Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Chicago Ridge during CMS and state inspections, most recent first.
A resident with vascular dementia, who was cognitively intact and previously described as calm and cooperative, was sent to the hospital for agitation and was not allowed to return based on behavior concerns decided by the Administrator and DON. The facility could not provide a physician assessment or psychiatric reassessment supporting that the resident could not be safely cared for, and the primary physician reported no evaluation had occurred. There was no written discharge notice, no discharge planning documentation, and no evidence the resident or representative was informed of appeal rights, despite facility policies requiring adherence to bed hold/readmission rules and proper discharge planning once a physician discharge order is obtained.
A resident with vascular dementia, CKD, CHF, A-fib, and diabetes did not have a documented physician visit within the required 60-day interval before a hospital transfer. Record review showed only an NP progress note, with no evidence that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed the resident’s medical management. The DON could not produce documentation of a timely physician visit, and the primary physician reported having neither seen the resident nor having records of NP visits, noting the last physician notes he saw were from another physician many months earlier. This failed to meet federal requirements and facility policy for physician visits and oversight.
A resident with multiple complex medical conditions and a gastrostomy tube had a physician order for continuous Osmolite 1.5 at 80 ml/hr with specified water flushes. During surveyor observation, an agency RN had the feeding pump set at 100 ml/hr and confirmed this rate, while the resident reported the nurse had increased the rate earlier. Review of the electronic record showed the ordered rate was 80 ml/hr, and the RN then reduced the pump setting to match the order. This resulted in the resident receiving enteral nutrition at a higher rate than prescribed, contrary to the facility’s enteral feeding policy and nursing job descriptions requiring adherence to physician orders.
A resident with a g-tube and complex medical conditions, including malignancies, COPD, CKD, and documented gastrostomy status, had a care plan and physician order requiring daily cleansing of the g-tube site with normal saline and application of a dry dressing. The order was not properly transcribed onto the Treatment Administration Record, and there was no documentation that g-tube site care was provided over multiple days. The resident reported that staff did not consistently clean the site or replace the dressing, and observation revealed a large amount of brownish-blackish crust around the stoma with no dressing in place. When the ADON and an agency LPN assessed the site, they acknowledged it should be cleansed and covered, and the resident exhibited pain on assessment, while facility policy and nurse job descriptions required daily stoma care and documentation of prescribed treatments.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
A resident with complex medical needs was financially exploited when a CNA stole the resident's credit card and made unauthorized purchases exceeding $1,000. The theft was discovered by the resident's family, who reported it to facility administration and law enforcement. Investigation confirmed the CNA's involvement, resulting in criminal charges for financial exploitation.
The facility failed to provide scheduled showers and grooming for residents dependent on staff for ADLs, affecting four residents. One resident with a pressure ulcer was left in urine and feces, while another reported never receiving a shower since admission. Documentation of showers or refusals was inconsistent, leading to the deficiency.
A resident at high risk for skin impairments developed a new moisture-associated skin disorder and experienced deterioration of an existing pressure ulcer due to the facility's failure to provide timely incontinence care. Despite being on a low air loss mattress, the resident was found soaked in urine and feces, and her call light was not answered. The facility did not adhere to its policies for skin care and incontinence checks, leading to significant harm.
The facility failed to label and store medications, such as insulin and inhalers, according to professional principles. Observations revealed that several insulin pens and inhalers on medication carts and in a medication room were not labeled with open dates, contrary to the manufacturer's guidelines. Staff interviews confirmed awareness of the requirement to date medications upon opening and discard them as recommended. This issue affected residents with conditions like Type 2 Diabetes Mellitus and COPD.
The facility failed to maintain proper sanitizer concentration in the kitchen's sanitation bucket, with test results showing levels significantly below the manufacturer's recommended range. This issue, observed during a survey, affects 158 residents who receive food from the kitchen, as improper sanitation can lead to foodborne illnesses. The Dietary Aide admitted to estimating the sanitizer solution, and the facility was unable to provide the manufacturer's dilution instructions.
The facility failed to ensure call lights were within reach for four residents, as observed on a specific date. Despite the facility's policy and care plans requiring accessible call lights, they were found on the floor, making them inaccessible. Staff confirmed the expectation for call lights to be within reach, highlighting a lapse in policy adherence.
The facility failed to adhere to infection control practices, including improper handling of respiratory equipment and inadequate disinfection of medical equipment between resident uses. A nebulizer mask was left uncovered, and a nurse did not disinfect equipment between residents. Additionally, staff did not follow proper procedures for residents on transmission-based precautions, such as wearing PPE and performing hand hygiene.
A resident with a fractured hip from a fall in the facility did not receive timely skilled therapy services as ordered by the physician. The resident, who was a fall risk, was initially hospitalized for chest pain and later diagnosed with fractures. Upon readmission, therapy services were delayed due to insurance approval processes, and the facility staff were unaware of the fracture diagnosis until after readmission. The facility lacked a policy on therapy services, leading to a deficiency in coordinated care.
Two residents at high risk for falls experienced incidents due to inadequate safety interventions. One resident, admitted for rehabilitation, fell while reaching for a phone, resulting in a laceration. Another resident fell during care due to improper positioning. The facility's fall prevention guidelines were not adequately followed, leading to these incidents.
A facility failed to refer a resident for a PASRR Level 2 screening after a new diagnosis of major depression was made. The Social Service Director was unaware of the diagnosis until the survey, despite the Administrator claiming to have informed her. The resident had a PASRR Level 1 screening before admission, but the facility policy requires updated screenings for new mental health diagnoses.
The facility failed to supervise two residents during medication administration, leaving them to self-administer without authorization. An LPN left medication with a resident during breakfast, and an RN left a resident with medication unattended. Additionally, the facility did not maintain accurate controlled substance records, with missing signatures and discrepancies in medication counts.
The facility failed to document incontinence care every shift for two residents dependent on staff for bowel and bladder incontinence. A review of records showed a lack of documentation indicating care was provided at least once per shift. Family members reported instances where residents were left soaked in urine, and the Director of Nursing confirmed the expectation for CNAs to document care per shift.
A resident with hemiplegia and hemiparesis developed a new stage II pressure ulcer despite being at risk and dependent on staff for care. The facility's failure to prevent this was linked to potential issues with turning, repositioning, and treatment plans, although no nutritional concerns were noted. Initial skin alterations were documented but progressed to a pressure ulcer, indicating insufficient preventive measures.
A facility failed to replace a damaged call light cord with exposed wires in a resident's room, which was identified during a survey. The resident, who had a femur fracture and cognitive communication deficit, was discharged before the issue was discovered. A family member reported the hazard, and a staff member removed the cord after being informed. The facility's policy requires the removal of hazardous items to ensure safety.
A resident with a history of falls and cognitive deficits sustained a foot fracture after attempting to toilet herself due to delayed assistance from staff. The facility failed to complete required fall risk assessments and did not provide timely toileting assistance, leading to the resident's fall and injury.
A resident with end-stage renal disease experienced severe complications, including sepsis and peritonitis, due to the facility's failure to properly manage her peritoneal dialysis catheter. The resident was found with a missing cap on her catheter, leading to an infection that required hospitalization and a switch to hemodialysis.
Failure to Honor Return Rights and Complete Required Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to return following hospitalization and to conduct proper discharge procedures. An older adult resident with vascular dementia, documented as cognitively intact with a BIMS score of 14/15 and described in an 8/31/2025 psychiatric evaluation as pleasant, calm, cooperative, and without behavioral issues, was transferred to the hospital on 9/29/2025 after exhibiting agitation and did not return. On interview, the DON stated that she and the Administrator decided not to allow the resident to return due to behavior concerns. The facility was unable to provide any physician assessment determining that the resident could not be safely cared for in the facility, and the resident’s primary physician confirmed he had not seen the resident and had no record of evaluation. No documentation was provided showing a psychiatric reassessment following the behaviors cited by the facility, and there was no change in condition noted in the resident’s medical record. Record review revealed no written discharge notice, no discharge planning documentation, and no evidence that the resident or representative was informed of appeal rights. When surveyors requested any and all documentation or assessments used in determining the resident’s involuntary discharge, none were provided. This failure occurred despite facility policies stating that the facility would adhere to federal regulations on bed hold and readmission, including permitting residents transferred for hospitalization to return to the first available bed after exceeding the bed hold period, and that proper discharge planning and instructions would be conducted once a discharge order is obtained from the attending physician.
Failure to Ensure Timely Physician Visits and Oversight of NP Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident and the attending physician had face-to-face visits within the federally mandated and facility-required 60-day timeframe. The resident, an older adult with vascular dementia, chronic kidney disease, congestive heart failure, atrial fibrillation, and diabetes, was transferred to the hospital on 9/29/2025 and did not return. Record review showed no documentation of a physician visit for more than 60 days prior to this hospital transfer, and the DON could not provide evidence of a required physician visit when requested on 1/24/2026. The only documentation provided was a nurse practitioner (NP) progress note dated 2/17/2025, with no documentation that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed or directed the resident’s medical care. During interview, the primary physician stated that he had not seen the resident, had no records of his NP seeing the resident, and that the last physician notes he saw in the electronic medical record were from another physician’s services dated 2/17/2024, adding that he would not see a resident who belonged to another physician. The facility’s own policy requires residents to be seen by a physician at least every 60 days with an evaluation of the resident’s condition and total program of care, which the facility was unable to demonstrate occurred within the required timeframes. The facility was therefore unable to show compliance with federal requirements and its own policy for timely physician visits and physician oversight of NP services for this resident.
Failure to Follow Physician Order for Enteral Feeding Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of quality for a resident receiving enteral nutrition. The resident is an adult male with multiple complex diagnoses, including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, gait and mobility abnormalities, gastrostomy status, and several psychiatric conditions. His BIMS score of 11 indicated moderate cognitive impairment. According to the Medication Administration Record for January 2026, the physician’s order dated 01/07/2026 specified continuous enteral feeding with Osmolite 1.5 at 80 ml/hr for a total feed volume of 1920 ml over 24 hours, with water flushes at 40 ml/hr for a total flush volume of 960 ml over 24 hours. Facility policy for enteral tube feeding care required the nurse to check the POS/MAR for the enteral feeding order, including formula, type, rate, and duration. On 01/17/2026 at 10:48 a.m., the resident was observed awake and alert in bed with the gastrostomy tube feeding infusing at 100 cc/hr of Osmolite 1.5. The resident stated that the nurse had changed his feeding rate to 100 earlier that morning. At 12:18 p.m., the feeding was still infusing at 100 cc/hr. At 12:20 p.m., an agency RN (V15) confirmed to the surveyor that the feeding pump was set at 100 cc/hr. After reviewing the resident’s order in the electronic record (PCC/PointClickCare), V15 acknowledged that the ordered rate was 80 cc/hr and stated that the rate needed to be changed to match the doctor’s order. At 12:25 p.m., V15 adjusted the feeding rate from 100 cc/hr to 80 cc/hr, stating that they were supposed to follow the physician’s order. This sequence of events shows that the resident received enteral feeding at a rate higher than ordered, contrary to the facility’s enteral feeding policy and the job descriptions for floor nurses, which require adherence to physician orders and established nursing policies and procedures.
Failure to Provide Ordered G-Tube Site Care and Maintain Clean, Dressed Stoma
Penalty
Summary
The deficiency involves the facility’s failure to follow its own enteral tube feeding care policy and physician orders for a male resident with a gastrostomy tube (g-tube). The resident, admitted with multiple diagnoses including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, bipolar disorder, and documented gastrostomy status, had a care plan dated 11/6/25 indicating he was receiving gastric tube feeding due to atresia of the esophagus with tracheoesophageal fistula and was at risk for infections, fluid overload, dehydration, and aspiration pneumonia. The care plan included an intervention to check the g-tube site for signs and symptoms of infection and notify the physician. An order dated 1/05/2026 at 1:30 p.m. directed staff to cleanse the enteral tube feeding site with normal saline and apply a dry dressing, and the facility’s policy required the g-tube stoma site to be cleansed and covered with dry gauze daily. Record review showed that this g-tube site care order was not transcribed onto the scheduled area of the Treatment Administration Record, and there was no documentation that g-tube site care was performed from 1/5/2026 through 1/16/2026. Nursing progress notes for 1/5/2026 also contained no documentation of g-tube care. During an observation on 1/16/2026 at 1:18 p.m., the resident reported that staff were supposed to clean his g-tube site and apply a dressing but did not do so consistently, stating that sometimes they cleaned it and sometimes they did not. He reported that a nurse removed the gauze the previous day and did not clean the site or replace the dressing. The surveyor observed a large amount of brownish-blackish crust encircling the g-tube stoma and noted that there was no dressing in place. When the ADON assessed the g-tube site at 1:36 p.m. on the same day, she stated that the site should be covered and appeared to need cleaning due to crust build-up; the resident winced in pain and stated the area was sore. After the ADON left, the resident stated that because staff did not clean his g-tube site, he would clean it himself with alcohol and that removal of the gauze the previous day had hurt. Later, an agency LPN entered the room and stated she had not changed the dressing because it was changed on night shift, but acknowledged that the g-tube was supposed to be cleansed with normal saline and gauze applied, and that the site had crust around it. The DON stated that nurses should be changing the g-tube dressing daily, ensuring the area is cleaned, and documenting it on the TAR or MAR, consistent with the facility’s enteral tube feeding care policy and the floor nurse job descriptions for LPNs and RNs, which require administering and supervising prescribed treatments such as tube care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Resident Financial Exploitation by Facility Staff
Penalty
Summary
A resident with multiple medical conditions, including a history of femur fracture, major depressive disorder, diabetes, COPD, hypertension, anemia, and generalized anxiety, was admitted to the facility and later became the victim of financial exploitation. The resident's family member discovered unauthorized charges totaling over $1,000 on the resident's credit card, which had been stolen. The charges were made at local restaurants and stores, and the card was never returned to the resident. The family reported the incident to the facility and filed a police report, providing documentation of the charges and the police report number to the facility administrator. Investigation revealed that a CNA who worked on the same floor as the resident during the relevant period was identified as a suspect. Security camera footage and police investigation led to the arrest and felony charge of financial exploitation against the CNA. The facility's abuse and neglect policy, which prohibits misappropriation and exploitation of resident property, was not adhered to, resulting in the resident's loss of property and financial exploitation by facility staff.
Failure to Provide Scheduled Showers and Grooming for Residents
Penalty
Summary
The facility failed to ensure that staff provided scheduled showers and grooming for residents dependent on staff for Activities of Daily Living (ADLs). This deficiency affected four residents, who were observed to have unmet hygiene needs. One resident, who has a history of Parkinson's disease and severe protein-calorie malnutrition, was reported by family members to be left sitting in urine and feces multiple times a week, despite having a pressure ulcer that should not be exposed to moisture. The resident was scheduled for showers twice a week, but documentation was lacking, and there was no record of shower refusals. Another resident, with a history of chronic obstructive pulmonary disease and type 2 diabetes, reported never receiving a shower since admission and only occasionally receiving bed baths. This resident was found wearing two incontinence briefs, one saturated with urine and feces, which the CNA stated was against facility policy. The resident was scheduled for showers twice a week, but there was no documentation of showers being given or refused. Additional residents were also affected, including one with a history of malignant neoplasms and chronic kidney disease, who appeared unclean and reported not receiving showers, only bed baths. Another resident, with a history of hemiplegia and chronic heart failure, was observed to have not been washed up and had no documentation of receiving scheduled showers. The facility's policy required documentation of showers or refusals, but this was not consistently followed, leading to the deficiency.
Failure to Prevent Pressure Ulcer Deterioration
Penalty
Summary
The facility failed to implement preventive measures to prevent the development and deterioration of pressure ulcers in a resident identified as R139, who was at high risk for skin impairments. The deficiency was observed when R139 was found soaked in urine and feces, with her bed wet from her upper back to her ankles. This incident was reported by her family member, who expressed concerns about the lack of incontinence care provided from the night shift until the morning shift. The resident, who was on a low air loss mattress, developed a new moisture-associated skin disorder (MASD) on her bilateral buttocks and her existing pressure ulcer on the sacrum deteriorated to an unstageable stage. R139, who was initially admitted with a stage 2 pressure ulcer on the sacral area, had a medical history that included hemiplegia, type 2 diabetes mellitus with diabetic neuropathy, obesity, and other conditions that increased her risk for pressure ulcers. Despite being on a low air loss mattress and having specific orders for wound care, the facility failed to ensure that incontinence care was provided every two hours as required. The resident reported that her call light was not answered, and her brief was not changed when soiled, contributing to the worsening of her skin condition. The facility's policies on skin care and incontinence care were not followed, as evidenced by the lack of timely incontinence checks and the improper functioning of the low air loss mattress. The Assistant Director of Nursing (ADON) and the Wound Care Coordinator confirmed the issues, acknowledging that prolonged exposure to soiled conditions could lead to the development and deterioration of pressure ulcers. The facility's failure to adhere to its own protocols resulted in significant harm to R139, as her pressure ulcer progressed from stage 2 to unstageable, and she developed a new MASD.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and store medications, specifically insulin and inhalers, according to the manufacturer's recommendations and professional principles. During an observation, it was found that several insulin pens and inhalers on the 2nd floor East-West and [NAME] medication carts, as well as in the 3rd floor medication room, were not labeled with the date they were opened. This included insulin glargine, insulin lispro, and various inhalers, which should have been discarded after a specific period as per the manufacturer's guidelines. Interviews with the nursing staff confirmed that they were aware of the requirement to date medications upon opening and to discard them according to the manufacturer's instructions. The report highlights specific instances where medications were not labeled with open dates, such as insulin glargine and lispro pens, and inhalers for residents with conditions like Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The facility's policy on medication labeling, which requires opened medications to be labeled with the date of opening and discarded within a specified timeframe, was not adhered to. This oversight was observed across multiple medication carts and storage areas, indicating a systemic issue in medication management within the facility.
Improper Sanitizer Concentration in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation levels in the kitchen, specifically in the sanitation bucket used for kitchen rags. During an observation, the Dietary Manager (DM) tested the sanitation bucket using Quaternary test strips and found that the sanitizer concentration was significantly below the manufacturer's recommended levels. The expected concentration should have been between 300 to 400 parts per million (ppm), but the test results showed only 0-100 ppm. This discrepancy was observed despite multiple attempts to achieve the correct concentration by stirring the solution. The Dietary Aide responsible for changing the sanitation bucket admitted to estimating the water and sanitizer solution rather than following precise measurements. The facility's policy requires that the sanitation bucket be filled with sanitizer according to the manufacturer's recommendations, which specify a concentration range of 150-400 ppm for Quaternary solutions. However, the facility was unable to provide the manufacturer's dilution instructions. Additionally, the Dietary Manager initially provided incorrect information regarding the acceptable concentration range, later correcting it to 200-300 ppm. The facility's failure to adhere to these guidelines has the potential to affect 158 residents who receive food from the kitchen, as improper sanitation levels can lead to foodborne illnesses.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach, affecting four residents in a sample of 32. Observations on January 7, 2025, revealed that the call lights for residents R3, R15, R150, and R416 were hanging on the floor next to their beds, making them inaccessible. Certified Nurse Aides V23 and V24 confirmed that call lights should be within reach and not on the floor, as residents need to be able to call for assistance. The Director of Nursing also stated that call lights should be clipped to the bed or tied to the bed rail, according to resident preference. The medical records of the affected residents indicated various diagnoses and care plans that required assistance with activities of daily living. For instance, R15 had a history of cerebrovascular accident, visual impairment, and other conditions, with a care plan intervention to keep call lights within reach. Similarly, R150 and R416 had care plans emphasizing the need for accessible call lights due to their medical conditions. Despite the facility's policy, revised in July 2024, which mandates that call lights be within reach at all times, the deficiency was observed, indicating a lapse in adherence to the policy.
Infection Control Deficiencies in Equipment Handling and Precautionary Measures
Penalty
Summary
The facility failed to ensure proper infection control practices in handling respiratory equipment and disinfecting medical equipment between resident uses. An observation revealed that a nebulizer mask used by a resident was left uncovered and hanging from a nightstand, contrary to the facility's policy that requires such equipment to be stored in a labeled plastic bag. Additionally, a Licensed Practical Nurse was unaware of who left the nebulizer mask in this condition, indicating a lapse in adherence to infection control protocols. Further deficiencies were noted in the disinfection of medical equipment. A Registered Nurse was observed taking vital signs of multiple residents without disinfecting the blood pressure apparatus and pulse oximeter between uses. This practice was contrary to the facility's policy, which mandates cleaning reusable equipment between residents. The Director of Nursing and the Infection Preventionist both acknowledged that the equipment should have been disinfected after each use. The facility also failed to implement appropriate infection control practices for residents on transmission-based precautions. A Certified Nurse Assistant entered a resident's room without performing hand hygiene and without wearing the required personal protective equipment. Additionally, a Licensed Practical Nurse did not change gloves or perform hand hygiene between different procedures on a resident. The transmission-based precaution setup outside certain residents' rooms lacked necessary personal protective equipment, such as gloves and masks, and some rooms did not have hand soap available, further compromising infection control measures.
Delayed Therapy Services for Resident with Fractured Hip
Penalty
Summary
The facility failed to provide coordinated care services to a resident who suffered a fractured hip from a fall within the facility. The resident, identified as R74, was not provided with skilled therapy services as ordered by the physician in a timely manner. The deficiency was identified during an observation, interview, and record review, affecting one of the three residents reviewed for quality of care. The resident was found in bed, alert but with some confusion, and was identified as a fall risk. Despite the fall occurring on 12/14/24, the facility staff, including the Director of Nursing, were not aware of the fracture diagnosis until after the resident's readmission. The resident was initially sent to the hospital due to chest pain and was diagnosed with a non-ST-elevation myocardial infarction (NSTEMI). During the hospital stay, the resident reported right thigh pain, and a subsequent CT scan revealed an intertrochanteric fracture of the right femur and closed fractures of the right superior and inferior pubic ramus. The resident underwent right hip pinning on 12/23/24. Upon readmission to the facility, the resident had orders for occupational, physical, and speech therapy, but there was a delay in starting these therapies due to insurance approval processes. The Rehab Director was unaware of the fracture diagnosis until notified by the Nurse Practitioner on 12/30/24, and therapy services did not commence until early January. The delay in therapy services was attributed to the need for pre-approval from insurance, as stated by the facility's Administrator. The facility was unable to provide a policy on therapy services and skilled rehabilitation services, highlighting a lack of coordination and communication regarding the resident's care needs and therapy orders.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to ensure safety interventions were in place for a resident, identified as R216, who was at high risk for falls. R216, who had a history of falls and was admitted for rehabilitation following a humerus fracture, experienced an unwitnessed fall on the day of admission. The fall occurred when R216 attempted to reach for a phone on the nightstand, resulting in a laceration to the right eyebrow that required hospital treatment. The admission assessment identified R216 as high risk for falls, but no specific interventions were documented in the care plan to mitigate this risk. Another resident, R27, also experienced a fall due to inadequate supervision and positioning. R27, who has a history of hemiplegia and hemiparesis following a cerebral infarction, was turned by a CNA during care and slid off the bed because they were positioned too close to the edge. The CNA did not realize the resident's proximity to the edge, which led to the fall. A post-fall investigation confirmed that R27 was too close to the edge of the bed, and staff were reminded to ensure proper positioning before performing activities of daily living. The facility's fall prevention program guidelines require the implementation of safety interventions for residents identified at risk for falls. However, in both cases, the necessary precautions were not adequately implemented or maintained, leading to the incidents. The Director of Nursing acknowledged the oversight in R216's care plan and the need for baseline fall interventions to be indicated upon admission.
Failure to Conduct PASRR Level 2 Screening for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a PASRR Level 2 screening after the resident received a new diagnosis of a serious mental illness. The Social Service Director (SSD) was responsible for ensuring that residents with new mental illness diagnoses received an updated PASRR Level 2 screening. However, the SSD was not made aware of the new diagnosis for the resident until the survey, at which point she contacted the agency to have the screening completed. The Admissions Director confirmed that a PASRR Level 1 screening was completed before admission and stated that social services would be responsible for obtaining a Level 2 screening if a new mental illness diagnosis was made. The Administrator acknowledged awareness of the resident's new diagnosis since admission and claimed to have informed the SSD of the need for a new PASRR Level 2 screening. The resident's medical records indicated a new diagnosis of major depression and other mental health conditions. The facility's policy, revised in August 2024, mandates that residents with mental disorders receive PASRR screenings within the allowed timeframe, but this was not adhered to in this case.
Medication Administration and Controlled Substance Management Deficiencies
Penalty
Summary
The facility failed to properly supervise residents during medication administration, as observed in two cases. In the first instance, a Licensed Practical Nurse (LPN) left a medication cup with three pills on a resident's food tray while the resident was eating breakfast, trusting the resident to take the medication independently. The Director of Nursing (DON) later confirmed that no residents in the facility are authorized to self-administer medications and that nurses are expected to supervise medication intake. The resident's Medication Administration Record indicated that the medications were recorded as administered, despite the lack of supervision. In another case, a Registered Nurse (RN) left a resident with a medication cup containing seven pills and a cup of water mixed with a laxative, then left the room to retrieve additional medication, failing to supervise the resident's medication intake. The RN assumed the resident would take the medications due to their alertness and orientation. Additionally, the facility failed to maintain accurate records for controlled substances, as evidenced by missing signatures on the Controlled Substance Count Log and discrepancies in the medication count for a resident's Tramadol prescription. The facility's policy requires nurses to sign the controlled medication sheet immediately after removing medication, which was not adhered to in this instance.
Failure to Document Incontinence Care Per Shift
Penalty
Summary
The facility failed to document incontinence care every shift as per its policy, affecting two residents, R1 and R2, who were reviewed for incontinence care. R1, a female resident with hemiplegia, hemiparesis, and a stage I pressure ulcer, was admitted on 8/6/24 and assessed as dependent on staff for bowel and bladder incontinence. R2, admitted on 8/30/24 with a femur fracture and cognitive communication deficit, was also dependent on nursing staff for mobility and incontinence care. A review of the point of care (POC) tasks over a 30-day period revealed a lack of documentation indicating that R1 and R2 received incontinence care at least once per shift every day. On 9/18/24, a family member of R2 expressed concerns that R2 did not receive overnight incontinence care, resulting in R2 being soaked in urine by morning. Similarly, on 9/11/24, a family member of R1 reported that R1 was left soaking in a disposable brief and did not receive incontinence care for over an hour after requesting assistance. Documentation for 9/11/24 showed only one instance of incontinence care for R1, recorded at 1:27 pm. The Director of Nursing confirmed that CNAs are expected to document incontinence care or toileting at least once every shift, as per the facility's policy revised in 7/24, which mandates rounds every 2 hours to check for incontinence.
Failure to Prevent New Pressure Ulcer in At-Risk Resident
Penalty
Summary
The facility failed to prevent the development of a new pressure ulcer in a resident who was already at risk for such conditions. The resident, a female with hemiplegia and hemiparesis following a cerebral infarction, was admitted with a stage I pressure ulcer on the sacrum. Despite being dependent on staff for activities of daily living, including turning, repositioning, and incontinence care, the resident developed additional skin alterations. These alterations were initially documented as a gluteal cleft tear and a right ischium skin tear, which were later reclassified as a stage II pressure ulcer. The Director of Nursing acknowledged that the worsening of the wounds could have been due to a lack of turning or repositioning, a decline in nutrition, or an ineffective treatment plan, although no nutritional concerns were noted for the resident. The facility's care plan, initiated prior to the development of the new ulcer, aimed to prevent additional skin breakdown by following facility protocols. However, the documentation and actions taken by the staff, including the application of wound paste and collagen, were insufficient to prevent the progression of the resident's condition.
Failure to Replace Damaged Call Light Cord
Penalty
Summary
The facility failed to replace a damaged call light cord in a resident's room, which was identified as a deficiency. A resident, who was admitted with a femur fracture, cognitive communication deficit, and generalized weakness, was discharged from the facility before the issue was discovered. On a subsequent visit, a family member informed a surveyor about the damaged call light with exposed wires in the resident's former room. The surveyor observed the damaged call light, which had been ineffectively taped to cover the exposed wires. A staff member from Guest Services, upon entering the room and seeing the damaged cord, removed it and stated it would be replaced immediately. The facility's policy on hazards, revised in July, mandates the removal of hazardous items to ensure resident safety, which was not adhered to in this instance.
Failure to Provide Timely Toileting Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to its fall prevention policy and procedures, resulting in a resident, R2, sustaining a left foot fracture. R2, a female resident with a complex medical history including partial paralysis, a history of falls, and cognitive deficits, required assistance with activities of daily living, including toileting. Despite these needs, the facility did not provide timely toileting assistance, leading to R2 attempting to toilet herself, which resulted in a fall and subsequent injury. On the day of the incident, R2 activated her call light to request assistance with toileting. However, the assigned Certified Nursing Assistant (CNA), V16, was occupied with other residents and did not immediately respond to R2's request. Although V16 acknowledged R2's call light and informed her that assistance would be provided shortly, R2 attempted to transfer herself to the bathroom, resulting in a fall. The facility's Director of Nursing later confirmed that R2 should not have attempted to transfer herself due to her physical limitations. The facility's failure to complete fall risk assessments quarterly and annually, as required by their policy, further contributed to the deficiency. R2's medical records only contained an admission fall risk assessment and a post-fall risk assessment, indicating a lack of ongoing evaluation of her fall risk. This oversight, combined with the delayed response to R2's toileting needs, highlights the facility's failure to provide adequate supervision and timely assistance to prevent accidents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to ensure dialysis services were provided in a manner consistent with professional standards for a resident who required peritoneal dialysis. The resident, who had a history of end-stage renal disease and was dependent on peritoneal dialysis, was found with a missing cap on her dialysis catheter. This incident was noted by the nursing staff prior to setting up the patient's dialysis, and the resident was subsequently transferred to an acute care hospital for a catheter exchange. The missing cap increased the risk of infection, and the resident was later diagnosed with sepsis and peritonitis, necessitating the removal of the peritoneal dialysis catheter and a switch to hemodialysis, which significantly altered her treatment regimen and required additional coordination for outpatient dialysis sessions. The resident's family reported that the facility's staff did not handle the dialysis in a sanitary manner, and the resident was left connected to the dialysis machine for an extended period, which contributed to the complications. The facility's policy required the peritoneal catheter to be capped when not in use and for the catheter site to be inspected daily for signs of infection, but these procedures were not followed, leading to the resident's severe infection and subsequent hospitalization.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chicago Ridge Snf | 0.5 mi | — | 6 | 0 |
| Aliya Of Oak Lawn | 1.1 mi | — | 7 | 2 |
| Aperion Care Oak Lawn | 1.2 mi | — | 16 | 0 |
| Landmark Of Oak Lawn Rehabilitation And Nursing Ce | 1.4 mi | — | 2 | 0 |
| Nexus At Palos | 1.6 mi | — | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.