Parc Joliet

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect a resident's right to be free from abuse. This failure applies to 1 of 3 residents (R1) reviewed for abuse. This failure resulted in R1 experiencing inappropriate physical assault when a visitor entered her room, unzipped his pants, and placed an item into her mouth and resulted in R1 experiencing inappropriate physical contact and assault.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to submit an accurate and complete abuse investigation report to the state agency. This failure applies to 1 of 3 residents (R1) reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide evidence to the state agency that an allegation of abuse was thoroughly investigated. This failure applies to 1 of 3 residents (R1) reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to report a resident's injury of unknown origin within required timeframes. This applies to 1 of 3 residents (R1) reviewed for abuse concerns.

Inspectors wroteBased on interviews and record reviews, the facility failed to investigate the cause of a resident's injury. This applies to 1 of 3 residents (R1) reviewed for unknown injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' medical records contained documentation to support new diagnoses of schizophrenia. This applies to 2 of 4 residents (R1, R3) reviewed for behavior documentation.

Inspectors wroteBased on interview and record review, the facility failed to transfer a resident safely with a mechanical lift. This failure resulted in a resident sustaining an 8 cm (centimeter) laceration, requiring 11 sutures. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident was not physically abused by a staff. This applies to 1 of 10 residents (R6) reviewed for physical abuse in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical and mental abuse by another resident (R3). This applies to 3 out of 5 residents (R1, R2, and R4) reviewed for resident-to-resident abuse.

Inspectors wroteBased on interview and record review, the facility failed to report a resident's allegation of abuse by another resident (R3). This applies to 1 out of 5 residents (R1) reviewed for resident-to-resident abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate residents' allegations of abuse by another resident (R3). This applies to 3 out of 5 residents (R1, R2, and R4) reviewed for resident-to-resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safety monitoring interventions for a resident with known aggressive behaviors towards others. This applies to 1 out of 4 residents (R3) reviewed for safety and supervision.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food was prepared, stored, and served under sanitary conditions. This failure applies to 144 residents who are served food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents shower room was free of black substances and failed to ensure that a resident's toilet was in good repair. This applies 16 of 16 residents (R24, R47, R58, R85, R92, R101, R103, R104, R105, R138, R140, R144, R149, R150, R156, and R164) reviewed for homelike environment in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and bed bath or shower. This applies to 6 of 7 residents (R6, R38, R49, R50, R52 and R137) reviewed for ADL (activities of daily living), in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who smoke and require supervision for smoking were monitored closely during smoking period. In addition, facility also failed to ensure that residents are not keeping their own cigarette lighters. This applies to 6 of 8 residents (R26, R71, R75, R110, R151, R164) reviewed for smoking in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene during range of motion assessments and administration of insulin. In addition, the facility failed to wear complete PPE (Personal Protective Equipment) during provision of wound treatment and administration of intravenous (IV) medication for residents who are under Enhance Barrier Precaution (EBP). This applies to 5 of 6 residents (R9, R29, R50, R135, R163) reviewed for infection control in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a demented male resident from kissing a demented female resident. This applies to 1 of 1 resident (R148) reviewed for abuse in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to ensure that updated PASRR (Preadmission Screening and Record Review) referrals were completed when new psychiatric diagnoses were identified after admission. This applies to for 3 of 3 residents (R10, R35, R61) reviewed for PASRR compliance in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly cleanse a resident's skin prior to application of skin treatment and failed to ensure that psychotropic medication was administered as ordered. This applies to 2 of 2 residents (R52, R121) reviewed for quality of care in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and provide orthotic devices and services to residents, to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 6 residents (R12 and R123) reviewed for limited ROM, in the sample of 29.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that continuous oxygen therapy was consistently provided and monitored as ordered. This applies to 1 of 2 residents (R35) reviewed for respiratory care in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered during medication administration observation. There were 25 medication administration opportunities with 2 errors resulting to 8% percent medication error rate. This applies to 2 of 4 residents (R147 and R163) reviewed for medication administration in a sample of 29.

Inspectors wroteBased on observation and interview the facility failed to ensure that couches inside resident rooms were clean and sanitary and in accordance with what a resident would expect in a clean homelike environment. This applies to 3 of 3 residents (R2, R5 and R6) reviewed for housekeeping issues in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer a resident from the bed to the chair. This failure resulted in R4 experiencing a right humeral neck fracture when the mechanical lift R4 was attached to tipped over and R4 struck the wall in her room. This applies to 1 of 3 residents (R4) reviewed for accidents in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure mechanical lift devices are maintained in safe, operating condition, are routinely inspected, and removed from service when repairs are needed. This applies to 30 of 30 residents (R4-R33) reviewed for mechanical lift transfers in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This applies to 1 of 3 residents (R3) reviewed for resident-to-resident assault in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an accurate medical record regarding a resident's incident during a mechanical lift transfer. This applies to 1 of 3 residents (R4) reviewed for falls in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to supervise a resident with impaired cognition while drinking a hot beverage. This failure resulted in the resident spilling the hot beverage, sustaining burns to her bilateral thighs and was transferred to hospital for treatment of the same. This applies to 1 of 3 residents (R1) reviewed for accidents and supervision in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' right to be free from abuse. This applies to 2 of 3 residents (R4, R5) reviewed for abuse in the sample of 14.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and dress a resident appropriately for an outside appointment. This applies to 1 of 3 residents (R1) reviewed for accommodation of resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions for 2 residents (R3, R5) who are at risk for falls in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label/date/seal/store items, remove expired items, and clean and address standing water by drain to avoid flies in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide call light access to residents, a functioning and useable bariatric shower bed, and a proper-sized incontinent brief for residents. This applies to 4 of 4 residents (R7, R35, R39, and R78) reviewed for reasonable accommodation of needs in a sample of 35. The Findings Includes: 1. R7 is a [AGE] year-old male with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R7 was admitted with diagnoses including falls, anxiety, depression, alcohol abuse, restlessness, and agitation. On 9/3/24 at 12:17 PM, R7 was in his bed sitting at the bedside and tried to put the call light on. The call light string was not connected to the call system to trigger the call. R7's call light string was observed tied to his roommate's (R78) call light string. 2. [...]

Inspectors wrote3. R20's 7/19/24 MDS (Minimum Data Set) showed her cognition is intact, and her MDS section GG showed she needs assistance for personal hygiene. R20's 8/8/23 care plan showed a self-care deficit (ADLs/Mobility) (assistance in daily living) related to diagnoses including type 2 Diabetes, insomnia, anemia, osteoarthritis, and hypertension with interventions including supervision or touching assistance with ADL tasks. On 09/03/24 at 11:26 AM, R20 was observed with long jagged fingernails. R20 said it has been months since she has had them cut and she would like for the staff to cut them. On 09/05/24 at 10:38 AM, V1 (Administrator) said R20's nails should not have been long and jagged. V1 said the nails should be trimmed and clean for safety, dignity, and for infection control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely foot care to meet the needs of all residents. This applies to 4 resident (R46, R35, R20, and R13) reviewed for podiatry services in a sample of 35 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to inform, provide written information, and formulate Advanced Directives upon admission for 1 resident (R116) in a sample of 35.

Inspectors wroteBased on observations, interview, and record review, the facility failed to apply splints to prevent contractures. This applies to 2 of 2 residents (R95 and R85) reviewed for contractures in a sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize safety interventions and maintain an environment free of trip hazards. This applies to 2 of 5 residents (R14 and R135) reviewed for accidents and hazards in a sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide humidification with oxygen therapy to avoid nasal dryness. This applies to 1 of 1 resident (R59) reviewed for respiratory therapy in a sample of 35. The Findings Includes: R59 is a [AGE] year-old female, with very mild cognitive impairment, as per the Minimum Data Set (MDS), dated [DATE]. R59 was admitted with an admitting diagnosis, including asthma, congestive heart failure, sleep apnea, and dyspnea. On 09/03/24 at 02:22 PM, R59 was in her bed, with oxygen therapy with a nasal cannula (NC) at 2.5 liters per minute (L/M) without any humidification. On 9/5/24 at 9:45 AM, R59 was observed again in her bed, with NC at 2.5 L/M. R59 stated her nares are dry. On 09/05/24 at 11:30 AM, V3 (Director of Nursing / DON) stated, Our policy is to administer oxygen with humidification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label, date, discard expired food/beverages, and complete daily temperature logs for resident's personal refrigerators. This applies to 2 of 2 residents (R2 and R51) in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Enhance Barrier Precautions (EBP) Guidelines by staff not wearing gowns during wound care to EBP resident,s and not having a trash can inside the resident room and near the exit for discarding PPE after removal. The facility also failed to maintain effective hand hygiene during resident care. This applies to 2 of 4 residents (R95 and R124) reviewed for infection control practices in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and notify the State Agency of an allegation of theft. This applies to 1 of 8 residents (R1) reviewed for misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide menu variety to meet resident's meal preferences. This failure could potentially affect all 144 residents who consume Food from the kitchen.

Inspectors wroteBased on observation, interview, and reord review, the facility failed to provide access to a call light for one resident. This applies to 1 of 25 residents (R1) reviewed for call light access in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 3 of 4 residents (R55, R59 and R173) reviewed for ADLs (activities of daily living) in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow doctor's order to schedule for a resident a doctor's office visit for an out-patient procedure. This affected 1 of 1 resident (R100) reviewed for quality of care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one resident's toenails that were extremely overgrown were cut by the podiatrist. This applies to 1 of 1 resident (R67) reviewed for foot care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide perineal and indwelling urinary catheter care and services in a manner that would prevent potential infection and maintain hygiene. The facility also failed to ensure that the urinary catheter tubing and urinary privacy bag containing the drainage bag were not touching the floor. This applies to 1 of 3 residents (R82) reviewed for perineal and urinary catheter care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's order with regards to use of the oxygen humidity bottles and administration of continuous oxygen. The facility also failed to label the oxygen tubing per policy and procedure. This applies to 3 of 3 residents (R31, R32 and R43) reviewed for oxygen therapy in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to refill prescribed pain medications for a resident. This applies to 1 of 25 residents (R88) reviewed for medication availability in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and assist one resident in obtaining routine oral care annually. The facility also failed to follow up to ensure one resident was seen by visiting dentist. This applies to 2 of 25 residents (R69, R72) reviewed for dental care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve thickened fluids to residents that have been identified having swallowing problems. This applies to 3 of 10 residents (R11, R69 and R72) reviewed for thickened liquids in the sample of 25.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain transmission based precautions for residents in isolation with infections, failed to perform hand hygiene, failed to use personal protective equipment, and failed to maintain sanitary conditions during patient care. This applies to 2 of 2 residents (R77 and R82) reviewed for infection control in the sample of 25.