Pearl of Hinsdale, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer and reposition dependent residents. This failure resulted in R3 sustaining ongoing discomfort and pain to the right upper extremity with a possible right shoulder subluxation and/or right humerus fracture and a hematoma on her forehead. This applies to 2 of 4 residents (R3 and R7) reviewed for accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu spreadsheet to serve portion sizes as shown for the pureed diets and failed to serve mechanical soft consistency foods as shown on the menu spreadsheet and recipe. This applies to 10 of 10 residents (R12, R13, R60, R73, R81, R84, R85, R91, R173, R174) reviewed for mechanically altered diets in the sample of 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy regarding the management and care of PICC (Peripherally Inserted Central Catheter) lines, including measurement of arm circumference and ensuring that PICC insertion sites were assessed and monitored every shift for signs of symptoms of infection. This applies to 2 of 2 residents (R113 and R196) reviewed for PICC line in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and report bleeding from a resident's dialysis access site. The facility also failed to reinforce dressing to a resident's dialysis access site. This applies to 2 of 7 (R14, R101) reviewed for dialysis in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident wound treatments as ordered by physicians. This applies to 2 of 3 residents (R1 and R2) reviewed for wound treatments in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure that there are enough supplies of linens and towels to meet resident needs. This applies to 5 of 7 residents (R5, R6, R7, R8, R9) reviewed for linens and towel supply in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that menus and dietary orders are being followed to meet resident's needs. This applies to 6 of the 6 residents (R4, R6, R7, R8, R9, R11) reviewed for meal portions in the sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff was trained and was able to demonstrate competency to care for residents with implanted cardiac LVADs (Left Ventricular Assist Devices). This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for improper nursing care in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide LVAD (Left Ventricular Assist Device) dressing changes as ordered by the physician. This applies to 3 of 4 residents (R1, R2, and R3) reviewed for improper nursing care in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician to residents with diagnoses of heart failure requiring the use of implanted LVADs (Left Ventricular Assist Devices). This applies to 2 of 4 residents (R2 and R4) reviewed for improper nursing care in the sample of 4.

Inspectors wroteBased on the observations, interviews, and record reviews, the facility failed to return the heart monitor devices to the cardiology monitoring departments per physician orders and label instructions. This applies to 2 of 3 (R2 and R3) residents reviewed for heart monitoring devices in a sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all resident that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly contain and cover garbage in the facility kitchen to control fruit fly population. 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 implement fall precaution interventions for residents at risk for falls. This applies to 3 of 3 residents (R5, R103, and R87) reviewed for accidents and supervision in a sample of 28. 1. R103 admitted to the facility with diagnoses of osteoarthritis of both knees, methicillin resistant staphylococcus aureus, morbid obesity, heart failure, lymphedema, hypotension, sleep apnea, chronic kidney disease, and hypertension. R103 current care plan states she is at risk for fall interventions include staff to assess the physical environment, device including furniture bed to ensure that they don't pose a safety hazard. Bed in a safe level position based on residents needs / risks. R103 MDS (Minimum Data Set) dated 9/28/24 shows she is dependent on staff for transfers and uses a manual wheelchair for mobility. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete accurate post-dialysis weights for residents on dialysis treatments. This applies to 5 of 7 residents (R41, R49, R91, R107, and R138) reviewed for dialysis in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for 3 residents (R87, R123, & R65) who are dependent on care for daily living in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately store and secure medications and biologics safely for 2 residents (R19 & R93) who were reviewed for medication storge in a sample of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to assure residents were not served food items to which they had allergies or sensitivities and follow up on a resident's food preferences. This applies to 2 of 4 residents (R40 and R30) reviewed for food concerns in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Enhanced Barrier Precautions (EBP) Guidelines and isolation policy by staff not wearing gowns during incontinent care for an EBP resident and having visitors visiting contact isolation residents without having gloves or gown. The facility also failed to maintain effective hand hygiene during resident care. This applies to 3 of 3 residents (R51, R80, and R87) reviewed for infection control practices in a sample of 28.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain residents' bed equipment. This applies to 2 residents (R87 & R123) reviewed for maintenance of furnishings and equipment in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident (R1) needing assistance with eating during meal services. This applies to 1 of 3 residents (R1) reviewed for feeding assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer recommendations and pressure ulcer treatments were completed as ordered. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and date intravenous fluid bag/tubing and timely administer physician ordered intravenous antibiotics as ordered for a resident (R1) with an infection. This applies to 1 of 3 residents (R1) reviewed for intravenous medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a clean, comfortable, home-like interior. This applies to 3 residents (R4, R7, R8) reviewed for sanitary and home-like environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide two person assistance during incontinence care and failed to implement a post fall intervention. This failure applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in the resident falling off the bed and sustaining a left femur and a right shoulder fracture.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged threat of harm made by a nurse toward a resident at the facility. This applies to 1 of 4 residents (R1) reviewed for abuse in a sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to check food temperatures after cooking food, before the start of meal service, and halfway through service to ensure safe temperatures were held to prevent foodborne illnesses. This applies to all 132 of 134 residents eating from the kitchen. Two residents were nothing by mouth or fed by gastrostomy tube.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve portion sizes of entrees as per the facility's planed menu. This applies to all residents residing in the facility receiving regular consistency diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pureed diets in a consistency per the facility's policy. This applies to 12 of 12 residents (R2, R10, R19, R26, R32, R35, R44, R60, R77, R333, R335, R336) reviewed for for pureed consistency diets.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's room was clean and without a strong smell of urine. This applies to 1 resident of 1 resident (R40) reviewed for homelike environment in a sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide treatment for an open skin blister for R93 and failed to follow a physician's order for an urology appointment for R36. This applies to 2 residents of 2 residents (R36, R93) reviewed for skin treatment and physician appointments from the total sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement elopement prevention interventions for resident identified at risk for elopement as per the facility policy. This applies to 1 of 1 residents (R104) reviewed for elopement in a sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence and catheter care in a manner that would prevent urinary tract infection (UTI). This applies to 3 of 4 residents (R3, R93, R117) reviewed for perineum and catheter care in the sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to assess intravenous midline catheter site and complete dressing changes in a timely manner. This applies to 1 resident of 1 resident (R126) reviewed for PICC (peripherally inserted central catheter)/midline in a sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to provide a pneumococcal vaccine to a resident who consented to receive the pneumococcal vaccine. This applies to 1 of 5 residents (R61) reviewed for pneumococcal vaccine administration in a sample of 24.