Health inspection·February 20, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a resident's medical records within two working days upon request for two of three residents (R1, R7) reviewed for medical records request in the sample of eight. The findings include: 1. R1's Face Sheet dated February 20, 2025 shows she was admitted to the facility on [DATE] with diagnoses including spinal stenosis, low back pain, history of falling, urinary retention, and lack of coordination. R1 was discharged from the facility January 16, 2025. On February 20, 2025 at 9:34 AM, V7 (R1's Spouse) said he has been waiting to receive R1's medical records for over a month. V7 said they requested the records from V8 (Medical Records). V7 said that R1 just had another surgery on her back. V7 said R1 is entitled to those records. V7 said that he nor R1 has heard anything back from the facility regarding their medical records request. On February 20, 2025 at 11:18 AM, V8 (Medical Records) said if someone is requesting medical records, then she has them fill out a form and she sends that form to her legal team. V8 said the legal team processes the medical records request. V8 said she received a request from R1's medical records request on January 25, 2025 and she sent that off to her legal department. V8 said she was always told that there was 30 days to get the request fulfilled if they were not current residents in the facility and two days if they were. V8 said she has not followed up with R1's request to see if she had received her medical records or not. V8 said that R1 called the facility on February 20, 2025 and said she had not received her records yet so V8 emailed her legal team to follow up. R1's Authorization for Use and Disclosure of Protected Health Information request was signed by R1 on January 24, 2025. 2. On February 20, 2025 at 11:42 AM, V6 (R7's Power of Attorney) said she requested R7's medical records on January 27, 2025 and still had not received them as of February 20, 2025. V6 said she has reached out to the facility one other time since the request and the facility said they would get R7's medical records to V6. R7's HIPPA Privacy Authorization for Disclosure of Protected Health Information Relevant to Litigation or Pending Claims request was signed by V6 on January 17, 2025. On February 20, 2025 at 11:18 AM, V8 (Medical Records) said R7's request was originally and Page 1 of 3 145980 145980 02/20/2025 Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incorrectly made to a sister facility. But the current and correct facility received the request on January 27, 2025. V8 said she has not heard from R7's family if they have received the medical records has not followed up to see if they have. The facility's Medical Records Request policy dated February 27, 2023 shows, Residents are always entitled to their medical records, but must follow the process for requesting them. Time to process a Record Request: Residents that have been discharged from the facility-30 days. The Illinois Long-Term Care Residents' Right booklet revised November 2018 shows, Your facility must allow you to see your records within 24 hours of your request (excluding weekends and holidays). You may purchase a copy of part or all of your records at a reasonable copy fee within two working days of your request. 145980 Page 2 of 3 145980 02/20/2025 Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174

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 interview and record review, the facility failed to perform a fall assessment and monitor a resident after a fall for one of three residents (R1) reviewed for quality of care in the sample of eight. Residents Affected - Few The findings include: R1's Face Sheet dated February 20, 2025 shows she was admitted to the facility on [DATE] with diagnoses including spinal stenosis, low back pain, history of falling, muscle wasting, urinary retention, abnormalities of gait and mobility, and lack of coordination. R1's Fall assessment dated [DATE] shows she is a high risk for falls. R1's Progress Note dated January 13, 2025 shows, R1 was reported to be lowered on the floor in her room. Per CNA (Certified Nursing Assistant) she was transferring R1 from her chair to her bed and R1's legs gave out and R1 was lowered to the floor. R1 denied any pain or discomfort. There was no fall report, fall assessment, or follow up assessment provided by the facility regarding R1's fall. On February 20, 2025 at 12:30 PM, V2 (Director of Nursing) said R1 was lowered to the floor. V2 said technically that is still a fall. V2 said normally a fall assessment, pain assessment, and change in condition forms would have been filled out. V2 said none of this was done after R1 was lowered to the floor. V2 said the facility thought it was not a fall because R1 kind of fell into the CNA and then the CNA lowered R1 to the floor. The facility's Fall Prevention and Management policy revised April 8, 2024 shows, Fall risk screening will be used after a fall. Procedure for Post-Fall Management: Perform assessment to the cause of the fall and potential for injury, perform physical assessment, document the fall event in the electronic health record under 'risk management'. Evaluate and monitor resident after the fall. Complete falls assessment and post fall documentation. 145980 Page 3 of 3