Health inspection·May 15, 2025

F 0689 On 05/12/25 at 12:46 PM R17 sitting in the reclined specialty chair by the room. R17 not interviewable. Level of Harm - Actual harm On 05/13/25 at 01:26 PM V8 (Family Member) said, I visit R17 all the time, I live only few minutes away from the facility. Before R17's fall (on 03/18/2025), R17 was pretty stable with walking with the walker. R17 would always go to the bathroom by herself. I don't know if she should have gone by herself, but she did. At the time of the fall, R17 was residing on the third-floor unit. R17's room was all the way at the end of the hallway, far from the enclosed nursing station. V8 started to cry and said, They ruined mine and her life by not preventing the fall, she's not the same anymore. That day (03/18/2025), I brought in food for R17 and left around 09:30 PM - 10:00 PM. I woke up the following morning and noticed missed call form the facility. V16 (Registered Nurse) said in the voicemail that R17 initiated emergency call light in the bathroom but by the time staff went into R17's room, she already attempted to go back to the bed, and fell in the middle of the room. That made me wonder how long she waited in the bathroom before she decided to attempt to go back to the bed. R17 was sent out to the hospital, had broken the hip, followed by surgery, and came back after 10 days. I tried asking her what happened but R17 doesn't remember. R17 is so different now. R17 only needed minimal assistance before the fall, and now she cannot even sit up in the chair and doesn't really talk either whereas before we talked all the time. R17's condition declined tremendously. Residents Affected - Few On 05/14/25 at 09:29 AM V10 (Certified Nurse Assistant) said, I worked on 3/17/2025 11:00 PM to 7:00 AM. Around 1:15 AM, R17's call light went off. I went to answer it and as I headed down to the room I heard her fall. R17 initiated the emergency bathroom call light. When emergency call light is initiated, it gives different sound, so I recognized it and started walking fast but didn't make it to R17's room before she got off the toilet. When I walked into the room, I saw R17 sitting on the floor with the walker in the front of her. I notified V16 (RN) right away, and he came in to assessed R17. I don't think R17 speaks English, but V16 (RN) asked her if she was in any pain and checked for injuries but there was no injury. We used the sit-to-stand lift to put R17 back in the bed and both, me, V9 (Certified Nurse Assistant), and V16 (RN) waited for an ambulance. I was not assigned to R17 that night, V9 (CNA) was. Everybody was checking on R17 frequently because she is not compliant and goes to the bathroom by herself. Surveyor asked what level of assistance R17 needs when going to the bathroom and what is her cognitive condition, V10 (CNA) said, R17 was supposed to be assisted to go the bathroom. I don't know how her cognitive ability was because she doesn't speak English. When I took care of R17, I used hand gestures. I think the facility uses translators, but I only work night shift, so I don't think they have one who speaks her language at night. R17 was not a high risk fall resident before the fall (03/18/2025) to my knowledge. We just had to watch her when she went to the bathroom. There were no special interventions for R17. V16 (Registered Nurse) not available per V2 (Director of Nursing). Per facility investigation report, V16 (Registered Nurse) who was the nurse caring for R17 at the time of the fall (03/18/2025), stated that he was called by V10 (CNA) to be notified that R17 was found on the floor in her room. V16 (RN) stated that he went immediately to R17's room and saw R17's walker and shoes next to the R17. V16 (RN) assessed R17 and concluded there were no injuries; however, R17 complained of the left leg pain. On 05/14/25 at 12:18 PM V2 (Director of Nursing) /Fall Coordinator) said, R17 was admitted on [DATE], she came into the facility for post fall rehab. R17 walked independently 50 feet with the walker, prior to the fall (03/18/2025). R17 always wants to do everything on her own. On 03/18/2025 she had unwitnessed fall. R17 went to the bathroom by herself and pulled the call light. V10 (Certified Nurse Assistant) headed to the room and found R17 on the floor. V16 (RN) came in immediately and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 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 - Actual harm Residents Affected - Few assessed R17. R17 pointed to the pain in the abdomen and a little later in the left leg. R17 was send to the hospital. She suffered left hip fracture and had subsequent surgery. R17 has diagnosis of hypertensive urgency that can cause weakness, dizziness, and syncope. It is hard to determine if R17's blood pressure was elevated right before the fall, so it could have been a contributing factor to R17's fall but it is hard to determine. Some other contributing factors were lack of light in the room and inappropriate footwear, R17 wore sandals. R17 was not able to verbalize what happened. Nursing staff does Purposeful Rounding to anticipate residents' needs. We know R17 likes to do things on her own, so the best way to prevent her from falling would be purposeful rounding. Need anticipation is recognized by purposeful rounding even though she doesn't speak English and her cognition is severely impaired. We determined that the root cause of R17's fall was poor safety awareness, no call for assistance, hypertensive urgency, lack of lighting in the room, and inappropriate footwear. On 05/14/25 at 12:42 PM V9 (Certified Nurse Assistant) said, I worked on 03/17/2025 11:00 PM - 7:00 AM. On 03/18/2025 between 1:00 AM - 2:00 AM, R17 pulled the call light. I was in the nursing station, and as I heard the call light, I headed out to R17's room which was the last room on the hallway. By the time I got to R17's room, V10 (CNA) was already there. V10 (CNA) told me that she found her on the floor. R17 was assigned to me that night. R17 was always independent and did everything for herself. R17 needed only supervision, such as hand her a brief, etc. Normally, we round on assigned residents every hour on the night shift. The last time I saw R17, was around 1:00 AM. I'm not sure what happened. I don't know about any prior falls R17 might have had. She was never at risk for falls before 3/18/2025. There were no special interventions to prevent R17 from falling. I don't know what Purposeful Rounding is, I haven't heard of it. Surveyor asked how she anticipates R17's needs when R17's cognition is severely impaired and she doesn't speak English, V9 (CNA) said, Normally, I would point to the item and R17 would nod her head. There is no other way to communicate with her, I don' know about any interpreting devices. On 05/14/2025 2:27 PM V15 (Nurse Practitioner) said, I'm very familiar with R17. R17 is a loner, alert x2, very independent, and, before the fall, ambulatory. R17 took herself to the bathroom back and forth all the time. I was notified of R17's fall on 3/18/2025. I was told that R17 was using the bathroom and was later discovered on the floor. R17 was complaining of pain in the hip, so I placed an order to send R17 to the hospital. R17 has never fallen like that before. Best interventions to prevent falls is to do rounds and monitor when residents are in bed, also, to let me know right away after each fall. Staff should monitor residents every 4 hours especially at night, or however often the facility fall protocol is. V16's progress note dated 03/18/2025 reads in part, (At) 2:10 AM Writer was notified by CNA who responded to (R17's) bathroom call light. (R17) was found by the CNA on the floor near her walker, a few feet from her bed. (R17) unable to describe events leading to the fall. HTT (head-to-toe) assessment done, claimed to have not hit her head on the floor, no observable bumps or bruises, complained of abdominal pain and was also holding her abdomen with facial grimace observed. BUE (bilateral upper extremities) and BLE (bilateral lower extremities) symmetrical in length, no internal or external rotation observed. Transferred to wheelchair, by 2 person assist and later to bed. Later observed to be having left leg pain but would not verbalize or confirm leg pain. V/S (vital signs) showed elevated BP 202/112. Other VS within normal limits. 2:40 (AM) (V15 (Nurse Practitioner notified and with orders to send patient to ER for further evaluation. Placed 911 Call. 2:50 (AM) (R17) brought to (local) ER. 2:55 (AM) Called (V8 Family Member), did not pick up. Left VM message. (R17) is ambulatory, able to toilet self and able to use the call button. Was last seen in her room [ROOM NUMBER]:15 AM. Per hospital record, progress note written by V12 (ER Physician) dated 03/18/2025 reads in part, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 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 - Actual harm Residents Affected - Few (R17) is a 90 y.o. female with PMH of dementia, CHF, HTN, Hyperthyroidism, 4 cm AAA, and internal hemorrhoids, seen for medical co-management and risk stratification following unwitnessed fall c/b femur fracture. L intertrochanteric femur fracture; ground level fall at SNF, unwitnessed; found to have L intertrochanteric femur fracture on imaging; defer to surgical service for management periprocedural abx., analgesia, DVT ppx/AC; bowel regimen; and urinary symptoms. The facility Fall Prevention and Management policy dated 10/29/21 reads in part, The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Procedures include Fall Risk Screening which include All residents and patients will be considered at risk for falling, regardless of fall risk score. High risk residents and patients for falls will receive individualized interventions as appropriate to risk factors. Fall Interventions include Universal Fall Precautions/Facility Fall Protocol will be implemented to all residents admitted to the facility regardless of risk scores. Fall Focus Program will be implemented to ensure purposeful rounding addresses residents positioning, pain, personal needs, personal items within reach, perils/safety hazards, and peaceful environment upon admission and throughout resident's stay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 4 of 4