F 0584
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on observation, interview, and record review, the facility failed provide a clean, comfortable, homelike
environment.
Residents Affected - Some
This applies to 6 of 6 residents (R1, R2, R3, R4, R5, R6) reviewed for clean, comfortable, homelike
environment in the sample of 6.
The findings include:
On September 25, 2024, from 9:30 AM through 2:00 PM, environmental observation was conducted. The
bedroom floors of R1, R2, R3, R4, R5, and R6, were all dull and dirty, with accumulated dirt and dust debris
which adhered to the floor. The floors were stained or marked with patches of dry spilled unidentified fluids.
Additionally, the bedroom floors were littered with small pieces of plastics from the packaging of gowns
(personal protective equipment/PPE). Interviews were conducted as well with residents and family
members. R1, R4, R6, and V7 (R5's family) also said their bedroom floor was dirty and needs a thorough
cleaning.
On September 25, 2024, at 12:54 PM, V6 (Housekeeper) was observed cleaning R6's bedroom; it had
accumulated debris of dust and other things like plastic from PPE wrapper and dry food debris. V6 said the
second floor is her regular floor. They just assigned her on the 1st floor today to clean, and she was aware it
was dirty. V6 also said they were supposed to sweep and mop the floors every day, and she could see
some of the bedrooms have not been swept for days.
The Resident Council Meeting from June through August 2025 has documentation of bedrooms and floors
needing to be cleaned.
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:
145372
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
09/26/2024
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, record review, the facility failed to provide timely incontinence care, and
failed to ensure a resident who requires total assistance is being assisted to get up from bed.
Residents Affected - Few
This applies to 3 of the 6 residents (R1, R2, R3) reviewed for activities of daily living (ADL) care in the
sample of 6.
The findings include:
1. On September 25, at 1:15 PM, V4 (Certified Nursing Assistant/CNA) rendered incontinence care to R3,
who was saturated with urine, and had a bowel movement which was pasty. The urine was dark yellow. V4
said the last time she changed R3's incontinence brief was about 9 AM.
2. On September 25, at 1:22 PM, V5 (CNA) rendered incontinence care to R2. R2's brief was saturated with
urine, dark in color, he had a small bowel movement that was somewhat pasty. R2 was unable to recall
when he had the bowel movement. V5 said the last time she changed R2's incontinence brief was after
breakfast, about 9:00 AM.
3. On September 25, 2024, from 9:30 AM to 2:00 PM, R1 was observed resting in bed. At 1:46 PM, V4
(CNA) and V3 (Respiratory Therapist) rendered incontinence care to R1. After R1 was cleaned, they did not
offer or assist R1 to get up from bed. Both V3 and V4 stated R1 doesn't like getting up from bed, and she
does not like sitting in the recliner for long period of time. When R1 was asked by surveyor if she wants to
get up, R1 said she does.
At 2:00 PM, V3 and V4 transferred R1 from bed to wheelchair via mechanical lift.
On September 25, at 2:20 PM, R1 stated the last time she was assisted to get up from the bed to the
recliner was early last week, either Monday or Tuesday. The staff does not offer to get her up from bed. R1
used to ask the staf to assist her to get up from bed, but there were always excuses that either they would
come back for her, or they are busy. So, she stopped asking them. Sometimes she wants to stay in the
recliner for only a short period of time, but it doesn't mean she does not want to get up at all.
R1's, R2's, and R3's most recent Minimum Data Set (MDS) shows these residents are alert and oriented,
and require extensive to total dependence with ADL care for hygiene/grooming and transfer.
On September 25, 2024, at 4:13 PM, V2 (Director of Nursing/DON) stated, The staff must check and
change residents for incontinence every 2 hours and as needed to ensure that skin would be kept dry and
intact, for cleanliness, comfort, and dignity. The resident has the right to sit in the chair unless there is a
doctor's order that they shouldn't get up.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145372
If continuation sheet
Page 2 of 2
