Pearl at the Tillers

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care for residents who require extensive assistance for ADL (Activities of Daily Living). The facility also failed to assist a resident who is totally dependent on staff for transfers to get up to a wheelchair. This applies to 3 of 18 residents (R4, R57, and R63) reviewed for ADLs in the sample of 18.

Inspectors wroteBased on interview, and record review the facility failed to follow physician orders and facility policy for the care and maintenance of PICC (Peripherally Inserted Central Catheters) lines or Midline Intravenous access devices. This applies to 3 of 3 residents (R3, R6, R9) reviewed for intravenous medication administration in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident from misappropriation of resident property when a staff member removed a resident's cellular telephone from the facility and later disposed of the cellular telephone in a trash receptacle at a local park. This applies to 1 of 3 residents (R1) reviewed for theft in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the facility kitchen and during meal service. This applies to 58 residents that received foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pureed corn bread as per planned menu to residents on pureed diets. This applies to 4 of 4 residents (R7, R15, R24, R273) reviewed for pureed diets in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform urinary catheter and perineal care in a manner that would prevent urinary tract infection (UTI). This applies to 2 of 3 residents (R13, R18) reviewed for incontinence and catheter care in the sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate and manage a resident's chronic pain. This applies to 1 of 1 resident (R26) reviewed for pain management in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of ADL (activities of daily living) care. This applies to 2 of 16 residents (R13, R27) reviewed for infection control in the sample of 16.

Inspectors wroteBased on interview and record review the facility failed to follow physician's order for oxygen administration. This applies to 1 of 3 residents (R1) reviewed for oxygen use in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from financial abuse. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience. This applies to 1 of 2 residents (R18) reviewed for dignity in a sample of 69.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that anti-contracture devices were applied as ordered. This applies to 1 of 3 residents (R34) reviewed for anti-contracture devices in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to position indwelling urinary catheters in a manner to prevent leakage, failed to cleanse urinary catheter tubing after residents are incontinent, and failed to ensure incontinent residents were changed in a timely manner to prevent infections. This applies to 3 of 5 residents (R3, R23, and R25) reviewed for bladder and bladder incontinence care in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure emergency tracheostomy supplies were available and failed to maintain sterile handling of a resident's sterile tracheostomy supplies. This applies to 1 of 2 (R38) reviewed for tracheostomy care.

Inspectors wroteBased on interview and record review, the facility failed to prevent the use of unnecessary antibiotic medications. This applies to 1 of 4 residents (R25) reviewed for antibiotics in a sample of 23.

Inspectors wroteBased on observation, interview and record review, facility failed to contain, handle, and transport soiled linen in a manner to prevent cross-contamination. This applies to 2 of 2 (R55 and R25) residents reviewed for infection control in a sample size of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have functional call lights. This applies to 2 of 3 residents (R8 and R266) reviewed for call lights in a sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food in a sanitary manner to prevent cross contamination. This applies to all 70 residents that consume meals orally.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 6 of 6 residents (R9, R13, R15, R35, R42 and R264) reviewed for ADL (activities of daily living) in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide perineal and indwelling urinary catheter care in a manner that would promote hygiene and prevent urinary tract infection. The facility also failed to ensure that a catheter bag and catheter tubing was not touching the floor. This applies to 4 of 6 residents (R15, R19, R30, R114) reviewed for perineal and urinary catheter in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy on changing gloves and hand hygiene when providing care to residents and when exiting isolation rooms. The facility failed to ensure isolation and non-isolation rooms are not cleaned using the same cleaning supplies. This applies to 7 of 19 residents (R3, R15, R26, R43, R114, R166, R216) reviewed for infection control practices in a sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to offer residents the COVID-19 vaccine. This applies to 4 of 5 residents (R31, R215, R36, and R4) reviewed for COVID-19 vaccinations in a sample of 19.

Inspectors wroteBased on interview and record review the facility failed to verify a physician's order for pain medication for a resident who had a post-operative procedure and failed to follow the physician's order and plan of care with regards to administration of steroid medication to a resident who receives chemotherapy. This applies to 2 of 19 residents (R56, R214) reviewed for care and treatment in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide an intervention for a resident who has a history of Moisture-Associated Skin Damage (MASD). This applies to 1 of 19 residents (R30) reviewed for care and treatment in the sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 27 opportunities with 2 errors, resulting in a 7.41% medication error rate. This applies to 1 of 4 residents (R28) observed during the medication pass in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a steroid inhaler as ordered by the physician for a resident who has Chronic Obstructive Pulmonary Disease (COPD). This applies to 1 of 19 residents (R34) reviewed for medications in the sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's order to administer a pneumococcal vaccine. This applies to 1 of 5 residents (R36) reviewed for pneumococcal vaccinations in a sample of 19.