F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide person-centered discharge plan of care for 5 out 5
residents (R1, R2, R3, R4 and R5) reviewed for care plan.
Finding includes:
R1 is [AGE] years old, initially admitted in the facility on 02/27/2025. R1 medical diagnosis includes atrial
fibrillation, deep vein thrombosis on the right leg, spinal stenosis, radiculopathy lumbosacral region and
malaise. R1's cognition based on her BIMS score of 15 dated 03/05/2025.
On 04/01/2025 at 10:32 PM, V3 (Ombudsman) stated that R1 and her daughter (V6) had concern about
being discharge prematurely.
Care plan of R1 was reviewed in relation to discharge planning. Per R1's care plan R1 does not plan to
make the community/facility a long-term home that was dated on 02/27/2025. Goal is for R1 to be assisted
with plan of stay in the community/facility until discharge is practicable, through the next review period.
Interventions includes associates/facility staff will support R1 plan to stay short term. And assist with
referrals, as needed, to meet the goals for discharge. It does not have specific information about R1 plan of
discharge.
Random residents care plan was reviewed including R2, R3, R4 and R5 related to discharge planning: All
return to community referral or discharge care planning of R2, R3, R4 and R5 are almost identical, except
that residents are categorized as short or long term.
On 04/01/2025 at 12:35 PM, V13 (Daughter of R2) said, I do not know any discharge plan. We don't get it
straight anywhere here. It is a problem. No social worker talked to me about plan for discharge. There is a
lot of issue here.
On 04/01/2025 at 12:49 PM, R3 when asked about her discharge plan. R3 said, I am hoping and praying to
let me go home this week. I don't want to say anything to make it unfavorable for me. R3 stated that she
currently on therapy (physical and occupational therapy). R3 said, I have no idea what the plan for my
discharge.
On 04/02/2025 at 10:15 AM, V4 (Social Worker) stated that facility use template to all residents on
discharge care planning. And each resident's care plan will not show any difference. Notes will show
difference in resident's situation but not care plan. R1, R2, R3, R4 and R5 care plan were reviewed with V4.
V4 said, You cannot see anything difference there. V4 reviewed discharge summary and plan
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145960
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145960
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ascension Resurrection Life
7370 West Talcott Avenue
Chicago, IL 60631
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
policy of the facility. After review V4, I see what you mean. I thought it was for the meeting of the IDT not the
actual care plan.
On 04/03/2025 at 12:25 PM V1 (Administrator) stated that she was not able to review care plan of residents
that were reviewed. Moving forward, facility will identify care plan improvement to make it person-centered.
Residents Affected - Some
Discharge Summary and Plan Policy dated 01/2024, reads:
Policy statement, when a resident's discharge plan is anticipated, a discharge summary and post-discharge
plan will be developed to assist the resident to adjust to his/her new living environment. Pre-discharge plan
will be developed by the Care Planning/Interdisciplinary Team (IDT) with the assistance of the resident and
his or her representative.
Care Plans - Comprehensive Person-Centered policy dated 09/2023, reads:
A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet
resident's physical, psychosocial and functional needs, that are identified through evaluation and
assessment, is developed, and implemented for each resident. The comprehensive, person-centered care
plan will include the resident's stated preference and potential for future discharge, including his or her
desire to return to the community and any referrals made to local agencies or other entities to support such
desire. It will also include discharge plans.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145960
If continuation sheet
Page 2 of 2
