Pearl Pointe Nursing Rehab & Care

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to appropriately assess a resident experiencing a change in condition.

This applies to 1 of 3 residents reviewed for quality of care and the sample of 3.

The findings include:R1's admission Record showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disorder (COPD, chronic lung disease); Dementia, atrial fibrillation (irregular, rapid heartbeat); Heart Failure; and Diabetes;. R1's 9/19/25 Alert Note from 12:00 PM (Authored by V7 Licensed Practical Nurse, LPN) showed R1 was more lethargic than usual; however, the note showed V7 believed this was due to R1's urinary tract infection, which R1 was being treated for.

The note does not document any vital signs, blood sugar, or complete head-to-toe assessment.

The note showed R1 was sent out via 911.R1's 9/19/25 at 2:26 PM, Narrative note showed vital signs transcribed from 9/18/25 at 5:34 PM.

The note did not show a blood sugar was checked or a complete head-to-toe assessment was completed.R1's Hospital Transfer assessment from 9/19/25 showed he was being sent to a local area hospital for a change in condition.

The assessment showed vital signs Most Recent blood pressure, pulse, respirations, and temperature were from 9/18/25 at 5:34 PM. On 10/15/25 at 11:53 AM, V7 (LPN) stated she did not take vitals for R1; however, she believed another staff member may have. V7 said if vitals were taken, they would be documented in R1's medical record. V7 said R1's assessment would also be documented in R1's electronic health record. V7 said she does not know if R1's blood sugar was checked.On 10/15/25 at 12:25 PM, V9 Certified Nursing Assistant (CNA) stated she believed R1's vitals were taken, and they were normal. V9 stated the vitals would have been given to the nurse. V9 said CNAs cannot check blood sugars and must be done by nursing staff.On 10/16/25 at 9:15 AM, V2 (DON/Director of Nursing) stated R1 is diabetic. V2 stated signs of low or high blood sugar could be lethargy and can be a serious condition. V2 stated, if a resident is experiencing increased lethargy and they are diabetic, the nurse should check the residents blood sugar as a part of their assessment. V2 said, in addition to blood sugar, the nurse should do a head-to-toe assessment checking for cognition, swelling, lung sounds, heart sounds, swelling, etc and this should be documented in the resident's electronic health record. R1's Vitals Electronic Health Record showed his last documented blood sugar measurement was on 9/14/25.

The facility's Change in Resident's Condition policy (dated 11/2023) showed, .Appropriate assessment and documentation will be completed based on the resident's change in condition or indication.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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