Health inspection·April 1, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Face Sheet dated 3/27/25 for R6 showed diagnoses including malignant neoplasm of lung, type 2 diabetes mellitus, chronic obstructive pulmonary disease, atherosclerotic heart disease, neuropathy, hyperlipidemia, hypertension, and depression. On 3/27/25 at 11:31 AM, V5 RN (Registered Nurse/ MDS Care Plan Coordinator) stated she came to assist V4 with the medication administration because the medications were late. On 3/27/25 at 11:34 AM, V4 LPN stated there is no way possible to get these (medications) done on time; not with 24 residents. V4 stated she was off for two days, came back and the medication cart was not stocked. V4 stated it takes time away from her medication administration to get the medications. V4 stated medications can be given one hour before and one hour after the time they are scheduled. On 3/27/25 at 11:39 AM, V4 gave R7 the following medications: MiraLAX, calcium with vitamin D, celecoxib, meclizine, buspirone, ferrous sulfate, preservision, senna plus, aspirin, cholecalciferol, Ellipta inhaler, and aspirin. R7's March 2025 MAR showed all these medications were due at 9:00 AM except aspirin which was due at 11:00 AM. The Face Sheet dated 3/27/25 for R7 showed diagnoses including chronic obstructive pulmonary disease, anxiety, peripheral vascular disease, hyperlipidemia, major depressive disorder, cerebral aneurysm, hypertension, gastro-esophageal reflux disease, osteoporosis, anemia, and vascular dementia. On 3/27/25 at 11:42 AM, V5 RN gave R8 preservision, multivitamin, senna plus, aspirin, loratadine, sodium chloride, and artificial tears eye drops. The March 2025 MAR for R8 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R8 showed diagnoses including pleural effusion, hyperlipidemia, atherosclerotic heart disease, myocardial infarction, personality disorder, delusional disorder, hypertension, monoplegia of lower limb, macular degeneration, transient ischemic attack, and dependence on supplemental oxygen. On 3/27/25 at 11:49 AM, V4 gave R9 duloxetine, gabapentin, and insulin glargine. The March 2025 MAR for R9 showed these were daily medications that were due at 9:00 AM. The Face Sheet dated 3/27/25 for R9 showed diagnoses including fibromyalgia, osteoarthritis, cervical disc degeneration, type 2 diabetes mellitus, hypertensive heart disease, anxiety, depression, gastro-esophageal reflux disease, and congestive heart failure. On 3/27/25 at 11:54 AM, V4 gave R10 the following medications: MiraLAX, aspirin, ferrous sulfate, and multivitamin. The March 2025 MAR for R10 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R10 showed diagnoses including chronic respiratory failure with hypoxia, encephalopathy, hypertensive heart disease, congestive heart failure, chronic atrial fibrillation, gastro-esophageal reflux disease, sleep apnea, and hyperkalemia. On 3/27/25 at 12:02 PM, V5 gave R11 the following medications: Aricept, aspirin, ferrous sulfate, ergocalciferol, docusate sodium, metoprolol, Tylenol, and voltaren external gel. The losartan was not available in the medication cart. V5 went to the medication dispensing machine, obtained the losartan, and gave R11 her dose of the medication at 12:17 PM. The March 2025 MAR for R11 showed these (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 If continuation sheet Page 2 of 4 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 04/01/2025 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 0755 medications were due at 9:00 AM. Level of Harm - Minimal harm or potential for actual harm The Face Sheet dated 3/27/25 for R11 showed diagnoses including hypertension, gastro-esophageal reflux disease, hydronephrosis, dementia, anemia, osteoporosis, hypo-osmolality, and hyponatremia. Residents Affected - Some On 3/27/25 at 12:55 PM, V4 gave R12 the following medications: divalproex, allopurinol, Colestipol, furosemide, ferrous sulfate, loratadine, magnesium oxide, primidone, Tylenol, and spironolactone. The March 2025 MAR for R12 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R12 showed diagnoses including hypertensive heart and chronic kidney disease, gout, hypothyroidism, type 2 diabetes mellitus, essential tremor, other seizures, iron deficiency anemia, glaucoma, paroxysmal atrial fibrillation, congestive heart failure, hyperuricemia, mixed hyperlipidemia, osteoarthritis, and gastro-esophageal reflux disease. On 3/27/25 at 12:48 PM, V4 gave R13 the following medications: Chlorthalidone, Lisinopril, Bactrim DS, and senna. The March 2025 MAR for R13 showed these medications were due at 9:00 AM. The Face Sheet dated 3/27/25 for R13 showed diagnoses including palliative care, protein-calorie malnutrition, acute respiratory failure, pleural effusion, pneumonia, atherosclerosis of coronary artery bypass graft, dementia, hypertension, hyperlipidemia, and pressure ulcer. On 3/27/25 at 1:53 PM, V2 DON (Director of Nursing) stated if medications are ordered at 9:00 AM they can be given one hour before and one hour after that time. V2 stated that was the facility's standard. V2 stated V4 did not call for assistance giving medications. V5 was the nurse manager assigned to that area, so she asked V5 to help V4. V2 stated the providers were notified of the late medications. V2 stated the night shift nurses are supposed to restock the medication carts. The facility's Medication Administration policy (4/18/24) showed, check medication administration record prior to administering medication for the right medication, dose, route, patient, and time. The policy did not show a policy in place that medications can be given one hour before and one hour after the scheduled time. 2. On 3/27/25 at 2:19 PM, R1 stated he had one day (3/18/25) that he had an agency person trying to give him his morning medications at 3:00 PM. R1 stated he had dinner medications coming up and didn't want to be overdosed. R1 stated he brought it up at resident council yesterday (3/26/25). On 3/27/25 at 3:13 PM, V2 DON (Director of Nursing) stated V3 ADON (Assistant Director of Nursing) noticed the agency nurse on 3/18/25 giving medications late that day and sent someone to help him. The morning medications were being given late in the afternoon. V2 stated that is not the facility's policy. V2 stated the medications can be given 1 hour before, and 1 hour after the scheduled time. On 3/27/25 at 3:30 PM, V3 ADON stated on 3/18/25 she ran into the agency nurse in the hallway that was coming on for the PM shift. That nurse said she couldn't start her shift because the AM nurse was there still giving medications. V3 stated she had a nurse help the AM nurse with the medication pass. V3 stated he was still giving morning medications and it was after 3:00 PM. The Medication Administration Audit Report dated 3/18/25 for R1 showed the following medications were due at 9:00 AM and were given at 3:13 PM/3:14 PM: Systane Balance eye drops, calcium 600/Vitamin D, bumex, Breo Ellipta inhaler, vitamin D3, metoprolol, lidocaine external patch, docusate sodium, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 If continuation sheet Page 3 of 4 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 04/01/2025 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 0755 acetaminophen, apixaban, finasteride, multivitamin, Jardiance, gabapentin, and Insulin Aspart. Level of Harm - Minimal harm or potential for actual harm The Face Sheet dated 3/27/25 for R1 showed diagnoses including chronic obstructive pulmonary disease, obstructive sleep apnea, type 2 diabetes mellitus, morbid obesity, erythema intertrigo, cellulitis, peripheral vascular disease, chronic kidney disease, atrial fibrillation, osteoarthritis, hypertension, hypokalemia, hyperlipidemia, and benign prostatic hyperplasia. Residents Affected - Some The facility's Medication Administration policy (4/18/24) showed, check medication administration record prior to administering medication for the right medication, dose, route, patient, and time. The policy did not show a policy in place that medications can be given one hour before and one hour after the scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145689 If continuation sheet Page 4 of 4