The Pearl of Fox River Valley

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer prevention measures for 2 of 6 residents (R10,R91) reviewed for pressure ulcers in the sample of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise 2 residents (R91,R94) during meal times, failed to transfer a resident (R60) with a gait belt, failed to ensure fall precautions were in place for a resident (R16). These failures apply to 4 of 9 residents reviewed for safety/supervision in the sample of 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide catheter care, ensure a drainage bag is not laying on the floor, and kept below the level of the bladder for 4 of 5 residents (R6, R13, R58, & R91) reviewed for catheters in the sample of 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents on a pureed diet received a pureed dinner roll during the lunch meal for 8 of 8 residents (R16, R18, R68, R69, R72, R79, R91, and R94) reviewed for pureed diets in the sample of 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dignity of a resident was maintained for 1 of 2 residents (R109) reviewed for dignity in the sample of 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy for a resident to self-administer medications for 1 of 1 resident (R108) reviewed for self-administration in the sample of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply compression stockings for 2 of 2 residents (R10,R91) reviewed for quality of care in the sample of 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician prescribed medications were administered as ordered for 1 of 1 resident (R3) reviewed for medication administration in the sample of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) during catheter care for a resident (R91) on Enhanced Barrier Precautions, failed to perform glove changes during resident care. This applies to 1 of 1 residents reviewed for infection control in the sample of 43.

Inspectors wroteBased on interview and record review, the pharmacist's Medication Regimen Review (MRR) failed to identify the transcription omission of a resident's thyroid medication for her hypothyroidism diagnosis at the time of her readmission. This applies to 1 of 3 (R1) residents reviewed for pharmacy services.

Inspectors wroteBased on interview and record review the facility failed to transcribe a resident's medications as ordered, resulting in the original does of thyroid medication not being administered for 79 days. This applies to 1 of 5 (R1) residents reviewed for medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe transport of resident to the shower room when a shower chair was utilized for the transfer in place of a wheelchair. This failure resulted in R24 falling from the chair and fracturing both of her legs. This applies to 1 of 4 residents (R24) reviewed for accidents in the sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to document and promptly resolve resident's stated concerns. This applies to 5 of 5 residents (R29, R43, R85, R38 and R24) reviewed for grievances in the sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to obtain resident weights in accordance with physician orders. This applies to 5 of 5 residents (R21, R60, R14, R37, R61) reviewed for weight documentation in the sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to puree foods to a smooth consistency. This applies to 6 of 6 residents (R1, R56, R66, R68, R99 and R406) reviewed for pureed diets.

Inspectors wroteBased on interview and record review, the facility failed to obtain treatment orders for a newly admitted resident with pressure ulcers. This applies to 1 of 3 residents (R256) reviewed for pressure ulcers in the sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide indwelling catheter care in a manner that would prevent infection. The facility also failed to ensure indwelling urinary catheter is kept secured to prevent from pulling and tugging and prevent catheter related skin trauma. This applies to 3 of 5 residents (R1, R70 and R86) reviewed for indwelling catheter care in the sample of 26.

Inspectors wroteBased on interview and record review the facility failed to ensure incontinence care was provided per a resident's request for 1 of 4 residents (R10) reviewed for incontinence care in the sample of 10.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that R10 was free from physical, mental, and emotional abuse from an agency staff, V15 (CNA/Certified Nurse Assistant). The facility also failed to implement its policy to keep R10 free from further abuse. This failure resulted in Immediate Jeopardy on 11/5/2023 at 9:00 A.M., when R10 had sustained physical, emotional harm and mental distress from abusive care provided by V15. The facility also failed to implement their abuse policy by not reporting and investigating V15's inappropriate behavior such as yanking resident's bed rail, abrupt with care, ignoring call lights, that had occurred on 11/1/2023, and this had led to physical abuse on 11/5/2023 when V15 jerked R10's arm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their abuse policy regarding immediate reporting and investigation of an alleged abuse. The delay in reporting and investigating meant that V15(CNA/Certified Nursing Assistant) staff continued to work after R10 made allegation of inappropriate behavior, yanking R10's bed rail and was abrupt with care. This failure resulted in R10 sustaining bruises, emotional harm and mental distress from abusive care provided by V15. This applies to one of three residents (R10) reviewed for injuries of unknown origin and abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's abuse policy and report and investigate an allegation of physical abuse. This applies to one of three residents (R10) reviewed for injuries of unknown origin.

Inspectors wroteBased on interview and record review, the facility failed to provide Covid 19 vaccine for a resident who did request to be vaccinated. This affects 1 resident (R1) of 3 reviewed for vaccination in the sample of 3. According to the facility face sheet, R1 was admitted to the facility 9/19/21 with multiple cardiac diagnoses and other diagnoses. R1 was [AGE] years old at the time of the investigation. On 11/21/22 at 11:44 am, V10 (family to R1) stated she had asked the infection control Nurse (V4) as early as October 1st for the latest vaccine for Covid 19 prevention and the request was not fulfilled and no explanation was given. On 11/21/23 at 1:15pm, V4 stated she was the infection control and preventionist (ICP) until she was let go by the facility one month ago. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident medications were stored at the required temperature for 4 of 4 residents (R2, R31, R34, R57) reviewed for medication storage in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure resident grievances/concerns were responded to in a timely manner for 2 of 5 residents (R18, R28) reviewed for grievances in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to assist a resident with ambulation and accurately document his progress to ensure his ability to ambulate did not diminish. This applies to 1 of 8 residents (R41) reviewed for restorative services in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident's non-pressure wound dressings were applied as ordered. This applies to 1 of 4 residents (R63) reviewed for for non-pressure wounds in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to identify and assess two resident's pressure wounds prior to them being a Stage 3 and Stage 4 pressure wound. This applies to 2 of 6 residents (R64 and R1) reviewed for pressure wounds in a sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications ordered. There were 30 opportunities with 2 errors resulting in a 6.67% error rate. This applies to 1 of 3 residents (R58) observed during the medication pass in a sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident received her insulin as ordered. This applies to 1 of 3 residents (R58) reviewed for significant medication errors in a sample of 18.

Inspectors wroteBased on observation interview and record review the facility failed to ensure housekeeping staff wore the correct Personal Protective Equipment (PPE) when cleaning a contact isolation room which applies to 1 of 18 residents (R61) reviewed for infection control in a sample of 18.