Pearl of Hinsdale, The

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Aug 18, 2021

  Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Center for Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering a Person Under Investigation (PUI) for COVID-19 resident rooms. This failure has the potential to effect all residents in the facility and has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on August 16, 2021 when V3 (Licensed Practical Nurse/LPN) was observed in R32's room without an isolation gown or gloves on. The Immediate Jeopardy was identified on August 16, 2021. […]

• Actual harm, isolatedF689Jul 22, 2026

  Based on observation, interview, and record review, the facility failed to safely transfer and reposition dependent residents. This failure resulted in R3 sustaining ongoing discomfort and pain to the right upper extremity with a possible right shoulder subluxation and/or right humerus fracture and a hematoma on her forehead.This applies to 2 of 4 residents (R3 and R7) reviewed for accidents.The findings include:1. R3's EMR (Electronic Medical Record) said she had multiple diagnoses including hemiplegia and hemiparesis affecting her right dominant side following a cerebral infarction, disorders of the musculoskeletal system and bone density, and history of falls. […]

• Actual harm, isolatedF689May 23, 2024

  Based on observation, interview and record review, the facility failed to provide two person assistance during incontinence care and failed to implement a post fall intervention. This failure applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in the resident falling off the bed and sustaining a left femur and a right shoulder fracture. The findings include: R1's EMR (electronic medical records) showed that R1 was sent to the ER (emergency room ) on May 9, 2024 post fall and readmitted to the facility on [DATE] after hospital stay with diagnoses of unspecified fall, subsequent encounter, nondisplaced fracture of lateral condyle of right femur, subsequent encounter for closed fracture with routine healing, fracture of unspecified shoulder girdle,… […]

• Actual harm, isolatedF686Aug 18, 2021

  Based on interview and record review the facility failed to identify a blister as a pressure ulcer, and failed to prevent a pressure ulcer from becoming infected. This failure resulted in R32 developing [CONDITION(S)] requiring surgery and a toe amputation. This applies to 1 of 10 residents (R32) reviewed for pressure in the sample of 26. The findings include: R32's active face sheet showed she was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's 3/5/2021 Minimum Data Set (MDS) showed that R32 was mildly cognitively impaired, she was not able to walk, she was remaining in bed most days and when she was up, she was using a wheelchair and needed staff to push her. […]

• No harm, potential for more than minimal, widespreadF812Oct 18, 2024

  Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all resident that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated [DATE] documents the total census was 138 residents. On [DATE] at 11:33 AM, V12 (Dietary Manager) said there are 3 NPO (Nothing by Mouth) residents and the rest of the residents eat from the facility kitchen. On [DATE] starting at 10:24 AM, the facility kitchen was toured. Starting at 10:37 AM, V13 (Regional Dietary Manager) was present for the tour. The following was found: At 10:53 AM in walk-in cooler #1: 1. […]