Pearl Of Orchard Valley

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on behavior monitoring log. Findings will be escalated to abuse officer and ADON for protocol implementation immediately.vi. QAPI with the QA Committee and Medical Director was held on September 17, 2025 to discuss the plan of removal, revisions to Sexual Abuse policy including environmental

observations, visual signs of abuse, and preservation of physical evidence, the Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider, and to ensure that all corrective actions and safety measures are consistently implemented.vii. Human Resources, and Director of Nursing initiated a staff in-service and will continue to conduct ongoing in-services on Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider. Staff to include dietary, housekeeping, therapy, nursing, and administrative departments. Any agency staff will be educated prior to the start of their first work shift; education will be provided by the Charge Nurse and/or manager designee.4. Monitoring of Corrective Actionsa. A tool has been created in which the Administrator and/or designee will select 5 random residents weekly x 4 weeks to ensure that residents are free from abuse. Start: September 10, 2025; goal: October 8, 2025.b. A tool has been created in which the DON and/or designee will select 5 random residents on the secured unit weekly x 4 weeks to ensure that residents are monitored for inappropriate sexual behaviors and wandering. Start: September 18, 2025; goal: October 16, 2025.c. A tool has been created in which the Administrator and/or designee will conduct video surveillance review twice a day x 4 weeks to observe for any inappropriate wandering behaviors.

Start: September 18, 2025; goal: October 16, 2025.d. Any quality assurance issue/s and progress will be reported to facility's monthly QAPI meeting for three months by the Administrator and recommendations given to assist in ensuring that the facility stay in compliance and if concerns are identified the Quality Assurance Committee will add on additional months until Compliance is sustained.e. Administrator and/or Director of Nursing will complete monthly in-servicing on the facility's sexual abuse policy and sexual behavior management for three months and quarterly thereafter. Start: October 1, 2025.Date of Completion: September 18, 2025

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Orchard Valley

2330 West Galena Boulevard Aurora, IL 60506

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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to timely report allegations of sexual and verbal abuse to the residents' Power of Attorney (POA), physician, the Illinois Department of Public Health (IDPH), and the local police department in accordance with the facility's abuse policy. This applies to 2 of 4 residents (Resident R1, Resident R3) reviewed for abuse in the sample of 11. The findings Include: 1. The EMR (Electronic Medical Record) shows that Resident R1 is a [AGE] year-old female, admitted [DATE REDACTED], with diagnoses including dementia, cerebral atherosclerosis, unspecified psychosis, anxiety disorder, and is under hospice care. The Minimum Data Set (MDS) dated [DATE REDACTED], indicates Resident R1 has severe cognitive impairment and requires total assistance for Activities of Daily Living (ADLs). The EMR shows that Resident R2 is a [AGE] year-old male admitted [DATE REDACTED], with diagnoses including dementia, bipolar disorder, alcoholic cirrhosis, and adjustment disorder. The MDS dated [DATE REDACTED], indicates cognitive intactness (BIMS 14/15), and a history of inappropriate behaviors such as wandering and entering other residents' room. The incident detail showed that on August 29, 2025, at 11:30 AM, an incident involving Resident R2 exposing his genitals to Resident R1 in Resident R1's room was observed. Resident R2 was alone in Resident R1's room for approximately 8 minutes with the door closed, as confirmed by video surveillance footage. Resident R2 was seen exiting Resident R1's room with sweatpants still not fully pulled up.On September 9, 2025 at 12:12 P.M., V4 (Restorative Aide) said she entered Resident R1's room at approximately 10:54 AM on August 29,2025 and observed Resident R2 standing by Resident R1's head, with pants lowered to the knees and buttocks exposed, while Resident R1 was lying sideways, facing Resident R2.The incident report showed the sexual abuse allegation was identified on August 29, 2025, Resident R1's POA was notified 7 days later, on September 4, 2025.; IDPH was notified on September 4, 2025, a 6 -day delay; local police were not notified until 10 days after the incident. On September 10, 2025 at 1:10 P.M., V16 (Resident R1's Family/POA) expressed dissatisfaction regarding the delay, stating that potential evidence was lost. On September 10, 2025 at 2:31 P.M., V18 (Hospice Physician) had confirmed that neither him nor his alternate physician were not notified. V18 added that if they would have been notified timely, an appropriate evaluations or treatments could have been initiated. On September 22, 2025 at 2:59 P.M., V22 (Primary Physician) had validated that neither him or his alternate was not informed and stated appropriate evaluations or treatments could have been initiated had they been notified timely.On September 9, 2025 at 3:30 P.M., V1 (Administrator) explained that the delay of reporting was he was new. 2, The EMR shows that Resident R3, is an [AGE] year-old, and was admitted to the facility on [DATE REDACTED]. Resident R3's diagnoses included unspecified dementia, major depressive disorder, PVD (peripheral vascular disease) and localized swelling.

The MDS dated [DATE REDACTED] showed that Resident R3's cognition was moderately impaired and that she required substantial assistance from staff for ADLs (Activities of Daily Living). The EMR shows that Resident R4, a [AGE] year-old admitted to the facility on [DATE REDACTED]. Resident R4's diagnoses included unspecified dementia, anxiety disorder and diabetes mellitus. The MDS dated [DATE REDACTED] showed that Resident R4 is moderately impaired in cognition and required supervision with ADLs. The facility's abuse allegation report showed that there was a verbal altercation between Resident R3 and Resident R4 on August 29, 2025. The abuse allegation report showed that Resident R3 had sustained a skin tear and was bleeding from her lower leg. The bleeding was a skin tear was sustained and hit her leg, when Resident R3 was startled from Resident R4's shouting to Resident R3. This abuse investigation was reported to IDPH

on September 4, 2025, which was 6 days after the verbal abuse allegation was identified. V1 had the same response as to the reason of delayed reporting. The facility's Abuse Prevention Policy (dated October 24, 2022) states: The Administrator or designee shall notify the resident's representative, the physician, and shall notify the local police department of any suspicion of criminal activity immediately.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Orchard Valley

2330 West Galena Boulevard Aurora, IL 60506

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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility's abuse policy dated October 24, 2022 showed that Residents have the right to be free from abuse.

Abuse means any physical or mental or sexual assault inflicted upon resident other than by accidental means. sexual abuse in non-consensual contact of any type with a resident. The facility prohibits abuse, neglect, exploitation of its residents including verbal, mental, sexual abuse.For investigation: As soon as possible, after the allegation of abuse, the administrator or designee will initiate an investigation into the allegation . investigation includes a review of all circumstances surrounding the incident.

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If continuation sheet