Pearl of Montclare, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) ensure medications were administered as ordered by the resident's physician and b.) provide pain management in accordance with the resident's comprehensive care plan and resident's goals for care and preferences. These failures affect two (R1, R2) out of four residents and caused R1 to experience severe pain while recovering from a spinal fracture in the facility.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure hot foods were served and maintained at safe and appetizing temperatures during meal service, in accordance with facility policy. This deficient practice had the potential to affect all 106 residents receiving food from the kitchen and placed residents at risk for receiving unappetizing meals, reduced food intake, decreased nutritional status, dissatisfaction with meals, and possible foodborne illness from improper food temperature control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the low air loss mattresses were used in accordance with facility policy to promote effective pressure redistribution (inappropriate layering of multiple linens) for two residents (R2 and R4); and failed to ensure a resident (R5) with a acquired stage 4 pressure ulcer received wound care as ordered by the physician resulting in the development of a wound infection, requiring IV (intravenous) antibiotic therapy. These failures affected 3 of 3 residents (R2, R4 and R5) reviewed for pressure ulcers in the sample of 61.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to prepare food in a safe sanitizing environment: staff did not wash hands after leaving and returning to food preparation, visibly soiled appliances/serving carts, and sticky floors throughout the kitchen/dining room. This applies to 101 residents (census of 103 residents minus 2 residents with gastronomy tubes) receiving food from the facility's kitchen. Finding Includes:During the puree session on 03/31/2026 starting at 9:32 AM, V16 (Cook) left the food preparation to switch out the blender to a food processor. V16 returned, took the hot dogs from the bin and placed them in the food processor without washing V16's hands. V16 left food preparation again, went to the refrigerator and returned with packaged hot dog buns to puree them. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to prepare food in a kitchen where the stove did not drip oil onto the floor and where the dishwasher did not leak puddles of water into buckets. This applies to 101 residents (census of 103 residents minus 2 residents with gastronomy tubes) receiving food from the facility's kitchen. Finding Includes:On 03/30/2026 at 9:23 AM, there was oil dripping from a pipe connected to the kitchen's grill-top stove. There was cardboard placed under/next to the stove to catch the oil drippings. The cardboard contained a puddle of oil about 4 inches in diameter. Also, there was water dripping and seeping from the Hot Water Temperature Dishwasher and there were two large rectangular black buckets placed underneath to catch the leaks. Bugs were flying over the water buckets. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper narcotic control count per facility policy due to the shift verification of controlled substances count form not being signed by one of two nurses (incoming and outgoing nurses) required to count narcotics during shift change and one nurse signing the controlled substances check form on her oncoming and outgoing shift on two floors of four floors reviewed for medication storage and labeling. This failure has the potential to affect 15 residents: 6 residents (R7, R9, R28, R30, R71, and R99) on 3 north cart and 9 residents (R2, R11, R12, R13, R19, R29, R68, R72 and R88) on the 2C cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were properly stored in a locked medication cart. This failure affected all 11 residents on the 1C unit on the first floor.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to puree food to a safe consistency which has the potential to cause choking among the recipients. This applies to 9 residents (R1, R20, R22, R24, R61, R62, R65, R76 and R80) in the sample of 9 receiving a puree diet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care received grooming and shaving. This failure affected one resident (R36) out of 61 residents reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician ordered high protein nutritional supplements were administered, failed to follow facility policies for nutritional assessments, monitor weights, monitor the effectiveness of interventions, and document meal intakes accurately for one of four residents (R23) reviewed for weight loss in a total sample of 61 residents. These deficient practices resulted in R23 sustaining a 7.5 percent significant weight loss from January 2026 through March 2026.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure alcohol beverages were monitored according to the physician's order by allowing 1 resident (R69) to store ten cans of beer in his personal refrigerator located in R69's room. This failure affects 1 resident in a total sample of 61 residents. R69's Face Sheet dated 4/1/2026 documents a diagnosis of but not limited to hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, gout, retention of urine, and peripheral vascular disease, Minimum Data Set Section C dated 1/2/2026, documents a BIMS (Brief Interview Mental Status) Score of 15 with indicates R69 has an intact cognition, care plan does not have a focus for alcohol consumption. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to monitor resident's personal refrigerator temperature logs; and failed to ensure that resident's personal refrigerators had a thermometer. These failures affected three residents (R19, R56, and R84) out of 61 residents in the total sample.

Inspectors wroteBased on interview and record review the facility failed to notify a physician and resident representative of a significant change in condition/status (newly identified deep tissue pressure injury) for one resident (R5). This failure affected 1 resident in the total sample of 3 residents reviewed for notification of changes.

Inspectors wroteBased on interview, and record reviewed the facility failed to ensure that a resident (R1) with a pressure ulcer received necessary treatment and services to promote healing. This failure affected one of three residents reviewed for wound care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of <5% for 2 (R2 and R5) residents of 4 (R2, R4, R5, and R6) residents reviewed for medication administration. There were 33 opportunities with 3 errors resulting in 9.09% medication administration error rate.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation to Illinois Department of Public Health (IDPH) for one resident (R1) out of 4 residents reviewed for abuse.

Inspectors wroteBased on interviews and records reviews, the facility failed to follow a resident's (R95) fall care plan intervention and physician recommendation with multiple history of falls to ensure soft head helmet was applied while in bed for 1 (R95) out of 1 resident reviewed for falls. This failure resulted in R95 sustaining a left subdural hematoma after falling and hitting head on the floor on 2/4/25. Findings Include: R95's clinical records show an initial admission date of 3/9/24 with included diagnoses but not limited to anxiety disorder, traumatic subdural hemorrhage, other lack of coordination, other abnormalities of gait and mobility, and epilepsy. R95' Minimum Data Set (MDS) dated [DATE] shows R95 has moderate cognitive impairment and is dependent with staff assistance on toileting, positioning in bed, personal hygiene, and dressing. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies and dispose of food items past their expiration/best buy/use by dates, label opened food item, store food and food related items away from cleaning solutions, perform hand hygiene during dishwashing, and cover prepared food to prevent contamination. This has the potential to affect all 108 residents that receive nutrition from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weights setting for residents (R28, R29) with current pressure ulcer and for residents (R6, 91) who are at risk in developing pressure ulcers. This failure has the potential to affect four (R6, R28, R29, R91) out of four residents reviewed for pressure ulcer care in a final sample of 22. Findings Include: On 3/11/2025 at 11:15 AM, R91 was lying in bed and noted on a low air loss mattress with the weight dial on the machine set to 400 pounds. R91's Minimum Data Set (MDS) dated [DATE] shows R91 requires staff assistance with positioning in bed. R91's BRADEN scale dated 2/20/25 shows R91 is at risk in developing skin breakdown. R91's weight records show R91 weighs 136.6 pounds dated 3/5/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure (a) oxygen and nebulization tubing were dated / changed; (b) BiPAP (Bilevel Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure) masks, oxygen and nebulization tubing were properly stored when not in used; and (c) obtain physician orders for use of BiPAP and CPAP. These failures affected four (R48, R61, R66, R86) out of four residents reviewed for respiratory care in a sample of 22.

Inspectors wroteResident #37 Accidents PLEASE SEE F700 CITATION FOR DETAILS. Resident #41 Accidents F700 Based on observation, interview and record review, the facility failed to ensure the appropriate side rails were used, evaluate the use of side rails quarterly and develop plan of care for use of side rails for four (R37, R41, R61 and R63) out of four residents reviewed for accident / hazard in a sample of 22.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide oral supplements on meal trays as part of the therapeutic diet prescribed by the physician for five (R15, R32, R40, R92, R106) residents reviewed for dining services in a total sample of 22.

Inspectors wroteR16's Order Summary Report documents in part an active order for Enhance Barrier Precaution due to: wound every shift (order date 1/29/2025). R16's Care Plan Report documents in part that R16 is on Enhanced Barrier Precautions related to wound (initiated 1/29/2025). Intervention initiated 1/29/2025 documents in part for staff to clean/wash hands, including before entering and when leaving the room. Staff are to wear gloves and a gown for high contact resident care activities such as changing briefs or assisting with toileting. On 3/11/2025 at 10:40 AM, there was no Enhanced Barrier Precaution (EBP) sign outside of R16's room or on the door. There was no Personal Protective Equipment bin readily accessible near R16's room. After the surveyor interviewed R16, V37 (Certified Nurse Aide) provided incontinence care and dressing assistance to R16. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to obtain a physician order and to determine if self-administration of medication was appropriate for one (R10) out of one resident observed with medications at bed side table in a sample of 22. Findings Include: On 3/11/25 at 11:32 AM, R10 received up in chair in bedroom alert and verbal on the phone. Surveyor observed one uncovered inhaler dispenser and nasal spray bottle on R10's bed side table. At 2:48 PM, R10 stated she has been having the inhaler and the nasal spray at her bed side for a long time since admitted to the facility. R10 stated that she uses the inhaler twice a day for wheezing and the nasal spray once a day for nasal congestion, and she uses the inhaler even when she does not have wheezing. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to refer a resident (R67) to the appropriate state-designated authority for a Preadmission Screening and Resident Review (PASRR) re-evaluation after new psychiatric diagnoses for one out of three residents reviewed for PASRRs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure nail care was provided for three (R14, R27, and R31) residents who are dependent in grooming reviewed for Activities of Daily Living (ADL) in a total sample of 22. Findings Include: On 3/11/25 at 12:27 PM, R27 observed lying in bed alert, legally blind, and with dirty long nail that overgrown the fingers tip. R27 stated, she would like her fingernails to be cut but she cannot remember the last time the staff cut her fingernails. On 3/11/25 at 12:30 PM, V6 (Certified Nursing Assistant/CNA) stated that R27's fingernails are dirty, nasty, and too long. V6 also stated that the CNAs should be providing nail clipping care during shower twice a week and as needed. V6 stated that failure to cut the long nail, could cause R27 to scratch herself. [...]

Inspectors wroteResident #92 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on observations, interviews, and record reviews, the facility failed to update a resident's (R92) comprehensive care plan and limit R92's PRN (as needed) psychotropic drug to 14 days for one out of a total sample of 22 residents.

Inspectors wroteFACILITY Medication Administration F759 Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of less than 5% for 1 (R51) of 3 residents reviewed for medication administration. There was a total of 32 opportunities with 2 errors observed, which resulted in a medication error rate of 6.25%. Findings Include: On 3/11/25 at 9:45 AM, after V8 (Registered Nurse) checked R51's blood pressure and heart rate, V8 started to prepare R51's morning medications. V8 started R51's nebulizer treatment Ipratropium-Albuterol and then prepared the oral pills Amlodipine 10 mg, Ferrous Sulfate 325 mg, Finasteride 5 mg, Fluoxetine 20 mg, Folic Acid 1 mg, Nebivolol 10 mg, Oxybutynin 5 mg, Senna 1 tablet, Sodium Bicarb 650 mg, and Vitamin B12 1000 mcg. At 9:56 AM, R51's nebulizer treatment was completed and took all his oral pills. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their menu and failed to follow cooking instructions. This affected all 108 residents receiving nutrition from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow physician orders for nectar-thick liquids for one resident (R40) out of a total sample of 22 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident (R1) with a known history of falls did not have nine repeated falls. This failure affected one of four residents reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to utilize a gait belt during resident transfer, from toilet to wheelchair, for one of three residents (R1) reviewed for falls. This failure resulted in R1 falling and sustaining a left femur fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) monitor call light system and answer call lights within a timely manner for four residents (R1, R3, R4, R7), b.) failed to provide incontinence care for five (R1, R3, R4, R5, R6) dependent residents, c.) failed to ensure medications were administered as ordered by the residents' physician for one (R1) resident, and d.) failed to provide sufficient nursing coverage to ensure adequate resident care and support. These failures have the potential to affect 20 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who depend on staff assistance for their ADL (Activities of Daily Living) care received grooming care, showers, personal hygiene and feeding assistance. This affects three residents (R1, R2, R3) of three residents reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served at a palatable temperature, and an appetizing appearance and taste. This deficient practice has the potential to affect all 107 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated per facility policy, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) properly store uncooked meat, f.) clean ice machine, g.) do proper hand hygiene during meal preparation, h.) reheat pureed foods to 165 degrees before serving, i.) use tongs when serving bread to avoid direct hand contamination. These failures have the potential to affect all 107 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of professional practice and facility policy relative to infection prevention and control. This failure has the potential to impact every resident in the facility. The facility census of one hundred and nine residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat five residents (R4, R37, R53, R65, R91) with respect and dignity by not serving all the residents sitting at the same table at the same time during dining observations.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide language support to non-English-speaking residents in accordance with professional standards of practice and facility policy. This failure impacts seven residents out of a total facility census of one hundred and nine residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a staff member supervised residents (R4, R7, R12, R26, R37, R53, R60, R63, R65, R86, R90, R91) sitting in the dining room.

Inspectors wroteBased on observation, interview and record review the facility failed to a.) provide thickened liquids as prescribed by physician affecting 1 resident (R71), b.) provide physician ordered oral nutritional supplements affecting 1 resident (R14), and c.) assess residents with a significant weight change and adjust nutrition interventions affecting 3 residents (R36, R71, R100) out of 6 residents reviewed for nutrition and weight loss in a final sample of 22.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate staffing to ensure that nurses administer medications on time, staff supervise the dining rooms when fall-risk residents are present and provide residents' care needs. This has the potential to affect all the residents that reside on the second and third floors.

Inspectors wroteBased on interview and record reviews, the facility failed (a) to follow their policy and procedure to ensure consents were obtained prior to administering psychotropic medications to 3 residents (R27, R74, R76), (b) to ensure Abnormal Involuntary Scale (AIMS) were completed every six months for 2 residents (R14, R76), (c) to follow physician recommendation to attempt a gradual dose reduction (GDR) for 1 (R27) resident, and (d) to provide adequate documentation to support that a GDR was attempted or if contraindicated for 1 (R14) out 4 residents reviewed for psychotropic medications in a final sample of 22. Findings Include: On 4/10/24 at 2:47 PM, R27's electronic health record (EHR) reviewed. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility (a) failed to properly discard multi-dose inhaler and insulins on expiration dates for 6 residents (R68, R362, R8, R56, R1, R89), (b) failed to date opened multi-dose insulins for 3 residents (R17, R34, R61), and (c) failed to follow their policy and procedure for medication storage and labeling to ensure medications were secured in a locked storage area from one out of three carts inspected for medication storage and labeling that could potentially affect all 53 residents residing on the second floor. Findings Include: On 4/09/24 at 9:03 AM, Surveyor observed a medication cart on the 2nd floor hallway left unattended and unlocked. There were house stocks medications sitting on top of the medication cart which include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure resident menus, individual food plan and preferences were followed affecting four residents (R29, R56, R75, R87), b.) provide menus that provide a variety of entrees which are not repetitive affecting three residents (R44, R70, R87), c.) communicate menu changes and/or food substitutions to residents affecting one resident (R70) out of 7 residents reviewed for menus in a final sample of 22. Findings Include: On 04/10/24 at 10:02 AM, during interview with Resident Council participants R29, R75, R87 all stated the kitchen was out of coffee this morning and no one received any coffee. R29 stated R29 did not receive any coffee this morning on R29's breakfast tray and when R29 asked the staff for a cup of coffee the staff told R29 there was no coffee to give her. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide needed care or services by not ensuring compression stockings or compression wrap were applied, midline dressing was dated, educate, and assess residents who decided to apply compression wrap and develop a plan of care. These failures affected 3 (R20, R70 and R83) residents reviewed for quality of care in a final sample of 22.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the low air loss mattress was in the correct setting for 1 (R47) resident and failed to ensure the left heel boot protector was in place for 1 (R14) out of 2 dependent residents reviewed for pressure wound prevention in a final sample of 22. Findings Include: R47's clinical records show R47 has diagnoses not limited to hemiplegia following cerebral infarction affecting left non-dominant side, dementia, and type 2 diabetes mellitus. R47's minimum data set (MDS) dated [DATE] shows R47 requires substantia/maximal assistance with rolling left and right on the bed. R47's Risk assessment dated [DATE] shows R47 is at risk in developing pressure wounds. R47's weight records show R47 weighs 196.6 pounds dated 4/4/24. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident receiving enteral feeding received appropriate care and services, enteral feeding was not administered as ordered and g-tube dressing was not changed daily for 1 (R1) resident reviewed for Tube feeding in a final sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that oxygen tubing and bubbler were dated, changed, and oxygen tubing was placed in a bag when not in use. These failures affected 2 (R65 and R106) residents reviewed for respiratory care in a final sample of 22.

Inspectors wroteBased on interviews and records review, the facility failed to ensure resident safety for one resident (R2) of three residents reviewed. This failure resulted in R2 falling and sustained right leg laceration. R2 was taken to the emergency room and received sutures on the right leg. R2 is not currently in the facility.

Inspectors wroteBased on interview and record review, the facility failed to assert the rights of the residents by not ensuring residents were afforded the opportunity to choose their own food menu items. This failure has the potential to affect 96 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their Involuntary Transfer and Discharge Process policy and failed to provide their bed hold policy upon discharge to hospital for one of one resident (R3), reviewed for involuntary discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide their bed hold policy, upon discharge to hospital, for one of one resident (R3), reviewed for discharge

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to return to the facility after hospitalization for one of one resident reviewed for discharge.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on infection control and prevention to prevent the spread of COVID by not properly cohorting residents with confirmed COVID infections. This failure has the potential to affect two (R8, R11) residents out of four residents reviewed for infection control.