CHICAGO, IL - Federal inspectors documented multiple safety violations at Pearl of Montclare nursing facility, where staff failed to follow basic infection control protocols and food safety standards, potentially affecting all 108 residents.
Infection Control Protocol Failures
The most serious violations involved staff members providing direct care to residents without wearing required protective equipment. During the March 14, 2025 inspection, surveyors observed certified nursing assistants performing wound care and incontinence care on residents with documented Enhanced Barrier Precautions orders without wearing protective gowns.
The facility's infection control failures extended beyond individual incidents. One resident requiring contact isolation for Clostridium difficile (C. diff) infection did not receive proper protection when a licensed practical nurse entered the room wearing only a mask, omitting the required gown and gloves.
Clostridium difficile is a highly contagious bacterial infection that causes severe intestinal inflammation and can be life-threatening, particularly for elderly residents with compromised immune systems. The bacteria can survive on surfaces for months and spreads through contact with contaminated surfaces or hands.
Enhanced Barrier Precautions are specifically designed to prevent transmission of antibiotic-resistant organisms and other serious infections. These protocols require staff to wear gowns and gloves during high-contact activities such as wound care, toileting assistance, and bathing.
Missing Safety Equipment and Signage
Inspectors found that one resident's room lacked the required Enhanced Barrier Precautions signage and accessible protective equipment, despite having active physician orders for these measures. The resident had wound care orders requiring special precautions, but staff assigned to care for this resident were unaware of the enhanced protection requirements.
A nurse responsible for the resident's care admitted during interviews that they did not know which residents qualified for Enhanced Barrier Precautions or understand the reasons for implementing these protocols. The lack of visible signage meant staff could unknowingly expose themselves and other residents to preventable infections.
Widespread Food Safety Violations
The kitchen and food storage areas presented multiple safety hazards that could affect every resident receiving meals from the facility. Inspectors documented expired food items throughout storage areas, including maraschino cherries past their expiration date and Caesar dressing beyond its use-by date.
An opened container of soy sauce requiring refrigeration was stored at room temperature, and an unlabeled bag of brownie mix sat on shelves without proper identification or dating. Food safety protocols require all opened items to be properly labeled with opening dates and stored according to manufacturer specifications.
Cross-contamination risks were evident in storage areas where food items were stored directly next to cleaning chemicals. Inspectors found food container lids next to gallon bottles of bleach solution, violating basic food safety principles that require separation of food items from toxic materials.
Kitchen Sanitation Breakdowns
Staff hygiene practices during food preparation posed additional contamination risks. Dietary aides handling dishwashing operations used the same dirty gloves throughout the process, touching both contaminated dishes and clean items without changing protective equipment or performing hand hygiene.
Uncovered food portions sat exposed to airflow from heating and air conditioning systems, creating opportunities for airborne contaminants to affect prepared meals. Coffee grounds remained exposed on work surfaces near sanitizing stations throughout the day, despite acknowledgment from management that cleaning solution splashes could contaminate the coffee.
Temperature monitoring protocols were not followed during meal service. Kitchen staff failed to document food temperatures before serving, with the cook admitting to taking temperatures but forgetting to record them on required logs.
Dietary Order Compliance Problems
Five residents with physician orders for high-calorie frozen dessert supplements did not receive these nutritionally important items during the inspection period. The dietary manager confirmed adequate supplies were available in facility freezers but could not explain why the supplements were not distributed.
These nutritional supplements are prescribed for residents who need additional calories to prevent weight loss, support wound healing, or address poor appetite. Failure to provide prescribed supplements can result in continued weight loss, delayed wound healing, and overall nutritional decline.
One resident requiring nectar-thick liquids for swallowing safety received regular thin apple juice instead of the prescribed consistency. This type of error creates serious choking and aspiration risks for residents with swallowing difficulties.
Food Preparation Standard Violations
Kitchen staff prepared pureed mashed potatoes without following manufacturer instructions for proper ratios of water to powder mix. The cook used unmeasured amounts of ingredients and failed to add required salt, potentially affecting the nutritional value and palatability of meals for residents requiring texture-modified foods.
The facility also failed to follow published menus, substituting different food items without proper planning. Residents at a council meeting reported that menu changes were common, with the facility serving different items than what was posted on weekly menus.
Systemic Training and Oversight Issues
These violations point to broader problems with staff training and supervisory oversight. Multiple staff members acknowledged knowing proper procedures but failed to implement them consistently during routine care activities.
The facility's infection preventionist and dietary manager both stated appropriate policies were in place, but enforcement and compliance monitoring appeared inadequate to ensure consistent adherence to safety protocols.
Proper infection control requires consistent application of protective measures, not selective compliance based on staff convenience or awareness. Similarly, food safety demands systematic attention to expiration dates, proper storage, and temperature monitoring throughout all preparation and service activities.
The violations demonstrate how breakdowns in basic safety protocols can create cumulative risks for vulnerable nursing home residents, who depend on facility staff for protection from preventable infections and foodborne illnesses.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethesda Rehab & Senior Care from 2025-03-14 including all violations, facility responses, and corrective action plans.
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