Pearl Pointe Nursing Rehab & Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a paraplegic resident was provided with a call light according to his needs to 1 of 9 (R1) residents reviewed for accommodation of needs in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident that is totally dependent on staff for Activities of daily living (ADL) care received showers and personal hygiene care. This failure effects 1 of 5 residents (R1) reviewed for ADL care in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staffing was scheduled to provide resident cares. This applies to all 64 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide shower assistance for residents who are dependent upon staff for assistance. This applies to 2 of 3 residents (R1, R2) reviewed for Activities of Daily Living in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective pain management to a resident with phantom pain in all 4 amputated extremities. This failure resulted in R1 having severe pain from 1/31/26 to 2/6/26 when he missed 11 doses of medication. This applies to 1 of 3 residents (R1) reviewed for pain management in the sample of four.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to prevent the misappropriation of resident's narcotic medication for three of three residents (R1, R2 & R3) reviewed for misappropriation of resident's property in the sample of four.

Inspectors wroteBased on interview and record review the facility failed to notify the Illinois Department of Public Health and local law enforcement immediately of misappropriation of resident property for 1 of 4 residents (R1) reviewed for misappropriation of resident property in the sample of four.

Inspectors wroteBased on interview and record review the facility failed to ensure there was a system in place to assure accurate receipt, dispensing, administration, and reconciliation of controlled substances for 3 of 4 residents (R1, R2, & R3) reviewed for pharmacy services in the sample of 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and supervise a resident from ingesting cannabis and failed to ensure a residents community pass privileges were re-assessed for safety. This applies to 2 of 3 residents (R1, R2) reviewed for safety in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure social services assisted residents with discharge services. This applies to 2 of 3 residents (R1, R2) reviewed for social services in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure serving temperatures were logged to ensure food was served at a palatable temperature. This failure has the potential to affect 64 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure final cooking temperatures were logged to ensure food was cooked to a food-safe temperature before serving. This failure has the potential to affect 64 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident equipment was maintained for two (R3, R4) of five residents reviewed for safe/clean/homelike in the sample of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from misappropriation for 1 of 3 residents (R1) reviewed for theft in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their Abuse Policy when a resident reported missing property for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an allegation of misappropriation of resident property was reported immediately for 1 of 3 residents (R1) reviewed for theft in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident 's walkway path in her room was free from accidental hazards this applies to 1 of 18 residents (R8) in the sample of 18. This failure resulted in R8 tripping in her cluttered room and sustaining a left ankle and foot fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hand hygiene was completed to prevent cross-contamination, kitchen equipment was cleaned, sanitized, and covered, and failed to ensure a thermometer was cleaned and sanitized before continued use. This has the potential to effect all residents receiving food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure residents with new diagnoses of mental health disorders were referred to the state designated authority. This applies to 4 of 4 (R9, R4, R6, R68) residents reviewed for pre-admission screening and resident reviews (PASRRs) in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to wear personal protective equipment when providing care and failed to remove personal protective equipment prior to exiting the room for residents on Enhanced Barrier Precautions. The facility failed to ensure hand hygiene was performed between resident care to prevent the spread of infection. This applies to 5 of 18 residents (R4, R7, R18, R22 and R59) reviewed for infection control in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident dignity by not applying a privacy covering to a urinary catheter bag for 1 of 18 residents (R22) reviewed for dignity in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was safe to self-administer medications for 1 of 18 residents (R66) reviewed for self-administration in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to follow their advanced directives policy by not obtaining an order for Do Not Resuscitate (DNR) for 1 of 18 residents (R66) reviewed for advanced directives in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that required Preadmission Screening and Resident Review (PASARR) Level I screening reflected a resident's possible/suspected developmental disability. This applies to 1 of 5 residents (R10) reviewed for PASARR in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who requires assistance with activities of daily living received assistance with showers. This applies to 1 of 18 residents (R54) reviewed for activities of daily living in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pressure ulcer prevention interventions were in place for at risk residents for 2 of 4 residents (R22 and R59) reviewed for pressure ulcers in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter drainage tubing and drainage bag was positioned to prevent from touching the floor for a resident with a history of urinary tract infection. This applies to 1 of 3 residents (R44) reviewed for indwelling catheters in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident had orders for oxygen administration and failed to ensure tubing was changed and humidifiers were monitored for 2 of 2 residents (R66 and R50) reviewed for oxygen in sample of 18.

Inspectors wroteBased on interview and record review the facility failed to appropriately assess a resident experiencing a change in condition. This applies to 1 of 3 residents reviewed for quality of care and the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide incontinence care for residents dependent upon staff for assistance. This applies to 3 of 3 residents (R1, R2, R3) reviewed for nursing care in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately transcribe a resident hospital discharge medication list, failed to follow a physician medication order for narcotics, and failed to follow their policy for controlled substances. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their menu. This has the potential to affect all residents receiving a regular diet at the lunch meal.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve the correct menu items for residents receiving a mechanical soft and pureed diet, and failed to provide the correct portion size of food for all residents. These failures have the potential to affect 63 of the 64 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper dishwasher sanitizer levels, failed to maintain overall kitchen cleanliness, failed to ensure foods were stored in a manner to prevent pests and rodents, and failed to store bulk dry foods in a manner to prevent cross contamination. These failures have the potential to affect 63 of the 64 residents residing in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment during dining for 5 of 5 residents (R3, R7, R13, R22, R53) in the sample of 20 and 5 residents outside of the sample (R4, R21, R29, R40, R164).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve residents a mechanical soft diet. This applies to 3 residents in the sample of 20 (R22, R23, R45) and 7 residents (R4, R12, R19, R24, R28, R40, R41) outside of the sample reviewed for mechanical soft diets.

Inspectors wroteBased on observation, interview and record review the facility failed to follow contact isolation precautions as ordered (R214), failed to follow enhanced barrier precautions (R57) and failed to implement enhanced barrier precautions (R38, R52 and R17). This applies to five (R214, R57, R38, R52, and R17) of six residents reviewed for infection control in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide daily dressing changes, assess a resident for a change in condition, and notify the physician and family of a change in condition for 2 of 2 residents (R52 & R23) reviewed for quality of care in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to transfer a resident in a safe manner (R25) and failed to supervise a resident walking unassisted down the hallway and update their care plan after a fall (R52). This applies to two of three residents reviewed for safety/supervision in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide catheter care daily, change suprapubic catheter dressing change daily and ensure catheter tubing secure device was in place for 1 of 4 residents (R38) reviewed for catheters in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dietary interventions were implemented for a resident with weight loss for 1 of 1 residents (R3) reviewed for weight loss in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen equipment was clean, filters were intact, bubblers had fluid, oxygen tubing was not too long or kinked, and changed for 2 of 2 residents (R39 & R22) reviewed for oxygen in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to have policy and procedures in place for the care of a dialysis resident for 1 of 2 residents (R13) reviewed for dialysis in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were taken by residents at the time of administration for 2 of 2 residents (R18, R13) reviewed for medications in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 32 opportunities with 2 errors resulting in a 28.5% medication error rate. This applies to 1 of 3 residents (R16) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage of narcotic medications, failed to ensure medications were stored in their original packaging, and failed to monitor the temperature of a medication refrigerator. This applies to 1 of 2 medication rooms and 1 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a shower or bath and/or hair care were provided for 3 of 3 residents (R1, R2, & R6) reviewed for activities of daily living in a sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a residents wound dressings were being changed for 1 of 3 residents (R3) reviewed for wounds in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers had pressure reducing/preventative measures in place for 2 of 3 residents (R2 and R3) reviewed for pressure injuries in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure catheter care was being provided, the drainage bag was kept off the floor, the drainage bag was maintained below the level of the bladder, and catheters were changed as needed for 2 of 3 residents (R1 & R5) reviewed for catheters in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to refund a resident's funds within 30 days of discharge for 1 of 3 residents (R1) reviewed for resident funds in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and document a resident's non-pressure (venous) wounds. The facility also failed to follow up with the resident's physician after a visit at his office and failed to follow physician orders written during that visit. This failure resulted in R1 having no wound assessments since January 2024 for 4 venous wounds on her legs, R1 having exposed open and bleeding wounds to the backs of her thighs, and R1experiencing an 18 day delay in increasing her pain medication. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance with ADL's (Activities of Daily Living). This failure resulted in R1 being left on the bed pan unattended leading to feelings of pain, frustration, panic and embarrassment. This applies to 1 of 3 residents reviewed for assistance with ADL's in a sample of 6 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan and interventions were developed and implemented to prevent pressure ulcers, failed to provide pressure ulcer treatment, and failed to update interventions to the care plan and update the skin risk assessment once pressure ulcers developed for 2 of 3 residents (R1, R3) reviewed for pressure ulcers on the sample list of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R14) with congestive heart failure was weighed daily to monitor for fluid overload. The facility also failed to ensure a resident (R57) received wound care as ordered. The facility also failed to identify a wound to the foot for (R24). These failures affect 3 of 7 residents (R14, R24, R57) reviewed for quality of care in the sample of 21. This failure resulted in R14's increased weights not being reported to the physician and R14 requiring hospitalization from 11/20/23 through 11/24/23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received pain medication as scheduled for 1 of 1 resident (R9) reviewed for pain in the sample of 20. This failure has resulted in R9 requesting further pain control on 7/18/23 while reporting pain at a level 10 on the pain scale and on 10/18/23 while reporting pain at a level of 8 on the pain scale.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This failure affects all 65 residents who currently reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was treated in a dignified way for 1 of 3 residents (R14) reviewed for dignity in the sample of 20.

Inspectors wrote2. R4's admission Record (Face Sheet) showed an original admission date of 11/16/23 with diagnoses to include contracture left hand, paranoid schizophrenia, and mood disorder. R4's 11/22/23 admission Minimum Data Set (MDS) showed moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. The MDS showed she required supervision or touching assistance for personal hygiene. On 12/12/23 at 12:19 PM R4's left hand was contracted. On three of the fingers of her left hand (thumb, middle, and pinky) the nails were 1/4 long and dirty. R4 stated, I wish they would cut them. I would prefer it [if the staff cut the nails]. They never cut my nails. I only get one shower a week. On 12/13/23 at 4:05 PM, R4 stated, I would like my nails trimmed they are too long. I do need help to trim my nails, I can't do it myself. I would let them trim my nails if they asked. [...]

Inspectors wroteBased on observation, interview and record review the facility failed administer medication to prevent cross contamination, failed to administer insulin per manufacturer's instructions, and failed to monitor a resident during medication administration. This applies to 2 of 4 residents reviewed for medication administration in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident equipment in a clean and sanitary manner for 1 of 1 resident (R14) reviewed for equipment on the sample list of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the State Survey Agency survey binder was in an area of access. This applies to all 63 residents who resides in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide care needs details to staff that R1 had a wound vacuum device, failed to provide monitoring and remain with/supervise R1 while he was experiencing hemorrhagic blood loss. The facility also failed to perform a full body assessment for R1 to determine the source of R1's bleeding to provide proper first aid to attempt to control the bleeding. These failures resulted in R1 sustaining hemorrhagic blood loss leading to R1's cardiac arrest. R1 required initiation of cardiopulmonary resuscitation (CPR) initiated by EMS staff upon their arrival to the facility, intubation for mechanical/artificial breathing support and transport to the local hospital emergency department. R1 required multiple rounds of CPR while in the emergency room, expiring on [DATE] at the local hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely respond to a report of an unresponsive resident, failed to ensure a resident was monitored and not left unattended once found unresponsive, failed to thoroughly assess a resident to identify the source of hemorrhagic blood loss and provide immediate treatment in attempt to control blood loss and failed to contact Emergency Medical Systems (EMS) in a timely manner. These failures resulted in R1 sustaining hemorrhagic blood loss leading to R1's cardiac arrest. R1 required initiation of cardiopulmonary resuscitation (CPR) initiated by EMS staff upon their arrival to the facility, intubation for mechanical/artificial breathing support and transport to the local hospital emergency department. R1 required multiple rounds of CPR while in the emergency room, expiring on [DATE] at the local hospital. [...]

Inspectors wroteBased on interview and record review the failed to identify and implement resident centered fall prevention interventions for a resident with a history of falls. This applies to 1 of 5 residents (R1) reviewed for safety in the sample of 5.