Pearl of Naperville, the

Inspectors wroteBased on interview and record review, the facility failed to ensure staff responded timely to residents' requests for care assistance and/or pain medication in accordance with their policy. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for call light response in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to provide residents or their representatives with written notices for room changes. This applies to 5 of 5 residents (R1-R5) reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure QAPI (Quality Assurance Performance Improvement) meetings were held quarterly, and the required members were in attendance. This has the potential to affect all 93 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow CDC (Centers for Disease Control and Prevention) guidelines for pneumococcal vaccines. This applies to 5 of 5 residents (R8, R12, R21, R39, and R50) reviewed for immunizations in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and issue a NOMNC (Notice of Medicare Non-Coverage) to residents at the end of their Medicare coverage. This applies to 3 of 3 residents (R34, R48, and R51) reviewed for beneficiary notification in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to notify the PASARR (Pre-admission Screening and Resident Review) program of residents with a newly diagnosed mental disorder. This applies to 2 of 2 residents (R1 and R8) reviewed for PASARR in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to have sufficient documentation to support a new mental health diagnosis. This applies to 1 of 1 resident (R1) reviewed for professional standards in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms and hallways were adequately cleaned and free of debris and urine odors, and failed to follow the facility's policy to deep clean each resident room at least once every quarter. This applies to all 79 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure prescribed medications were available and administered in accordance with facility policy. This applies to 1 of 3 residents (R3) reviewed for medication administration in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for 5 of 8 residents (R2-R6) reviewed for call lights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to residents with ADLs (Activities of Daily Living), specifically incontinence care and bathing, in accordance with resident needs and as outlined in their policy. This applies to 4 of 4 residents (R1, R3, R5 and R6) reviewed for ADL care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to provide staff in sufficient quantity to meet the residents' bathing, incontinence, and mobility care needs, and ensure timely answering of call lights during the evening and night shifts. This applies to 4 of 5 residents (R1, R3, R5, R6) reviewed for ADL care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to provide an environment where residents are treated with dignity and respect and requests for care are honored. This applies to 2 of 3 residents (R1 and R3) reviewed for ADLs (Activities of Daily Living) in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by the physician. There were 27 opportunities with 3 medication errors resulting in a 11.11% medication error rate. This applies to 1 of 3 residents (R2) reviewed for medication administration in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse. This resulted in R1 being being afraid and in shock. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report an allegation of potential abuse/neglect. This applies to 1 of 6 residents (R1) reviewed for potential abuse/neglect in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care to dependent residents. This applies to 2 of 5 residents (R7 and R10) reviewed for incontinence care in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional supplement to prevent weight loss to a resident who had history of significant weight loss. This applies to 1 of 3 residents (R1) reviewed for nutritional supplement in the sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to administer neuromuscular medication to a resident (R1) with diagnosis of ALS (amyotrophic lateral scoliosis) and a neuropathy pain medication to a resident (R2) with diagnosis of diabetic neuropathy. This applies to 2 of 2 residents (R1 and R2) reviewed for significant medications in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that kitchen was maintain clean, foods were stored properly, and washed pans and buckets for beverages were air dried. This applies to 85 residents who receives meals prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their water management plan for Legionella. This applies to all 87 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a COVID-19 immunization policy for staff and residents. This applies to all 87 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide re-screening of residents with serious mental illness as instructed on each of the residents Level I PASARR (Preadmission Screening and Resident Review), to ensure that residents are offered the most appropriate setting and services for their individual needs. This applies to 4 of 4 residents (R6, R50, R53, and R75) reviewed for PASARR in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 4 of 6 residents (R23, R28, R58 and R77) reviewed for ADL (activities of daily living) in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to notify a provider of a resident not receiving anticoagulant medication. This applies to 1 of 1 resident (R45) reviewed for provider notification in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to residents who were receiving Medicare Part A Services in the facility. This applies to 2 of 3 residents (R76 and R392) reviewed for beneficiary notice in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to follow provider orders to administer anticoagulant medication to a resident. This applies to 1 of 1 resident (R45) reviewed for significant medications in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal care to dependent residents. This applies to 6 of 7 residents (R2, R3, R4, R5, R6, and R7) reviewed for activities of daily (ADL) care in a sample of 7. The Findings Include: 1. R2 is a [AGE] year-old male with cognition intact as per the MDS (Minimum Data Set), dated 7/5/24. The MDS also documented R2 (deaf and blind) requires substantial assistance with toileting hygiene. On 8/17/24 at 10:25 AM, R2 was observed with a soaked incontinent brief with urine and feces. On 8/17/24 at 10:25 AM, V7 (Manager on Duty / MOD/Licensed Practical Nurse/LPN) stated, Our staff is supposed to check on residents every two hours and as needed. They are shorthanded today. A review of R2's incontinent care plan documents: Clean peri-area after each incontinent episode. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate staffing to meet the care needs of residents. Staffing was insufficient to provide residents with assistance in Activities of Daily Living. This applies to 6 of 7 residents (R2-R7) reviewed for staffing concerns in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medicated patch was removed before another medicated patch was applied to prevent potential overdose of the medication. This applies to 1 of 3 residents (R1) reviewed for application of medicated patch/gel in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to discontinue the resident's IV (Intravenous) catheter as ordered, and failed to ensure that maintenance care of the IV catheter was performed and documented. This applies to 1 of 3 residents (R1) reviewed for IV (intravenous) catheter in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R2 is an [AGE] year-old female with severely impaired cognition as per the Minimum Data Set (MDS) Assessment, dated 2/23/24, and dependent on toileting hygiene. On 5/18/24 at 10:20 AM, R2 was in her bed, totally confused, and with a urine smell. On 5/18/24 at 10:22 AM, V12 (Certified Nursing Assistant/CNA) checked R2's incontinent brief and observed R2 with urine-soaked incontinent brief and discoloration from prolonged wetness. On 5/18/24 at 10:20 AM, V12 stated, I am not her assigned CNA, and I am unsure who is assigned to (R2). I am going to change her now. A review of R2's incontinent care plan document: [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate and revise fall care plans as per their fall policy and procedure. This applies to 2 of the 3 residents reviewed (R1 and R2) for fall in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and immediately report an allegation of abuse to the administrator and report to the state agency. This applies to 1 of 3 residents (R2) reviewed for abuse in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary fashion. This applies to all 73 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have a water management program for Legionella in place, and failed to wear proper PPE (Personal Protective Equipment) in isolation rooms. This applies to all 73 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician prescribed medications were not left with a resident for 1 of 1 resident (R9) reviewed for self-administration of medications in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pressure relieving mattress was set to meet the resident's needs were in place for 1 of 4 residents (R35) reviewed for pressure in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain relief for 1 of 2 residents (R224) reviewed for pain in the sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was available from pharmacy for 1 of 1 residents (R226) reviewed for pharmacy services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received CPAP/BiPAP (Continuous Positive Airway Pressure/BiLevel Positive Airway Pressure) as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were implemented for a resident with a history of falls. This applies to 1 of 3 residents (R2) reviewed for falls. Findings Include: R2's Face Sheet showed R2 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R2's 11/9/23 MDS (Minimum Data Set) showed R2 has severely impaired cognition. R2's listed diagnoses include fetal alcohol syndrome, dementia, Tourette's disorder, unspecified hearing loss, psychotic disturbance, and unspecified forms of tremor. R2's records indicated R2 had two different falls at the facility since admission, and both falls were unwitnessed with no pain or injury. One fall was on 11/9/23 at 4:00 AM, where the nurse noted R2 kneeling on the floor mat. [...]