Pearl of Crystal Lake, the

Inspectors wroteBased on observation, interview and record review, the facility failed to unload the clean dishes from the dishwasher in a sanitary manner and failed to document cooling temperatures. This applies to all the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by a physician for 3 residents (R65, R100, R101), failed to safely administer medications to 1 resident (R38), failed to ensure medications were not left at the bedside for 2 residents (R41, R45). These failures apply to 6 of 6 residents reviewed for pharmacy services in the sample of 44.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's provider when the resident's blood sugar was outside the specified parameters. This applies to 1 of 1 residents (R7) reviewed for notification in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the transfer to the hospital was documented and the basis for transfer was documented for 1 of 1 resident (R77) reviewed for transfers in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care for a 1 of 1 residents (R9) reviewed for activities of daily living in sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer prevention measures were in place for 2 of 7 residents (R62,R65) reviewed for pressure ulcers in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall preventative measures were in place for a resident at high risk for falls for 1 of 4 residents (R45) reviewed for falls in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's nebulizer was stored in a manner to prevent cross contamination for 1 of 1 residents (R41) reviewed for oxygen/respiratory treatments in the sample of 44.

Inspectors wroteBased on interview and record review the facility failed to provide pain medication for a resident prior to therapy. This applies to 1 of 1 residents (R101) reviewed for pain control in the sample of 44.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R66) was free from a significant medication error. This applies to 1 of 1 residents reviewed for significant medication errors in the sample of 44.

Inspectors wroteBased on observation, interview and record review, the facility failed to puree foods following the recipe to maintain palatability of the food served. This applies to two of two residents (R9, R65) reviewed for puree foods in the sample of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were followed for 1 of 7 residents (R21) reviewed for infection control in the sample of 44.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the menu was followed to meet the nutritional needs of residents on a pureed diet for 4 of 4 residents (R13, R49, R54 and R65) reviewed for menus and nutritional adequacy in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is morbidly obese received the appropriate wheelchair for 1 of 18 residents (R128) reviewed for accommodation of needs in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain treatment orders for a non-pressure wound and failed to obtain daily weights as ordered for a resident with congestive heart failure. This applies to 2 of 18 residents (R177 and R128) reviewed for quality of care in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to put interventions in place for residents with pressure injuries to 3 of 8 residents (R127, R62, and R44) reviewed for pressure injuries in the sample of 18

Inspectors wroteBased on interview and record review the facility failed to implement a care plan intervention for a resident at risk for malnutrition for 1 of 3 residents (R73) reviewed for nutrition in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) for a resident on enhanced barrier precautions for 1 of 18 residents (R178) reviewed for infection control in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received a pneumococcal vaccine for 1 of 5 residents (R52) reviewed for immunizations in the sample of 18.

Inspectors wroteBased on interviews and record review, the facility failed to prevent the theft of a resident's personal money for one of three residents (R1) reviewed for misappropriation of property.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering COVID-19 isolation rooms and for resident rooms that were on isolation for suspected/ruling out COVID-19. The facility also failed to ensure staff disposed of a face shield after use and failed to ensure staff did not wear surgical masks under N95 masks. This applies to 7 of 9 residents (R1, R2, R3, R4, R7, R8, and R9) reviewed for infection control in the sample of 9.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure an as needed medication was documented in R1's Medication Administration Record (MAR) for 1 of 10 residents reviewed for pharmacy services in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff safely assisted a resident with repositioning in bed. This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's call lights were answered in a timely manner in order to maintain the resident's quality of life and dignity for 4 of 5 residents (R2, R4, R50 & R40) reviewed for dignity in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure orders for do not resuscitate (DNR) were documented in the physician's orders for 1 of 1 resident (R33) reviewed for advanced directives in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with poor trunk control was properly positioned; failed to ensure a resident with CHF (Congestive Heart Failure) was weighed daily; and failed to ensure a dressing was in a place to a non-pressure wound for 2 of 7 residents (R23, R282) in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's restorative program of passive range of motion to upper and lower extremities was being provided daily for 1 of 3 residents (R2) reviewed for restorative services in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to provide indwelling urinary catheter care for 1 of 3 residents (R40) reviewed for catheters in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement contact precautions to alert staff and visitors of a resident with an active infection, failed to ensure catheter care was provided in a manner to prevent cross-contamination for a resident with an active infection, and failed to ensure supplies used for personal cares were not contaminated. The facility also failed to ensure staff wore PPE (personal protection equipment) when performing wound care for a resident on enhanced barrier precautions. This applies to 2 of 8 residents (R67, R44) reviewed for infection control in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ongoing monitoring of a resident for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance to a resident that needed extensive assist with activities of daily living (ADL's) for 1 of 4 residents (R2) reviewed for ADLs in the sample of 4.