Pearl of Hillside,The

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Mar 2, 2022

  Based on interview and record review, the facility failed to immediately initiate CPR (cardiopulmonary resuscitation) or call a code blue for a full code resident (R3) after the resident was found unresponsive. This failure affected one resident in a total sample of seven. This failure resulted in CPR not being initiated on R3 until paramedics arrived to the facility approximately 9 minutes after R3 was found without a pulse or not breathing. R3 was pronounced dead after not being able to be revived by paramedics. This situation was identified as an Immediate Jeopardy. The immediate jeopardy began on [DATE]. […]

• Actual harm, isolatedF689Feb 18, 2026

  Based 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. Findings include:R1's admission Record documents initial admission as 2/28/25 and latest admission as 7/05/25.R1's electronic medical record admission Record documents diagnose that includes but not limited to Unstable burst fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing, altered mental status unspecified, unspecified fall subsequent encounter,… […]

• Actual harm, isolatedF689Oct 30, 2025

  Based 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).Findings include:R1 was admitted to the facility on [DATE] with a diagnosis of down syndrome, severe intellectual disabilities, mood disorder and osteoarthritis. R1's brief interview for mental status score dated 9/26/25 documents a score of 8/15 which indicates mildly impaired. […]

• Actual harm, isolatedF689Jul 28, 2024

  Based on interview and record review, the facility failed to supervise/monitor resident during smoke break. This affected one of three residents (R1) reviewed for monitoring and supervsion. This failure resulted in R1 having a face forward fall sustaining an open fracture of nasal bone and a nasal laceration requiring four sutures. Findings Include: R1 was admitted with Schizophrenia, Dementia with behavioral disturbance, restlessness, agitation and generalized anxiety. Brief interview for mental status dated 2/8/24 documents a score of six out of fifteen which indicates severe cognitive impairment. Fall assessment dated [DATE] documents: high risk for falls with a score of 17.0. On 7/27/24 at 2:56PM, V5 (ADON) said, V7 (nurse) took R1 to smoke. V7 is not a smoker. […]

• Actual harm, isolatedF600Mar 27, 2024

  Based 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. Findings include: Facility Reported Incident of 02/13/2024 10:15 PM reds in part, (V20, Certified Nursing Assistant) was walking passed R1's room while completing rounds and saw (R1) on the ground. (R1) complained of pain to the right shoulder and right arm. (R2) was noted in (R1's) room holding onto (R1's) arm. (R2) stated that she thought (R1) was in her room. 1. […]