Pearl of Naperville, The

In the surveyor’s words

From the most serious findings on record at Pearl of Naperville, The, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Jun 10, 2022

  Based on interviews and record reviews, the facility failed to prevent neglect when the facility was left without a licensed nurse in the building for over four hours. This failure resulted in the potential for serious harm or death when residents did not receive services, monitoring, and medications. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/21/22 at 8:30 PM when the last licensed nurse present in the building left. This failure applies to all residents in the facility. The facility's 5/21/22 Daily Census Sheet showed 67 residents reside in the facility. The Immediate Jeopardy was identified on 6/2/22. V1 (Director of Nursing), V6 (Assistant Administrator), and V22 (Regional Administrator) were notified of the IJ on 6/3/22 at 11:31 AM. […]

• Immediate jeopardy, widespreadF725Jun 10, 2022

  Based on interview and record review, the facility failed to ensure licensed nurses were always present in the building to care for residents. This failure resulted in the potential for serious harm or death. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on 5/21/22 at 8:30 PM when there was no longer a licensed nurse working in the building. This applies to all residents in the facility. The facility's 5/21/22 Daily Census Sheet showed 67 residents reside at the facility. The Immediate Jeopardy was identified on 6/2/22. V1 (Director of Nursing), V6 (Assistant Administrator), and V22 (Regional Administrator) were notified of the Immediate Jeopardy on 6/3/22 at 11:31 AM. […]

• Immediate jeopardy, isolatedF689Sep 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident identified as a wandering/elopement risk was provided adequate supervision and failed to develop and implement a procedure for monitoring residents that leave the facility to ensure they return to the facility. This applies to 2 of 5 residents (R1, R2) reviewed for safety concerns in the sample of 8 residents. This failure resulted in R1 wandering from the facility without being witnessed by facility. R1 was found wandering in the neighboring apartment complex parking lot, and R1 crossed a moderately busy street. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on August 30, 2022, when R1 wandered off from the facility without being witnessed by facility staff. […]

• Actual harm, isolatedF600Nov 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse. This resulted in R1 being being afraid and in shock. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility 8/9/23, with diagnoses including major depressive disorder, unspecified dementia, and frontotemporal neurocognitive disorder. R1's Minimum Data Set assessment dated [DATE] shows she is cognitively intact with a Brief Interview for Mental Status score of 15, with no behaviors of psychosis including hallucinations, delusions, no behavioral symptoms or rejections of cares. […]

• Actual harm, isolatedF697Nov 14, 2022

  Based on observation, interview, and record review, the facility failed to provide medications for fecal impaction and address the resident's cries of pain related to the impaction. This failure led to R1 suffering pain and anxiety related to fecal impaction and R1 needing to call 911 emergency services for assistance. This applies to 1 of 3 residents (R1) reviewed for pain. The findings include: R1's quarterly MDS (Minimum Data Set), dated 10/13/22, showed R1 was cognitively intact. Hospital ER (emergency room ) records, dated 10/31/22, showed R1 fell in ER room and sustained a fracture to right tibia and had an immobilizer. […]