Health inspection·April 22, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms and hallways were adequately cleaned and free of debris and urine odors, and failed to follow the facility's policy to deep clean each resident room at least once every quarter. This applies to all 79 residents residing in the facility. The findings include: The Facility Data Sheet, dated April 21, 2025, shows 79 residents reside in the facility. 1. On April 21, 2025 at 10:03 AM, upon entrance to the facility and while walking in the resident hallways, a strong urine odor was present throughout the facility. The white/light gray tiled section of the hallway near R8 and R9's room, in front of the nurse's station, appeared dirty with multiple black/brown marks and smudges. Multiple trash receptacles and soiled linen receptacles in the hallway where R8 and R9 reside were full, and some old meal trays were sitting on top of the trash receptacles. 2. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, dementia, hypertension, insomnia, adult failure to thrive, falls, lack of coordination, and difficulty walking. R1's MDS (Minimum Data Set), dated March 21, 2025, shows R1 is rarely/never understood, has moderate cognitive impairment, requires setup assistance with eating and personal hygiene, and supervision with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. On April 21, 2025 at 10:24 AM, R1 was sitting up in a wheelchair in her room. R1 was unable to answer questions regarding the condition of her room. On the floor near R1's bed was a piece of dark brown wood, possibly from the headboard of R1's bed. Also, on the floor near R1, was a piece of plexiglass, approximately 18 to 24 inches long by 4 inches wide. The plexiglass appeared to be from an overhead lighting fixture. Multiple wadded up paper towels, medication cups, and food debris was strewn on the floor near R1. On April 21, 2025 at 1:31 PM, R1 was transferring herself from her wheelchair to her bed without staff present to assist her. Copious amounts of food debris, including dark brown food crumbs littered the floor around R1's wheelchair and the seat of R1's wheelchair. Multiple clear, plastic food wrappers were strewn around R1's bed and wheelchair. Page 1 of 3 145045 145045 04/22/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, atrial fibrillation, anemia, PVD (Peripheral Vascular Disease), congestive heart failure, lymphedema, cardiac arrhythmia, muscle wasting and atrophy, difficulty walking, lack of coordination, repeated falls, and overactive bladder. R3's MDS, dated [DATE], shows R3 has severe cognitive impairment, requires setup assistance with eating, partial/moderate assistance with oral and personal hygiene, and substantial/maximal assistance with all other ADLs. R3 is frequently incontinent of bowel and bladder On April 21, 2025 at 10:33 AM, R3 was sitting up in her wheelchair in the hallway just outside of her room. The floor in the hallway just outside of R3's doorway was filled with clutter, including the support legs from another resident's wheelchair, paper wrappers from drinking straws, full trash bins, and crumpled paper towels. The hallway floor appeared dirty and smudged with a black substance. Food debris was present on the floor. No housekeeping staff were observed sweeping or mopping the hallway floor. R3 pointed inside her room doorway and said her bed was located nearest to the door. Just inside R3's doorway, next to R3's bed on the floor, was a whole banana with a completely black banana peel, multiple foil-wrapped candies, and an empty plastic drinking cup, turned on its side, as well as food debris. R3 said, Oh, if I leave my room, someone will come in here and clean it up sometime today. 4. The EMR shows R4 was admitted to the facility on [DATE], with multiple diagnoses including wedge compression fracture of T11-T12 vertebra, cirrhosis of the liver, schizoaffective disorder, dementia, gallbladder disease, psychosis, and history of falling. R4's MDS dated [DATE], shows R4 is rarely/never understood, has moderate cognitive impairment, requires setup assistance with eating, partial/moderate assistance with oral and personal hygiene, substantial/maximal assistance with toilet hygiene, showering, and lower body dressing, and dependent on facility staff for bed mobility, and transfers between surfaces. R4 is frequently incontinent of urine, and always incontinent of stool. R4's care plan for potential for falls, initiated on November 9, 2024, shows multiple interventions, including, rooms and hallways should be clutter-free. Floors and surfaces should be clean and dry. On April 21, at 10:25 AM, R4 was walking in the hallway outside of her room. R4 had multiple bed blankets stacked up on her walker as she was walking towards her room. There was debris on the floor in the hallway outside of R4's room, which R4 had to step over to walk into her room, including a crumpled brown paper towel, multiple small medication cups, a torn plastic bag, and copious amounts of a crumbled dark black substance, which appeared like dried, caked mud from the bottom of someone's shoes. Once R4 entered her room, she took the blankets she was carrying on her walker and placed the folded blankets on almost every surface in her room, including the heating/air conditioning unit on the wall. The garbage can in R4's room was overflowing, and small medication cups were littered on the floor of her room next to the garbage can. 5. On April 21, 2025 at 2:15 PM, R5 said she is the Resident Council President, and has resided at the facility for many years. R5's room had a lot of personal clutter from the many personal items R5 preferred to keep in her room. R5's floor had debris on the floor and appeared to need sweeping. R5 said, There used to be a great housekeeper here named (V13). I don't think she works here anymore. Since she left, my room has not been kept clean. I really miss her. 145045 Page 2 of 3 145045 04/22/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 6. On April 21, 2025 at 12:52 PM, the floor in R6's room had a large area, approximately six to eight feet in diameter of a dark brown, crumbled food item. R6 was not in the room at the time. R6's half-eaten lunch meal tray had a few pieces of chocolate brownie remaining on the tray. 7. On April 21, 2025 at 10:23 AM, R7 was lying in bed in his room. R7 was lying directly on the low air loss mattress. No sheets were on the bed. Three white sheets were crumpled in [NAME] on the floor of his room and food debris was on the floor. On April 21, 2025 at 1:08 PM, V3 (Housekeeping Director) said, Most of the residents eat in their rooms. There are 52 rooms in the facility. After each meal, the housekeeping staff has to go to each resident room to sweep. We have three housekeepers here right now to clean the resident rooms, and a person to clean the hallways, and help me with maintenance. We clean/buff the hallway floors two times a month. It was done three weeks ago. We do a deep clean of one room per week. On April 21, 2025 at 1:35 PM, V10 (Housekeeper) said she was responsible for cleaning resident rooms only, and was not assigned to clean resident hallways. On April 22, 2025 at 10:53 AM, V1 (Administrator) and V3 (Housekeeping Director) said the facility does a deep cleaning of one resident room per week, so each room gets deep cleaned one time per year. V3 corrected his previous statement and said the facility has 56 resident rooms, not 52 as stated on April 21, 2025. V1 (Administrator) said the facility does not have documentation to show each resident room is deep cleaned at least quarterly as shown in the facility's policy. V3 continued to say the facility has one person assigned to clean the hallways and empty hallway trash receptacles, another person to clean the public restroom, showers, internet café area, and dining room, and assist with maintenance, and a total of three housekeepers, each assigned to one of the three resident hallways. The housekeepers assigned to a block of rooms in a resident hallway are responsible to clean inside the resident rooms, including sweeping the floors in those resident rooms. V3 said the staff member (V11) assigned to clean the hallway floors did not work on April 20 or 21, 2025. V12 (Housekeeper) was expected to clean the hallway floors as well as his other duties of picking up hallway trash, cleaning the public restroom, showers, internet café area, and dining room. V1 (Administrator) said V13 (Housekeeper) has taken a medical leave and only works at the facility sporadically. The facility does not have documentation to show monthly cleaning schedules for quarterly deep cleaning of each resident room. The facility does not have documentation to show the use of audit tools to ensure compliance with the facility policy. The facility's policy entitled Physical Environment, adopted 07/11/2018, shows, Policy: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Procedures: 1. Routine Deep Cleaning: A. Each resident room will be deep cleaned at least once every quarter. B. A cleaning schedule shall be developed at the beginning of each month by the Housekeeping Supervisor. C. Schedule considerations include room occupancy, resident needs, and staff availability.10. Post-Cleaning Procedures: .C. Document the completion of cleaning, including the date, time, and staff involved in the housekeeping log.12. Training and Accountability: A. All housekeeping staff shall receive training on deep cleaning procedures and infection control practices. B. The Housekeeping Supervisor will conduct regular audits to ensure compliance with the policy . 145045 Page 3 of 3