Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearl Of Montclare, The during CMS and state inspections, most recent first.
Hot foods were not kept at safe temperatures during meal service. Meal trays were checked in the kitchen at proper temperatures before service, but temperatures dropped substantially after delivery to the floors, including one floor where the test tray measured as low as 90 F. The DSD acknowledged the temperatures were not acceptable and noted the second floor did not use the same insulated hotbox carriers as other floors. Residents with intact cognition reported that meals, including breakfast eggs and lunch items, were often served cold, and the resident council president said this concern had been raised repeatedly in food committee meetings.
A resident with multiple comorbidities and moderate cognitive deficits developed a new sacral deep tissue pressure injury that was identified by therapy staff and assessed by the wound care LPN. Although the wound was documented in a wound summary, there were no corresponding physician orders or treatments on the POS or TAR, and no documented notification of the physician or the resident’s representative. The LPN later stated she must have forgotten to carry out physician orders and acknowledged that facility practice and written policy require notifying the physician and family and documenting the change in condition and any new treatment plan.
A resident with multiple comorbidities, including CVA, diabetes, malnutrition, and reduced mobility, was identified as at risk for pressure ulcers and later developed a sacral DTPI noted by therapy staff and assessed by the wound care nurse. However, no corresponding physician orders, TAR entries, or care plan problem, goals, or interventions were documented for the wound. An LPN caring for the resident reported only assessing the resident’s front side and not turning the resident, and was unaware of the sacral wound. The wound care nurse stated she notified the physician but there was no documentation of physician or family notification or implementation of treatment orders, despite facility policy requiring physician-directed wound care and multidisciplinary oversight.
Surveyors identified that two residents received incorrect medications or dosages due to staff administering products that did not match physician orders, resulting in a medication error rate of 9.09%. In one case, a nurse gave a resident the wrong formulation and dose of Senna and Folic Acid, while in another, a nurse administered Calcium Carbonate without the required Vitamin D. These actions did not comply with facility policy or prescribed orders.
A resident with severe cognitive impairment was found with unexplained discoloration under the eye after admission. The resident reported that something fell on her head during ambulance transport, but the administrator did not report the incident to IDPH, as the resident stated it was unintentional and the ambulance company denied any incident. The facility's reportable binder lacked documentation of the event, contrary to policy requiring reporting of such allegations.
A resident with a history of falls and cognitive impairment fell and sustained a subdural hematoma due to the facility's failure to apply a soft head helmet as per the care plan. Despite being at moderate risk for falls, the resident was found attempting to walk without assistance and fell, hitting her head. Staff interviews confirmed the helmet was not applied while the resident was in bed, contrary to physician orders.
The facility failed to follow its policies on food storage, labeling, and hygiene, affecting all 108 residents. Expired food items were found, and food lids were stored next to bleach solutions. A Dietary Aide handled clean dishes without changing gloves, and uncovered food was left under an air conditioning unit. In the refrigerator, spoiled cucumbers and freezer-burned ice were found, and food temperatures were not checked before serving.
The facility failed to set low air loss mattresses to the correct weight settings for residents with pressure ulcers or at risk of developing them. Observations showed incorrect settings for four residents, compromising the intended pressure relief and potentially affecting skin integrity. The Wound Care LPN confirmed the importance of correct settings as per facility policy.
The facility failed to provide proper respiratory care for residents, with issues including undated and improperly stored oxygen and nebulization tubing, and missing physician orders for BiPAP and CPAP use. Four residents were affected, with conditions such as heart failure, sleep apnea, and COPD. Staff confirmed the need for weekly changes and proper storage to prevent infection.
The facility failed to ensure proper use and evaluation of side rails for several residents, leading to a deficiency in accident prevention. Observations showed residents using side rails without care plans or recent assessments. The Director of Nursing confirmed that assessments should be quarterly, but this protocol was not followed, violating the facility's policy on bedrail management.
The facility failed to provide prescribed High Calorie Frozen Desserts to several residents as part of their therapeutic diets. Despite having sufficient stock, the dietary staff did not distribute these supplements, which are crucial for residents at nutritional risk, such as those experiencing weight loss or needing extra calories for wound healing. Observations and interviews confirmed the absence of these supplements on meal trays, contrary to physician orders and facility policies.
The facility failed to follow infection control protocols by not using appropriate PPE for residents under Enhanced Barrier Precautions and Contact Isolation. Staff provided care without gowns and gloves, and signage was missing, leading to unawareness of necessary precautions. These actions risked cross-contamination and infection transmission.
A resident was found with medications at their bedside without a physician's order or a self-administration safety assessment. Staff confirmed that medications should not be left at a resident's bedside without proper authorization. The facility's policy requires physician authorization for self-administration, which was not documented in the resident's records.
A facility failed to refer a resident for a PASRR re-evaluation after new psychiatric diagnoses were made. Initially, the resident did not require a Level II PASRR, but later received diagnoses of anxiety disorder, unspecified psychosis, and major depressive disorder, along with prescriptions for Escitalopram Oxalate and Risperidone. The Social Service Director had not reviewed the resident's PASRR, and the facility's policy lacked procedures for re-evaluation due to new diagnoses.
The facility failed to provide adequate nail care for three residents who were dependent on staff for grooming. Observations showed these residents had dirty, overgrown fingernails, which they could not manage themselves. Staff interviews confirmed that nail care should be part of the grooming routine during showers twice a week and as needed, but this was not consistently provided. The facility's DON and Administrator acknowledged that nail care is part of ADL grooming, yet there was no specific policy in place.
A facility failed to maintain a medication error rate below 5% when a nurse did not administer two scheduled medications to a resident but documented them as given. The nurse prepared and administered several medications, but the surveyor did not observe the administration of Advair Diskus and Lisinopril, which were documented as administered. This resulted in a medication error rate of 6.25%, exceeding the acceptable threshold.
The facility failed to follow its menu and cooking instructions, affecting all 108 residents receiving nutrition. Lemon meringue pies were not served as planned due to improper defrosting, and pureed mashed potatoes were prepared without following the specified instructions. Residents expressed concerns about the facility not adhering to the menu, indicating issues in food service management.
A facility failed to follow physician orders for a resident requiring nectar-thick liquids due to swallowing difficulties. Despite an active diet order and care plan specifying nectar-thick consistency, a CNA provided thin apple juice during a meal. The facility's policy requires meal accuracy checks, which were not adhered to, resulting in this deficiency.
A resident with severe cognitive impairment and a history of falls experienced nine falls after the removal of a 1:1 aide, despite being identified as a high fall risk. The facility's fall policy was not effectively implemented, leading to repeated incidents and a significant injury requiring medical attention.
A resident, who is legally blind and requires supervision, fell and fractured her femur during a transfer from the toilet to a wheelchair due to the failure of a CNA to use a gait belt. The CNA was standing in the doorway and did not provide the necessary assistance, leading to the resident's fall. Interviews with staff confirmed that gait belts are required for transfers, but the protocol was not followed in this instance.
The facility failed to respond to call lights promptly, provide adequate incontinence care, and administer medications as ordered. A resident reported waiting hours for incontinence care, while another experienced a delay in colostomy care. The call light system lacked an audible alert, and staffing issues, particularly with agency staff, contributed to these deficiencies.
The facility failed to ensure residents who depend on staff assistance for ADL care received proper grooming, showers, personal hygiene, and feeding assistance. Three residents were affected, with observations revealing unshaven beards, dry scalps, disheveled appearances, and missed meals. Facility records lacked documentation of bed baths or showers for the entire month of April.
Hot Foods Served at Unsafe Temperatures During Meal Delivery
Penalty
Summary
Hot foods were not maintained at safe and appetizing temperatures during meal service, contrary to facility policy. During observation of meal service in the kitchen, the dining services director and cook checked tray temperatures before service and recorded fish at 176 F, sweet potatoes at 171 F, mashed potatoes at 165 F, and peas with mushrooms at 180 F. The dining services director stated the first floor was served first, followed by the third floor, fourth floor, and then the second floor last, and stated food temperatures should hold at 165 F but drop during transport and delivery. After trays were delivered, the test tray temperatures had dropped significantly. After the last tray was served on the first floor, temperatures were fish 114 F, sweet potatoes 132 F, and peas with mushrooms 104 F. After the last tray was served on the second floor, temperatures were fish 90 F, sweet potatoes 126 F, and peas with mushrooms 93 F. The dining services director acknowledged these temperatures were not acceptable and stated the second floor did not have the same insulated hotbox meal carriers used on other floors. Residents also reported that food was often cold, including a resident with intact cognition who said breakfast eggs were cold, another resident who said lunch was not warm enough and had repeatedly raised the concern in food committee meetings, and the resident council president who stated food is served cold often and that other residents had reported the same concern.
Failure to Notify Physician and Representative of New Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and resident representative of a significant change in condition when a new deep tissue pressure injury (DTPI) was identified for one resident (R5). R5 had multiple diagnoses, including cerebral infarction with right middle cerebral artery involvement, dysphagia, reduced mobility, polycythemia vera, elevated white blood cell count, cerebral edema, type 2 diabetes mellitus, unspecified protein calorie malnutrition, and acute respiratory issues. A Brief Interview for Mental Status (BIMS) showed a score of 12, indicating moderate cognitive deficits. On 1/19/26, the wound care nurse (V7, LPN) documented that therapy staff notified her of a skin condition on the resident’s buttocks, and her assessment identified a DTPI to the sacral region. A wound summary completed the same day recorded a newly acquired DTPI to the sacrum measuring 1.20 cm by 0.40 cm with unknown depth. Despite this documented new wound, the physician order sheet contained no orders for treatment or management of the sacral wound, and the treatment administration record for January showed no wound treatment. During interview, V7 stated she had informed the physician about the sacral wound but, upon review of the progress notes with the surveyor, there was no documentation of physician or family notification and no physician orders implemented for the DTPI. V7 acknowledged she did not carry out physician orders and stated she “must have forgot,” and also described that facility practice requires notifying the resident’s family and physician and documenting the conversation when a new wound is acquired. The occupational therapist (V16) recalled observing a reddened area on the resident’s tailbone and immediately reporting it to V7, who said she would take care of it. The DON (V2) stated she did not recall the resident having a wound and explained that when a resident acquires a wound, nurses should be aware through communication tools, wound care orders, and progress notes, and that physicians and family should be notified with documentation of the change in condition. The facility’s written policy on Notification of Change in Condition requires immediate notification of the resident, physician, and resident representative when treatment must be significantly altered or a new form of treatment commenced, and requires documentation of notifications and new orders in the medical record, which did not occur in this case.
Failure to Assess, Document, and Treat a New Sacral Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for a resident with a newly identified sacral deep tissue pressure injury (DTPI). The resident had multiple diagnoses including cerebral infarction, dysphagia, reduced mobility, diabetes, malnutrition, and other conditions, and Braden/pressure risk scales completed on several dates showed the resident was at risk for pressure ulcers. On 1/19/26, the wound care nurse documented that therapy staff notified her of a skin condition on the buttocks, and she assessed a DTPI to the sacral region measuring 1.20 cm by 0.40 cm with unknown depth. Despite this, the physician order sheet contained no orders for treatment or management of the sacral wound, the treatment administration record for the month showed no wound treatment, and the care plan contained no problem statement, goals, or interventions related to the sacral wound. Staff interviews further showed that the wound was not consistently recognized or acted upon. The LPN who was the resident’s nurse prior to transfer to the hospital stated she only assessed the resident’s front side for skin issues, did not turn the resident because she could not do so alone, and was unaware of any sacral wound. The wound care nurse stated that the occupational therapist had reported a reddened area on the tailbone, that she assessed the sacral wound, and that she informed the physician, but review of the record revealed no documentation of physician or family notification and no physician orders for the DTPI. She acknowledged she did not carry out physician orders and stated she “must have forgot,” and also stated that when a resident acquires a new wound, the family and physician should be notified and the conversation documented. The DON reported she did not recall the resident having a wound and described that, per facility practice and policy, new wounds should be communicated via the communication board, physician orders, progress notes, and assessments, with physician and family notification documented. The facility’s wound prevention and healing policy required wound care treatments under physician direction and oversight by certified wound care nurses, which was not reflected in the resident’s record for this sacral DTPI.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required, with 3 errors identified out of 33 opportunities, resulting in a 9.09% error rate. One incident involved a nurse administering Senna 8.6 mg tablets and Folic Acid 800 mcg to a resident, instead of the prescribed Senna S (Sennosides-Docusate sodium) 8.6-50 mg and Folic Acid 1 mg. The nurse confirmed to the surveyor and the Director of Nursing that the medications given did not match the physician's orders, and documentation showed the resident had moderate cognitive impairment and multiple diagnoses, including chronic ulcers and swelling in the lower limbs. Another error occurred when a registered nurse administered Calcium Carbonate 500 mg (Alkums Antacid) to a different resident, instead of the ordered Calcium Carbonate-Vitamin D 500-200 mg. The product given did not contain vitamin D, as required by the physician's order. This resident was cognitively intact and had diagnoses including hypokalemia, hyponatremia, and hypertension. Facility policy and job descriptions require staff to administer medications as prescribed and verify medications before administration, but these procedures were not followed in the cited instances.
Failure to Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an abuse allegation to the Illinois Department of Public Health (IDPH) for one resident who was admitted with multiple diagnoses, including severe cognitive impairment and communication deficits. Upon a family visit, discoloration was observed under the resident's left eye, which was not present at admission. The administrator and DON assessed the resident in the presence of family, and the resident reported that something had fallen on her head during ambulance transport to the facility. The administrator contacted the ambulance company to investigate, and the resident's physician was notified, resulting in an x-ray that was negative for injury. The ambulance company later reported no incident during transport. Despite the resident's report of an object falling on her head and visible injury, the administrator did not submit an abuse allegation report to the state agency, as the resident stated the incident was unintentional and the ambulance company denied any incident. The facility's reportable binder did not contain documentation of the incident, and the administrator determined that, since the resident could explain the injury and denied intent, it did not meet the threshold for reporting to IDPH. This decision was made despite facility policy requiring investigation and reporting of unexplained injuries and abuse allegations.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to a resident's fall care plan intervention and physician recommendation, which required the application of a soft head helmet while the resident was in bed. This oversight involved a resident with a history of multiple falls, moderate cognitive impairment, and a previous skull surgery. The resident, who was at moderate risk for falls, was found attempting to walk without assistance and subsequently fell, hitting her head on the floor, resulting in a left subdural hematoma. The incident occurred when the resident was in her room without the soft helmet, which was supposed to be worn while in bed as per the care plan. The resident's fall risk assessment indicated several risk factors, including inadequate vision, loss of balance, and a history of falls. Despite these risks, the helmet was not applied while the resident was in bed, contrary to the care plan and physician's orders. The resident was later found on the floor by a CNA, who noted that the resident had fallen and hit her head. Interviews with facility staff, including the Director of Nursing and the resident's physician, confirmed that the helmet was a critical intervention to minimize injury due to the resident's impulsive behavior and history of falls. The staff acknowledged that the helmet was not applied while the resident was in bed, which was a deviation from the prescribed care plan. This failure to implement the necessary fall prevention measures led to the resident sustaining a serious head injury.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its policies regarding food storage, labeling, and hygiene practices, which were observed during a survey. In the dry goods stock room, expired food items such as maraschino cherries, soy sauce, and Caesar dressing were found, and an opened bag of brownie mix was not labeled. Additionally, food lids were stored next to bleach cleaning solutions, contrary to the facility's chemical storage guidelines. The Dietary Manager, V11, acknowledged these issues, indicating a lack of compliance with the facility's policy to check and discard expired items and to store food-related items away from cleaning solutions. During dishwashing, a Dietary Aide, V13, was observed handling clean dishes with the same gloves used for dirty dishes, without performing hand hygiene, which violates the facility's dish room safe handling policy. Furthermore, coffee grounds were left open next to sanitation buckets, posing a risk of cross-contamination. Uncovered pre-portioned pears were also left on the counter under a blowing air conditioning unit, which could lead to contamination, as acknowledged by V11. In the walk-in refrigerator, mushy and black-spotted cucumbers were found, and a large bag of ice with freezer burn was present in the freezer, which had been there for seven months without a known purpose. Additionally, the Cook, V14, did not check or record food temperatures before serving, leaving the temperature log for the current meal empty. These observations highlight a failure to follow the facility's policies on food storage, labeling, and temperature control, potentially affecting the nutrition and safety of all 108 residents receiving meals from the kitchen.
Incorrect Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that low air loss mattress devices were set to the correct weight settings for residents with current pressure ulcers and those at risk of developing them. During observations, it was noted that the weight settings on the low air loss mattresses for four residents were incorrect. For instance, one resident with a weight of 136.6 pounds had their mattress set to 400 pounds, and another resident weighing 230 pounds had their mattress set to 350 pounds. These incorrect settings were observed despite the facility's policy requiring that mattress settings be checked every shift to ensure proper functioning. Interviews with the Wound Care LPN revealed that the low air loss mattresses are intended to relieve pressure and aid in wound healing, and they must be set according to the resident's current weight. The LPN confirmed that the incorrect settings observed would not provide the intended pressure relief, potentially compromising the residents' skin integrity. The facility's policies on wound prevention and specialty mattress management emphasize the importance of using the Braden scale to assess risk and implementing appropriate interventions, including correct mattress settings, to prevent pressure injuries.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for residents, as evidenced by the lack of dated and properly stored oxygen and nebulization tubing, as well as the absence of physician orders for the use of BiPAP and CPAP machines. Four residents were affected by these deficiencies. One resident, admitted with conditions including atrial fibrillation and heart failure, had oxygen and nebulization tubing that was not dated and was improperly stored, touching the floor. The Licensed Practical Nurse (LPN) confirmed that the tubing should be changed weekly and stored in a plastic bag when not in use. The Director of Nursing (DON) reiterated the need for proper storage and physician orders for CPAP and BiPAP use. Another resident, diagnosed with obstructive sleep apnea and morbid obesity, had a BiPAP mask on the floor, not stored in a bag, and lacked a physician order for its use. A third resident, with chronic obstructive pulmonary disease and Parkinson's disease, had undated oxygen tubing and a CPAP mask not stored in a bag. The fourth resident, admitted for palliative care, had an oxygen nasal cannula that was not dated or stored in a plastic bag. The DON confirmed the expectation for weekly changes and proper storage to prevent infection.
Deficiency in Side Rail Use and Assessment
Penalty
Summary
The facility failed to ensure the appropriate use and evaluation of side rails for four residents, leading to a deficiency in accident and hazard prevention. Observations revealed that residents were using side rails without a corresponding care plan or recent assessment. For instance, Resident 63, admitted with conditions such as Alzheimer's disease and heart failure, was observed with both upper side rails up, yet no care plan for side rail use was found in their electronic health record (EHR). Similarly, Resident 61, with diagnoses including atrial fibrillation and heart failure, also had side rails up without a care plan, and their last assessment was outdated. The deficiency was further highlighted by the lack of quarterly assessments and care plans for Residents 41 and 37, both of whom were observed with side rails up. Resident 41, with conditions like hemiplegia and diabetes, and Resident 37, with a history of cerebral infarction and rheumatoid arthritis, had not been reassessed for side rail use since late 2024. The Director of Nursing confirmed that side rail assessments should be conducted quarterly and that care plans should guide staff in their use, but these protocols were not followed. The facility's policy mandates the management of bedrails to ensure residents' well-being, yet this was not adhered to, resulting in the cited deficiency.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide oral supplements, specifically High Calorie Frozen Desserts, as part of the therapeutic diet prescribed by the physician for five residents. These residents had dietary supplement orders documented in their Order Summary Reports and meal tickets, which indicated that the Frozen Nutritional Treat should be served daily at lunch. However, observations revealed that these supplements were not consistently provided. For instance, one resident did not receive the supplement during lunch and mentioned that it was not provided every day. Another resident's guardian confirmed the absence of the supplement on the lunch tray. A dietary aide admitted to not distributing the supplements due to a perceived lack of stock, although the dietary manager confirmed that the kitchen had sufficient supplies. The dietary manager and registered dietitian acknowledged the importance of these supplements for residents at nutritional risk, such as those experiencing weight loss or requiring additional calories for wound healing. Despite having the supplements in stock, the facility staff failed to distribute them, potentially impacting the residents' nutritional status. The registered dietitian highlighted that the absence of these supplements could lead to continued weight loss or hinder wound healing. The facility's policies on fortified foods and tray line service emphasize the need for accurate meal assembly and the provision of necessary dietary items, which were not adhered to in this instance.
Inadequate PPE Use and Signage for Infection Control
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of Personal Protective Equipment (PPE) for residents under Enhanced Barrier Precautions (EBP) and Contact Isolation. On multiple occasions, staff members did not don the required gowns and gloves when providing high-contact care to residents with wounds or those under contact precautions. For instance, a Certified Nursing Assistant (CNA) provided incontinence care to a resident with a sacral wound without wearing a gown, despite the presence of EBP signage. Similarly, a Wound Care Licensed Practical Nurse and a CNA provided wound care to another resident without the appropriate PPE, acknowledging the risk of cross-contamination. Additionally, the facility failed to display EBP signage and provide accessible PPE outside a resident's room, leading to staff being unaware of the need for enhanced precautions. A nurse assigned to care for this resident was not informed of the EBP orders due to the absence of signage, resulting in the provision of care without the necessary protective measures. Furthermore, a Nursing Supervisor entered a room of a resident on Contact Isolation for Clostridium Difficile without wearing a gown or gloves, contrary to the facility's policy and the posted signage. These lapses in protocol could potentially lead to the transmission of infections among residents.
Failure to Obtain Physician Order for Self-Administration of Medications
Penalty
Summary
The facility failed to obtain a physician order and conduct a medication self-administration safety assessment for a resident who was observed with medications at their bedside. On multiple occasions, a resident was found with an inhaler and nasal spray on their bedside table without a physician's order permitting self-administration. The resident reported using the inhaler twice daily for wheezing and the nasal spray once daily for nasal congestion, even when not experiencing symptoms. Staff, including an LPN and RN, confirmed that medications should not be left at a resident's bedside without a physician's order, and the Director of Nursing stated that a safety assessment and physician order are required for self-administration. The resident's clinical records did not contain documentation of a self-administration assessment or a physician order for self-administration of medications. The facility's policy requires physician authorization for residents to self-administer medications. Additionally, another resident's records showed active orders for similar medications, but no order allowing them to be kept at the bedside. The lack of proper documentation and adherence to facility policy led to the deficiency observed by the surveyors.
Failure to Update PASRR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) re-evaluation after the resident received new psychiatric diagnoses. Initially, the resident did not require a Level II PASRR as they did not have severe mental illness, intellectual disabilities, or related conditions, nor were they prescribed mental health medications. However, the resident's admission record later documented new diagnoses of anxiety disorder, unspecified psychosis, and major depressive disorder, along with medication orders for Escitalopram Oxalate and Risperidone. Interviews revealed that the facility's staff had not reviewed the resident's PASRR since the initial evaluation. The Social Service Director, responsible for reviewing current PASRRs, had not started this process, and the Admissions Director only handled initial PASRRs. The facility's policy did not include procedures for re-evaluation due to new diagnoses, contributing to the oversight in updating the resident's PASRR status.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for three residents who are dependent on staff for grooming and personal hygiene. Observations revealed that these residents had dirty, overgrown fingernails, which they were unable to manage themselves due to their conditions. One resident, who is legally blind, expressed a desire to have her nails cut but could not recall the last time this was done. Another resident was observed with long, dirty fingernails while dining, and a third resident had food debris under her nails. Interviews with staff, including CNAs and LPNs, confirmed that nail care should be part of the grooming routine during showers twice a week and as needed, but this was not consistently provided. The facility's Director of Nursing and Administrator acknowledged that nail care is part of the Activities of Daily Living (ADL) grooming, yet there was no specific policy in place for nail care. The Minimum Data Set (MDS) assessments for the involved residents indicated they required moderate to maximum assistance with personal hygiene. Despite this, the facility's failure to ensure regular nail care resulted in the observed deficiencies, as staff did not adhere to the expected grooming practices.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication administration observation for one resident. On the specified date, a registered nurse (V8) was observed administering medications to a resident (R51). The nurse prepared and administered several oral medications and a nebulizer treatment. However, the surveyor noted that two medications, Advair Diskus Aerosol Powder and Lisinopril, which were scheduled to be administered between 7:00 AM and 11:00 AM, were not observed being given to the resident during the medication pass. Despite this, the nurse documented in the Electronic Medication Administration Record (EMAR) that these medications were administered at 9:57 AM. The Director of Nursing (V2) confirmed that nurses are required to follow the five rights of medication administration: right resident, right route, right medication, right time, and right dose. The facility's policy mandates that nurses document the administration of medications accurately, including any missed or refused doses. The failure to administer the medications as per the physician's orders and the subsequent inaccurate documentation resulted in a medication error rate of 6.25%, exceeding the acceptable threshold of less than 5% for the facility.
Failure to Follow Menu and Cooking Instructions in LTC Facility
Penalty
Summary
The facility failed to adhere to its menu and cooking instructions, affecting all 108 residents receiving nutrition from the kitchen. During a kitchen tour, it was observed that the facility did not serve the planned lemon meringue pies for lunch as they did not defrost in time, and instead served a 4-ounce serving of pears. This deviation from the menu was confirmed by the Dietary Manager, who acknowledged the issue. Additionally, during a Resident Council meeting, two residents expressed concerns that the facility frequently does not follow the menus, serving different food items than what is listed. Furthermore, the facility did not follow proper cooking instructions for pureed mashed potatoes. The cook, unaware of the number of residents on a pureed diet, prepared the mashed potatoes without measuring the water or granules, contrary to the instructions on the container. The instructions specified using boiling water and specific measurements for the granules and salt, which were not followed. This lack of adherence to cooking instructions and menu planning indicates a failure in the facility's food service management, impacting the nutritional care provided to the residents.
Failure to Provide Nectar-Thick Liquids as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring nectar-thick liquids due to swallowing and chewing difficulties. The resident had an active diet order for nectar-thick consistency liquids, documented in their Order Summary Report, and their Care Plan Report indicated the need for a mechanically altered diet with thickened liquids. Despite these orders, a Certified Nurse Aide assisted the resident with a lunch meal and provided apple juice in a thin consistency instead of the required nectar-thick consistency. The facility's policy on the Accuracy of Quality of Tray Line Service mandates that all meals be checked for accuracy against the therapeutic diet spreadsheet and meal identification card, but this protocol was not followed, leading to the deficiency.
Failure to Prevent Repeated Falls for High-Risk Resident
Penalty
Summary
The facility failed to prevent repeated falls for a resident with a known history of falls and severe cognitive impairment. The resident, who has diagnoses including unspecified dementia and muscle weakness, experienced nine falls over a period of time. Despite being identified as a high fall risk in multiple assessments, the resident did not have consistent supervision or interventions in place to prevent these incidents. Initially, a 1:1 aide was provided, which effectively prevented falls, but this support was gradually removed, leading to repeated falls. The resident's care plan acknowledged the risk of falls due to impaired mobility and other factors, yet the interventions were insufficient to prevent the incidents. The facility's fall policy emphasizes reducing fall risks and maintaining a safe environment, but the repeated falls indicate a failure to adhere to this policy. The resident sustained a significant injury from one of the falls, requiring emergency medical attention and treatment for a scalp laceration.
Failure to Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
The facility failed to utilize a gait belt during the transfer of a resident from the toilet to a wheelchair, resulting in the resident falling and sustaining a left femur fracture. The resident, who is legally blind and requires supervision with toileting and transfers, was assisted to the bathroom by a CNA. After the resident finished toileting, the CNA instructed her to stand and move towards the sink. The resident, who was severely visually impaired, missed a step and fell, sustaining a fracture. The incident report and interviews reveal that the CNA was standing in the doorway and did not use a gait belt during the transfer, which is against the facility's protocol. The resident's son reported that the resident had multiple falls in the past and required assistance in the bathroom due to her blindness. The resident herself stated that she believed someone should have been with her in the bathroom, and she was unaware if anyone helped her during the fall. Interviews with facility staff, including an LPN and the DON, confirmed that gait belts are part of the CNA's uniform and should be used during transfers. The physical therapist also noted that the resident requires contact guard assistance and the use of a gait belt during transfers. The CNA involved in the incident was not available for an interview, and the LPN who responded to the fall confirmed that the resident was left on the floor until emergency services arrived.
Deficiencies in Call Light Response, Incontinence Care, and Medication Administration
Penalty
Summary
The facility failed to monitor and respond to the call light system in a timely manner, affecting several residents. One resident reported pressing the call light at 2:00 AM for incontinence care and not receiving assistance until 6:00 AM, remaining soiled during this period. Another resident with a colostomy bag experienced a 45-minute delay in response to their call light, leading to a ruptured bag and requiring external assistance to contact the facility. Observations confirmed that the call light system lacked an audible alert, relying solely on visual cues, which staff often overlooked. In addition to the call light issues, the facility failed to provide adequate incontinence care for multiple residents. Several residents were found with soiled incontinence briefs, indicating a lack of timely assistance. One resident, who is blind and requires assistance with toileting, reported that their call light was not answered for an extended period, resulting in discomfort and unmet needs. The facility's staffing issues, particularly with agency staff, contributed to these deficiencies, as one CNA left their shift early without ensuring coverage for their assigned residents. The facility also failed to administer medications as ordered by the physician for at least one resident. This resident did not receive their prescribed medications on a specific date due to the absence of a nurse to administer them. The facility's policies on medication administration and call light use were not adhered to, leading to these deficiencies. The lack of sufficient nursing coverage further exacerbated the situation, as staff were unable to meet the residents' needs effectively.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to ensure residents who depend on staff assistance for their Activities of Daily Living (ADL) care received proper grooming care, showers, personal hygiene, and feeding assistance. This deficiency affected three residents who were reviewed for ADL care. The observations, interviews, and record reviews revealed significant lapses in the care provided to these residents. Resident 1 (R1) had multiple diagnoses including congestive heart failure, Parkinson's disease, and depression. Despite requiring substantial assistance with personal hygiene and being dependent on staff for showers, R1 was observed with an overgrown beard, dry flaky scalp, and wearing a hospital gown. R1 reported not being shaved for a month and receiving a bed bath only after complaining. Additionally, R1's meal tray was delivered late, and he was left without assistance for 45 minutes, resulting in spilled food and juice. The facility's records lacked documentation of bed baths or showers for R1 for the entire month of April. Resident 2 (R2) and Resident 3 (R3) also experienced similar neglect. R2, who had chronic obstructive pulmonary disease and dementia, reported not receiving proper showers and only getting cleaned when a friend visited. R3, with diagnoses including muscle weakness and diabetes, was observed disheveled and reported not receiving assistance with dressing or showers. The facility's records for both R2 and R3 also lacked documentation of bed baths or showers for the entire month of April. The Director of Nursing confirmed the expectation for CNAs to assist with ADLs and document the care provided, which was not met in these cases.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of Elmwood Park | 1 mi | ★★★★★ | 26 | 2 |
| Berkeley Nursing & Rehab Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Central Nursing Home | 2 mi | ★★★★★ | 10 | 0 |
| Community First Medical Center | 2 mi | ★★★★★ | 0 | 0 |
| Norridge Gardens | 2.2 mi | ★★★★★ | 1 | 0 |
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