Health inspection·April 30, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 to ensure resident rooms were maintained in a clean and sanitary manner for 4 of 7 residents (R3, R6, R7, R8) reviewed for a clean, comfortable, homelike environment in the sample of 11. The findings include: On 4/24/24 at 8:39 AM, V10 (Family of R3) stated, This place is a nightmare. (R3) has only been here three days. Come look at the bathroom. V10 and this surveyor went into R3's bathroom. The garbage container, on the floor by the sink, was full of garbage. Stool was noted in the toilet and up to the bowl of the toilet. Soiled, damp washcloths hung from a towel bar and off the side of the sink. White, clumpy food debris was noted in the sink. Two toothbrushes laid on the sink by the faucet. A paper towel and two wadded tissues were on the bathroom floor. V10 stated, This place is dirty and unsanitary. The same stool was in the toilet yesterday. The food clumps in the sink were there yesterday. (R3) shares this bathroom with his neighbor so I assume all of these stains and things belong to him (neighbor) because (R3) doesn't really get out of bed right now. I was here twelve hours on Monday and Tuesday with (R3). No one has come to clean his room. Yesterday (Tuesday), I went looking for a housekeeper and couldn't find one. On 4/24/24 at 9:25 AM, both garbage containers in R8's room were full of garbage. Food debris was noted scattered across the floor of R8's room. On 4/24/24 at 9:45 AM, the floor of R7's room had tissues and food debris on the floor by R7's bed. On 4/24/24 at 9:50 AM, R6 was seated in a chair in her room. A large, dried, dark brown stain was noted down one of the sides of R6's chair. Food debris was noted on the floor by R6's bed. On 4/24/24 at 10:47 AM, V7 Housekeeper stated he just started working as a housekeeper at the facility three weeks ago. V7 stated he was instructed to clean each resident room, daily, on his assigned hall but, some days I just can't get all of my work done. Sometimes, all of the rooms don't get cleaned. V7 stated the facility had two housekeepers on the day shift, seven days a week, but no housekeeper on the evening or night shifts. On 4/24/24 at 1:06 PM, V1 Administrator stated she had received a few recent complaints about rooms needing to be cleaned. V1 stated each occupied resident room is to be cleaned once a day by housekeeping. The facility's Cleaning and Disinfecting Environmental Services policy (undated) showed, Page 1 of 4 145657 145657 04/30/2024 The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Environmental surfaces will be cleaned and disinfected according to CDC (Centers for Disease Control) recommendations for disinfection of healthcare facilities and OSHA (Occupational Safety and Health Administration) bloodborne pathogens standard . The facility's Housekeeping checklist (undated) showed each resident room was to be cleaned daily which included sweeping and mopping the floor, emptying trash, cleaning all furniture, and disinfecting/cleaning the bathroom. 145657 Page 2 of 4 145657 04/30/2024 The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance to residents that required staff assistance for toileting/incontinence care for 2 of 3 residents (R2, R3) reviewed for activities of daily living in the sample of 11. Residents Affected - Few The findings include: 1. R2's resident assessment dated [DATE] showed R2 was dependent on staff for toileting/incontinence care. The assessment showed R2 was incontinent of urine and stool. On 4/24/24 at 8:04 AM, R2 was in bed, dressed in a hospital gown. An odor of urine was noted in the room. R2 stated, I think I might be wet. I don't get up to the toilet. I just go in my brief. R2 stated her incontinence brief was last changed at 4:30 AM that morning. R2 complained of pain to her buttocks. At 8:25 AM, V8 Certified Nursing Assistant (CNA) and V9 Licensed Practical Nurse (LPN) entered R2's room to check R2's buttocks due to her complaint of pain to that area. V8 and V9 repositioned R2 on her side and pulled down R2's brief. R2's brief was saturated with dark yellow urine. R2's buttocks and vaginal area were bright red. V8 stated, No, it doesn't look like she has any wounds (to R2's buttocks). V8 and V9 repositioned R2 back onto the soiled brief and secured the brief in place. As V8 and V9 were walking out of R2's room, R2 stated out loud, Isn't someone going to change me? No response was noted from V8 or V9. On 4/24/24 at 9:30 AM, R2 remained in bed, lying on her back. R2 stated, No one has been in to change me. I'm still wet. On 4/24/24 at 9:35 AM, V8 CNA changed R2's soiled brief and provided her with incontinence care. R2's buttocks and vaginal area remained bright red in color. 2. R3's admission Evaluation dated 4/22/24 showed R3 was cognitively impaired to due his diagnoses of CVA (cerebral vascular accident) and cerebral hemorrhage. The evaluation showed R2 was incontinent of urine and stool. R3 was dependent on staff for toileting/incontinence care. On 4/24/24 at 8:39 AM, R3 was asleep in bed. V10 (Family of R3) and V8 CNA were at R3's bedside. V8 CNA stated she had not done cares at all on (R3) yet today. V10 stated, When I got here yesterday, (R3) still had the same clothes on that he was wearing the day before. He was so wet with urine that his brief had leaked, and his bedding was wet. It's to the point that I just expect (R3) to be dirty and wet when I get here everyday. I have to come daily if I expect anything to get done. At 8:48 AM, V8 CNA and V11 CNA changed R3's incontinence brief and provided him with incontinence care. R3's incontinence brief was saturated with urine and a large amount of stool. Urine, from R3's brief, had leaked onto R3's bed sheet. V10 (Family of R3) looked at the urine on R3's bed sheet and stated, Why am I not surprised by this? On 4/24/24 at 12:21 PM, V2 (Director of Nursing) stated incontinence care should be provided every two hours to residents that require assistance with toileting/incontinence care. The facility's Activities of Daily Living (ADLs) policy (undated) showed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily 145657 Page 3 of 4 145657 04/30/2024 The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515

F 0677 living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145657 Page 4 of 4