Health inspection·March 25, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that she talked to V12 yesterday and V12 complained that she emailed two emails to V3, and he never responded back. V12 forwarded those emails to V1. V1 then printed those emails and submitted them to surveyor. V1 stated that V3 should have replied back to (R1's) concerns. V1 stated she did not have concerns form for R1. Review of V12's emails to V3 shows there were two emails sent on 3/14/24 at 2:58 PM and 4:16 PM. V12 had concerns of R1's Medicare coverage of therapy, missing medications for R1 and a bill, having a difficult time making phone calls, having problems eating, speech therapy, R1's falls from her wheelchair, and transportation cost of $100 dollars to her appointment. R1's care plan progress notes from 3/13/24 by Social Services shows the following key points discussed during the care plan meeting: (R1) is unable to put weight on her left wrist, hindering her ability to use the walker effectively. An upcoming appointment will determine (R1's) weight-bearing status, potentially impacting her rehabilitation goals. The family expressed a desire for long-term care within the facility. The family expressed interest in exploring private therapy options after discharge. (R1) reporting a non-functioning room phone. Social services will arrange a replacement. The family mentioned concerns regarding (R1's) swallowing difficulties, which she had not previously disclosed to staff. The therapy manager advised a speech evaluation. Action items: Schedule a speech evaluation for (R1). Address the reported phone malfunction with social services. On 3/23/24 at 2:42 PM, telephone interview was done with V13 (Unit Manager/LPN). V13 stated, Yes, 3/13/24 was (R1's) care plan meeting. I told (V12) that I would look for (R1's) medications. (V8-LPN) had put them in the medication room because she found them in the medication cart. (V8) thought we are not supposed to use the resident's medications from home as per her prior DON (Director of Nursing) when it was a different company. I put the medications in my office. I did not tell (V12) that I found (R1's) medications. I wanted to send (V12) a professional email, but then maybe I thought I should give her a quick phone call. But I didn't get time. I'm still learning things. I got busy helping out CNA's (Certified Nursing Assistants) on the floor, attending meetings, and just being pulled in every direction. So, I'm sorry for that. I should have got back to her. On 3/24/24 at 11:30 AM, V15 called back surveyor. She stated she was not made aware that V12 received a bill for R1's medications from the pharmacy. She said she was never told by V1 or V3 to reimburse V12. Facility's policy titled Grievances/Complaints, Recording and investigation (Unknown Date) shows: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. 5. The Grievance officer/designee will record and maintain all grievances and complaints on the facility approved logs. 6. The administrator will be notified of receipt of the grievance, plans for investigation, conclusions and actions taken in response to the grievance. 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well any corrective actions recommended. 9. Documentation of the investigation and actions taken in response to the will be maintained at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 2 of 7 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 03/25/2024 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 - Many Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to supervise/monitor and provide a safe environment for residents by not having a front desk receptionist or locking facility doors during certain hours for one day (Sunday) of the week. This applies to all 76 residents in the facility. The findings include: On 3/23/24 at 9:55 AM, the Manager on Duty, V16 (Central Supply and Medical Records Coordinator), submitted a resident roster with 76 residents. On 3/23/24 at 10:28 AM, V2 (DON-Director of Nursing) stated, We don't have a front desk receptionist on Sundays. There is always a MOD (Manager on Duty) on the weekends, but they are not at the front desk. They are on the floors. Anyone can come in until 8 PM on Sundays. The evening nurse locks the front doors at 8 PM. There's a sign on the door that says visitors can come in through the unlocked doors on Sunday and they have to sign the visitor book. I talked to Corporate and the Administrator about this. It's not safe. I told them we need to hire another front desk receptionist. We need to make sure no one except resident visitors are coming in. We haven't hired anyone as of yet. Sometimes, V4 (Front Desk Receptionist) has to work in the assisted living for a couple of hours leaving the skilled front desk. You can't monitor who's coming in then. On 3/23/24 at 10:42 AM, V16 stated, (V5-Front Desk Receptionist) had an accident about a month ago, I think. So, we don't have a front desk receptionist on Sundays. The door is open from 8 AM to 8 PM. Visitors and family members can come in and they just have to sign in the book. Management is trying to recruit someone to fill the position. Anyone can walk in, so I think it's better to have someone at the front desk, so we can see who's coming in and going out. It's safer. On 3/23/24 at 10:47 AM, V8 (LPN-Licensed Practical Nurse) stated, I usually come to the building through the back doors. We have to swipe our badge. On Sundays, there is no desk receptionist. Anyone can walk in the building because the doors are unlocked. That's not safe. If they don't have a desk receptionist, then they should lock the front doors. There is a doorbell, and the nurses can hear it at the nursing station and let the visitor in. On 3/23/24 at 11:16 AM, V4 (Front Desk Receptionist) stated, Yes, I'm working today and tomorrow (Sunday). Tomorrow is the first Sunday that I will be working. Yes, there were some Sundays where there was no desk receptionist. I am not sure of the exact dates. The main receptionist (V5) is out. I think she has been out for 3 weeks maybe. I'm not sure. On Sundays, the nurses open the door in the morning and then it's open till 8 PM, where it's locked by the nurses. I don't think it's safe because anyone can come in. Visitors just sign in and then they go to the floors on Sundays. That's not right. On 3/23/24 at 11:35 AM, R1 stated, That's not safe if there is no front desk receptionist working on Sundays. There should be someone at the front desk if those doors are unlocked. On 3/23/24 at 11:51 AM, R2 stated, I feel safe here. It's a nice area. But yes, they could be safer here if they had a front desk receptionist on Sundays because the door is unlocked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 3 of 7 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 03/25/2024 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 - Many On 3/23/24 at 11:53 AM, R3 stated, There should be someone at the front desk because if the doors are open, someone can come in because we have incapacitated residents here. And someone can steal from the residents. Anything can happen. On 3/23/24 at 12:00 PM, V6 (LPN) stated, I think they should have a desk receptionist also on Sundays for safety problems. What if someone who was banned from coming into the building enters and hurts the residents. Anyone can walk in because those doors are unlocked. That's an issue. On 3/23/24 at 12:15 PM, V1 (Administrator) submitted a facility data sheet which shows the facility has 76 residents. On 3/23/24 at 12:29 PM, V1 (Administrator) stated, (V5) who was our desk receptionist has been gone about 3 weeks. She had an extreme hand injury. On 3/17/24, we must not have had that Sunday covered with a front desk receptionist. I don't know the exact dates when we didn't have one. I know (V4) is currently working a few hours here in skilled and a few hours in assisted living. She's splitting her time. We are hiring for that position. We had 2 interviews for a part time position. Of course, there should be a front desk receptionist because the doors are unlocked. We need to know who's coming in. There's always family drama bound to happen. We need to keep our residents safe. On 3/23/24 at 1:40 PM, V12 (R1's daughter) stated via telephone the following, On Sunday 3/17/24, my sister (V17-R1's daughter) and V18 (R1's son-in-law) came to visit her. The doors were open to the facility and there was no front desk receptionist working that day. Visitors had to sign in the book. What if my mom rolls out in her wheelchair outside of the building. Some residents do that. I'm sure there are other residents who might do that or run away. Also, what if unknown people who are violent or banned from the facility come in? My sister is bipolar, and she could be violent. What if I had her banned from visiting my mom but she was able to come in on a Sunday because there was no front desk receptionist. She could harm my mom and that's concerning to me. On 3/23/24 at 2:30 PM, V9 (MDS/Minimum Data Set Coordinator/LPN) confirmed that R4, R5, and R6 are residents that are an elopement risk. R4-R6's elopement risk assessments and care plans show that they are at risk and wear an electronic monitoring bracelet. V9 confirmed that these residents can be affected by the open doors and no front desk receptionist on Sundays. Facility's policy titled Elopement/Missing Person (Unknown Date) shows: It is the intent of the facility to provide a safe and home-like environment for all residents to provide adequate supervision and assistance to prevent accidents. V1 was unable to provide a policy on front desk receptionists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 4 of 7 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 03/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to use resident's medications brought from home at the time of admission and verify and reconcile those medications with the physician and pharmacist. This caused R1 to be charged by the insurance company for medications that were ordered through the facility's pharmacy. The facility also failed to return the medications back to the responsible party. This applies to 1 of 3 residents (R1) reviewed for medications in sample of 6. The findings include: On 3/23/24 at 9:58 AM, telephone interview was conducted with V2 (DON-Director of Nursing). V2 stated the following: (V13-Unit Manager/LPN-Licensed Practical Nurse) is working on this issue. She attended (R1's) care plan meeting with (R1), (V3-Social worker), V9 (MDS/Minimum Data Set Coordinator/LPN), and (V12-R1's daughter) who lives out of state via phone. We did not know where R1's medications were. (V12) stated she gave it to the nurse at the time of admission. No one notified the management team that (R1's) medication was brought in. We tried to talk to (V12) as much as we could. We didn't know about the missing medications until the care plan meeting. (V13) started looking for (R1's) medications. When we had our stand down meeting which are in the late afternoons, we discussed reimbursing the family for the medications. On 2/23/24, the admitting nurse for (R1) was (V11 LPN/Agency). I tried to get in touch with her, but I was unable to contact her. She never replied back. (R1) came that day to us during shift change. V11 (LPN) worked in the evening that day. I'm not sure who did the actual admission. I talked to (V9) a few minutes ago and she said that (V13) found (R1's) medications on 3/13/24, the day of the care plan meeting. (V8-LPN) found the medication and gave it to (V13). I don't know what (V13) did with the medications. When residents or families bring medications from home, the nurses are able to use those medications, but we have to get a doctor's order once we enter the medications into the computer. We have to reconcile with the doctor and verify with pharmacy. The nurse should have put a label on those medications that has the name, date of birth , and room number. The nurse should have let the other nurses know that R1's medications were in the medication cart. I told (V13) later that R1's medications should have been labeled and the nurses should have used (R1's) medications brought from home. After this incident, we did a whole sweep of the facility and made sure if other residents brought medications from home. On 3/23/24 at 10:47 AM, V8 (LPN) stated, I didn't work on 2/23/24 when (R1) was admitted . I never received (R1's) medications from (V12). I found it in the medication cart. I put it in a bag and then put it in the medication room. As per our previous Director of Nursing, we were not allowed to take medications from the family. We had to order from our pharmacy. If it was a high cost medication like medications for cancer, then we would take it from the family and use it. I didn't know about the new policy of using a resident's new medications brought from home. (V2) never said anything to me. A couple of weeks ago, (V13) asked us if we saw (R1's) medications from home. I told her that I put her medications in the medication room. I went and got it and gave it to (V13). I don't know what (V13) did with it. On 3/23/24 at 11:35 AM, R1 stated, I remember when I came here with my daughter, we brought my medications from home and my daughter gave it to the nurse. I don't remember which nurse it was. I don't know anything about if I'm getting those meds from home or not. My daughter is my POA (Power of Attorney) and she takes care of that stuff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 5 of 7 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 03/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/23/24 at 12:00 PM, V6 (LPN) stated, I started on 1/31/24 and I work full time here. I'm a new graduate nurse. I never had an admission so I'm not used to the family bringing medications for a resident. I'm not sure if we can use them or not. I would have to take it to my supervisor. On 3/23/24 at 12:11 PM, V7 (LPN) stated, I'm new here. I'm a regular nurse and I started in January 2024. I have never had any residents or their families bring medications from home at the time of admission. But if they did, I would take the medications and put it in a bag and then put it in the drawers by the nursing station. When I see (V2), I would then give it to her. I think most residents use our own pharmacy for their medications. (V2) never told me that we could use the resident's medications brought from home. On 3/23/24 at 11:12 AM, V3 (Social Worker) stated, I took part in R1's care plan meeting. (V12) had concerns with R1 not receiving her medications that she brought at the time of admission. She got a bill from the pharmacy and was upset. I know that (V13) followed up and found her meds. I think the business off and administrator were to going to work on this and reimburse her. I don't know what happened afterwards. I'm not clinical, so I don't know if nurses can use resident's medications brought from home. On 3/23/24 at 12:29 PM, V1 (Administrator) stated she talked to V12 about many concerns including R1's medications. V1 stated she was not clinical and did not know an answer to whether nurses are supposed to use resident medications brought from home. V1 submitted emails from V12 to V3 (Social worker) dated Thursday March 14th, 24 at 2:58 PM which documents the following: Medication-As I stated, when mom (R1) was admitted , I left a bag containing sealed bottles of Eliquis (at least 3 months worth), several new inhalers, potassium and water pills prescribed by her doctor. I received an explanation of benefits from her insurance company that all new meds were ordered upon her admission and were not fully covered by insurance, leaving a copay amount due. I need to know what happened to the medication I dropped off and who is responsible for the additional payment since there was no need to order more medication. On 3/23/24 at 12:53 PM, V9 (MDS Coordinator/LPN) stated, I attended (R1's) care plan meeting on 3/13/24. (V12) had concerns that she provided (R1's) medications from home at the time of admission. She was upset we didn't use them. Instead, we ordered (R1's) medications from our pharmacy. She wanted (R1's) medications brought from home back. (V13) went to look for it and she found them. That's all I know. On 3/23/24 at 1:40 PM, telephone interview was done with V12 (R1's daughter). V12 stated, I came with my mom (R1) to the facility and I gave the nurse (R1's) medications. I don't remember the name of the nurse exactly. When (R1) came, she was in one room and then changed to another room. So, there were several nurses involved. I told the nurse that she needs to use up there medications first. They are brand new from (R1's) pharmacy. The bottles were sealed. There were nebulizer meds, inhaler, and water pills. I thought that was rule that they are to use the resident's medications first. Then I got a bill from the facility's pharmacy for over a 100 dollars. I shouldn't have to pay for that because the nurse should have used the 3 month supply of my mom's brand new medications. On 3/23/24 at 2:42 PM, telephone interview was conducted with V13 (Unit Manager/LPN). V13 stated the following: I was there during the time of admission. I didn't see any of (R1's) medications during the time of admission. But, (V12) said she brought them and gave it to the nurse. I'm not sure which one. It was only brought to my attention during the care plan meeting that (R1)'s medications are missing and she is getting charged by the pharmacy. I reached out to the nurses, but I couldn't find (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 6 of 7 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 03/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it. I was going to wait for (V8) who's a strong and regular nurse to come back from vacation. When (V8) came back, she told me it was in the medication room. When the facility was owned by the old company, nurses were not expected to use the residents' medications brought from home. Instead, residents got there medications from the pharmacy that the facility uses. I have not seen the new policy when the facility was bought by the new company. I don't know what the new policy is and I have to talk to (V2) about medications brought during admission. On 3/23/24 at 1:44 PM, V9 went to V13's office and brought a bag of medications that belonged to R1. Surveyor and V9 went over the medications which included 1 bottle of women's multivitamins, 6 Albuterol Sulfate inhalers, 5 containers of Potassium Chloride SR MCP 80 MEQ (Milliequivalents), 1 container of Furosemide 20 MG (Milligrams), 2 containers of Eliquis 2.5 MG, and 2 boxes of Duoneb (Ipratropium/Albuterol). On 3/23/24 at 11:10 AM, surveyor called V14 (LPN) on her phone, but there was no answer. On 3/23/24 at 1:08 AM, surveyor called V15 (Business Office Manager) on her phone, but there was no answer. On 3/24/24 at 11:30 AM, V15 called back surveyor. She stated she was not made aware of V12 received a bill for R1's medications from the pharmacy. She said she was never told by V1 or V3 to reimburse V12. On 3/23/24 at 2:29 PM, surveyor called V11 via phone, but there was no answer. On 3/23/24 at 5:00 PM, V12 emailed surveyor the bill from the facility's pharmacy which shows she was charged $106.67 for the following medications: Eliquis 2.5 MG, Albuterol HFA 90 MCG/ACT, Furosemide 20 MG, Potassium Chloride ER8 MEQ CAP, Alprazolam 0.25 MG, Diphenox/Atropine 2.5-0.025 MG and Alprazolam 0.25 MG. R1's face sheet shows an admission date of 2/23/24. R1's MDS (Minimum Data Set) dated 2/29/24 shows a BIMS (Brief Interview of Mental Status) score of 15, which means she is cognitively intact. R1's admission evaluation completed by V11 and progress notes dated 2/23/24 do not mention anything that the family brought R1's medications from home. Facility's policy titled Medications Brought to Nursing Care Center by Resident or Responsible Party (1/23) shows: 1. Use of medications brought to the nursing care center by a resident or responsible party is allowed only when the following conditions are met and as allowed per state regulation: a. The medication name, dosage form, and strength have been verified by the nurse accepting the medication by: consulting a tablet identification reference or calling the dispensing pharmacy, Drug information center or Poison Control Center for physical description of the medication. Medications brought in to the nursing care center by a resident or responsible party are accepted only with a current order by the resident's prescriber, after the contents are verified by the nurse. 2. Medications not ordered by the resident's prescriber, or unacceptable for other reasons (such as questions of the identity, improper packaging or labeling of the medication), are returned to the family or responsible party. If unclaimed, the medications are disposed of in accordance with nursing care center's medication destruction/disposal procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145657 If continuation sheet Page 7 of 7