F 0585
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must
establish a grievance policy and make prompt efforts to resolve grievances.
Based on interview and record review the facility failed to resolve resident grievances for 5 of 6 residents
(R1, R3, R4, R5 R6) reviewed for grievances in the sample of 6.
Residents Affected - Some
The findings include:
On 12/17/24 at 9:55 AM, R1 stated he has seen R2 standing at the lunch time steam cart in the hall. R1
said R2 continually touches the trays and removes plate lids with his bare hands. R1 said it is unsanitary
and spreads germs. R1 said it has been discussed at group meetings when staff members are present.
Nothing is being done about it.
On 12/17/24 at 12:37 PM, R4 stated she has seen R2 pick food off resident trays and hovers over the
steam carts to find his tray. R4 said she has seen R2 pick food off used trays and then touch fresh food
trays. R4 said R2 touches the warming covers with his dirty hands. R4 said it was discussed at the last food
focus meeting and staff know about the issue. R4 said no one is doing anything about it.
On 12/17/24 at 11:21 AM, V3 (Registered Nurse) said R2 does touch the food trays at mealtimes. R2 is
alert and has OCD (obsessive compulsive disorder). Timing is important to him. If his tray is not delivered to
his room at the same time each meal, R2 will go to the steam cart and look for it. He touches trays and
tickets to find his own. R2 picks up warming lids to see if the trays have been eaten or not.
On 12/17/24 at 11:42 AM, V5 (Registered Nurse) said R2 can independently walk up and down the halls.
V5 stated he was aware of R2 looking at the food trays in the past but thought that concern had been
corrected. V5 said R2 does carry his used tray back to the hall steam cart after he is done eating.
On 12/17/24 at 12:17 PM, V6 (Social Service Director) stated he heard R1 and R2 arguing outside his door
about one week ago. V6 said R1 was telling R2 to stop touching food trays. V6 said he interviewed both
residents and determined the issue had been brought up by several residents at past food focus meetings.
On 12/17/24 at 1:35 PM, V7 (Food Service Manager) stated residents have been complaining at food focus
meetings regarding R2 picking at food on the steam carts. Residents said he touches the trays and snack
items. V7 said R1, R3, R4, R5 and R6 were the residents that had witnessed R2 and voiced their concerns.
V7 said they are all alert and oriented with no memory issues. V7 said she reported the complaints to the
DON (Director of Nurses) but was not sure how it was followed up.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145689
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
12/17/2024
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 0585
R1, R3, R4, R5 and R6's facility assessments showed no cognitive impairment.
Level of Harm - Minimal harm
or potential for actual harm
The food focus meeting notes dated 12/11/24 (six days ago) showed R2 still messing with the food trays
and interfering with staff passing the trays. The notes showed R2 takes snacks, sandwiches, and checks
the food trays himself.
Residents Affected - Some
On 12/17/24 at 2:20 PM, V2 (Director of Nurses) stated residents are not allowed to pass food trays and
should not be anywhere near the steam carts. There is the potential for germs to be spread or residents get
the wrong food tray. V2 said she was told by V7 about the complaints at past food focus meetings. V2 said
she did speak with R2 about the concerns but unfortunately did not document the follow up or resolution
anywhere.
The facility's Grievance Program policy last review dated 5/15/24 states: 7. b. The grievance will be logged
on the facility grievance log .h. All facility grievance investigations will be initiated as soon as possible after
the grievance is filed. Completed and timely follow up will be conducted by the department supervisor, the
Grievance Office and/or the Administrator.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145689
If continuation sheet
Page 2 of 2
