Inspection·November 1, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from resident-to-resident verbal abuse. This applies to 3 of 6 residents (R1, R2, and R3) reviewed for abuse in the sample of 6. The findings include: On 11/1/24 at 10:36 AM, R1 said R2 and R3 told him to get out of the city, they don't want Mexicans here. On 11/1/24 at 11:45 AM, R3 was propelling backward in his wheelchair using his right leg. R3's left side appeared to be non-functional. R3 said he called R1 a p***y and R1 called him one arm. R1's current care plan provided by the facility shows R1 may have an increased susceptibility to abuse and is considered a vulnerable adult. R1 is to be treated with respect and dignity and will reside in the facility free of abuse. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively intact and has no behaviors including hallucinations, delusions, physical or verbal behavioral symptoms directed toward others, rejection of care, or wandering. R1's Progress Notes dated 10/31/24 at 11:11 AM shows SS discussed with R1 his behaviors of aggression, antagonizing, combativeness, instigating, manipulation, provoking, threatening, swearing, and racial slurs at peers during designated smoking times on the patio. R1's behavior note on 10/29/24 at 3:46 PM shows R1 was yelling at another resident and using derogatory language when referencing other residents. R1's behavior note on 10/28/24 at 2:40 PM shows staff reported R1 antagonizing the other residents and using derogatory and offensive language. On 11/1/24, R2 was out of the facility during the investigation. R2's current care plan provided by the facility shows R2 may have an increased susceptibility to abuse and is considered a vulnerable adult. R2 is to be treated with respect and dignity and will reside in the facility free of abuse. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact and has no behaviors including hallucinations, delusions, physical or verbal behavioral symptoms directed toward others, rejection of care, or wandering. R3's admission Record dated 11/1/24 shows R3 has hemiplegia and hemiparesis following cerebral infarction affecting his left, non-dominant side. R3's current care plan provided by the facility shows R3 may have an increased susceptibility to abuse and is considered a vulnerable adult. R3 is to be treated with respect and dignity and will reside in the facility free of abuse. R3's MDS dated [DATE] shows R3 is cognitively intact and has no behaviors including hallucinations and delusions, physical or verbal behavioral symptoms directed toward others, rejection of care, or wandering. (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: 145980 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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)