Health inspection·February 2, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an environment where residents are treated with dignity and respect and requests for care are honored. This applies to 2 of 3 residents (R1 and R3) reviewed for ADLs (Activities of Daily Living) in the sample of 6. The findings include: 1). The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnosis including ALS (Amyotrophic Lateral Sclerosis), ulcerative colitis, juvenile myoclonic epilepsy, benign prostatic hyperplasia without lower urinary tract symptoms, generalized anxiety disorder, and essential hypertension. R1's MDS (Minimum Data Set), dated January 1, 2025, showed R1 was cognitively intact and required assistance with ADLs partial assistance with eating, upper body dressing, and personal hygiene, substantial assistance with lower body dressing, bathing, tub transfer and toileting and dependent on staff for bed mobility and transfer. The mobility device is listed as a wheelchair. On February 1, 2025, at 12:26 PM, R1 stated he used to get around the facility in his electric wheelchair, but he has not gotten out of bed into his chair since October 31, 2024. R1 stated he is tired of just lying in the bed and only gets out of bed by a gurney to go to medical appointments. R1's electric wheelchair was sitting in his room. R1 stated it is more difficult for him now to manage the control on the wheelchair, but he is still capable of sitting in his chair and staff could assist him to maneuver the wheelchair until his rehabilitation clinic provided an adaptation to the control. R1 also expressed frustration that staff don't even offer to assist him to get out of bed. R1 stated none of his health care providers have told him he could not get out of bed. R1 also stated last Sunday early morning around 6:00 AM, V8 (Certified Nursing Assistant/CNA) and V9 (CNA orientee) provided incontinence care to R1. R1 stated he told them he did not feel clean. R1 stated V8 told him their shift was over and they had to leave, leaving R1 soiled. R1 also complained R2 closed his door during the night shift on January 23, 2025, and he waited a long time for his call light to be answered because R1 wasn't sure if the call light was working. R1 had an adaptive call light that activates when R1 touches the pad with his head. R1 stated he reported to V11 (CNA) and V13 (CNA) while they provided care to him during the evening shift on January 24, 2025. The staff schedule showed V8 was assigned to R1 during the overnight shift January 25, 2025, and V9 was also working that shift. Page 1 of 9 145045 145045 02/02/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0550 The staff schedule showed V11 was assigned to R1 on the evening shift of January 24, 2025. Level of Harm - Minimal harm or potential for actual harm On January 31, 2025, at 4:34 PM, V11 stated while he and V13 were providing care, R1 reported R2 closed the door to his room during the previous night shift. V11 stated R1 was really upset he was left behind a closed door, and was anxious while telling V11 about it. Residents Affected - Few On February 1, 2025, at 10:58 AM, V13 stated she did assist V11 with R1's care on January 24, 2025, during the evening shift, and R1 did report R2 had closed the door on R1 during the previous overnight shift. On February 1, 2025, at 12:16 PM, R2 stated he did close R1's door during the overnight shift on January 23, 2025. R2 stated he closed R1's door because he was yelling for the staff to come and help him. Review of R1's current physician order summary showed R1 did not have an order for bedrest. R1's orders showed R1 was able to go out on pass with supervision and medications. R1's medical record contained an after-visit summary from the rehabilitation outpatient clinic dated December 3, 2024, that showed R1 needed an appointment to be scheduled at the clinic for a wheelchair evaluation and adjustment of the controller. The facility did not provide documentation the appointment was scheduled when requested. On February 1, 2025, at 3:37 PM, in response to the request for the scheduling of the wheelchair clinic appointment, V1 stated the facility's maintenance staff repaired R1's wheelchair. V18 (Maintenance Director) explained he repaired R1's wheelchair. V18 stated R1's wheelchair is in good repair and able to be used. V18 stated there is also an alternative wheelchair with supportive seating available for use already in the facility that R1 could use. V18 stated he used to see R1 out of bed and going all around the facility and that made R1 happy. V18 stated he has not seen R1 out of bed for months. 2). R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including asthma, heart failure, type 2 diabetes, obesity (severe), autonomic neuropathy in diseases classified elsewhere, primary osteoarthritis of both right and left knees, and acquired absence of kidney. R3's MDS, dated [DATE], showed R3 was cognitively intact and required assistance with ADLs including set up assistance with eating, oral hygiene, and personal hygiene, supervision with upper body dressing, substantial assistance with dressing, and dependent on staff for toileting, bathing, bed mobility and transfer. On January 31, 2025, at 1:24 PM, R3 identified herself as the Resident Council President. R3 stated she does not like to complain because she does not want staff to be mad at her. R3 stated because she is the Resident Council President, other residents come and complain to her regarding care. R3 was unable to provide specific dates or times of recent complaints from residents. R3 stated she was upset recently regarding not being provided incontinence care when she needed it, and not being provided with a shower and getting her hair washed for over a week. R3 stated on the evening and night shift beginning on January 29, 2025, R3 asked V14 (CNA) to provide her with incontinence care after her zoom meeting call ended at 8:30 PM. R3 stated at 9:00 PM, she put on her call light to request assistance with incontinence care, but no staff came, and V14 did 145045 Page 2 of 9 145045 02/02/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not return to R3's room. R3 stated V15 (CNA) came to her room around 10:00 PM, and R3 asked V15 to change her. R3 stated V15 did not change R3 until 5:30 AM on January 30, 2025. R3 stated V15 told her she would not change her at the beginning of her shift because she would not do the work the second shift was supposed to do. V15 declined to be interviewed during this investigation. On February 1, 2025, at 1:58 PM, V1 (Administrator) stated staff should be treating residents as if they are family members, with respect. The facility's policy titled Activities of Daily Living: dated October 22, 2024, showed Policy Statement: Facility ensures that residents receive ADL assistance and maintains the resident's safety and dignity .Procedures 6. Assist the resident to be clean, neat and well groomed . 8. Resident will be up out of bed dressed as per the resident's choice.13. Patient Dignity will always be maintained. 145045 Page 3 of 9 145045 02/02/2025 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 provide assistance to residents with ADLs (Activities of Daily Living), specifically incontinence care and bathing, in accordance with resident needs and as outlined in their policy. Residents Affected - Some This applies to 4 of 4 residents (R1, R3, R5 and R6) reviewed for ADL care in the sample of 6. The findings include: 1). R6's EMR (Electronic Medical Record) showed R6 was admitted to the facility on [DATE], with multiple diagnoses including encounter for orthopedic after care following surgical amputation, type 2 diabetes with foot ulcer, acquired absence of left above knee, peripheral vascular disease, obstructive sleep apnea, and other disorders of the nervous system. R6's MDS (Minimum Data Set), dated January 6, 2025, showed R6 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, supervision with personal hygiene, substantial assistance with bathing, and dependent on staff with lower body dressing, toileting, bed mobility, and transfer. On January 31, 2025, at 3:26 PM, V17 (Certified Nursing Assistant/CNA) was observed giving incontinence care to R6. R6's brief was saturated; the indicator lines had disappeared from the brief indicating excessive wetness. V17 validated R6's brief was saturated. R6's perianal and posterior upper left thigh skin was pink under white cream. R6 stated the area under his left upper posterior thigh felt like it was burning. R6 stated he had not been changed since earlier that morning. R6 also stated he did not get the shower that was scheduled for that day during the AM shift. R6 stated the CNA on the day shift told R6 he would be getting a shower that day, and then came back around 1:30 PM and told R6 the scheduled had been changed, and R6 would not be getting his shower as scheduled. V17 was asked how showers are documented as given. V17 stated showers are documented in the POC (Point of Care) task in PCC (Point Click Care), the EMR software. On February 1, 2025, at 1:58 PM, V2 (Director of Nursing/DON) stated she was not aware of any schedule or assignment change on January 31, 2025, day/AM shift. V2 stated if a shower is missed as scheduled, it should be done on the next shift. The POC task documentation showed R6 did not receive a shower on Friday January 31, 2025. The facility's shower schedule, dated December 6, 2024, showed R6 was scheduled for a shower on Friday AM shift and Tuesday PM shift each week. 2). R1's EMR showed R1 was admitted to the facility on [DATE], with multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), ulcerative colitis, juvenile myoclonic epilepsy, benign prostatic hyperplasia without lower urinary tract symptoms, generalized anxiety disorder, and essential hypertension. R1's MDS, dated [DATE], showed R1 was cognitively intact and required assistance with ADLs partial assistance with eating, upper body dressing, and personal hygiene, substantial assistance with lower body dressing, bathing, tub transfer and toileting and dependent on staff for bed mobility and transfer. 145045 Page 4 of 9 145045 02/02/2025 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 On February 1, 2025, at 12:26 PM, R1 stated he had not been getting his showers as scheduled, especially in early January. R1 stated he prefers a shower to a bed bath, and has his own sling for the full mechanical lift device used to transfer R1 to the shower gurney. R1 stated he does not feel clean after a bed bath, and has not had a shower, only a bed bath offered to him. R1's bathing POC documentation January 2025, showed R1 did not receive a shower until January 9, 2025, and the next documented shower was January 20, 2025. The facility's shower schedule, dated December 6, 2024, showed R1 was scheduled to receive showers on Monday AM shift and Thursday PM shift each week. 3). R5's EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure, unspecified, type 2 diabetes with diabetic polyneuropathy, unspecified asthma, mild protein calorie malnutrition, obstructive and reflux uropathy, and adult failure to thrive. R5's MDS, dated [DATE]. 2024, showed R5 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, partial assistance with personal hygiene, substantial assistance with toileting, bathing, dressing, and bed mobility, dependent on staff for transfer. On January 31, 2025, at 3:11 PM, R5 stated she does not get the assistance she needs with showers. R5 stated she does not get a shower when scheduled. R5's POC documentation for the past 30 days for showers, showed R5 received one shower on January 14, 2025. Not applicable is documented on January 4, 2025 and January 19, 2025. There is no documentation regarding showers after January 21, 2025. According to the facility shower schedule, dated December 6, 2024, R5 is scheduled for a shower on Saturday AM shift and Tuesday PM shift. 4). R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including asthma, heart failure, type 2 diabetes, obesity (severe), autonomic neuropathy in diseases classified elsewhere, primary osteoarthritis of both right and left knees, and acquired absence of kidney. R3's MDS, dated [DATE], showed R3 was cognitively intact and required assistance with ADLs including set up assistance with eating, oral hygiene, and personal hygiene, supervision with upper body dressing, substantial assistance with dressing, and dependent on staff for toileting, bathing, bed mobility and transfer. On January 31, 2025, at 1:24 PM, R3 stated she is the Resident Council President. R3 stated she had a concern about incontinence care not being done timely, and not getting a shower and hair washed when scheduled. R3 stated on the evening and night shift beginning on January 29, 2025, R3 asked V14 (CNA) to provide her with incontinence care after her zoom meeting call ended at 8:30 PM. R3 stated at 9:00 PM, she put on her call light to request assistance with incontinence care, but no staff came, and V14 did not return to R3's room. R3 stated V15 (CNA) came to her room around 10:00 PM and R3 asked V15 to change her. R3 stated V15 did not change R3 until 5:30 AM on January 30, 2025. R3 stated she did not get her shower and hair washed last week. R3's POC documentation for showers showed there was no documentation of a shower being given to R3 145045 Page 5 of 9 145045 02/02/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0677 between January 17 and January 27, 2025. Level of Harm - Minimal harm or potential for actual harm According to the facility shower schedule, dated December 6, 2024, R3 is scheduled for shower on Thursday AM shift and Monday PM shift. Residents Affected - Some The facility's policy titled Activities of Daily Living Support, dated July 24, 2024, showed, Policy statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs .in accordance with the plan of care including assistance with Elimination (Toileting) .Showers/bathing will be provided at least weekly, PRN, and or based on resident preferences .Documentation and Record facility staff will record showers on the shower sheet or POC after showers are given. 145045 Page 6 of 9 145045 02/02/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide staff in sufficient quantity to meet the residents' bathing, incontinence, and mobility care needs, and ensure timely answering of call lights during the evening and night shifts. This applies to 4 of 5 residents (R1, R3, R5, R6) reviewed for ADL care in the sample of 6. The findings include: The Facility Data sheet completed by V1 (Administrator), dated January 31, 2025, showed the facility census was 87. The Resident Council Meeting Minutes of November 22, 2024, showed one member requested more staff were needed each shift. The minutes reflect V1's (Administrator) response indicated it was quality of staff not quantity of staff the facility was looking for. On January 31, 2025, at 12:50 PM, V4 (Staff Scheduler) stated the staffing pattern included CNAs (Certified Nursing Assistants) work 8-hour shifts, and Nurses work 12-hour shifts. V4 stated there are 3-4 scheduled CNAs for the overnight shift (10PM-6AM), and 5-6 CNAs scheduled for the evening shift (2PM-10 PM) and 6-7 CNAs scheduled for the day shift (6AM-2:00 PM). Review of the schedules as worked from January 23, through January 31, 2025, showed over the course of 9 days: The CNAs for the evening shift worked with 4 staff on 4 out of 9 days and worked with 5 staff on 5 out of 9 days. During the evening shift, 4 of 9 shifts worked with less than the staffing pattern described by V4. During the overnight shift, 10 PM-6 AM, 5 out of 9 days worked with 3 CNAs, and 4 out of 9 shifts worked with 4 CNAs. Based on the resident census of 87, the CNA ratio of staff to residents on the overnight shift for 4 staff was 1:22 and 3 staff 1:29. 1). R1's MDS (Minimum Data Set), dated January 1, 2025, showed R1 was cognitively intact and required assistance with ADLs partial assistance with eating, upper body dressing, and personal hygiene, substantial assistance with lower body dressing, bathing, tub transfer and toileting and dependent on staff for bed mobility and transfer. The mobility device is listed as a wheelchair. On February 1, 2025, at 12:26 PM, R1 stated he used to get around the facility in his electric wheelchair, but he has not gotten out of bed into his chair since October 31, 2024. R1 stated when he asks staff to get him out of bed, staff tell him it takes too long to get him up and they don't have time. R1 stated his son brings him water and keeps it in R1's bedside refrigerator, and staff appreciate that because when R1 asks for water, the staff don't have to walk so far to bring the water to him. R1 stated he doesn't get showers because staff tell him they don't have time. During the night shift of January 23, 2025, R1 stated he waited an extended period for his call light to be answered and a resident peer closed the door to his room, which made him feel unsafe. On February 1, 2025, at 3:37 PM, V18 (Maintenance Director) stated R1's wheelchair is in good repair and able to be used. V18 stated there is also an alternative wheelchair with supportive seating available for use already in the facility that R1 could use if needed. 145045 Page 7 of 9 145045 02/02/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0725 R1's wheelchair was parked in his room. Level of Harm - Minimal harm or potential for actual harm R1's POC (Point of Care) documentation showed R1 did not receive a shower between January 9, 2025, and January 20, 2025. Residents Affected - Some On February 1, 2025, at 12:15 PM, R2 stated he did close the door to R1's room during the night shift on January 23, 2025. R2 stated he closed R1's door because R1 was yelling for staff to help him. The staffing schedule, dated January 23, 2025, showed there were 3 CNAs working the night shift. 2). R3's MDS, dated [DATE], showed R3 was cognitively intact and required assistance with ADLs including set up assistance with eating, oral hygiene, and personal hygiene, supervision with upper body dressing, substantial assistance with dressing, and dependent on staff for toileting, bathing, bed mobility and transfer. On January 31, 2025, at 1:24 PM, R3 identified herself as the Resident Council President. R3 stated she waited over an hour for her call light to be answered on January 29, 2025. R3 requested V14 to provide incontinence care during the evening shift on January 29, 2025. The schedule dated January 29, 2025, showed V14 worked both the evening and night shift that day. R3 stated she was not provided incontinence care by V14. 3). R5's MDS, dated [DATE]. 2024, showed R5 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, partial assistance with personal hygiene, substantial assistance with toileting, bathing, dressing, and bed mobility, dependent on staff for transfer. On January 31, 2025, at 3:11 PM, R5 stated she does not get the assistance she needs with showers. R5 stated she does not get a shower when scheduled. R5's POC documentation for the past 30 days for showers, showed R5 received one shower on January 14, 2025. According to the facility shower schedule, dated December 6, 2024, R5 is scheduled for a shower on Saturday AM shift and Tuesday PM shift. R5's shower was scheduled to be given on January 25, 2025, on day shift and January 28th PM shift. The staffing assignment sheet for January 25, 2025, day shift showed there were 6 CNAs assigned for that shift. The staff assigned to give R5 a shower had a total of 4 showers assigned to be given. No other staff were assigned to give 4 showers that shift. Of the remaining staff, on that shift, 2 were assigned 1 shower, 2 were assigned 2 showers, and 1 was assigned 3 showers. R5 did not receive a shower that shift. The staffing assignment shift, dated January 28, PM shift, showed there were 5 CNAs assigned to that shift. The staff assigned to give R5 a shower had 4 showers assigned to give that shift. Of the remaining staff, 3 staff had 3 showers assigned to give and 1 staff assigned to 2 showers. The staff assigned to R5 had 17 assigned residents to care for and 4 showers to give. R5 did not receive a shower that shift. 4). R6's MDS (Minimum Data Set), dated January 6, 2025, showed R6 was cognitively intact and 145045 Page 8 of 9 145045 02/02/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some required assistance with ADLs including set up assistance with eating, and oral hygiene, supervision with personal hygiene, substantial assistance with bathing, and dependent on staff with lower body dressing, toileting, bed mobility, and transfer. On January 31, 2025, at 3:26 PM, V17 (CNA) was observed giving incontinence care to R6. R6's brief was saturated, as validated by V17. R6 stated he had not been changed since earlier that morning. R6 also stated he was supposed to get a shower that day and did not receive a shower. The staffing assignment sheet, dated January 31, 2025, showed there were 7 CNA staff scheduled for the day shift. The staff assigned to R6 had 13 residents assigned to be cared for and 3 residents assigned to be given showers during that shift. R6 did not receive incontinence care, or a shower as needed that shift. On January 31, 2025, at 4:34 PM, V11 (agency CNA) stated he has been a CNA for 17 years and has worked in different facilities. R1 identified V11 as a CNA who takes good care of him. V11 stated compared to other facilities, the assignments at this facility are hard to give good care, because there are too many residents who need a lot of care assigned to one CNA. V11 stated he has spoken to colleagues who also work for the agency who stated working at the facility is a last choice due to the workload of the assignments. On February 1, 2025, at 10:58 AM, V13 (CNA) stated she works on a PRN (as needed) basis and finds the assignments keep her busy the whole shift and she rarely has time to take a break. V13 stated, at times, there is an inequity in the assignments, especially when it comes to shower assignments, as sometimes staff are assigned to 1 shower while other staff are assigned to 4 on the same shift. The facility policy titled Activities of Daily Living Support, dated July 24, 2024, showed, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs .including appropriate support and assistance with hygiene (bathing, dressing, grooming) Elimination (toileting). Documentation and Record Facility staff will record showers on the shower sheets and or POC after showers are given. 145045 Page 9 of 9