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 Ryze At The Ridge during CMS and state inspections, most recent first.
Surveyors found that multiple staff members, including CNAs, LPNs, an RN, and the Social Services Director, were not wearing required ID badges while on duty, despite facility policy mandating badges for all employees. A resident reported being unable to identify staff when attempting to file complaints because staff did not wear badges and often used nicknames. Staff interviewed acknowledged that badges are required so residents and visitors can identify who is providing care and that it is a resident right and a safety issue when staff are not properly identified.
Two cognitively intact residents with complex medical and psychiatric histories were involved in a physical altercation, during which one resident grabbed another by the throat in a hallway near the smoking area. Staff and other residents witnessed the incident, and staff intervened to separate the individuals. The only immediate response was to move the aggressor to a different room, and the event was reported to the administrator. The facility's policy prohibits abuse, but the measures in place did not prevent this occurrence.
Surveyors observed multiple instances of mouse droppings in several rooms, including between walls and bedside cabinets and under floor heat registers. Multiple residents reported seeing mice in their rooms at night, often coming from under heat registers or from the walls. The facility's pest management policy was not effectively implemented, resulting in ongoing pest issues.
A resident with a history of diabetes and a healing abdominal surgical wound experienced a re-opening of the wound, but staff failed to notify the physician, obtain a treatment order, monitor and document the wound status, or develop an individualized care plan. The wound was not included in the facility's wound tracking or care planning systems, and required protocols for assessment and documentation were not followed.
Two residents engaged in a physical altercation in the dining room, which staff failed to prevent despite witnessing the escalation from a verbal argument. One resident, with a history of aggression, hit the other, causing a head injury. Staff expressed fear and inexperience in handling the situation, contributing to the deficiency.
The facility failed to submit the Abuse Final Reportable within the mandated timeframe, affecting two residents. The initial report was made on time, but the final report was delayed by one working day. One resident had a history of aggression and was cognitively intact, while the other had auditory hallucinations and was moderately impaired. The facility's policy requires submission within five working days, which was not met.
The facility failed to ensure proper food preparation and sanitization practices, as the cook did not follow standardized recipes, using a regular soup spoon instead of a measuring tablespoon, resulting in overly salty pureed tater tots. Additionally, improper sanitization of kitchen equipment was observed, with the blender lid not submerged in sanitizing solution for the required time, risking cross-contamination.
The facility failed to properly label and date food items and did not sanitize cooking equipment according to guidelines, potentially affecting all 128 residents. Observations revealed unlabeled food items and improper sanitization of a blender lid, contrary to the facility's policies. These deficiencies could lead to foodborne illnesses.
The facility failed to conduct quarterly reassessments for residents who smoke, affecting their ability to smoke safely. One resident was observed smoking without a required apron, and the Social Service Director was unaware of this intervention. Other residents also had outdated smoking assessments, and their care plans were not updated to reflect current needs.
The facility failed to properly label and store medications, affecting seven residents. Observations revealed that multiple medications, including Risperidone solution and Albuterol inhalers, were opened without labeling the date of opening. An unopened Insulin Lispro vial was improperly stored outside refrigeration, and expired medications were found in storage. The DON emphasized the importance of labeling and proper storage to ensure medication efficacy and safety.
The facility failed to assess eligibility and offer pneumococcal vaccinations to four residents, as well as provide education on the benefits and side effects. The Infection Control Nurse provided verbal education without materials, and no immunization tracker was maintained. EHR reviews showed no documentation of vaccination status or education. Interviews with residents confirmed the lack of education and vaccination, and the Director of Nursing highlighted the importance of documentation.
The facility failed to assess eligibility and offer COVID-19 vaccinations to several residents, and did not document vaccination status or education provided. Interviews revealed that while verbal education was claimed to be given, there was no documentation in the EHRs. The Director of Nursing acknowledged that documentation should be completed, but the lack of records suggests non-compliance with the facility's policy.
A facility failed to complete a significant change in status MDS assessment for a resident admitted to hospice care. The resident's last MDS was a quarterly assessment, and the required significant change assessment was not conducted within the regulatory timeframe. Interviews confirmed that the facility's protocol mandates such assessments for hospice admissions, but it was not completed as required.
A facility failed to develop a comprehensive care plan for a resident receiving hospice services, despite the resident's complex medical history and admission to hospice care. The care plan, which should have been generated to address the resident's medical, nursing, mental, and psychosocial needs, was only added nearly two months after the resident's hospice admission.
A facility failed to properly store oxygen tubing for a resident with respiratory failure, as required by their policy. The tubing was observed on the floor instead of in a plastic bag, risking contamination. Staff confirmed the tubing was not changed as per schedule, despite the facility's policy for weekly changes and proper storage.
Two residents experienced medication administration errors, resulting in a 12.9% error rate. A nurse failed to administer a nasal spray as ordered and did not notify the physician of its unavailability. Additionally, the nurse did not follow proper procedures for administering ear drops. The facility's policies for medication administration were not adhered to, contributing to the errors.
A facility failed to protect a resident's right to manage their financial affairs, resulting in the misuse of a $10,000 check. The resident, who was cognitively intact, was instructed to sign the check over to the facility without proper authorization or explanation of charges. The facility did not provide an itemized bill until months later, and the resident's family received inconsistent explanations about the funds. The facility's documentation was outdated, and there was no evidence of the resident's agreement to private pay status.
The facility failed to maintain a clean and sanitary environment, with surveyors noting foul odors, unclean floors, and malfunctioning equipment. Residents reported missing dresser drawers, clogged toilets, and non-functioning overhead lights. The maintenance and housekeeping practices were inadequate, with issues persisting for months despite being reported. The facility's administrator was aware of these ongoing problems.
A facility failed to maintain accurate records of a resident's personal funds and did not provide financial records as required. The resident, who was alert and oriented, reported not receiving cash withdrawals listed in their account. Staff admitted to signing for withdrawals instead of the resident, despite the resident's capability to sign. Discrepancies were found between withdrawal forms and account statements, and the resident's family received conflicting explanations about the funds.
A resident with intact cognitive function experienced a delay in resolving a financial grievance involving a $10,000 check. Despite multiple attempts to contact facility staff, including the Administrator and Psychiatric Rehabilitation Services Director, the resident received inadequate communication and updates. Interviews revealed a lack of coordination and follow-up, leading to the resident's dissatisfaction and distress.
A cognitively intact resident's $10,000 check was misappropriated for room and board, leaving her with only $160. The facility failed to report the incident to the Illinois State agency within the required timeframe. The resident expressed dissatisfaction and contacted external authorities. The facility's administrator and staff were aware but did not provide timely updates or resolutions, leading to a deficiency finding.
The facility failed to protect a resident from abuse, resulting in abrasions to the face and wrist after being attacked by another resident with a history of aggression. Despite visible signs of agitation and a known history of aggressive behavior, the staff did not implement appropriate interventions, including one-to-one monitoring, leading to the altercation.
Failure to Ensure Staff Wore Identification Badges for Resident Identification
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently wore identification badges, preventing residents from knowing staff names and titles as required by facility policy. During an interview, one resident reported being unable to identify staff when wanting to make a complaint because many staff did not wear identification badges and often used nicknames. The resident stated he had spoken with the Assistant DON and nurses but could not identify which specific staff members he had reported concerns to. The facility’s employee handbook dated 1/2025 states that name badges are supplied by the facility and must be worn by all employees when on duty, and that each employee is responsible for their badge and its replacement if lost or misplaced. Surveyors observed multiple staff members across different roles and units not wearing identification badges while on duty. A CNA who identified as a new employee stated he did not have an identification badge and was observed in the hallway with towels in hand. Another CNA verified she was not wearing her badge and was seen entering resident rooms without identification, acknowledging that her badge should not be in her pocket and that badges help residents identify who is caring for them. An LPN on the second floor, an RN, the Social Services Director, another LPN on the first-floor unit, and an additional LPN on the first-floor unit were all observed without identification badges and each confirmed they were not wearing them. Several of these staff members stated that facility policy requires all staff to wear ID badges, that badges allow residents and visitors to identify staff, and that it is a resident’s right to know who is caring for them, with one LPN characterizing it as a safety issue if a resident cannot identify a staff member or another person in the building not wearing an ID badge.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two cognitively intact residents with multiple medical and psychiatric diagnoses. One resident reported being grabbed by the throat by their roommate during a confrontation in the hallway near the smoking area. Multiple interviews confirmed that the altercation occurred, with one resident admitting to grabbing the other's throat after becoming aggravated by ongoing complaints. Several witnesses, including staff and other residents, observed or heard the commotion and confirmed the physical contact. Staff responded to the incident by separating the residents and assessing for injuries, but there were no visible marks or signs of injury. The only immediate action taken was moving the resident who initiated the physical contact to a different room. The incident was reported to the facility administrator and abuse prevention coordinator, and staff acknowledged awareness that the event constituted abuse. The facility's policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the actions taken did not prevent the occurrence of physical abuse between residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on one of three resident floors, as evidenced by direct observations and resident interviews. During a facility tour, numerous mouse droppings were found in multiple resident rooms, specifically between the wall and bedside cabinet, along the top of floor heat registers, and under floor heat registers. Several residents reported frequently seeing mice in their rooms, particularly at night, with some stating the mice appeared to come from under the floor heat registers or from the walls. The facility's own Integrated Pest Management (IPM) policy outlines procedures to protect the health and safety of residents, staff, and visitors from pest hazards, and aims to eliminate significant threats caused by pests, but these procedures were not effectively implemented as evidenced by the ongoing presence of mice and droppings.
Failure to Notify Physician and Care Plan for Re-Opened Surgical Wound
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a re-opened surgical wound. Upon admission, the resident had a healing surgical wound on the abdomen following a hernia repair, and reported that the site had re-opened about a month prior. The resident stated that staff were not providing any treatment for the re-opened wound. Observation confirmed a small, open wound near the navel, with no dressing applied and no signs of infection. The registered nurse acknowledged seeing the wound previously but had not notified the physician or obtained a treatment order. Further interviews revealed that the Assistant Director of Nursing was unaware of the resident's wound and had not been notified, despite being responsible for tracking wounds in the facility. The nurse involved stated that she had only documented the issue on the communication board and did not contact the physician, as she did not observe signs of infection. The MDS Coordinator also confirmed that the wound was not included in the care plan or the facility's list of residents with current skin breakdown, and was only made aware of the wound the previous night. Record review showed no physician orders or treatment administration records for the wound, and the comprehensive care plan lacked individualized goals or interventions for the surgical wound. Facility policies required notification of the physician and updates to the care plan for changes in condition, as well as consistent monitoring and documentation of wounds, but these protocols were not followed in this case.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure residents were free from resident-to-resident physical altercations, affecting two residents involved in an incident. On January 27, 2025, a physical altercation occurred between two residents, R1 and R2, in the first-floor dining room. Witnesses, including another resident and staff members, reported that the altercation began with a verbal argument that escalated into physical violence, with R1 hitting R2's head, causing R2 to fall. Staff members present did not effectively intervene to deescalate the situation, and one staff member, V9, expressed fear and inexperience in handling such situations, which contributed to the failure to prevent the altercation. R1 has a history of aggression, as documented in their care plan and medical records, which include diagnoses of bipolar disorder and schizoaffective disorder. R1's mental status was noted as cognitively intact. R2, on the other hand, has a history of auditory hallucinations and schizoaffective disorder, with a moderately impaired mental status. Following the altercation, R2 sustained a contusion of the scalp, as documented in their medical records. The facility's abuse policy emphasizes the right of residents to be free from abuse, including abuse by other residents. The policy outlines the need for staff to be trained in handling difficult situations to prevent abuse. However, during the incident, staff failed to follow these guidelines, as they did not intervene promptly or effectively to prevent the escalation of the argument into a physical altercation. The facility's failure to protect residents from abuse by other residents constitutes a deficiency in providing a safe environment.
Failure to Timely Submit Abuse Final Reportable
Penalty
Summary
The facility failed to ensure that the Abuse Final Reportable was sent to the Survey Agency within the mandated timeframe, affecting two residents. The initial report for the abuse incident involving these residents was documented as reported to the state on December 15, 2024, at 3:38 PM. However, the final reportable was not uploaded to the Department of Public Health Incident portal until December 23, 2024, which was six working days later, exceeding the mandated five working days for submission. The administrator confirmed this timeline during an interview, acknowledging the delay in submission. The residents involved in the incident had significant medical histories. One resident had diagnoses including bipolar disorder and schizoaffective disorder, with a cognitive status documented as intact. This resident had a history of aggression towards staff. The other resident had diagnoses including auditory hallucinations and schizoaffective disorder, with a moderately impaired cognitive status. This resident was involved in an altercation that resulted in a contusion of the scalp. The facility's abuse policy mandates that a complete written report of the investigation's conclusion be sent within five working days, which was not adhered to in this case.
Inadequate Food Preparation and Sanitization Practices
Penalty
Summary
The facility failed to ensure that the cook had the appropriate competencies and skills, resulting in recipes not being followed during food preparation. This deficiency was observed when the cook, responsible for preparing pureed foods for lunch, did not adhere to the standardized recipe for pureed pork fritter and tater tots. Instead of using a standard measuring tablespoon, the cook used a regular soup spoon to scoop out chicken base, leading to an excessive amount being added to the dishes. This resulted in the pureed tater tots being too salty and inedible. Additionally, the facility's kitchen was not equipped with a second blender lid, which led to improper sanitization practices. The cook was observed washing the blender lid in a three-compartment sink but did not submerge it in the sanitizing solution for the required 60 seconds. This was noted by the Dietary Manager, who acknowledged the potential for cross-contamination and foodborne illness due to inadequate sanitization. The facility's policies and procedures, including the use of standardized recipes and proper sanitization techniques, were not followed. The Dietary Manager confirmed that the cook did not use the correct measurements, which affected the taste and quality of the food. The failure to follow recipes and proper sanitization procedures could potentially impact the residents' meal intake and nutrition, especially for those on a low-salt diet.
Deficiencies in Food Safety and Equipment Sanitization
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen, which could potentially affect all 128 residents receiving food prepared there. During an inspection, it was observed that several food items in the reach-in cooler were not labeled with an opened or use-by date, contrary to the facility's policy. For instance, a 5-pound bag of shredded mozzarella cheese was only labeled with a delivery date, and two cartons of thickened honey orange juice were not discarded after the manufacturer's recommended 7-day period post-opening. Additionally, a container of cornstarch in the spice storage area lacked an opened or use-by date, and garlic bread in the walk-in cooler was not discarded by its use-by date. The facility also failed to sanitize cooking equipment according to the manufacturer's guidelines. During the preparation of pureed food, a cook was observed improperly sanitizing a blender lid by not leaving it in the sanitizing solution for the required 60 seconds. The dietary manager intervened and corrected the process, but initially, the dietary aide also failed to sanitize the lid properly, indicating a lack of understanding of the correct procedure. The manufacturer's instructions, posted above the sink, clearly stated that items need to be submerged in the sanitizing solution for a full minute to ensure proper disinfection. The facility's policies on food safety and infection control were not adhered to, as evidenced by the improper labeling, dating, and sanitizing practices observed. These deficiencies in food handling and equipment sanitization could potentially lead to foodborne illnesses among residents. The dietary manager acknowledged the importance of these practices in preventing cross-contamination and ensuring food safety, yet the observed practices did not align with the established guidelines.
Failure to Reassess Smoking Safety and Update Care Plans
Penalty
Summary
The facility failed to ensure that residents who smoke are re-evaluated on a quarterly basis for their ability to smoke safely, and that their smoking care plans were followed. This deficiency affected four residents who were reviewed for smoking. The facility's policy requires smoking assessments to be conducted quarterly, but the assessments for these residents were not completed as required. Additionally, the care plans for these residents were not updated to reflect their current needs, and interventions specified in the care plans were not consistently implemented. One resident, identified as R41, had a history of violating the facility's smoking program and was observed smoking without a required smoking apron. Despite having a care plan that indicated the need for a smoking apron, the resident had never used one since being at the facility. The Social Service Director, V2, was unaware of the intervention requiring a smoking apron and acknowledged that the resident's care plan should reflect current needs. The last smoking assessment for this resident was completed in April 2024, and a reassessment was overdue by mid-July 2024. Other residents, including R1, R62, and R18, also had outdated smoking assessments, with the last assessments completed in April 2024. These residents were observed smoking, and their care plans indicated a need for regular reassessment to ensure safe smoking practices. The facility's failure to conduct timely reassessments and update care plans as needed contributed to the deficiency, as the residents' ability to smoke safely was not adequately monitored or managed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, affecting seven residents. During an inspection, it was observed that multiple medications, including Risperidone solution, Brimonidine solution, and Albuterol inhalers, were opened without being labeled with the date of opening. This oversight was noted across several medication carts and storage rooms. Additionally, an unopened Insulin Lispro vial was improperly stored outside of refrigeration, contrary to the pharmacy's instructions. Expired medications, such as Vitamin B6 tablets, were also found in the medication storage room, indicating a lapse in the facility's medication management practices. The Director of Nursing acknowledged the importance of labeling medications with the date of opening to ensure timely disposal and maintain their efficacy. The facility's policy mandates that medications requiring refrigeration should be stored accordingly, and expired drugs should be immediately removed from stock. The failure to comply with these protocols could result in residents receiving ineffective or potentially harmful medications. The report highlights the need for strict adherence to medication labeling and storage guidelines to ensure resident safety and medication effectiveness.
Failure to Assess and Educate on Pneumococcal Vaccinations
Penalty
Summary
The facility failed to assess eligibility and offer pneumococcal vaccinations to four residents, as well as provide education regarding the benefits and potential side effects of the vaccinations. The Infection Control Nurse, identified as V14, stated that vaccination clinics are set up for residents, and education is provided verbally without any educational materials. Consents are obtained and uploaded to the residents' electronic health records (EHR), but there is no immunization tracker maintained. The review of the EHRs for residents R128, R102, R11, and R1 revealed no documentation of their pneumococcal vaccination status, eligibility assessment, or education provided. Interviews with the residents confirmed the lack of education and vaccination. R128, who is cognitively impaired, could not recall receiving the vaccine or any education. R11, who has been in the facility for four months, stated they did not receive the vaccine or any education on immunizations. R102, who is cognitively intact, mentioned being vaccinated years ago but could not recall the specifics and expressed a desire for education on vaccines. The Director of Nursing, V3, emphasized that documentation should be completed after education is provided, and if it's not documented, it means it wasn't done. The facility's policy requires screening and offering the pneumonia vaccine within the first week of admission and annually if eligible, with documentation in the EHR.
Deficiencies in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to assess eligibility and offer COVID-19 vaccinations to four residents, and did not document the vaccination status for five residents. Additionally, the facility did not document that education regarding the benefits and potential side effects of the COVID-19 vaccination was provided to six residents. These deficiencies were identified during a review of the electronic health records (EHR) of the residents in question. Interviews with the Infection Control Nurse revealed that while vaccination clinics were set up and verbal education was provided, there was no educational material distributed, and consents were uploaded to the EHR. However, the EHRs of the residents reviewed did not contain documentation of their COVID-19 vaccination status or evidence of education provided. Interviews with the residents confirmed that they either did not receive the vaccine or were not educated about it, despite being in the facility for varying lengths of time. The Director of Nursing stated that documentation should be completed after education is provided, but the lack of documentation in the EHRs suggests this was not done. The facility's policy requires that all residents be offered the COVID-19 vaccine and that vaccination data be reported weekly, but the absence of documentation indicates a failure to adhere to this policy.
Failure to Complete Timely MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident who was admitted to hospice care. The resident was admitted to hospice on June 26, 2024, but the last MDS assessment was completed on June 14, 2024, as a quarterly assessment. According to the Resident Assessment Instrument (RAI) Manual, a significant change in status assessment should have been initiated within 14 days of the hospice admission and completed by day 21. However, this assessment was not conducted within the required timeframe. Interviews with the MDS Coordinator and the Regional Director confirmed that the facility's protocol requires a significant change assessment when a resident is admitted to hospice. The MDS Coordinator acknowledged that the assessment should have been started by July 9, 2024, and completed by the 21st day. The Regional Director also stated that a new MDS assessment should be completed when a resident is put on hospice, regardless of the reason. The failure to conduct the assessment as required by the RAI Manual resulted in a deficiency in the facility's compliance with regulatory timeframes for resident assessments.
Failure to Implement Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving hospice services. This deficiency was identified during a review of the resident's electronic health record (EHR), which revealed that the resident was admitted to hospice care on June 26, 2024, but did not have a corresponding hospice care plan until August 21, 2024. The absence of a hospice care plan was confirmed by the MDS Coordinator, who acknowledged that a care plan should have been generated to inform staff that the resident was receiving specialized hospice care. The resident in question has a complex medical history, including chronic respiratory failure, unsteadiness on feet, dysphagia following cerebral infarction, and several other conditions. The facility's policy mandates the development of a comprehensive care plan that includes measurable goals and interventions tailored to the resident's medical, nursing, mental, and psychosocial needs. Despite this policy, the care plan for the resident on hospice was only added on August 21, 2024, by the Regional Director, highlighting a lapse in ensuring the resident's psychosocial needs were met in a timely manner.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the proper storage of oxygen tubing for a resident, identified as R70, who is cognitively intact and has an active physician order for continuous oxygen therapy due to acute and chronic respiratory failure with hypoxia. During an observation, a surveyor noted that R70's oxygen nasal cannula tubing was left on the floor when not in use, which was contrary to the facility's policy that requires the tubing to be stored in a plastic bag to prevent infection. A Certified Nursing Assistant (CNA) was observed picking up the tubing from the floor and placing it on the oxygen tank, indicating a lapse in following proper infection control procedures. Further interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the expectation was for the oxygen tubing to be stored in a plastic zip bag when not in use. Despite this, the RN admitted to not changing the tubing, as it was scheduled to be replaced on a specific day of the week. The facility's policy, dated January 2024, mandates weekly changes of oxygen tubing and proper storage to prevent contamination, which was not followed in this instance.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 12.9% error rate during the survey. This deficiency involved two residents, R27 and R103, out of a sample of 11. For R27, the nurse, V6, did not administer the saline nasal spray as ordered at 8 AM and 12 noon, and there was no documentation of notifying the physician about the unavailability of the medication. Additionally, V6 did not adhere to the facility's policy of waiting at least 2 minutes between puffs of nasal spray and inhaler, potentially affecting the medication's efficacy. R27's medical history includes Type 2 diabetes mellitus, chronic obstructive pulmonary disease, and other conditions. For R103, V6 administered earwax softener drops without following the proper procedure, which includes cleansing the external auditory canal, straightening the auditory canal by pulling up and back, and inserting a small cotton ball afterward. The facility's policies for medication administration, oral inhalation, and ear drops were not followed, contributing to the medication errors observed. The Director of Nursing confirmed the expectations for medication administration, emphasizing the importance of following the 5R's and notifying the physician if medications are unavailable.
Failure to Protect Resident's Financial Rights
Penalty
Summary
The facility failed to protect a resident's right to manage their financial affairs and inform them of charges imposed against their personal funds. The resident, who was cognitively intact and oriented, received a $10,000 check from a family member's estate. The resident approached the Psychiatric Rehabilitation Services Director for advice and was later instructed by the former Business Office Manager to sign the check over to the facility, under the pretense that Medicaid would refuse to pay for care if the money was kept. The resident did not provide written authorization for the check to be deposited into the Resident Fund Management Service account and was not informed of the subsequent billing process. The facility did not provide the resident with an itemized bill until several months later, despite repeated requests. The resident's family member, who held power of attorney, was also given inconsistent explanations about the whereabouts of the funds. The facility's administrator at the time acknowledged the receipt of the check but did not ensure that the resident's rights regarding personal funds were explained or that proper authorization was obtained for the deposit. The facility's documentation was outdated, reflecting an old Medicaid asset limit, and there was no evidence that the resident had declined Medicaid benefits or agreed to private pay status. The facility's policy required residents to receive receipts for deposits and to authorize withdrawals, which was not adhered to in this case. The facility also failed to update the resident's personal trust fund policy to reflect current Medicaid asset limits. The survey team found no documentation supporting the resident's agreement to the charges or a switch to private pay, and the facility did not provide any such documentation by the survey's conclusion.
Deficiencies in Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by observations of offensive odors, unclean floors, and malfunctioning equipment. During a facility tour, surveyors noted foul odors and missing drawers in bedside dressers for several residents. Additionally, one of the elevators was out of service, which affected the residents' ability to move freely within the facility. The surveyor, along with a Certified Nurse Assistant, observed a yellow liquid substance on a resident's bathroom floor, which was identified as urine. The bathroom, shared by multiple residents, was not cleaned regularly, leading to persistent strong odors. The facility also failed to ensure that furniture and equipment were functioning properly. Several residents reported missing dresser drawers, which had been an issue for months. One resident mentioned that their toilet frequently clogged and took days to be fixed, while another resident's toilet was leaking and emitting a sewage smell for over three weeks. The maintenance staff was reportedly aware of these issues but had not addressed them in a timely manner. Furthermore, the overhead lights in two residents' rooms were not functioning, despite being reported as repaired in the facility's work order log. The facility's housekeeping and maintenance practices were inadequate, as evidenced by the observations of unclean conditions and broken furniture. The Housekeeping Director acknowledged that the rooms and bathrooms needed frequent cleaning due to residents' behaviors, such as urinating on the floor and smearing feces. The Maintenance Director confirmed the widespread issue of missing dresser drawers and stated that a furniture company had been contacted for replacements. However, the timeline for repairs and replacements was uncertain, and the facility's administrator was aware of these ongoing issues.
Failure to Maintain Accurate Resident Fund Records
Penalty
Summary
The facility failed to maintain accurate and complete records of a resident's personal funds and did not provide the resident with financial records quarterly or upon request. The resident, who was cognitively intact and alert, reported receiving a $10,000 check from a family member's estate, which was handed over to the facility. Despite multiple requests for updates and billing statements, the resident was only provided with an inaccurate account statement in July. The resident claimed not to have received any of the cash withdrawals listed in the account statement for the year. Interviews with facility staff revealed inconsistencies in the process of handling the resident's funds. The Psychiatric Rehabilitation Services Director and other staff members admitted to signing for the resident's cash withdrawals instead of having the resident sign, despite the resident being capable of doing so. The process involved staff counting the money, placing it in an envelope, and delivering it to the resident's room, but the resident did not sign the withdrawal forms. The facility's Business Office Manager confirmed that this process was a continuation of the previous manager's practices. Further discrepancies were found when comparing the cash withdrawal forms with the resident's account statement, showing mismatched dates and amounts. The resident's family member, who held power of attorney, also reported being given conflicting explanations about the whereabouts of the funds. The facility's policy required residents to sign for any withdrawals, but this was not followed. Additionally, the facility failed to document the resident's check or provide quarterly statements as required.
Failure to Resolve Resident's Financial Grievance
Penalty
Summary
The facility failed to promptly resolve a grievance and keep a resident informed about the progress of the investigation. The resident, who was cognitively intact, had a $10,000 check deposited, which was not reflected in her account. The facility's follow-up documentation indicated that the issue was assigned for resolution, but the resident was not satisfied with the outcome, and there was a lack of communication regarding the status of her funds. The resident expressed concerns about the misuse of her trust funds and the lack of accountability from the facility. Despite multiple attempts to contact the facility's staff, including the Administrator and the Psychiatric Rehabilitation Services Director, the resident felt ignored and was not provided with timely updates. The resident's attempts to escalate the issue included contacting external organizations, but the facility's response remained inadequate. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's grievance. The Administrator admitted to not responding to the resident's emails and not providing updates due to a lack of concrete information. The Business Office Manager and Psychiatric Rehabilitation Services Director also failed to follow up adequately, resulting in the resident's continued dissatisfaction and distress over the unresolved financial issue.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's funds to the Illinois State agency within the required timeframe. The resident, who was cognitively intact, had a check for $10,000 that was not properly reflected in her account. The facility's documentation indicated that the funds were used for room and board, leaving the resident with only $160 from the original amount. The resident expressed dissatisfaction with the resolution and reported the issue to various authorities, including the state Medicaid office, which confirmed that her services were never interrupted and that Medicaid had covered the charges. The facility's administrator and staff were aware of the resident's concerns but failed to provide timely updates or resolutions. The administrator admitted to not responding to the resident's emails and not providing updates until concrete information was available. The resident continued to express dissatisfaction and escalated the issue by contacting external organizations. The facility's internal communication and grievance handling were inadequate, as the resident's concerns were not addressed promptly, and the misclassification of her payment status was not corrected in a timely manner. The facility's policy required immediate reporting of any allegations of misappropriation of resident property, but the administrator did not initially consider the situation as misappropriation. The administrator later acknowledged the need to report the incident after being questioned by the surveyor. The facility's failure to report the incident and address the resident's concerns in a timely manner resulted in a deficiency finding by the surveyors.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident (R4) from abuse, resulting in R4 sustaining abrasions to the face and right wrist. The incident occurred when another resident (R5), who had a history of aggressive behaviors, became agitated and attacked R4 with punches and kicks. Multiple staff members, including an Activity Aide (V8), Housekeeping Director (V12), and Certified Nurse Aide (V15), witnessed the altercation and confirmed that R5 was visibly agitated and had been pacing and slamming doors prior to the attack. Despite R5's known history of aggression and the visible signs of agitation, the staff did not intervene appropriately to prevent the altercation. Interviews with staff revealed that R5's behavior was abnormal and should have prompted immediate intervention, including one-to-one monitoring. However, the staff failed to implement these measures. The Psychiatric Rehabilitation Services Director (V16) stated that there were no social workers in the building at the time of the incident, and the staff should have attempted to talk and redirect R5. The Assistant Director of Nursing (V20) also confirmed that R5's behavior warranted one-to-one monitoring, which was not provided. R5's comprehensive care plan documented the potential for physical and verbal aggression and included interventions such as monitoring and reporting signs of danger. However, these interventions were not effectively implemented. The facility's abuse policy affirmed the right of residents to be free from abuse and required immediate interventions to assure resident safety, which were not followed in this case. The failure to provide sufficient protection and immediate intervention led to the resident-to-resident abuse incident involving R4 and R5.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Park Health & Living Ctr | 0.3 mi | — | 12 | 0 |
| Park View Rehab Center | 0.8 mi | — | 14 | 0 |
| Atrium Health Care Center | 1 mi | — | 2 | 0 |
| Elevate Care Chicago North | 1.2 mi | — | 5 | 0 |
| Westwood Vlge Nrsg And Rhb Ctr | 1.2 mi | — | 2 | 0 |
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