Health inspection·January 8, 2026

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 implement its policy regarding the management and care of PICC (Peripherally Inserted Central Catheter) lines, including measurement of arm circumference and ensuring that PICC insertion sites were assessed and monitored every shift for signs of symptoms of infection. This applies to 2 of 2 residents (R113 and R196) reviewed for PICC line in the sample of 34.The findings include: 1.R196's face sheet showed that she was admitted on [DATE], with multiple diagnoses including hemiplegia, unspecified affecting unspecified side, cervical disc disorder with myelopathy, unspecified cervical region, other staphylococcus as the cause of diseases classified elsewhere, enterococcus as the cause of diseases classified elsewhere, malignant neoplasm of spinal cord, encounter for surgical aftercare following surgery on the nervous system.R196's comprehensive MDS (minimum data set) dated January 5, 2026, showed that R196 was cognitively intact. R196's POS (Physician Order Summary) showed midline dressing change and measurement of Arm Circumference and length of exposed midline after every midline dressing change on admission and every 7 days. Document Insertion site appearance every shift.On January 5, 2026, at 12:29 PM, R196 stated I am on PICC line IV (intravenous) for antibiotics. They changed it yesterday and put a date on it. The nurse cleaned it today.R196's IV site on right arm had a clean transparent dressing (dated January 4, 2026) taped over a round dry patch that was covering the IV insertion tip. The area around the insertion site was not visible with the presence of the round dry patch. On January 6, 2026, at 2:33 PM, R196's IV site was checked in presence of V5 (Registered Nurse/RN). R196's IV site had the same transparent dressing dated January 4, 2026, which was taped over the round dry patch that was covering the IV insertion tip. V5 stated that R196 received normal saline via the IV site. When asked how she checks the insertion site, as per orders, V5 stated that she only checks around the area and not the insertion site. V5 stated that she was not the one who changed the dressing on January 4, 2026. R196's care plan, initiated January 5, 2025, included that R196 has a right arm-midline with a goal to maintain a patent midline without signs of phlebitis, infiltration, or deep vein thrombosis. Interventions included as follows for dressing integrity: Maintain a transparent semi-permeable dressing. Change it every 7 days, or immediately if it becomes damp, loose, or soiled and Midline dressing change and measurement of Arm Circumference and length of exposed midline after every Midline change on admission and every 7 days. 2. R113's face sheet showed that he was admitted on [DATE], with multiple diagnoses including osteomyelitis of vertebra, long term (current) use of antibiotics, thoracic region, other lack of coordination, unsteadiness on feet, encounter for adjustment and management of vascular access device, neoplasm of uncertain behavior of colon.R113's admission MDS dated [DATE], showed that R113 was moderately impaired in cognition. R113's POS showed that R113 was on antibiotic Vancomycin Hydrochloride Intravenous Solution 1250 milligram/250 ml/milliliter intravenously every 12 hours for Osteomyelitis until January 8, 2026. R113 was admitted with orders start date December 6, 2025, with IV Residents Affected - Few Page 1 of 7 145246 145246 01/08/2026 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PICC line, flush with 10 ml normal saline before and after medications. The same POS showed orders as follows: Left PICC line dressing change and measurement of Arm Circumference and length of exposed PICC line after every PICC line dressing change on admission and every 7 days every night shift every Wednesday and as needed, Document insertion site appearance every shift, Monitor for any signs of infection, Check for any redness, swelling, warmth, tenderness or bleeding, every shift for IV care.R113's care plan revised January 5, 2026, included that R113 has a PICC line for IV Antibiotic Infusion secondary to Osteomyelitis. R113's care plan created December 6, 2025, included that R113 has a PICC line or Mid-Line.Interventions for the above included: To assess the PICC/Mid-line insertion site for redness, tenderness, or swelling. To keep an eye on any swelling, the patient's arm circumference can be compared with the baseline measurement taken before PICC line insertion. Left PICC line dressing change and measurement of Arm Circumference and length of exposed PICC line after every PICC line change on admission and every 7 days, Monitor for signs and symptoms of infection. On January 6, 2026, at 2:04 PM, R113's IV site on left arm was checked in presence of V4 (Nurse Manager/RN). The IV site was covered over by a round dry patch with a transparent dressing taped over the patch and was dated January 5, 2026. V4 stated that the dressing is changed once a week. On January 6, 2026, at 2:28 PM, V6 (Licensed Practical Nurse) stated that the night nurse changes the dressing, and the policy is to check around the IV insertion site for drainage. V6 stated that she usually does not work in R113's wing and was not sure of where to find documentation of insertion site and dressing change. On January 6, 2026, at 2:49 PM, R196's and R113's EMAR (Electronic Medication Administration) and ETAR (Electronic Treatment Administration) and nurses progress notes were reviewed in presence of V4 and showed no documentation of monitoring measurement of Arm Circumference and length of exposed midline after every midline dressing change or description of monitoring the insertion site. V4 stated that the IV site has an antimicrobial patch at the insertion site and a transparent dressing taped over it and that the insertion should be checked every shift. V4 acknowledged that the IV tip was not visible when covered with the bio patch. V4 added that the arm circumference measurements should have been recorded in EMAR. On January 7, 2026, at 8:10 AM and 9:36 AM, V3 (Infectious Disease RN) stated that the night nurse changes the dressing per orders but does not write down the measurements and that he checks around the site for infection the next day and documents the same in progress notes. V3 stated that the nurse who changes the dressing should document the measurements. V3 added that this was not done as there is no area currently for nurses to document.On January 7, 2026, at 12:30 PM, V11(Chief Nursing Officer) stated that she understands that the orders to monitor the insertion site every shift will not be able if there is a covering over the site. V11 stated that the facility will review their orders to reflect the current practice. Facility policy for Central Line (reviewed April 15, 2025) included:d. Peripherally Inserted Central Catheter (PICC).9) Upper arm circumference should be measured on admission and weekly to monitor infiltration.10) External catheter length should be monitored on admission, and weekly to monitor for outward migration of the catheter. Facility did not have a policy for checking insertion site every shift. 145246 Page 2 of 7 145246 01/08/2026 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to assess and report bleeding from a resident's dialysis access site. The facility also failed to reinforce dressing to a resident's dialysis access site. This applies to 2 of 7 (R14, R101) reviewed for dialysis in a sample of 34.The findings include: Residents Affected - Few 1. According to the face sheet, R101 had multiple diagnoses, including end-stage renal disease, anemia in chronic kidney disease, and dependence on renal dialysis. R101's MDS (Minimum Data Set) dated December 26, 2025, showed R101 was cognitively intact, required maximum staff assistance for upper body dressing, and was dependent on staff for lower body dressing. R101's POS (Physician Order Summary) dated December 25, 2025, showed an order for renal dialysis at the facility's dialysis center every Monday, Wednesday, and Friday. The same POS also showed to check dialysis access site for bruit and thrill, record and report abnormalities immediately, every shift. Record, or notify the physician if absent, and may reinforce dressing to the dialysis site as needed. R101's care plan initiated on December 27, 2025, showed that R101 needs hemodialysis related to end-stage renal disease. Interventions for the same care plan included checking and changing dressing daily at access site and documenting. On Monday, January 5, 2025, at 11:57 AM, R101's left upper arm dialysis access site on her left upper arm was checked in the presence of V12 (Licensed Practical Nurse/LPN). V101's dialysis access site dressing was undated, completely saturated with dried dark brown drainage, and the tape was loose and almost falling off R101's arm. R101 said she gets dialysis treatment at the facility's dialysis center on Mondays, Wednesdays, and Fridays, and her dialysis access site dressing was bloody since Friday (her last day of dialysis). R101 also said she would be going to dialysis later the same day for her Monday treatment. V12 said she was the day shift nurse for R101. V12 said she started her shift at 7 AM, gave R101 her morning medications, and did not assess R101's dialysis access site. V12 removed the gauze dressing from R101's dialysis access site and the entire dressings was saturated with dried dark brown drainage. V12 said the dressing she removed from R101's dialysis site was most likely the same one she had from dialysis (since Friday). V12 said the dialysis center changes R101's dialysis site dressing, and nurses on the unit reinforce dressings as needed. V101's Dialysis Communication Report reviewed from December 24, 2025, to January 5, 2026. R101's Dialysis Communication Report dated Friday, January 2, 2026, showed R101 had a left AV (Arteriovenous Fistula) dialysis access site. The same report showed, Post Treatment Special Instructions: monitor for bleeding from access site. A review of R101's Nursing Progress Note, reviewed from Friday, January 2, 2025, to Monday January 5, 2025, did not show nursing documentation of R101's dialysis access site bleeding or notification to the dialysis center or physician. On January 7, 2026, at 10:35 AM, V2 (Director of Nursing/DON) said nurses are expected to assess the resident's dialysis access site for bruit and thrill by palpating the dialysis access site and listening with a stethoscope. V12 said the facility's nurses are expected to monitor and assess R101's 145246 Page 3 of 7 145246 01/08/2026 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0698 Level of Harm - Minimal harm or potential for actual harm dialysis access site before and after dialysis, and every shift for bleeding, and any signs of infection. V12 said if the resident's dialysis access site dressing is bleeding, the nurse must reinforce the dressing and notify the dialysis center. V12 also said if a resident's dressing is bleeding during the weekend when the facility's dialysis center is closed, the nurse must notify the physician, and the resident would be sent to the hospital if the bleeding persists. Residents Affected - Few The facility's Dialysis Protocol Guideline, with the review date of March 2025, showed, General: To provide guidance to the facility on how to care for the dialysis resident. Responsible Party: Registered Nurse, LPN. 4. The dialysis site will be checked every shift for signs and symptoms of infection or bleeding. 5. The dialysis site will be monitored every shift for thrill and bruit. 6. Communication with the dialysis center will be done by nursing, dietary, and/or social services on an ongoing basis. 2.R14's face sheet included diagnoses of cerebral infarction due to thrombosis of right middle cerebral artery, dysphagia, oropharyngeal phase, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acute kidney failure, chronic kidney disease, stage 4 (severe), dependence on renal dialysis. R14's POS (Physician Order Summary) showed that R14 received Renal dialysis at an offsite dialysis center once weekly. The same orders showed to check right Central Venous Catheter site daily and upon return from dialysis, include check that caps are secure, may reinforce dressing to dialysis site as needed. R14's quarterly MDS (minimum data set) dated November 21, 2025, showed that R14 was severely impaired in cognition and required substantial maximal assistance (helper does more than half the effort) for upper body dressing and was dependent on staff for lower body dressing and personal hygiene. On January 5, 2026, at 11:23 AM, during family interview, V7 (R14's family) stated that R14 goes once a week, every Wednesday to dialysis. On January 6, 2026, at 2:30 PM, R14's dialysis site on subclavian catheter was checked in presence of V5 (Registered Nurse). A gauze dressing was noted hanging loosely under R14's shirt with the dialysis site exposed to show dry crusted brownish substance around the insertion site. V5 stated that R14 goes out for dialysis once weekly, and the site was checked in the morning. V5 added that the dressing may have come off when the CNA (Certified Nursing Assistant) who worked the morning shift changed R14's clothes. R14's care plan created July 30, 2025, showed that R14 needs hemodialysis related to chronic kidney disease, stage 4 (severe) with Right Chest Central Venous Catheter. Interventions for the same included to check and change dressing daily at access site and document. On January 7, 2026, at 8:13 AM, V2 (Director of Nursing) stated that the dressing change at the catheter site is done at the dialysis center. V2 stated that if the dressing has come off, it should be reinforced by the nurse on duty. V2 stated that the catheter site should be always covered to prevent infection. Facility policy titled Dialysis Protocol (reviewed March 2025) included: General: To provide guidance to the facility on how to care for the dialysis resident. 145246 Page 4 of 7 145246 01/08/2026 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0698 Guideline: 3. Any line dressings for dialysis residents will be done at dialysis unless specifically ordered to be done at the facility. The dressing, may however, be reinforced. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145246 Page 5 of 7 145246 01/08/2026 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the menu spreadsheet to serve portion sizes as shown for the pureed diets and failed to serve mechanical soft consistency foods as shown on the menu spreadsheet and recipe. This applies to 10 of 10 residents (R12, R13, R60, R73, R81, R84, R85, R91, R173, R174) reviewed for mechanically altered diets in the sample of 34. The findings include: Facility week at a glance menu for Monday January 5, 2026, lunch meal, included chicken Fajita with peppers and onions, refried beans, mixed vegetables and Spanish rice. On January 5, 2026, at 11:43 AM, during lunch meal observations, V8 (Cook), was platting the food. 1. Menu spreadsheet for the above menu for pureed diets showed to serve pureed Fajita chicken with #10 scoop, pureed peppers and onions #8 scoop, pureed bread #16 scoop, pureed carrots #8 scoop, 4 oz seasoned cream of rice. Facility scoop equivalents showed that #12= 3-1/4 oz/ounces, #10 =3-3/4 oz, #8 = 4 oz and #16 =2-3/4 oz. V8 used #12 scoop to serve pureed chicken and pureed rice respectively and #8 scoop of pureed refried beans. V8 stated that the facility does not have a #10 scoop so he will use a heaped #12 scoop to serve the pureed chicken and the pureed rice respectively. V8 stated that he did not prepare the pureed tortilla. R12, R60, R73 and R81 received a heaped #12 scoop of pureed chicken and pureed rice respectively and a #8 scoop of refried beans. 2. Menu spreadsheets for above menu for mechanical soft diets included to serve course ground chicken fajita (#10 scoop) with ground peppers and onions (#8 scoop) on bread. The ground chicken with diced green peppers and onion mixture prepared and served for the mechanical soft diet, had large pieces of onions that were between 2 -3 inches long and appeared crunchy. This mixture was placed on a tortilla and served to the residents on mechanical soft diets along with sides of Spanish rice and black beans. R13, R84, R85, R91, R173 and R174 received the same. On January 5, 2025, at 11:59 AM, on request, V9 (Regional Director of Operation) provided the recipe of mechanical soft Chicken Fajita with Peppers and Onions. Recipe for the same included to follow the process shown on extension and production sheet for modified consistency diets. For the Ground consistency, the same recipe showed to process the number of servings of prepared Chicken Fajita with Peppers and Onions servings in a food processor until even ground texture is achieved with no pieces larger than 1/8 inch. On January 5, 2025, at 12:02 PM, V9 agreed that the onions that were in the ground chicken mixture for mechanical soft diets should have been less than 1/8th inch. When asked if residents on mechanical soft diets could have tortillas, V9 stated that tortillas are soft and that she would consider it odd to serve the chicken mixture on bread. V9 was requested to provide the facility policy for foods allowed for mechanical soft diets. Facility policy and procedure for Mechanical Soft Diet taken from 2025 edition of Diet Manual included as follows: The mechanical soft diet consists of foods that are in easy to chew form. The mechanical soft diet is indicated for residents with chewing difficulty, teeth loss, poor fitting dentures, mouth pain, or residents that require extensive time to complete a meal. Regular diet items should be mechanically altered, chopped or ground, so that it can be consumed by a resident with chewing difficulty. Food Characteristics included: Can be mashed/broken down with pressure from fork, spoon or chopsticks, bite size pieces (1/2 inch or less). Vegetables allowed: Vegetables that are cooked to a fork tender and mash able texture (no larger than 1/2-inch pieces). Starches: Foods to avoid included tortillas. On January 7, 2026, at 11:39 AM, V10 (Dietitian) stated that the facility should have followed the recipe to serve mechanical soft consistency chicken fajita with vegetables and foods allowed per policy. V10 stated that the scoop sizes for pureed diets should have been followed to provide adequate portions and nutrients for the meal. Facility Diet Order listing printed on January 5, 2026, included that R12, R60, 145246 Page 6 of 7 145246 01/08/2026 Pearl of Hinsdale, The 600 West Ogden Avenue Hinsdale, IL 60521

F 0803 R73 and R81 were on pureed diet and that R13, R84, R85, R91, R173 and R174 were on mechanical soft diet. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145246 Page 7 of 7