Pearl of Hillside: Fall With Brain Bleed, No Care Plan - IL
The day shift nursing aide assigned to his unit was in another resident's room.
Hospital records tell the rest. A CT scan of his head showed multiple rounded areas of hemorrhage in the left cerebral hemisphere, a finding the radiologist described as intraparenchymal contusion with hemorrhagic conversion. The scan also showed extensive edema involving the left parieto-occipital region and left temporal region, with associated internal hemorrhage. An MRI of the brain confirmed a subacute infarct with hemorrhage and surrounding edema involving the left basal ganglia, temporal lobe, and parietal occipital lobes.
He had no fall care plan.
A nurse identified in the inspection report as V2 confirmed it on September 25, 2025, the day inspectors visited the facility at 4600 North Frontage Road. The resident, referred to in inspection documents as R1, did not have a fall care plan implemented upon his admission. V2 said when a resident has no fall care plan in place, staff are supposed to follow what the facility calls its "fall focus system."
The fall focus system, an undated document, lists six principles the facility calls "pearls." One addresses personal needs: staff will assess and anticipate residents' personal and daily living needs, including toileting and incontinent care, during rounds, and attend to needs as they are identified.
What it does not address is what happens when a resident who has not yet been assessed for fall risk walks down a hallway alone in the early morning.
The incident statement, dated September 5, 2025, places the fall at 7:30 a.m. The facility's own fall prevention policy, dated October 29, 2021, states that Pearl of Hillside is committed to its duty of care in reducing the risk, number, and consequences of falls, including those resulting in harm, and to ensuring a safe environment. The policy is nearly four years old. The care plan for R1 did not exist.
Inspectors classified the deficiency under F0689, the federal tag covering accidents and supervision, with a finding of minimal harm or potential for actual harm affecting few residents.
That classification reflects regulatory language. The hospital records reflect something else. Hemorrhage in multiple regions of the brain. Edema spreading across the left hemisphere. A man found on his back on a hallway floor while the aide assigned to his unit was somewhere else.
The fall focus system the facility relies on in the absence of individual care plans does not appear to have assigned anyone to be watching R1 that morning. It does not appear to have flagged him as a resident who needed closer attention. It anticipated toileting needs and daily living assistance. It did not anticipate this.
V2, the nurse who spoke with inspectors, did not dispute any of it. No fall care plan had been put in place. That was the answer, given at 12:42 in the afternoon on the day inspectors came, three weeks after the resident had already been taken to the hospital.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pearl of Hillside,the from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
PEARL OF HILLSIDE,THE in HILLSIDE, IL was cited for violations during a health inspection on September 25, 2025.
The day shift nursing aide assigned to his unit was in another resident's room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.