Health inspection·May 31, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 no medications were kept at resident 's bedside without a physician order. The facility also failed to assess resident for safe medication self-administration. This deficiency affects 1 (R8) of 3 residents in the sample of 25 reviewed for medication safety. Residents Affected - Few Findings include: On 5/28/24 at 7:43AM, V16 Registered Nurse (RN) said R8 already took his medications around 5:30am for his 6am medications but she did not sign it. V16 said R8 has his medications in bedside drawers. V16 enumerated the following medications are scheduled for 6am: Spiriva Handihaler inhalation capsule is 18mcg 2 puffs inhale orally daily, Budesonide-Formoterol Fumarate inhalation aerosol 160-4.5 mcg/act 2 puff inhale orally two times a day, Fluticasone-Salmeterol inhalation aerosol powder breath activated 250-50mcg/act 1 puff inhale orally every 12 hours, Combivent Respimat inhalation aerosol solution 20-100mcg/act 1 puff inhale orally four times a day and Diclofenac sodium external gel 1% apply to affected joints topically four times a day. On 5/28/24 at 7:45AM, Surveyor and V16 RN went to R8's room. Observed R8 lying in bed. He is alert and oriented, able to express said he has been taking his medications since he was admitted . R8 showed where he keeps his medications. Observed medications at bedside drawer: Allergy relief 25mg opened bottle, Emergen-C 1000mg 1 box, Fluticasone Salmeterol 100mcg/62.5mcg, Fluticasone Salmeterol 250mcg/50mcg and Combivent Respimat inhalation aerosol solution 20-100mcg/act. Both surveyor and V16 RN cannot find the Budesonide- formoterol fumarate inhalation, Spiriva HandiHaler inhalation and Diclofenac Gel listed on R8's medication administration record. Called for V2 Director of Nursing (DON). On 5/28/24 at 7:50AM, above observation showed to V2 DON. V2 said they don't allow resident to keep medication at bedside without physician orders. V2 added if resident wishes to self-administer his medication the interdisciplinary team will evaluate the resident and call the physician for order. R8 was admitted on [DATE] with diagnosis listed in part but not limited to Chronic Obstructive pulmonary disease (COPD), Chronic congestive heart failure, Age related nuclear cataract bilateral, Osteoarthritis (OA). Active physician order sheet indicates: Spiriva Handihaler inhalation capsule is 18mcg 2 puffs inhale orally daily related to COPD, Budesonide-Formoterol Fumarate inhalation aerosol 160-4.5 mcg/act 2 puff inhale orally two times a day related to COPD, Fluticasone-Salmeterol inhalation aerosol powder breath activated 250-50mcg/act 1 puff inhale orally every 12 hours related to COPD, Combivent Respimat inhalation aerosol solution 20-100mcg/act 1 puff inhale orally four times a day related to COPD and Diclofenac sodium external gel 1% apply to affected joints topically four times a day for OA/pain. No order for Allergy relief 25mg opened bottle and Emergen-C 1000mg 1 box found in R306's bedside drawer. No order to have medications at bedside for self-administration. Facility's policy on Self Administration of Medication reviewed 4/20/23 indicates: Policy statement: it is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team it is clinically appropriate. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 2 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 0554 Level of Harm - Minimal harm or potential for actual harm 1. The facility will allow the resident to self-administer drugs if the interdisciplinary team (IDT), has determined this practice is safe. Nurse will complete a Self-Administration of Medication Assessment. 2. The admitting Nurse will ask the resident and or responsible party if they are interested in participating in the Self-Administration of Medication Program. Residents Affected - Few 3. When the resident and or responsible party request to participate in the program, the admitting Nurse will inform the resident's IDT. 5. If a resident requests to self-administer drugs, it is the responsibility of the IDT to determine it is safe for the resident to self-administer drugs, before the resident may exercise right. 6. When determining if self-administration is clinically appropriate for resident, the IDT will at a minimum consider the following: a. The medication appropriate and safe for self-administration b. The resident's physical capacity to swallow without difficulty and to open medication bottles. c. The resident's cognitive status, including their ability to correctly name their medication and know what conditions they are taken for; d. The resident's capability to follow directions and tell time to know when medications need to be taken. e. The resident's comprehension of instructions for the medications they are taking including the dose, timing, and signs of the side effects and when to report to facility staff. f. The resident's ability to understand what refusal of medication is and appropriate steps taken by staff to educate when this occurs. g. The resident's ability to ensure medication is stored and securely. 7. The admitting nurse or designee will complete the Self Administration of medication evaluation and report the findings to the unit manager or designee. 8. The IDT team must also determine: a. Who will be responsible for storage medications are stored at the resident's bedside, a lockbox or locked drawer must be used to store the medications. b. Who will be responsible for documentation of the administration of drugs. c. The location of the drug administration 9. Once the resident has deemed safe by IDT an order will be obtained from the resident's physician or physician extender listing the medications may be self-administered, where the medications will be stored, will be stored, who will be responsible for documentation and the location of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 3 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 0554 administration. Level of Harm - Minimal harm or potential for actual harm 10. Appropriate documentation of the above determinations will be documented in the resident's care plan. Residents Affected - Few 12. The resident will be re-evaluated on their ability to continue to self-administer medications in conjunction with the resident assessment instrument. Facility's policy on Medication Administration review date 8/10/23 indicates: Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: 1. An order is required for administration of all medication. 2. Medications are administered by licensed personnel only. 25. Medications will not be left at bedside unless with order from physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 4 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 a copy of hospice plan of care for 1 of 4 residents (R76) reviewed for quality of care in a sample of 25. Residents Affected - Few Findings include: On 05/29/2024 at 11:36AM during record review with V17 (Licensed Practical Nurse), R76's hospice binder was did not contain hospice plan of care coordinated with the facility. On 05/29/2024 at 11:59AM during record review with V8 (Director of Social Services), R76's electronic health records were not observed with hospice plan of care. On 05/29/2024 at 11:36AM during interview with V17, V17 stated that all documents for hospice should be in the hospice binder including the hospice coordinated plan of care. On 05/29/2024 at 11:59AM during interview with V8, V8 stated hospice coordinated plan of care should always be in R76's hospice binder or scanned into R76's electronic health records readily available to access for all staff. Review of R76's Order Summary Report dated 05/29/2024 indicated admission date of 10/30/2021, diagnoses of not limited to unspecified dementia and moderate protein-calorie malnutrition, and order for hospice services with order date of 02/13/2024. Review of facility document entitled Hospice Services Agreement dated 7/5/2018 indicated the following: E. Communication and Hospice Plan of Care With the consent of the Resident Hospice Patient (or his/her legal representative), Hospice shall furnish Nursing Facility with a copy f such Plan of Care. Hospice shall also furnish Nursing Facility with a copy of any modifications to such Plan of Care as soon as possible after such modifications are made. Review of facility document entitled Hospice Program reviewed on 6/5/2023 indicated the following: Procedure: 10. Facility designates our Social Services Director/coordinators to coordinate care provided to the resident by our facility staff and the hospice staff. Responsibilities include: d. Obtaining the following information from the hospice: - The most recent hospice plan of care specific to each resident; 12. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care services provided by the facility. 13. The coordinated plan of care will reflect the resident's goals and wishes, as stated in his or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 5 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 her advance directives and during ongoing communication with the resident or representative. Level of Harm - Minimal harm or potential for actual harm 14. The coordinated plan of care shall be revised and updated as necessary to reflect the resident's current status. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 6 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 services and treatment to maintain and prevent further decrease in range of motion for 3 of 6 residents (R3, R40, R41) reviewed for range of motion in a sample of 25. Findings include: 1. On 5/28/2024 at 10:50am R40 was observed up in wheelchair with left arm sling and left-hand contracture closed in a fist. On 5/28/2024 at 10:55am R40 said, I've been here for a couple of weeks, and I really want something placed in my hand because I do not want my nails to dig into my skin. It's happened before. On 5/28/2024 at 11:00am V16 (Registered Nurse-RN) observed R40's left hand contracture and said R40 has never had any device in his hand to prevent further contracture I'll notify the restorative nurse. On 5/28/2024 at 1:30pm V6 (Restorative Nurse) said he was familiar with R40 and that he should have preventive measures in place for his left-hand contracture and will have the Occupational therapist evaluate R40 for therapy and recommendations. On 5/30/2024 at 9:38am V21 (Occupational Therapist) said V6 informed her about R40 on 5/28/2024 for evaluation and that a recommendation was put in place to have a carrot placed in his left hand to prevent further contracture or maintain his left hand at the current level. On 5/30/2024 V2(Director of Nursing-DON) said the restorative nurse should evaluate all residents and put in for recommendations as needed and assure that they are carried out. An Order Summary Report dated 5/29/2024 indicated that R40 has a history of left side hemiplegia and hemiparesis following unspecified cerebrovascular disease. A therapy recommendation dated 5/28/2024 for restorative to apply a carrot splint for left hand. A care plan dated 2/20/2024 for Physical and Occupational therapy to evaluate and treat as per medical doctor orders. Facility Policy: Restorative Nursing program Review date 08/20/2023 Intent: It is the policy of the facility to assist each resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance with state and federal regulations. Procedure: 1. Each resident will be screened and or evaluated by the nurse designated to oversee the restorative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 7 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 nursing process for inclusion into the appropriate facility restorative nursing program when it has been identified by the interdisciplinary team that the resident is in need or may benefit from such program. 2. On 05/29/2024 at 11:30AM R3 was observed lying on bed, non-verbal, with right fingers touching the right palm without any hand roll or carrot splint. Residents Affected - Few On 05/30/2024 at 12:20PM during observation with V6 (Restorative Nurse), R3 was observed with right fingers touching the right palm without any hand roll or carrot splint. On 05/30/2024 at 12:20PM V6 stated R3 should have a hand roll or a carrot splint on but will check if there were any most recent occupational therapy (OT) recommendations with R3. V6 stated the current restorative nursing program for R3 includes passive range of motion of left upper extremities and both lower extremities. V6 stated no restorative program currently being provided on right hand. On 05/30/2024 at 3:00PM during interview with V2 (Director of Nursing), V2 stated R3 was not eligible for splint or hand roll at the time of her first admission in the facility but the most recent therapy to nursing recommendations were passive range of motion on both upper and lower extremities as tolerated and active range of motion on both upper and lower extremities as tolerated. Review of R3's Order Summary Report dated 05/29/2024 indicated admission date of 11/29/2022 and diagnoses but not limited to cerebrovascular disease, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of R3's Therapy to Nursing Recommendations dated 11/07/2023 indicated Restorative Recommendations of passive range of motion on both upper and lower extremities as tolerated and active range of motion on both upper and lower extremities as tolerated. Review of R3's facility care plan revised 01/30/2024 indicated passive range of motion (PROM) of left upper extremities in planes as tolerated and both lower extremities to hip, knees, ankles within available range of motion (ROM). 3. On 05/28/24 at 11:07 AM, R41 was in bed with bilateral elbow hand wrist flexion contracture with no hand rolls in place. On 05/28/24 01:57 PM, V6 (RESTORATIVE NURSE) said R41 should have preventative measures in place for her hands to prevent further contractures. V6 added R41 was discharged from therapy on 5/24/24, and on restorative program for bed mobility. On 5/29/24 at 12:11PM, R41 was observed in bed with bilateral elbow and wrist flexion contracture with no rolls in place. V22 (CERTIFIED NURSE AIDE) said he usually does range of motion in morning and the restorative aide will apply hand rolls. On 5/29/24 at 12:12 PM, V23 (LICENSED PRACTICAL NURSE) said R41 should have her preventative measures in place such as hand rolls and right hand elevated with pillow to decrease her swelling. V23 said range of motion is done by restorative aide. V23 verified that no hand rolls where in place for R41 and right hand not elevated on pillow. On 5/31/24 at 11:50 AM, V36 (RESTORATIVE AIDE) said his responsibilities as a restorative aide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 8 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 include Range of motion, bed mobility, transfers, dressing, ADL care (activities of daily living) and helping the CNA (certified nursing aides) if needed. V36 said therapy sees the resident and then gives recommendations to restorative therapy to follow. V36 said he is not aware of any new recommendations from therapy for R41. V36 said he meets with V6 (RESTORATIVE DIRECTOR) daily and will notify if any new therapy recommendations need to be implemented. Residents Affected - Few Review R41 medical records. R41 was admitted on [DATE] with diagnosis listed in part but not limited to Muscle weakness (Generalized), other lack of coordination, spinal stenosis, site unspecified, age-related osteoporosis without current pathological fracture, and metabolic encephalopathy. Comprehensive care plan did not indicate that restorative program care plan for right hand contractures, until surveyor informed restorative nurse of concern. On 5/28/24 resident care plan indicated Resident has a contracture to right hand. Intervention: Apply carrot splint/rolled towel 1-2 hrs. per patients' tolerance. R41's Occupational Therapy (OT) Therapy to Nursing recommendations indicated discharged recommendation date of 5/24/24 to Restorative program recommending towel rolled up in hands or carrot splint per 1-2 hrs. per patient tolerance, elevate Right hand with pillow to decrease/prevent swelling on Right hand. Passive Range of Motion: PROM BUE/BLE. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 9 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 implement its safety smoking policy to resident who is a smoker. This deficiency affects 1 (R6) of 3 residents in the sample of 25 reviewed for Safety Smoking Policy. Findings include: On 5/28/24 at 9:48AM, R6 is alert and oriented x 3, able to express self to others. R6 is ambulatory in steady gait. Observed CPAP (Continuous positive airway pressure) machine at bedside. R6 said she smokes five (5) times a day. R6 said she uses CPAP machine at night due to her sleep apnea. On 5/29/24 at 11:51 AM, V8 Social Service Director (SSD) said that smoking assessment are completed upon resident's admission, quarterly and as needed. Smoking care plan is formulated upon completion of smoking assessment. V8 is aware that he did not complete R6's smoking assessment and care plan until yesterday when surveyor asked for it. V8 said he still getting acclimated to the facility, and he has priority assessment to do, but moving forward it will be done. R6 was admitted on [DATE] with diagnosis listed in part but not limited to Obstructive sleep apnea, Post trauma stress disorder, schizoaffective disorder depressive type. Smoking assessment and care plan were only initiated and formulated on 5/28/24 when surveyor asked for it. Facility's policy on Smoking Residents reviewed 1/8/23 indicates: Policy statement: This facility shall establish and maintain safe resident smoking practices. Policy interpretation and implementation: 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker, evaluation will include: a. Current level of tobacco consumption b. Method of tobacco consumption (traditional cigarettes) c. Desire to quit smoking, if a current smoker d. Ability to smoke safely with or without supervision. 9. Any smoking-related privileges, restrictions and concerns shall be noted on the care plan and all personnel caring for the resident shall be alerted to these issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 10 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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. Based on observation, interview, and record review the facility failed to ensure controlled substance/narcotic medications are kept locked compartment in the medication cart; failed to keep the medication cart locked during medication administration when cart was out of site; failed to keep the medications refrigerated as manufacturer recommends; and failed to date the ophthalmic medications after opening. This deficiency affects all nine (R32, R37, R43, R48, R54, R59, R62, R98 and R100) in the sample of 25 reviewed for Medication Safety Storage. Findings include: On 5/28/24 at 6:20AM, in 2nd floor medication room with V15 Registered Nurse (RN) observed medication refrigerator not locked. V15 said the medication refrigerator should be locked at all times. On 5/28/24 at 6:51AM, Observed V14 Nursing Supervisor prepare medications for R32. V14 left the 2 controlled substance/narcotic medication bingo cards- (Lorazepam 1mg oral table 1 tab by mouth every 12 hour and Tramadol HCl 50mg oral tablet 1 tab by mouth as needed for pain) inside the narcotic binder on top of the unlocked medication cart. V14 left the unlocked cart and administered medications of R32. At 6:53am, V30 Central Supply called V14 and asked her to open the supply room. V14 left the unlocked medication cart in the hallway with the 2 narcotic medications left on top on the cart and went with V30. V14 left the med cart from 6:53 and to 6:56am. On 5/28/24 at 6:56AM, Informed V14 Nursing Supervisor of observation made. V14 said that she should keep the controlled substance /narcotic medications in locked compartment in the medication cart after using it. V14 said she should lock the cart when it is out of her site during medication administration. On 5/28/24 at 7:03AM, Counted controlled substance/narcotic meds with V16 RN. Observed Hydromorphone 2mg/ml solution bottle for R59, Lorazepam conc 2mg /ml bottle for R62, Morphine Sulfate 20mg/ml for R62 and Lorazepam con 2mg/ml bottle for R48. All 4 medications indicated manufacturer recommendation to keep it in refrigerator. V16 said they keep all narcotics/controlled medications in the medication cart. V16 added that they should follow manufacturer recommendation and should keep the above medications in the refrigerator for storage after using it. Noted discrepancy of medication dose accounted for R59's hydromorphone solution-controlled substance proof of use form indicated 5/27/24 6am quantity remaining 49ml, 5/27/24 time 6pm, 1ml quantity used, 43ml quantity remaining. On 5/28/24 at 7:13AM, Observed V16 RN prepared medications for R100. Both eye medicationsBrimonidine tartrate optha solution and Dosol/timolol 2-0.5% optha solution are not dated when it was opened. V16 said eye medications should be dated when it was opened. Observed V16 left medication cart unlocked when she administered medications to R100. On 5/28/24 at 7:27AM, Observed V16 RN left medication cart unlocked when she administered medication to R37. On 5/28/24 at 7:31AM, Observed V16 RN left medication cart unlocked when she administered medications to R98. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 11 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 On 5/28/24 at 7:36AM, Observed V16 RN left medication cart unlocked when she administered medication to R54. On 5/28/24 at 7:38AM, Observed V16 RN left medication cart unlocked when she administered medications to R43. Residents Affected - Some On 5/28/24 at 7:50AM, Informed V2 Director of Nursing (DON) of above concerns. V2 said that medication refrigerator should be kept always locked. They should follow manufacturer's medication for storage. They should keep the medication cart always locked when out of site. They should keep the controlled substance/narcotic medications in locked compartment in medication cart. They should write the date after opening the eye medication. On 5/28/24 at 10:19AM, Checked 5th floor medication room with V6 Restorative Nurse. Observed refrigerator monitoring temperature was not done on 5/28/24. V6 said the 11-7 shift nurse does the monitoring and recording of the refrigerator temperature daily. Also noted that April 2024 monitoring temperature has missing dates of completions- 4/20/24, 4/23/24, 4/25/24, 4/27/24, 4/28/24 and 4/29/24. On 5/28/24 at 11:30AM, V2 DON said that they should monitor and record medication refrigerator daily. Facility's policy on Storage of Medications revision date 5/1/2018 indicates: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Procedures: B. Medication rooms, carts, emergency kits/boxes and medication supplies are locked when not attended by persons with authorized access. Temperature A. Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. C. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2C (36F) and 8C (46F) with a thermometer to allow temperatures monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within the refrigerator or a locked refrigerator, at or near the nurses' station or in a refrigerator within a locked medication room per IL Administrative Code section 300.1640 d) labeling and storage of medication. E. The facility should maintain a temperature log in the storage area to record temperature at least once a day. Expiration Dating: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 12 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 E. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. Level of Harm - Minimal harm or potential for actual harm Facility's policy on Medication Administration review date 8/10/23 indicates: Residents Affected - Some Guideline: 25. Never leave the medication cart open and unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 13 of 14 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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 0880 Provide and implement an infection prevention and control program. 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 implement enhanced barrier precaution when providing high contact resident care. This deficiency affects 1 (R97) of 3 residents in the sample for 25 reviewed for Infection Control Protocol. Residents Affected - Few Findings include: On 5/28/24 at 9:38AM, Observed R97's room without Enhanced Barrier Precaution sign posted at the door. No commonly share isolation cart outside the door/hallway that was accessible to staff. R97 was lying in bed. V17 Licensed Practical Nurse (LPN) administered medications and bolus feeding via gastrointestinal tube wearing gloves. V17 did not don gloves when providing high contact care. On 5/29/24 at 10:10AM, V2 Director of Nursing presented updated list of residents on enhanced barrier precaution. R97 is not on the list presented. V2 said the R97 should be included on the list on EBP. V2 said that V17 LPN should wear gloves and gown when she administered medications and bolus feeding via GT to R97. R97 is admitted on [DATE] with diagnosis of Dysphagia oropharyngeal phase, Gastrostomy status, Cachexia, Apraxia. Active physician order sheet indicates on Enhanced Barrier Precautions related gastric tube (GT). Care plan indicates R97 is on enhanced barrier precautions related to presence of GT. Intervention: Wear gloves and a gown for high contact resident care activities-device care of use: feeding tube. Facility's policy on Enhanced barrier precautions review date 10/14/22 indicates: General: Enhanced barrier precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S aureus and Multidrug Resistant Organism (MDRO). Example of High Contact Resident Care Activities: *Device care or use (Feeding tubes) Responsible party: Nursing, All facility personnel Guideline: 3. When a resident is placed in EBP, gown and gloves will be used during high contact resident care activities. 4. Examples of high contact resident care activities requiring gown and glove use for EBP include: g. Device care or use of a device: feeding tube. 7. Make PPE (personal protective equipment) including gowns and gloves, available and accessible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 14 of 14