Pearl of Elk Grove, the

Inspectors wroteBased on interviews and records review, the facility failed to ensure high fall risk residents received adequate supervision and used assistive devices to prevent avoidable falls for two residents, and the facility failed to ensure nursing staff promptly reported resident accident resulting in injury to their immediate supervisor for one resident. These failures affected two (R1 and R2) of three residents reviewed for falls in a sample of 5. These failures resulted in R1 acquiring fractures of three toes on the right foot and R2 acquiring a head injury; contusion of right knee; and fracture of phalanx of right index finger.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the Medication Storage Policy by failing to ensure medications are secured and by failing to ensure medications are labeled. This failure has the capacity to affect 20 residents reviewed for medications in a total sample of 31 and 1 cart of 7 reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the Acute Respiratory Infection Policy when V3 (Registered Nurse) failed to wear a mask during a facility wide COVID outbreak and the facility failed to follow the Enhanced Barrier Precaution Policy when V3 was not wearing a gown when applying pain patch (direct physical contact) on a resident with Enhanced Barrier Precautions. This failure has the capacity to affect 4 residents in a total sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Call Light Policy by not ensuring the call light was placed within easy reach of a resident. This deficient practice affected one resident (R83) out of three residents reviewed for accommodation of needs, within a total sample of 31 residents. R83 is a [AGE] year-old-female re-admitted to the facility on [DATE]. R83's medical diagnoses include, but not limited to Secondary parkinsonism, Alzheimer's disease, type 2 diabetes, anxiety, bipolar, hypertension, gout, hyperlipidemia, hypothyroidism. On 12/16/2025 at 9:54 AM during room rounds, R83 was observed in bed awake and resting. R83's call light string was noted on top of the bedside table and not within R83's reach. V5 (Certified Nursing Assistant/CNA) entered the room and was asked why R83's call light was positioned out of her reach; [...]

Inspectors wroteBased on interview and record review the facility failed to follow the Fall Prevention and Management Policy by not completing post fall assessment dated [DATE] after a fall incident. This failure affected 1 resident (R3) of 3 residents reviewed for falls in a total sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to initiate the Level II PASRR (Preadmission Screening and Resident Review) process for residents identified with mental illness. This deficient practice affected 3 residents (R133, R12, and R9) reviewed for PASRR within a total sample of 31 residents. 1 -R9 is a [AGE] year-old female, admission record documents initial admission date to the facility was on 6/19/2019 with diagnosis of, not limited to, Dementia unspecified severity with other behavioral disturbance, onset date 10/01/2022. Major depressive disorder single episode unspecified, onset date 7/22/2020. Unspecified psychosis not due to substance or known psychological condition, onset date 7/29/2020. Personal history of other mental behavioral disorders, onset date 10/01/2020. Depression unspecified, onset date 5/20/2024. R9's OBRA I- Initial Screening dated: [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate a new Pre-admission Screening and Resident Review (PASRR) Level I and Level II screenings for 1 (R31) of 3 residents reviewed for PASRR screening in the sample of 31. R31 is a [AGE] year-old-male, admission record documents initial admission date 9/5/2025, with diagnosis of, not limited to anxiety disorder onset date 5/4/2020, bipolar disorder 1/27/2020, major depressive disorder recurrent moderate onset date 3/7/2018, unspecified psychosis not due to a substance or known physiological condition onset date 8/18/2013, unspecified dementia onset date 10/15/2010. On 12/18/2025 at 10:18AM, V7 (Social Service Coordinator) and V8 (Social Service Director) stated there was no Pre-admission Screening and Resident Review (PASARR) completed for R31 prior to admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure common areas are free of accident hazards for one of three residents (R42) reviewed for accidents in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents who needed help with toileting, grooming, eating, and transfers. This applies to 5 out of 5 residents (R1, R2, R6, R7, and R8) reviewed for activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's (R4) right to be free from sexual abuse by a facility staff member. This failure resulted in R4 experiencing psycho-social harm from V13's (Certified Nursing Assistant/CNA) inappropriate sexual touching. The facility also failed to protect a resident's (R2) right to be free from physical abuse by another resident (R1). This applies to 2 of 6 residents (R2 and R4) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and immediately report an allegation of abuse to the abuse coordinator. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were given at the correct time for 12 of 13 residents (R1, R2, R4-R13) reviewed for medications in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure patient care equipment was maintained to ensure residents were able to get out of bed for 4 of 4 residents (R1,R2,R3,R6) reviewed for full body mechanical sling lifts in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to monitor for behaviors and report the side effects of a resident's anti-psychotic medication. This failure resulted in R4 continuing to receive Seroquel and experiencing a hospitalization, increased falls, and inability to participate in his rehab care. This applies to 1 out of 3 (R4) residents reviewed for psychotropics.

Inspectors wroteBased on interview and record review the facility failed to resolve resident grievances for 5 of 6 residents (R1, R3, R4, R5 R6) reviewed for grievances in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sufficient amount of nursing staff/providers to notify family of change in condition, provide grooming needs, and distribute meals in a timely manner. This applies to 7 of 11 residents (R2-R8) reviewed for nursing care.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to notify the family, physician, and hospice provider in a timely manner about the change of conditions for a resident. This applies to 1 of 1 resident (R3) who was reviewed for significant change in condition in a sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for residents' dependent on staff. This applies to 3 of 8 residents (R2, R4, and R8) reviewed for Activities of Daily Living (ADL) care in a sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at palatable temperatures. This applies to 3 of 5 residents (R5-R7) reviewed for meal service.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a fluid restriction for a resident with congestive heart failure (CHF) and failed to do daily weights for residents with CHF. This applies to 3 of 29 residents (R6, R13, and R82) reviewed for quality of care in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's arm was supported by a sling during a transfer and while up in the wheelchair for 1 of 6 residents (R105) reviewed for range of motion in the sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with a diagnosis of dysphagia (difficulty swallowing) was cued/followed safe swallowing strategies, failed to transfer a resident in a safe manner, and failed to have a fall intervention in place for a resident at risk for falling. This applies to 3 of 29 residents (R3, R73, and R92) reviewed for safety in the sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN (as needed) anti-anxiety (psychotropic) medications had a duration/end date for 4 of 8 residents (R66, R40, R299, R106) reviewed for unnecessary medications in the sample of 29. 1. R66's Order Summary Report dated 10/22/24 shows an active order for Lorazepam (an anti-anxiety medication) 2mg (milligram)/mL (milliliter) give 0.5mL by mouth every 2 hours as needed for severe anxiety/nausea started on 5/31/24 with no duration listed. On 10/23/24 at 11:04 AM, V2 (Director of Nursing/DON) said PRN (as needed) antipsychotic and psychotropic medications should have a stop date or duration. 2. R40's Physician Orders for October 2024 shows an order dated 9/19/24 for Lorazepam Oral Tablet 0.5mg tablet by mouth every 8 hours as needed for restlessness related to anxiety disorder. There is no stop date listed for this order. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of expired medications in the medication refrigerator for 2 of 29 residents (R120, R89) reviewed for medications in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wore gowns when providing direct patient care to 1 of 29 residents (R73) on Enhanced Barrier Precautions (EBP) in the sample of 29 reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to conduct a thorough investigation of a sexual abuse allegation. This failure resulted in immediate jeopardy when V3 (CNA-Certified Nursing Assistant) reported to V1 (Administrator) that she observed R2 exposing his genitals to R1 and attempting to insert his penis into R1's mouth. The facility unsubstantiated sexual abuse without interviewing all possible witnesses. The immediate jeopardy began on September 10, 2024 when the facility failed to thoroughly investigate an allegation of sexual abuse. V1 (Administrator) was notified of the Immediate Jeopardy on September 24, 2024 at 11:44 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse by a resident with known sexual behaviors and public displays of affection. This failure resulted in R2, a [AGE] year old male resident exposing his genitals to R1, a [AGE] year old female resident and attempting to insert his penis into R1's mouth. R1 has severe cognitive impairment and is unable to consent to sexual relations. This failure resulted in immediate jeopardy when the facility lacked interventions and processes to protect female residents from a resident with known sexual behaviors. The immediate jeopardy began on August 6, 2024 when R2 was moved from a secure Dementia Unit after allegedly kissing and hugging R3. R2's new room was located directly next to R1. [...]

Inspectors wroteBased on interview and record review, the facility failed to update a resident's care plan when a resident exhibited sexual behaviors and public displays of affection and required a room change. This applies to 1 of 5 residents (R2) reviewed for resident-to-resident sexual assault in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was seen by their attending physician as shown in the facility's policy. This applies to 1 of 5 residents (R2) reviewed for physician visits in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was not administered a medication that was not prescribed for them, and failed to notify the Director of Nursing, or a nurse manager, regarding a medication error in a timely manner for 1 of 3 residents reviewed for medication error in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was permitted to return to the facility following a behavioral hospitalization for 1 of 3 residents (R2) reviewed for involuntary discharge in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to provide incontinence care to a resident who is dependent on staff for activities of daily living (ADL's) to 1 of 3 residents (R1) reviewed for ADLs in the sample of 4.

Inspectors wroteBased on record review and interview, the facility failed to ensure two staff assisted a dependent resident while providing incontinent care. This failure resulted in R2 falling from the bed to the floor, sustaining a left eye laceration along her hairline. This applies to 1 of 4 residents (R2) reviewed for falls and accidents in a sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor a resident's weight, assess the resident's nutritional status, and assist the resident with eating to prevent significant weight loss. This failure resulted in R1 experiencing a weight loss of 11.5% in one month. This applies to 1 out of 3 residents (R11) reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure neurological assessments were completed accurately for a resident who fell and hit her head, and failed to complete post-fall documentation and include it in the resident's medical record. This applies to 1 out of 5 (R1) residents reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility consistently failed to serve food items on their facility planned and approved menu to ensure adequate nutritional intake. This failure resulted in weight loss for R3 and R20 due to insufficient calories, prolonged feelings of sadness, anger, frustration, and low self-worth for R1, R2, R4, R13, and R18, and financial hardship to the residents and families of R1, R3, R13, and R21 who brought in food to supplement their food intake. This applies to 19 of 19 residents (R1-R4, R6-R14, R16-R21) reviewed for menus served as planned in a sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility consistently failed to provide palatable, appetizing meals to residents. This failure resulted in weight loss for R3 and R20 due to insufficient calories, prolonged feelings of sadness, anger, frustration, and low self-worth for R1, R2, R4, R13, and R18, and financial hardship to the residents and families of R1, R3, R13, and R21 who bought food to supplement their food intake. This applies to 12 of 12 residents (R1-R4, R6, R9, R13, R14-R15, R18, R20 and R21) reviewed for food palatability a sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident grievances were documented and timely resolutions were provided. This applies to all 151 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely ADL (Activities of Daily Living) care to residents who required staff assistance with toileting hygiene. This applies to 6 of 6 residents (R1, R2, R4, R5, R6, and R13) reviewed for ADLs (Activities of Daily Living) in a sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were reordered in a timely fashion to be available for medication administration. This applies to 2 of 3 residents (R1 and R4) reviewed for medications in the sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to properly store resident diabetic medication resulting in a delay of the medication administration. This applies to 1 of 3 residents (R5) reviewed for medications in a sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse. This resulted in R1's left pinky finger being pulled backwards during care and x-ray showed a non-displaced fracture of the left finger. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed heights were at the lowest level and failed to provide two staff assist to prevent injuries. As a result, R1 and R3 sustained left and right hip fractures, respectively, and were admitted to the hospital. This applies to 2 of 5 residents (R1 and R3) reviewed for falls in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure that state survey results were available to residents and visitors. This applies to 2 of 4 residents (R1 and R3) reviewed for accessing survey results in the sample of 14. On 12/12/2023 at 1:16PM, V11(R1's family) said he asked for survey results after he had some concerns about R1's care, and the last survey result available to review was dated 12/12/2022. On 12/12/2023 at 1:45PM, R3 and V12 (R3's family) said he was not aware of the availability of the survey reports. A review of the list of surveys for the facility showed the Department of Health initiated an annual survey on 09/12/2023 and complaints surveys on 01/24/2023, 02/03/2023, 03/16/2023, 04/11/2023, 05/03/2023, 05/30/2023, 06/01/2023, 06/05/2023, 06/20/2023, 06/27/2023, 07/14/2023, 09/29/2023,10/20/2023, and 11/29/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide toileting, bathing/showering and transfer help to residents who required staff assistance for ADLs. (Activities of Daily Living). This applies to 10 of 12 residents (R1-R3 and R6-R12) reviewed for ADL assistance in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing to assist residents who require help to perform ADLs. (Activities of Daily Living). This applies to 10 of 12 residents (R1-R3 and R6-R12) reviewed for ADL assistance in a sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to attend to call lights in a timely manner as per facility policy. This applies to 4 of 4 residents (R1-R3, R8) reviewed for improper nursing care in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents with nail care and shaving/trimming facial hair. This applies to 5 of 32 residents (R43, R52, R54, R106, R99) reviewed for ADL's (Activities of Daily Living) in a sample of 32.

Inspectors wrote4. On 9/12/23 at 10:29 AM, R34 was lying in bed and eating her breakfast. Next to her tray was a medication cup with 7 oral pills. Surveyor asked R34 who gave her these medications. R34 replied, The girl outside gave it to me in the morning. It was like 15 minutes ago. On 9/12/23 at 10:32 AM, V14 (RN-Registered Nurse) stated, Yes, I am (R34's) nurse this morning. I brought (R34's medications) to her, but she said she would be nauseated if she didn't take it after breakfast. So, I left it there because I thought she would take it after breakfast. It's still there? Review of R34's EMAR (Electronic Medication Administration Record shows the following medications were in R34's medication cup: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to perform hand hygiene while administering medications, while providing incontinence care, before putting on gloves and removing gloves, failed to properly sanitize a glucometer, failed to provide a resident with a clean, unused mechanical lift sling, failed to empty and store a resident's urinal, and failed to properly dispose of biohazard waste. This effects 12 residents (R6, R12, R32, R80, R106, R110, R125, R88, R11, R24, R66, & R127) in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have call lights accessible to dependent resident. This applies to 1 of 1 resident (R57) reviewed for accommodation of needs in a sample of 32.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively communicate with 1 resident (R53) that did not speak English, in a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers and ensure that it was readily available in the resident's medical record. This applies to 3 out of 3 residents (R4, R34, R52) reviewed for pacemakers in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer and monitor a resident on intravenous fluid therapy. This applies to 1 of 1 resident (R119) reviewed for intravenous therapy in a sample of 32.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to contain reusable nebulizer treatment masks, and incentive spirometers. This effects 3 residents (R3, R11, and R68) in a sample of 32.