Pearl of Orchard Valley: Fall Care Failures Harm Resident - IL
Federal inspectors cited the facility for causing actual harm to the resident, identified in inspection records only as R1....
Latest reports, citations, and penalties from CMS data
Federal inspectors cited the facility for causing actual harm to the resident, identified in inspection records only as R1....
The November 2025 inspection, triggered by a complaint, turned up medication gaps affecting multiple residents....
The incident happened on October 8, 2025, around 1:30 in the afternoon at Reformed Presbyterian Home on Perrysville Avenue in Pittsburgh....
That is the core of what federal inspectors documented at Horsham Center for Jewish Life following a complaint inspection completed November 24, 2025....
That was the core finding when inspectors arrived at the facility at 625 36th Street SW on November 21, 2025....
The missing narcotics came to light in a sequence that a licensed practical nurse described in detail to inspectors on November 21, 2025....
That is what inspectors found at Evercare at Stearns after a complaint investigation completed in November 2025....
The inspection, conducted following a complaint, centered on a single resident with a urinary catheter....
The violation was cited under F0602, which covers a facility's obligation to operate with integrity in its management of controlled substances....
The inspection, conducted November 20, 2025, was triggered by a complaint....
Inspectors arrived at the resident's room on the morning of November 17, 2025, at 10:28 a.m....
The antibiotic was Macrobid, typically used to treat urinary tract infections....
The pattern shows up in the resident council meeting minutes with unusual clarity....
Staff called the nursing home administrator, the NHA, directly....
Federal inspectors cited the facility in November 2025 for failing to maintain comprehensive care plans that reflected residents' actual needs....
The Director of Nursing confirmed the gaps on the spot....
The finding covered a small number of residents....
The deficiency was tagged F0600, covering protection from abuse, and inspectors found the level of harm as minimal or potential, with few residents affected....
A physician order requires a doctor to authorize the treatment and provide a diagnosis explaining why oxygen is needed....
When she returned from the hospital on September 30, 2025, the nurse who transcribed her discharge orders recorded the antibiotic stop date as October 10....