Pearl of Evanston,The

In the surveyor’s words

From the most serious findings on record at Pearl of Evanston,The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF609Apr 25, 2023

  Based on interview and record review the facility failed to follow/practice their abuse policy by failing to report an allegation that staff held and twisted resident's (R1) left arm/wrist. Staff (V2) remained on duty to work with other residents, placing residents at risk for abuse. This failure affects 1 of 4 residents (R1) reviewed for abuse. R1 was sent to hospital for evaluation where R1 was diagnosed with a left wrist hairline fracture. This failure also has the potential to affect the other 86 residents residing in the facility. The Immediate Jeopardy began on 04/05/23 when R1 reported being physically assaulted by V2 and V4 did not report the allegation of abuse. V6 (Administrator) was notified of the Immediate Jeopardy on 04/14/23 at 11.04am. […]

• Actual harm, isolatedF689May 15, 2025

  Based on interviews and record review the facility failed to supervise a resident at high risk for falls with history of falls; failed to train nursing staff to recognize resident's physical ability and level of assistance; and failed to implement measures to prevent a fall for 1 of 2 (R17) residents reviewed for falls in the sample of 55. These failures resulted in R17 being emergently transferred to the hospital and admitted with left hip fracture that required surgical intervention. […]

• Actual harm, isolatedF600Apr 25, 2023

  Based on observation, interview, and record review the facility failed to protect the resident right to be free from abuse from staff. This failure affects 1 of 4 residents reviewed for abuse prevention. R1's left arm/wrist was held and twisted. R1 was subsequently sent to hospital and diagnosed with an acute hair line fracture of the left wrist. R1 has complaints of pain and stated she is afraid to return to the facility. Findings include: R1 face sheet shows diagnosis of MDS (Minimum Data Set) dated 1/1/23 denotes in-part that R1 has BIMS score of 15 (cognitively intact). […]

• No harm, potential for more than minimal, widespreadF804Jan 12, 2023

  Based on observation, interview, and record review, the facility failed to ensure that food served was palatable and attractive. This failure affected three (R3, R4, and R11) residents reviewed for dining services and has the potential to affect all 90 residents currently residing in the facility. Findings include: On 1/9/23 at 11:40 AM, R4 was interviewed regarding food service and meals. R4 said, The food here is terrible. One day over the weekend I only received mashed potatoes and a piece of bread. I take pictures of the food sometimes when it is so bad to show the staff. The food is either undercooked or overcooked. I have difficulty chewing and at times the food is so tough at times I cannot eat it. At 12:10 PM, surveyor observed lunch service. Observed ten trays on second floor. […]

• No harm, potential for more than minimal, widespreadF806Jan 12, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents were able to make choices regarding their meals and failed to provide substitutions for residents. This failure applied to three (R3, R4, and R11) residents reviewed for food choices and has the potential to affect all 90 residents currently residing in the facility. Findings include: On 1/9/23 at 11:40 AM, R4 was interviewed regarding food service and meals. R4 was observed to have a variety of snacks located in bins in room. R4 said he does not get a menu at all and is unable to choose his own meals. R4 stated, I call the meals 'mystery meals' because I never know what I am going to receive. We do not get any sort of menu or anything to fill out saying what we want. […]