Pearl of Elgin, the

Inspectors wroteBased on interview and record review, the facility failed to administer timely and correct treatment for a resident with a UTI (Urinary Tract Infection). The facility also failed to administer medications as ordered by the provider. This failure resulted in R1 being hospitalized for metabolic encephalopathy and UTI due to not receiving the correct antibiotic to treat her UTI. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for UTI in the sample of 5.

Inspectors wroteBased on the interview and record review, the facility failed to inform a resident's Power of Attorney (POA) before facilitating the completion of guardianship paperwork by another family member. This applies to 1 of 6 residents (R1) reviewed for the right exercised by the representative.

Inspectors wroteBased on interview and record review, the facility failed to timely respond to a resident's Power of Attorney after being notified of a concern with a resident's damaged hearing aids. The facility failed to follow their grievance policy. This applies to 1 of 6 residents (R1) reviewed for grievances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for hand hygiene during provisions of care with R59. The facility also failed to follow their water management plan for Legionella. This has the potential to affect all 121 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve mechanically ground coleslaw and pureed consistency pork riblet and bun to residents on diet order consistencies for the same. This applies to 11 of 11 residents (R5, R8, R12, R34, R41, R46, R62, R65,R71, R168, R270) reviewed for dining in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to offer pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines. This applies to 5 of 5 residents (R1, R15, R21, R63, and R69) reviewed for immunizations in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were able to exercise their right to make a complaint without interference. The facility also failed to document resident's concerns and follow their grievance policy. This applies to 3 of 3 residents (R13, R26, and R76) reviewed for grievances in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to conduct a screening for Preadmission Screening and Resident Review (PASRR) on admission to facility for a resident with mental disorder. This applies to 1 of 4 residents (R21) reviewed for PASRR in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's gauze central line dressing was changed every 48 hours for prevention of infection. This applies to 1 of 1 resident (R113) reviewed for intravenous therapy in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to store insulin and house stock medication in accordance with their policy. This applies to 1 of 24 residents (R10) reviewed for medication storage in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to have the required policy regarding missing or lost dentures and financial responsibility, in accordance with 483.55(b)(4) and failed to assist a resident in need of dentures, to obtain them. This applies to 1 of 1 resident (R26) reviewed for dental services in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to employ and schedule a sufficient number of competent food service staff to safely and adequately serve resident meals. This has the potential to affect all 119 residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve the facility menus as planned. This has the potential to affect all 119 residents receiving oral diets in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to serve palatable meals to facility residents. This has the potential to affect all 119 residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility food preparation and storage was performed in a sanitary manner and under sanitary conditions. This has the potential to affect all 119 residents receiving oral diets in the facility.

Inspectors wroteBased on interview and record review the facility failed to identify and implement interventions for performance improvement regarding kitchen sanitation and ADLs (Activities of Daily Living) care. This applies to all 122 residents who reside in the facility.

Inspectors wrote5. The Electronic Medical Record (EMR) shows that R33, an [AGE] year-old female, with diagnoses of bilateral osteoarthritis, peripheral neuropathy, chronic obstructive pulmonary disease exacerbation, diabetes mellitus type 2, major depressive disorder, obesity, and cerebral infarction. R33 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE] showed that R33 was cognitively intact with a BIMS (Brief Interview Mental Status) score of 14/15. The MDS also showed that R33 required extensive assistance from 1-2 staff for bed mobility, transfer, dressing and hygiene. On 9/05/23 at 10:43 AM, R33 was observed in her room. R33 was sitting in her wheelchair. R33 was observed with a long facial hair surrounding her chin and upper lip and looked like a moustache. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement physician order regarding the use of compression stockings and compression wrap to treat and manage edema. This applies to four of four residents (R1, R70, R80 and R102) reviewed for edema in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to puree resident food to a smooth consistency per facility policy. This applies to 6 of 6 residents (R5, R10, R15, R34, R82, and R104) reviewed for pureed diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve residents double protein servings and supplements per physician orders. This applies to 4 residents (R5, R31, R68 and R83) reviewed for therapeutic diets.

Inspectors wroteBased on observation and interview, the facility failed to ensure that privacy was provided to residents during administration of insulin and eye drops medications. This applies to 2 of 7 residents (R33 and R80) observed during medication pass administration in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility. This applies to 1 of 6 residents (R55) reviewed for limited range of motion (ROM) in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean a resident during incontinence care in a manner that would prevent potential infection. This applies to 1 of 1 resident (R34) reviewed for incontinence care in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to evaluate and put interventions in place to prevent weight loss. This affects 1 resident of 3 residents (R71) reviewed for significant weight loss in the sample of 24 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's order with regards to administration of continuous oxygen. This applies to 2 of 2 residents (R50 and R61) reviewed for oxygen therapy in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adaptive equipment to residents as per physician orders. This applies to 2 residents (R10 and R11) reviewed for adaptive equipment.

Inspectors wroteBased on observation and interview the facility failed to change gloves and perform hand hygiene during provisions of care. This applies to 1 of 2 residents (R34) reviewed for incontinence care in the sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 staff were present during resident care to prevent resident injury for 2 residents (R9 and R77), and failed to ensure 2 staff were present for a resident transfer for 1 resident (R46). This failure resulted in R77 rolling out of bed, sustaining subdural hematomas requiring emergency care and hospitalization. This applies to 3 of 25 residents (R9, R77, R46) reviewed for safety/supervision in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food prep areas were free of food debris. The facility also failed to ensure plates were clean and dry before using them for the noon meal. This applies to all 124 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the kitchen, cooler and freezers were clean and sanitary. This applies to all 124 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on mechanical soft and pureed diets received the same menu as the regular diet. This applies to 24 of 24 residents (R6, R27, R127, R19, R64, R22, R82, R80, R43, R75, R44, R60, R38, R24, R182, R93, R3, R15, R88, R115, R51, R90, R36, & R103) reviewed for mechanical soft and pureed diets in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed diets were served in a smooth, soft texture. This applies to 4 of 4 residents (R6, R27, R127 and R19) reviewed for pureed diets in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R331) was free from physical abuse for 1 of 25 residents reviewed for abuse in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify restraining a resident by restricting their movement which applies to 1 of 24 residents (R44) reviewed for restraints in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and apply pressure relieving interventions for residents who are high risk for pressure injuries. This applies to 3 of 11 residents (R76, R103 & R106) reviewed for pressure injuries in the sample of 25. 1. R76's electronic medical records (EMRs) list her diagnoses to include: cognitive communication deficit, urine retention, chronic kidney disease, disorientation and dementia. R76's EMR shows she was admitted to the facility on [DATE]. The facility's pressure ulcers as of October 17, 2022 provided on October 17, 2022 shows, R76 has two pressure injuries. Her left heel- DTI (deep tissue injury) and sacrum- DTI. Both were acquired at the facility. R76's initial admission/re-admission nursing note dated August 30, 2022 shows, she was admitted with redness on her sacrum. [...]

Inspectors wrote2.) R9's face sheet shows she has diagnoses including hemiplegia and hemiparesis following a cerebral infarction. R9's 7/22/22 facility assessment shows her cognition is mildly impaired, and she requires extensive staff assistance with her activities of daily living (ADL's) R9's mobility care plan revised on 8/11/2021 shows that R9 has limited mobility to her left hand and a hand towel roll should be put in her hand each shift. R9's restorative range of motion task charting shows R9 should receive a hand rolled towel in her left hand to prevent further contractures. The chart for R9 is checked off on 10/17/22 at 10:36 AM, and again on 10/18/22 at 11:05 AM, indicating that R9 did have a hand roll towel put into her left hand. On 10/17/22 at 9:56 AM, R9 was in bed her left arm was positioned in front of her and her left hand was in a clenched position with no hand roll in it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with COVID symptoms was placed on isolation precautions. This applies to 1 of 25 residents (R93) reviewed for infection control in the sample of 25.