Health inspection·March 8, 2024

F 0684 Staffing sheet for Saturday March 2nd, 2024 shows V4 worked from 7 PM to 7 AM. Level of Harm - Minimal harm or potential for actual harm Facility's grievance/concern form for R1, dated 3/4/24 and completed by V2, shows the following: (R1's) daughter was upset about night nurse (V4-LPN) who didn't assist (R1) to washroom without oxygen. Investigation: Due to (V4)'s discourteous behavior. She is suspended. Resolution: No return call received. (V4) was terminated from facility. This form was also signed off by V1. Residents Affected - Few Facility's Resident Council Meeting Minutes were reviewed. On 1/30/24, it documents: Concerns: Residents state that Nursing need to listen to residents more about their concerns. On 2/27/24, it documents: Night nurses or CNA's (Certified Nursing Assistants) will not or takes a long tie to answer call lights or take residents to the washroom. Residents feel that this happens on all shifts. On 3/7/24 at 11:02 AM, surveyor and V3 (ADON-Assistant Director of Nursing) went to R1's room. R1 was lying in bed. He had a nasal cannula which was connected to a concentrator. He was on 3 to 4 liters of oxygen. V3 asked R1 how he was doing, and he stated he still had shortness of breath due to his history of pneumonia. R1 stated, I don't remember the exact date, but (V4--LPN-Licensed Practical Nurse) worked the night shift. I pressed my call light. She came in and asked me what I want. I told her that I needed to use the bathroom. She never helped me. I needed to get in my wheelchair, and I needed my oxygen tubing (from my concentrator) switched out to the tank because it won't reach the bathroom. (V4) told me that I don't need oxygen, and I can go to the bathroom myself. Then she left the room and didn't call the CNA (Certified Nursing Assistant) to help me. R2 (R1's roommate) confirmed what R1 had said because he witnessed everything that night. On 3/7/24 at 11:10 AM, V3 stated, (R1) can't walk. He has to use his wheelchair. He can't transfer safely. Staff should be there to supervise. (V4) should have called the aide. On 3/7/24 at 10:24 AM, V1 (Administrator) stated, (R1's) daughter spoke to me to on the phone. She told me she talked to (V2-DON/Director of Nursing). She was upset because over the weekend, (V4) did not help (R1) to the bathroom and she felt (V4) should have. (R1's) daughter never talked to me about the oxygen tank. We let (V4) go. She was discourteous and not a good fit for our facility. We are trying to weed out our bad apples. (V4) wouldn't return any of our phone calls, and we left a message on her voicemail that she was terminated on 3/4/24. On 3/7/24 at 10:29 AM, V2 (DON) stated, (R1's) daughter told me that (R1) and (R2-(R1's roommate) told her that (R1) wanted to go to the bathroom in the night and be switched over to his portable tank. (V4) did not put him on the portable tank or take him to the bathroom. (R1) is a hands on transfer and 1 person stand by assist. We called (V4) and she would not answer our phone calls. She never called back and we took her off the schedule. We eventually terminated her. On 3/7/24 at 11:40 AM, V6 (LPN/Restorative Nurse) stated, (R1's) is an 1 person assist. (R1) can transfer himself to the wheelchair by himself, but staff needs to supervise and change his oxygen when assisting him to the bathroom. Someone should be there when he gets on the toilet seat. They can leave, and when he is through, he should press his call light. The staff should come back and assist him off the toilet. On 3/7/24 at 11:58 AM, telephone interview was conducted with V5 (RN-Registered Nurse/Night Supervisor). V5 stated, (R1) told me that (V4) didn't give him his oxygen or help him go to the bathroom during the night shift. (V4) should be assisting him. If (R1) is transferring himself, staff has to supervise him. She also is supposed to switch to the oxygen tank and watch him to see the oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145372 If continuation sheet Page 2 of 5 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 145372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Joliet, The 306 North Larkin Avenue Joliet, IL 60435 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)

F 0684 tubing doesn't get tangled up which might cause him to fall. Level of Harm - Minimal harm or potential for actual harm Facility's policy titled Supporting Activities of Daily Living (ADL) (12/5/23) shows: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (turning, re-positioning, transfers and ambulation, including walking); c. Elimination (toileting). Residents Affected - Few Facility's policy titled Accomodation of Needs/Preferences (7/23/23) documents: 1. The resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 4. In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. A. Staff will interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication and maintains dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145372 If continuation sheet Page 3 of 5 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 145372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Joliet, The 306 North Larkin Avenue Joliet, IL 60435 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician to a resident. This applies to 1 of 4 residents (R1) reviewed for medications in a sample of 4. Residents Affected - Few The findings include: R1's face sheet documents the following diagnoses: secondary parkinsonism, COPD (Chronic Obstructive Pulmonary Disease), pneumonia, chronic respiratory failure with hypoxia, peripheral vascular disease, hypertensive heart and chronic kidney disease without heart failure, benign prostatic hyperplasia without lower urinary tract symptoms, major depressive disorder, gastro-esophageal reflux disease without esophagitis, and chronic kidney disease stage 2 (mild). R1's hospice physician orders from hospice (company) show R1 was placed on hospice on 1/17/24 with a diagnosis of COPD. R1's MDS (Minimum Data Set), dated 2/11/24, shows R1's BIMS (Brief Interview for Mental Status) score as 15, which means he is cognitively intact. Staffing sheet for Saturday March 2nd, 2024 V4 worked from 7 PM to 7 AM. R1's EMAR (Electronic Medication Administration Record) shows V4 signed off on the following medications that were supposedly administered on Saturday March 3rd, 2024 late by about 2 to 3 hours: Amlodipine Besylate Oral 5 MG (Milligrams) at bedtime, Melatonin 5 MG in the evening, Mirtazipine 7.5 MG in the evening, Rivaroxaban 20 MG in the evening, Ipratropium Albuterol nebulizer, Trazodone HCL 50 MG in the evening, and Acetaminophen 650 MG every 4 hours PRN (As Needed). R1's POS (Physician Order Sheet) shows R1 had orders for the above medications. On 3/7/24 at 11:02 AM, surveyor and V3 (ADON-Assistant Director of Nursing) went to R1's room. R1 was lying in bed. R1 stated, (V4) didn't bring my medications that night (3/2/24). I didn't get my sleeping medications either. I didn't sleep at all that night. I am sure I didn't get it. R2-(R1's roommate) also confirmed he didn't see V4 bringing R1's medication that evening. On 3/7/24 at 10:49 AM, V3 stated V5 (RN-Registered Nurse/Night Supervisor) told her she was observing V4 working on the night shift because she was fairly new. V3 stated, (V5) had reason to believe she was not administering medications to the residents because she would be standing for a long time in front of the medication cart in the hallway. She didn't see her going into the resident's room to pass out the medications. That prompted us to want to ask (V4) about medications. We wanted to talk to her directly, but she wouldn't return our phone calls. On 3/7/24 at 10:24 AM, V1 (Administrator) stated, (V4) was discourteous and not a good fit for our facility. We are trying to weed out our bad apples. (V4) wouldn't return any of our phone calls and we left a message on her voicemail that she was terminated on 3/4/24. I will notify IDPH (Illinois Department of Public Health) about (R1) not receiving his medications by (V4). On 3/7/24 at 10:29 AM, V2 (DON) stated, We called (V4) and she would not answer our phone calls. She never called back and we took her off the schedule. We eventually terminated her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145372 If continuation sheet Page 4 of 5 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 145372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Joliet, The 306 North Larkin Avenue Joliet, IL 60435 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/7/24 at 11:58 AM, telephone interview was conducted with V5 (RN-Registered Nurse/Night Supervisor). V5 stated, I didn't work with (V4) on Saturday 3/2/24), but I have worked with her on other nights. She's fairly new. I would notice that (V4) would stand too long in front of her medication cart in the hallway. I saw her popping pills and putting it in the medication cup and placing it on top of her cart. But she wasn't moving. I was like is she really passing meds to the residents? Then I saw one day she put a medication cup of meds in the drawer. I was hoping to find something in her cart but I didn't. (R1) told me he didn't get his medications on 3/2/24, and his roommate verified it. I looked in the EMAR (Electronic Medication Administration Record), but it was signed off for by (V4). But I don't know if they were really given. Facility's policy titled Medication Administration (8/10/23) shows the following: Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guidelines: 1. An order is required for administration of all medications. 2. Medications are administered by licensed personnel only. 16. Explain procedure to resident and give the medication. 17. Remain with the resident to ensure that the resident swallows the medication. 18. If medication is not given as ordered, document the reason on the MAR. 19. If the medication is given at a time different from the scheduled time, update the MAR to reflect administration time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145372 If continuation sheet Page 5 of 5