Pearl of Hillside,the

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate footwear as a fall prevention intervention for a cognitively impaired resident with a history of repeated falls. This failure affected one resident (R72), reviewed for fall prevention in a total sample of 68 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the standard of practice and physician orders for the care of urinary catheters. This applies to 2 of 3 residents (R2 and R4) reviewed for catheter care in a sample of 6.

Inspectors wroteBased on the interview and record review, the facility failed to follow its appointments and transportation policy by not arranging transportation for outside appointments. This applies to 1 of 3 residents (R1) reviewed for appointments and transportation in a sample of 6.

Inspectors wroteBased on interview and record review the facility failed to protect and prevent one (R1) of three residents from injury of unknown origin. This failure resulted in R1 sustaining multiple fractures, left subdural hematoma, right parietal subarachnoid hemorrhage, anterior wall bruising, and left shoulder bruising. This failure affected R1 and has the potential to affect all 163 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough and credible investigation was conducted for 1 of 3 residents (R1) reviewed for abuse. Specifically, the facility's investigative process failed to: 1) Reconcile conflicting evidence between a staff member's motive and the resident's initial allegation of being 'hit'; 2) Include critical witness testimony from the first clinician on the scene (V4 Agency RN) in reports provided to law enforcement; 3) Conduct a clinical review to assess the feasibility of a catastrophic orbital globe rupture and depressed fracture being caused by a minor 'accidental' strike; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their fall focus program for one resident who was identified as moderate risk for falls, by not ensuring the resident's entire bathroom floor was dry prior to assisting him with care. This affected one of three residents (R1) reviewed for safety during care. This failure resulted in R1 sustaining a witnessed fall resulting in an impacted intertrochanteric fracture of the proximal right femur (right hip fracture).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an effective pest management program. This affected two of four (R5, R6) residents reviewed for pest. This has the potential to affect all 154-resident having their meals prepared in the kitchen. This failure resulted in gnats being observed in R5, and R5 rooms and observed in flying in the kitchen dish area. Findings Include:On 9.23.25 there were currently 154 residents residing in the facility that utilize the kitchen to have their meals prepared. On 9/23/25 at 12:15pm, R5's room was observed with two trash cans with lids near his entry way. Multiple gnats were observed flying around the two trash cans when surveyor entered R5's room. More than ten gnats were crawling on the outside of R5's white trash can. R5 was observed in bed asleep with a few gnats on his bed sheet resting above R5's head. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to check and provide incontinence care at least every two hours for one resident who was identified as dependent on staff for toileting. This affected one of three residents (R3) reviewed for incontinence care. This failure resulted in R3 being saturated with a urine filled adult brief for over four hours. Findings Include:R3 was diagnosed with Hemiplegia and Hemiparesis following other Nontraumatic Intracranial Hemorrhage affecting left dominant side. R3's care plan dated 3/28/24 documents: provide incontinence care after each incontinent episode. Section C (cognitive patterns) dated 6/20/25 documents a score of twelve which indicated moderate cognitive impairment. Section GG (functional abilities) documents dependent with toileting hygiene. Section H (bladder and bowel) documents: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care with increased monitoring /supervision for a resident identified to have safety awareness of urinating in a trash can, resident had a history of falls and unsteady gait. This affected one of three residents (R1) reviewed for falls, supervision and safety awareness. This failure resulted in slipping his own urine falling to the floor sustaining a bump to the head and change in consciousness. Findings Include: R1 was admitted on [DATE] with the diagnosis of abnormal gait and mobility, lack of coordination, dizziness and giddiness, hypotension, cerebral infraction due to embolism of left middle cerebral artery and aphasia following a cerebral infraction. Care plan initiated: 09/03/2025 documents: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a functional sanitary environment for one (R1) of three residents reviewed functional and comfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to safely handle foods for all 144 residents receiving food from the kitchen. The facility also failed to ensure resident refrigerators are clean and the temperatures are monitored for two of two residents (R23, R46) reviewed for food safety in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that necessary treatment and services to promote healing and prevent development of pressure injury are implemented for 5 of 12 residents (R53, R117, R127, R136, R151) reviewed for pressure injury in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to re-screen residents with mental disorder for two of five residents (R95, R105) reviewed for pre-admission screening in a sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 3 of 5 residents (R34, R87, R91) reviewed for PASARR in a total sample of 31. Findings Include: On 3/26/2025 at 10:30AM, V20 (Regional Director of Social Work) stated there was no PASARR completed for R87 prior to admission. A Level I was requested this morning. On 3/27/2025 at 9:30 AM, V1 (Administrator) stated PASARR needs to be completed prior to resident admission and if Level I is positive, Level II will have to be completed to ensure residents will receive appropriate services. R87's admission Record indicated an admission date of 10/29/2024. Diagnosis Information include Schizoaffective Disorder, Unspecified. Care Plan report state, Focus: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to provide nail and foot care to dependent resident. This deficiency affects three (R60, R117, and R130) residents in the sample of 31 reviewed for Activities of Daily Living (ADL) Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure comprehensive restorative nursing evaluation and ongoing assessment is completed for a resident with limited range of motion/ contractures to upper extremities. This deficiency affects two (R60 and R79) of three residents in the sample of 31 reviewed for Restorative program.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident's environment is free of accident hazards and failed to perform ongoing smoking assessments for a smoking resident for two of three residents (R46, R95) reviewed for accidents in a sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician oxygen orders for 1 of 2 residents (R141) reviewed for oxygen administration in a total sample of 31. Findings Include: On 3/25/2025 at 10:30 AM, R141 is laying flat in bed with oxygen on per nasal cannula. R141 stated he likes to lay flat in the bed even with oxygen on. Oxygen concentrator positioned at bedside with a setting of 4 liters (L)/minute. On 3/25/2025 at 10:35 AM, V25 (Licensed Practical Nurse/Agency) checked R141's physician order and indicated Oxygen (02) @ 2 Liters/Minute per nasal cannula/mask. V25 proceeded to R141's room and adjusted oxygen concentrator setting from 4L to 2L. V25 stated R141 should be on 2L per physician order. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their medication storage facility policy for 2 of 6 residents (R115, R79) reviewed for medication labeling and storage.

Inspectors wroteBased on interview and record review, the facility failed to grant the resident or his or her representative the right to rescind the arbitration agreement within 30 calendar days of signing it. This failure affected three (R7, R37, R67) out of three residents reviewed for arbitration agreement in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure most recent hospice plan of care specific to each resident is available and accessible to facility's staff for collaborated and coordinated care. This deficiency affects three (R24, R82 and R117) residents in the sample of 31, reviewed for Hospice care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents are provided with the opportunity to receive annual dental exams as well as routine monitoring to identify any changes in dental care needs to the extent covered under the State health plan. This failure applied to five (R1, R4, R5, R6, and R7) of seven residents reviewed for dental services.

Inspectors wroteBased on interview and record review, the facility failed to prevent a resident from developing a catheter associated urinary tract infection (UTI) which required transfer to a local hospital for treatment. This failure affected one (R5) of three residents reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident from physically abused by another resident; and failed to have abuse risk assessments, including plans of care and interventions in place for R1 and R2. These failures applied to two (R1, R2) of four residents reviewed for abuse, and resulted in R1 sustaining a right arm fracture after being found being pulled by R2 across room floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on hair restraints for staff working in the kitchen. This failure have the potential to affect 141 residents eating from the facility's kitchen. Findings Include: On 01/24/24 at 10:05 AM, during initial tour with V7 (Food Service Director), V8 (Dietary Aide) and V9 (Dietary Aide) did not have their hair nets on. V7 said V8 and V9 are supposed to have their hair nets on. On 1/25/2024 at 10:06 AM, V2 (Director of Nursing) said staff that are working in the kitchen should have their hair covered, and don on apron and gloves. Dietary Department Sanitation & Safety Operation HAIR RESTRAINTS/JEWLRY/NAIL POLISH POLICY: To reduce the spread of microorganism, employees shall use effective hair restraints, avoid excessive jewelry and wear nail polish or acrylic nails only with precautions. PROCEDURE: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have oxygen in use signs for four residents (R31, R50, R98, and R198) and failed to provide humidification for one resident (R98) receiving continuous oxygen at 5L/min (liters per minute) of six residents reviewed for respiratory therapy in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to put open dates on multi-dose medications and store according to pharmacy recommendations. This failure has the potential to affect all 40 residents in Transition Care Unit.

Inspectors wroteBased on interview and record review, the facility failed to provide influenza and Pneumococcal immunization as required for four of five residents (R7, R84, R104 and R142) reviewed for immunizations in a sample of 30 residents. Findings Include: On 1/24/24 at 11:45 AM, V3 (Infection Preventionist) and V15 (Assistant Director of Nursing) both stated all immunization refusals should be documented. V3 stated she is responsible for checking residents' immunizations are up to date once admitted into the facility. On 1/25/24 at 10:15 AM, V2 (Director of Nursing) stated V3 is responsible for keeping resident's immunizations up to date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light is accessible to three (R15, R57, R91) of seven residents reviewed for call light accessibility in the sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to enter the code status and order for one resident (R6) of eight residents reviewed for code status in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to residents who are unable to shave themselves safely for two of three residents (R9, R23) reviewed for activities of daily living in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it is free of medication error rate of five percent or greater. During medication administration observation, two medication errors were observed out of 25 opportunities, resulting in an eight percent medication error rate. This deficiency applies to two (R9, R21) of six residents observed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to good hand hygiene practices, and cleaning and disinfection of resident-care equipment during medication administration for two of six residents (R21, and R9) reviewed for medication administration in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and/or provide proper staff assistance and supervision when providing care to a resident (R1) who was completely dependent on staff for Activities of Daily Living (ADL's), at high risk for falls and known to require at least two staff members while care is being provided and with bed mobility, for 1 of 3 residents reviewed for falls and safety (R1,R2 and R3). This failure caused R1 to have a fall out of bed where resident sustained lacerations to his right eyebrow and to his right lower extremity that required emergent transfer to a local hospital for sutures to R1's facial lacerations.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was provided for a resident to a scheduled hip surgery (R3) and to a diagnostic procedure (R2) for 2 of 4 residents reviewed for quality of care in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Nurse Staffing was posted daily. This failure affected all 136 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to call lights in a timely fashion for 3 residents (R45, R70 and R103), and to ensure the call light is within reach for one resident (R67). This failure affected 4 residents out of a sample of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who depend on staff assistance for their ADL (Activities of Daily Living) and grooming receive shaving and nail care. This affected four residents, (R61, R67, R90, and R334), in the sample of 46 residents reviewed for ADL care and grooming.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: implement individualized fall prevention interventions for residents identified to be at risk for falls; failed to ensure that oxygen tank was placed in a holder; and failed to ensure that floor tiles on the units were even and not sinking. These failures have the potential to affect R19, R28, R38, R47, R336, and 49 other residents on three units of the second floor, reviewed for hazards and prevention of falls with injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medication, dispose of loose pills in the medication carts, and to label open and expiration dates on open medications. These failures have the potential to affect (R5, R7, R14, R85) and all residents receiving medications from Parkview1 medication cart 1 on 1st floor, Heritage Place medication cart 1A/1B on the 2nd floor, Transitional Care Unit medication cart 1 and 2 on the 1st floor. Findings Include: On 10/24/22 at 1:30pm, V22, LPN (License Practical Nurse), review of 1st floor Park View 1 medication cart 1(rooms 171-187): *R5's bottle of Humalog Insulin, with an open date of 9/10/22, and an expiration date of 10/7/22. V22 stated, This (Insulin bottle) is expired and should have been thrown away. V22 held the expired insulin bottle and stated, I will throw the bottle away. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (R22 and R119) received privacy in regards to urine collection bags. This failure affected two residents (R22 and R119), whose urine collection bags were not covered for privacy and was visible from the hallway, in the sample of 46 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the code status in the resident's electronic medical record which affected one resident (R108) in a sample of 46.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident's midline was flushed before and after administration of medication and during the time the resident's midline was not in use. This failure affected 1 (R15) resident reviewed for professional standard of care in the total sample of 46 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions for two residents with history of pressure ulcers, and at risk for further pressure ulcers. These failures affected two residents (R19 and R38) of three residents, reviewed for pressure ulcers and pressure ulcer prevention interventions, in a total sample of 46 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand splints or other restorative devices were applied on resident's upper extremities as indicated in the assessments and care plans, to prevent further contractures. This affects one resident (R28) of three residents, reviewed for restorative care, in a total sample of 46 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate account of controlled substance records for two residents (R15 and R33) reviewed for controlled substance in a sample of 46 residents. Findings Include: On 10/26/22 at 11:35am V28 (Registered Nurse) review of 1st floor Transitional Care Unit medication cart 1(rooms 101-117, and 24-27). V28 stated, Narcotic count is done at the beginning of each shift and at the end of each shift. On 10/26/22 at 11:50 am, R15's Oxycodone/APAP 5-325mg tablet, should be 13 tablets; observed 11 tablets. V28 stated, I gave that to (R15) this morning, I forgot to sign out the medication when I gave it. Surveyor observed V28 sign out the medication on the Controlled Drug Receipt/Record/Disposition Form. Dated 10/26/22, Time 9:00 am, Given 2 left 11 with V28 signature. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's midline dressing was not soiled ,and failed to ensure the IV (intravenous) medication bag and the IV tubing were labeled with date. These failures affected 1 (R15) resident reviewed for infection control in the total sample of 46 residents.