyor fined the 144 certified bed for-profit Medicare/Medicaid-participating nursing home $25,000 for multiple Type A violations. Currently, Warren Barr Lincolnshire Nursing Facility maintains a two out of five stars rating for health inspection issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated April 19, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Prevent the Development of a Pressure Injury That Developed into a Stage IV Bedsore

The state investigators conducted a review of records, interviews, and observations and noted that the facility “failed to prevent the development of a pressure injury. The facility failed to implement interventions to reduce pressure to a resident Stage IV pressure injury and for a resident who is a high risk for pressure injury.” The deficient practice by the nursing staff “resulted in harm by worsening of a pressure injury and osteomyelitis [bone infection)” involving two residents at the facility. The wounds Specialist Assessment for Ulcer Avoidability/Unavoidability revealed that the resident was admitted to the facility “on August 14, 2017 [with a] Stage III pressure injury ‘date of onset’ [as] August 28, 2017.” The initial skin evaluation performed on August 17, 2017, three days after the admission to the facility, reveal that the resident “had no alterations and skin integrity, pressure ulcers, or wounds. This evaluation also showed [the resident] had difficulty repositioning yourself and required staff to assist with redistributing her body weight.”

By August 29, 2017, the resident’s Wound Care Consultation Note revealed that the resident “had developed an open Stage III pressure ulcer to her right coccyx measuring 3.5 cm x 3.5 cm x 0.2 cm.” The resident’s Magnetic Resonance Imaging (MRI) dated February 2, 2018, revealed “Impression: coccygeal midline decubitus ulcer extends to the coccygeal tip with bone marrow edema of the distal coccyx consistent with osteomyelitis.” A subsequent April 10, 2018, Wound Care Consultation Note revealed the resident’s “skin alteration was in her coccyx area with an open Stage IV pressure ulcer, osteomyelitis of coccyx bone, and measured 1.4 cm x 1.4 cm x 2.0 cm with ‘undermining and tunneling.’”

The resident’s Order Summary Report dated April 17, 2018, revealed that the resident “had diagnoses which include CBA (cerebrovascular accident) with hemiplegia, and hemiparesis and osteomyelitis. This report also showed ‘frequent turning and repositioning at least every 2 hours and as appropriate every shift for immobility.’”

An observation was made of the resident at 11:30 AM on April 16, 2018 while “lying on her back in bed watching television with her husband and daughter at bedside.” The Wound Nurse and a Certify Nursing Assistant were also at the resident’s bedside. The observer noted that the resident “had a circular wound to her coccyx area with a small white spot noted inside the wound, next to the left edge of the wound skin border. The skin around the wound was red and slightly swollen.” The Wound Nurse stated “that white spot is [the resident’s] tailbone. [The resident’s] wound has gotten worse because [the resident] was up in a wheelchair a lot so now she is in bed more. The wound is deeper than it was one month ago. The wound is facility-acquired. She got shortly after she was admitted here.”

A follow-up observation was made of the resident at 1:15 PM the same day while “lying on her back in bed asleep. [The resident’s] family remained at her bedside.” One family member “stated he was concerned that the facility was not repositioning [the resident] as needed.” The Wound Nurse stated “they do not change her position. When she was up in her wheelchair, she would be up in it for hours at a time. See here; they have not been back in to reposition her since she left this morning. She is still lying on her back. They do not have enough staff, or the flawed staff of the unit that do not know what to do for her.” Additional observations were made on April 17 at 8:35 PM, when the resident “was lying on her back watching TV. Additionally, the resident was observed at 8:00 AM, 10:00 AM, and 11:19 AM on April 17, 2018 “lying on her back in bed.”

West Suburban Nursing and Rehab Center
311 Edgewater Dr.
Bloomingdale, IL 60108

http://dph.illinois.gov/sites/default/files/publications/NH18-C0194-03-27-18-West-Suburban-Nsg%26RehabCrtr.pdf

Fine:

The State surveyor fined the 259 certified bed for-profit Medicare/Medicaid-participating nursing home $25,000 for multiple Type A violations. Currently, West Suburban Nursing and Rehabilitation Center maintains a one out of five stars rating for health inspection problems, and two out of five stars for staffing issues, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated March 27, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure That All Services Provided by the Nursing Home Meet Professional Standards of Quality

After the state investigators reviewed medical records and interviews, they determined that the facility “failed to meet professional standards of nursing by signing the resident’s MAR (Medication Administration Record) without administering the medications.” The deficient practice by the nursing staff affected two residents of facility who were “reviewed for improper nursing care.”

The state investigator reviewed the resident’s Medication Administration Record that revealed that five members of the nursing staff documented administering Nilotinib on eight occasions to the resident. However, “facility documentation shows a medication was no longer available at the facility” during that time. To support that findings, the investigators interviewed the Pharmacy Service Representative who said that the Nilotinib medication was never dispensed to the facility by a specialty pharmacy” at the time the resident was there. The investigators interviewed the Director of Nursing who stated that the resident “was not given the Nilotinib medication despite documentation in the medical record by [five members of the nursing team] showing the medication was administered. The nurses never gave the Nilotinib medication on those dates. This is not acceptable.”

In a second incident, another resident’s Medication Administration Record revealed that the “facility did not have the controlled substance sheet for the Lacosamide to show medication was signed by the nursing staff on the dates documented.” The pharmacist stated that “Lacosamide was never sent to the facility because it is a controlled substance and we never received a hard copy of the order from the physician. Therefore, we did not dispense the medication to the facility.” The Director of Nursing said that for members of the nursing staff “never administered the Lacosamide” to the resident during that time frame. The investigator reviewed the facility Medication Administration Procedure Policy initiated in 2011 that read in part:

“Procedure: Read each order entirely. Give the resident the medication. Return the medication cart and document medication administration with initials and appropriate spaces on the Ministration Administration Record. If medication is ordered but not present, call the pharmacy or supervisor to obtain the medication.”

  • Failure to Ensure That Every Resident Remains Free from Significant Medication Errors

Based on the investigator’s interviews, record reviews, it was noted that the facility “failed to administer [medication], anti-rejection, anticonvulsant and anticoagulant medications to residents as ordered by the physician and failed to follow the facility policy for medication administration.” The deficient practice by the nursing staff “resulted in Immediate Jeopardy.”

The investigators notified the Administrator, Director of Nursing, Nursing Consultants and Regional Director of a severe level to immediate Jeopardy involving multiple incidents. In one incident, a resident returned to the facility with orders to take multiple medications including an antirejection medication by mouth every night. “The order was never transcribed into the physician’s orders sheet.” In an interview with the resident’s nephrologist, was revealed that the resident “could reject his transplanting kidney because of the missed doses of [the antirejection medication]. It is in something that happens right away; he usually takes some time. Even if is lab work’s normal right now, we still will not know the repercussions of this. Time will tell, and we will have to monitor him closely.”

The Director of Nursing stated that “the nurse missed the order for [the resident ’s anti-rejection medication] 1 mg, every evening, when she entered the orders into the computer, and therefore, [the resident] never received the medication as ordered by the physician.” The Director also stated that “the facility did not have a procedure in place to ensure the nursing staff accurately entered medications into the computer one resident returned to the facility from the hospital.” A Registered Nurse documented a refill of the resident’s Nilotinib upon request from the resident’s oncologist. However, the nursing documentation revealed that the resident’s Nilotinib was not available at the facility during the time the resident was there until they were discharged the hospital for medical treatment.

Winchester House
1125 N. Milwaukee Ave.
Libertyville, IL 60048

http://dph.illinois.gov/sites/default/files/publications/NH18-S0127-02-22-18-Winchester-House.pdf

Fine:

The State surveyor fined the 224 certified bed for-profit Medicaid/Medicare-participating nursing home $25,000 for multiple Type A violations. Currently, Winchester House Nursing Facility maintains a two out of five stars rating for health inspection problems, which is substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated February 22, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Provide Basic Life Support, Including CPR, Prior to the Arrival of the Emergency Medical Personnel According to the Resident’s Advanced Directives

After a comprehensive review of records and interviews, the state investigators determined that the facility staff “failed to ensure staff maintain current CPR (cardiopulmonary resuscitation) certification for healthcare providers.” The incident involved a resident who “experience a choking episode [while] eating in his room with his roommate.” The resident “was alert and oriented on a general died and had no swallowing precautions. Nursing staff was alert that the resident was having a choking episode of responded and performed the Heimlich maneuver. Upon the third thrust, a food particle expelled. [The resident] then lost consciousness, CPR (cardiopulmonary resuscitation) was initiated and 911 call. CPR continued by paramedics as [the resident] was transferred out of the facility. Per the local hospital, [the resident] expired.”

According to facility documentation, the Licensed Practical Nurse (LPN) stated that “she was walking down the hall and a Certified Nursing Assistant came running up to her and stated, ‘we need help.’” The LPN ran into the resident’s room where she saw the resident “lying on the floor, and a dark-haired lady was doing chest compressions to the resident. The LPN said she performed a mouth sweep and two rescue breaths.” At that time, the dark-haired lady and the LPN exchange places where they continued CPR “until the paramedics arrived.” As a part of the investigation, the dark-haired lady said that she “was visiting her mom… [When she] heard a scream.” The woman entered the room and began chest compressions with another nurse who came in.

The LPN stated that “someone was supposed to get a suction machine then EMS arrived.” The LPN said, “she did not know how long the resident was not breathing, a code blue was not called overhead.” The hospital records indicated that “at 6:27 PM, large foreign body [measuring] 5.0 by 4.0 cm of undigested food was removed from the resident’s trachea by a medical doctor. The same report showed the resident was pronounced dead at 6:35 PM.” The investigator reviewed the facility’s Cardiopulmonary Resuscitation Policy that reads in part:

“Staff or to initiate CPR when a resident is found to have had either respiratory or [a medical condition]. Until EMS arrives is to continue to perform CPR until code blue documentation is to be completed in the medical record.”

Windsor Estates Nursing and Rehabilitation Center
18300 S. Lavergne
Country Club Hills, IL 60478

http://dph.illinois.gov/sites/default/files/publications/NH18-C0100-02-15-18-Windsor-Estates-Nsg%26Rehab.pdf

Fine:

The State surveyor fined the 200 certified bed for-profit Medicare/Medicaid-participating nursing facility $25,000 for multiple Type A violations. Currently, Windsor Estates Nursing and Rehabilitation Center maintains a one out of five stars rating for health inspection problems, and two out of five stars for quality measures issues, which are substantially lower than the national average.

Violations:

In a summary statement of deficiencies dated February 15, 2018, the state investigators identified deficient practices by the nursing staff including a:

  • Failure to Ensure Services Provided by the Nursing Home Meet Professional Standards of Quality

After a comprehensive review of medical records and interviews, the investigators determined that the facility had “failed to treat low blood pressure sugar for [one resident] and monitor blood glucose levels as ordered for [another resident].” In one incident, the first resident “was noticed lying in bed, breathing, skin cold to touch, and climbing, verbally unresponsive, drooling on the right side of the mouth, spasms noted on fingers, at 3:15 AM” on January 22, 2018. The nursing staff elevated their head off the bed but “was unable to obtain a temperature reading. Blood sugar monitored with the result of 55 mg/dL” 20 minutes later “at 3:35 AM, local private emblems was called and was given estimate arrival time of 20-25 minutes. Blood glucose rechecked and obtained a result of 52 mg/dL. No medications were administered to treat [the resident’s condition] while at the facility.” The resident was transferred at 3:40 PM to the local community Hospital. Upon arrival at the hospital, doctor’s check the resident’s blood sugar levels and found to be “18 mg/dL.”

A few weeks later on February 14, 2018, at 3:25 PM, the pharmacist stated that “the orders on the right side of the physician’s order sheet or call standing orders… The POS is a typed/computer-generated document which is produced by the pharmacy after the transcription of the orders from the physician. If the resident has a standing order for [their medication], the nurse can obtain the medication from the emergency medication kit of that unit.” The following day, a Licensed Practical Nurse stated that “I took care of this resident only for two days. As much as I know, the resident is alert, oriented to name in place, when I take medications to her, she was able to follow the commands to set up, open eyes, take meds with water, say thank you can go back to sleep. I was aware that she was diabetic; I never offered her any bedtime’s neck. On January 21, 2018, when I received this resident at the beginning of my shift, at 11:00 PM, she was sleeping, I did not see her in distress, did not wake her up. Generally, I do not take vital signs at 11:00 PM; I take [them] at 3:00 AM.”

The following day at 3:00 AM, the Licensed Practical Nurse stated “when I was trying to check her vital signs, I found her sweating, cold and clammy, checked or blood sugar, it was 55 mg/dL. I checked the emergency care for [her medication] injection, and I could not find any. I called the physician on call, and he ordered to transfer the resident to the emergency room; no orders for [a medication] were given at that time. I called the local ambulance, they gave away time of 45 minutes, and then I called 911. The standing orders on the right side of the POS and as a general nurse practice I knew I had to give [the medication] but I did not see any orders.”

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

Based on the state investigator’s observations, interviews and record reviews was determined that the facility “failed to implement preventive interventions for [two residents] reviewed for pressure ulcers.” The state’s findings included a wound report dated February 7, 2018, that revealed the resident “has a stage IV sacral wound and [another resident] has a stage III wound on both buttocks. On February 13, 2018, at 11:14 AM, [the first resident was observed] lying atop a low air loss mattress, however, pillows were observed under both thighs causing pressure on the sacrum.” Two Certified Nursing Assistants providing the resident care “removed the pillows from beneath [the resident], reposition him and place the pillows beneath his left hip and right thigh. The surveyor inquired about the pillows place between [the resident] and the low air loss mattress.” One Certified Nursing Assistant “stated these pillows right here? We have to move them; it defeats the purpose of the mattress.”

That same day at 11:35 AM, a different resident “was lying atop of a low air loss mattress. However a bath blanket full the twice (4 layers), incontinence brief, and a flat sheet were beneath him. The surveyor inquired about the layers between [the resident] and the low air loss mattress.” A different Certify Nursing Assistant “stated its only supposed to be a flat sheet on the air mattress.”

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

The state investigators made a comprehensive review of medical records, interviews and made observations at the facility to determine that Windsor Estates failed to implement “fall prevention interventions for [3 residents] reviewed for falls.” Some of the findings included a resident’s January 31, 2018, Care Plan that reads “resident is at risk for falls due to impaired balance, unsteady gait, and medication. On February 13, 2018, at 11:14 AM, [the resident was observed] lying in bed, the call light was clipped to the side of the mattress (above his head) and out of reach.” The surveyor inquired if [the resident] could reach the call light.” The resident “responded no. The surveyor inquired if [the resident] was able to walk.” The resident replied, “not yet.”

In a separate incident, another resident’s December 27, 2017, Care Plan stated that “resident is at risk for falls due to [their medical condition], impaired mobility, impaired safety awareness, and overestimates ability. On February 13, 2017, at 11:30 AM, [the resident was observed] lying in bed.” A Certified Nursing Assistant will raise the resident’s “bed and remove the blanket beneath him.” The CNA “then left the room and discarded the blanket in the soiled utility (down the hall).” The resident “was left unattended with the bed and high position.” A review of the resident’s February 3, 2018, Care Plan shows that the resident “is at risk for falls due to impaired mobility, impaired balance, and unsteady gait. On February 13, 2018, at 11:55 AM, [the resident] was sitting in a wheelchair.” The same Certify Nursing Assistant place the resident’s “feet onto the (sit to stand) mechanical lift as [the resident] was unable to lift them herself.” The CNA “proceeded to lift the resident (VS sit to stand lift), lowered her pants, and opened her incontinence brief while dangling.” The CNA “was unassisted by staff.” At 1:12 PM the same day, the surveyor “inquired how many staff are required while operating a mechanical lift.” The Director of Nursing replied “to people obviously when using the lift. One person to guide the patient, the other will operate the lift.” The investigator reviewed the facility’s August 2008 Lifting Machine Procedures that read in part:

“The portable lift should be used by two staff members.”
“The fall risk managing policy and procedure (August 2008) includes but not limited to: staff will identify and implement relevant interventions to try to minimize serious consequences of falling.”

Additional Information On Illinois Nursing Home Violations

According to the CDC (Centers for Disease Control and Prevention), the federal agency regularly updates their quarterly rating system to include every Illinois nursing facility, Rehabilitation Center, and assisted living home. Many families use the publicly available data to make a well-informed decision of where to place a loved one who requires the highest level of health and hygiene care. The grading system and the detailed information provides can help families quickly identify the level of care the skilled facilities provide to ensure their loved one receives the care they need.

Contact the patient injury attorneys at Rosenfeld Injury Lawyers at (888) 424-5757 today if you suspect your loved one was injured but through neglect, mistreatment or abuse at any Illinois nursing home. We accept all personal injury cases and wrongful death lawsuits through contingency fee agreements. This arrangement postpones payment of all our legal services until after we have successfully resolved your case through a negotiated out-of-court settlement or jury trial award. If we are unable to secure compensation on your behalf, you owe us nothing. Time is of the essence. All documentation and paperwork must be filed in the proper county courthouse before the Illinois statute of limitations expires.

Want to learn more about a specific Illinois nursing facility? Look up information on violations and fines here.

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