Inspection·February 2, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide personal ADL (Activities of daily living) care for 4 residents (R5, R19, R17, & R65) who are dependent on ADL care in a sample of 31. Residents Affected - Some Findings include: 1. On 01/30/24 at 01:08 PM R5 was observed in her bed with long hair on her upper lip. R5 said that she did not like the hair on her lip and that staff never offer to shave her. R5's 1/9/24 care plan showed an ADL self-care deficit with interventions of physical assist with ADLs daily and as needed. R5's 1/15/24 MDS (minimum data set) section C showed that R5's mental cognition is intact. Section GG showed R5 needs setup or clean up assistance with personal hygiene. 2. On 01/30/24 at 12:21 PM, R17 was observed with long jagged fingernails with brown substances under the nails, hair on her chin, and her hair was observed oily. R17 said the last time her hair was washed was the previous week and that it bothers her very badly that her nails are not cut, she has hair on her chin and that her hair is dirty. R17 then told the surveyor that she needed her toenails cut badly. V14 (Nurse) came in the room and removed R17's shoes and socks. R17's toenails were observed long and curling under her toes. R14 said that she would put R17 on the list for the podiatrist to see. R17's EHR (electronic health record) showed that R17 is a diabetic. R17's MDS section C showed that her cognition is intact, and section GG showed that she needs supervision or touching assistance with personal hygiene. R17's 10/13/24 care plan showed ADL self-care deficit with interventions including physical assist with her ADLs. 3. On 01/30/24 at 11:27 AM R19 was observed with long jagged nails with brown substances under the nails. On 1/31/23 at 10:40am R19 was observed with long jagged nails with brown substances under the nails. R19's 12/20/23 care plan showed R19 has an ADL self-care performance deficit, with interventions including physical assist as needed with her ADLs. R19's care plan also showed a 10/20/23 care need for risk of pressure injuries and skin breakdowns with interventions including to keep fingernails short to avoid scratching. R19's 12/20/23 MDS section GG showed that R19 needs substantial maximal assistance with personal hygiene. 4. On 1/30/24 at 10:41 AM R65 was observed with long jagged nails with brown substances under the nails and a brown substance on his lips. R65 was also observed with long hair on his upper lip, chin, and neck. R65 told the surveyor that he would like to be shaved. On 1/31/24 at 11:48am R65 was observed with long jagged nails with brown substances under the nails and thick dry flaking skin on his scalp and face. R65's 1/24/24 care plan showed care needs due to a diagnosis of dementia with interventions including staff assisting with ADLs. R65's 1/23/24 MDS section GG showed that R65 is totally dependent for personal hygiene. On 1/31/24 at 11:48pm the state surveyor showed V4 (ADON) - Assistant Director of Nursing, the thick dry flaking skin on R65's scalp and face. V4 was then observed picking at R65's thick, dry, flaking skin, and said that personal hygiene should be done every day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 2 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete V22 CNA (Certified Nursing Assistant) said that she was R65's CNA for the day and she had not provided personal hygiene for him for that day. V22 said that she had only changed his brief and cleaned his perineal area that morning at the start of her shift. The facility's ADL policy (no date) showed residents will be provided with care treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene. Event ID: Facility ID: 145657 If continuation sheet Page 3 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers and ensure that it was readily available in the resident's medical record. This applies to 4 out of 4 residents (R13, R28, R34, R54) reviewed for pacemakers in a sample of 31. Residents Affected - Some Findings include: 1. R13's face sheet documents an admission date of 10/28/2021. R13's face sheet shows diagnoses including hypertension, atrioventricular block, heart disease with heart failure, and presence of cardiac pacemaker. R13's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked prior to the start of the survey. R13's POS (Physician Order Sheet) showed an order on 01/31/24 (during the survey) for Pacemaker checks every 3 months and Pacemaker site monitoring: Inspect site. Notify physician of discomfort, redness, or discharge at site. Document condition of incision on Skin Integrity Report. R13's record did not show assessments in the progress notes, admission assessment or care plans that document the manufacturer, model, and serial number of the pacemaker. R13's care plan dated 11/16/22 showed Pacemaker checks and document in chart: Heart rate, Rhythm, Battery check. R13's January 2024 TAR (Treatment Administration Record) did not show any orders for pacemaker site monitoring. R13's February 2024 TAR showed an order for pacemaker site monitoring starting 02/01/24. 2. R28's face sheet documents an admission date of 02/27/23. R28's face sheet documents diagnoses including Encounter for adjustment and management of other cardiac device, hypertension, and presence of cardiac pacemaker. R28's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked prior to the start of the survey. R28's POS (Physician Order Sheet) showed an order on 01/31/24 (during the survey) for Pacemaker checks per EP/cardiologist orders and Pacemaker site monitoring: Inspect site. Notify physician of discomfort, redness, or discharge at site. Document condition of incision on Skin Integrity Report. R28's record did not show assessments in the progress notes after her pacemaker was replaced in 06/23. R28's admission assessment did not mention the presence of a pacemaker, and R28's care plans did not document the manufacturer, model, and serial number of the pacemaker. R28's January 2024 TAR did not show any orders for pacemaker site monitoring. R28's February 2024 TAR showed an order for pacemaker site monitoring starting 02/01/24. 3. R34's face sheet documents an admission date of 03/03/23. R34's face sheet shows she was admitted with diagnoses including presence of cardiac pacemaker, type 2 diabetes mellitus, hyperlipidemia, and muscle weakness. R34's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked prior to the start of the survey. R34's POS (Physician Order Sheet) showed an order on 01/31/24 (during the survey) for Pacemaker checks per EP/cardiologist orders and Pacemaker site monitoring: Inspect site. Notify physician of discomfort, redness, or discharge at site. Document condition of incision on Skin Integrity Report. R34's progress notes did not show the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 4 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0684 Level of Harm - Minimal harm or potential for actual harm pacemaker was being checked and assessed. R34's care plan did not have any care plan showing she had a pacemaker or document the manufacturer, model, and serial number of the pacemaker. R34's January 2024 TAR showed pacemaker site monitoring starting 01/31/24. 4. R54's face sheet documents an admission date of 08/22/22. Residents Affected - Some R54's face sheet documents the following diagnoses: hypertension, atherosclerotic heart disease, and presence of cardiac pacemaker. R54's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked prior to the start of the survey. R54's POS (Physician Order Sheet) showed an order on 01/31/24 (during the survey) for Pacemaker checks every 3 months and Pacemaker site monitoring: Inspect site. Notify physician of discomfort, redness, or discharge at site. Document condition of incision on Skin Integrity Report. R54's record did not show assessments in the progress notes. R54's care plan did not have any care plans showing he had a pacemaker or document the manufacturer, model, and serial number of the pacemaker. R34's January 2024 TAR did not show an order for pacemaker site monitoring. R34's February 2024 TAR showed pacemaker site monitoring starting 01/31/24. On 01/31/24 at 10:28 AM, V11 (LPN/Licensed Practical Nurse) said she was unable to find progress notes showing the facility staff were checking the pacemakers for residents on her unit. On 01/31/24 at 10:42 AM, V32 (RN/Registered Nurse) said the pacemaker orders went into the POS today (01/31/24). V32 said she was not aware of residents other than R34 who had a pacemaker. On 01/30/24 at 01:44 PM, V2 (DON/Director of Nursing) said the facility did not have any residents with pacemakers. On 01/31/24 at 03:43 PM, V2 said she did an audit of the facility and found there were residents with pacemakers. V2 said the staff are responsible for checking and assessing the site of the pacemaker, and to make sure the pacemaker is functioning properly. V2 said the residents have a monitor in their room which needed to be checked to make sure it was operating properly. V2 said the facility's policy said the pacemaker should be checked every three to six months per the EP (Electrophysiology) orders. V2 said the nurses should be documenting their assessments of the site and the pacemaker checks in a progress note. V2 said the type of pacemaker and serial number should go into an admission note. V2 was not able to provide a log showing the pacemakers were being checked. The facility's Care of a Resident with a Pacemaker policy dated 10/01/21 showed, Documentation- 1. For each resident with a pacemaker, document the following in the medical record on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate. 2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, internet); b. Type of heart rhythm; c. Functioning of the leads; d. Frequency of utilization; and e. Battery life. 3. Use of and monitoring of the pacemaker will be addressed in the resident's comprehensive plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 5 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to prevent acquired pressure ulcers from worsening and new pressure ulcers from developing for 2 residents (R19 and R65) who were reviewed for wound care in a sample of 7. Residents Affected - Few Findings include: 1. On 1/31/24 at 10:40am R19 was observed in her bed. On the floor in her room was an air mattress. V14 (Nurse) said that the air mattress is supposed to be on her bed and the staff brought it in today and will be putting it on her bed. No specialized mattress was observed on R19's bed the previous day, 1/30/24, only a standard mattress was observed. R19's nails were observed long and jagged. V14 (Nurse) started providing wound care for R19, and V8 ADON (Assistant Director of Nursing) assisted V14. R19 was observed with 2 new wounds to her right and left buttocks. Right buttock with open wound with bright red liquid in wound size 3.5cm X 3 cm. the left buttock with bright red liquid size 4cm X 3.5 cm. R19's brief was observed with bright red liquid in brief. The wound to the sacrum was 1.5 cm X 1 cm and open. After wound care was completed, V8 pushed R19's soiled brief against all three cleaned wounds. At 11:15am V8 said she should not have pushed the dirty brief up on the clean wounds because of infection control. R19's EHR (Electronic Health Record) did not show any wounds to R19's right and left buttocks and the wound to sacrum (most recent notes provided dated 1/17/24) showed the sacrum size 0.9 X 6.1 X 0/1 cm. R19's 10/20/23 care plan showed a risk for pressure injuries and skin breakdown with interventions of air loss mattress and for fingernails to be cut short. R19's January's EMAR (electronic medication administration record) showed sacrum, clean with normal saline and pat dry, apply 6 by 6 boulder foam dressing every Monday Wednesday and Friday start date January 3rd, 2024. There was no documentation for Friday January 19th showing that this treatment was done. 2. On 1/31/24 at 11:48 am V14 (Nurse) was providing wound care for R65, V8 (ADON) and V21 (Hospice Nurse) were assisting V14. V14 removed dressing the from R65's left chest wound and the date on the dressing was 1/26/24, (last wound care was to be on Monday 1/29/24). The lower left back dressing was removed with a date of 1/26/24 on it, (last wound care was to be done on Monday 1/29/24). There was a total of 5 days between wound care for R65's Left chest wound and his lower left back wound. R65's EHR showed that on 1/31/23 R65's wound to his sacrum was now positive for MRSA (Methicillin Resistant Staphylococcus Aureus) R65's current physician order sheets showed orders: 1/18/24 left buttock - paint with skin prep and let dry. Apply border form dressing every Mon, Wed, and Fridays. 1/3/24 left chest anterior apply calcium alginate and border form dressing every Mon, Wed, and Fridays. 1/18/24 left lower back paint with skin prep and let dry. Cover with border foam dressing every Mon, Wed, and Fridays. 1/18/24 Right upper back paint with skin prep and let dry. Cover with border foam dressing every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 6 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0686 Mon, Wed, and Fridays. Level of Harm - Minimal harm or potential for actual harm 1/18/24 sacrum apply Dakins solution daily and as needed to wound. R65's January EMAR (electronic medication administration record) showed: Residents Affected - Few Left lower back - paint with skin prep cover with border foam dressing every Mon, Wed, Fri. - not done 1/19/24 Right upper back - paint with skin prep and apply border foam dressing every Mon, Wed, Fri. - not done 1/19/24. Left chest anterior - cleanse with normal saline apply calcium alginate and apply border foam dressing Mon, Wed, Fri - not done 1/19/24. Sacrum - apply Santyl ointment every day for wound care after cleanse with normal saline - not done on 1/19/24. Apply Dakins to sacrum every day - not done on 1/19/24. Left buttock - paint with skin prep and let dry, apply border foam dressing - not done on 1/19/24. R65's 10/20/23 care plan showed a focus on pressure injuries and skin breakdowns with interventions of treatment per physician orders. R65's Sacrum wound notes showed 1/24/24 - stage 4 4.0 X 10.3 X 0.6 cm. 2/1/24 - Sacrum stage 4 13.6 X 15 X 2. R65's left buttock wound notes: 1/24/24 - 7.1 X 6.9 X not measurable. 2/1/24 - signed off because wound merged into another site. R65's right upper back wound notes: 1/24/24 - 2.9 X 4 X 4cm. 2/1/24 - 2.9 X 3.5 X not measurable. On 1/31/24 at 3:35pm V2 DON (Director of Nursing) said that the facility did not have a wound care nurse and some residents wound care treatments are being missed because they do not have enough floor nurses to do the wound care. On 2/1/24 at 1:45pm V2 said that if a resident is to have an air mattress on their bed for a pressure wound and they don't have it on they can develop a new wound or the wound they have can worsen. On 2/1/24 at 10:01 V4 (Staffing Coordinator) said that since the wound nurse left, she sometimes is unable to get nurses in to do wound care. On 2/2/24 at 3:36 PM, V1 (Administrator) said that when the medication is given or treatment is completed the nurse is to initial the EMAR, if it is blank, I would assume the medication was not given or the treatment was not completed. The facilities pressure injury prevention and management policy dated May 2023 shows that the intent of this organization is to develop and maintain systems and processes to ensure that the residents do not develop pressure ulcers/injuries . The facility provides care and services consistent with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 7 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete professional standards of practice to promote the prevention of pressure ulcers and injury development, to promote the healing of existing pressure ulcers or injuries including prevention of infection to the extent possible and prevent development of additional pressure ulcers or injuries. The policy showed that the preventive measures and preventive interventions will be implemented based on pressure ulcer injury risk assessment. The interventions include the use of pressure reducing relieving support surfaces or devices that assist with pressure redistribution of tissue load, assist with personal hygiene and ADLs .Treatments will be ordered by the physician or practitioner, treatments and interventions may include but not limited to medication, biologics, wound coverings, and support devices. Treatments including preventive interventions will be documented in a resident's medical records, the physician or practitioner will be notified of the resident's refusal of prescribed treatment and or interventions for prevention of care. Event ID: Facility ID: 145657 If continuation sheet Page 8 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative services or treatment to prevent a decreased range of motion for a resident admitted with a limited range of motion. This applies 1 of 5 (R7) reviewed for range of motion in a sample of 31. The findings include: The EMR (Electronic Medical Record) showed R7 admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, gout, muscle weakness, and fibromyalgia. The MDS (Minimum Data Set) dated 10/20/2023 showed R7 was severely cognitively impaired. The MDS continued to show R7 had upper extremity impairment on one side and was dependent on facility staff for self-care needs. R7's Nursing admission assessment dated [DATE] showed R7 had decreased left-hand grasp and left arm and leg weakness at the time of admission to the facility. The assessment continued to show that R7 had general weakness and a decline in functional mobility to the left side due to a history of cerebral vascular accident. On 1/30/2024 at 10:58 AM, R7 was in bed sleeping. R7's left hand was in a flexed fixed grip and her left foot was turned inward in a fixed extended position. R7's left hand and foot were contracted. On 2/01/2024 at 9:05 AM, V11 (Licensed Practical Nurse/LPN) said she was assigned to R7. V11 said she reviewed R7's chart and asked nursing staff and confirmed R7 was not receiving restorative services or had an order for hand splints. V11 said the facility did not have a restorative nurse. On 2/01/2024, V2 (Director of Nursing/DON) and V9 (Regional DON) said the facility did not have a restorative program. V2 continued to say that there was no staff doing mobility assessments for the residents. On 2/01/2024 at 10:27 AM, V10 (Therapy Director) said he was not familiar with R7 but was informed that there was a physician order for therapy evaluation for left contraction today. V10 said residents with contractions need to be assisted to maintain their highest level of function, if not they can get more contracted and have decreased mobility. V10 said residents with contractions may need range of motion and stretching exercises, or splints. The facility's Restorative Nursing Services policy undated, showed Policy: Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Specific Procedures/Guidance .2. Restorative nursing care will be provided by qualified and competent staff and in accordance with federal/state regulation and/or guidance. 3. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 4. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care .6. Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining or strengthening his/her physiological and psychological resources; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 9 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow fall interventions for residents identified as high risk for falls. This applies to 3 of 5 (R28, R42, and R64) reviewed for falls in a sample of 31. The findings included: 1. The EMR (Electronic Medical Record) showed R28 was admitted to the facility on [DATE], with multiple diagnoses including dementia, muscle weakness, abnormalities of gait and mobility, and age-related physical debility. The MDS (Minimum Data Set) dated 12/31/2023 showed R28 was severely cognitively impaired. The MDS continued to show R28 required substantial to maximal physical assistance with bed mobility and transfers from facility staff. R28's Morse Fall Scale dated 1/26/2024, showed R28 was a high risk for falls. R28's fall incident reports from 12/15/2023 to 1/15/2024, showed R28 had a total of six unwitnessed falls in her room. R28's fall incident reports dated 1/07/2024 at 3:50 PM, 1/15/2024 at 8:00 AM, and 1/15/2024 at 10:08 PM, all showed R28 was observed on the floor beside her bed. R28's fall care plan dated 2/01/2024, showed multiple fall interventions including applying a mat on the floor and a low bed landing mat in place when in bed. On 1/30/2024 at 11:04 AM, R28 was lying diagonally across her bed with her legs extending out and resting on top of her wheelchair seat. There was a floor mat folded up on the side of the room, not on the floor. 2. The EMR showed R42 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, epilepsy, dementia, and muscle weakness. The MDS dated [DATE] showed R42 was severely cognitively impaired. The MDS continued to show R42 was dependent on facility staff for transfers. R42's Morse Fall Scale dated 11/05/2023, showed R42 was a high risk for falls. R42's fall incident reports dated 8/14/2023 and 11/05/2023, showed R42's falls were unwitnessed in the dining room. R42's fall incident reports continued to show R42 slid down from his chair during both incidents. R42's fall care plan dated 2/01/2024, showed multiple fall interventions including applying a Dycem (non-slip material) device to his reclining geriatric wheelchair and keeping in an area of high visibility. On 1/30/2024 at 10:52 AM and 1/31/2024 at 1:12 PM, R42 was sitting in his reclining geriatric wheelchair in his room. R42 did not have a Dycem (non-slip material) device placed on his reclining geriatric wheelchair at the time of both observations. 3. The EMR showed R64 was admitted to the facility on [DATE], with multiple diagnoses of fractures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 10 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0689 Level of Harm - Minimal harm or potential for actual harm to his left fibula, lumbar vertebra, and left side ribs, muscle weakness, repeated falls, and dementia. The MDS dated [DATE] showed R64 was cognitively impaired. The MDS continued to show R64 required substantial to maximal physical assistance from facility staff for transfers. R64's Morse Fall Scale dated 12/16/2023, showed R64 was a high risk for falls. Residents Affected - Few R64's fall incident report dated 5/24/2023, showed R64's fall was unwitnessed and slid from his recliner chair. R64's fall care plan dated 2/01/2024, showed multiple fall interventions including providing a high-back recliner wheelchair with Dycem (non-slip material) device. On 1/30/2024 at 11:10 AM and 1/31/2024 at 11:44 AM, R64 was sitting in his high-back wheelchair in his room. R64 did not have a Dycem (non-slip material) device placed on his wheelchair at the time of both observations. On 2/01/2024 at 11:28 AM, V2 (Director of Nursing/DON) said she expects the nursing staff to implement resident fall interventions such as low bed, floor mats, and Dycem (non-slip material) devices to prevent falls from happening and keep fall risk residents safe. The facility's Fall and Fall Risk Management policy undated, showed Policy: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Resident-Centered Approaches to Managing Falls and Fall Risk- .7. In conjunction with the attending physician/practitioner, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 11 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 32 opportunities with 4 errors, resulting in a 12.5% error rate. This applies to 2 (R15 and R26) of the 5 residents observed in medication pass. Residents Affected - Few 1. On 1/31/24 at 9:25 AM, V14 (LPN/Licensed Practical Nurse) had finished removing and preparing medications for morning medication pass and was going into R15's room to give medications. Surveyor then counted the pills in R15's pill cup and noticed there were only 8 pills when there should have been 10 pills. The medication pass was stopped and V14 was told she was missing 2 pills. V14 then went back through each due medication again and realized she did not remove the Amiodarone 200 mg (milligram) tab or the Furosemide 20 mg tab from their pill cards and she would have missed giving them to R15. This counts as two errors, for two missed medications. R15's Face sheet shows the following diagnoses: Atrial Fibrillation and Hypertension. R15's POS (Physician Order Sheet) shows the following orders: Amiodarone 200 mg tab orally one time a day related to atrial fibrillation and Furosemide 20 mg tab orally one time a day related to edema. R15's MAR (Medication Administration Record) shows Amiodarone and Furosemide are both scheduled for AM medication pass. 2. On 1/31/24 at 12:09 PM, V11 (LPN) administered 2 units of Humulin N insulin to R26 from insulin pen. After providing privacy for R26 and performing hand hygiene, V11 put on gloves, pulled the cap off the Humulin N insulin pen, cleaned the top of the pen with alcohol, screwed the needle onto the top of the pen, dialed the pen up to 2 units, wiped R26's right lower abdominal quadrant with alcohol, and administered 2 units from Humulin N pen. V11 did not expel air from the Humulin N pen prior to administering the insulin. Surveyor then verified R26's insulin order against R26's POS (Physician Order Sheet) and MAR (Medication Administration Record) and saw the insulin ordered was Humalog Lispro insulin, NOT Humulin N. R26's Face sheet shows diagnoses of type 2 Diabetes Mellitus and long term use of insulin. R26's POS shows order with start date of 11/30/2023: Humalog Kwikpen (insulin Lispro) subcutaneous 100units/mL (milliliter) Inject as per sliding scale, subcutaneously three times a day. R26's January MAR shows the Humalog Kwikpen (insulin Lispro) sliding scale is ordered three times a day at 9 AM, 1 PM, and 5 PM. Neither R26's POS nor her MAR show a current order for Humulin N insulin. On 1/31/24 at 1:24 PM, V11 (LPN) was asked to remove R26's insulin pen that she administered insulin at 12:09 PM from the medication cart. V11 removed the Humulin N pen from the cart and surveyor asked V11 to pull up R26's MAR on her computer screen to verify the insulin order. V11 realized she administered the wrong insulin to R26, and she said she was going to call R26's doctor to notify them that she gave the wrong insulin. V11 then said she should have primed the air from R26's insulin pen to make sure the resident gets the insulin during the injection, and not just the air from the pen. V11 said the harm with administering the wrong type of insulin is that the resident's blood sugar can drop too low. These two insulin errors, wrong insulin and wrong administration technique, count as two medication errors. On 1/31/24 at 4:16 PM, V2 (DON/Director of Nursing) said missing a dose of Amiodarone is harmful because it can cause the resident's heart rate to become unstable. V2 said missing a dose of Furosemide is harmful because it can cause the resident to become fluid overloaded which can lead to swelling and breathing difficulty. V2 said giving a resident Humulin N insulin instead of Novolog Lispro (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 12 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insulin is harmful because it can cause a major drop in the resident's blood sugar which can lead to seizures or shock. V2 said all insulin pens need to be primed before insulin is administered to remove the air from the pen. V2 said if the pen is not primed before insulin administration, the resident will not get the correct dose of insulin which can lead to hyperglycemia/high blood sugar. The facility's policy titled, General Guidelines for Medication Administration dated 09/2018 states, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices .Procedures: I. Preparation: .4. At a minimum, the 5 Rights-right resident, right drug, right dose, right route, and right time-should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared .a. Check #1: Select the medication, check the label, container, and contents for integrity, and compare the medication against the Medication Administration Record (MAR) by reviewing the 5 rights. b. Check #2: Prepare the dose by removing the dose from the container and verifying it against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights .II. Administration: .2. Medications are administered in accordance with written orders of the prescriber . The facility's policy titled, Insulin Administration dated 10/1/2021 states, Policy: To provide guidelines for the safe administration of insulin to residents with diabetes . General Guidelines .Steps in the Procedure (Insulin injections via Insulin Pen)- .Prime the insulin pen by removing air bubbles from the needle and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears. Select the dose of insulin that has been prescribed by turning the dosage knob. Check that the dose is correct . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 13 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0760 Ensure that residents are free from significant medication errors. 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 ensure residents were free from significant medication errors related to cardiac medications, insulin, and intravenous antibiotics. This applies to 4 residents (R15, R26, R36 and R63) reviewed for medications. Residents Affected - Some The findings include: 1. On 1/31/24 at 9:25 AM, V14 (LPN/Licensed Practical Nurse) had finished removing and preparing medications for morning medication pass and was going into R15's room to give medications. Surveyor then counted the pills in R15's pill cup and noticed there were only 8 pills when there should have been 10 pills. The medication pass was stopped and V14 was told she was missing 2 pills. V14 then went back through each due medication again and realized she did not remove the Amiodarone 200 mg (milligram) tab or the Furosemide 20 mg tab from their pill cards and she would have missed giving them to R15. R15's Face sheet shows the following diagnoses: Atrial Fibrillation and Hypertension. R15's POS (Physician Order Sheet) shows the following orders: Amiodarone 200 mg tab orally one time a day related to atrial fibrillation and Furosemide 20 mg tab orally one time a day related to edema. R15's MAR (Medication Administration Record) shows Amiodarone and Furosemide are both scheduled for AM medication pass. R15's Care Plan dated 11/28/23 shows R15 is on diuretic therapy related to hypertension and interventions include administer diuretic medication Furosemide as ordered by physician. Care plan also shows R15 has altered cardiac status related to hypertension and atrial fibrillation. 2. On 1/31/24 at 12:09 PM, V11 (LPN) administered 2 units of Humulin N insulin to R26 from insulin pen. After providing privacy for R26 and performing hand hygiene, V11 put on gloves, pulled the cap off the Humulin N insulin pen, cleaned the top of the pen with alcohol, screwed the needle onto the top of the pen, dialed the pen up to 2 units, wiped R26's right lower abdominal quadrant with alcohol, and administered 2 units from Humulin N pen. V11 did not expel air from the Humulin N pen prior to administering the insulin. Surveyor then verified R26's insulin order against R26's POS (Physician Order Sheet) and MAR (Medication Administration Record) and saw the insulin ordered was Humalog Lispro insulin, NOT Humulin N. R26's Face sheet shows diagnoses of type 2 Diabetes Mellitus and long term use of insulin. R26's POS shows order with start date of 11/30/2023: Humalog Kwikpen (insulin Lispro) subcutaneous 100units/mL (milliliter) Inject as per sliding scale, subcutaneously three times a day. R26's January MAR shows the Humalog Kwikpen (insulin Lispro) sliding scale is ordered three times a day at 9 AM, 1 PM, and 5 PM. Neither R26's POS nor her MAR show a current order for Humulin N insulin. R26's Care Plan dated 11/17/23 shows R26 has Diabetes Mellitus and receives insulin and interventions include administer Diabetes medication as ordered by doctor. On 1/31/24 at 1:24 PM, V11 (LPN) was asked to remove R26's insulin pen that she administered insulin at 12:09 PM with from the medication cart. V11 removed the Humulin N pen from the cart and surveyor asked V11 to pull up R26's MAR on her computer screen to verify the insulin order. V11 realized she administered the wrong insulin to R26, and she said she was going to call R26's doctor to notify them that she gave the wrong insulin. V11 then said she should have primed the air from R26's insulin pen to make sure the resident gets the insulin during the injection, and not just the air from the pen. V11 said the harm with administering the wrong type of insulin is that the resident's blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 14 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0760 sugar can drop too low. Level of Harm - Minimal harm or potential for actual harm On 1/31/24 at 4:16 PM, V2 (DON/Director of Nursing) said missing a dose of Amiodarone is harmful because it can cause the resident's heart rate to become unstable. V2 said missing a dose of Furosemide is harmful because it can cause the resident to become fluid overloaded which can lead to swelling and breathing difficulty. V2 said giving a resident Humulin N insulin instead of Novolog Lispro insulin is harmful because it can cause a major drop in the resident's blood sugar which can lead to seizures or shock. V2 said all insulin pens need to be primed before insulin is administered to remove the air from the pen. V2 said if the pen is not primed before insulin administration, the resident will not get the correct dose of insulin which can lead to hyperglycemia/high blood sugar. Residents Affected - Some 3. R36's face sheet showed R36 had osteomyelitis on the left ankle and foot and methicillin-resistant staphylococcus aureus infection of the left leg wound. R1's face sheet's special instruction also showed Contact isolation for Escherichia coli (stomach infection), Methicillin Sensitive Staphylococcus Aureus (MSSA), Streptococcus, and Enterococcus of the Wound. 01/30/24 11:38 AM R36, who is alert and interviewable, said he has been receiving Vancomycin intravenous (IV) administration therapy since he was admitted on [DATE]. R36 said that he did not receive his full antibiotics on 01/30/2024 morning since most of his IV medications were leaked, and medication administration ended within 15 minutes instead of one and a half hours. Observed fluid under the IV pole on the floor, and V16(Registered Nurse) said the administration was done by V30 (Registered Nurse- night nurse), and she does not know anything about it. The writer could not reach V30, and V2(Director of Nursing) said she could not reach V30 either. R36's Physician order sheets dated 01/13/2024 and 01/25/2023 showed to administer Vancomycin 1000 milligrams two times for infection. A review of the Vancomycin Administration record showed that R36 missed the morning dose of 1000 milligrams of Vancomycin on 01/26/2024 and 01/27/2024. On 02/01/2024 at 3:30 PM, V2(Director of Nursing) said V30 should have disconnected the medication's administration and called R36's physician to readminister the correct dose. V2 said nurses should have ensured R36 received Vancomycin as scheduled, notified the physician of the error, and reported it to the supervisors. 4. R63's face sheet showed R63 had diagnoses of cellulitis of the upper and lower limbs, sepsis, and bacteremia. R63's Physician order sheet dated 12/28/2023 to 01/15/2024, 01/16/2024-01/17/2024, and 01/17/2024 to 01/26/2024 showed Vancomycin 750 milligrams intravenously daily for infection. Reviewed R63's Vancomycin Administration sheet, and it showed R63 received medication administration at inconsistent times, including significant variations dated 01/19/2024 at 09:31 PM, 01/20/2024 at 00:21 AM, 01/21/2024 AT 10:33 PM, On 02/01/2024 at 3:30 PM, V2(Director of Nursing) said Vancomycin daily orders should be administered every 24 hours. On 02/02/2024, V31(Pharmacist-Director of Quality) said antibiotics should be administered within a standard time frame. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 15 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's General Guidelines for Medication Administration policy was revised in August 2020 in part showed 1. The facility establishes a schedule of routine administration time and utilizes it on the administration record. 2. Medications are administered within 60 minutes of scheduled administration times. The facility's policy titled, General Guidelines for Medication Administration dated 09/2018 states, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices .Procedures: I. Preparation: .4. At a minimum, the 5 Rights-right resident, right drug, right dose, right route, and right time-should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared .a. Check #1: Select the medication, check the label, container, and contents for integrity, and compare the medication against the Medication Administration Record (MAR) by reviewing the 5 rights. b. Check #2: Prepare the dose by removing the dose from the container and verifying it against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights .II. Administration: .2. Medications are administered in accordance with written orders of the prescriber . The facility's policy titled, Insulin Administration dated 10/1/2021 states, Policy: To provide guidelines for the safe administration of insulin to residents with diabetes . General Guidelines .Steps in the Procedure (Insulin injections via Insulin Pen)- .Prime the insulin pen by removing air bubbles from the needle and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears. Select the dose of insulin that has been prescribed by turning the dosage knob. Check that the dose is correct . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 16 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly label, contain, and store medications. This applies to 5 residents (R17, R15, R24, R16, and R49) reviewed for medication storage in a sample of 31. Findings include: 1. On 2/1/24 at 10:09 AM, the [NAME] back hall medication cart was checked with V13 (RN/Registered Nurse). When checking narcotics on this cart, R17's bingo card for Hydrocodone-APAP 5-325mg tablets was found with 13 pills in it, but the pill in the 13th slot/hole was different than the other 12 pills and the 13th slot/hole was punctured and taped closed. The pill in the 13th slot was an ovular white pill, scored on one side and 'G037' printed on the other side. The pills in slots 1-12 were not punctured, ovular with a slight pink shade, scored on one side and 'WES301' printed on the other side. V13 verified that it was a different pill in slot 13 and said he did not know anything about the pill being switched with another pill. It was verified the pill in the 13th slot was Hydrocodone 10/325 and the pills in slots 1-12 were Hydrocodone 5/325, so the narcotic pill in the 13th slot was twice as strong as the pills in slots 1-12. On 2/1/24 at 10:47 AM, V2 (DON/Director of Nursing) was shown the bingo card for R17 and confirmed the pill in the 13th slot was different from the other On 2/1/24 at 2:04 PM, V2 said once a narcotic is punched out of a bingo card and the seal is broken, the nurse is supposed to waste the medication with another nurse verification and document the pill as wasted. V2 said the pill is not supposed to be put back in the bingo card and taped once it is removed, because the nurse may accidentally put the wrong pill back in the card and create a medication error. 2. On 1/31/24 at 9:55 AM, during incontinent care, R15 asked V12 (CNA/Certified Nurse Assistant) to get her powder from her bin with her belongings, to put under her breasts and her abdominal folds. V12 then went into R15's belongings at the bedside and found a small container of Nystatin powder. V12 asked R15 if that was what she was talking about and R15 said yes, that's the powder. V12 then asked V14 (LPN/Licensed Practical Nurse) if she could put the Nystatin powder on R15. V14 (LPN) told V12 (CNA) that she could not put the Nystatin powder on R15, and she needed to obtain a doctor's order for the medication. On 1/31/24 at 10:30 AM, R15 said she puts the Nystatin powder on herself twice a day and she does not tell her nurse because, it's not medicine, it's just powder. R15's MDS (Minimum Data Set) dated 11/28/23 shows her cognition is severely impaired. R15's Face sheet shows diagnosis of Dementia. On 1/31/24 at 4:16 PM, V2 (DON/Director of Nursing) said R15 has dementia and does not have an order to administer her own medications. V2 said R15's Nystatin should not be kept at her bedside and if R15 was self-administering Nystatin and she did not have a doctor's order for the medication, the facility would not be in compliance and the doctor would not be aware that R15 was receiving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 17 of 18 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 145657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pearl of Downers Grove 3450 Saratoga Avenue Downers Grove, IL 60515 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 Nystatin. Level of Harm - Minimal harm or potential for actual harm 3. On 1/31/24 at 11:54 AM, the [NAME] back hall medication cart was checked with V11 (LPN/Licensed Practical Nurse) and the following was found: 1. A Ventolin HFA-albuterol sulfate inhaler with no resident name label and expiration date of April 2020, 2. An uncontained/unbagged fluticasone nasal spray for R24 with no cap on the nasal applicator, 3. An uncapped/unbagged fluticasone nasal spray for R16 with no cap on the nasal applicator, and 4. An uncapped/unbagged fluticasone nasal spray for R49 with no cap on the nasal applicator. V11 said the nasal sprays not properly capped or contained is a hygiene and infection control issue because she did not know if the uncapped tips that go into the 3 residents' noses are touching each other and becoming contaminated. Residents Affected - Some On 1/31/24 at 4:16 PM, V2 said all medications should be labeled and contained in the medication carts. V2 said you need to be able to decipher who each medication belongs to and not keeping all medications capped and bagged is a contamination risk. V2 said the fluticasone nasal sprays not being capped can lead to contamination and respiratory infection. V2 said all expired medications should be thrown away. The facility's policy titled, Controlled Substance Disposal revised 10/19/22 states, Policy: Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Specific Procedures/ Guidance: .2. When a dose of a controlled substance is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed personnel, and/or in accordance with the facility policy and state regulations, and the disposal is documented on the accountability record on the line representing that dose . The facility's undated policy titled, Medication Storage states, Policy: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Specific Procedures/Guidance: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 18 of 18