Health inspection·September 19, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a provider of a resident not receiving anticoagulant medication. This applies to 1 of 1 resident (R45) reviewed for provider notification in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R45 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, atrial fibrillation, and peripheral vascular disease. R45's anticoagulant care plan, revised on September 8, 2024, showed, The resident is on anticoagulant therapy (aspirin) for prophylaxis. On warfarin as ordered. The care plan continued to show multiple interventions, dated August 7, 2024, including, Administer anticoagulant as ordered by physician. Monitor for side effects and effectiveness every shift. R45's Order Audit Report, dated September 19, 2024, showed an order, dated August 10, 2024, for Rivaroxaban starter pack oral tablet therapy pack 15 and 20 mg (milligram), give 15 mg by mouth two times a day. R45's Order Audit Report, dated September 19, 2024, showed an order, dated August 12, 2024, for, Enoxaparin Sodium Injection Solution, inject 50 mg subcutaneously every 12 hours for bridging with warfarin. A progress note, dated August 12, 2024, at 1:25 PM, by V7 showed, .PE (Pulmonary Embolism: Review of eMAR (Electronic Medication Administration Record) indicates patient has not received anticoagulant rivaroxaban since returned from hospital on August 10. Per nurse notes prior authorization was needed. No documentation found that provider was notified of this. Instructed nurse to give rivaroxaban scheduled doses today with plan to start warfarin and bridge with enoxaparin until INR (International Normalized Ratio) therapeutic. This provider notified In-house PCP (Primary Care Physician) of above and agreeable with plan of care . On September 18, 2024, at 11:48 AM, V7 (Nurse Practitioner) said R45 was hospitalized with a pulmonary embolism and was readmitted to the facility on [DATE]. V7 continued to say R45 was ordered to receive rivaroxaban twice a day upon discharge from the hospital. V7 said on August 12, 2024, she performed a chart review, and found R45 had not been receiving the rivaroxaban due to the need for prior authorization from R45's insurance. V7 said she was not notified R45 was not receiving Page 1 of 16 145045 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anticoagulant medication. V7 continued to say no provider was notified R45 was not receiving anticoagulant medicine. V7 said a provider should have been notified there was a delay in R45 receiving an anticoagulant. R45's August 2024 MAR (Medication Administer Record) showed R45 did not receive rivaroxaban on August 11, 2024. The MAR continued to show R45 did not receive six out of 25 doses of prescribed enoxaparin. The facility does not have documentation to show a provider was notified of R45 not receiving anticoagulation medication. On September 18, 2024, at 11:55 AM, V2 (Regional Nurse Consultant/Acting Director of Nursing) said nurses should have notified R45's provider about R45 not receiving anticoagulation medication. On September 3, 2024, at 3:00 PM, V3 (Assistant Director of Nursing) said nurses should document when a provider is notified. The facility's policy titled Policy: Resident Change in Condition, dated January 1, 2021, showed, Policy Statement: Our facility will ensure and provide appropriate services and treatment to the extent possible when a change in condition occurs. Guidelines: 1. The nurse will notify the resident's, physician, on call, or NP (Nurse Practitioner) when there has been a significant occurrence, accident or incident involving the resident, a pattern of refusal of care and or treatments or any significant change in resident's physical, medical, and mental condition . 145045 Page 2 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to residents who were receiving Medicare Part A Services in the facility. Residents Affected - Few This applies to 2 of 3 residents (R76 and R392) reviewed for beneficiary notice in the sample of 18. The findings include: 1. R76's EMR (Electronic Medical Record) showed R76 was admitted to the facility on [DATE], with diagnoses that included other disorders of the nervous system, morbid obesity, vasculitis limited to the skin, polyneuropathy, and cellulitis of bilateral lower limbs. R76's SNF ABN (Skilled Nursing Facility Advance Beneficiary Notification) form showed R76's Medicare Part A skilled services started on February 24, 2024, and last covered day of Medicare Part A services was May 24, 2024. R76 was discharged from Medicare Part A services by the facility when the Medicare Part A services days were exhausted. The facility did not issue a NOMNC (Notice of Medicare Non- Coverage), instead they documented on the SNF Beneficiary Notification Review form not an insurance plan. On September 17, 2024, at 9:29 AM, V20 (SSD/Social Services Director) stated R76 was admitted to the facility on [DATE], and remained in the facility as private pay. V20 said, The NOMNC (Notice of Medicare Non-Coverage) form is presented to a resident when they are no longer covered by their insurance. Typically, residents are notified as soon as the facility is made aware of the last covered Medicare Part A days. V20 said she did not issue R76 an ABN form because she was new to the facility and was not aware she had to do so. 2. R396's EMR (Electronic Medical Record) showed R392 was admitted to the facility on [DATE], with diagnosis that included multiple fractures of ribs on the left side, difficulty walking, and muscle weakness. R76 was discharged from the facility on March 15, 2024. On September 17, 2024, at 9:17 AM, V20 (SSD) said R392 was admitted on [DATE], and discharged from the facility on March 15, 2024, when family initiated the discharge. V20 said she was unable to provide any evidence of documentation that family initiated R392's discharge from the facility. R392's progress note from the business office dated March 6, 2024, showed V21 (R392's family member) reported she was not notified that R392 was going to be private pay. On September 17, 2024, at 12:02 PM, V12 said, When residents are done with their Medicare days, they would either become private pay or they need to apply for Medicaid. When residents are admitted to the facility to receive Medicare Part A services, the first 20 days Medicare pays 100%, the next 80 days Medicare pays 80%, and the remaining 20 % is either covered by either supplemental insurance or out of pocket payment. V12 said once a week they have a Medicare meeting and that is when they discuss each resident who is receiving Medicare Part A services and they look to see how many more days each resident has left of Medicare Part A services coverage. Residents are given the opportunity to appeal for private insurance coverage. 145045 Page 3 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide re-screening of residents with serious mental illness as instructed on each of the residents Level I PASARR (Preadmission Screening and Resident Review), to ensure that residents are offered the most appropriate setting and services for their individual needs. Residents Affected - Some This applies to 4 of 4 residents (R6, R50, R53, and R75) reviewed for PASARR in the sample of 18. The findings include: 1. R50 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, schizoaffective disorder, and anxiety disorder, based on the face sheet. R50's screening verification form, dated February 5, 2024, showed the resident was screened on January 16, 2024, and the screening indicated nursing facility services are appropriate. R50's PASARR level I screening, dated February 2, 2024, showed the resident had mental health disability, documenting the resident was diagnosed or suspected with schizophrenia and schizoaffective disorder. The screening documented R50's primary medical conditions requiring nursing facility care were unsteady gait, frequent falls, normal pressure hydrocephalus, and therapy was recommended for short term rehabilitation. The screening showed the physician had required 30 days or less of nursing facility care. The same screening documented under outcome rationale showed, Exempted hospital Discharge 30 day approval - A 30 day or less stay in the NF (Nursing Facility) is authorized. Re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. On September 16, 2024 at 5:02 PM, V9 (admission Director) stated R50 was assessed at the hospital for the Level I PASARR prior to admission to the facility. V9 stated she was not aware, and had missed to have the re-screening of R50 before his 30th day of stay at the facility. According to V9, R50 was only re-screened on September 15, 2024 (more than seven months of stay at the facility) and had triggered the Level II onsite PASARR assessment. R50's Level II PASARR report, dated September 18, 2024, documented the resident had a serious mental health condition, and his care needs are appropriate to be serviced in a nursing facility setting. The report documented under PASARR determination explanation, R50's PASARR level II mental health condition of schizoaffective disorder requires regular follow up with mental health provider and regular management of medication regimen. The same report showed R50 does not require specialized services, however, attending groups may provide support and socialization for the resident. 2. R75's EMR (Electronic Medical Record) showed R75 was admitted to the facility on [DATE], with diagnoses that included depression, schizoaffective disorder, and alcohol abuse. R75's PASRR (Pre-admission Screening and Resident Review), dated April 9, 2024, showed R75's PASRR Level I screen was completed. The Level I screen showed R75 may have a serious mental illness or intellectual/developmental disability (IDD). R75 met the criteria for Convalescent Care and was approved for up to 60 calendar days in the nursing facility without further PASRR assessment as long as he 145045 Page 4 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some also required the level of services provided by a nursing facility. R75's PASRR Level I showed if R75 needed to stay longer than the approved days, the nursing facility must submit a new PASRR screen request to Maximus, 7 to 10 days before the time approval expires. 3.R6's EMR showed R6 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, depression, and anxiety disorder. R6's PASRR, dated March 27, 2024, showed the Level 1 determination was an exempted hospital discharge. A 30-day stay is authorized. A re-screening must occur on or before the 30th day if the individual is expected to stay in the nursing facility beyond the authorization timeframe. 4. R53's EMR showed R53 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse with intoxication, major depressive disorder single episode, and generalized anxiety disorder. R53's PASRR, dated September 26, 2023, showed the Level 1 determination was an exempted hospital discharge. A 30-day stay is authorized. A re-screening must occur on or before the 30th day if the individual is expected to stay in the nursing facility beyond the authorization timeframe. On September 17, 2024 at 10:26 AM, V9 (Admissions Director) said when residents are admitted to the facility, they need to have a PASSAR (Pre-admission Screening and Resident Review) Level I done. V9 said once they are in the facility, she said she will log into (system) on her computer, and it is there where we can see if someone has an alert to have an updated PASARR I or if they need a PASARR II screening. V9 said R6 and R53 should have had an updated screening 30 days from their admission, and R75 should have had an updated screening after 60 days. The facility provided their policy titled admission Criteria, with a revision date of April 18, 2024. The policy showed 9. All new admissions and readmissions are screened for a mental disorder (MD), intellectual disorder (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process . b. If the Level I screen indicates that the individual may meet the criteria for a MS, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 145045 Page 5 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. Residents Affected - Some This applies to 4 of 6 residents (R23, R28, R58 and R77) reviewed for ADL (activities of daily living) in the sample of 18. The findings include: 1. R23 had multiple diagnoses including cerebral infarction, neurologic neglect syndrome, Alzheimer's disease and dementia without behavioral disturbance, based on the face sheet. R23's quarterly MDS (minimum data set), dated June 27, 2024, showed the resident was severely impaired with cognitive skills for daily decision making. The same MDS showed the resident required assistance from staff with personal hygiene. R23's active care plan, initiated on April 22, 2022, showed the resident had ADL self-care performance deficit and decreased functional mobility. The same care plan showed multiple interventions including staff assistance with personal hygiene and to check nail length and trim and clean on bath day and as necessary. On September 16, 2024 at 12:20 PM, R23 was sitting in his wheelchair near the nursing station. R23 was alert, verbally responsive, but confused. His fingernails were short, jagged, with black substances underneath the nails. V3 (Assistant Director of Nursing) was present during the observation, and stated R23 needs the assistance of the staff to file and clean his nails. At 12:31 PM, R23 was eating his lunch independently. R23 was served tuna sandwich and macaroni salad, which he ate using his fingers. V2 (Regional Nurse Consultant/acting Director of Nursing) and V3 were present during this lunch observation. V2 and V3 saw the black substances underneath R23's fingernails while the resident was eating using his fingers. V2 acknowledged R23's fingernails needs to be cleaned by the staff. On September 18, 2024 at 10:52 AM, R23 was sitting in his wheelchair near the nursing station. R23 was alert, verbally responsive, but confused. R23's fingernails were short, with black substances underneath the nails. V3 was present during the observation and acknowledged the resident's fingernails needs cleaning because there were black substances under the nails. 2. R77 had multiple diagnoses including ALS (amyotrophic lateral sclerosis), based on the face sheet. R77's quarterly MDS, dated [DATE], showed the resident was cognitively intact. The same MDS showed R77 had functional limitation in range of motion to one side of the upper extremity and required assistance from the staff with personal hygiene. R77's active care plan last, revised by the facility on September 13, 2024, showed the resident had ADL self-care performance deficit related to ALS. The same care plan showed multiple interventions including, Check nail length and trim and clean on bath day and as necessary. On September 16, 2024 at 10:26 AM, R77 was sitting in his motorized wheelchair inside his room. R77 145045 Page 6 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was alert, oriented, and verbally responsive. His fingernails were long and jagged. R77 stated he wanted the staff to trim his fingernails because he has problem with his hands. R77 had weakness in his hands and some of his fingers were stiff with minimal movement. V16 (CNA/Certified Nursing Assistant) was present during the observation, and heard R77's request for assistance to have his nails trimmed. On September 17, 2024 at 12:50 PM, R77 was sitting in his motorized wheelchair at the hallway. R77 was alert, oriented, and verbally responsive. R77's fingernails remained long and jagged. According to R77, the staff did not trim his fingernails, even after he made the request on September 16, 2024 V3 (Assistant Director of Nursing) was informed of R77's request to have his fingernails trimmed. According to V3, R77 requires staff assistance with trimming and cleaning his fingernails. 3. R28 had multiple diagnoses including cerebral atherosclerosis, transient cerebral ischemic attack and dementia with other behavioral disturbance, based on the face sheet. R28's quarterly MDS, dated [DATE], showed the resident was severely impaired with cognitive skills for daily decision making and required maximum assistance from the staff with personal hygiene. R28's active care plan, initiated on February 3, 2021, showed the resident had ADL self-care performance deficit. The same care plan showed multiple interventions including staff assistance with personal hygiene and to check nail length and trim and clean on bath day and as necessary. On September 17, 2024 at 12:30 PM, R28 was sitting in her reclining wheelchair near the nursing station. R28 was alert, verbally responsive with confusion. R28's fingernails were long, jagged, and with black substances under the nails. On September 18, 2024 at 11:15 AM, R28 was sitting in her reclining wheelchair near the nursing station. R28 was alert, verbally responsive with confusion. R28's fingernails were long, jagged, and with black substances under the nails. V5 (CNA) was present during the observation, and stated R28 needs extensive to total assistance from the staff with trimming and cleaning her fingernails. 4. R58 had multiple diagnoses including dementia without behavioral disturbance, based on the face sheet. R58's quarterly MDS, dated [DATE], showed the resident was severely impaired with cognitive skills for daily decision making. The same MDS showed R58 required maximum assistance from the staff with most of her ADLs including dressing. R58's active care plan, initiated on February 22, 2024, showed the resident had ADL self-care performance deficit related to weakness. On September 16, 2024 at 12:17 PM, R58 was sitting in her wheelchair near the nursing station. R58 was alert but non-verbal. R58's maroon colored pants were observed with lots of white flaky debris on the lap area. V3 was present during the observation. According to V3, R58 requires staff assistance with dressing. On September 18, 2024 at 10:59 AM, V3 stated it is part of the facility's nursing care and services to assist all residents needing assistance with ADLs including nail trimming, nail cleaning, and dressing. V3 added all residents needing assistance with ADLs should be assisted by the staff to 145045 Page 7 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0677 ensure and maintain the residents good hygiene and grooming. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure regarding activities of daily living support showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The same policy showed in-part under the procedure, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs (activities of daily living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming and oral care). Residents Affected - Some 145045 Page 8 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow provider orders to administer anticoagulant medication to a resident. Residents Affected - Few This applies to 1 of 1 resident (R45) reviewed for significant medications in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R45 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, atrial fibrillation, and peripheral vascular disease. R45's Order Audit Report ,dated September 19, 2024, showed an order, dated August 10, 2024, for Rivaroxaban starter pack oral tablet therapy pack 15 and 20 mg (milligram), give 15 mg by mouth two times a day. A progress note, dated August 10, 2024, at 5:03 PM, by V22 (RN/Registered Nurse) showed, Resident has returned from hospital in stable condition. New orders for oral antibiotic, [rivaroxaban], and losartan. All orders verified by [V8 (Nurse Practitioner)] . R45's anticoagulant care plan, revised on September 8, 2024, showed, The resident is on anticoagulant therapy (aspirin) for prophylaxis. On warfarin as ordered. The care plan continued to show multiple interventions dated August 7, 2024, including, Administer anticoagulant as ordered by physician. Monitor for side effects and effectiveness every shift. A progress note, dated August 12, 2024, at 1:25 PM, by V7 showed, .PE (Pulmonary Embolism: Review of eMAR (Electronic Medication Administration Record) indicates patient has not received anticoagulant rivaroxaban since returned from hospital on August 10. Per nurse notes prior authorization was needed. No documentation found that provider was notified of this. Instructed nurse to give rivaroxaban scheduled doses today with plan to started warfarin and bridge with enoxaparin until INR (International Normalized Ratio) therapeutic. This provider notified In-house PCP (Primary Care Physician) of above and agreeable with plan of care . R45's August 2024 MAR (Medication Administer Record) showed R45 did not receive rivaroxaban on August 11, 2024. R45's Order Audit Report, dated September 19, 2024, showed an order, dated August 12, 2024, for Enoxaparin Sodium Injection Solution, inject 50 mg subcutaneously every 12 hours for bridging with warfarin. R45's August 2024 MAR showed R45 did not receive six out of 25 doses of prescribed enoxaparin. The facility does not have documentation to show R45 refused the enoxaparin. On September 18, 2024, at 11:48 AM, V7 (Nurse Practitioner) said R45 was hospitalized with a pulmonary embolism and was readmitted to the facility on [DATE]. V7 continued to say R45 was ordered to receive rivaroxaban twice a day upon discharge from the hospital. V7 said on August 12, 2024, she performed a chart review and found R45 had not been receiving the rivaroxaban due to the need for prior authorization from R45's insurance. V7 said she was not notified R45 was not receiving anticoagulant 145045 Page 9 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0760 Level of Harm - Minimal harm or potential for actual harm medication. V7 continued to say no provider was notified R45 was not receiving anticoagulant medicine. V7 said a provider should have been notified there was a delay in R45 receiving an anticoagulant. V7 said it is very important for a resident with a new diagnosis of a pulmonary embolism to receive anticoagulation to prevent further complications. V7 continued to say her expectation is facility staff should follow provider orders and administer medications as ordered. Residents Affected - Few A progress note, dated September 15, 2024, at 6:13 PM, by V17 (Registered Nurse/RN) showed, Lab results received and relayed to nurse practitioner. New order received to increase warfarin to 5 mg . R45's September 2024 MAR showed R45 was not administer warfarin on September 15, 2024. The facility does not have documentation to show R45 refused the warfarin dose. On September 17, 2024, at 10:48 AM, V7 said on September 15, 2024, V7 ordered warfarin 5 mg to be administered to R45. V7 said it was her expectation R45 was administered warfarin on September 15, since R45's laboratory results showed his levels were subtherapeutic. V7 said R45 missing a dose of warfarin puts R45 at an increased risk for developing blood clots. On September 18, 2024, at 11:55 AM, V2 (Regional Nurse Consultant/Acting Director of Nursing) said R45 should have received anticoagulant medication as ordered in August and should have received warfarin on September 15, 2024, as ordered. The facility's policy titled Anticoagulant Therapy, dated 9/16, showed, General: To provide guidance for the staff for residents on anticoagulation therapy of [enoxaparin/warfarin] . Policy: 1. All residents on anticoagulation therapy can have a flow sheet produced by the electronic medical records system. 2. When the lab is called to the physician, the nurse will give the current dosage, previous dosage, current PT (Pro-Time) and INR, and any new medications started. 3. The medication will not be given until the physician is notified of the lab results. 4. Once the physician is notified, the new order will be recorded in the electronic medical recrd. If there is no new order, it will be so noted in the medical record. 145045 Page 10 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure that kitchen was maintain clean, foods were stored properly, and washed pans and buckets for beverages were air dried. Residents Affected - Many This applies to 85 residents who receives meals prepared in the facility kitchen. The findings include: Facility provided information that the census on September 16, 2024, was 85 residents with 2 (two) residents on NPO (nothing by mouth) status. On September 16 ,2024, at 10:00 AM during the initial tour of the kitchen with V15 (Food Service Dietary Manager), the following were observed: -a Dietary Aide was washing dishes using the dish machine. The left side of the dish machine were clean dishes and right side were dirty dishes. The dish machine was entirely soiled with heavy buildup of greenish colored lime debris. The floor under the dish machine all the way to the opening of the sewage drain was a heavy buildup of black debris that looks like a mud puddle. The pipe that goes to the sewer drain that was exposed was rusted. V15 said they will clean the dish machine and use a lime build up degreaser. V15 said she does not know when the kitchen was deep cleaned and why there was a buildup of the mud- puddle like under the dish machine. - 2 big plastic buckets stacked wet, and water drops in between buckets water were visible. V15 said they use the buckets as mixing containers for beverages, such as iced tea, orange drink, and fruit punch. -multiple sizes of washed pans stored in the 3 tier shelves cart. All the pans were stacked together and were stored wet, and drops of water noted from inside the pans. -walk in cooler showed 2 large pitchers of orange colored beverage with no label. -walk in freezer showed a large bag, open and no label. Also found staff lunches (yogurts and lunch bag) next to pan of oatmeal for the residents. V15 said staff lunches should be placed on the designated refrigerator for employees and not mixed with residents' food. -walk in freezer showed a large bag of round deli meat that was unlabeled -side of oven next to flat top stove had heavy buildup of debris -dry storage area showed open bag of undated elbow macaroni. On September 16, 2024, a quick tour for second time in the kitchen was made. There were 2 large plastic bucket containers on the food preparation area. These 2 large bucket containers were stacked together and were wet. V15 was aware, and said same buckets were used for mixing beverages. On September 17, 2024, at 10:00 AM, during the observation for the pureed diet preparation, V14 145045 Page 11 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (Cook) had pureed eggs for egg salad sandwich. V14 took a quart size stainless pan from the 3 tier shelves cart. The quart sixe was stored together with other pans that were stacked together. There were drops of water from the pans that were stacked wet. V14 used the quart size pan that was stored wet and not air dried. On September 17, 2024 at 10:15 AM, together with V15, the walk-in cooler was checked. There were 2 staff lunches still stored in the residents' food area. V15 said these employee lunches should be stored in the staff lounge refrigerator. Facility Policy titled Major Kitchen and Floor Cleaning (undated) included as follows: Policy Statement: The Dining Services Department will keep the kitchen maintained in good condition . ensuring is kept cleaned, sanitize . Facility policy titled Air Drying Tableware and Utensils (undated) included as follows: Policy Statement: Food is stored, prepared, distributed and served under sanitary condition .Once utensils are clean and sanitized, they are allowed to air dry . Facility policy titled Labeling and Dating: Air Drying Tableware and Utensils (July 30, 2023) included as follows: Policy Statement: Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use .label includes: name of food item; discard date . Facility policy titled Staff Personal Food Storage dated June 14, 2019, included as follows: Policy Statement:1. Food brought in by staff will be in by staff shall be stored in designated areas only .1. Food brought in by staff will be identified with name of owner and date placed in designated refrigerator. 145045 Page 12 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow their water management plan for Legionella. Residents Affected - Many This applies to all 87 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated September 16, 2024, at 11:50 AM, showed the facility census was 87 residents. On September 18, 2024, at 9:02 AM, V18 (Maintenance Director) said he has been in charge of the monitoring for the water management plan for Legionella for about two months. V18 continued to say he is supposed to check water temperatures including the hot water tank weekly, but V18 has not started monitoring or logging the temperatures yet. V18 said chlorine testing of the water is supposed to be performed, but he has not started testing yet. V18 said the facility has two eye wash stations. V18 continued to say he has only cleaned and tested the eye wash stations to ensure the caps come off twice in the past two months. V18 said he does not flush the eye wash stations. On September 18, 2024, at 9:09 AM, in the laundry room, V18 demonstrated how he tests the eye wash stations. V18 turned the water on and within five seconds the caps came off the eye wash station, and V18 turned the water off. V18 did not flush the eye was station for two minutes. On September 18, 2024, at 11:45 AM, V1 (Administrator) said V18 has been monitoring the water management plan for legionella for about two months. V1 continued to say the facility does not have any documentation of monitoring of the water management plan for Legionella, including temperature gauge checks and chlorine testing. V1 said the expectation is V18 completes the monitoring required in the water management plan for Legionella. On September 18, 2024, at 2:01 PM, V1 said the facility just received chlorine testing kits to start performing chlorine level tests. The facility's Water Management Plan, revised on July 23, 2024, showed the facility's Hazard Analysis of the facility's Cold Water Distribution was Risk Basis: Medium Risk: Based on the potential variable chlorine present in the cold-water supply, the potential for microbiological growth is reduced compared to a hot water system. The factors for microbiological growth in conjunction with the potential for water to be aerosolized present a medium risk at this processing step. In addition, distribution piping materials vary based on the various building ages and construction practices. Controls: 1. Systematic water flushing to move disinfectant through the piping system. 2. Emergency disinfection when indicated by added secondary disinfection to the cold-water system. 3. Temporary utilization of Point of Use Filters when indicated. 4. Identify, remove and/or mitigate potential dead-legs and/or cross connections that may exist within the distribution system. 5. Identify, remove and/or mitigate aerators/faucet flow restrictors that may exist within the distribution system. The Plan continued to show the Cold Water Distribution's Critical Control Limit was Potable Water Oxidant: 'Free' Chlorine 0.2 to 4.0 ppm (Parts per Million); monitoring: Free Residual Oxidant Check (Chlorine); Frequency: weekly; Limit Deviation Corrective Action: Vacant resident care areas or any other area/room with plumbing fixtures are to be manually flushed for two minutes every day. The Plan continued to show the facility's Hazard Analysis of the facility's Hot Water Tank Heater and/or Hot Water 145045 Page 13 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Storage, MV Mixing Valve was High Risk: There is potential for microbiological growth at the heating step. This is reduced at temperatures greater than 124 degrees Fahrenheit. Elevated temperatures targets also present a noticeable scalding hazard. These factors provide further reason why maintenance of the target temperatures are an essential control measure. Controls: 1. Adjust temperature to provide further microbiological control and prevent scalding. The Plan showed the Critical Control Limit was Hot Water Storage: Domestic Tanks- not less than 140 degrees Fahrenheit. Mixing valve to prevent scalding and to deliver water between 100 degrees Fahrenheit and 110 degrees Fahrenheit. Deliver water to kitchen/laundry not less than 140 degrees Fahrenheit; Monitoring: Temperature gauge check; Frequency: Daily. The Plan continued to show the facility's Hazard Analysis for Emergency Eye Wash was Medium Risk: The Emergency Eye Washes and Showers are usually classified as medium risk due to the rarity of their use and the specific situation when they are used. Controls: 1. Monthly Preventative Maintenance/Testing of Emergency Eye washes and showers. The Plan showed Emergency Eye Wash: Critical Control Limit: Perform Regular Flushing; Monitoring: Manually flush for two minutes; Frequency: weekly. The facility does not have documentation to show monitoring was completed for the water management plan for Legionella. The facility's undated policy titled Water Management Program Policy showed General: Facility will participate in the Water Management Program described below to prevent introduction and growth of Legionella in the facility environment. All facilities have been identified as increased risk due to: Patient/residents staying overnight; Treatment of chronic/acute medical problems or weakened immune systems; Patients/residents 65 years and over. Responsible Party: Administrator; Maintenance Supervisor; Housekeeping/Laundry Supervisor; Regional Director of Operations. Assessment: 1. Complete facility legionella environment assessment. Testing: .3. The Maintenance Supervisor will test the potable water system as required for residual chlorine at no less than four locations using test kit provided. Prescribed locations for monthly testing include: Source Water Tank; Hot water holding tank; A random resident faucetHot water; A random resident shower- handheld or fixed shower head- Hot water. 4. A reading of 0.4 to 1.0 at the cold water main site and 0.2 to 1.0 at the hot water holding tank and the hot water resident tap locations listed above is considered a safe residual for controlling legionella bacteria growth. 5. If chlorine levels at the end points (faucets/tubs/showers) are below 0.2 the following actions are necessary: Flush the sample point for 10 minutes and retest. Test other sources in the general are- adjacent rooms. Note results on log; If low levels continue notify the facility Water Quality Management Team and share results on log sheet. The Water Quality Management Team will contact the licensed contractor to formulate remedy action for low levels; All points will be retested to assure remedy action is effective . Program Monitoring and Documentation: 1. The Maintenance Supervisor will fill out the water management log sheets . As of September 18, 2024, at 2:01 PM, the facility did not have completed water management log sheets. 145045 Page 14 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0887 Level of Harm - Minimal harm or potential for actual harm Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to develop and implement a COVID-19 immunization policy for staff and residents. Residents Affected - Many This applies to all 87 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated September 16, 2024 at 11:50 AM, showed the facility census was 87 residents. On September 16, 2024, at 10:00 AM, V1, Administrator, was requested to provide a COVID-19 immunization policy and procedure. As of September 19, 2024, at 3:00 PM, the facility had not provided a COVID-19 immunization policy and procedure despite multiple requests. The facility provided a policy titled COVID-19 Guidance, dated May 25, 2023, which showed .b. Vaccinations: Facility will encourage residents, staff, and families to remain up to date with COVID-19 vaccination, including all eligible booster doses. 4. Reporting of Staff and Resident COVID-19 Vaccinations and Testing: Facility will continue to report SARS-CoV-2 infection and vaccination data to the National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module . The facility's policy does not include the following: procedures for offering the COVID-19 vaccine to residents and staff members; providing education to residents and staff members regarding the benefits, risks, and potential side effects associated with the vaccine; allowing the resident or staff member the opportunity to accept or refuse the COVID-19 vaccine; and the required documentation in the resident's medical record. On September 18, 2024, at 10:00 AM, V3 (Assistant Director of Nursing/Infection Preventionist) said it is her understanding the facility does not offer the COVID-19 vaccine to staff members without health insurance. V3 continued to say these staff members are expected to receive the vaccine on their own. V3 said the facility had a vaccine clinic in January 2024, and multiple staff members consented to receiving the COVID-19 vaccine, but were not able to receive the vaccine at the facility because they did not have health insurance. V3 said corporate told her the staff without health insurance cannot receive the vaccine at the facility, but V3 has been asking corporate to provide vaccination to staff members without health insurance. On September 18, 2024, at 11:16 AM, V19 (CNA/Certified Nursing Assistant) said she requested to receive the COVID-19 vaccine at the facility's January 2024 vaccine clinic. V19 continued to say she did not get the COVID-19 vaccine at the facility, and had to go to a pharmacy and pay to receive the vaccine, because she does not have health insurance. On September 19, 2024, at 9:48 AM, V3 said the provided list showed the highlighted staff members who requested to receive the COVID-19 vaccine at the facility, but were not able to due to not having health insurance. 145045 Page 15 of 16 145045 09/19/2024 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0887 The list showed eight employees requested the COVID-19 vaccine at the January 2024 vaccine clinic, but did not receive the vaccine at the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 145045 Page 16 of 16