13 CMS Surveys
Inspection Report — May 29, 2025
Date: May 29, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to ensure a medication administration error rate below 5%, with errors found in medication administration for two residents.
Deficiencies (1)
F0759 (no section number) - The facility failed to ensure a medication administration error rate below 5%, resulting in errors for 2 of 4 residents reviewed.
Report Facts
Residents affected: 2
Residents reviewed: 4
Medication administration opportunities: 33
Medication administration errors: 3
Medication administration error rate: 9
Inspection Report — Apr 18, 2025
Complaint Investigation
Date: Apr 18, 2025
Visit Reason
This survey was a complaint investigation conducted on 04/15/2025 regarding an allegation of abuse involving resident R1.
Complaint Details
Complaint # not explicitly stated in the document; complaint investigation regarding failure to report abuse allegation for resident R1.
Findings
The facility failed to report an abuse allegation to the Illinois Department of Public Health for one resident (R1) out of four residents reviewed for abuse. The investigation found that the resident reported an incident during ambulance transport, but the facility did not deem it an abuse allegation and did not report it to the state agency.
Deficiencies (1)
F0609 (Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities) - The facility failed to report an abuse allegation to the Illinois Department of Public Health for one resident out of four residents reviewed for abuse.
Report Facts
Residents affected: 1
Residents reviewed: 4
Inspection Report — Mar 14, 2025
Annual Inspection
Date: Mar 14, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including medication administration errors, failure to follow infection control precautions, inadequate dietary practices, and failure to provide appropriate care and services as ordered.
Deficiencies (14)
F0554 (77 Ill. Adm. Code Part 295) - The facility failed to obtain a physician order and to determine if self-administration of medication was appropriate for one resident observed with medications at bedside.
F0644 (77 Ill. Adm. Code Part 295) - The facility failed to refer a resident to the appropriate state-designated authority for PASRR re-evaluation after new psychiatric diagnoses.
F0677 (77 Ill. Adm. Code Part 295) - The facility failed to ensure nail care was provided for three residents dependent in grooming.
F0686 (77 Ill. Adm. Code Part 295) - The facility failed to ensure low air loss mattress devices were set to the correct weight settings for residents with pressure ulcers or at risk for pressure ulcers.
F0689 (77 Ill. Adm. Code Part 295) - The facility failed to follow a resident's fall care plan intervention and physician recommendation to ensure a soft head helmet was applied while in bed, resulting in a subdural hematoma after a fall.
F0695 (77 Ill. Adm. Code Part 295) - The facility failed to ensure oxygen and nebulization tubing were dated/changed, BiPAP and CPAP masks and tubing were properly stored, and physician orders were obtained for BiPAP and CPAP use.
F0700 (77 Ill. Adm. Code Part 295) - The facility failed to ensure appropriate side rails were used, evaluated quarterly, and care plans developed for four residents.
F0758 (77 Ill. Adm. Code Part 295) - The facility failed to update a resident's care plan and limit PRN psychotropic medication to 14 days as required.
F0759 (77 Ill. Adm. Code Part 295) - The facility failed to maintain a medication error rate below 5%, with two medication errors observed for one resident.
F0803 (77 Ill. Adm. Code Part 295) - The facility failed to follow the menu and cooking instructions, including failure to serve lemon meringue pies as planned and improper preparation of pureed mashed potatoes.
F0805 (77 Ill. Adm. Code Part 295) - The facility failed to follow physician orders for nectar-thick liquids for one resident.
F0808 (77 Ill. Adm. Code Part 295) - The facility failed to provide oral supplements as ordered for five residents.
F0812 (77 Ill. Adm. Code Part 295) - The facility failed to properly store, label, and dispose of food items, failed to perform hand hygiene during dishwashing, and failed to cover prepared food to prevent contamination.
F0880 (77 Ill. Adm. Code Part 295) - The facility failed to follow infection prevention and control program requirements including failure to don PPE for residents on Enhanced Barrier Precautions and Contact Isolation.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 4
Residents affected: 108
Medication opportunities: 32
Medication errors: 2
Inspection Report — Nov 14, 2024
Complaint Investigation
Date: Nov 14, 2024
Visit Reason
Complaint Investigation regarding repeated falls of one resident (R1) with a known history of falls.
Complaint Details
Complaint #145844: Facility failed to prevent repeated falls of resident R1; no explicit outcome stated.
Findings
The facility failed to ensure that one resident (R1) with a known history of falls did not have nine repeated falls between 9/27/2024 and 11/8/2024, despite being identified as a high fall risk and previously having a 1:1 aide.
Deficiencies (1)
F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to ensure that one resident (R1) with a known history of falls did not have nine repeated falls despite being identified as a high fall risk and previously having a 1:1 aide.
Report Facts
Residents affected: 1
Fall incidents: 9
Inspection Report — Aug 12, 2024
Date: Aug 12, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to utilize a gait belt during resident transfer for one resident, resulting in a fall and left femur fracture.
Deficiencies (1)
F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to utilize a gait belt during resident transfer from toilet to wheelchair for one of three residents reviewed, resulting in a fall and left femur fracture.
Report Facts
Residents affected: 1
Inspection Report — Jun 3, 2024
Annual Inspection
Date: Jun 3, 2024
Visit Reason
Annual Licensure Survey. For this survey, the establishment is not in compliance with Part 295 as evidenced by multiple failures in resident care and nursing coverage.
Findings
The facility failed to monitor and respond to call lights timely, provide incontinence care, administer medications as ordered, and ensure adequate nursing coverage. These failures potentially affected 20 residents residing in the facility.
Deficiencies (1)
F0684 (295.2040) - The facility failed to monitor call light system and answer call lights timely for four residents, failed to provide incontinence care for five dependent residents, failed to ensure medications were administered as ordered for one resident, and failed to provide sufficient nursing coverage to ensure adequate resident care and support.
Report Facts
Residents affected: 20
Residents affected: 4
Residents affected: 5
Residents affected: 1
Inspection Report — Apr 19, 2024
Annual Inspection
Date: Apr 19, 2024
Visit Reason
Annual Licensure Survey. For this survey, the establishment was found not in compliance with Part 295 due to failures in providing adequate assistance with activities of daily living including grooming, showers, personal hygiene, and feeding assistance.
Findings
The facility failed to ensure residents dependent on staff assistance received proper grooming, showers, personal hygiene, and feeding assistance. Three residents were affected by these deficiencies.
Deficiencies (1)
F0677 (Activities of Daily Living) - The facility failed to provide adequate assistance with grooming, showers, personal hygiene, and feeding for three residents, resulting in unmet care needs such as unshaved facial hair, missed showers, and delayed feeding assistance.
Report Facts
Residents affected: 3
Inspection Report — Apr 12, 2024
Annual Inspection
Date: Apr 12, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide timely meals and supervision in the dining room, inadequate language support, failure to follow physician orders for compression stockings and pressure ulcer prevention, inadequate staffing, improper medication storage and labeling, food safety and palatability issues, and lapses in infection control practices.
Deficiencies (15)
F0550 (77 Ill. Adm. Code Part 295) - The facility failed to treat five residents with respect and dignity by not serving all residents sitting at the same table at the same time during dining observations.
F0676 (77 Ill. Adm. Code Part 295) - The facility failed to provide language support to non-English-speaking residents in accordance with professional standards and facility policy, impacting seven residents.
F0684 (77 Ill. Adm. Code Part 295) - The facility failed to provide needed care by not ensuring compression stockings or wraps were applied as ordered, midline dressings were dated, and care plans developed for three residents.
F0686 (77 Ill. Adm. Code Part 295) - The facility failed to ensure the low air loss mattress was set correctly and left heel boot protector was applied for two residents at risk for pressure wounds.
F0689 (77 Ill. Adm. Code Part 295) - The facility failed to ensure adequate supervision of residents in the dining room, leaving multiple high fall risk residents unsupervised.
F0692 (77 Ill. Adm. Code Part 295) - The facility failed to provide thickened liquids as prescribed, provide ordered nutritional supplements, and assess and adjust nutrition interventions for residents with significant weight loss.
F0693 (77 Ill. Adm. Code Part 295) - The facility failed to ensure appropriate care and services for a resident with a feeding tube, including administering enteral feeding as ordered and changing g-tube dressing daily.
F0695 (77 Ill. Adm. Code Part 295) - The facility failed to ensure oxygen tubing and bubbler were dated, changed weekly, and oxygen tubing stored properly for two residents receiving oxygen therapy.
F0725 (77 Ill. Adm. Code Part 295) - The facility failed to provide adequate nursing staffing to ensure timely medication administration, supervision in dining rooms, and resident care needs.
F0758 (77 Ill. Adm. Code Part 295) - The facility failed to obtain consents prior to administering psychotropic medications to three residents, failed to complete Abnormal Involuntary Movement Scale assessments every six months for two residents, and failed to document attempts or contraindications for gradual dose reductions for two residents.
F0761 (77 Ill. Adm. Code Part 295) - The facility failed to properly discard expired multi-dose inhalers and insulins, failed to date opened multi-dose insulins, and failed to secure medication carts, potentially affecting all residents on the second floor.
F0803 (77 Ill. Adm. Code Part 295) - The facility failed to ensure menus met residents' nutritional needs, were followed, updated, and communicated, resulting in residents not receiving requested foods and beverages and repetitive menus.
F0804 (77 Ill. Adm. Code Part 295) - The facility failed to ensure food was served at palatable temperatures, with appetizing appearance and taste, failed to properly reheat pureed foods, and failed to use proper serving utensils, risking resident dissatisfaction and food safety.
F0812 (77 Ill. Adm. Code Part 295) - The facility failed to ensure food items were labeled and dated, discarded expired or rotten foods, followed manufacturer storage guidelines, maintained clean food storage areas, properly stored uncooked meat, cleaned the ice machine, and practiced proper hand hygiene during meal preparation.
F0880 (77 Ill. Adm. Code Part 295) - The facility failed to implement an effective infection prevention and control program, including inconsistent use of enhanced barrier precautions, inadequate hand hygiene, lack of hand sanitizer availability, and failure to properly post isolation signage.
Report Facts
Residents affected: 5
Residents affected: 7
Residents affected: 3
Residents affected: 2
Residents affected: 12
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 53
Residents affected: 107
Residents affected: 109
Inspection Report — Apr 12, 2024
Annual Inspection
Date: Apr 12, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility failed to ensure menus met residents' nutritional needs, were followed, and communicated properly. Issues included lack of coffee availability, repetitive menus, unnotified menu substitutions, and failure to follow individual food plans affecting multiple residents.
Deficiencies (1)
F0803 (295.2040 Food and Nutrition Services) - The facility failed to ensure resident menus, individual food plans, and preferences were followed, provide a variety of entrees, and communicate menu changes or food substitutions to residents, affecting multiple residents.
Report Facts
Residents affected: 7
Residents affected: 4
Residents affected: 3
Residents affected: 1
Inspection Report — Nov 17, 2023
Date: Nov 17, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a deficiency report for a fall incident resulting in injury to a resident.
Findings
The facility failed to ensure resident safety for one resident who fell and sustained a laceration to the right lower leg requiring emergency room treatment.
Deficiencies (1)
F0689 - The facility failed to ensure resident safety, resulting in a resident falling and sustaining a laceration to the right lower leg that required emergency room treatment.
Report Facts
Residents affected: 1
Inspection Report — Sep 10, 2023
Annual Inspection
Date: Sep 10, 2023
Visit Reason
Annual Licensure Survey. For this survey, the establishment is not in compliance with Part 295 as evidenced by the cited deficiencies.
Findings
The facility failed to ensure residents were provided menus to choose their own food items, failed to implement involuntary transfer and discharge policies including providing bed hold policy and permitting return after hospitalization for one resident, and failed to properly cohort COVID-19 positive and PUI residents according to policy.
Deficiencies (5)
F0550 (295.2050 Resident Rights) - The facility failed to assert residents' rights by not ensuring residents were afforded the opportunity to choose their own food menu items, potentially affecting 96 residents.
F0622 (295.2040 Transfer and Discharge) - 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 resident.
F0625 (295.2040 Transfer and Discharge) - The facility failed to notify the resident or representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave for one resident.
F0626 (295.2040 Transfer and Discharge) - The facility failed to permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeded the bed-hold policy for one resident.
F0880 (295.3000 Infection Control) - The facility failed to follow its infection control policy by cohorting COVID positive residents with PUI residents, potentially affecting two residents.
Report Facts
Residents affected: 96
Residents affected: 1
Residents affected: 2
Inspection Report — May 5, 2023
Annual Inspection
Date: May 5, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to protect residents from abuse, failure to report and investigate abuse allegations properly, failure to maintain safe respiratory care equipment, failure to properly manage psychotropic medications, failure to maintain kitchen cleanliness and food safety, improper garbage disposal, failure to implement infection prevention and control programs including Legionella water management and COVID-19 testing, and failure to properly document and offer vaccinations for influenza, pneumococcal, and COVID-19 to residents and staff.
Deficiencies (11)
F0600 (295.6000 Resident Rights) - The facility failed to protect residents from physical and mental abuse, including rough handling causing pain and rude behavior causing mental anguish to three residents.
F0609 (295.6009 Reporting and Investigation) - The facility failed to timely report suspected abuse to the Illinois Department of Public Health and failed to conduct thorough investigations of abuse allegations for two residents.
F0695 (295.6095 Respiratory Care) - The facility failed to ensure oxygen nasal cannula tubing and humidifier bottle were labeled with dates for one resident, risking infection.
F0758 (295.7058 Psychotropic Medications) - The facility failed to discontinue a PRN psychotropic medication after 14 days for one resident.
F0812 (295.8112 Food Safety) - The facility failed to ensure disposal of expired food items and maintain proper cleaning and sanitation practices in the kitchen, risking contamination for many residents.
F0814 (295.8114 Garbage Disposal) - The facility failed to properly dispose of garbage and refuse, leaving heavy, uncovered garbage bins outside, risking contamination and pest infestation.
F0880 (295.8880 Infection Control) - The facility failed to implement an infection prevention program including failure to test domestic water for Legionella, failure to disinfect blood pressure cuffs between residents, and failure to label oxygen tubing and humidifier bottles.
F0883 (295.8883 Vaccination Policies) - The facility failed to properly offer, educate, and document influenza and pneumococcal vaccinations for four residents.
F0886 (295.8886 COVID-19 Testing) - The facility failed to follow COVID-19 testing policy during an outbreak by not testing exposed residents and staff, risking spread of infection.
F0887 (295.8887 COVID-19 Vaccination) - The facility failed to offer, educate, and document COVID-19 vaccinations for four residents.
F0888 (295.8888 COVID-19 Staff Vaccination) - The facility failed to monitor COVID-19 vaccination status of healthcare workers including contracted/agency staff and failed to ensure policies addressed vaccination of all staff.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 78
Residents affected: 80
Residents affected: 80
Residents affected: 4
Residents affected: 80
Residents affected: 4
Residents affected: 80
Inspection Report — Apr 12, 2023
Date: Apr 12, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. It is a Statement of Deficiencies for Pearl of Montclare, The, dated 04/12/2023.
Findings
The facility failed to ensure proper medication administration and adherence to transfer protocols, resulting in medication errors and a resident injury requiring hospital transfer and sutures.
Deficiencies (2)
F0684 - The facility failed to ensure only ordered medication was administered and failed to ensure doctor's orders were followed for one resident, resulting in medication errors and unnecessary lab draws.
F0689 - The facility failed to transfer a resident using a total body lift and failed to ensure the resident's environment was free of hazards, resulting in a laceration requiring hospital transfer and 25 sutures.
Report Facts
Residents affected: 1
Residents affected: 1
Sutures: 25
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