Health inspection·March 27, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an alleged threat of harm made by a nurse toward a resident at the facility. This applies to 1 of 4 residents (R1) reviewed for abuse in a sample of 24. The findings include: Face sheet, dated 3/25/24, shows R1 was admitted to the facility on [DATE] and R1's diagnoses included polyneuropathy, spondylosis, regional pain syndrome, and osteoarthritis. On 3/20/24 at 1:55 PM, R1 stated late one night she was trying to turn her wheelchair around in her room and bumped the footboard of her roommate's bed. R1 stated V3 (Licensed Practical Nurse) entered her room and asked what R1 was doing. R1 stated she told V3 she was trying to turn around and accidentally bumped her roommate's footboard. R1 alleged V3 responded by saying it was no accident and if R1 bumped it again she would be harmed and harmed real bad. R1 stated she wanted to call the police because she felt threatened. On 3/20/24 at 9:30 AM, V1 (Former Administrator) stated R1 alleged V3 responded to R1's banging her wheelchair against her roommate's bed footboard and V3 was threatening to hurt R1. On 3/20/24 at 3:20 PM, V1 stated she did not call the police when she received R1's allegation or investigated the allegation because she did not get the impression R1 was feeling unsafe. V1 stated she asked R1 at the conclusion of the investigation if R1 felt safe and R1 stated she had no concerns about her safety. Email, dated 3/26/24, shows V1 (Former Administrator) stated she did not call the police regarding R1's allegations because there was no reasonable suspicion of a crime. Final facility investigation report, dated 2/1/24, shows R1 alleged V3 said additional things that made her feel uncomfortable Witness statement, dated 2/1/24, shows R1 alleged V3 stated, I saw you and it was not accident . R1 stated, She said, 'If I ever do that again she is gonna hurt me and hurt me bad.'' The investigation showed V11 (Registered Nurse) responded to R1 after the incident. Witness statement, dated 2/2/24, shows, [R1] said then [V3] came in and said if you do that again I'm going to make sure that you hurt. And I'm going to make sure you hurt hard. She said then she didn't feel safe [R1] stated she didn't feel safe . She said she was going to call the police because she couldn't sleep and she didn't feel safe . Review of the facility investigation shows at no time were the police called and informed of the allegation. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145246 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145246 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)