Health inspection·February 5, 2026

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on interview and record review, the facility failed to provide residents or their representatives with written notices for room changes. This applies to 5 of 5 residents (R1-R5) reviewed for resident rights.The findings include:1.On 2/04/2026 at 10:30 AM, R1 was in her room, upset. R1 said she moved into her current room without being notified for the reason of the move on 1/28/2026. R1 said she had been admitted to the facility in 2021 and had always resided in the same room. R1 said maintenance staff came to her room and started packing her personal belongings on 1/28/2026, and she became upset because she had not been informed prior to the room change. R1 said then the management staff came to her room and informed her that her daughter (V14) was notified of the room change. R1 said she made her own decisions and filed a grievance on 1/28/2026. R1 continued to say she was still so upset with the facility's failure to notify her prior to the room change and was still unsure why she was moved. On 2/04/2026 at 12:30 PM, V12 (Maintenance Director) said on the morning of 1/28/2026, he was informed to assist in R1's room move. V12 said when he started to move R1 in the afternoon, she became very upset and yelled for an explanation regarding her decision to be moved. V12 said he immediately stopped and informed V10 (Social Worker Director/SWD) and V11 (Admissions Director) of R1's concern. V12 said after V10 and V11 spoke to R1, she agreed to the move but was still upset.R1's Grievance form, dated 1/28/2026, said, Resident questioned the reason for the room change. The form said V10 (Social Worker Director) and V11 (Admissions Director) met with R1 and explained the reason for the move and that V14 (R1's Family Member) was also notified of the resolution.On 2/04/2026 at 11:40 AM, V11 (Admissions Director) said the facility was scheduled to start remodeling in the unit where R1 previously resided, and management had decided she had to be moved to another room. V11 said she was not aware of the facility's process for notifying residents or representatives regarding room changes. V11 said she believed V10 (Social Worker Director/SWD) had notified V14 (R1's daughter) prior to the change. V11 said she assisted in explaining the reason for the room change to R1 during the move.On 2/04/2026 at 1:45 PM, V10 (SWD) said she contacted V14 prior to the room change, and V14 agreed as long as R1 approved the room change. V10 said during the room change, she responded to R1's grievance regarding the move and explained to her the reason for the move. V10 said then R1 agreed to the room change. V10 said she was not aware of V14's emailed grievance to V1 (Administrator) requesting a further explanation regarding the reason for R1's room change on 1/29/2026. V10 said she was also not aware of the facility's policy regarding the need to provide residents or their representatives with a written notice regarding room changes, prior to the move. V10 said she only obtained verbal consents for room changes and never notified the new roommates of the change. V10 said R1 was cognitively intact and able to make her own decisions. V10 said residents had the right to be informed of their room changes prior to the move and explained the reason for the move.V10's social service note, dated 1/28/2026 at 4:50 PM, said she contacted V14 to obtain consent for R1's room change. V14's (R1's Family Member) e-mail grievance, dated Page 1 of 2 145045 145045 02/05/2026 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1/29/2026, said she had a concern regarding R1's room move. The e-mail said, Social worker stated she had spoken with [R1] and she was OK with moving to another room. Just after this call, [R1] called me very upset to tell me that your staff was present in her room and packing all of [R1's] belongings in boxes. She was unaware why they were doing this. This was very upsetting for [R1]. Your staff should have handled this better as big changes like this are very stressful for the elderly.2. On 2/04/2026 at 12:40 PM, V9 (Family Member) was visiting R2 (R1's roommate). V9 said R2 was nonverbal, and he was her Power of Attorney (POA). V9 said R2 was moved multiple times during her stay at the facility, and he never received a written notice prior to her room moves. V9 said last week during his daily visit, he noticed R1 had been moved to the room, and she was visibly upset regarding her move. V9 said he was also not made aware prior to R1 moving in.3. On 2/04/2026 at 12:45 PM, R3 was visibly upset in her room. R3 said on the evening of 1/30/2026 after bingo, she went to her room, and her bed was gone. R3 said she was extremely upset because the facility staff had moved her to another room without her knowledge. R3 said she had then informed her she was moved because her wound culture showed she had an infection and required her to be placed in Transmission-Based Precautions. R3 said most of her personal belongings were still in the other room. R3 continued to say the facility staff had still not informed her why she was not notified prior to her room change.4. On 2/04/2026 at 1 PM, R5 was in her room and said R4 (her roommate) had recently moved in. R5 said she was not notified prior to the room move. R5 said she was a long-term resident, and she wished her roommate was some she could talk to. R5 said it was upsetting because R4 was non-verbal. R4 was in bed and unable to be interviewed because she was non-verbal. R4's EMR (Electronic Medical Record) showed she moved in with R5 on 1/30/2026 and was severely cognitively impaired.On 2/04/2026 at 2 PM, V1 (Administrator) said the facility was scheduled to start remodeling resident rooms and residents were being moved within the facility. V1 said the facility was not following their notification policy regarding room moves; they were not providing residents or their representatives with written notices prior to and with an explanation for the move. V1 said residents and their representatives should be notified accordingly of room moves because it was their right to be informed of where they were moving within the facility.The facility's policy titled Resident Right- Choose/Be Notified of Room/Roommate Change, dated 5/01/2024, said the facility allowed the resident and or their legal representatives the right to choose a roommate, be notified of room changes, as well as roommate changes in such a manner to acknowledge and respect resident rights. The residents have the right to share a room with his or her roommate of choice when practicable, and both residents have to consent to the arrangement. The residents also have the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility changes. 145045 Page 2 of 2