LIBERTYVILLE MANOR EXT CARE
For profit - Corporation
174 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
8/100
#565 of 665 in IL
Photo by Michael Babicz
Photo by Michael Babicz
Photo by Michael Babicz
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Libertyville Manor Extended Care has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #565 out of 665 facilities in Illinois places it in the bottom half of nursing homes statewide, and #22 out of 24 in Lake County means there are only a couple of local options that are better. Unfortunately, the facility's performance is worsening, with an increase in issues from 7 in 2024 to 10 in 2025. While staffing is a strength with a 4/5 rating and no staff turnover, the facility has faced $246,461 in fines, which is troubling and suggests ongoing compliance issues. Specific incidents include failing to weigh residents upon admission, resulting in significant weight loss for some, and not having a Registered Nurse present consistently, which compromises resident care.
- Trust Score
- F
- In Illinois
- #565/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $246,461 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Illinois. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
8/100
Bottom 16%
Review needed
7 → 10 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 10 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Federal Fines: $246,461
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 23 deficiencies on record
1 life-threatening 1 actual harm
Jan 2025
10 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0692
(Tag F0692)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R135's face sheet shows she was admitted to the facility on [DATE].
R135's hospital records shows she weighed 132 lbs (pound...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R135's face sheet shows she was admitted to the facility on [DATE].
R135's hospital records shows she weighed 132 lbs (pounds) on December 14, 2024 in the hospital.
The facility did not weigh R135 on admission. The first weight done in the facility was on January 9, 2025 (23 days after admission). R135's weight was 119.4 lbs. (13 lb weight loss in 23 days).
On January 16, 2025 at 10:57 AM, V4, Director of Nursing, stated R135's weight was not done because she was on contact isolation when she was admitted to the facility.
3. R10's face sheet shows she was admitted to the facility on [DATE].
R10 was not weighed until January 1, 2025 (12 days later).
4. R86's face sheet shows, she was admitted to the facility on [DATE].
R86 was not weighed until January 3, 2025 (22 days later).
On January 16, 2025 at 10:57 AM, V4, Director of Nursing, stated weights should be done on admission.
Based on observation, interview, and record review, the facility failed to have a system in place to monitor residents (R135, R10, R86) for weight loss, including a resident (R183) with a gastrostomy tube (G-Tube); failed to ensure physician ordered weights were performed (R183, R135, R10, R86); failed to report a resident's decreased oral intake and obtain/report this resident's current weight to the physician prior to discontinuing this resident's (R183) enteral feeding; failed to notify the Registered Dietician that a resident's (R183) enteral feedings were discontinued; and failed to ensure interventions were in place to maintain nutritional intake prior to discontinuing an enteral feeding (R183). These failures apply to 4 of 9 residents (R183, R135, R10, R86) reviewed for weight loss in the sample of 12. These failures resulted in R183 sustaining a weight loss of 3.3% in 41 days despite having a gastrostomy tube (G-Tube) in place.
These failures resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 12/5/24 when R183 was not weighed upon admission to the facility. These failures resulted in R183 sustaining a weight loss. V1, Administrator, was notified of the Immediate Jeopardy on 1/16/25 at 9:40 AM. This surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 1/17/25, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of in-service training.
The findings include:
1. R183's hospital records, dated September 29, 2024 to November 13, 2024, showed R183 was admitted to the hospital on [DATE] due to fracturing her left hip after falling at home. R183 had surgery to repair her left hip fracture on September 30, 2024. The records showed R183 also had diagnoses of alcohol abuse, alcoholic polyneuropathy, altered mental status, protein-calorie malnutrition, UTI (urinary tract infection), esophageal ulcers, and esophagitis. During R183's hospitalization, a gastrostomy tube (G-Tube) was placed in R183 to supplement her feedings, due to her decreased oral intake. The hospital records also showed complications of delayed-healing to R183's left hip surgical wound. The records showed R183 was discharged to a local skilled nursing facility on November 13, 2024.
R183's admission records, dated December 5, 2024, showed R183 was admitted to the facility from another local skilled nursing care facility. R183's physician discharge orders and records, dated December 5, 2024, from the local skilled nursing facility showed an order for R183 to be weighed once a day. The records showed R183's discharge weight as 154 pounds (lbs) on December 5, 2024. The discharge orders showed R183 was prescribed a regular diet to eat orally, but was to also receive supplemental bolus enteral feedings via G-Tube, every 4 hours during the day, for nutritional support.
R183's December 2024/January 2025 Weight Report showed R183 was not weighed on December 5, 2024, upon admission to the facility. The report showed no weights were obtained on R183 from December 5, 2024 to January 14, 2025.
R183's nursing notes/progress notes, dated December 5, 2024 to January 14, 2025, showed multiple entries of R183 having a fair-poor oral intake/appetite and/or refusing meals at times. R183's medical records dated December 5, 2024 to January 14, 2025 showed no documentation of staff monitoring and recording R183's daily oral intake.
R183's Dietary Note, dated December 9, 2024, showed she was seen by V6, Dietician. The note showed R183's appetite and oral intake have been poor. The note showed V6, Dietician, added an order for a continuous enteral feeding for R183 at night; Jevity 1.2 cal (enteral feeding/nutritional supplement) at 60 cc/hour (cubic centimeters per hour) from 7 AM-7 PM, due to R183's poor oral intake. The note showed, RD (Registered Dietician) recommends to add nocturnal feeding to promote oral/calorie intake during day time hours .Goals for tolerance to new enteral feeding order, weight stability and improvement in oral intake . RD will monitor for change/tolerance issues and follow up as needed. R183's daytime bolus enteral feeding were discontinued.
A physician order, dated January 6, 2025, showed R183's continuous nighttime enteral feedings were discontinued by V12 (Physician of R183). The order showed V3, Nurse Manager, got the verbal order from V12 on January 6, 2025 to discontinue the feedings.
R183's medical records, dated January 6, 2025 to January 14, 2025 showed R183 received no supplemental enteral feedings during this time, despite continuing to have poor-fair oral intake.
R183's January 2025 Weight Report showed R183 was weighed for the first time in the facility on January 15, 2025 and was 140.2 pounds. R183 was re-weighed on January 16, 2025 and was 149 lbs. This showed R183 sustained a 3.3% weight loss from December 5, 2024 to January 16, 2025 (41 days).
On January 14, 2025 at 12:10 PM, R183 was seated in a high-back wheelchair in her room. R183 appeared thin and slightly jaundiced. R138's gastrostomy tubing hung down by her waist. R138 stated, I don't think I have ever been weighed here. The last time I was weighed was at the old rehab place. No one has asked to weigh me here. When R138 was asked about her appetite, she stated, I don't like the food here and I am not real hungry.
On January 15, 2025 at 10:49 AM, V3, Nurse Manager, stated she got the verbal order from V12 (Physician of R183) on January 6, 2025 to discontinue R183's enteral feedings because the family wanted her to get hungry and eat more. V3 stated she was aware of R183's poor-fair appetite when she spoke with V12 on January 6, 2025. V3 stated, I wasn't aware she had never been weighed until yesterday. When I called and got the order, (V12) didn't ask for a current weight on (R183). I didn't look for one. I didn't say anything about her appetite and he didn't ask about it. V3 stated she had never notified V6, Dietician, that R183's enteral feedings had been discontinued.
On January 15, 2025 at 10:11 AM, V4, Director of Nursing (DON), confirmed R183 was not weighed upon admission to the facility. V4 stated she was unaware R183 had not been weighed at all in the facility until January 15, 2025. V4 stated R183 was not weighed until January 15, 2025 because someone did not put the physician order for her to be weighed. It got missed when she got admitted . She should have been weighed at least once a week for the first four weeks of her admission. The admitting nurse should have put the order in. Myself and the Dietician are responsible for making sure the weights are done. V4 stated she was aware R183 was no longer receiving enteral feedings, but was not sure how long she had gone without. V4 stated she had not notified V6, Dietician, that R183 had never been weighed in the facility or that R183's enteral feedings had been discontinued. V4 stated she had not notified V6, Dietician, or V12 (Physician of R183) of R183's poor-fair oral intake. V4 stated, The family wanted the enteral feeding to be stopped to see if she would eat more. V4 stated R183's oral appetite had not really improved since discontinuing R183's enteral feeding. V4 state she had not notified R183's family R183 had never been weighed in the facility.
On January 14, 2025 at 2:36 PM, V6, Dietician, stated all new admissions should be weighed within 24 hours of admission and once a week for the first four weeks of admission. V6 stated, I was not aware (R183) was not being weighed. She should have been weighed once a week. When I saw her on December 9, 2024, I started her on continuous enteral feedings at night because I was concerned about her losing weight and she had not been eating much. Checking weights and monitoring oral intakes are ways that I monitor for weight loss. I am contracted so I am only at the facility for eight hours a month. No one called me to let me know she had not been weighed or that her appetite had not improved.
On January 15, 2025 at 11:21 AM, V6, Dietician, was asked if she had been notified R183's enteral feedings had been discontinued and/or of R183's weights from January 4 to January 15, 2025. V6 stated, No one told me her (enteral) feedings had been discontinued. Why? No one has called to let me know she lost weight. If I had known they were considering stopping her enteral feedings, I would have come in to assess her, get an accurate weight and review her oral intakes. If I had been aware of her poor appetite and weight loss, I would have recommended to not discontinue her feedings.
On January 16, 2025 at 1:13 PM, V12 (Physician of R183) stated he discontinued R183's enteral feeding order on January 6, 2025 because the family requested, however, I was not notified that she had never been weighed or that her oral intake had continued to be poor. V12 stated R183 should have been weighed once a week upon admission to the facility. V12 stated had he known R183's appetite was not improving and that she had not been weighed, he probably would not have given the order to discontinue her enteral feeding.
On January 15, 2025 at 11:46 AM, V13 (Family of R183) stated she had not been notified R183 had not been weighed in the facility. V13 stated, I knew she wasn't eating a lot. That's why I wanted to stop her other feedings to see if would eat more, but I did not know they weren't weighing her. No one has called to tell me her appetite had not improved since stopping the feedings. She is not hospice. We are trying to get her better to get her home.
The facility's Weight Maintenance policy, dated February 26, 2024, showed, The purpose of this policy is to assess the proper nutrition and weight maintenance of each resident. This can be accomplished through a weight schedule that will allow the facility to monitor any changes in weight . Each resident will be weighed on admission. Medicare residents will be weighed weekly, every Monday. Skilled residents will be weighed on admission and monthly thereafter . Recommendations given by dietary or the physician will be followed .
The facility presented an abatement plan to remove the immediacy on January 16, 2025. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on January 16, 2025. The survey team was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a third revised abatement plan on January 16, 2025 and the survey team accepted the abatement plan on January 16, 2025.
The Immediate Jeopardy that began on December 5, 2024 was removed on January 17, 2025 when the facility took the following actions to remove the immediacy:
Corrective actions for the resident includes:
-An order for daily weights on the day shift was obtained and implemented by the V3 nurse supervisor for R183.
-V24, Dietician, arrived at the facility on January 16, 2025 at 1:45 PM, and will assess the resident, provide recommendations and documentation.
-V4, Director of Nursing, spoke to the R183's POA (Power of Attorney) on January 16, 2025 at 11:30 AM, and the POA is in agreement to start the tube feedings again.
-The nursing staff will monitor all resident's oral intake and notify physician and dietician with any complications.
-V3, Nurse Supervisor, has contacted V12, R183's physician, on January 16, 2025 and he will be in contact with the facility within the next hour.
-V5, QAPI (Quality Assurance Performance Improvement) had an emergency meeting with V25, Medical Director, V1, Administrator, V4, DON, and V3, Nurse Supervisor on January 16, 2025 at 9:30 AM. The problem was discussed, identified, and a system will be put into place for monitoring the compliance with the facility weight protocol.
-The facility will follow the recommendations from the Dietician as well as any orders from V12, R183's physician, and these will be implemented. Both are being completed at this time January 16, 2025 at 2:00 pm.
-The staff will be in serviced by V4, DON, V3, Nurse Supervisor, and V7, Unit Manager, on the facility policy for obtaining weights on admission on all residents and the facility policy on obtaining weights for medicare and skilled residents. This will involve all nursing staff and CNA's and will be completed by 11:30 pm on January 16, 2025.
-The facility will weigh all residents on January 16, 2025. Any significant weight gain or loss of 5 percent or more, the physician will be contacted and the Dietician will be consulted for an assessment. This will be done by Janaury 17, 2025 by V4, Director of Nursing.
-The Dietician currently visits twice a month, 4 hours each visit, and as needed.
-V3, Nurse Supervisor, and V7, Unit Manager, will audit all weights on their units for new admissions, weekly weights, and monthly weights, and provide the weights daily to the Director of Nursing.
-Any weights that are missing will be obtained immediately, the employee responsible for the missed weight will be in serviced to ensure compliance in the future.
-The audit will be provided to V5, QAPI, at the weekly management meeting to ensure compliance.
-The QAPI committee will be updated quarterly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident protected health information was not ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident protected health information was not displayed for two of 12 residents (R5, R135) reviewed for privacy in the sample of 12.
The findings include:
1. R5's Record of admission shows she was admitted to the facility on [DATE].
R5's Physician Orders, dated January 1, 2025-January 31, 2025, shows starting January 10, 2025 R5 was on Covid-19 Quarantine for ten days until January 20, 2025.
On January 15, 2025 at 1:22 PM, there was a red stop sign on the outside of R5's door that showed, STOP COVID 19. This stop was was visible to all those that walked in the facility's hallway.
2. R135's Record of admission shows she was admitted to the facility on [DATE] with diagnoses including enterocolitis due to Clostridium Difficile (bacteria infection that causes diarrhea).
On January 13, 2025 at 11:30 AM, there was a typed up letter on a white piece of paper that was hanging on the outside of R135's room. The letter shows R135 had clostridium difficile, and explained to wash hands with soap and water. This letter also explained what exactly clostridium difficile is.
On January 15, 2025 at 10:37 AM, V11, CNA (Certified Nursing Assistant), said residents information should not be visible. That information is private.
The facility's Resident [NAME] of Rights policy, not dated, shows on admission to the facility, residents will be assured confidential treatment of personal and medical records, and may approve or refuse their release to any individual outside the facility, except in the case of transfer to another health care facility, or as required by law or third party payment contract.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance wa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided for residents that required assistance for two of 12 residents (R15, R9) reviewed for ADL care.
The findings include:
1. R15's Physician Orders shows he was admitted to the facility on [DATE], with diagnoses including traumatic brain injury, epileptic syndrome, dysphagia, anemia, and major depressive disorder.
R15's MDS (Minimum Data Set), dated October 23, 2024, shows R15 is dependent on staff for toileting hygiene, personal hygiene, and is always incontinent of bowel and bladder.
On January 13, 2025 at 12:12 PM, V9 and V10, CNAs (Certified Nursing Assistants), provided incontinence care for R15. R15's incontinence brief was completely saturated with dark urine. There was a strong urine odor. V9 said R15 was last changed on night shift, about 5:00 AM, when night shift got R15 up for the day. R15's right ring finger nail was long. R15's right ring fingernail was about one inch long.
2. R9's Record of admission shows he was admitted to the facility on [DATE].
R9's Physician Orders, dated January 1, 2024-January 31, 2025, shows he has diagnoses including urinary tract infection, elevated white blood cell count, and chronic kidney disease.
R9's MDS, dated [DATE], shows R9 requires substantial/maximal assistance with personal hygiene. R9 is frequently incontinent of bowel and bladder.
On January 13, 2025 at 11:10 AM, V10, CNA, provided incontinence care for R9. R9 was laying crooked in bed. R9's head was where his waist should be in the bed, and his legs were bent with his feet on his bed. V10 did not reposition R9 in his bed when she was finished provided incontinence care.
On January 15, 2025 at 10:37 AM, V11, CNA, said, Before leaving the room after incontinence care, make sure the residents are laying comfortably in bed. Incontinence care should be done at least every two hours because it is important to keep the residents clean and dry.
The facility's Personal Hygiene policy, not dated, shows the purpose is to ensure that the facility is providing all residents the necessary personal care to meet the needs of the resident. All residents shall be assessed to determine the resident's needs regarding bathing, dressing, grooming and all personal hygiene needs and the staff shall ensure that these are being completed for each resident based on the resident's needs. Ensure resident is receiving daily attention to skin, peri care, foot care, nails, hair and oral hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was thoroughly cleansed after a bow...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was thoroughly cleansed after a bowel movement for one of four residents (R9) reviewed for incontinence care in the sample of 12.
The findings include:
R9's Record of admission shows he was admitted to the facility on [DATE].
R9's Physician Orders, dated January 1, 2024-January 31, 2025, shows he has diagnoses including urinary tract infection, elevated white blood cell count, and chronic kidney disease.
R9's Minimum Data Set/MDS, dated [DATE], shows R9 requires substantial/maximal assistance with personal hygiene. R9 is frequently incontinent of bowel and bladder.
On January 13, 2025 at 11:10 AM, V10, CNA (Certified Nursing Assistant), provided incontinence care to R9 while he was laying in bed. There was stool in R9's rectum and on his buttocks. There was still visible stool present to R9's buttocks when V10 placed a clean incontinence brief onto R9 and pulled up his pants.
On January 15, 2025 at 10:37 AM, V11, CNA, said staff should make sure all the bowel movement is cleaned off of residents because it can prevent infection and bring the resident comfort. V11 said if stool is not cleaned off of residents, then it can cause odor.
The facility's Incontinence Care policy, revised on April 5, 2023, shows, If a resident's clinical condition becomes such that continence is not possible to maintain, the facility will ensure that correct incontinence care will occur.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were administered uncrushed. There...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were administered uncrushed. There were 25 opportunities with three errors, resulting in a 12% error rate.
This applies to one of three residents (R5) observed in the medication pass.
The findings include:
R5's Physician Orders show she was admitted to the facility on [DATE], with diagnoses including humerus fracture, femur fracture, and methicillin resistant staph infection. R5 has orders for potassium chloride 20 meq extended release, potassium chloride 10 meq extended release, and metoprolol succinate (blood pressure medication) 50 mg extended release.
On January 13, 2025 at 10:04 AM, V7, LPN (Licensed Practical Nurse), crushed all of R5's ordered medications and placed them in one cup with pudding. V7 then administered all the medications to R5.
On January 15, 2025 at 10:42 AM, V7 said she believe all of R5's medications were crushable, except potassium. V7 said liquid potassium is available from the pharmacy.
The facility's Medication Administration Policy, not dated, shows, When crushing make sure that the tablet does not get crushed in such a way that it will mix with previous medications that have been crushed. Do not crush enteric coated or sustained action medications. (see enclosed list of drugs which should not be crushed).
The facility's List of Oral Dosage Forms that Should Not be Crushed, dated September 27, 2023, shows metoprolol succinate is a modified release medication and should not be crushed, and potassium chloride is a modified release and should not be crushed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R5's Physician Orders shows she was admitted to the facility on [DATE] with diagnoses including right humerus fracture, and f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R5's Physician Orders shows she was admitted to the facility on [DATE] with diagnoses including right humerus fracture, and femur fracture.
R5's Care Plan, dated August 29, 2024 shows, Fall potential related to weakness and unsteady gait related to recent fall and fractured right humerus and right femur. Call light within reach.
R5's Progress Notes shows she had a fall on December 24, 2024 and January 7, 2025.
On January 13, 2025 at 10:04 AM, R5 was sitting in her wheelchair in the middle of her room. R5's call light was attached to the bed. R5's call light was not within reach.
On January 15, 2025 at 12:24 PM, V4, Director of Nursing, said fall prevention interventions include chair alarms, bed alarms, frequent monitoring, and ensuring everyone has their call lights within reach.
The facility's Fall Risk Assessment and Fall Prevention policy, revised April 25, 2024, shows, Interventions should be established to reduce the risk of falls. These may include: Resident's call light to be placed within resident's reach.
Based on observation, interview, and record review, the facility failed to assess if a dementia resident was safe to smoke; failed to ensure a resident at risk for aspiration received fluids in a consistency that were safe to drink; failed to ensure a resident was transferred in a safe manner; and failed to ensure fall interventions were in place for a resident with a history of falling. These failures apply to 4 of 12 residents (R28, R13, R6, R5) reviewed for safety and supervision in the sample of 12.
The findings include:
1 A facility list, dated January 14, 2025 showed R28 was listed as a resident who smoked in the facility.
R28's initial/admission care plan, dated May 11, 2023, showed R28 was admitted to the facility with a diagnosis of dementia. The care plan showed no documentation R28 was a smoker until January 14, 2025.
On January 13, 2025 at 1:34 PM, R28 was seated in a recliner in his room. R28 was receiving supplemental oxygen via nasal cannula. R28 stated he usually goes out to smoke cigarettes, three times a day, after meals.
On January 14, 2025 at 10:48 AM, V16, Resident Assistant (RA), stated when assigned, she has gone out with R28 when he smoked. V16 stated, He usually likes to smoke after every meal. I don't know if (R28) has a diagnosis of dementia. I don't know if he is safe to smoke. Lately, he's been dropping the cigarettes out of his hand onto the ground. I just pick it back up and give it to him. V16 stated she did not report R28's recent episodes of R28 having difficulty holding his cigarette to any nursing staff.
On January 14, 2025 at 1:52 PM, V4, Director of Nursing (DON), stated the facility currently does not complete safe smoking assessments on residents that smoke.
The facility's Smoking in Nursing Home policy, dated February 8, 2024, showed no documentation that safe smoking assessments should be completed on residents that choose to smoke.
2. R13's interdisciplinary plan of care note, dated November 18, 2024, showed R13 required a mechanical soft diet with nectar thickened liquids due to her diagnosis of dysphagia. R13 was at risk for aspiration. R13 also had a diagnosis of dementia.
R13's January 2025 Physician Order report showed R13's diet had been downgraded to a pureed diet with nectar thick liquids.
On January 13, 2025 at 10:18 AM, R13 was seated in a high back wheelchair in her room. No staff were present. R13 was slowly trying to drink from a cup that contained a thickened orange colored drink. A cup of un-thickened coffee was also noted on the table in front of R13.
On January 13, 2025 at 12:29 PM, R13 remained seated in her room with no staff present. The cup of thickened orange drink was in front of her on the table. R13 was holding onto the cup of un-thickened coffee and attempting to lift it to her mouth.
On Januayr 14, 2025 at 12:08 PM, V15, Licensed Practical Nurse (LPN), stated, (R13) has trouble swallowing so she is on thickened liquids so she doesn't choke.
On January 15, 2025 at 2:14 PM, V4, Director of Nursing/DON, stated she did not know why R13 required a pureed diet with nectar-thick liquids but stated, If a resident requires a special diet, the information should be in the resident's care plan. V4 stated the facility did not have a policy on aspiration prevention for residents with dysphagia.
R13's current care plan, dated October 20, 2024, showed no documentation related to R13's nutritional needs including no documentation of R13's dysphagia diagnosis and/or her need for a pureed diet with thickened liquids.
3. R6's care plan, dated November 18, 2024, showed R6 was at high risk for falling due to previous multiple falls in the facility. The plan showed R6 needed staff assistance when transferring and walking. The plan showed, Utilize gait belt at all times.
On January 13, 2025 at 9:42 AM, V15, Licensed Practical Nurse/LPN, transferred R6 from her recliner to wheelchair by holding onto R6's arm. No gait belt was used. V15 then wheeled R6 into the bathroom. V15 transferred R6 from the wheelchair to the toilet by placing both hands under R6's buttocks and lifting R6 onto the toilet. No gait belt was used.
On January 14, 2025 at 1:52 PM, V4, DON, stated R6 is at high risk for falls. V4 stated, She is a one person assist for transfers. A gait belt should be used on all of her transfers.
An undated facility Proper Body Mechanics staff inservice record showed, Use your gait belt! You, as well as your patient, will be less likely to suffer an injury if you use your gait belt appropriately. Using your gait belt will allow you to be prepared to support the weight of your patient if they suddenly need assist. Make sure the belt is cinched up securely and you have a hand on it or be prepared to grasp it if necessary.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure a resident who is vegetarian was offered a protein substitute, and failed to ensure residents on puree diets were serv...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure a resident who is vegetarian was offered a protein substitute, and failed to ensure residents on puree diets were served the same menu as regular diets. This applies to 5 of 12 residents (R184, R11, R25, R13 & R15) reviewed for following menus in the sample of 12.
The findings include:
The facility's week three menu shows: Monday (January 13, 2025): lemon chicken over noodles, broccoli, green salad, chilled pears, coffee/tea. Tuesday (January 14, 2025): Salisbury steak, mashed potato & gravy, buttered corn, garden salad w/thousand island, chilled peaches, coffee/tea.
1. R184's current diet order shows he is on a general diet, vegetarian.
On January 13, 2025 at the noon meal, V3, Nurse Manager, gave R184 noodles, broccoli, green salad, and chilled pears. He was not provided with any protein substitutes. She stated, He is a vegetarian so he doesn't eat meat.
On January 14, 2025 at the noon meal, V3, Nurse Manager, gave R184 mashed potatoes, corn, and a garden salad. He was not provided with any protein substitutes.
On January 14, 2025 at 12:57 PM, V17, Cook, stated R184 will get everything except the meat. He did not make anything else for him.
On January 14, 205 at 2:37 PM, V6, Dietician, stated she didn't know what the facility was providing for R184 as a protein substitute, and it was up to V19, Dietary Manager.
2. The facility's diet type provided on January 14, 2025 shows R11, R25, R13, and R15 are all on a pureed diet.
On January 14, 2025 at the noon meal, R11, R25, R13, & R15 were served Salisbury steak and mashed potatoes. There was no corn, garden salad, or peaches.
On January 14, 2025 at 12:57 PM, V17, Cook, stated he did not puree the corn, salad, or peaches. He didn't think you could puree corn because of the hull/shell.
The facility's spreadsheet for the noon meal shows residents on a puree diet can have pureed corn, garden salad, and peaches.
On January 14, 2025 at 2:37 PM, V6, Dietitian, stated corn can be pureed.
The facility's puree policy, dated February 15, 2017, shows, Purpose: .Here at the facility, residents that are on a pureed diet receive the same menu items as all other residents with the exception of other diet order restrictions .
The facility's diets policy, dated March 1, 2024, shows, Purpose: The purpose of this policy is to assure the facility is providing standard and therapeutic diets that will meet the nutritional needs of residents in accordance with established national guidelines Procedure: Menus and nutritional adequacy: The facility will offer diets based on a resident's nutritional needs and requirements. The facility will make reasonable efforts to accommodate religious, cultural and ethnic diet needs of a resident. The facility dietitian will review the diets and diet order for nutritional adequacy. Food will accommodate a resident's allergies, intolerance's and preferences .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's medications were administered in ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's medications were administered in a manner to prevent cross contamination, failed to ensure gloves were changed and hand hygiene was performed in a manner to prevent cross contamination, and failed to ensure enhanced barrier precautions were implemented for residents with wounds and gastrostomy tube for five of 12 residents (R5, R9, R15, R183, R13) reviewed for infection control in the sample of 12.
The findings include:
1. R5's Physician Orders show she was admitted to the facility on [DATE], with diagnoses including humerus fracture, femur fracture, and methicillin resistant staph infection.
On January 13, 2025 at 10:04 AM, V7, LPN (Licensed Practical Nurse), was preparing R5's morning medications. V7 pressed R5's medications out of the bingo cards directly into V7's hand. V7 then placed the medications in the medication cup. V7 crushed all of V7's medications and then administered the medications to R5. V7 did not have gloves on when she was preparing R5's medications.
On January 15, 2025 at 10:42 AM, V7 said medication should be placed into the cups and not in the nurses hand.
The facility's Medication Administration policy not dated shows, Do not touch the medication when opening the bottle of unit dose.
2. R9's Record of admission shows he was admitted to the facility on [DATE].
R9's Physician Orders, dated January 1, 2024-January 31, 2025, shows he has diagnoses including urinary tract infection, elevated white blood cell count, and chronic kidney disease.
On January 13, 2025 at 11:10 AM, V10 CNA (Certified Nursing Assistant), provided incontinence care to R9. V10 folded the front of R9's incontinence brief in between his legs while he was laying in bed on his back. V10 wiped R9's front peri area, touched R9's body to help him turn onto his side, wiped the stool from his buttocks, and then placed a clean incontinence brief on. V10 did not change her gloves nor perform hand hygiene.
3. R15's Physician Orders shows he was admitted to the facility on [DATE], with diagnoses including traumatic brain injury, epileptic syndrome, dysphagia, anemia, and major depressive disorder.
R15's MDS (Minimum Data Set), dated October 23, 2024, shows R15 is dependent on staff for toileting hygiene, personal hygiene, and is always incontinent of bowel and bladder.
On January 13, 2025 at 12:12 PM, V9 and V10, CNAs, transferred R15 into his bed. R15's incontinence brief was saturated with dark urine. V10 folded the front of R15's incontinence brief in between his legs while he was laying on his back. V10 wiped R15's front peri area, then touched R15's body to help him to turn onto his side. V10 did not change her gloves or perform hand hygiene before touching R15's body.
On January 15, 2025 at 10:37 AM, V11, CNA, said she changes her gloves when they are visibly soiled.
The facility's Handwashing Policy revised on April 5, 2023 shows, Hand Hygiene should occur immediately after touching a patient, contaminating items or surfaces, after contact with bodily fluids or excretions. Change gloves when conducting a task from a dirty area to a clean area
4. R183's admission records, dated December 5, 2024, showed R183 was admitted with a gastrostomy tube in place. R183 received enteral feedings and medications via her gastrostomy tube.
On January 13, 2025 at 10:05 AM, R183 was in bed with the end of her gastrostomy tube hanging out of the bottom of her shirt. No Enhanced Barrier Precautions (EBP) isolation sign hung on the doorway to R183's room. No isolation cart was noted outside of her room.
5. R13's skin wound and wound care note, dated January 10, 2025, showed R13 had a stage 3 pressure injury to her right hip.
On January 13, 2025 at 10:18 AM, R13 was seated in a wheelchair in her room. No Enhanced Barrier Precautions (EBP) isolation sign hung on the doorway to R13's room. No isolation cart was noted outside of her room.
On January 14, 2025 at 1:52 PM, V4, Director of Nursing, stated any residents that have gastrostomy tubes, catheters, and/or wounds, should be on Enhanced Barrier Precautions. V4 stated, Staff will know if the resident is on EBP because there will be an EBP sign on the door to the room and a cart available with PPE (personal protective equipment) supplies.
The facility's Enhanced Barrier Precautions policy, dated May 17, 2024, showed, If a resident has an indwelling medical device, they should be placed in EBP. Examples of indwelling medical devices: central venous catheter, urinary catheter, feeding tube (PEG Tube, G-Tube), and tracheostomy. If a resident has a wound, they need to be placed in EBP .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have a Registered Nurse (RN) 8 hours a day, 7 days a week. This deficiency affects all 35 residents living in the facility.
...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to have a Registered Nurse (RN) 8 hours a day, 7 days a week. This deficiency affects all 35 residents living in the facility.
The findings include:
The CMS-671 long-term care facility application for Medicare and Medicaid, dated January 14, 2025, shows there were 35 residents residing in the facility.
On January 13th, 14th & 15th, 2025, a violation notice was on the entrance door of the facility saying they were in violation of staffing requirements from the Illinois Department of Public Health for the period of July 1, 2024 - September 30, 2024.
On July 4, 2024 and September 2, 2024, there were no RNs available in the facility.
On January 15, 2025 at 2:57 PM, V4, Director of Nursing, stated, There was two days with no RN coverage. They were July 4th and Septemeber 2nd, 2024.
The facility's minimum staffing requirements (no date) shows, R.N.- 1 per shift is 24 hours per day (Only one is need for 2 shifts per day).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food temperatures were monitored and failed to ensure dry food scoops were not stored in bins. This applies to all 35 ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure food temperatures were monitored and failed to ensure dry food scoops were not stored in bins. This applies to all 35 residents living in the facility.
The findings include:
The CMS-671 long-term care facility application for Medicare and Medicaid, dated January 14, 2025, shows there were 35 residents residing in the facility.
1. On January 13, 2025 at 12:40 PM, V18, Dietary Aide, brought the food from the kitchen to the kitchenette on the unit. He took the food out of the hot box and placed it on the counter in the kitchenette. He did not place the food in the steam table. The steam table did not appear to be on. At 12:51 PM, V3, Nurse Manager, moved the food from the counter to the steam table. She started plating the food for the residents. She did not check the temperature of the food prior to serving the food. The steam table and food did not appear to be hot.
On January 14, 2025 at 9:13 AM, V3, Nurse Manager, was serving breakfast. At 12:41 PM, V3, Nurse Manager, was serving lunch. She did not check the temperature of the food prior to serving either meal. She stated she did not know that she was supposed too. She was just helping because there was no one else to serve the meals.
On January 13, 2025 at 1:45 PM, V17, Cook, stated he checks the food temperatures, but doesn't know where the logs are, so he doesn't log it. I'm new here since Thursday. They all need to log temperatures. They should be checking temperatures before serving the food.
The facility did not provide any food temperature logs.
The facility's food temperature monitoring policy (no date) shows, Purpose: The purpose of this policy is to ensure that the facility is serving all foods provided to the residents at the correct temperature. Procedure: 1. The Dietary temperature will be taken in the kitchen. The foods tested will be identified on the Temperature Monitoring Sheet and the temperature taken shall be documented on this form as well. 2. The Food Temperature will be taken when the food arrives on the floor. This will be documented on this form as well. 3. The food temperatures will be taken for the breakfast, lunch and supper meals. 4. It will be the responsibility of the dietary aide to ensure that this is completed.
2. On January 13, 2025 at 11:07 AM, there were three metal bins with sugar, flour, and oatmeal. All three bins had a scoop lying inside of the bin on the flour, sugar, and oatmeal.
The facility's scoops in bins policy, dated February 15, 2017, shows, Purpose: The purpose of this policy is to avoid unnecessary manual contact with food. Procedure: Suitable dispensing utensils used by employees shall be stored in the food with the dispensing utensil handle extending out of the food. Dispensing utensils shall be stored clean and dry.
The facility's diets policy, dated March 1, 2024, shows, Food safety requirements: Food should be stored, prepared, distributed and served in accordance with professional standards for food service safety.
Feb 2024
7 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident with a significant weight loss was followed up and re-evaluated by a Registered Dietitian when she continue...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure a resident with a significant weight loss was followed up and re-evaluated by a Registered Dietitian when she continued to have further significant weight loss for 1 of 3 residents (R66) reviewed for weight loss in the sample of 14.
This failure resulted in R66 having a 25.93% weigh loss in 6 months.
The findings include:
R66's Record of Admission, provided by the facility on 2/8/24, showed she was admitted with diagnoses including dementia, Parkinson's disease, and bipolar disorder.
On 2/6/24 at 12:35 PM, R66 was sitting at a table by herself in the middle of the room. R66's lunch tray was on the table in front of her. R66 was sitting there, looking forward, not eating. As one staff member walked by R66 she was heard asking R66 if she was going to eat her lunch. R66 did not reply. At 12:53 PM, R66 was still looking forward and not eating. A staff member went up to R66 and sat down next to her. R66 picked up her fork and poked at the food, then put the fork down on her plate. R66 did not take a bite. The staff member asked R66 to eat her lunch, then got up and walked away. A minute later, R66 picked up her fork and started eating her lunch.
On 2/8/24 at 12:23 PM, R66 was observed in the dining room, sitting at the same table by herself in the middle of the dining room. her tray was in front of her. R66 was looking ahead and not eating. At 12:40 PM, R66 was still looking straight ahead. The food on R66's tray was not touched. The silverware on her tray were clean and still in the same place as observed at 12:23 PM.
On 2/8/24, R66's weight history for the last six months was requested. The facility provided R66's Vital Parameters documents showing R66's weight history from 6/5/2023-1/4/2024. The documents showed R66's weight history was as follows:
7/25/23 189.0 pounds
8/28/23 180.0 pounds
9/8/23 161.0 pounds
10/1/23 159.0 pounds
No weight was entered for November 2023
12/4/23 144.0 pounds
1/4/24 140 pounds
On 7/25/2023, R66 weighed 189 lbs. On 1/4/2024, R66 weighed 140 pounds. This is a 25.93 % loss in six months.
On 2/7/24 at 1:30 PM, V8 (Registered Dietitian) said the facility informs her if a resident has weight loss and she will assess the resident. V8 said she had not assessed R66 yet, adding that she just started as the Registered Dietitian for this facility in January 2024. V8 looked on R66's electronic medical record with this surveyor and said the last assessment she sees in R66's electronic medical record, showing R66 was assessed by a Registered Dietitian, was in October of 2023. V8 said she comes to the facility one to two times a month for a total of around eight hours a month.
R66's weight loss care plan, dated 9/15/23, showed she had a 13.5% weight loss at that time (9/15/23). The goal of the care plan was that R66 would maintain her current weight within 3 pounds by the next review date. The care plan did not have any revisions or updates after the original 9/15/23 date. The care plan showed intervention in place were to: Serve prescribed diet as ordered, monitor monthly weights, monitor oral intake, monitor resident's weight monthly and as needed for any significant weight change, monitor lab results. and to monitor for compliance of diet ordered.
R66's Registered Dietitian's Nutrition Assessment, dated 10/25/23 by V19 (the facility's previous RD), showed at that time, R66 had a nutrition risk related to a significant weight loss of 11% in the previous 6 months. At that time, R66 weighed 159 pounds. The assessment showed V19 spoke with R66 and discussed food preferences. Resident was agreeable to add yogurt at breakfast and ice cream every lunch for additional nutrition. The facility was asked to provide the last three RD assessments for R66. The facility provided the 10/25/23 RD Nutrition Assessment and V19's Dietary Consulting Reports from March 2023 through December 14, 2023. The Dietary Consulting Reports showed the hours V19 spent in the facility, and a summary of V19's service performed on those days. The Reports did not have R66's name on them, nor did they list any current weights, supplements, or recommendations.
On 2/8/24 at 1:00 PM, V2 (Director of Nursing-DON) said R66's weight loss is a mental behavior. She has bipolar disorder, and she has the idea her family doesn't want her to eat. We leave her in the dining room and as soon as everyone leaves, she starts to eat. V2 said sometimes she will remove R66 from the dining room and take her to the day room. V2 said she will sit with R66 and she will eat. V2 said R66 has this idea that she has to hide to eat.V2 said some things that work one day, will not work another day. V2 said if a resident has continued weight loss, and the Registered Dietitian comes every month, then the resident should be seen every month.
The facility's 10/21/2010 policy titled Weight Maintenance showed, 1. Each resident will be weighed on admission. Medicare residents will be weighed weekly, every Monday. Skilled residents will be weighed on admission and monthly thereafter. 2. If there are no significant weight shifts of plus or minus five pounds, skilled residents will remain on a monthly schedule unless there are complications and/or the physician has ordered more frequent weight to be obtained. 3. A resident will be assessed for nutritional risk initially, quarterly, annually and as per Medicare schedule. 4. If a resident has a shift of plus or minus 5 pounds, weights will be monitored and recorded weekly. 5. If the weekly weight shows a loss of 5 pounds or more, appropriate supplements will be added to each meal. Weights will be monitored for 2 weeks until stable. The physician shall be contacted as well as the dietary department. Recommendations given by dietary, and physician should be followed. This may include daily weights, or calorie counts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to encode and transmit resident MDS assessments within the required time frames for 3 of 3 residents (R1, R2, R4) reviewed for resident assess...
Read full inspector narrative →
Based on interview and record review, the facility failed to encode and transmit resident MDS assessments within the required time frames for 3 of 3 residents (R1, R2, R4) reviewed for resident assessments in the sample of 14.
The findings include:
On 2/8/24 during the facility's annual survey, the Long Term Care Survey Process system identified R1, R2 and R4 having MDS (Minimum Data Set) assessment records over 120 days of submission.
R1's face sheet showed an admission date of 5/22/17.
R2's face sheet showed an admission date of 2/17/21.
R4's face sheet showed an admission date of 3/8/23.
On 2/8/24 at 11:37 AM, V12 (MDS aide) stated the nurses are responsible for the MDS assessments and once the sections are complete, she submits them electronically to the portal. V12 said the assessments are due at admission to the facility, at day five, quarterly, and annually. Assessments are due when a resident discharges or there is a significant change. V12 stated there have been problems with the submissions lately. V12 said the assessments are repeatedly coming back from the electronic submission program as rejected. V12 said it has been happening since October of 2023. V12 said the facility is working on the problem, and are still not sure what the problem is. V12 said, It is a problem on the facility's end. Either a software issue or an error on the way the MDS assessments are being submitted.
V12 and this surveyor reviewed R1, R2 and R4's quarterly MDS assessment submission information. Documents showed R1's submissions rejected twice since 11/20/23. Documents showed R2's submission rejected 12/15/23. Documents showed R4's submission rejected on 12/21/23.
On 2/8/24 at 12:10 PM, V13 (MDS Coordinator/Registered Nurse) stated the MDS assessment program had a system upgrade awhile back. V13 said it was some time in October of 2023, and since then they are having issues filling out the MDS assessments correctly. V13 said she is still not quite sure what is wrong, and some assessments get rejected. There is no consistency to the errors. V13 said, It has been a trial and error process. Some assessments go through just fine and others get kicked back. V13 said they are at a loss as to what the problem is.
The facility was unable to provide any policy related to timely submission of resident MDS assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R265's face sheet, printed on 2/8/24, showed R265 was admitted on [DATE]
R265's physicians order sheet, printed on 2/8/24, sh...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R265's face sheet, printed on 2/8/24, showed R265 was admitted on [DATE]
R265's physicians order sheet, printed on 2/8/24, showed diagnoses to include but not limited to acute on chronic diastolic (congestive) heart failure, encounter for other specified aftercare, dementia, and fall precautions, bed alarm, may use bed alarm.
R265's Minimum Data Set (MDS) was requested. None was provided.
R265's care plan, printed on 2/7/24, showed fall potential related to weakness, unsteady gait, blindness.
R265's fall incident, dated 9/26/23, showed R265 was found on the mattress next to her bed .No injuries noted . Care plan shows R265 has had multiple falls.
R265's quarterly fall risk evaluation, dated 12/7/23, showed a history of falls with/without injury, 2 or more falls in 30 days and high risk for falls.
R265's progress noted, dated 9/1/23 at 4:33 PM, showed, Writer found (R265) lying on floor next to her bed. R265's bed alarm was sounding . Resident on floor was shouting for help writer assessed and assisted (R265) to a sitting position .R265 was assisted to wheel chair with staff assist x 2, primary care provider was notified. Husband and son was notified.
R265's progress note, dated 9/1/23 at 4:40 PM, showed, Writer was called from other unit to assist (R265) back into her chair as she had thrown herself out of her (specialized) chair .(R265) assisted back into wheelchair with staff assist times three. (R265) assessed .Notified power of attorney (POA), POA agreed that because (R265) continues to complain about headache that he would prefer if (R265) went to emergency room for assessment .
On 02/07/24 at 1:59 PM, R265 was in bed lying on left side. The bed was in the low position. The reclining chair was next to the bed. There was no mat on the floor and the bed alarm was not operable, nor was there a green light on to show it was working.
On 02/07/24 at 1:53 PM, V14 (Certified Nursing Assistant/CNA) said R265 had not had any falls lately.
On 02/07/24 at 1:55 PM, V11 (Certified Nursing Assistant) said, We keep monitoring her all the time in the room. If she is in bed, we have a bed alarm, her bed is in the low position, and she has a mat on the floor.
On 02/07/24 at 2:03 PM, V14 (Certified Nursing Assistant) entered the room and said, No her bed alarm is not engaged. I am now putting the mat down.
On 02/07/24 at 2:05 PM, V15 (Certified Nursing Assistant) said, There was no alarm engaged, and there was no mat on the floor when we went into (R265's) room.
On 02/07/24 at 02:07 PM, V14, CNA, said, She (R265) would fall and get hurt. The battery was dead so I changed it.
On 02/07/24 at 2:09 PM, V10 (License Practical Nurse/LPN) said, No, she (R265) has not fallen recently. We had the reclining chair and the table that goes with it per her family request. They (CNA's) should have the mat on the floor, the bed alarm engaged, and she should have a low bed. She could get hurt if the bed alarm was not engaged or the mat was not on the floor. She could fall out of bed and break something.
On 02/07/24 at 2:18 PM, V2 (Director of Nursing) said, Yes I am familiar with (R265). She is a fall risk. She has a reclining chair, low bed, a mat on the floor, and she has a bed alarm for interventions. When she is in bed, the bed alarm should be engaged and the mat should be on the floor. If the alarm is not engaged and she starts getting out of the bed, we would not know. If she tries to get out of bed she could fall and get injured.
The facility's fall log, dated September 2023, showed R265 had a fall on 9/1/23 two times, a fall on 9/24/23 and 9/26/23.
The facility's Fall Risk assessment and Fall Prevention Policy, dated revised 3/15/2023, showed, 3. Interventions should be established to reduce the risk of falls. These may include: .Use of personal alarm in chair and or bed to alert staff of unsafe actions, Use of fall mats beside resident's bed.
Based on observation, interview, and record review, the facility failed to reassess a resident (R63) for elopement risk after the resident asked for directions and said he thinks he is going to go out the door. The facility also failed to ensure fall interventions were in place for a resident (R265) at high-risk for falls. This applies to 2 of 9 residents reviewed for safety/supervision in the sample of 14.
The findings include:
1. R63's Client Diagnosis Report, printed by the facility on 2/8/24, showed he had diagnoses including Alzheimer's disease, Parkinson's disease, and anxiety disorder.
R63's Psychotropic Drug Monitoring Record, dated 12/19/23, showed he continues to show symptoms of sundowning daily with increased confusion in the early afternoon/evening.
R63's facility assessment, dated 9/19/23, showed he requires limited assistance of one staff member for locomotion, transfers and walking.
R63's care plan, with a revision date of 1/2/24, showed he had impaired cognition as relates to Parkinson's disease, dementia, related to visual hallucinations.
R63's care plan ,dated 1/2/24, showed he had altered thought processes related to anxiety and deficits in coping due to a decline in his cognitive level and fear.
On 2/6/24 at 1:20 PM, R63 was sitting in his wheelchair in the entrance to the lounge area, near the nurse's station. R63 called this surveyor over and asked which way he should go when he got out of here. This surveyor asked R63 if he was asking how to get to his room. R63 said, No, when you go outside, which way do I go to get home. This surveyor told R63 she was not from the area, and informed him his family wants him to get better before he goes home. R63 said he does not think he is going to get better, and he thinks he is going out the door. R63 said, What's the plan? Do we go tonight or what? This surveyor informed R63 she would get a staff person to talk to him. Two nurses were at the nurse's station. This surveyor informed V16 (Licensed Practical Nurse-LPN/Unit Manager and V17 (LPN-R63's Nurse) what R63 was saying. V16 and V17 said they would keep an eye on him.
On 2/7/24, a review of R63's Nurse Progress Notes showed no mention of R63 voicing he was going to go out the door to the facility.
On 2/8/24, R63's most recent Elopement and Wandering Assessment was requested. The assessment provided by the facility was dated 1/31/24. The assessment showed R63 was either ambulatory or able to mobilize in wheelchair. The assessment showed R63 was cognitively impaired with poor insight to make safe decisions and /or has a pertinent diagnosis of Alzheimer's, dementia, delusions, or hallucinations. The assessment showed R63 was not appropriate on 1/31/24 to be placed on Elopement/Wanderguard watch.
On 2/8/24 at 12:26 PM, V16 (LPN/Unit Manager) said she will have to reassess R63 for elopement risk. V16 said R63 has asked before How do I get home? V16 said, We just direct him to his room and that works. (R63) has dementia and Parkinson's disease.
2/8/24 at 12:55 PM, V2 (Director of Nursing-DON) said she would have expected an elopement risk assessment to be done on R63 when this surveyor reported what he said to V16 and V17. V2 added, If a resident is expressing a clear plan about leaving or getting out of the facility, we (the facility) would put a monitor on him to ensure he cannot get out of facility.
The facility's policy titled Elopement and Wandering, with a revision date of 10/31/23, showed, It is the policy of (the facility) to maintain and ensure the safety of all residents in the facility. The facility has a process in place to assess all residents for risk of elopement and wandering and to implement a risk reduction plan of action for any resident identified as an elopement or wandering risk. The policy showed an elopement and wandering assessment will be reviewed quarterly and revised when necessary. An Elopement and Wandering Assessment will also be completed with a resident's change of condition or mental status. The risk evaluation tool will have a scoring system to identify the residents that will need to be place in the wander guard/elopement program. The policy showed if the assessment was identified as an elopement risk, the family would be notified, a wanderguard would be placed on the resident, the risk would be identified next to their name on the assignment sheet, the resident's care plan would be updated and more frequent monitoring, in addition to other interventions would be implemented.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have a Registered Nurse on duty at least eight hours a day. This applies to all 31 residents in the facility.
The findings include:
The Cen...
Read full inspector narrative →
Based on interview and record review, the facility failed to have a Registered Nurse on duty at least eight hours a day. This applies to all 31 residents in the facility.
The findings include:
The Center for Medicare and Medicaid Services 671, dated 2/7/24, shows there are 31 residents in the facility.
The payroll based journal (PBJ) Staffing Data Report for quarter 4 of 2023 shows no Registered Nurse (RN) was on duty 7/8/23, 7/9/23, 7/16/23, 7/29/23, 8/6/23 and 8/13/23. The facility was unable to prove a RN was on duty 7/8/23 and 7/9/23.
On 2/8/24 at 11:32 AM, V4 Business Office Manager (BOM), said there are 2 days the facility did not have RN nurse coverage. V4 said, When an agency nurse works for the facility, the agency sends me a bill, and this is how I know what staff worked in the facility. V4 said the bill comes after she has to submit the PBJ information, so she does not always have the correct information when submitting the data into the PBJ system.
On 2/8/24 at 12:00 PM, V2, Director of Nursing, said she covers the shifts where there is not an RN working, and since she is salaried, the BOM, who submits the PBJ data, does not have a time card for her and unable to submit she was working the floor and a RN was in the building. V2 said there needs to be a better system in place for the data to be submitted into the PBJ system.
The facility provided the Administrative Code section 300.1240 to this surveyor when asked to provide a policy for RN coverage. The code shows there shall be at least one registered nurse on duty seven days per week, 8 consecutive hours in a skilled nursing facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have a Dietary Manager in the facility. This applies to all 31 residents in the facility.
The findings include:
The Center fo...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to have a Dietary Manager in the facility. This applies to all 31 residents in the facility.
The findings include:
The Center for Medicare and Medicaid 671, dated 2/7/24, shows there were 31 residents in the facility.
On 2/6/24 at 10:27 AM, there was no Dietary Manager in the kitchen. V5, Cook, said the facility does not have a Dietary Manager.
On 2/7/24 at 10:50 AM, V1, Administrator, said the facility has not had a Dietary Manager since 10/4/23. V1 said they have had a difficult time keeping a Dietary Manager.
On 2/7/24 at 1:30 PM, V8, facility Dietician, said the Dietary Manager would be in charge of the menus, the specialty diets, and making sure the residents get the proper diets.
The undated job description for the food service supervisor shows they are responsible for monitoring all the nutritional needs of all the residents within the facility. They will follow and comply with all physician orders regarding therapeutic diets and meeting the nutritional needs of the residents. The food service supervisor is responsible for the daily operations of the dietary department, updating diet orders as they change, and dealing with significant weight fluctuations of the residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to provide the residents with snacks. This applies to all 31 residents in the facility.
The findings include:
The Centers for Me...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to provide the residents with snacks. This applies to all 31 residents in the facility.
The findings include:
The Centers for Medicare and Medicaid 671, dated 2/7/24, shows there are 31 residents in the facility.
On 2/7/24 at 9:30AM, during the resident group meeting, R116, R118, and R3 said the facility does not offer the residents snacks. All three residents agreed they would prefer to have snacks offered to them.
On 2/07/24 at 10:30 AM, V1, Administrator, said the facility has been spotty on getting the snacks out to the residents, and the facility needs to do a better job on getting this done, and needs to have a new system in place.
On 2/08/24 at 8:47 AM, V11, CNA (Certified Nursing Assistant), said the kitchen does not supply snacks for the residents.
On 2/08/24 at 8:47 AM, V10, LPN (Licensed Practical Nurse), said the kitchen does not supply the residents with a snack cart.
On 2/08/24 at 9:28 AM, V9, LPN, said there are no snacks supplied for the residents. V9 said the staff have asked V1 for snacks to be made available to the residents for a while now.
The facility policy, with a revision date of 10/15/23 for HS snacks, shows residents are to be offered an HS (night time) snack.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the facility had a licensed administrator. This applies to all 31 residents residing at the facility.
The findings include:
The fac...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure the facility had a licensed administrator. This applies to all 31 residents residing at the facility.
The findings include:
The facility resident roster, printed on 2/6/24, showed 31 residents residing in the facility.
On 2/6/24 at 10:31 AM, V1 (Administrator) stated his brother was the administrator of the facility until he passed away in October of 2022. V1 said he became the facility administrator at that time. V1 said he submitted paperwork to the IDFPR (Illinois Department of Financial and Professional Regulation) to obtain his administrator license sometime in February or March of 2023. V1 said he was told the paperwork was not complete, and he submitted the correct information just yesterday (2/5/24).
On 2/8/24 at 1:25 PM, V1 stated he submitted paperwork in April of 2023 for a temporary non-examination nursing home administrator license, and is still in the process of getting it. V1 said he called the IDFPR in November of 2023 to follow up on his application for administrator. V1 said he was told there were missing pages on the application. He was told pages 2, 3, and 4 were missing. V1 said he just resubmitted those pages on 2/5/24 (four months later). V1 said there has not been a licensed administrator in the building since 2022. V1 said he is still working on getting his administrator license from the process that began in April of 2023 (ten months ago).
On 2/8/24 at 1:14 PM, V2 (Director of Nurses) stated V1 was supposed to be working on his administrator license for over the past year. V2 said she was unaware the facility has not had a licensed administrator for such a long time.
V1's IDFPR Application- Certification of Acceptance Form, dated 4/3/23, shows, To ensure timely receipt of a temporary license, the completed application packet for licensure must be received in the Department of Financial and Professional Regulation at least 60 days prior to the appointment of the individual as a nursing home administrator. This form shows V1 was accepted or appointed as nursing home Administrator on 12/01/22.
V1's IDFPR Application for Licensure and/or Examination form, dated 2/5/24, shows V1 applied for the nonexamination license method, and the box was checked stating: This is the first time I have made application for this profession in Illinois.
Mar 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R2's current Plan of Care, dated 3/21/23, shows R2 has a potential risk for infection related to indwelling Foley catheter an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R2's current Plan of Care, dated 3/21/23, shows R2 has a potential risk for infection related to indwelling Foley catheter and past medical history of urinary tract infection.
R2's Minimum Data Set, dated [DATE], shows R2 has severe cognitive impairment and is dependent on care givers for toilet use and personal hygiene.
On 3/20/23 at 1:32 PM, V3, CNA, used a dry washcloth to clean stool from R2's backside. Smears of stool remained on R2's skin. R2 had an indwelling urinary catheter. No frontal pericare or catheter care was provided. V3 did not wet the washcloth, use soap, a pre-moistened wipe or peri spray during R2's incontinence care.
On 3/21/23 at 1:20 PM, V4, Unit Manager/Licensed Practical Nurse, said during incontinence care, staff are to use wet washcloths and either soap or peri spray to clean the resident thoroughly. V4 said staff should do frontal peri care when changing a resident's brief whether the resident had a bowel movement or not. V4 said catheter care should be done when a resident has a BM (bowel movement) if they see the catheter is soiled.
The facility's Incontinence Care Policy (effective 7/20/22) shows the correct incontinence care procedure includes obtaining washcloth(s) with soap and water or wipes and peri wash. Using wipes, the caregiver will clean all excrements off the resident's skin. The caregiver will cleanse the resident's genital area first and always cleanse from front to back, taking care to get into all of the crevices (inner legs, labia, and groin) and clean the anal area last.
Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter bag was kept below the level of the bladder and failed to ensue thorough incontinence care was performed to prevent infections for 2 of 4 residents (R2 and R63) reviewed for catheters/incontinence care in the sample of 9.
The findings include:
1. R63's Care Plan shows, potential risk for infection related to use of indwelling catheter clean and change indwelling catheter bags as per protocol.
On 3/21/23 at 1:40 PM, R63 was laying in bed. R63 had an indwelling urinary catheter in place. R63 had a leg bag attached to the catheter. The leg bag was three quarters of the way full and parallel to his bladder.
On 3/20/23 at 10:25 AM, V7 (Licensed Practical Nurse/LPN) said R63 recently returned from the hospital and was diagnosed with a urinary tract infection and has an appointment to see urology.
On 3/21/23 at 1:27 PM, V6 (Certified Nursing Assistant/CNA) said if a resident has a leg bag for their catheter, it is changed to a regular bag in the evenings when they go to bed. V6 said it is not usually changed if they are just laying in bed to take a nap. At 1:33 PM, V2 (Director of Nursing) said the leg bag should be changed into a regular bag at night time, or when a resident is taking a nap in bed during the day.
The facility's undated Urinary Leg Bags Policy shows, Disconnect the leg bag and reapply the drainage bag when resident returns to bed.
The facility's undated Urinary Foley Catheter-Care of Indwelling Catheter Policy shows, The drainage bag should be kept in a dependent position at a level lower than the bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure oxygen administration supplies were changed as ordered for 1 of 3 residents (R2) reviewed for oxygen administration in...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure oxygen administration supplies were changed as ordered for 1 of 3 residents (R2) reviewed for oxygen administration in the sample of 9.
The findings include:
R2's Physician's Order Sheet shows an order for, O2 (oxygen) via NC (nasal cannula) at 2-5 liters continuous as needed for shortness of breath .Change oxygen tubing/cannula and bubbler (humidifier) weekly.
R2's Care Plan, printed on 3/22/2,3 does not have a plan of care for oxygen.
R2's Treatment Administration Record shows the tubing and bubbler should be changed on 3/8/23 and 3/15/23.
On 3/20/23 at 9:46 AM, R2 had an oxygen concentrator in her room. The humidifier bottle (bubbler) on the concentrator was half full and was labeled 3/10.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure an as needed antianxiety medication had a duration, and failed to ensure psychotropic medications were reduced as recommended for 2 ...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure an as needed antianxiety medication had a duration, and failed to ensure psychotropic medications were reduced as recommended for 2 of 5 residents (R1 and R2) reviewed for psychotropic medications in the sample of 9.
The findings include:
1. R2's March Physician's Order Sheet shows orders for: Mirtazapine (antidepressant) 7.5 milligrams (mg)-Give one tablet at bedtime ordered on 2/18/21 and Lorazepam (anti-anxiety medication) 2mg/1 milliliter-Give 0.5 ml every 2 hours as needed ordered on 3/11/21 and had no discontinuation date documented.
R2's Pharmacist Recommendation to Prescriber/Physician Form, dated 1/23/23, shows, Resident has ordered Mirtazapine 7.5 mg at bedtime. Periodic dosage reductions are strongly recommended by nursing facility recommendations. May we attempt a trial dosage reduction to Mirtazapine 7.5 mg every other night at bedtime to help the this facility maintain regulatory compliance? The bottom portion of the form was not filled out with the physician/prescriber response.
2. R1's March Physician's Order Sheet shows an order for: Mirtazapine 15 mg-Give one tablet at bedtime with a start date of 2/19/21.
R1's Pharmacist Recommendation to Prescriber/Physician Form, dated 1/23/23, shows, Resident has ordered Mirtazapine 15 mg at bedtime. Periodic dosage reductions are strongly recommended by nursing facility recommendations. May we attempt a trial dosage reduction to Mirtazapine 7.5 mg at bedtime to help the this facility maintain regulatory compliance? The bottom portion of the form was not filled out with the physician/prescriber response.
On 3/22/23 at 10:38 AM, V4 (Licensed Practical Nurse-Unit Manager) said pharmacy reviews are reviewed by her or the Director of Nursing, and then sent to the prescribing physician for a response. V4 said when the recommenation form is returned, the response is carried out, and the form is put in the resident's chart. V4 reviewed R1 and R2's chart, and could not find a response documented. V4 said they review all psychotropic medications periodically for dose reductions. V4 said all as needed psychotropic medications have to have a stop date of 14 days. V4 said after the 14 days, the provider is contacted about renewing it, and if it is renewed, a new order is placed in the computer with a stop date.
The facility's Behavioral and Psychotropic Monitoring Policy, revised on 4/2020, shows, The resident must be assessed to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose based on target symptoms and any adverse affects. The drug dosage of psychotropic medications must be monitored by the nursing staff, the resident's physician or psychiatrist. The drug dosage must be periodically reduced to the lowest effective dose unless such action is clinically contraindicated by the resident's physician or psychiatrist .Any PRN (as needed) psychotropic medications should be reevaluated after a 14 day duration, the physician or prescribing practitioner should determine if it is appropriate for the PRN order to be extended beyond 14 days and the rationale for doing so.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff changed their gloves and performed hand ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff changed their gloves and performed hand hygiene during and after incontinence care for 1 of 9 residents (R2) reviewed for infection control in the sample of 9.
The findings include:
R2's current Plan of Care, dated 3/21/23, shows R2 has a potential risk for infection related to indwelling Foley catheter and past medical history of urinary tract infection.
R2's Minimum Data Set, dated [DATE], shows R2 has severe cognitive impairment and is dependent on care givers for toilet use and personal hygiene.
On 3/20/23 at 1:32 PM, V3, Certified Nursing Assistant (CNA), used gloved hands to remove R2's pants and brief. V3 placed the stool soiled brief on the carpeted floor next to R2's bed, and wiped stool from R2's backside using a dry washcloth. V3 placed the soiled washcloth on the floor with the soiled brief. V3 then pulled up R2's blankets to cover her and left the room to get more washcloths. V3 touched the door and door handle on her way out of the room, without removing her gloves or performing hand hygiene. V3 returned with clean washcloths, then changed her gloves. V3 finished wiping the stool from R2's backside and, without changing her gloves or performing hand hygiene, applied a clean brief, pulled up R2's pants, and picked up the soiled brief and washcloths from the floor and carried them out of the room. V3, again, touched the door and door handle on her way out of the room.
On 03/21/23 at 1:20 PM, V4, Unit Manager/Licensed Practical Nurse, said staff should change their gloves during incontinence care between the dirty and the clean. V4 said after taking off a soiled brief, it should be placed in a plastic garbage bag, V4 said no wash cloths or briefs should ever be thrown on the floor. V4 said gloves should be removed and hand hygiene should be done before applying a clean brief.
The facility's Incontinence Care Policy (effective 7/20/2022) shows staff are to remove their gloves after the resident is cleaned, wash hands and apply new gloves. The same policy also shows once staff are finished, they should remove their gloves and perform hand hygiene.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the facility employed/contracted a Registered Dietitian. This failure applies to all 12 residents residing in the facility.
The find...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure the facility employed/contracted a Registered Dietitian. This failure applies to all 12 residents residing in the facility.
The findings include:
The CMS-672 Form, dated 3/21/23, showed a facility census of 12
On 3/20/23 at 9:20 AM, V8, Dietary Supervisor, stated there was not a Dietitian at this time.
On 3/22/23 at 10:50 AM, V10, Registered Dietitian, stated she was contracted with the facility on Monday (3/20/23), but has not been to the facility yet.
On 3/22/23 at 11:30 AM, V9, Facility Office Manager, stated the previous Dietitian's last day with the facility was 9/30/22. The new dietary contract was initiated on 3/20/23.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure controlled drugs were stored in a manner to pr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure controlled drugs were stored in a manner to prevent diversion for 3 residents (R3, R4, R5) reviewed for medications in the sample of 10.
The findings include:
1. R3's face sheet showed a [AGE] year-old woman with diagnosis of palliative care, pneumonia, heart failure, chronic kidney disease, and vascular syndromes of the brain.
R3's physician order sheet (POS) showed an order for lorazepam 2 milligrams (mg) per 1 ml solution, give 0.5ml (1 mg) sublingual (under the tongue) every two hours as needed. This POS showed an order for morphine sulfate 20 mg per 5 ml solution, give 1.2 ml (5 mg) sublingual (sl (under the tongue)) every hour as needed.
On 1/19/23 at 10:03 AM, V2, Director of Nursing (DON), opened the unlocked 300 hall medication room door. V2 then opened the unlocked medication refrigerator. Inside the refrigerator was a large tackle box type plastic container that was easily lifted out and onto the counter. V2 unlocked the box using a combination. Inside the box were two opened 15 milliliter (ml) medication bottles with a dropper top. Both bottles were labeled as belonging to R3. One bottle was labeled lorazepam and the other as morphine sulfate.
On 1/19/23 at 12:05 PM, V2 said controlled drugs should be double locked during storage to prevent diversion.
2. R5's face sheet showed an [AGE] year-old male with diagnosis of Diabetes, anemia, insomnia, and cerebrovascular disease.
R5's POS showed an order for lorazepam 2 mg per ml solution, give 0.25 mg by mouth every four hours as needed. This POS showed an order for morphine sulfate 20 mg per ml solution, give .25 ml (.5 mg) by mouth every four hours as needed.
At 10:23 AM, the 400-hall medication door was wide open. V2 entered and opened an unlocked medication refrigerator. Inside the refrigerator was a large tackle box type plastic container that was easily lifted out and onto the counter. V2 unlocked the box using a combination. Inside the box were two opened medication bottles with a dropper top. Both bottles were labeled with R5's information. One bottle contained lorazepam and the other contained morphine sulfate.
3. R4's face sheet showed an [AGE] year-old female with diagnosis of palliative care, traumatic subdural hemorrhage, hemiplegia, and metabolic encephalopathy.
R4's POS showed an order for lorazepam 2 mg per 1 ml solution, give 0.5 ml (1 mg) sl every two hours as needed.
The 400-hall medication refrigerator container also contained a third unopened bottle. This bottle was labeled with R4's information and showed it contained lorazepam.
The 11/29/22 federal Drug Administration (FDA) requirements for controlled drug storage showed Sec. 1301.75 Physical security controls for practitioners: (a) Controlled substances listed in Schedule I shall be stored in a securely locked, substantially constructed cabinet. (b) Controlled substances listed in Schedules II, III, IV, and V shall be stored in a securely locked, substantially constructed cabinet. However, pharmacies and institutional practitioners may disperse such substances throughout the stock of noncontrolled substances in such a manner as to obstruct the theft or diversion of the controlled substances.
The United States Drug Enforcement Agency (DEA) website showed lorazepam is classified as a Schedule 4 controlled substance and morphine is a Schedule 2.
The facility's 1/14/20 Narcotic Count Policy showed the narcotics supply is to be kept under two locks at all times.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $246,461 in fines, Payment denial on record. Review inspection reports carefully.
- • 23 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $246,461 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (8/100). Below average facility with significant concerns.
Bottom line: Trust Score of 8/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Libertyville Manor Ext Care's CMS Rating?
CMS assigns LIBERTYVILLE MANOR EXT CARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Libertyville Manor Ext Care Staffed?
CMS rates LIBERTYVILLE MANOR EXT CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes.
What Have Inspectors Found at Libertyville Manor Ext Care?
State health inspectors documented 23 deficiencies at LIBERTYVILLE MANOR EXT CARE during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 21 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Libertyville Manor Ext Care?
LIBERTYVILLE MANOR EXT CARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 174 certified beds and approximately 29 residents (about 17% occupancy), it is a mid-sized facility located in LIBERTYVILLE, Illinois.
How Does Libertyville Manor Ext Care Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, LIBERTYVILLE MANOR EXT CARE's overall rating (1 stars) is below the state average of 2.5 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Libertyville Manor Ext Care?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Libertyville Manor Ext Care Safe?
Based on CMS inspection data, LIBERTYVILLE MANOR EXT CARE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Libertyville Manor Ext Care Stick Around?
LIBERTYVILLE MANOR EXT CARE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Libertyville Manor Ext Care Ever Fined?
LIBERTYVILLE MANOR EXT CARE has been fined $246,461 across 2 penalty actions. This is 6.9x the Illinois average of $35,543. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Libertyville Manor Ext Care on Any Federal Watch List?
LIBERTYVILLE MANOR EXT CARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.