Grove of Skokie, The

In the surveyor’s words

From the most serious findings on record at Grove of Skokie, The, in the surveyor’s own words.

• Actual harm, isolatedF686May 18, 2023

  Based on observation, interview, and record review, the facility failed to prevent or identify the formation of a pressure injury; failed to follow physician's orders to provide adequate pressure ulcer treatment to prevent the worsening of a pressure injury, and failed to follow their skin care treatment facility policy for 1 of 4 (R49) residents reviewed for pressure injury in a sample size of 30. As a result, R49 acquired a right heel pressure ulcer which progress to an open stage 4 pressure injury Findings include: R49's face sheet showed she is a [AGE] year-old female resident with a past medical history not limited to rhabdomyolysis, acute kidney failure, hypertension and history of Covid-19. She admitted to the facility on [DATE]. […]

• Actual harm, isolatedF697May 18, 2023

  Based on observation, interview and record review, the facility failed to perform comprehensive pain assessments as scheduled to promote effective pain management; failed to administer pain medication as requested/needed by a resident to prevent the negative effect of uncontrolled pain on a resident's function and mood; and failed to follow their pain policy and procedure for 2 of 4 (R115, R129) residents reviewed for pain management in a sample size of 30. As a result, R115 was left in periods of unbareable pain level which causes him to cry out to staff for medication for pain relief. Findings include: 1. […]

• Actual harm, isolatedF689Apr 30, 2021

  Based on observation, interview and record review the facility failed to develop fall prevention interventions to include supervision to reduce or prevent the risk of falling for 1 of 3 residents (R55) in the sample of 29 residents reviewed for supervisions and fall preventions. This failure resulted in R55 having multiple falls with injury resulting in treatments at the local hospital for nasal bone fracture, non-displaced fracture of the third cervical vertebra, and injury to right upper extremity. Findings include: On 4/27/21 at 10:00am, R55 is up in the wheelchair in the corner of her room doing coloring using her left hand. She is alert and oriented to self but does not speaks English. She has right arm sling which not properly placed. The sling is not supporting the right elbow. […]

• No harm, potential for more than minimal, widespreadF812Jun 7, 2024

  Based on observation, interview, and record review the facility failed to follow the Kitchen Policy by not labeling and dating a package of pita bread and a bulk bag of Indian (Baking) Flour. This failure has the capacity to affect 131 residents with an oral diet. The facility also failed to follow Sanitizer Manufacturer Instructions and Procedures for 3 Compartment Sinks by not immersing blender items for one minute. This failure has the capacity to affect 13 residents on a puree diet. Findings include: On 6-4-24 at 8:00 AM, surveyor observed walk-in refrigerator and noted pita bread wrapped in foil. The pita had no label with open/made date and expiration date. […]

• No harm, potential for more than minimal, widespreadF755May 18, 2023

  Based on observation, interview and record review the facility failed to follow controlled medications count policy by failing to maintain an accurate count of schedule II controlled pain medication for 1 of 85 (R129) residents during the medication storage and labeling task. This failure has a potential to affect all 133 residents residing at the facility. Findings include: On 5/15/23 at 9:45 AM, V1 (Administrator) presented survey team with facility matrix showing 133 current residents. On 05/16/23 at 10:19 AM Surveyor conducted inspection of Unit C medication cart. R129's oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) bottle - surveyor observed about half an inch of medication at the bottom of the bottle. […]