Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure residents were able to operate their
televisions for 2 of 2 residents (R31 & R8) reviewed for choices in the sample of 14. The findings include:1.
On 7/23/25 at 8:17 AM, R31 was sitting in a wheelchair in the dining room at the table. R31's right lower
extremity was elevated up on a footrest with an elastic wrap around her leg. R31 had a wound vacuum in
place and a device to provide cold therapy to her knee. R31 stated she was admitted to the facility a few
days ago and her television (TV) did not work; it would not turn on with her remote. R31 stated someone
came in, got up on a ladder, and pushed the button on the tv to turn it on. She stated after that the TV
remained on; it couldn't be turned off, changed, or the volume controlled. R31 stated told staff about it. She
said she hasn't been able to sleep because the TV stayed on. At 8:20 AM the surveyor went to the
resident's room with her permission. There were two remote controls sitting on her bedside table and
neither one would control the TV; the TV was on in her room. On 7/23/25 at 8:22 AM, V11 Maintenance
Director was asked if he knew anything about R31's TV/remotes. V11 stated the remote just needed to be
programmed. V11 stated staff know how to get the TV's working and they should have let him know the
remote wasn't working. On 7/23/25 at 8:25 AM, V2 Director of Nursing (DON) stated she got a text this
morning that R31 was really complaining about her TV last night and it is staying on. R31 stated she
couldn't sleep. V2 stated the patient needs their sleep. V2 stated normally residents complain about their
TV's not coming on. The Face Sheet dated 7/24/25 for R1 showed she was admitted on [DATE] with
diagnoses including aftercare following joint replacement surgery, hypothyroidism, type 2 diabetes mellitus,
hyperlipidemia, hypertension, depression, atherosclerotic heart disease, chronic kidney disease, presence
of right artificial knee joint, infection, and inflammatory reaction due to internal right knee prosthesis. The
Care Plan dated 7/21/25 for R31 showed, I am a new resident at this facility for short term rehabilitation. My
leisure interests include watching TV, being with family, going outside, and music. My focus is therapy so I
can go back home. I have a potential for falls and injury from falls related to deconditioning. The facility's
Notice of Resident Rights and Responsibilities policy (2/1/25) showed the facility shall inform the resident
both orally and in writing of his or her rights as a resident, and the rules and regulations governing the
resident's conduct and responsibilities during his or her stay in the facility. The policy did not show anything
related to resident choices. The facility did not have a resident choices policy. 2. On 7/23/25 at 8:29 AM, R8
stated that her remote for her television (tv) has been missing since yesterday. R8 stated before her remote
came up missing it worked just fine. R8 stated she always kept it on her over the bed table. R8 told
someone about it yesterday but they were busy, and no one located her remote. R8 stated she likes to
watch tv, so she doesn't get bored; it keeps her mind off things. R8 said she noticed her remote was gone
around lunch time on 7/22/25 and it is still missing. At 8:38 AM, V11 Maintenance Director came
(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 4
Event ID:
146069
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
146069
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
East Bank Center, LLC
6131 Park Ridge Road
Loves Park, IL 61111
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 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
stated the extra remote in R31's room was the remote for R8's television. The Face Sheet dated 7/24/25 for
R8 showed diagnoses including unspecified cord compression, muscle weakness, difficulty walking,
gastro-esophageal reflux disease, hyperlipidemia, intervertebral disc disorder, spinal stenosis, spondylosis
with myelopathy, and anterior spinal artery compression syndromes of the thoracic region. The Minimum
Data Set, dated [DATE] for R8 showed no cognitive impairment; partial/moderate assistance for bed
mobility, sit to stand, chair/bed transfer, toilet transfer, and walking 10 feet. The Care Plan dated 7/11/25 for
R8 showed, I am a new resident to this facility for short term rehabilitation. My leisure interests include
talking to my family when they come to visit, watching movies on TV, reading magazines my family bring in,
talking to others about my horses I own. Continue to Assess and explore my leisure preference with me
and/or my family. Remind me that independent activities are always available such as crosswords,
television, games, puzzles, magazines, and books, etc.
Event ID:
Facility ID:
146069
If continuation sheet
Page 2 of 4
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
146069
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
East Bank Center, LLC
6131 Park Ridge Road
Loves Park, IL 61111
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to adequately store food items by not
properly labeling and/or dating items; and failed to ensure the sanitizing solution was at the recommended
level. This failure has the potential to affect all 29 residents currently residing in facility.Findings include:On
07/22/2025, upon entering facility, V1 (Administrator) indicated resident in-house census of 29. Facility
provided a completed CMS 802 form that indicated resident census of 29.On 07/22/2025 at 10:40 AM,
initiated kitchen tour with V4 (Food Service Director) with the following observations. At 10:51 AM, red
sanitation bucket near the three compartment sink was tested by V4 (Food Service Director) and test strip
read 150 ppm (parts per million). V4 indicated that the sanitizer level should be at 200 ppm. V4 added that
staff have been using this same sanitizing solution all morning. At 11:40 AM, observed in storage
refrigerator, a jar of marble glaze and minced garlic both opened and undated, and both visibly used. At
11:43 AM, observed in storage freezer an undated bag of fish filets that was not properly closed with visible
ice crystals on several filets. V5 said food items should be labeled with an open and discard date. On
07/24/2025 at 1:56 PM V3 (Infection Preventionist) said the red bucket sanitation solution should be at the
recommended levels to kill any bacteria. Undated Labeling and Dating Foods policy reads in part: to
decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date
received, the date opened and the date by which the item should be discarded.Undated Sanitation
Buckets/Wiping Cloths Policy reads in part: in the red sanitation bucket mix the water and the chemical
sanitizer. The most common chemical sanitizers include but not limited to quaternary ammonia. Sanitizing
of food contact surfaces and equipment is accomplished according to the following.quaternary 200-400 per
manufacturer's directions.
Event ID:
Facility ID:
146069
If continuation sheet
Page 3 of 4
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
146069
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
East Bank Center, LLC
6131 Park Ridge Road
Loves Park, IL 61111
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure infection control was
maintained and prevent any cross contamination during wound care for 1 of 1 residents reviewed for
wounds in the sample of 14. Findings include:On 7/23/25 at 7:56 AM, V10 Licensed Practical Nurse (LPN)
went into R38's room to provide wound care to his right elbow and right knee. V10 put gloves on, removed
normal saline and triple antibiotic ointment from the treatment cart and placed it on a small disposable tray
next to some gauze. V10 changed her gloves, took the tray into the resident's room, and sat it on the over
the bed tray table next to R38. V10 opened a small pink saline tube and squirted it onto the gauze and then
cleaned off scabs and abrasion to his right elbow. V10 used the second pink tube of saline and squirted it
over his right elbow. V2 Director of Nursing (DON) walked into the room. V10 put antibiotic ointment on her
gloved finger and applied it to the scabs and abrasion on R38's right elbow. V10 removed her gloves, left
the room to get more saline tubes. V2 went out into the hall just prior to the nurse leaving the room and
spoke with the nurse when she exited the room. V10 grabbed more saline tubes, and a cotton tipped
applicator. V10 put gloves on and placed the cotton tipped applicator on the bedside table and not on the
disposable tray taken in for wound care. R38 lifted his right pant leg up and had scabbed area to his right
knee. V10 cleaned the area with saline. V10 removed her gloves, put new gloves on, and grabbed the
cotton tipped applicator from the bedside table V10 put antibiotic ointment on the cotton tipped applicator
and applied it to his right knee. V10 removed her gloves. V10 stated V2 told her when she left the room to
use a cotton tipped applicator to apply the antibiotic ointment because she had used her finger before to
put it on and it is important to keep it sterile. On 7/23/25 at 8:02 AM, V2 DON stated she talked to V10 LPN
because she didn't change her gloves after cleaning the area and before putting the ointment on. V10 also
applied the ointment with her fingers. This is for infection control. V2 stated she expects gloves to be
changed and cotton tipped applicators to be used. The Face Sheet dated 7/24/25 for R38 showed
diagnoses including right pubic fracture, muscle weakness, difficulty walking, unsteadiness on feet, lack of
coordination, depression, hypothyroidism, hypertension, congestive heart failure, chronic respiratory failure
with hypoxia, chronic kidney disease, and unspecified open wound of the right elbow. The Physician Order
Summary Report dated 7/24/25 for R38 showed, right elbow and bilateral lower extremity abrasions, clean
with normal saline and apply triple antibiotic ointment daily. Every day for wound care. On 7/24/25 the
facility presented some policies from the facility's Infection Control Policy and Procedure manual (2012)
such as Employee Training on Infection Control which showed the facility shall provide staff with appropriate
information and instruction about infection control through various means, including initial orientation and
ongoing training programs. Policies and Practices - Infection Control - the facility's infection control policies
and practices are intended to facilitate a safe, sanitary, and comfortable environment and to help prevent
and manage transmission of diseases and infections. The facility did not provide a policy regarding general
wound care. The facility provided a policy for Dry/Clean Dressings and Soiled/Contaminated Dressings;
neither policy related to wound care and infection control practices without a dressing.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146069
If continuation sheet
Page 4 of 4
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Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0531GeneralS&S Epotential for harm
Have elevators that firefighters can control in the event of a fire.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
FAQ · About this visit
Common questions about this visit
What happened during the July 24, 2025 survey of EAST BANK CENTER, LLC?
This was a inspection survey of EAST BANK CENTER, LLC on July 24, 2025. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EAST BANK CENTER, LLC on July 24, 2025?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.