Facility profile · CCN 145689
Pearl Of Elk Grove, The
75 federal citations on record , including 2 at the Immediate Jeopardy level, and 8 federal enforcement actions totaling $159,227.
Record summary
Federal record · Q1 202675
Total citations
52
Last 3 years
10
Actual harm+
8
Federal penalties
$159,227
Total fines
2
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
75 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Jul 30, 2025 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Complaint |
| Jun 4, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint |
| May 8, 2025 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Complaint |
| Apr 1, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint |
| Jan 15, 2025 | F558 | Reasonably accommodate the needs and preferences of each resident. | E | Complaint |
| Jan 2, 2025 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | G | Complaint |
| Dec 17, 2024 | F585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | E | Complaint |
| Nov 8, 2024 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | D | Complaint |
| Nov 8, 2024 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Complaint |
| Nov 8, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Nov 8, 2024 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Oct 23, 2024 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Oct 23, 2024 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard |
| Oct 23, 2024 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard |
| Oct 23, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Oct 23, 2024 | F688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D | Standard |
| Oct 23, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Sep 26, 2024 | F712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | D | Complaint |
| Sep 26, 2024 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Sep 26, 2024 | F610 | Respond appropriately to all alleged violations. | L | Complaint |
| Sep 26, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint |
| Aug 20, 2024 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Complaint |
| Aug 10, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Aug 10, 2024 | F626 | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | D | Complaint |
| Jul 11, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Jun 14, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | G | Complaint |
| Jun 14, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Jun 7, 2024 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | H | Complaint |
| Jun 7, 2024 | F803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | H | Complaint |
| Jun 7, 2024 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Complaint |
| Jun 7, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| Jun 7, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Complaint |
| Jun 7, 2024 | F585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | F | Complaint |
| Mar 26, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint |
| Dec 19, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Dec 19, 2023 | F577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | D | Complaint |
| Nov 15, 2023 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Complaint |
| Nov 15, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Complaint |
| Oct 1, 2023 | F558 | Reasonably accommodate the needs and preferences of each resident. | E | Complaint |
| Sep 15, 2023 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Sep 15, 2023 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Standard |
| Sep 15, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Sep 15, 2023 | F694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | Standard |
| Sep 15, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Sep 15, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Standard |
| Sep 15, 2023 | F676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Standard |
| Sep 15, 2023 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
| Jul 16, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Jul 16, 2023 | F602 | Protect each resident from the wrongful use of the resident's belongings or money. | D | Complaint |
| Jun 22, 2023 | F803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | E | Complaint |
| Jun 22, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Jun 2, 2023 | F660 | Plan the resident's discharge to meet the resident's goals and needs. | D | Complaint |
| Apr 12, 2023 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Complaint |
| Mar 22, 2023 | F808 | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | E | Complaint |
| Mar 22, 2023 | F806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | E | Complaint |
| Mar 22, 2023 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | F | Complaint |
| Mar 22, 2023 | F800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | F | Complaint |
| Mar 22, 2023 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Complaint |
| Mar 22, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Complaint |
| Aug 3, 2022 | F886 | Perform COVID19 testing on residents and staff. | F | Standard |
| Aug 3, 2022 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Aug 3, 2022 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Standard |
| Aug 3, 2022 | F760 | Ensure that residents are free from significant medication errors. | D | Standard |
| Aug 3, 2022 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Aug 3, 2022 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard |
| Aug 3, 2022 | F745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D | Standard |
| Aug 3, 2022 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Aug 3, 2022 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Aug 3, 2022 | F688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | E | Standard |
| Aug 3, 2022 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Aug 3, 2022 | F679 | Provide activities to meet all resident's needs. | D | Standard |
| Aug 3, 2022 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Aug 3, 2022 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard |
| Aug 3, 2022 | F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Standard |
| Aug 3, 2022 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
Federal enforcement history
Federal regulators have imposed 8 enforcement actions against this facility, including 7 civil money penalties totaling $159,227 and 1 payment-denial actions spanning 20 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Jun 4, 2025 | Fine | $29,100 | — |
| Sep 26, 2024 | Fine | $58,852 | — |
| Jul 11, 2024 | Payment Denial | — | Aug 2, 2024 · 20 days |
| Jul 11, 2024 | Fine | $14,307 | — |
| Jun 7, 2024 | Fine | $42,224 | — |
| Mar 26, 2024 | Fine | $9,835 | — |
| Jun 20, 2023 | Fine | $1,764 | — |
| May 30, 2023 | Fine | $3,145 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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