Crescent Care of Elgin

Inspectors wroteBased on interview and record review, the facility failed to provide the required twelve (12) hours per year of continuing competence training for Certified Nursing Assistant (CNAs), including dementia management training. This failure has the potential to affect all 68 residents, as indicated in the facility's Centers for Medicare and Medicaid Services (CMS) Form 671, Long-Term Care Facility Application for Medicare and Medicaid report of their current census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label residents' medications when opened. This applies to 4 out of 4 (R79, R65, R63, and R17) residents reviewed for medication storage in a sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders from the physician to have resident medication at the bedside. The facility also failed to complete self-administration of medication assessments. This applies to 3 of 3 residents (R1, R63, and R70) reviewed for medications in a sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to give residents and/or their POA (Power of Attorney) written notification for the reason of the transfer to the hospital. The facility also failed to provide a bed hold notice and notify the ombudsman. This applies to 2 of 4 residents (R5, R63) reviewed for transfers and discharges in a sample of 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor and obtain a treatment order for a resident with a known pressure wound. This affects 1 of 4 residents (R89) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet the ADL (Activities of Daily Living) needs of the residents in the facility. This applies to all 79 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, homelike environment when it failed to provide window shades, or equivalent, that are in good repair, without stains or tears. This applies to 13 of 18 residents (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18) reviewed for lack of window shades/curtains and homelike environment in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care. This applies to 2 of 3 residents (R1 and R4) reviewed for timely incontinence care in the sample of 18.

Inspectors wroteBased on observation and interview the facility failed to ensure electrical wires are not left exposed, near a resident's metal bed frame. This applies to 1 of 4 residents (R1) reviewed for safe environment in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their water management plan. The facility also failed to follow their policy regarding catheter care to prevent infection and to follow Enhanced Barrier Precautions. The facility also failed to perform hand hygiene and glove changes during provisions of care. This applies to all 70 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to offer and administer the COVID-19 vaccine to residents. This applies to 4 of 5 residents (R1, R22, R32, and R39) reviewed for vaccinations in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure indwelling urinary catheter was anchored to prevent the catheter from being pulled, tugged, and avoid catheter related trauma. This applies to 1 of 1 resident (R64) reviewed for catheter care in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to offer and administer pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines. This applies to 3 of 5 residents (R1, R22, and R32) reviewed for vaccinations in the sample of 18.

Inspectors wroteBased on interview and record reviews, the facility's most recent arbitration agreements failed to include language that stated signing the agreement was not a condition/requirement to admission or receiving care at the facility. The facility also failed to update previously signed arbitration agreements which did not include language that: 1. The arbitration agreement could be rescinded in 30 days. 2. An arbitrator and meeting location would be mutually decided between parties. This applies to all 70 residents residing in the facility.

Inspectors wroteThere are multiple deficient practice statements. A. Based on observation, interview and record review the facility failed to ensure water temperatures in resident bathrooms were maintained at a safe level to prevent potential resident injury. This failure resulted in the water in five residents' bathrooms measuring 150(+) degrees Fahrenheit, having the potential to cause third degree burns within 1-2 seconds, at 12:40 PM on 11/13/23. This applies to 5 of 5 residents (R16, R17, R38, R53 and R55) reviewed for safety in the sample of 22. B. Based on observation, interview and record review the facility failed to ensure a resident on a mechanically altered diet was safely assisted to eat for 1 of 22 residents (R39) reviewed for safety in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to have ordered pressure reducing interventions in place to prevent R72's stage 2 sacral pressure wound from deteriorating to a stage 3. R72's pressure wound increased in size and depth and worsened in condition. This applies to 1 of 3 residents (R72) reviewed for pressure wounds in the sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to test and record the wash and rinse temperatures of their high temperature dishwasher three times a day. This failure has the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review facility failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents. The facility failed to ensure 5 residents (R51, R58, R2, R15, R7) on contact/droplet transmission-based precautions had the required isolation signage outside of their rooms. The facility failed to have an effective system in place to test staff and 5 residents (R68, R48, R61, R23, R60) for COVID-19 during a facility outbreak. The facility failed to ensure COVID negative residents were not exposed to 3 residents (R68, R4, R51) who were COVID positive. These failures resulted in a facility outbreak of COVID-19 which, as of 11/13/23, included twenty-nine positive residents and sixteen positive staff. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to put interventions in place for a resident with significant weight loss. The facility also failed to provide ordered nutritional supplements for residents at risk for weight loss. This applies to 3 of 3 resident (R72, R39 and R46) reviewed for weight loss in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident had a care plan to address pain for 1 of 22 residents (R44) reviewed for the development and implementation of a comprehensive care plan in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to remove a resident's facial hair and failed to provide set up assistance for meals for 2 of 22 residents (R17, R70) reviewed for activities of daily living in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the catheter tubing for an indwelling urinary catheter was kept below the level of the bladder for 1 of 2 residents (R65) reviewed for urinary catheters in the sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were offered and/or received a pneumococcal immunization for 1 of 5 residents (R51) reviewed for immunizations in the sample of 22.