Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearl Of Hillside,the during CMS and state inspections, most recent first.
Two residents did not receive catheter care according to standard practice and MD orders. A resident with severe cognitive impairment and a urinary catheter had stool on the catheter, and a CNA was observed wiping the catheter toward the urethra instead of from the insertion site outward; the spouse reported repeated infections and hospitalizations for UTI and sepsis. Another resident with a suprapubic catheter had a dirty insertion site with dry blood extending several inches around it, despite MD orders to cleanse the site daily and PRN with soap and water.
A resident with mild cognitive impairment and malignant neoplasm of the mouth missed multiple outside oncology and infusion appointments because staff did not arrange transportation in accordance with the facility’s appointments and transportation policy. Records showed that the resident was transported only to a cardiology visit while scheduled oncology and infusion appointments on the same day, as well as a separate oncology appointment, were not attended. An oncology clinic NP reported that the resident missed several appointments with various providers and that the resident attributed these missed visits to lack of transportation, poor communication, and failure to document appointments for staff follow-up, while the DON acknowledged that staff are responsible for setting up such appointments.
A cognitively intact, Spanish-speaking resident with a history of spinal fracture, hepatic encephalopathy, and prior falls, who was non-ambulatory and required substantial/maximal assistance and a transfer device with two staff for transfers, was assessed as low fall risk and later developed severe left-sided pain and immobility. Staff reported the resident complained of left arm and leg pain after lying on his left side, EMS documented pain beginning the prior night with denial of falls, and the resident was sent to the ER to rule out stroke, where imaging revealed multiple acute and chronic fractures, intracranial and intra-abdominal hemorrhages, and bruising estimated to be several days old. Hospital documentation noted the resident at one point accepted that someone hurt him but was reluctant to provide details, while a facility liaison later recorded the resident’s account that he attempted to get out of bed, fell toward the window, and was helped back to bed by staff; in a later interview with an interpreter, the resident said he did not remember falling. Numerous CNAs, LPNs, and RNs denied witnessing a fall or knowing what happened, no fall incident report was available, and staff consistently described the resident as unable to get out of bed or walk independently, while the physician stated the injuries were consistent with a fall and that the resident should never have been rated low fall risk.
A resident with Mild Alzheimer's and on Eliquis sustained a depressed orbital floor fracture and orbital globe rupture after an incident involving a CNA and a broken necklace. The first clinician on the scene documented the resident’s immediate allegation that the CNA hit him, observed the CNA’s agitation and anger, and reported these findings, including that a staff member had called 911 to report an assault. The facility’s investigation omitted these critical observations from the report to law enforcement, concluded the injury was accidental and self-inflicted, did not clinically evaluate whether the necklace or a self-blow could cause such trauma, and did not consider the resident’s cognitive impairment or have a neutral advocate present when the resident allegedly recanted. As a result, an incomplete and medically implausible account of the incident was provided to law enforcement.
Two residents experienced issues with gnats in their rooms, including gnats around full trash cans and food items, while gnats and a mosquito were also observed in the kitchen dishwashing area. The maintenance director linked the pest issue to unemptied trash, and a pest control inspection confirmed fruit flies in the kitchen, with recommendations for floor maintenance.
A resident with hemiplegia and moderate cognitive impairment, who was dependent on staff for toileting and always incontinent, was not provided incontinence care for over four hours. The resident was found with a saturated brief, wet bed pad, and dried urine stain on the sheet, despite staff and care plan requirements for care every two hours.
A resident with a history of falls, cognitive deficits, and unsteady gait did not have a specific fall care plan or adequate supervision upon admission. The resident, who had limited English proficiency, was found urinating on the floor and subsequently slipped in the urine, resulting in a head injury and hospitalization for intracranial bleeding. Staff interviews revealed that the resident's needs for supervision and toileting assistance were not adequately addressed, and the assigned CNA was attending to another resident at the time.
A resident with significant medical needs reported a leaking bathroom sink that had gone unrepaired for two weeks, with staff placing a bucket under the sink to collect water. Despite the facility's work order system, the maintenance issue was not reported or addressed until the survey, resulting in an unsanitary and non-functional environment for the resident.
The facility failed to provide annual dental exams and routine monitoring for dental care needs for several residents, as required under the State health plan. Five residents did not have documented dental visits or evidence of declining services, despite being covered by Medicaid or a combination of Medicare and Medicaid. Staff provided inconsistent information about dental visit frequency and insurance impact, and there was no documentation to support claims of service provision.
A resident with severe cognitive impairment and neuromuscular dysfunction of the bladder developed a catheter-associated UTI due to inadequate care at the facility. The resident's urinary catheter was found with maggots, indicating poor hygiene. Staff reported challenges in cleaning the catheter and a lack of documentation on catheter care and output. The resident was hospitalized with proteus bacteremia and a complicated UTI.
A resident with severe cognitive impairment and high fall risk fell during a smoke break due to inadequate supervision. The nurse monitoring the resident stood over seven feet away, and when the resident dropped a cigarette, he attempted to pick it up and fell from his wheelchair, sustaining a nasal fracture and laceration. The resident had been given a reacher for safety but forgot to use it.
Failure to Follow Standard and Ordered Catheter Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow standard practice and physician orders for urinary catheter care for two residents. One resident with severe cognitive impairment had a urinary catheter with stool present on it. A CNA was observed providing catheter care by wiping the catheter toward the urethra and then away from it, rather than from the insertion site outward as described by the DON as standard practice. The resident’s spouse reported that the resident had been sent to the hospital for a severe infection and alleged that staff were not changing gloves between care, which was causing infection. Health status notes documented multiple hospital admissions for this resident for UTI and sepsis on several prior dates. Another resident with intact cognition and a suprapubic catheter was observed in bed with the suprapubic catheter insertion site dirty and surrounded by dry blood extending almost four inches around the site. The physician’s orders for this resident directed staff to cleanse the suprapubic catheter insertion site daily and as needed with soap and water unless otherwise ordered. At the time of observation, the suprapubic catheter site was not clean as ordered, and the DON stated that the suprapubic catheter should have been kept clean to prevent potential infection.
Failure to Arrange Transportation for Oncology and Infusion Appointments
Penalty
Summary
The deficiency involves the facility’s failure to follow its appointments and transportation policy by not arranging transportation for a resident’s outside oncology and infusion appointments. The resident is an adult male with mild cognitive impairment and an admitting diagnosis that includes malignant neoplasm of the mouth, as documented on the MDS. On one observation, he was noted in bed with swollen lips and was unable to communicate effectively. The facility’s policy, reviewed on 4/16/2025, states that when a resident has an appointment outside the facility, staff will make transportation arrangements unless the responsible party chooses to make them. The DON acknowledged not remembering why the resident missed appointments and stated that the resident has the right to go for an appointment and that staff are supposed to set it up. Record review showed that the resident had multiple scheduled outside appointments, including cardiology, oncology, and infusion visits. Physician orders documented that on 2/4/26 he was scheduled for a cardiology appointment at 9:05 AM, an oncology appointment at 12:00 PM, and an infusion appointment at 2:00 PM. The transportation schedule and nursing progress notes from 2/1/26 through 2/6/26 showed that he was sent only to the cardiology appointment and not to the oncology or infusion appointments. A review of the January transportation schedule and nursing progress notes from 1/25/26 through 1/30/26 further documented that he was not sent to an oncology appointment scheduled for 1/27/26 at 11:40 AM. The oncology clinic nurse practitioner reported that the resident missed around five appointments with various care providers, and that the resident stated he missed appointments due to lack of transportation, communication, and not writing the appointments in the records for staff to follow up after setting transportation. The nurse practitioner stated the resident is at high risk for relapse if he misses his oncology appointments.
Failure to Prevent and Adequately Account for Resident’s Multiple Traumatic Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to protect and prevent a cognitively intact resident from sustaining injuries of unknown origin, including multiple fractures and intracranial and intra-abdominal hemorrhages. The resident was admitted with significant medical history including an unstable burst fracture of T11–T12, hepatic encephalopathy, cirrhosis, pancytopenia, and a history of falls and alcohol dependence. The resident’s primary language was Spanish, and the most recent MDS documented a BIMS score of 15, indicating intact cognition, with use of a wheelchair for ambulation and a need for supervision or touching assistance for transfers. Therapy records and staff interviews consistently indicated that the resident could not walk independently, could not transfer independently, and required substantial/maximal assistance and a transfer device with two staff for transfers. Despite this, the resident’s fall risk assessments categorized him as low risk for falls, and the physician later stated that the resident should never have been rated low risk and that he was high risk for falls. On the day of the incident, the resident complained of left shoulder and left leg pain with limited mobility and inability to move the affected extremities. A CNA who spoke Spanish reported that the resident stated he had slept on his left side for a long time and requested help to turn; she assisted by pulling the incontinent pad to reposition him and notified the RN. Another CNA assigned to the resident that morning observed him in pain, with a swollen left arm, and heard him indicate pain in the left arm, again with the explanation that he had been lying on his left side. The RN assessed the resident, noted extreme pain and numbness in the left upper extremity and limited mobility in the left arm and leg, and obtained orders from the NP to send the resident to the ER to rule out stroke. The EMS run sheet documented that the resident complained of left shoulder and hip pain that began the previous night and denied any falls or trauma. The facility’s initial incident report recorded that the resident denied anyone hurting him and stated he felt safe at the facility. At the hospital, diagnostic imaging revealed multiple acute and chronic fractures, including an acute comminuted and displaced left humeral head fracture, bilateral subcapital femoral neck fractures, sacral fractures, a right L4 transverse process fracture, a small left subdural hematoma, a right parietal subarachnoid hemorrhage, intra-abdominal hemorrhage, and bruising to the anterior chest wall and left shoulder estimated to be 3–4 days old. The ER RN, who spoke Spanish, reported that the resident initially said he did not remember what happened, and hospital documentation noted that at one point he accepted that somebody hurt him but was reluctant to provide details due to fear of police involvement or other social reasons. A facility liaison later interviewed the resident in the hospital; the resident stated he had been doing exercises in bed, felt stronger than normal, attempted to get out of bed, fell toward the window side, and was assisted back to bed by staff, but he reported no pain at that time and said he did not want anyone to get in trouble. During a subsequent in-facility interview with an interpreter, the resident stated he did not know what happened, did not remember falling, and only recalled waking up in pain and being sent to the hospital. Throughout the facility’s internal investigation, multiple CNAs, LPNs, and RNs who worked with or around the time of the incident denied witnessing any fall or knowing what happened to the resident, and no fall incident report could be produced. Staff interviews consistently described the resident as unable to get out of bed, unable to sit on the edge of the bed or scoot, and requiring two-person assistance with a transfer device for any out-of-bed activity. The physician and NP both stated that the resident had not been able to walk since admission and could not independently get up from bed or dangle his feet to exercise. The physician opined that the resident’s injuries were consistent with a fall and that he was a high fall risk. The administrator and DON maintained that the resident did not fall based on staff interviews, and one CNA who worked the night before the resident’s complaints denied picking the resident up from the floor. However, when shown pictures of night CNAs, the resident identified that CNA as the person who picked him up from the floor. The facility’s abuse prevention policy defined injury of unknown source as an injury not observed and not explainable by the resident, with suspicious extent or location, and the facility concluded that none of the staff knew what happened or the cause of the resident’s injuries.
Failure to Conduct Thorough and Credible Abuse Investigation After Severe Eye Injury
Penalty
Summary
The facility failed to conduct a thorough and credible abuse investigation for one resident who sustained a depressed orbital floor fracture and left orbital globe rupture requiring emergent surgical intervention. The resident, who had Mild Alzheimer's and was taking Eliquis (Apixaban), initially alleged that a CNA hit him, an allegation documented by the first clinician on the scene, an agency RN. This RN also observed the CNA in an agitated and angry state over a broken necklace and reported these observations, including the resident’s statement that the CNA hit him and that a staff member had reported the incident as an assault via a 911 call, to the Administrator and management. However, these critical observations and the documented allegation of assault were omitted from the facility’s formal report to law enforcement. The facility concluded that the injury was accidental, suggesting the resident struck his own eye, and did not consider or document the possibility that the necklace chain or pendant could have been the blunt object causing the injury. There was no evidence that the facility consulted a medical professional to assess whether a swinging pendant or a self-inflicted blow by an elderly resident with Mild Alzheimer's could generate sufficient force to cause the documented orbital fracture and globe rupture, or to reconcile how a minor accident could result in severe hemorrhaging requiring emergent surgery in a resident on Eliquis. Additionally, the Administrator reported to police that the resident recanted the allegation, but facility records did not show that the resident’s cognitive impairment or potential suggestibility after traumatic injury were considered, nor that a neutral advocate or social worker was present during the recantation. These omissions and failures in the investigative process resulted in an incomplete and medically implausible narrative being provided to law enforcement and demonstrated that the facility lacked a thorough implementation of an abuse investigation system required by Federal regulations.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest management program, resulting in the presence of gnats in resident rooms and the kitchen area. In one resident's room, multiple gnats were observed flying around two trash cans near the entryway, with more than ten gnats crawling on the outside of a white trash can. The trash can was noted to be full, and the maintenance director attributed the presence of gnats to the trash not being emptied by CNAs. The same resident was also observed with gnats on his bed sheet and around a partially open bag of restaurant food on his bedside table, with several gnats crawling on and inside the food bag and on the wall nearby. Another resident reported having a problem with gnats, and three gnats were observed flying around her bed and bedside table. During a tour of the kitchen, three to four gnats and a large mosquito were observed flying near the handwashing sink in the dishwashing area. The dietary manager confirmed the presence of gnats and a mosquito in this area. A pest control service inspection report documented the presence of fruit flies in the main kitchen area and noted that the kitchen floor needed to be regrouped to prevent fruit flies from breeding. The facility's pest control policy emphasized the importance of maintaining a healthy environment and specifically mentioned the need to keep trash cans lined and emptied regularly.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with hemiplegia and hemiparesis, who was documented as always incontinent and dependent on staff for toileting, was not provided incontinence care at least every two hours as required by their care plan. On observation, the resident was found with a saturated adult brief, a wet bed pad, and a dried urine stain on the fitted sheet, indicating that incontinence care had not been provided for over four hours. The resident reported last being changed in the early morning, and the assigned CNA confirmed the last care was provided at 9:00am, despite facility policy and staff statements that care should be provided every two hours and as needed. Documentation and staff interviews confirmed the resident's need for frequent incontinence care due to heavy urinary incontinence.
Failure to Implement Adequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to develop and implement an adequate care plan with increased monitoring and supervision for a resident who was identified as having poor safety awareness, a history of falls, unsteady gait, and cognitive deficits. Despite being newly admitted with diagnoses including abnormal gait, lack of coordination, hypotension, and aphasia, the resident did not have a fall care plan in place upon admission. Staff relied on a general fall focus system rather than a resident-specific plan, and the resident's needs for supervision and toileting assistance were not sufficiently anticipated or addressed. As a result, the resident was found urinating on the floor and subsequently slipped in his own urine, leading to a fall that caused a bump to the head and a change in consciousness. The resident, who only spoke Mandarin and had limited ability to communicate, was found lethargic and drowsy after the incident and was later diagnosed with intracranial bleeding and admitted to the hospital. Staff interviews confirmed that the resident was unsupervised at the time of the incident, and that the CNA assigned to the unit was attending to another resident. The lack of a tailored fall prevention plan and insufficient supervision directly contributed to the accident.
Failure to Maintain Functional and Sanitary Resident Environment Due to Unaddressed Sink Leak
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including diabetes, congestive heart failure, atrial fibrillation, hypertension, acute kidney disease, osteomyelitis, and bilateral leg amputations, reported that their bathroom sink had been leaking for two weeks. The resident, who was cognitively intact and required partial/moderate assistance for mobility, stated that staff had placed a gray bucket under the sink to catch the leaking water but had not arranged for repairs despite being notified. Upon observation, the surveyor found the bucket half full of dirty water and witnessed water dripping into it when the faucet was used. Interviews with facility staff revealed that the Maintenance Director was only made aware of the issue on the day of the survey and began repairs immediately. The Administrator and Director of Nursing both stated they were not previously informed of the leak, despite the facility having a policy and system in place for submitting maintenance work orders, including QR codes for easy reporting. The failure to report and address the leaking sink resulted in the resident's environment not being maintained in a functional and sanitary condition.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that residents received annual dental exams and routine monitoring for dental care needs, as required under the State health plan. This deficiency was identified for five out of seven residents reviewed for dental services. Specifically, one resident had not received a dental visit within the past year, and there was no documentation indicating that the resident declined services. Four other residents had no documented dental visits or evidence of declining services since their admission to the facility. All these residents were covered by Medicaid or a combination of Medicare and Medicaid. During the survey, facility staff provided inconsistent information regarding the frequency of dental visits and the impact of insurance on service provision. The Assistant Director of Nursing was unsure about the frequency of dental visits, while the Social Worker mentioned that an in-house dentist visits twice a month and that transportation is arranged for residents using outside dentists. However, there was no documentation to support these claims for the residents in question. The facility's policy states that it will provide routine and emergency dental services and assist residents with appointments and transportation, but the lack of documentation and follow-through indicates a failure to adhere to this policy.
Inadequate Catheter Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to prevent a resident from developing a catheter-associated urinary tract infection (UTI), which necessitated hospitalization. The resident, a male with severe cognitive impairment and neuromuscular dysfunction of the bladder, was dependent on staff for toileting and hygiene. Observations and interviews revealed that the resident's urinary catheter care was inadequate, with reports of dark, cloudy urine and a lack of proper documentation of catheter care and output. The resident was found to be lethargic and unresponsive, leading to his transfer to the hospital. Upon examination at the hospital, the resident was diagnosed with proteus bacteremia and a complicated UTI, with maggots found in the urinary catheter. This indicated poor hygiene and improper catheter care at the facility. The facility's staff, including a CNA and an LPN, reported challenges in cleaning the catheter due to the resident's contracted lower extremities and noted a lack of urine output documentation. The facility's policy required daily catheter care, but there was no documentation of such care being performed. The facility's failure to document and perform adequate catheter care led to the resident's severe infection and subsequent hospitalization. The lack of documentation and communication among staff members contributed to the oversight in the resident's care. The facility's policy on indwelling catheter care was not adhered to, resulting in the resident's deteriorating condition and the presence of maggots in the catheter, which is a sign of neglect and poor hygiene practices.
Inadequate Supervision During Smoke Break Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise and monitor a resident during a smoke break, resulting in an accident. The resident, who has schizophrenia, dementia with behavioral disturbances, and severe cognitive impairment, was identified as high risk for falls. During a smoke break, the resident dropped a cigarette and attempted to pick it up, leading to a face-forward fall from his wheelchair. The fall resulted in an open fracture of the nasal bone and a nasal laceration requiring sutures. The incident occurred when a nurse, who was not a smoker, took the resident to the smoking area. The nurse stood inside the entrance/exit smoking patio door, monitoring the resident from a distance of seven feet and seven inches. When the resident bent down to pick up the cigarette, the nurse attempted to intervene but was unable to prevent the fall. The resident's jacket slipped off as the nurse tried to grab it, and the resident fell onto the concrete patio. The resident had previously been given a reacher to assist with picking up items from the floor due to poor safety awareness and impulsiveness. Despite this, the resident forgot to use the reacher during the incident. The facility's fall prevention and management policy emphasizes the need for individualized interventions for high-risk residents, but the supervision provided during the smoke break was insufficient to prevent the fall.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hillside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Hillside | 0.7 mi | — | 0 | 0 |
| Park Place Christian Community | 2.2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Westchester | 2.4 mi | ★★★★★ | 4 | 0 |
| Bella Terra Elmhurst | 3 mi | ★★★★★ | 1 | 0 |
| Citadel At Casa Scalabrini | 3.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.