The Illinois Department of Public Health: October – December 2017 Quarterly Nursing Home Report

The Illinois Department of Public Health (IDPH) performs routine investigations and surveys on nursing facilities throughout the state. Their efforts help to identify any nursing facility, Rehabilitation Center or Assisted Living Home that has violated regulations according to the Nursing Home Care Act. When violations are identified, federal and state nursing home regulators can impose severe fines and penalties.

The Illinois Public Health Department publishes the data to inform the public Through a Released Quarterly Nursing Home Report. This publicly available information details inspections, investigations, and surveys. The current Nursing Homes and Rehabilitation Center throughout Illinois that were recently cited during the last quarter of 2017 are listed below. These facilities include those cited with Type A (severe violations) and Type AA (extreme violations) that resulted in fines that ranged from $12,500-$50,000. These facilities include:

Aperion Care Bloomington
1509 North Calhoun Street
Bloomington, IL 61701

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145371&SURVEYDATE=08/24/2017&INSPTYPE=CMPL&profTab=1&Distn=1.7&loc=61701&lat=40.477779&lng=-88.9892448

Fine:
The State surveyor fined the 115-certified bed facility $27,200 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated August 24, 2017, the state surveyor noted that the facility violated 12 type A violations and doubled the fine in one incident because one code violation was considered a high-risk designation.

  • Failure to Develop and Enforce Policies and Forbid Mistreatment, Neglect or Abuse of Residents

The state investigators identified an F-0224 violation that resulted in actual harm of a resident due to the facility’s failure to “provide services that a line with physician’s orders.” The resident:

  • “was not given breakfast daily prior to [their medical treatment] and
  • not given bedtime snacks,
  • not given insulin as ordered,
  • not given a renal diet as ordered, [and]
  • did not have blood glucose monitoring as ordered, and was
  • not given a fluid restriction with daily weights as ordered by the physician.”

These failures resulted in the resident being hospitalized.

As a part of the investigation, surveyors determined that the facility “failed to prevent misappropriation of the resident’s medications resulting in missing narcotic medications for [one resident] reviewed for misappropriation of narcotic medications.” The investigators reviewed the resident’s Medication Administration Record (MAR) documented between August 14, 2017, and August 18, 2017. The records indicated that the resident’s “blood sugars were not obtained along with the sliding-scale insulin as ordered on August 15, 2017, at 11:00 AM, August 16, 2017, at 7:30 AM, and 11:00 AM, and August 17, 2017, at 11:00 AM.”

The resident’s Nutritional Intake Report with the same dates as the MAR revealed that the resident did not receive breakfast on those days, nor snacks nor have insulin monitoring, fluid intake or a daily weight documented.

The resident’s Hospital History and Physical dated August 18, 2017, revealed that the resident was transferred to the emergency department complaining of confusion that started earlier in the day. The emergency room doctors determine that the resident had very low blood sugar and a low temperature (96°F) upon admittance.

  • Failure to Provide Necessary Care and Services to Maintain the Highest Well-Being of Each Resident

In a separate incident, surveyors identified that the facility had “failed to access pain, provide pain-relieving interventions, and control pain for [a resident].” The failures of the nursing staff resulted in the resident “experiencing acute exacerbation of unrelieved chronic pain resulting in hospitalization… [that] resulted in elevated blood pressure.”

In this incident, the failure of the nursing staff to provide adequate care to treat the resident’s Diabetes Mellitus type II and osteomyelitis resulted in serious harm. The resident had “a change in their level of consciousness, [which resulted in] falling, and requiring hospitalization for confusion, fluid overload, chronic osteomyelitis of the right foot, hypothermia, and other medical conditions.

Aperion Care Moline
430 South 30th Avenue
East Moline, IL 61244

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146041&SURVEYDATE=08/29/2017&INSPTYPE=CMPL&profTab=1&Distn=5.1&loc=61244&lat=41.5306294&lng=-90.3842527&dist=25

Fine:
The State surveyor fined the 120-certified bed, Medicare/Medicaid-participating facility $50,000 for multiple Type A violations and was given an overall one-star rating for health inspections which was much below average.

Violations:
In a summary statement of deficiencies dated August 29, 2017, the state surveyors identify a significant failure of the nursing staff and their:

  • Refusal of Treatment and Refusal to Take Part to Formulate Advanced Directives

The incident involved the facility’s failure “to initiate cardiopulmonary resuscitation (CPR) [by] the advance directives set forth by the resident [before] the incident. While at the facility, the resident “was found unresponsive on the floor, hanging by the ties of [their] nightgown around the footboard of [their] bed. No CPR was initiated until Emergency Medical Services arrived over 15 minutes later. These failures contributed to the resident expiring at the facility that night at 9:15 PM. The investigators determined in immediate jeopardy had begun at the moment that the resident “was found unresponsive.”

At 2:45 PM on the day the resident died, a Certified Nursing Aide (CNA) responded to a call light in the resident’s room. The roommate looked at the Certified Nursing Assistant and said that the resident had fallen. The CNA found the resident “with a nightgown tied around [their] neck, and it was caught on the (decorative) post on [the resident’s] footboard of the bed.” The resident’s “face was toward the door in the rest of [their] body was lying on the floor.” The CNA attempted to get the resident to respond. However, the resident’s “face was turning dark blue and [their] fingertips were blue.

The CNA remove the tie string around the resident’s neck, lowered the residents head to the floor when vomit began coming out of the resident’s mouth. The CNA’s could not find a nurse and believed that the resident was a DNR (Do Not Resuscitate). A Licensed Practical Nurse arriving at the scene questioned the resident’s code status. After they determined that the resident was a full code, requiring resuscitation, they began compressions and suction.

  • Failure to Provide Adequate Supervision to Prevent Avoidable Accidents

The state investigators also identified during the survey that the facility had failed to “ensure that resident call lights were answered to respond to a resident fall.” The facility also failed to “ensure emergency equipment supplies were available for use on the crash cart,” and failed to “ensure that all staff is trained in CPR within 90 days of their hire” as per the facility’s policy.

Aperion Care Moline
430 South 30th Avenue
East Moline, IL 61244

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146041&SURVEYDATE=11/07/2017&INSPTYPE=CMPL&profTab=1&Distn=5.1&loc=61244&lat=41.5306294&lng=-90.3842527&dist=25

Fine:
The State surveyor fined the facility $25,000 for multiple Type A violations and gave the nursing home an overall one-star rating for health inspections, which was much below average.

Violations:
In a summary statement of deficiencies dated November 7, 2017, the state investigators identified an F-0157 violation to:

  • Make Sure That the Nursing Home Area Is Free from Accident Hazards and Risks, and Provide Adequate Supervision to Prevent Avoidable Accidents

An incident involved the facility’s failure “to identify interventions for a resident for elopement and failed to have a system for ensuring door alarms were working correctly during the evening and at night. The deficient practice of the nursing staff resulted in the resident eloping from the facility. “This failure also had the potential to affect [for other residents].” The investigators placed the facility in Immediate Jeopardy.”

A review of the resident’s Nurse’s Notes dated 5:30 PM on October 25, 2017 documents that the resident was “restless, agitated, and hard to redirect.” The resident was “pacing up the hall and attempted to exit C Hall two times.” The resident’s Admission Observation dated October 25, 2017, documents that the resident “is oriented to person only … wanders daily, [and] has the behavior of displaying anger, verbally aggressive, and resistive to cares.” Other documentation revealed that the resident was “at risk to elopement and should be placed on the Elopement Risk Protocol.”

On the late morning hours of October 30, 2017, a Licensed Practical Nurse at the facility stated that “none of the door alarms went off.” The resident “ended up going out D Hall exit, and it has to alarms and neither of them when off. If they were going off, you would be able to hear them anywhere. I do not know what time we figured out he was missing, but from the video surveillance we found out he left around 5:35 AM. I would say around 5:15-5:20 AM, he was sitting in the dining room drinking a soda.”

By 6:30 AM that afternoon a Registered Nurse stated that they “called the Code Pink (missing resident)” when they realize the resident was missing.” At 11:20 AM on October 31, 2017, a police officer stated that a citizen in the community dropped the resident “off at a retail store then called [law enforcement, who picked the resident up] walking toward the highway.”

The citizen had picked up the resident “approximately one mile from the facility” while the resident “was wearing only gym shorts, T-shirt, and socks with no shoes. His indwelling urinary catheter was disconnected, and he had urine all over him. He was freezing cold. It was 38 degrees [outside] that morning.” The resident was so cold that the police officer placed the resident in the police car and “drove him to the Fire Department. They took him to the hospital.” The resident “was confused the whole time.” It was determined that the resident had been on a highly trafficked 35 mile per hour road directly off a four-lane 45 mile-per-hour highly trafficked road.”

Bria of Cahokia
3354 Jerome Lane
Cahokia, IL 62206

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145613&SURVEYDATE=10/05/2017&INSPTYPE=CMPL&profTab=1&Distn=2.4&loc=62206&lat=38.5794331&lng=-90.1588618&dist=25

Fine:
The State surveyor fined the 133-certified bed facility $25,000 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated October 5, 2017, the state investigators determined the facility had failed to “provide supervision during a meal to prevent choking.” This F-03223 violation involved a:

  • Failure to Ensure That the Nursing Home Area is Free from Accident Hazards and Provide Adequate Supervision to Prevent Avoidable Accidents

The investigators determined the facility’s failure “to attempt cardiopulmonary resuscitation on an unconscious resident with swallowing difficulties resulted in the resident’s death from “asphyxiation from a foreign body.” According to the resident’s Electronic Medical Record, the physician had diagnosed the resident with Intellectual Disabilities, Oropharyngeal Dysplasia, Aphasia (Difficulty in Communicating), History of Gastronomy, and General Muscle Weakness. The medical record also revealed that the resident was to receive a mechanical soft diet and can feed themselves with “set up help.” However, the doctor noted that the resident should be monitored for choking because they tend to eat fast. The staff was instructed to provide supervision to remind the resident to “take small bites, reduce the rate of intake and alternate foods with liquids.”

According to the facility’s Final Incident Investigation Report, the resident was found to be “slumped over at the dinner table.” The staff knew that the resident was a DNR (do not resuscitate), and “went with the assumption that [the resident] was choking. There were no visible food particles in her mouth at the start of the Heimlich maneuver. The staff began doing the Heimlich immediately, with no positive result. The staff removed [the resident] from the dining area [and then] placed her in the television room, for privacy and to continue the Heimlich. Emergency Medical Services had been called on the onset and had arrived at this time.” After EMS attempted to perform the Heimlich, the resident was pronounced dead.

The medical examiner/coroner determined that the resident died from sudden death that occurred while choking on a hotdog while eating dinner. A Certified Nursing Assistant who had provided the resident care stated that they were unaware that the hotdog had been caught up [before] consumption.

Chateau Nursing & Rehab Center
7050 Madison Street
Willowbrook, IL 60521

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145614&SURVEYDATE=10/18/2017&INSPTYPE=CMPL&profTab=1&Distn=2.4&loc=60521&lat=41.7967461&lng=-87.9285777&dist=25

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145614&SURVEYDATE=10/26/2017&INSPTYPE=CMPL&profTab=1&Distn=2.4&loc=60521&lat=41.7967461&lng=-87.9285777&dist=25

Fine:
The State surveyor fined the 150-certified bed Medicare/Medicaid-participating facility $50,000 for Type A violations and gave the nursing home an overall one out of five-star rating, which is significantly below national averages.

Violations:
In a summary statement of deficiencies dated October 18, 2017, state investigators determined that there was not adequate staff to ensure that every resident’s needs were met.

  • Failure to Ensure Adequate Nursing Staff for Every Resident in a Way That Maximizes Everyone’s Well-Being

The state investigator determined that the facility had “failed to provide sufficient staff to assist residents who require extensive assistance to total dependence for grooming/hygiene and toileting, wound dressing, change monitoring, and supervision to prevent fall incidents.” One incident was revealed upon observations of a Certified Nursing Assistant rendering morning care and incontinent care to a resident at 10:15 AM on October 5, 2017.

The resident “was wet with urine. There was a strong odor of urine inside [the resident’s] room which was coming from [his] incontinence brief.” The investigators observed the Certified Nursing Assistant (CNA) providing “partial bed baths to [the resident].” However, the CNA, “did not clean [the resident’s] left and right groins (inner thighs.)” A review of the resident’s Urinary Incontinence Care Plan Dated July 17, 2017, revealed a goal of maintaining “dignity by being clean, dry and odor free. Intervention: Keep skin clean and dry, use barrier cream as needed. Provide personal hygiene after incontinence episode to reduce infection.

  • Failure to Assist Residents Who Require Additional Help with Eating/Drinking, Grooming, and Oral/Personal Hygiene

State investigators identified a facility’s failure “to check residents for incontinence, change incontinence brief [promptly] and provide complete incontinence care.” The investigators notified the nursing staff of their failure to provide care according to the facility’s policy and procedure for perineal care.

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

In a separate summary statement of deficiencies dated October 26, 2017, the state investigators identified a facility’s failure “to ensure fall precaution interventions were implemented for two residents.” Surveyors also identified the facility had failed to “ensure resident safety while providing care” which resulted in a resident “falling out of bed and sustaining” severe injury.

Detailed information provided in the resident’s electronic health records revealed that the resident had fallen numerous times including on:

  • September 18, 2017 – two falls “including a fall between the bed in the wall; [and] a fall next to the bed.”
  • September 27, 2017 – one fall “where the resident slid off the left side of the bed.”
  • September 30, 2017 – one fall “near the foot of the bed.”
  • October 2, 2017 – one fall “at the bedside.”
  • October 21, 2017 – one fall “next to the bed.”
  • October 22, 2017 – one fall when the resident “slid out of the high-back wheelchair.”

On October 23, 2017, a member of the family spoke to the nursing staff at 1:12 PM detailing that the resident had “multiple falls while in the facility and [they] would like to know what the facility was going to do about it.” The family member stated that the resident’s “bed was not always in the lowest position, and they gave [the resident] a scoop mattress but did not feel it would keep [the resident] from falling out of the bed.” The resident’s family member stated that “she often comes into the room and the floor mat was not on the floor in the room.”

  • Failure to Provide Adequate Supervision to Prevent Avoidable Accidents

The state investigator documented during the investigation on October 26, 2017, that the facility had failed “to ensure fall precaution interventions were implemented for two residents and failed to ensure resident safety while providing care which resulted in a resident falling out of bed, sustaining a hip fracture. This failure resulted in a hip fracture requiring hip surgery and hospitalization with blood transfusions.”

Citadel Care Center – Elgin
180 South State Street
Elgin, IL 60123

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145004&SURVEYDATE=11/02/2017&INSPTYPE=CMPL&profTab=1&Distn=1.9&loc=60123&lat=42.0361546&lng=-88.314212&dist=25

Fine:
The State surveyor fined the 88-certified bed Medicaid/Medicare-participating facility $25,000 for multiple Type A violations. The investigators designated the facility as an overall one-star out of five-stars rating, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated November 2, 2017, investigators revealed that the facility had “failed to provide necessary care and services to promote healing, prevent infection and prevent facility-acquired pressure ulcers for deterioration.”

  • Failure to Provide Proper Treatment to Residents to Prevent the Development of New Bedsores or Allow an Existing Bedsore to Heal

The state investigators documented that the failure of the nursing staff resulted in the resident “developing a facility-acquired pressure ulcer from a Stage II [wound] that it worsened to a Stage IV [life-threatening].” The resident “was sent to the hospital and was identified with an infection of the coccyx pressure ulcer and pain on the site.” The resident “had undergone two surgical debridements [cutting away dead (necrotic) tissue] in the pressure ulcer.”

The resident’s admission/discharge log show that the resident “was originally admitted to the facility and required multiple hospital visits to treat urinary tract infections and kidney stones. However, the resident upon readmission “had no pressure ulcer” that were developed at the facility. At that time, the Stage II pressure ulcer measured 1.0 centimeters by 1.0 centimeters. By October 3, 2017, it had increased in size, and by October 23, 2017, had become unstageable, or greater than a stage IV decubitus ulcer.

The state investigator reviewed the resident’s August 3, 2017, Care Plan revealed that the resident “is at risk for impaired skin integrity related to impaired mobility and incontinence associated with cerebral infarction and [other medical conditions].” Surveyors observed the resident on October 30, 2017, at 12:15 PM, 1:30 PM, and 3:20 PM while “lying in bed in a supine position.” The resident “was in the same position during these observations.” However, the nursing staff was required to manipulate the resident’s posture manually and repositioned the resident at least once every 1.5 hours to eliminate the potential for skin breakdown and the development of bedsores.

Collinsville Rehabilitation & Health Care Center
614 North Summit
Collinsville, IL 62234

Fine:
The State surveyor fined the Medicare/Medicaid-participating 94-certified bed facility $50,000 for multiple Type A violations. The state investigators designated the nursing home as an overall one out of five-star rating facility, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated October 24, 2017, opened an investigation at the facility after a resident expired when the nursing home failed to follow the resident’s advance directives by not initiating cardiopulmonary resuscitation (CPR).

  • Failure to Follow a Resident’s Advance Directives That Resulted in the Resident’s Death

The state investigator documented that the facility “failed to initiate cardiopulmonary resuscitation (CPR) for [a resident]” and “failed to follow the resident’s Advanced Directives by not initiating CPR. The resident subsequently died.” The failure of the nursing staff had the potential to affect 52 out of 65 residents “whose Advance Directives indicate Full Code Status.”

According to the facility’s physician’s orders, the resident was a full code. The resident’s Nurses’ Notes stated the resident’s time of death at 4:45 PM. At that time, the nursing staff verified the resident had “no pulse, no heartbeat, and no respirations. The staff notified the coroner and the resident’s physician 15 minutes later and made arrangements with the local funeral home at 6:45 PM to pick up the resident’s remains.

However, a “facility letter to the Illinois Department of Public Health…” stated “please accept this letter as the final report to the initial notification… regarding an allegation of neglect involving [the resident and a Licensed Practical Nurse (LPN)].” During the investigation, it was noted that at approximately 4:40 PM on [the day the resident died] the resident “was found unresponsive. The staff members notified [the Licensed Practical Nurse] of the resident’s change of condition and reported that [the LPN] failed to thoroughly assess [the resident].”

The LPN was “interviewed, and she made a visual assessment of her condition.” The LPN reported that a second nurse “assisted with the assessment of the resident’s condition. However, the second nurse denied assessment of the resident. In conclusion, the facility was unable to substantiate the allegation and [the LPN] was terminated from her position.”

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

The state investigators determined that the facility had “failed to immediately inform the physician and the resident’s representative of a change in condition that resulted in hospitalization [two residents] reviewed for notification.”

In one incident, a resident’s Nurses’ Notes dated 11:10 AM on September 29, 2017, revealed that the resident was “to be seen in the emergency room related to a mental status change in the hospital [involving] dehydration.” However, there is no documentation in the Nurses Notes that the resident’s family representative was notified at the time.”

A review of the resident’s transfer form dated September 29, 2017 documented that the reason for the transfer “was not eating or drinking, complaints of pain all over her body.” The investigator reviewed the resident’s admission record that provided “three phone numbers documented for her family members, which included one listed on the Transfer Form. There was no evidence that the facility made any further attempts at notifying [the family members] using all telephone numbers available that [the resident] had been sent to the emergency room at 11:10 AM on September 29, 2017, after she was transferred” to the hospital.

Countryview Terrace
52 Old Route 45
Louisville, IL 62858

Fine:
The State surveyor fined the facility $25,000 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated August 15, 2017, investigators determined the facility had “failed to ensure that the IDPH was notified” about an incident. By law, the facility was required to make a notification “of a hospitalization of [an individual] who was admitted to the hospital on July 31, 2017, after falling on July 28, 2017, and was treated for a subdermal hematoma.” Additionally, the investigators documented a peer-to-peer incident for [one] “incident that occurred since the survey date of June 27, 2016, involving [two residents].”

One incident involved a 67-year-old male patient with “profound mental retardation. His sister who has power of attorney also stated that he fell asleep while talking to her on the phone a couple of days ago. She received the call from the staff of the healthcare group yesterday that he is not himself having some gait problems and shaking.” Also, the resident became incontinent and was taken to the local hospital “where a CT scan showed in a large left subdermal mass with mass effect…the patient underwent a bur hole evacuation of the left side subdural hematoma…”

The state investigators interviewed the facility Administrator on the morning of August 2, 2017, who stated that the “facility staff/register nurse consultant had not reported this incident to her, and she was just being made aware of the fall [the resident] had on July 28, 2017.” The administrator stated that “she had talked to the hospital and they told her it was unlikely the subdural hematoma would have worsened unless there had been a subsequent injury.” The administrator stated that “she had been [that the resident had] fallen on July 28, 2017.” The Social Services Director at the facility also stated on the same day that “she was not made aware of the fall [that the resident] had on July 28, 2007.”

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

Fine:
The State surveyor fined the Medicare/Medicaid-participating 78-certified bed facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated August 24, 2017, investigators noted that the facility had failed to “ensure a resident at risk for choking, did not have access to and did not consume nectar consistency liquids.”

  • Failure to Provide Adequate Supervision to Prevent Avoidable Accidents and Maintain an Environment Free of Accident Hazards

The state investigator noted that the failure by the nursing staff contributed to the resident “being given nectar consistency liquids and aspirating.” The deficient practice by the nursing staff led to the resident’s death after a “choking episode which resulted in aspiration after a Certified Nursing Assistant (CNA) gave the resident nutritional supplements that was left in the dining room table by the nurse.”

In an interview with the Director of Nursing, it was revealed that “she received a call from a Licensed Practical Nurse” on the evening of the incident stating that the resident “had a choking episode at dinner.” The Director stated that the resident “did not have a physician’s order” and that the “nutritional supplement is nectar thick consistency, not honey thick consistency.” The Director stated “I have no idea who put the nutritional supplement on the resident’s table. The nurses administer the nutritional supplements to the residents. The nutritional supplement should never be left for a resident to finish. The nurse is to weight and watched as the resident consumes the supplement.”

Investigators interviewed the hospice physician who stated that “he was notified that the resident had a choking episode” but did not “recall being told that [the resident] had received the wrong fluids.” The resident “had been on increased aspiration precautions such as sitting upright in a chair in the dining room eating the puréed diet.” The vicious and stated that they believed the resident’s “cause of death was aspiration” but would have to check.

Franklin Grove Living & Rehabilitation
502 North State Street
Franklin Grove, IL 61031

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145200&SURVEYDATE=08/18/2017&INSPTYPE=CMPL&profTab=1&Distn=2.4&loc=61031&lat=41.8182244&lng=-89.3037147&dist=50

Fine:
The State surveyor fined the 132-certified bed Medicare/Medicaid-participating facility $25,000 for Type A violations. The investigators currently designate the facility as a one-star rating out of five stars, which is much below the national average.

Violations:
In a summary statement of deficiencies dated August 18, 2017, the investigator determined that the facility had “failed to adequately supervise a new admission with a history of falls and have an individualized intervention in place to safely care for the resident at risk for falls.”

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

The facility’s Nursing Discharge/Transfer Hospital Communication Form dated July 31, 2017, revealed the resident “was alert and confused with more confusion noted at night.” The resident “was a fall risk at the hospital and was using a bed alarm.” The facility’s Fall Log for October 2017 revealed that the resident “slid out of her recliner on August 1, 2017, at 6:30 AM (the next morning after admission) and fell a second time at 11:30 PM (17 hours later) the same day.”

The Director of Nurses stated that the resident’s “daughter brought to the facility a pink incontinent pad for her mother to use.” The Director stated that the facility “does not use these in the recliner as they have been identified as a risk for falls from the recliner. The Director also said she was “not aware how long the pink incontinent pad was in the [resident’s] recliner, but she would have preferred it to have been removed.” However, there was no documentation as to how often the staff monitored the resident [by] the resident’s Care Plan. The facility policy says that the “resident will be checked approximately every 30 minutes.”

On the morning of the incident, a Certified Nursing Assistant stated that the resident “was very confused [and] would keep trying to get up and down from her recliner [and] did not know where she was and would pick at her incontinent briefs.” That same morning, the Licensed Practical Nurse said that the resident “was alert but had periods of confusion [and] at times thought she was at work as a nurse and a hospital and had forgotten she had a broken hip.” The LPN stated that at the time of the incident, the resident “did not have a chair alarm until after the second fall.”

A Review of the Nurses Progress Note dated August 2, 2017, at 7:30 AM revealed that the resident’s daughter “told the nurse she heard a pop from [the resident ‘s] hip. The nurse documented that the left leg was shorter than the right leg. An x-ray report That dated August 2, 2017, shows acute periprosthetic fracture (fractured bone around the surgical hip implant) involving the lateral femoral cortex of the left leg.” This injury was the “same leg originally fractured and just repaired.”

Granite Nursing and Rehabilitation Center
3500 Century Drive
Granite City, IL 62040

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146075&SURVEYDATE=10/19/2017&INSPTYPE=CMPL&profTab=1&Distn=1.1&loc=62040&lat=38.7157973&lng=-90.1307797&dist=50

Fine:
The State surveyor fined the 86-certified bed Medicaid/Medicare-participating facility $27,200 for multiple Type A violations. The investigators currently give the facility a two out of five stars overall rating, which is below average.

Violations:

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

In a summary statement of deficiencies dated October 19, 2017, the state investigator determined that the facility failed to “provide supervision to prevent resident-to-resident altercations and implement interventions after an incident occurred.” The deficient practice by the nursing staff resulted in a resident “inappropriately touching [another resident] causing her to be fearful during the hour-long incident and experiencing nightmares related to the incident.”

In a separate incident, Investigators conducted interviews, made observations and reviewed records to determine that the facility “failed to supervise and implement fall interventions for [one resident] reviewed for falls that resulted in a resident “falling [and] sustaining a fracture of the left femoral neck and the left distal radial metaphyseal fracture.

In the first incident, a review of the resident’s Social History/Psychosocial Assessment dated September 7, 2017, revealed diagnoses of anxiety and physical aggression. The resident’s Initial Screen Identification of Individuals for Wound There is a Reasonable Basis to Suspect a Developmental Disability or a Mental Illness Form, dated September 6, 2017, revealed in part “intellectual disability, other indicators of mental illness.”

The resident’s Incident Care Plan dated September 7, 2017, documented “inappropriately touching another resident. The interventions documented as 15-minute location monitoring, behavior tracking.” However, the resident’s October 2017 Behavior/Intervention Monthly Flow Record revealed “tracking behaviors of pushing wheelchairs into others, disruptive, signs and symptoms of aggression.” Even with this disturbing behavior, there is “no documentation of behavior tracking of [the resident] touching others inappropriately.”

During the investigation, a Physical Therapy Eight stated to another surveyor “to be careful of [the resident] due to his inappropriate touching, because [the resident] was attempting to touch the surveyor’s arm.” The Physical Therapy Aide stated that the resident “has the behavior of grabbing a person’s arm and touching further up the arm until [the resident] was told to stop.” The resident could propel themselves throughout the facility without supervision.

A review of the resident’s Abuse Investigation Statement dated October 5, 2017 documents in part that the resident “came into another resident’s room and inappropriately touched her.” The victim stated that it was “around 6:30 PM when [the allegedly aggressive resident] came into her room and continued to get closer to her [while watching] to watch TV, and the resident replied there is nothing to watch at the time.” Sometime later, the victim stated that the [backspace allegedly aggressive resident “placed his hand on her stomach and began rubbing and would not stop.”

The victim stated that she replied, “No!” At that time, the allegedly aggressive resident stopped. The Executive Director at the facility asked the victim “if she had called for help. A statement documents that the [victim] replied she did not because she was afraid of what [the perpetrator] would have done to her.” The victim stated that “she has had traumatic experiences in her life, one almost near-death experience when she was beaten.” The Social Services Director stated that the resident always leaves her door room open because she is claustrophobic. The incident apparently lasted for more than an hour.

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

In a separate incident, the investigators documented that the “facility failed to notify the physician a resident’s representative of signs and symptoms of infection.” The incident involved the development of a pressure ulcer that had a “foul smell present at the wound bed”. The investigator noted that there is “no documentation in the Departmental Notes that the resident’s physician or resident’s responsible party was notified of the resident’s wound status.

Illini Restorative Care
1455 Hospital Road
Silvis, IL 61282

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145703&SURVEYDATE=09/26/2017&INSPTYPE=CMPL&profTab=1&Distn=0.3&loc=61282&lat=41.4955255&lng=-90.417231&dist=25

Fine:
The State surveyor fined the 92-certified bed Medicare/Medicaid-participating facility the $25,000 for multipleType A violations. Since September 26, 2017, the state investigators gave the facility a two out of five-star rating for health inspections, which is below the national average.

Violations:
In a summary statement of deficiencies dated September 26, 2017, the state investigators determined that the facility had:

  • Failed to Provide Protection for Every Resident from Abuse, Physical Punishment, and Being Separated from Others

Investigators determined that the facility had failed to “ensure that the resident’s rights to be free from exploitation on social media for [one resident]. The failure by the nursing staff and administration resulted in the resident, who was unable to express [themselves], to suffer public humiliation and dehumanization, when a partially closed photo of [the resident] was posted on a social media site.”

The facility’s Alleged Abuse/Neglect Report dated September 10, 2017, revealed that a Certified Nursing Assistant (CNA) reported to the Director of Nurses that another CNA had taken a picture of [the resident] and placed it on social media.” The reporting CNA stated that “she had proof of the picture as [the CNA] had taken a screenshot of it [and then] sent the photo to [the Director of Nursing]. The photo included [the posting CNA’s] name and time.” The resident “was identified as lying in bed, unclothed from the waist up.” The posting CNA stated that “she is unsure how many people saw it (the picture of the resident) on the Internet.”

  • Failure to Provide Care for Residents in a Way That Keeps or Builds Each Resident’s Dignity

The state investigators concluded that the facility had “failed to ensure a resident’s dignity was maintained” and failed to follow the facility’s policies involving mental abuse and photographs dated October 14, 2016. That policy states that:

“A Nursing Home resident has a right to personal privacy of not only his/her own physical body, but also her/his personal space, including accommodations and personal care. Taking unauthorized photographs or recordings of residents using any type of equipment (cameras, smartphone, and other electronic devices) and/or keeping or distributing them throughout multimedia message or on social media networks is a violation of the resident’s right to privacy and confidentiality.”

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

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145655&SURVEYDATE=10/11/2017&INSPTYPE=CMPL&profTab=1&Distn=0.2&loc=62095&lat=38.8675607&lng=-90.0886948&dist=25

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145655&SURVEYDATE=10/19/2017&INSPTYPE=CMPL&profTab=1&Distn=0.2&loc=62095&lat=38.8675607&lng=-90.0886948&dist=25

Fine:
The State surveyor fined the 106-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Since September 14, 2017, the state investigators have given the facility an overall two out of five-stars rating, which is below the national average.

Violations:

  • Failure to Provide Care and Services That Meet Professional Standards of Care

In a summary statement of deficiencies dated September 14, 2017, the state investigator documented that the facility had “failed to perform dressing changes as ordered for [two residents].” In one incident, a resident was observed at 1:45 AM on October 18, 2017, “with a dressing on his inferior groin, which was dated October 17, 2017, but was untimed.” A review of the resident’s MDS (Minimum Data Set) revealed wound evaluations and wound care including wound care provided by a specialist that states “wound of the inferior groin – Continue: dry protective dressing – twice daily… Packing – twice daily.”

However, a review of the resident’s September 2017 Treatment Administration Record (TAR) indicated that the resident’s “dressing changes were not documented as being done” on seven different dates between September 8, 2017, and September 30, 2017. An interview with the resident at 3:00 PM on October 18, 2017, revealed that “he felt that if the dressing changes had been done as ordered, he may have been able to be discharged to home by now.” The resident stated that “his dressings are only done once a day on most days.”

In a separate summary statement of deficiencies dated October 11, 2017, the state investigator documented that the facility had failed to “administer treatments as ordered for two residents. According to the resident’s October 2017 Treatment Administration Record (TAR) documentation revealed that the “resident’s treatment was not done as ordered on the 2:00 PM to 10:00 PM shift on October 1, 2017, October 9, 2017, and October 10, 2017. The dressing changes were also not performed on the 10:00 PM to 6:00 AM shift on October 17, 2017 through October 7, 2017 and [again] on October 10, 2017.

The state investigator interviewed the nurse providing the resident care on October 11, 2017, stated that “the nurses only apply his medicated cream to his face and behind his ears once a day.” However, the resident stated that “the evening shift nurse in the night shift nurse do not apply cream to his face and behind his years” as ordered by the resident’s doctor.

Jerseyville Nursing and Rehabilitation Center
1001 South State Street
Jerseyville, IL 62052

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145733&SURVEYDATE=10/31/2017&INSPTYPE=CMPL&profTab=1&Distn=0.9&loc=62052&lat=39.1122495&lng=-90.3371889&dist=25

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145733&SURVEYDATE=12/27/2017&INSPTYPE=STD&profTab=1&Distn=0.9&loc=62052&lat=39.1122495&lng=-90.3371889&dist=25

Fine:
The State surveyor fined the 160-certified bed Medicare/Medicaid-participating facility $25,000 for multiple Type A violations. Since the last quarter of 2017, state investigators have given Jerseyville Manor an overall two out of five stars rating, which is below the national average.

Violations:
In a summary statement of deficiencies dated October 12, 2017, state investigators determined that the facility had:

  • Failure to Develop and Implement a Program That Investigates, Controls and Keeps Infection from Spreading

The state investigator documented that the facility’s failure “to perform adequate hand hygiene and glove-changing during care for [two residents] reviewed for infection control.” In one incident, documented a 10:05 AM on October 30, 2017, a Certified Nursing Assistant (CNA) “performed perineal care to [a resident]. After cleaning and perineal care, [the CNA] continued to wear soiled gloves to roll [the resident] onto [their] right side, touching [the resident’s] hip with soiled gloves.” The CNA then cleansed the resident’s “buttocks and rectal area [and] while still wearing the soiled gloves, remove the wet pad under [the resident] and placed a clean pad in its place.

  • Failure to Ensure That Every Resident Entering the Nursing Facility without a Catheter Is Not Given a Catheter and Provided Adequate Services to Prevent Urinary Tract Infections

In a separate incident, the investigator documented that the facility had failed “to perform complete incontinence care for [one resident] reviewed for urinary tract infections.” The incident involved interviews, observations and record reviews. At 10:18 AM on October 30, 2017, the resident “was incontinent of urine.” A Certified Nursing Aide (CNA) cleansed the resident’s “buttocks and rectum with disposable wipe, but did not cleanse [the resident’s] size, labia, or urethra.”

The state investigators interviewed the facility’s Director of Nursing on the afternoon of October 30, 2017, who stated that “she would expect staff to perform complete incontinence care, including washing the perineal area and buttocks, when a resident has been incontinent of urine.”

  • Failure to Provide Residents Proper Treatment to Prevent the Development of Pressure Sores or Allow an Existing Bedsore to Heal

In a summary statement of deficiencies dated December 27, 2017, the state investigator documented that the facility’s failure “to perform a dressing change as ordered for treatment of a pressure ulcer.” An observation was made of a resident on December 19, 2017, at 11:07 AM when the dressing on the residents left hip was clean, dry and intact [and] dated December 18, 2017.”

At 1:45 PM that afternoon, a Licensed Practical Nurse (LPN) stated that the resident’s “hospice nurse had changed [the resident’s] dressing to the resident’s left hip today so [the LPN] would not be changing it.” However, the following day at 9:23 AM, the Licensed Practical Nurse removed the resident’s dressing dated December 18, 2017, from the left hip. Observations were made of a “small amount of yellow drainage in the center of the dressing.” Another Licensed Practical Nurse stated that “that dressing should have been changed yesterday, as it was ordered to be changed daily.”

The state investigator interviewed the facility’s Director of Nursing that morning who stated that the resident’s “dressing to the pressure ulcer on the left hip should be changed daily as ordered.”

Lexington Health Care Center – Lombard
South Finley Road
Lombard, IL 60148

https://ltc.dph.illinois.gov/webapp/LTCApp/surveyResults.jsp?eventId=5SS511

Fine:
The State surveyor fined the Medicare/Medicaid-approved 215-certified bed facility $25,000 for mulitiple Type A violations. Since the investigations in the fourth quarter of 2017, surveyors have given Lexington Health Care Center – Lombard an overall one out of five stars rating, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated November 16, 2017, the surveyors noted that the facility had:

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

The state investigators documented that the facility failed to ensure that residents environments remain as free from accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents.” Also, the facility “failed to ensure safe transfers involving one resident. The failure by the nursing staff resulted in a resident “falling from a sling of a mechanical lift and sustaining multiple spinous process fractures.”

The facility’s Incident Report dated November 10, 2017, revealed that while a Certified Nursing Assistant (CNA) “was positioning the patient to put in the chair, [the] patient slipped out of the lift. What was the resident doing one last observed: transferring to or from bed, or chair.” However, this computerized report was not finalized…” The Director of Nursing stated that the incident report is never finalized until the entire investigation is completed.

The resident’s 5:52 PM November 10, 2017 Nurse’s Note revealed that at approximately 7:50 AM, the resident “was sent to the emergency room for evaluation and treatment due to a fall and the patient complained of pain to the head and back.” The report indicates that the patient was admitted to the hospital “with acute multiple fractures to the lumbar spine.”

The Certified Nursing Assistant (CNA) providing the resident care stated that they “came into the room when the patient was already hooked up and everything.” The CNA began lifting the heavy patient and that “as soon as we got directly on the side of the chair, [the resident’s] hands when up, the hook came up, and the resident came down. Only one of the hooks was off, the left side.”

The CNA stated that the resident “is heavier at the top [so the resident’s top] came out, and then the resident’s head hit the wheelchair [while the resident] slid out of the sling. The foot hook came out [while the resident’s] left leg was still on the machine.” Another member of the facility’s staff stated that the back of the resident’s head was bleeding and that the resident was confused and was screaming “my head hurts.”

Parkway Manor
3116 Williamson County Parkway
Marion, IL 62959

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145841&SURVEYDATE=10/03/2017&INSPTYPE=CMPL&profTab=1&Distn=5.5&loc=62959&lat=37.6975961&lng=-88.9222277

Fine:
The State surveyor fined the Medicaid/Medicare-approved 131-certified bed facility $25,000 for multiple Type A violations. Since the inspection in the fourth quarter of 2017, Parkway Manor has maintained a two out of five stars overall rating, which is below average.

Violations:
In a summary statement of deficiencies dated October 3, 2017, the state investigator documented numerous failures at the facility including a:

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

The state investigator documented that the facility’s failure “to provide supervision during toileting for [one resident] reviewed for falls. The deficient practice by the nursing staff resulted in the resident “sustaining multiple skin tears to the right forearm and thigh, a laceration to the left side of the head, and a periprosthetic fracture of the right femur that required surgical repair.”

The incident was revealed to the surveyors that in the early morning hours of September 22, 2017 two Certified Nursing Assistants (CNAs) assisted the resident “from her bed into a wheelchair.” One CNA said that they “took the resident to the bathroom that is located in the resident’s room and helped the resident out of the wheelchair and onto the toilet.” One of the CNAs “walked out of the bathroom and began removing the sheets from the resident’s bed. The other CNA “stepped out of the bathroom and told [her associate] she was going to get a trash bag.” After returning to the toilet area after 45 seconds, she found the resident “sitting on the floor next to the toilet [with their] arm and head bleeding. The resident was saying ‘my arm, my arm.’”

After being transferred to the local hospital, the resident physician stated that the resident had a “fracture [that] was clearly a new injury, caused by trauma.” The resident’s History and Physical Note dated September 22, 2017, revealed that the resident “had been in the hospital a week ago on September 16, 2017, to repair a fracture to the right distal femur, that occurred at home. This same History and Physical Notes that on September 21, 2017, [the resident] was discharged from the hospital and sent to a rehab facility.”

Pinecrest Manor
414 South Wesley Avenue
Mount Morris, IL 61054

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145024&SURVEYDATE=10/11/2017&INSPTYPE=CMPL&profTab=1&Distn=1.8&loc=61054&lat=42.0571009&lng=-89.4553088&dist=25

Fine:
The State surveyor fined the 125-certified bed Medicaid/Medicare-apporved facility $25,000 for multiple Type A violations.

Violations:
In a summary statement of deficiencies dated October 11, 2017, the state investigator documented that the facility had a:

  • Failure to Allow a Resident to Refuse Treatment or Take Part in Formulating an Advanced Directive

The state investigator documented that the facility’s failure “to initiate cardiopulmonary resuscitation plus one a resident had no vital signs or respirations. The resident decided to be a Full Code in case of [an emergency].” The resident “was found unresponsive [but] no resuscitative efforts were initiated by the facility staff. The Immediate Jeopardy began [at the time] when the facility did not initiate CPR on a resident who was a Full Code.”

The incident occurred when a Certified Nursing Assistant (CNA) observed the resident at 10:00 PM and then around 12:30 AM. By approximately 2:30 AM, the CNA found the resident “to be unresponsive and her nail beds appeared bluish in color.” The CNA immediately notified the Registered Nurse on duty of the resident’s condition.” The Registered Nurse at stated that “he had observed a resident at the beginning of the shift at 10:00 PM and approximately one hour later.” The Registered Nurse said that the resident “appear to be fine and made a grunting noise as he flushed her feeding tube.”

The RN stated that “he was notified by the CNA that the resident had possibly died [and] immediately went to the room, grabbing a stethoscope and the resident’s chart and assessed the resident who was “found to have no vital signs.” The RN determined that “the resident had died.” However, the RN never immediately looked at the Practitioner Orders for Life-Sustaining Treatment (POLST) Form to verify code status. The Registered Nurse called for paramedics but stated that the resident was a “Do Not Resuscitate” without looking at the form. The emergency medical team pronounced the resident dead at the facility.

During an interview with the Social Services Director, it was revealed that at the time of the resident’s admission the resident’s family and resident indicated that she would be a Full Code and signed the form to be placed in the chart. The Director stated that full code heart stickers are “placed on the spine of the chart, on the nameplate outside the resident’s room, and the nurses will place a sticker on the MAR plus.” However, this was not done and the Director “could not say why this did not happen.”

  • Failure to Develop and Enforce Policies and Forbid Mistreatment, Neglect or Abuse of Residents

The state investigators identified a deficient practice of the facility when they “neglected to operationalize the policy and procedure for cardiopulmonary resuscitation and provide CPR for resident designated as a Full Code. Investigators also determined the facility failed to “locate and review the code status for [the resident above] when she was found to be unresponsive and without a heartbeat and as a result, [the resident] did not receive any life-saving measures as she had requested.” Consequentially, the resident died as a result of substandard care.

Pleasant View Luther Home
505 College Avenue
Ottawa, IL 61350

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

Fine:
The State surveyor fined the 90-certified bed Medicaid/Medicare-participating facility $25,000 for multiple Type A violations. Since the fourth quarter of 2017, Pleasant View Luther Home has maintained a two out of five stars rating for health inspections.

Violations:
In a summary statement of deficiencies dated December 8, 2017, the state investigators determined numerous deficient practice is by the facility. These failures include:

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

The state investigators acknowledged the facility’s failure to “identify prevent worsening of a pressure ulcer (bedsore) for one of for residents reviewed for pressure ulcers. The deficient practice by the nursing staff “resulted in the development, decline and increase in size of a Stage III pressure ulcer.”

The state investigator conducted interviews and reviewed records to determine that there was “no coccyx pressure ulcer issues or treatments documented.” The resident’s October 20, 2017, Current Care Plan documented “incontinence care, assessment of skin and perineal area, and … give proper hygiene and that [the resident] requires limited to extensive assistance with Activities of Daily Living. No coccyx pressure ulcer issues or interventions were documented.”

When reviewing the resident’s Admission Nursing Evaluation dated October 12, 2017 it was revealed that the resident “had a large bruise to the neck, posterior right hip, redness to bilateral heels, a hematoma to the center of the forehead, and two small abrasions to bilateral collar bones. The Admission Nursing Evaluation documents that [the resident] is continent of bowel and bladder and does not document any issues with [the resident’s] coccyx.”

However, the resident’s MDS (Minimum Data Set) dated October 19, 2017 documents that the resident “was occasionally incontinent of urine infrequently incontinent of bowel.” The document also reveals that the resident “had pain in the last five days and received/or was offered pain medication.” However, this document does not mention pressure ulcers but only being “at risk for pressure ulcers.”

The resident’s October 26, 2017 MDS (Minimum Data Set) documents “an unhealed Stage III or IV pressure ulcer measuring 2.5 cm by 1.2 cm with no depth.” By October 31, 2017, there are documents that the resident has an appointment with the surgeon for surgical debridement of the coccyx pressure ulcer.

Presence Nazarethville
300 North River Road
Des Plaines, IL 60016

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146180&SURVEYDATE=09/27/2017&INSPTYPE=STD&profTab=1&Distn=1.2&loc=60016&lat=42.0488548&lng=-87.8844309&dist=25

Fine:
The State surveyor fined the 68-certified bed Medicaid/Medicare-approved facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated September 27, 2017, the state investigators identified deficient practices is including:

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

The state investigators identified the facility’s failure “to ensure the staff to safely utilize a mechanical lift, which affected one resident.” The deficient practice by the nursing staff resulted in the resident “sustaining and intracranial hemorrhage after slipping out of the mechanical lift sling and hitting her head on the floor. This injury required a seven-day hospital stay.” At 10:35 AM on September 25, 2017 ,the resident “was asked if she had any issues with staff.” The resident “shook head and stated, ‘except when they dropped me on my head. It happened two months ago. They did not think I would make it. I was on hospice and the whole 9 yards. Hospice may be feel helpless. Like they were just waiting for me to die.’”

The facility Resident Incident Report noted that on July 11, 2017, at 9:30 AM, the resident experienced a fall after being” transferred via the manual lift by [two Certified Nursing Assistants (CNAs). While being transferred using the mechanical lift from the bed to the wheelchair, the resident “slid out of the sling on the floor, hitting her head.” The resident suffered an abrasion on the left occipital area of the head. The resident was transferred to the emergency room and stayed at the hospital for seven days.

River North of Bradley Health Care and Rehabilitation Center
650 North Kinzie
Bradley, IL 60915

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146112&SURVEYDATE=12/12/2017&INSPTYPE=CMPL&profTab=1&Distn=0.9&loc=60915&lat=41.1454805&lng=-87.8598861&dist=25

Fine:
The State surveyor fined the Medicaid/Medicare-approved 120-certified bed facility $25,000 for multiple Type A violations. Since the fourth quarter of 2017, River North of Bradley has maintained a one out of five stars rating for health inspections, which is significantly below the national average.

Violations:
In a summary statement of deficiencies dated August 3, 2017, the state investigator document at numerous deficient practice is by the nursing staff and administration. These failures include a:

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

The state investigator documented that the facility’s failure “to ensure that the resident’s care was rendered in a manner to prevent an accident injury to the resident.” The incident involved the use of a mechanical chairlift for transfers in a geriatric chair during a group activity.” On December 7, 2017, the resident “was seated in a geriatric chair with the head of the chair at a 45 degree angle, bolster pillows were in place at each chair arm.” The resident’s “face was turned to the left shoulder away from the front of the room [and their] mouth was open, and [their] jaw was relaxed.” The resident’s feet “were elevated on the chair footrest and pillow. The resident was not participating in the group activity, but instead was sleeping quietly

A week earlier on December 1, 2017, a Registered Nurse stated that he “was called to the resident’s room by the resident’s CNA to see a bruise on the resident. The Registered Nurse stated that the resident had bruises on the breast, torso, down toward the back, [and stated that he] was surprised when he saw the bruise, and I got bigger later in the morning.” The resident “showed no signs of pain to the bruised area.”

During an interview with the facility Administrator, it was stated that “she had been investigating the cause of the bruise and provided documents from the investigation in the reports initial and final reports fax to the Illinois Department of Public Health.” On the afternoon of December 7, 2017, the Administrator stated that “the facility’s investigation of the cause of the bruise show that the likely cause was that the resident was dropped into her chair during transfer.” A review of the statement of the Certified Nursing Assistant will showed that the “resident was in her chair [during the day shift] of November 30, 2017. The CNA said that nobody had assisted her in transferring the resident back into her chair.”

On December 12, 2017, the Administrator stated that “no staff member admitted to direct or indirect knowledge of the cause of the bruise.” The Administrator stated that “the investigation resulted in the termination of a staff member who had been assigned to provide care for the resident.”

Rosewood Care Center of St. Charles
850 Dunham Road
St. Charles, IL 60174

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145980&SURVEYDATE=10/11/2017&INSPTYPE=CMPL&profTab=1&Distn=1.0&loc=60174&lat=41.9169525&lng=-88.2947675&dist=25

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145980&SURVEYDATE=11/21/2017&INSPTYPE=CMPL&profTab=1&Distn=1.0&loc=60174&lat=41.9169525&lng=-88.2947675&dist=25

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145980&

Fine:
The State surveyor fined the 107-certified bed Medicaid/Medicare-approved facility $27,200 for multiple Type A violations. Since the fourth quarter of 2017, Rosewood Care Center of St. Charles has maintained a two out of five-stars rating for health inspections, which is below national averages.

Violations:
In a summary statement of deficiencies dated October 11, 2017, the state investigator documented numerous deficient practices at the facility including:

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

The state investigator identified the Rosewood Care Center’s failure “to ensure one resident was not subjected to sexual abuse from another resident.” The incident involved one resident whose Care Plan revealed they have “impaired memory with decreased safety awareness, is able to propel using a wheelchair, and has a behavior of wandering.”

An observation was made of the resident at 3:50 PM on October 10, 2017 while “lying in bed.” The resident “was pleasant, alert and oriented to name only and had confusion.” The resident “was not able to answer simple questions besides her name.”

On October 10, 2017, at approximately 7:15 AM, a Restorative Aide Staff Member saw a male resident “waiving his hands in the air and calling out ‘hey, hey’.” The Restorative Aide “at first thought [the male resident] was calling for her but saw [the female resident] at the table next to [the male resident]. The female resident “started propelling herself to [the male’s] table. When the [female resident] arrived at the [male’s] table, the male grabbed the female’s right hand with his right hand as if to shake it. The Restorative Aide said the male resident held onto the [female’s hand] and saying, ‘hey, how is it going, yeah, yeah, and continue to hold [the female resident’s] hands while reaching under [the female resident’s blouse and] with his left hand groped and fondled the female resident’s breasts.

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

In a separate summary statement of deficiencies dated November 21, 2017, the state investigator documented the facility’s failure to “implement individualized fall risk interventions for a resident identified as a high fall risk.” The investigator also noted the facility’s failure “to identify and implement new interventions to prevent further falls, [and a failure] to ensure agency staff received training to determine resident transfer status.”

  • Failure to Provide Adequate Care and Assistance to Ensure Residents Can Perform Activities of Daily Living

The state investigator documented in a third summary statement of deficiencies dated December 19, 2017, that the facility had failed to “provide Activities of Daily Living care and grooming. The facility also failed to monitor resident bowel movements (BM) and carry out physician’s orders.”

Sharon Health Care Pines
3614 North Rochelle
Peoria, IL 61604

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=14E322&SURVEYDATE=08/18/2017&INSPTYPE=STD&profTab=1&Distn=2.9&loc=61604&lat=40.7001416&lng=-89.6581073&dist=25

Fine:
The State surveyor fined the Medicaid-participating 116-certified bed facility $25,000 for multiple Type A violations.

Violations:

In a summary statement of deficiencies dated August 18, 2017, the state investigator documented a series of deficient practice is by the administration and nursing staff. These failures include:

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

The investigators documented that the facility had failed to “create and implement fall interventions for [two residents] reviewed for falls. The deficient practice by the nursing staff resulted in one resident “experiencing several falls and eventually being hospitalized for [medical care].”

The facility’s Incident/Accident Report dated 5:20 PM on March 11, 2017, revealed that the resident “stood up from [their] wheelchair at the nurses’ station and fell to the floor, sustained no injuries, and was station close to the nurse for observation.” Thirty minutes later, another notation was made that the resident “stood up again from [their] wheelchair at the nurses’ station, fell to the floor, hitting [their] head, and became unresponsive with unresponsive pupils.” The nursing staff had the resident transferred to the local hospital.

The resident’s Hospital Discharge Summary revealed that the resident had been hospitalized for injuries and was “found to have a cerebral bleed.” The Care Plan Coordinator noted that on August 18, 2017, that there were “no new fall prevention interventions for [the resident’s] November 15, 2016, or March 11, 2017 falls.” The Care Plan stated that they “will update the resident’s fall Care Plan by inputting the fall date and mechanical lift as medical treatments related to injuries but does not include new fall prevention interventions.”

The state investigator interviewed the Director of Nursing at noon on August 17, 2017, who stated “we do not do root cause analysis here, the nurses fill out these Incident/Accident Report Forms, complete the Follow-Up Reports, and forward the forms to the Director of Nursing.

In a separate incident, a different resident’s MDS (Minimum Data Set) dated July 3, 2017 documents that the resident “requires extensive assistance for transfer and ambulation. On August 16, 2017, at 11:20 AM, [that resident] was lying in bed with [their] eyes closed, swelling and dark purple discoloration around [their] entire left eye area, with for intact sutures to [their] left lateral eye area.”

An observation of the resident occurred between noon and 3:10 PM on that day, between 8:30 AM and noon the following day, during cares. At that time, “while sitting in the dining room, and while sitting in the television room, [this resident] repeatedly stood up independently with an unsteady balance and attempted to ambulate with an unsteady gait.”

The state investigator reviewed the facility’s Incident/Accident report forms for this resident between March 13, 2017 and August 10, 2017.” The reports revealed that the resident had “fallen to the floor” with mulitple injuries that include:

  • March 13, 2017 two lip wounds,
  • April 20, 2017, laceration and bruise to the right eyebrow,
  • June 16, 2017, laceration to the upper lip and jaw,
  • July 15, 2017, laceration to the nose and head bruising,
  • August 7, 2017, laceration and hematoma to the right cheek, and
  • August 10, 2017, gash to the left eyebrow.

The report also revealed that on three separate occasions, the resident was transferred to the hospital emergency department to receive sutures. During an interview with the Care Plan Coordinator on August 18, 2017, it was confirmed that “there were no fall prevention interventions for the resident’s falls…”

Smith Village
2320 West 113th Place
Chicago, IL 60643

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145904&SURVEYDATE=10/13/2017&INSPTYPE=STD&profTab=1&Distn=1.8&loc=60643&lat=41.6773775&lng=-87.6538017&dist=25

Fine:
The State surveyor fined the 100-certified bed dedicates/Medicare-approved facility $25,000 for mulitple Type A violations.

Violations:

In a summary statement of deficiencies dated October 13, 2017, the state investigators identified various deficiencies including a:

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

The state surveyors documented the facility’s failure to “implement fall prevention monitoring and interventions to prevent [a resident from falling.]” The failure by the nursing staff resulted in a subsequent fall by the resident with a laceration on the scalp requiring staples, and cerebral hemorrhage (intraventricular hemorrhage).”

The initial admission/transfer discharge logs show that the resident was “initially admitted to the facility (assisted living) and had a fall on October 13, 2016, with a fracture of the left leg. In the skilled unit, the resident had falls on October 21, 2016, October 25, 2016, and April 12, 2017. With the fall on April 12, 2017, the resident had lacerations on the scalp with severe bleeding [that was] repaired with staples and intraventricular hemorrhage.”

Documentation by the Primary Care Physician at 3:45 PM on October 12, 2017, that because of the cerebral hemorrhage, anticoagulant was kept on hold and Vitamin K was given. When a resident is at high risk for falls, the resident should not be kept on anticoagulants, or it depends on the clinical condition of the resident and judgment of the cardiologist. Or the staff should have close supervision of the resident to avoid falls.”

The facility’s Restorative Director made a statement to investigators on the morning of October 13, 2017. The Director reported that “after the fall on October 25, 2016 in the dining room, the fall prevention interventions in place were to make sure that she [the resident] was not left alone in the dining room and to monitor closely[ when] in the dining room. But, the number of falls were increasing in number, [and the resident] was not able to be redirected, if the staff had monitored her closely, we could have avoided the fall and injury on April 12, 2017.”

Spring Creek Nursing and Rehabilitation Center
777 Draper Avenue
Joliet, IL 60432

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146172&SURVEYDATE=12/05/2017&INSPTYPE=CMPL&profTab=1&Distn=0.5&loc=60432&lat=41.5397073&lng=-88.0460894&dist=25

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146172&SURVEYDATE=11/08/2017&INSPTYPE=STD&profTab=1&Distn=0.5&loc=60432&lat=41.5397073&lng=-88.0460894&dist=25

Fine:
The State surveyor fined the Medicare/Medicaid-participating 168-certified bed facility $25,000 for multipleType A violations. Since the fourth quarter of 2017, Spring Creek Nursing and Rehabilitation Center has maintained a two out of five-stars rating for health inspections, which is below the national averages.

Violations:
In a summary statement of deficiencies dated November 8, 2017, state investigators identified a series of deficient practices at the nursing facility which include:

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

The state surveyors identified a facility’s failure to “provide assistance to a resident identified as at high-risk for falls and needing to person physical assistance during transfer to promote resident safety.” The deficient practice by the nursing staff resulted in the resident “falling during one staff assist transfer. The resident was sent to the hospital.

The Facility Initial and Final Reportable Report identified the incident as involving the resident who “had a fall incident on January 26, 2017, at 3:30 PM. The report showed that at approximately 3:30 PM, the resident Certified Nursing Assistant (CNA) was using her gait belt to transfer the resident from the wheelchair to the toilet. Upon transfer, the resident’s knees buckled, the resident lost her balance, and the CNA lowered the resident to the floor.

The Certified Nursing Assistant immediately called for the nurse.” The resident complained of pain and was transferred to the hospital to care for her injuries. The Director of Nursing stated that the accident with injuries could have been prevented had the Certified Nursing Assistant (CNA) followed protocols and had the assistance of another CNA during the transfer.

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

In a separate summary statement of deficiencies dated December 5, 2017, the state investigators identified the facility’s failure to “position a resident off her wound, do pressure ulcer assessments in a timely manner, and develop individualized care plans with specific nursing interventions to manage or promote the healing of the resident’s wounds.”

According to the Wound Care Physician, the “resident needs to be positioned so no pressure is on her wound and turned frequently. Two hours or less. Because of her amputations … she needs to be positioned with wedge cushions and pillows to keep [the resident] off her back. Keeping pressure off her back can promote healing of her wound.”

However, that same day, the pressure sore “had increased in size. It was 0.8 cm x 0.7 cm the day before, but now measured 3.0 cm x 2.5 cm. It is getting worse because the resident is not able to move or turn herself and she needs staff to reposition her.” The investigators determined that the facility’s Pressure Ulcer and Wound Prevention/Management Program dated December 5, 2017, was not followed in providing skincare for the resident.

St. Anthony’s Nursing and Rehabilitation Center
767 30th Street
Rock Island, IL 61201

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145387&SURVEYDATE=09/15/2017&INSPTYPE=CMPL&profTab=1&Distn=1.6&loc=61201&lat=41.4898568&lng=-90.5730713

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145387&SURVEYDATE=10/14/2017&INSPTYPE=CMPL&profTab=1&Distn=1.6&loc=61201&lat=41.4898568&lng=-90.5730713

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145387&SURVEYDATE=11/15/2017&INSPTYPE=CMPL&profTab=1&Distn=1.6&loc=61201&lat=41.4898568&lng=-90.5730713

Fine:
The State surveyor fined the 130-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Since the fourth quarter of 2017, Saint Anthony’s Nursing and Rehabilitation Center has maintained a one out of five stars overall rating, which is significantly lower than the national average.

Violations:
In a summary statement of deficiencies dated August 18, 2017, the state investigators identified the failure of the facility “to notify the family or physician” of a change in their condition. These failures include:

  • Failure to Immediately Notify the Resident’s Doctor or Family Member of a Decline in Their Health

The surveyors reviewed a Nurse’s Report dated September 12, 2017, that revealed the resident “was observed to fall face first out of the wheelchair in the hallway with a minor injury of a cut above the eye [and was] sent to the local emergency room.” The state investigators interviewed a family member on the afternoon of September 13, 2017, who stated that they “did not know [the resident] was sent to the hospital until the hospital called the [resident’s attending physician].”

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

In a separate summary statement of deficiencies dated October 14, 2017, the state investigators identified the facility’s failure “to prevent a fall for [one resident who] was left alone on the toilet and fell.” The resident “sustained a left distal femur fracture.” The incident occurred when a Certified Nurses’ Aide assisting the resident during toileting “stepped out of the bathroom to obtain additional staff to assist with a transfer. When the staff returned to the bathroom, the resident was noted in a sitting position on the bathroom floor next to the toilet.” The resident was “assessed and noted to have hip discomfort.”

The nursing staff sent the resident to the emergency room for an x-ray that noted a “left distal femoral fracture” that required surgical intervention. The surveyors documented an immediate intervention because the resident should “not have been left unattended on the toilet.”

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

In a third summary statement of deficiencies dated November 15, 2017, the state investigator documented the facility’s failure to ensure that a resident “was not verbally abused by a Certified Nursing Assistant (CNA).” The failure by the nursing staff resulted in the resident “having extreme anxiety requiring medication to alleviate [their] anxiety.”

The surveyors interviewed the identified Certified Nursing Assistant (CNA) on November 8, 2017, who stated “I have worked here for the past six years. At work full-time on the fourth floor. That resident “is an instigator and a liar.” Both that resident and another CNA “are always ganging up on me. I remember the night that [the resident] and I got into it.”

Sunrise Skilled Nursing & Rehabilitation
333 South Wrightsman Street
Virden, IL 62690

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145783&SURVEYDATE=09/01/2017&INSPTYPE=CMPL&profTab=1&Distn=0.7&loc=62690&lat=39.4965558&lng=-89.7661527&dist=25

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

Violations:
In a separate summary statement of deficiencies dated September 1, 2017, the state investigators identified a failure at the facility “to complete an initial evaluation and ongoing assessment for the use of physical restraints for [two residents at the facility].”

  • Failure to Ensure Residents Remained Free from Unauthorized and Unnecessary Physical Restraints

The state investigators observed the resident “sitting in a motorized wheelchair with the seatbelt engaged at 8:30 AM on August 29, 2017. At that time, the Licensed Practical Nurse providing the resident care asked the resident “to demonstrate the removal of the seatbelt.” However, the resident “was unable to demonstrate seatbelt release.” Approximately 15 minutes later, a Certified Nursing Aide (CNA) asked the resident “to demonstrate the removal of the seatbelt.” The resident “was still unable to demonstrate a seatbelt release.”

The surveyors conducted an interview with the facility Assistant Director of Nursing on the morning of August 30, 2017, who stated that “there was no physician order or ]restraint assessment for [the resident’s] use [of a restraint] while in a motorized wheelchair.” The Assistant Director also stated that “the restraint assessment and consent was not obtained until August 29, 2017, and the physician’s order was not obtained until” that day “August 30, 2017.”

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

In a summary statement of deficiencies dated September 1, 2017, the state investigators identified a facility failure to “assess, monitor the effectiveness of interventions and implement interventions while providing adequate supervision for [two residents reviewed for falls].” The deficient practice by the nursing staff resulted in one resident “sustaining an epidermal hematoma, multiple facial fractures, and a nondisplaced fracture of the spine.”

The investigator reviewed the resident’s MDS (Minimum Data Set) and Care Plan dated March 9, 2016, and revised March 7, 2017, that said that the resident will “resist care at times due to a self-transferring safety issue.” The resident “removes or alarming will fold it so you the legal as were a will not go off or hide it.” The Care Plan also documented that the resident “had repeated attempts to walk unassisted.”

The revise Care Plan document that the resident “had a fall with injury to her left hand [and] was at risk for falls and injuries related to osteoporosis, Parkinson’s, pain, weakness, and having a history of falls.” The Care Plan listed nine documented falls between January 10, 2017 and August 16, 2017, and the only interventions listed was for the “August 16, 2017 fall [when the resident was toileting].”

The Care Plan never documented the August 21, 2017 fall where the resident “suffered an epidermal hematoma, multiple facial fractures, and a nondisplaced fracture of the spine, or list any interventions related to [that] fall.” On the following day, information was updated to the resident’s Care Plan that stated that the resident “refuses care from certain staff members at times and tells them to get out of her room.”

Symphony at the Tillers
4390 Route 71
Oswego, IL 60543

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146034&SURVEYDATE=10/27/2017&INSPTYPE=CMPL&profTab=1&Distn=2.7&loc=60543&lat=41.658687&lng=-88.314212&dist=25

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146034&SURVEYDATE=08/16/2017&INSPTYPE=CMPL&profTab=1&Distn=2.7&loc=60543&lat=41.658687&lng=-88.314212&dist=25

Fine:
The State surveyor fined the 105-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Since the fourth quarter of 2017, Symphony at the Tillers has maintained a two out of five-stars rating for health inspections, which is significantly lower than the national average.

Violations:
In a separate summary statement of deficiencies dated October 27, 2017, the state investigators identified a facility failure “to provide adequate supervision for a resident at high risk for falls.” The deficient practice by the nursing staff resulted in the resident “falling sustaining a traumatic brain injury/acute subdermal hemorrhage requiring emergent craniotomy surgery.”

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

The facility Incident/Accident Report documented that on April 13, 2017, at approximately 11:30 PM “staff attended to the alarm that when often noted the patient on the floor with bleeding on the patient’s head.” A Certified Nursing Aides (CNA) stated, “I heard the alarm sounding, so I went to the room right away as I was turning off the alarm.” At that time, the resident “fell backward … [The] bathroom door opened up [and the patient] fell backward to the floor.” The facility Fall Event stated that the resident was seated on the toilet just before falling. EMT transported the resident to the local medical center because of the “visible bleeding to the back of the head.”

Investigators reviewed the resident’s interim Care Plan dated April 13, 2017, that revealed that the resident has a “history of falls, increase weakness; Interventions – fall protocol, safety alarms as indicated; Goal – Will be free from serious injury from falls during [their] stay.”

In a separate summary statement of deficiencies, the state investigator documented a facility failure “to ensure adequate supervision for a resident deemed to be at risk for elopement [wandering away from the facility].” The deficient practice by the nursing staff led to the resident “eloping from the facility in the early morning hours and being found and brought back by the police.”

Symphony of Decatur
(also known as Generations at McKinley Place)
2530 North Monroe Street
Decatur, IL 62526

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=146003&SURVEYDATE=08/24/2017&INSPTYPE=CMPL&profTab=1&Distn=3.5&loc=62526&lat=39.9049392&lng=-88.9892448&dist=25

Fine:
The State surveyor fined the 195-certified bed Medicaid/Medicare-approved facility $25,000 for multiple Type A violations. Since the fourth quarter of 2017, the facility has maintained a one out of five-star rating for health inspections, which is significantly lower than the national average.

Violations:
In a separate summary statement of deficiencies dated October 24, 2017, the state investigators identified the facility’s failure to “attempt to a gradual dose reduction, provide justification for the use and continued use of antipsychotic medication, and to have a Plan of Care for an antipsychotic medication for [one resident].”

  • Failure to Ensure That Every Resident’s Drug Regimen Is Free from Unnecessary Medications

The state investigator reviewed a resident’s Nursing Notes dated March 30, 2017, that revealed a new order received from the physician to help treat the resident’s behaviors. The documentation revealed that the Physician “was in the building and witness behaviors of hitting and striking out the staff.” However, the resident’s Behavior Tracking documentation dated from April 1, 2017, through April 21, 2017, “does not document episodes of hitting the staff.” The confusion in the documentation was confirmed by the Quality Assurance Nurse just before noon on August 21, 2017, and stated that “there are no behaviors of … hitting the staff documented in [the resident’s] medical record after March 31, 2017.”

Additionally, a review of the resident’s Medical Record “does not document an attempt to reduce or discontinue the resident’s order for [antipsychotic medication prescribed at] 0.5 mg every day.”

  • Failure to Provide Sufficient Care for Residents Requiring Special Services

In a summary statement of deficiencies dated August 24, 2017, the state investigator documented the facility’s failure to “immediately answer a ventilator machine alarm for [one resident] reviewed for specialty care.” The deficient practice by the nursing staff resulted in the resident “requiring cardiopulmonary resuscitation (CPR).”

Valley Hi Nursing Home
2406 Hartland Road
Woodstock, IL 60098

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145652&SURVEYDATE=08/23/2017&INSPTYPE=CMPL&profTab=1&Distn=4.6&loc=60098&lat=42.3439139&lng=-88.4403883&dist=25

Fine:
The State surveyor fined the Medicare/Medicaid-participating 128-certified bed facility $25,000 for multiple Type A violations. Since the fourth quarter of 2017, Valley Hi Nursing Home has maintained a two out of five-star rating for health inspections, which is below the national average.

Violations:

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

In a separate summary statement of deficiencies dated August 23, 2017, the state investigators identifed a failure the facility “to ensure adequate supervision was provided for a resident with dementia who is at risk for choking.” The deficient practice by the nursing staff resulted in the resident “choking on a hotdog and dying of acute fatal cardiopulmonary arrest secondary to respiratory arrest.” The state investigator placed the facility in Immediate Jeopardy that began at the moment the resident “ate a regular consistency hotdog for dinner, choking and later dying at the local hospital.”

The Illinois Department of Public Health accepted the facility’s Final Report documenting the incident that occurred “in the second-floor dining room [when the resident] started choking during the resident meal.” The resident “was witnessed to be in distress by a nurse, and he pointed to his throat and was unable to speak or breathe. The staff in the dining room immediately responded and began abdominal thrusts which were not successful. The resident was taken to his room the staff began chest compressions and suctioning. Food particles were dislodged at that time. Cardiopulmonary resuscitation (CPR) was continued and a palpable femoral pulse was obtained. Upon arrival of paramedics, [EMT] took over and the resident was taken to the emergency room… [Where the resident] passed away at 8:00 PM in the hospital.”

An investigation determined that the resident “was given the proper diet consistency of mechanical soft [food] when he was given his hotdog that evening. Multiple staff also indicated that [the resident] has a history of taking food off his tablemate’s plates, which may have been how he had eaten nonmechanical soft hotdog, causing [the resident] to choke.”

Winchester House
1125 North Milwaukee Avenue
Libertyville, IL 60048

https://www.medicare.gov/nursinghomecompare/InspectionReportDetail.aspx?ID=145460&SURVEYDATE=11/06/2017&INSPTYPE=STD&profTab=1&Distn=1.1&loc=60048&lat=42.2868698&lng=-87.9432837&dist=25

Fine:
The State surveyor fined the 224-certified bed Medicare/Medicaid-approved facility $25,000 for multiple Type A violations. Since the fourth quarter of 2017, Winchester House has maintained a two out of five-star rating for health inspections, which is significantly lower than the national average.

Violations:

In a summary statement of deficiencies dated November 6, 2017, surveyors for the state identified a failure the facility “to assess a resident’s left leg deformity and increased pain following a fall on July 25, 2017.” The deficient practice by the nursing staff contributed to the resident “experiencing untreated pain and a delay in treatment for two days for a fractured left femur.”

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

The state investigators reviewed the July 25, 2017 Resident Accident Report that revealed little 7:55 PM the resident “fell from her wheelchair on to her left side in the solarium. The report shows that [the resident] can move all the upper extremities and has no apparent injury.” The documentation stated that the resident “is unable to verbalize what happened [but] was lifted using a mechanical lift back into her wheelchair.” After the incident, the nursing staff performed follow-up neuro-checks.

On July 27, 2017, a Certified Nursing Assistant (CNA) reported to the Memory Care Director that the resident “was having pain and something was not right.” The Director said that the resident’s “left leg looked crooked and [the resident] was verbalizing pain and grimacing.” The Director stated that “nursing did not report to her [the resident’s] condition [and that when she found out she then notified the resident’s physician of the resident’s pain.

In a separate incident documented on the same statement of deficiencies, surveyors noted the facility’s failure “to maintain a safe environment by not securing bleach wipes, hydrogen peroxide wipes, and shampoo/body washed in a safe manner.” The deficient practice by the employees at the facility “failed to reposition the resident in a safe manner.”

The incident involved a resident in the dementia care unit who on the morning of August 31, 2017, was “observed seated in the lounge chair area and near the nursing station on the dementia care unit. There was no staff present in the area.” The following morning on November 1, 2017 “during the environmental tour, two built-in storage cabinets in the nurse station were unlocked. The cabinets contain one container of germicidal bleach wipes, one container hydrogen peroxide wipes, and two bottles of shampoo/body washed. All three items stated, “keep out of the reach of children” on the label.” During the tour “there was no staff present in the area.” The Maintenance Director confirmed at noon on that same day that “the cabinets stay open at all times.”

  • Failure to Develop, Implement and Enforce Programs That Investigate, Control and Keep Infections from Spreading

The state investigators identified the facility’s failure “to dispose of soiled incontinent briefs and remove gloves and wash hands after providing care to prevent cross-contamination.” An observation was made of a Certified Nursing Assistant (CNA) on the early afternoon of October 30, 2017, who “removed incontinent briefs soiled with stool from [a resident] and placed it on the floor.” The CNA “picked up debris from the floor and placed it in the resident’s bedside chair in the top of a jacket.” During an interview with the Director of Nursing on November 1, 2017, it was revealed that “soiled briefs should be placed in a bag.”

In a separate incident occurring on October 30, 2017, a Certified Nursing Assistant (CNA) was observed transferring a resident “to the toilet using a mechanical lift. After [the resident urinated, the CNA wiped the resident’s peri area. Without removing gloves and hand washing, [the CNA]:

  • Applied barrier cream to [the resident’s] bottom,
  • Applied an incontinence brief, pulled up and buttoned [the resident’s] pants,
  • Pushed the button on the mechanical lift to lower [the resident] to the wheelchair,
  • Disconnected and removed the sling from behind [the resident],
  • Moved the mechanical lift to the other side of the room and,
  • Put on [the resident’s] footrests.”

The state investigator interviewed the Certified Nursing Assistant the following day who stated that “handwashing should be done after cleaning a resident.”

Additional Information

The CDC (Centers for Disease Control and Prevention) update their quarterly rating system on every facility in Illinois by ranking the facility’s overall performance. The specific information involves protecting every resident’s safety, health and well-being. Family members often use the effective grading system to become knowledgeable of where to place a loved one who requires the highest level of personalized hygiene assistance and medical care. This information is important because nearly every nursing facility that was recently cited for providing substandard care at a severe or extreme level continues to provide services and care to Illinois residents.

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