Health inspection·June 4, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was treated in a dignified manner for 1 of 7 residents (R1) reviewed for dignity in the sample of 7. The findings include: On 6/4/25 at 11:48 AM, R1 was in a hospital gown in bed. R1 said she was really upset about how the night shift doesn't help her. R1 said she puts on her call light to have her incontinence brief changed and it will be on for 5-6 hours before anyone will respond. R1 said one night a girl came in and she was all ticked off that she had to change her and said she would come back and then never did. R1 said she was sitting in a stool and urine filled incontinence brief for hours. R1 said she knows she is a big lady, but she is able to help move herself to be changed. R1 stated it makes me feel like crap, like I'm a bother! R1 said that same girl came the next day and R1 said she reminded her she never came back to change her, and the girl said yes I did leave you in that with an attitude. R1 said she is afraid to urinate at night because she will be sitting in it for hours. R1's Minimum Data Set, dated [DATE] shows R1 is [AGE] years old, cognitively intact, and requires substantial/max assist for toileting. On 6/4/25 at 2:30 PM, V1 Administrator said residents should be treated with dignity and not left to sit in their urine when asked to be changed. The facility's Resident Right - Respect, Dignity/Right to have Personal Property Policy dated 8/30/24 shows: It is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. Page 1 of 3 145473 145473 06/04/2025 Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to document and obtain treatment orders for a resident at risk for skin breakdown who had complaints of redness and burning to her buttock area for 1 of 7 residents (R1) reviewed for quality of care in the sample of 7. Residents Affected - Few The findings include: On 6/4/25 at 11:06 AM, V5 Certified Nursing Assistant (CNA) was providing incontinence care for R1. V5 lowered R1's incontinence brief (with R1 rolled on her left side) and R1's right and left buttocks area was red in color. R1 had a dressing to her right inner buttocks. R1 said her bottom is red since she sits in urine because the CNAs at night don't change her. R1 said she could feel something was burning and hurting her, so she told the nurse who had the wound nurse come look at her bottom. R1 said this was a few days ago and the wound nurse came in and took pictures and put the dressing on her bottom. V5 lifted the corner of the dressing to reveal 3 round open areas about the size of a pencil eraser surrounded by denuded skin approximately two inches by two inches. On 6/4/25 at 11:48 AM, R1 said she was really upset about how the night shift doesn't help her. R1 said she puts on her call light to have her incontinence brief changed and it will be on for 5-6 hours before anyone will respond so she will be sitting in feces/urine soaked brief for hours. On 6/4/25 at 12:14 PM, V6 Wound Licensed Practical Nurse said she looked at R1's bottom yesterday and only saw redness. V6 said she did put a dressing on the area. V6 said she did not chart anything yesterday and denied taking photos of the area or seeing the area prior to yesterday. V6 said sitting in a wet brief for hours would contribute to redness and open areas in the skin. V6 said she would do an assessment and report back with her findings. On 6/4/25 at 2:01 PM, V6 said she assessed R1's bottom and R1 has Moisture Associated Skin Damage (MASD) to her right medial buttock. V6 said MASD is caused from prolonged moisture to the skin. V6 said she did an assessment, and the treatment will be zinc oxide cream for 14 days. On 6/4/25 at 10:25 AM, V5 CNA said residents are rounded on every 2 hours and as needed for incontinence care. V5 said residents that are alert will let you know when they need to be changed. V5 said R1 is alert and uses the call light when she needs to be changed. R1's Minimum Data Set, dated [DATE] shows R1 is [AGE] years old, cognitively intact, and requires substantial/max assist for toileting. On 6/4/25 at 2:30 PM, V1 Administrator said incontinence care should be provided to residents when requested and residents should not be left to sit in their urine. R1's Wound Summary dated 6/4/25 shows right medial buttocks facility acquired MASD, denuded, with light sero-sanguineous drainage. There are no measurements documented on this form. R1's Skin Risk Profile dated 4/30/25 shows R1 is at risk for skin breakdown. R1's Care Plan dated 4/9/25 shows R1 has potential impairment to skin integrity related to fragile skin and status post open reduction internal fixation of left femur fracture with interventions to 145473 Page 2 of 3 145473 06/04/2025 Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506

F 0684 keep skin clean and dry, notify nurse of any new skin breakdown or redness, and report changes in skin to the physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145473 Page 3 of 3