Pearl of St Charles, The

In the surveyor’s words

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

• Immediate jeopardy, isolatedF624Aug 28, 2024

  Based on interview and record review the facility failed to provide a safe discharge for a resident with insulin-dependent diabetes and end-stage renal failure, requiring hemodialysis. This failure resulted in R1 being discharged from the facility and sent to a homeless shelter without the shelter's knowledge or ability to accept and care for the resident. Because of the resident's homelessness, R1 was transported to the local hospital, where he remained as of August 22, 2024, awaiting placement in another long-term care facility. These failures resulted in an immediate jeopardy. […]

• Actual harm, isolatedF689Dec 13, 2024

  Based on interview and record review the facility failed to safely assist and position a resident (R1) in bed when rendering care. This failure resulted in the resident falling out of bed and sustaining left tibial and ankle fractures. This applies to 1 out of 3 (R1) residents reviewed for accidents. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, post-orthopedic surgery to both ankle tendons, history of other disease of the nervous system, and history of malignant neoplasm of the brain. R1's Hospital Records dated 12/8/2024, said [R1] fell approx. […]

• Actual harm, isolatedF697Nov 1, 2023

  Based on interview and record review the facility failed to ensure a resident's pain was being managed after being discharged from the hospital for an ankle fracture. This failure resulted R1 experiencing uncontrolled pain for 4 days. This applies to 1 of 3 residents reviewed for pain (R1) in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] from a local community hospital with diagnoses including Bipolar Disorder, Mood Disorder, Depression and Pathological fracture to her right ankle. R1's 10/20/23 facility assessment shows her cognition is intact and she has no memory impairments. […]

• Actual harm, isolatedF755Nov 1, 2023

  Based on interview and record review the facility failed to call to clarify a medication order and failed to obtain prescriptions for a resident's medication. This failure resulted in a 4-day delay in R1 receiving her psychotropic medications and experiencing symptoms of mania. This applies to 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] from a local community hospital with diagnoses including Bipolar Disorder, Mood Disorder, Depression and Pathological fracture to her right ankle. R1's 10/20/23 facility assessment shows her cognition is intact and she has no memory impairments. […]

• Actual harm, isolatedF692Jan 25, 2023

  Based on observation, interview, and record review the facility failed to ensure weekly weights were obtained for a resident receiving enteral nutrition. This failure resulted in R73 sustaining an 18.2 lb (10.47%) weight loss in three weeks. This applies to 1 of 2 residents (R73) reviewed for enteral nutrition in the sample of 19. The findings include: R73's Admission Record sheet shows the following diagnoses: right humerus fracture, hemiplegia and hemiparesis, type 2 diabetes mellitus, respiratory failure, dysphagia, cerebral infarction, paroxysmal atrial fibrillation, Barrett's esophagus, dysphagia, aphasia, and chronic kidney disease stage 2. R73's Minimum Data Set (MDS) dated [DATE], showed R73 was receiving 51 percent (%) or more of total calories through a tube feeding. […]