Health inspection·February 6, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 ensure call lights were within reach for 5 of 8 residents (R2-R6) reviewed for call lights. Residents Affected - Some Findings include: 1) On 02/05/25 at 11:10 AM, R2 was in her bed. R2's call light was not visible, and R2 said she hadn't had a call light for at least a couple of months. R2 said she gets help when they make rounds, and having a call light for emergencies would be helpful. R2 confirmed knowing the function of call light and having the ability to use it appropriately. V4 (Director of Maintenance) and V5(Registered Nurse) witnessed R2 not having the working call light access. R2's EMR (Electronic Medical Records) showed R2 is a [AGE] year-old female, with diagnoses including diabetes, restless leg syndrome, spinal stenosis, intraverbal disc degeneration with back pain, and hypertensive cardiac diseases. R2's MDS (Minimum Data Set), dated 11/09/2024, showed R2 is cognitively intact and requires one person's assistance for activities of daily living. R2's Current care plan, dated 11/05/2024, showed R2 is a fall risk potential resident with a fall event on 11/08/2024, and intervention included the call light to be within reach of the resident. 2) On 02/05/2025 at 11:45 AM, R4 was in her bed. R4 did not have a call light, and R4 said she hadn't had one for a long time. R4 and R4's roommate said this problem is not new. R4 confirmed knowing the call light's function and ability to use it appropriately. V8 (Certified Nursing Assistant) said R4 had her call light within reach earlier, and she might have dropped it. V8 was asked to show the call light, and she was unable to show one. R4's EMR (Electronic Medical Records) showed R4 is a [AGE] year-old female, with diagnoses including diabetes type 2, hemiplegia, pathological fracture, and hypertension. R4's MDS (Minimum Data Set), dated 11/05/2024, showed that R4 is cognitively intact and requires supervision of one person's assistance for activities of daily living. R4's Current care plan, dated 02/01/2025, showed R4 is a potential fall risk resident due to hemiplegia and hemiparesis with a fall event on 10/12/2024, and intervention included the call light to be within reach of the resident. 3) On 02/05/2025 at 12:00PM, R3 was in the dining room, ambulating with a walker, said she is a roommate of R2, and they don't have call light access. R3 said when R2 (Roommate) had a fall, she had to come out of her room and scream for help. R3 said it has been reported, and nothing has been done yet. R3 confirmed knowing the function of the call light and being able to use it appropriately. R3 said if there are any emergencies that would be a problem. V4 (Director of Maintenance) witnessed not having the working call light for R3. Page 1 of 2 145045 145045 02/06/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R3's EMR (Electronic Medical Records) showed R3 is a [AGE] year-old female, with diagnoses including pain in both legs, abnormality of gait, cellulitis of left limb, history of falls, and hypertension. R3's MDS (Minimum Data Set), dated 02/28/2024, showed R3 is cognitively moderately intact and requires the supervision of one staff assistance for daily living activities. R3's current care plan, dated 12/20/2024, showed R3 is a fall-risk potential resident due to poor balance and unsteady gait. The intervention included the call light being within reach of the resident. 4) On 02/05/2025 at 12:27 PM, R5's call light was on the floor by the head end of R5's bedside. R5 was asked where R5's call light was, and how R5 called for help. R5 said, I don't know what to do, and confirmed knowing the function of the call light and using it appropriately. V2(Director of Nursing), V2(Assistant Director of Nursing), and V5(Registered Nurse) witnessed R5 not having the call light within reach. R5's EMR (Electronic Medical Records) showed R5 is a [AGE] year-old female, with diagnoses including hemiplegia, diabetes, cardiac disease, morbid obesity, and end-stage renal failure dependent on dialysis. R5's MDS (Minimum Data Set), dated 11/245/2024, showed R5 is cognitively intact and two persons maximum assistance for activities of daily living, including mobility and transfer. R5's care plan, dated 01/082024, showed R5 is a potential fall risk resident due to incontinence and muscle weakness, and intervention included the call light being within reach of the resident. 5) On 02/05/2025 at 2:00 PM, R6's call light was not visible, and R6 said she didn't know where it was. R6 confirmed knowing the function of the call light and using it appropriately. V5(Registered Nurse) witnessed the call light under the blanket, and not having a call light within reach of R6. R6's EMR (Electronic Medical Records) showed R6 is an [AGE] year-old female, with diagnoses including osteoarthritis, congestive heart failure, high blood pressure with low heart rate, and unsteady gait. R6's MDS (Minimum Data Set), dated 11/27/2024, showed R6 is cognitively moderately intact and one to two persons maximum assistance for activities of daily living, including mobility and transfer. R6's care plan, dated 11/26/2024, showed R6 is a fall risk potential resident with a recent incident dated 12/24/2024, and intervention included the call light being within reach of the resident. During an interview on 02/05/2025, at different times, V2 (Director of Nursing), V3(Assist Director of Nursing), V4 (Director of Maintenance), R5(Registered Nurse), and V8 (Certified Nursing Assistant) all indicated residents should have call light access. A policy titled Call Lights Use, revised on 06/2024, showed residents capable of using call lights appropriately will have call lights accessible at all times. Direct care staff will check these residents during check-and-change rounds and ADL care, and call lights will be checked by the maintenance director and maintained at least monthly and as needed. 145045 Page 2 of 2