Morgan Park Healthcare

In the surveyor’s words

From the most serious findings on record at Morgan Park Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 13, 2026

  Based on interview and record review, the facility failed to monitor, supervise, and intervene for seven residents (R1, R3, R7, R19, R20, R21, R22) with known substance use disorders. This failure resulted in the residents engaging in activities suspected of drug use and overdose. R1, R7, R19, and R21 were found unresponsive in the facility. R3 was found unresponsive in the facility and expired with suspicion of drug overdose. The facility also failed to provide supervision and monitoring for residents. As a result of these failures, R4 fell on the floor on [DATE], while located inside the facility and sustained a left femur fracture. The facility also failed to update a fall care plan and follow assessments to prevent 1 out of three residents (R6) from falling. […]

• Immediate jeopardy, isolatedF684Aug 12, 2024

  Based on interviews and record reviews, the facility failed to follow the recommendation of the dietitian and obtain a doctor's order for one-to-one feeding assistance for one resident (R4); failed to provide one-to-one feeding assistance; failed to elevate the head of the bed to an upright position for eating; and failed to care plan for one-to-one feeding assistance. These failures resulted in R4 being given food for lunch without one-to-one feeding assistance; R4 choked on the food and subsequently expired on [DATE]. These failures resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF600Nov 7, 2023

  Based on observations, interviews and record reviews, the facility failed to ensure one resident (R22) was free from severe physical abuse and emotional trauma caused by three staff members. This failure resulted in R22 sustaining a right black eye, scratches under the eye and a scratch on top of R22's head after being repeatedly punched by staff members. The staff failed to recognize abusive behavior towards R22. Staff continued to work in the facility; facility staff failed to assess and monitor R22 for injuries. This was identified as an immediate jeopardy which began on 10/12/23 when R22 was attacked by three facility staff members. On 10/19/23 at 2:06 PM the Administrator and Nurse Consultant were notified and presented with the immediate jeopardy template. […]

• Immediate jeopardy, isolatedF689Nov 7, 2023

  Based on interviews and record reviews, the facility failed to ensure that the resident's environment remains free of accidental hazards for one resident (R6) who had 13 disposable shaving razors stored at bedside; failed to provide supervision and interventions for two residents (R10 and R13) with substance abuse; and failed to provide adequate supervision for a cognitively impaired resident (R3) and assess and diagnose the resident (R3) for a history of substance abuse which resulted in R3 overdosing on opiates in the facility. R3 was intubated and admitted to the hospital with a diagnosis that included but not limited to Hypercapnic respiratory failure secondary to opiates overdose, altered mental status, secondary to opiate overdose and opiate abuse. […]

• Actual harm, isolatedF689Aug 27, 2026

  Based on interview and record review, the facility failed to ensure that two residents (R1 and R2) with history of illicit drug use, without individual community pass privileges, gain access to illicit drugs. This failure affected 2 of 3 residents reviewed for supervision and accidents. This failure resulted in R1 testing positive for Cocaine and Cannabinoid and R2 found unresponsive and treated with Narcan.Findings include:R1's medical diagnoses include but are not limited to human immunodeficiency virus, schizophrenia, anxiety, bipolar, essential hypertension, major depressive disorder. […]