Pearl Pointe Nursing Rehab & Care

In the surveyor’s words

From the most serious findings on record at Pearl Pointe Nursing Rehab & Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 28, 2023

  Based on interview and record review, the facility failed to provide care needs details to staff that R1 had a wound vacuum device, failed to provide monitoring and remain with/supervise R1 while he was experiencing hemorrhagic blood loss. The facility also failed to perform a full body assessment for R1 to determine the source of R1's bleeding to provide proper first aid to attempt to control the bleeding. These failures resulted in R1 sustaining hemorrhagic blood loss leading to R1's cardiac arrest. R1 required initiation of cardiopulmonary resuscitation (CPR) initiated by EMS staff upon their arrival to the facility, intubation for mechanical/artificial breathing support and transport to the local hospital emergency department. […]

• Immediate jeopardy, isolatedF684Nov 28, 2023

  Based on interview and record review, the facility failed to timely respond to a report of an unresponsive resident, failed to ensure a resident was monitored and not left unattended once found unresponsive, failed to thoroughly assess a resident to identify the source of hemorrhagic blood loss and provide immediate treatment in attempt to control blood loss and failed to contact Emergency Medical Systems (EMS) in a timely manner. These failures resulted in R1 sustaining hemorrhagic blood loss leading to R1's cardiac arrest. R1 required initiation of cardiopulmonary resuscitation (CPR) initiated by EMS staff upon their arrival to the facility, intubation for mechanical/artificial breathing support and transport to the local hospital emergency department. […]

• Immediate jeopardy, isolatedF684Mar 3, 2021

  Based on observation, interview, and record review the facility failed to monitor blood glucose levels for residents receiving diabetic medications to avoid adverse diabetic reactions, for 3 of 3 residents (R2, R4, R5) reviewed for [DIAGNOSES REDACTED]. R2 was hospitalized due to critical low blood glucose levels. There was no evidence of blood glucose monitoring found in R2's chart from 1/20/21 at 11:00 AM through 2/10/21 when R2 was transferred to the hospital. This failure contributed to R2 being transferred to an acute care hospital with a critically low blood glucose level on 12/31/20 and again on 2/10/21. These failures resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF689Aug 28, 2026

  Based on interview and record review the facility failed to ensure safety was provided for a resident when given hot coffee. This failure resulted in R1 sustaining a second degree burn to her arm from hot coffee on 8/1/26. This is for 1 of 2 residents (R1) reviewed for safety and supervision in the sample of 8.The findings include:The Incident Report dated 8/1/26 for R1 showed under the notes section; R1 sustained a thermal burn to her right forearm after accidentally spilling hot coffee. The certified nursing assistant (CNA) delivered the breakfast tray with meal set up and notified this nurse that she had spilled coffee. Upon immediate assessment, a burn measuring 13 centimeters (cm) x 5.3 cm was noted to the right forearm. […]

• Actual harm, isolatedF697Feb 18, 2026

  Based on observation, interview, and record review, the facility failed to provide effective pain management to a resident with phantom pain in all 4 amputated extremities. This failure resulted in R1 having severe pain from 1/31/26 to 2/6/26 when he missed 11 doses of medication. This applies to 1 of 3 residents (R1) reviewed for pain management in the sample of four.The findings include:On 2/11/26 at 7:32 AM, R1 was in his room in bed on his back with head of his bed elevated. R1 had all 4 extremities amputated. R1 had a tray table in front of him with personal items on it. R1 stated he was without his pain medication for 4 days and was told that they couldn't get it from the pharmacy. R2 stated he was in a lot of pain. He stated his pain was a 10/10 on the pain scale. […]