Pearl of Elk Grove, The

In the surveyor’s words

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

• Immediate jeopardy, widespreadF610Sep 26, 2024

  Based 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. […]

• Immediate jeopardy, patternF689Apr 12, 2022

  Based on observation, interview and record review, the facility failed to ensure a resident with recent attempt of elopement was provided adequate supervision to prevent elopement from the facility. The facility also failed to ensure all facility exit alarm systems were monitored by staff to be able to respond to residents exiting the facility from the 300/South unit. This failure resulted in Immediate Jeopardy when R1 eloped from the facility without being witnessed by facility staff on 3/25/22. This applies to 6 of 6 residents (R1- R6) reviewed for supervision in the sample of 6. The Immediate Jeopardy began on 3/25/22 at 2:00 PM, when R1 eloped from the facility without being witnessed by facility staff. […]

• Immediate jeopardy, isolatedF600Sep 26, 2024

  Based 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. […]

• Actual harm, patternF803Jun 7, 2024

  Based 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. […]

• Actual harm, patternF804Jun 7, 2024

  Based 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. The findings include: 1. Face sheet, dated 6/5/24, shows R3's diagnoses included end stage renal disease, dependence on renal dialysis, type 1 diabetes, deficiency of Vitamin K, and depression. […]