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Inspection visit

Health inspection

PEARL OF HINSDALE, THECMS #1452461 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

145246 05/14/2025 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide resident wound treatments as ordered by physicians. Residents Affected - Few This applies to 2 of 3 residents (R1 and R2) reviewed for wound treatments in a sample of 5. The findings include: 1. Face sheet, printed 5/13/25, shows R1's diagnoses included peripheral vascular disease, osteoarthritis, pain, chronic kidney disease, venous insufficiency, and mild protein-calorie malnutrition. On 5/13/25 at 11:07 AM, V3 (Wound Nurse RN - Registered Nurse) stated R1 had a physician order for wound treatments to be completed every Monday, Wednesday and Friday. V3 stated R1 should have received wound treatments the day prior, on Monday. V4 (Wound Tech CNA - Certified Nursing Assistant) stated she worked with V5 (Wound Nurse RN) the day prior and V5 and V4 did not complete wound treatments on R1's wounds. At 11:32 AM, V4 began to perform wound treatments on R1's wounds. On 5/14/25 at 9:54 AM, V5 stated on 5/12/25 she was being pulled in many directions, had an eye injury, and was unable to complete R2's wound treatments as ordered by the physician. V5 stated she had every intention of performing the wound treatments but was unable to complete them as ordered. Review of R1's TAR (Treatment Administration Record), printed 5/13/25, shows R1 had physician orders for wound treatments to her right heel, right ischial tuberosity, right lateral foot every Monday, Wednesday, and Friday. The TAR shows R1 did not receive any of the physician-ordered wound treatments to her right heel, right ischial tuberosity, or right lateral foot on 5/12/25. Review of R1's TAR, dated 4/2025, shows R1 had physician orders for wound treatments to her right heel, right ischial tuberosity, and right lateral foot every Monday, Wednesday and Friday. The TAR showed R1 did not receive any of the physician-ordered wound treatments to her right heel, right ischial tuberosity or right lateral foot on 4/7/25. Review of R1's TAR, dated 3/2025, shows R1 had physician orders for wound treatments to her right heel, right ischial tuberosity, and right lateral foot every Monday, Wednesday, and Friday. The TAR showed R1 did not receive any of the physician-ordered wound treatments to her right heel, right ischial tuberosity, or right lateral foot on 3/19/25. On 5/13/25 at 2:32 PM, V2 (Director of Nursing) stated the wound treatments for R1 should be performed every Monday, Wednesday, and Friday as ordered by the physician. Page 1 of 2 145246 145246 05/14/2025 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521
F 0684 Level of Harm - Minimal harm or potential for actual harm Facility policy/procedure, reviewed 3/1/25, shows 1. Licensed Professional Nurses/Registered nurses will follow orders from physicians and documented in a timely manner 2. Face sheet, dated 5/13/25, shows R2's diagnoses included pleural effusion, peripheral vascular disease, protein calorie malnutrition, and chronic obstructive pulmonary disease. Residents Affected - Few TAR, dated March 2025, shows R2 had physician orders for wound treatments for right lower extremities and left lower leg to be performed three times a week (every day shift every Monday, Wednesday, and Friday) and as needed. Review of R2's March 2025 TAR shows none of the wound treatments were performed on 3/10/25. 145246 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

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

FAQ · About this visit

Common questions about this visit

What happened during the May 14, 2025 survey of PEARL OF HINSDALE, THE?

This was a inspection survey of PEARL OF HINSDALE, THE on May 14, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PEARL OF HINSDALE, THE on May 14, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.