Inspection·November 8, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm The facility's policy, Change in Condition, revised on 12/18/2023, states that regardless of the resident's current medical and physical conditions, a nurse will inform the resident representative/guardian of any changes in any incident, including medical care or nursing treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 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 145689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nail care for residents' dependent on staff. This applies to 3 of 8 residents (R2, R4, and R8) reviewed for Activities of Daily Living (ADL) care in a sample of 12. Residents Affected - Few The findings include: 1. R2's EMR showed R2's diagnoses include morbid obesity, acute kidney failure, h/o fracture, osteoarthritis, bipolar, anxiety, and mood disorder. R2's Minimum Data Set (MDS) dated [DATE] showed that R2 was cognitively intact and required one to two extensive assists for most of his daily activities. R2 had quarter inch-long right-hand fingers with blackish dirt under the nails and said that only once the staff cut his nails and they don't care. 2. On 11/02/2024 at noon, observed R4 with about an inch-long nails on both hands, with sharp edges and brownish dirt under the nails. R4 said no one cuts her nails. R4's EMR showed R4 had diagnoses including hypertensive heart disease, acute kidney disease, palliative care, dementia, and cerebrovascular disease. R4's MDS dated [DATE] showed R4 is cognitively moderately intact and requires one to two staff assistance for most daily care activities. 3. On 11/02/2024 around 1:00 PM, R8 was minimally interviewable and had an inch long nail with blackish/brownish discoloration under fingernails with right index fingernails broken with a wrapped dirty band-aid. When the writer asked whether it was painful, R3 said yes and wanted the writer to change her dirty band aid. The writer reported to V7(Agency Licensed Practical Nurse). On 11/05/2024, around 10:00 AM, R8 still had the wrapped falling off band aide, and no nail care was provided. R8's EMR showed R8 had diagnoses including chronic respiratory failure, atrial fibrillation, and heart failure. R8's MDS dated [DATE] showed R8's cognitive abilities were severely impaired and required one to two staff assistance for activities of daily living. On 11/05/2024 at 10:00 AM, V7(Agency-Licensed Practical Nurse) and V8 (Registered Nurse) said that usually, Certified Nursing assistants do the nail care. V7 and V8 said the residents' nails should be short to prevent them from getting dirty and reduce the risk of infection. On 11/05/2024 at 10:30 AM, V2(Director of Nursing) said CNAs are responsible for cutting the residents' nails. V2 said nail care was done as needed, typically on shower days. V2 said nails should be cut short to prevent scratching, inadvertently hurting themselves, and could also accumulate dirt under them. The facility's policy, Activities of Daily Living, revised 05/22/2024, in part states that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 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 145689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a sufficient amount of nursing staff/providers to notify family of change in condition, provide grooming needs, and distribute meals in a timely manner. This applies to 7 of 11 residents (R2-R8) reviewed for nursing care. Findings include: 1.R3's Electronic Medical Records (EMR) showed R3's diagnoses include paraplegia, congenital hydrocephalus, heart failure, and palliative care. R3's Minimum Data Set (MDS) dated [DATE] showed R3 was cognitively moderately impaired and dependent on one to two staff assistants for daily care activities. During the observation on 11/02/2024 at 1:35 PM, R3 was in bed sleeping with noisy breathing, and the meal tray was by his bedside untouched. V15 (Agency- Certified Nursing Assistant) said he didn't know about R3. Since morning, he has had noisy breathing and didn't even eat breakfast. V15 said V6(Agency Registered Nurse) is aware of R3's condition. Around 1:45 PM, R6 said he had been having the issues since morning, and when the writer asked R6 whether the family and provider knew about the change in conditions of R3, V6 said she did not get a chance and would notify as soon as she could. On 11/04/2024 at 10:54 AM, V18 (R3's family member) said care and Staffing are a big concern in the facility since the new management took over, and around 2:40 PM on 11/02/2024 a nurse from the facility called her to say that R3 was choking, and he will be placed on thin consistency diet. V18 said around 3:36 PM, someone called her and said R3 had passed away. V18 said she is very upset about the way they care for residents. V18 said that doesn't happen right away and why they took so long to call her. On 11/04/2024 at 1:45 PM, V19(RN-Hospice) said he and the Certified Nursing assistant last saw R3 on 10/28/2024, and he was minimally verbally responsive and appeared to be comfortable. V19 said the hospice received the call regarding his change in condition around 2:27 PM. Usually, the facility notifies the hospice as soon as the changes are identified so that the hospice can send some to the resident to make him comfortable. On 11/04/2024 at 2:30 PM, V2(Director of Nursing) said any change in conditions should be notified to family, physician, and hospice as applicable as soon as a change is identified. On 11/05/2024 at 10:30 AM, V7(Agency- Licensed Practical Nurse) and V8 (Registered Nurse) said any change in resident conditions is notified to the appropriate parties as soon as it occurs. The facility policy titled Change in Condition (revised dated 12/18/2023) states that regardless of the resident's current mental, medical, and physical conditions, a nurse will inform the resident representative/guardian of any changes in any incident, including medical or nursing treatment. 2. R2's EMR showed R2's diagnoses include morbid obesity, acute kidney failure, h/o fracture osteo arthritis, bipolar, anxiety, and mood disorder. R2's MDS dated [DATE] showed that R2 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 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 145689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007 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 0725 cognitively intact and required one to two extensive assists for most of his daily activities. Level of Harm - Minimal harm or potential for actual harm On 11/02/2024 at 2:00 PM, two urinals with urine were in R2's drawer. R2 said one urinal had urine before breakfast, and the second one had urine after lunchtime. R2 had quarter inch-long right-hand fingers with blackish dirt under the nails and said that staff only cut his nails once, they do not care. Residents Affected - Some 3. R4's EMR showed R4 had diagnoses including hypertensive heart disease, acute kidney disease, palliative care, dementia, and cerebrovascular disease. R4's MDS dated [DATE] showed R4 is cognitively moderately intact and requires one to two staff assistance for most daily care activities. On 11/02/2024 at noon, observed R4 with more than a quarter inch-long nails on both hands, with sharp edges and brownish dirt under the nails. R4 said no one cuts her nails. 4. R8's EMR showed R8 had diagnoses including chronic respiratory failure, atrial fibrillation, and heart failure. R8's MDS dated [DATE] showed R8's cognitive abilities were severely impaired and required one to two staff assistance for activities of daily living. On 11/02/2024 around 1:00 PM, R8 was minimally interviewable and had more than a quarter-inch nails with blackish/brownish discoloration under fingernails with right index fingernails broken with a wrapped dirty band aid. When the writer asked whether it was painful, R3 said yes and wanted the writer to change her dirty band, Aide. The writer. Reported to V7(Agency Licensed Practical Nurse). On 11/05/2024, around 10:00 AM, R8 still had the wrapped falling off band aide, and no nail care was provided. 5. R5's EMR showed R5 had diagnoses including fibromyalgia, osteoarthritis, abnormal aortic aneurism, and atrial fibrillation. R5's MDS dated [DATE] showed R5 is cognitively intact. A random meal lunch tray temperature on 11/02/2024 at 1:00 PM showed the temperature of sweet potato at 92 degrees Fahrenheit and beans at 97 degrees Fahrenheit. On 11/04/2024 at 1:30 PM, R5 said food trays were not served in a timely manner, and it was always cold. 6. R6's EMR showed R6 had diagnoses including Type 2 diabetes, kidney diseases, anxiety disorder, and dementia. R5's MDS dated [DATE] showed R6 is cognitively moderately intact. The random meal lunch tray temperature on 11/02/2024 at 12:58 PM showed the temperature of sweet potato at 94 degrees Fahrenheit and beans at 87 degrees Fahrenheit. On 11/02/2024 at noon, R6 said food trays are usually given late, and the food is cold. 7. R7's EMR showed R7 had diagnoses including Parkinson's disease, Type 2 diabetes, osteoarthritis, and agitation. R7's MDS dated [DATE] showed that R7 is cognitively intact and requires one to two assistances for most activities of daily living. The random meal lunch tray on 11/02/2024 at 12:55 PM showed a sweet potato temperature of 94 degrees Fahrenheit and beans at 88 degrees Fahrenheit. On 11/02/2024 at 12:05 PM, R7 said food is usually cold and given late. R7 said they have different staff each time and don't have enough help. On 11/02/2024, during lunchtime, V13-V15(Agency- Certified Nursing Assistants) delivered meal trays and said they were doing it as fast as possible. On 11/02/2024 at 12:30 PM and 11/04/2024 at 1:15 PM, V5(Cook) and V3(Food Service Director) said meal trays are sent with hot plates, sit in the unit for a while and are not distributed to all residents on time. V3 said several times she addressed the concerns about cold food with management before the new administrator started, and it continues to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 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 145689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007 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 0725 be the problem. Level of Harm - Minimal harm or potential for actual harm The review of the facility staffing schedule showed that over the weekend on 11/02/2024 and 11/03/2024, an average of 45 percent of staff was working from the Agency. The review of resident council meeting minutes from August 2024 to the present showed residents complaining about Agency staff's slow response time for their care. Residents Affected - Some On 11/05/2024, around 10:30 PM, V2(Director of Nursing) said the facility management knew the issue. They placed many agency staff on Do Not Rehire (DNR), and the facility ran out of providers. V2 said the facility has a new Administrator and will work with human resources to place regular staff and provide the right training. The facility policy titled 'Staffing) dated 09/01/2024, in part, stated the facility provides sufficient staff members with the skills and competency necessary to provide care and services for all residents per resident care plans and facility assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 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 145689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 food was served at palatable temperatures. This applies to 3 of 5 residents (R5-R7) reviewed for meal service. Residents Affected - Few Finding includes: Observation of the lunch meal on 11/02/2024 between 12:10 PM and 1:15 PM at the 100 halls, where the residents were served meals to rooms. A random temperature check of R5, R6, and R7 trays showed that sweet potatoes and beans delivered to residents were below 100 degrees Fahrenheit. On 11/04/2024 at 1:15 PM, V3 (Food Service Director) said the temperature of the meal tray should not be going below 135 degrees Fahrenheit. V3 said she addressed the concerns about cold food due to staff distributing it on time with management several times before the new administrator started, and it continues to be a problem. On 11/02/2024, between 12:15 PM and 1:00 PM, V5(Cook) recorded the temperature of random residents' meal trays and said that during lunchtime meal trays are sent with hot plates, but they sit on the unit for a while and are not distributed to all the residents quickly enough. On 11/02/2024 at 12:30 PM and 11/04/2024, V13-V14(Agency Certified Nursing Assistants) delivered meal trays at 100 Hall and said they were doing it as fast as they could. 1. R5's EMR showed R5 had diagnoses including fibromyalgia, osteoarthritis, abnormal aortic aneurism, and atrial fibrillation. R5's MDS dated [DATE] showed R5 is cognitively intact. A random meal lunch tray temperature on 11/02/2024 at 1:00 PM showed the temperature of sweet potato at 92 degrees Fahrenheit and beans at 97 degrees Fahrenheit. On 11/04/2024 at 1:30 PM, R5 said food trays were not served in a timely manner, and it was always cold. 2. R6's EMR showed R6 had diagnoses including Type 2 diabetes, kidney diseases, anxiety disorder, and dementia. R6's MDS dated [DATE] showed R6 is cognitively moderately intact. The random meal lunch tray temperature on 11/02/2024 at 12:58 PM showed the temperature of sweet potato at 94 degrees Fahrenheit and beans at 87 degrees Fahrenheit. On 11/02/2024 at noon, R6 said food trays are usually given late, and the food is cold. 3. R7's EMR showed R7 had diagnoses including Parkinson's disease, Type 2 diabetes, osteoarthritis, and agitation. R7's MDS dated [DATE] showed that R7 is cognitively intact and requires one to two assistances for most activities of daily living. The random meal lunch tray on 11/02/2024 at 12:55 PM showed a sweet potato temperature of 94 degrees Fahrenheit and beans at 88 degrees Fahrenheit. On 11/02/2024 at 12:05 PM, R7 said food is usually cold and given late. R7 said they have different staff each time and don't have enough help. On 11/05/2024 at 10:30 AM, V1(Administrator) and V2 (Director of Nursing) said residents are expected to get food at a palatable temperature. The facility policy titled Food Temperature with no date in part showed food will be held at 135 degrees or above before serving to maintain food safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 If continuation sheet Page 7 of 7