Inspection·February 9, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to check for GT (gastrostomy tube) placement prior to administration of medication and enteral feeding. This deficiency affects one (R71) of one resident in the sample of 27 reviewed for tube feeding management. Findings include: R71 was re-admitted on [DATE], with diagnoses listed in part but not limited to Dysphagia, Gastrostomy, and Encephalopathy. Physician order sheet indicates: Glucerna 1.2 150 ml every 4 hours. Flush with 120ml water every 6 hours. Flush enteral tube with 30ml water pre/post medication administration and 5-10ml water between each medication. On 2/6/24 at 3:35PM, V20, LPN (Licensed Practical Nurse), prepared R71's medication. V20 mixed and crushed medication with 5ml water in a medicine cup. V20 prepared 2 medicine cups and placed 5 ml of water each. R71 was lying in semi-sitting position. V20 took the GT 60ml syringe and removed the plunger. V20 connected the syringe into R71's gastric tube and poured the 5ml water for flushing, then the prepared medication, then 5ml water for flushing. V20 then connected the GT feeding of Glucerna 1.2 with 500ml remaining at 150ml/hr. V20 said that she does not have to check for GT placement, just need to flush with water. On 2/6/24 at 4:10PM, V2 DON (Director of Nursing) said they have to check for GT placement prior to administration of medication or enteral feeding. Facility's policy on Enteral tube medication administration, effective date 10/25/14, indicates: Policy: The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian and consultant pharmacist. Procedures: 8). With gloves on, check for proper tube placement using air and auscultation only. Never check placement with water. Facility's policy on General guidelines for administering medication via enteral tube, effective date 10/25/14, indicates: Policy: The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian and consultant pharmacist. Procedures: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145350 If continuation sheet Page 2 of 6 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 145350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Rolling Meadows,the 4225 Kirchoff Road Rolling Meadows, IL 60008 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 0693 F. Enteral tubes are flushed with at least 30ml of water before administering medications and after all medications have been administered. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145350 If continuation sheet Page 3 of 6 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 145350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Rolling Meadows,the 4225 Kirchoff Road Rolling Meadows, IL 60008 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to keep the controlled substance medications in the refrigerator per pharmaceutical/manufacturer's recommendation. This deficiency affects four (R36, R41, R97 and R98) of four residents reviewed for Medication Storage. Findings include: On 2/6/24 at 11:14AM, Checked narcotic medications in medication cart with V14, LPN (Licensed Practical Nurse). Observed the following medications with pharmaceutical instruction to store in refrigerator as written in medication container. V14 said those medications- morphine and lorazepam liquids should be kept in the refrigerator after administration. V14 said they should follow pharmaceutical recommendation. The following medications were found: 1)R41's Morphine sulfate 20mg /ml solution ( 5ml), left 4.25ml and Lorazepam 2mg/ml oral solution ( 5ml ), left 4.5ml. 2)R36's Morphine sulfate solution 20mg/ml ( 5ml), left 4.5ml. 3)R97's Morphine sulfate 20mg /ml ( 30ml) unopened; Morphine sulfate 20mg/ml ( 5ml), left 1.75ml and Lorazepam 2mg/ml( 5ml), left 2ml. 4)R98's Morphine sulfate 20mg/ml ( 5ml ) unopened and Lorazepam 2mg/ml ( 5ml) unopened. On 2/6/24 at 11:40AM, V2 DON (Director of Nursing) said morphine and lorazepam solution should be kept in refrigerator after using. Facility's policy on Storage of Medications, revision date 5/1/2018, indicates: Policy: Medication and biological are stored safely, securely, and properly, following manufacturer's recommendation of those of supplier. The medication supply is accessible only by licensed personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Procedures: C. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2C (36F) and 8C(46F) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within refrigerator or locked refrigerator at or near the nurses' station to in a refrigerator within locked medication room per IL Administrative Code Section 300.1640 d) Labeling and Storage of Medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145350 If continuation sheet Page 4 of 6 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 145350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Rolling Meadows,the 4225 Kirchoff Road Rolling Meadows, IL 60008 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure facility kitchen staff are wearing hair restraints (e.g., hairnet, hat and/or beard restraint) while preparing food to prevent hair from contacting food. This deficiency has potential to affect 127 residents who consumes meal from the kitchen. Findings include: On 02/06/24 at 10:05 AM, During initial round in the kitchen, V10, Dietary Director (DD), and V27, Cook, did not have a hair restraint. V27 was in the process of preparing food and cutting off ham meat. V27 was wearing a hairnet, and hair was exposed while preparing food. V10 came into the kitchen just wearing a hat with exposed long hair and beard, but no restraint. Rounded the kitchen with V10 who was not wearing hair restraint. On 02/07/24 at 10:10 AM, V10, DD, was wearing a hat with exposed long hair while cutting the carrots. V10 said he's wearing a hat. Surveyor asked if he is aware his hair is not fully restrained with just the hat on. V10 shrugged his shoulders On 02/07/24 at 10:15 AM, V1, Administrator, said kitchen staff should wear a hair restraint while in the kitchen. Facility Policy: TITLE: HAIR RESTRAINTS/JEWELRY/NAIL POLISH - No date Policy: Food and nutrition services employees shall wear hair restraints and beard guards. Employees shall avoid wearing excessive jewelry, nail polish or acrylic nails. Procedure: Hairnet, hat, or hair restraint will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145350 If continuation sheet Page 5 of 6 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 145350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Rolling Meadows,the 4225 Kirchoff Road Rolling Meadows, IL 60008 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to disinfect/sanitize medical equipment (digital blood pressure monitor and pulse oximeter) used after each resident during medication administration. This deficiency affects two (R86 and R112) of six residents in the sample of 27 reviewed for Infection control. Residents Affected - Few Findings include: On 2/6/24 at 10:17AM, V13, Registered Nurse (RN), took the digital blood pressure monitor from the medication cart and placed it on R112's left upper arm. V13 placed the pulse oximeter on R112's left index finger. V13 scanned R112's forehead to check for her body temperature. After taking vital signs, V13 placed all the medical equipment used on top of the medication cart without disinfecting/sanitizing them. V13 prepared scheduled medications and administered to R112. On 2/6/24 at 10:27AM, V13, RN, took the vital signs equipment (digital BP monitor, Pulse oximeter and thermometer) from the medication cart, without disinfecting it. V13 placed the digital BP monitor on R86's left upper arm. V13 placed pulse oximeter on left middle finger. After taking vital signs, V13 placed all the medical equipment used on top of the medication cart without disinfecting/sanitizing. V13 prepared scheduled medications and administered to R86. On 2/6/24 at 10:51AM, V13, RN, said she does not need to disinfect or sanitize the digital BP equipment and pulse oximeter after each resident use. V13 said she will sanitize/disinfect them at the end of each shift or after morning and noon time med pass, not after each resident usage. On 2/6/24 at 2:09PM, V3, Assistant Director of Nursing (ADON)/Infection Preventionist, said medical equipment such digital BP monitor and pulse oximeter should be sanitized/disinfected after each resident use. V3 added they use the disinfectant wipes to clean the medical equipment. Facility's policy on Cleaning and disinfection of Resident-Care items and Equipment, reviewed 5/28/23, indicates: Policy statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Procedure: 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment (DME)) 3. DME must be cleaned and disinfected before reuse by another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145350 If continuation sheet Page 6 of 6