Inspection·May 30, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and check glucose blood sugar levels for a resident with a known history of Diabetic Ketoacidosis and elevated blood sugars. This failure resulted in R1 needing hospitalization for Diabetic Ketoacidosis (grossly elevated blood sugars). Residents Affected - Few This applies to 1 of 3 residents (R1) review for Diabetes and blood glucose monitoring in the sample of 4. The findings include: Face sheet shows R1 is 63 years-old who has multiple diagnoses which include acute embolism and thrombosis of deep veins of upper extremity, bilateral, type 2 diabetes mellitus with ketoacidosis without coma, cardiac arrest due to other underlying condition, cardiac arrest, cause unspecified, diabetes mellitus due to underlying condition with ketoacidosis without coma, elevated white blood cell count, unspecified, schizoaffective disorder, bipolar type, acute kidney failure, unspecified, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, acute respiratory failure with hypoxia, unspecified protein-calorie malnutrition, anemia in other chronic diseases classified elsewhere, hyperkalemia, pneumonia due to streptococcus, group b, pneumonia due to klebsiella pneumoniae, sepsis, unspecified organism, acute diastolic (congestive) heart failure, metabolic encephalopathy, hypoxic ischemic encephalopathy, unspecified, acute metabolic acidosis, type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, other hypotension, other symptoms and signs involving cognitive functions and awareness, relevant medical history is: CHF diabetes chronic renal failure/ESRD. Nurse Practitioner Notes, dated May 17, 2024, shows R1 is a [AGE] year-old male who was admitted to the facility on [DATE], after suffering a cardiac arrest and was resuscitated in the emergency room. R1 was also diagnosed with DKA (Diabetic Ketoacidosis), AKI (Acute Kidney Injury), EKG showed right bundle branch block, septal infarct, MI (Myocardial Infarction). In the ER, R1 became bradycardic and went into cardiac arrest. His blood sugar was 1229 mg/dL (milligram per deciliter). Medication Administration Record (MAR) showed R1's blood sugar level is to be monitored every 7:30 AM, 12:00 PM, and 4:30 PM. The same MAR shows Insulin Aspart 35 units was given twice a day (9 AM and 5 PM) and 15 units every 12 PM. Humalog Insulin sliding scale was also prescribed according to the blood sugar result every 7:30 AM, 12 PM, and 4:30 PM. R1's blood glucose monitoring log shows the following readings: 5/21/2024, at 1:14 PM- 400.0 mg/dL, 5/21/2024 at 5:04 PM- 345.0 mg/dL, 5/22/2024 at 9:20 AM- 400.0 mg/dL, 5/22/2024 at 4:33 PM- 350.0 mg/dL, 5/22/2024 at 4:34 PM- 399.0 mg/dL, 5/23/2024 at 6:15 AM- 600.0 mg/dL. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145372 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Joliet, The 306 North Larkin Avenue Joliet, IL 60435 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)