Pearlview Rehab & Wellness CTR

In the surveyor’s words

From the most serious findings on record at Pearlview Rehab & Wellness CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF607Jun 25, 2026

  Based on record review, review of personnel files, review of the facility's background check log, interview, and review of facility policy, the facility failed to implement their abuse policy regarding screening potential employees through background and reference checks and maintaining evidence those screenings were completed. This affected all 40 residents residing in the facility. Findings include: 1. Review of the personnel file for Certified Nursing Assistant (CNA) #220 revealed a hire date of 09/10/25. The personal reference check page contained the name and contact information for the references, however, there was no evidence the references were ever contacted. […]

• No harm, potential for more than minimal, widespreadF610Jun 25, 2026

  Based on review of the facility's self-reported incident (SRI), facility investigation review, review of police reports, interviews, and review of facility policy, the facility failed to conduct a thorough investigation of an allegation of misappropriation of resident social security numbers. This had the potential to affect all 40 residents residing in the facility. Findings include:Review of the police report dated 06/04/26 at 5:29 P.M. revealed local law enforcement was dispatched to the facility regarding an anonymous tip that Certified Nursing Assistant (CNA) #220 had multiple felony warrants. CNA #220 was arrested at the facility and transported to jail. […]

• No harm, potential for more than minimal, widespreadF726Jun 25, 2026

  Based on personnel file review and staff interview, the facility failed to ensure that required staff orientation and performance evaluations were completed as part of the competency assessment process. This had the potential to affect all 40 residents residing in the facility. Findings include:Review of the personnel file for Certified Nursing Assistant (CNA) #220 revealed a hire date of 09/10/25. There was no evidence of CNA #220 completing an orientation, an initial skills evaluation, a 30-day performance evaluation, or a 90-day performance evaluation. On 06/17/26 at 12:35 P.M., an interview with the Administrator verified the findings in CNA #220's personnel file. […]

• No harm, potential for more than minimal, widespreadF812Jun 25, 2026

  Based on observation, interview, and review of facility policy, the facility failed to ensure food was stored, prepared and serviced in a sanitary manner. This had the potential to affect all 39 residents who received food from the kitchen excluding Resident #2 who was identified by the facility as having orders for nothing by mouth. The facility census was 40. Findings include: On 06/15/26 at 8:34 A.M., an observation of the kitchen revealed the following: Reach-in freezer #1 had no visible interior thermometer and there was significant ice build-up within the freezer including on food products. Reach-in freezer #2 had significant ice build-up within the freezer including on food products. […]

• No harm, potential for more than minimal, widespreadF880Jun 25, 2026

  Based on record review, observation, and interviews, the facility failed to conduct initial tuberculosis testing upon hire for all staff, which had the potential to affect all 40 residents residing in the facility. In addition, the facility failed to ensure staff performed appropriate hand hygiene during incontinence care, affecting Resident #39, and failed to ensure staff did not handle ready-to-eat foods with bare hands while assisting Resident #37 with eating. The facility census was 40. Findings include: 1. Review of the personnel files for former Administrator #230, Certified Nursing Assistant (CNA) #220, and Registered Nurse (RN) #232 revealed there was no documented evidence tuberculosis (TB) testing was performed prior to hire. […]