Health inspection·August 29, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plastic bag, removed the PPE and performed hand hygiene before getting out of the room. Both added V9 should have performed hand hygiene before donning new pair of gloves. On 8/26/25 at 12:23PM, V16 Family member of R3 showed to surveyor Surveillance video camera they installed inside R3's room showing no CNAs provided care to R3 between 6:30am to 10:30am. V16 said her sister V11, called her to go to the facility when she saw from the surveillance video surveyor came with nursing staff observing them providing care to R3. V16 showed 2 nursing employees (1 female without PPE, only wearing gloves and 1 male wearing PPE- mask, gown, and gloves) providing incontinence care to R3 at 6:05 AM to 6:23AM. No one came to check R3 for incontinence not until surveyor came around 10:30am. Surveyor spoke with V11 family member over the phone regarding concerns she called to IDPH. Both denied they requested nystatin powdered and cream medications at bedside. Both also denied they applied the medications to R3. Both denied they requested cloth pad over the mattress. Both said they are aware multi layers of linen will impede the purpose of the LAL mattress. On 8/26/25 at 1:20PM Informed both V1 Administrator and V2 DON (Director of Nursing) of concerns identified. On 8/27/25 at 9:53AM, V21 CNA said she and V22 CNA provided incontinence care to R3 on 8/26/25 around 6:00AM. Both said they are aware the family installed surveillance video camera inside R3's room. V21 said she forgot to wear proper PPE when providing care to R3. V21 is aware R3 is on EBP, and V21 should wear appropriate PPE when providing incontinence care. On 8/28/25 at 10:30AM, V2 DON presented staff in-services for concerns identified for R3. On 8/28/25 at 1:36PM, reviewed facility's video surveillance camera on 2nd floor hallway of where R3's room is located with V26 admission as requested by V1 Administrator. The surveillance video showed at 6:05am to 6:33am, 2 CNAs and 1 nurse came to R3's room. At 7:00am CNA went inside the room for 15 seconds. At 7:23am Nurse went inside the room for 15 seconds. At 8:15am to 8:22am nurse went inside the room with medications. At 9:04am, CNA went for 15 seconds to bring linens. At 9:23am Housekeeping went inside the room. At 10:08am Housekeeping went inside the room. At 10:26am to 10:49am Surveyor, CNA and WCC went inside the room. Showed also in the video CNA came out from the room with PPE holding on to soiled brief and cloth pad, looking for the soiled linen cart to bring outside R3's room. Informed V26 the video surveillance showed the nursing staff failed to check for incontinence every 2 hours. R3 is nonverbal and incontinence of bowel and bladder. R3 needs total assist with ADLs. R3 needs to be repositioned to be check for incontinence. On 8/28/25 at 2:01PM, Informed V27 VP of clinical operations of concerns identified in facility's surveillance video. V28 said they don't have written policy on checking/rounding resident every 2 hours for incontinence care but it's the standard practice of the facility. R3 is initially admitted on [DATE] and re-admitted on [DATE] with diagnosis listed in part but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Aphasia, Acute embolism thrombosis of deep vein of left upper extremity, Type 2 diabetes mellitus, Peripheral vascular disease, Dysphagia. Active physician order sheet for August 2025 indicated: Nystatin external powder 100,000 unit/gm apply to under breast topically every hour and as needed for redness. No order found for Nystatin and triamcinolone Acetonide cream USP 60 grams. Comprehensive care plan indicated: R3 is nonverbal but can comprehend and understand. She has communication challenges related to expressive aphasia. She has potential/at risk for skin impairment in skin integrity related to incontinent and need of assistance with bed mobility and incontinent care. Intervention: Pressure redistribution mattress. She is on EBP related to left foot wound and gastric tube feeding. She has fungal dermatitis to skin folds (Nystatin powder active). Intervention: Apply medication as ordered. She has an ADL (Activity of Daily living) self-care performance deficit. Care plan indicated R3's family member did not request for treatment medications to be at bedside and application of cloth pad over the Low air loss mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 2 of 5 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 08/29/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility's policy on Incontinence care review date 3/9/25 indicated: General: Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. It also helps in preventing skin breakdown. Guideline: 4. Removed soiled clothing and linen. Doff gloves and perform hand washing. 5. Clean peri area with appropriate cleanse and dry. Doff gloves and perform hand hygiene7. Apply barrier cream if appropriate.10. Dispose of soiled clothes and linen in appropriate areas. Remove gloves.11. Wash hands. Facility unable to provide policy on checking for incontinence care every 2 hours. Facility's policy on Medication storage in the facility November 2021 indicated: Procedures: B. Only licensed nurses, pharmacy personnel and those lawful authorized to administer medications permitted to access medications. Medication rooms, carts and medication supplies are locked when not attended by the persons with authorized access. Facility's policy on Physician orders review date 3/20/25 indicated: Policy: 1. Licensed Professional nurses/registered nurses will follow orders from physicians. 2. All completed orders are entered in the HER.Facility's policy on Specialty mattress review date 5/24/25 indicated: Procedure: 1. As per manufacturer guidelines, no more than 1 piece of linen will be placed between the mattress and the resident. Facility's policy on Enhanced barrier precautions (EBP) review date 10/2024 indicated: General: EBP is an approach of targeted gown and gloves use during high contact resident care activities. Examples of high contact resident care activities: *Providing hygiene*Changing briefs or assisting with toileting Event ID: Facility ID: 145803 If continuation sheet Page 3 of 5 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 08/29/2025 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 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 interview and record review the facility failed to complete and monitor ongoing Restorative assessment after admission to attain or maintain resident's individual highest functional level. The facility also failed to follow therapy discharge recommendation to Restorative nursing without comprehensive assessment. This deficiency affects one (R1) of three residents reviewed for Restorative Program. Findings include: On 8/26/25 at 10:01AM and at 2:22PM, V19 Family member called regarding her concerns presented to IDPH and left message but did not call back. R1 was admitted on [DATE] with diagnosis listed in part but not limited to Alzheimer's disease, Chronic kidney disease, Disorder of muscle, Dysphagia, Underweight, Protein calorie malnutrition. Restorative admission assessment done on 8/13/24. No succeeding restorative assessment was done since admission. Therapy Physical and Occupational therapy discharge recommendation to restorative nursing on 2/24/25 indicated: Active range of motion exercise, minimal assist for bed mobility, minimal assist for transfer and minimal assist with rolling walker for at least 1 lap for walking. Physician order form as of 7/24/25 did not indicated that R1 was on restorative program. Most recent MDS/resident quarterly assessment section O Special treatment and programs 0500 Restorative Nursing Programs indicated: Active range of Motion (AROM) marked 6 days Walking marked 6 days. Reviewed R2's restorative log 7 days prior to discharged from the hospital indicated that staff still marked participated in AROM and walking program on 7/25/25 despite R2 was discharged to hospital on 7/24/25. The restorative log indicated that R2 did not participated in program from 7/17/25 to 7/24/25 except for 7/23/25 which staff indicated that he participated for both AROM and walking but there was discrepancy because of nursing progress notes dated 7/23/25 indicated R1 was very weak, lethargic and failure to thrive. Comprehensive care plan indicated R1 needs to maintain ROM trough self-performance related to cognitive deficit and risk of fall. R1 exhibits decreased in ability to dress self-related to decline cognition. R1 has an ADL (Activity of daily living) self-care performance deficit related to Alzheimer's, fall risk, impaired balance. R1 needs assistance to ambulate and would benefit from ambulation program to maintain current abilities related to disorder of muscle. R1 demonstrates cognitive impairment related to dementia. R1 has communication challenges due to dementia. R1 has nutritional problem or potential nutritional problem related to medical history. R1's care plan interventions were not updated since admission. On 8/27/25 at 9:59AM, V4 Restorative Nursing denied complaint allegations presented by V19 Family member/daughter of R1 that the facility failed to maintain mobility post rehab despite of repeated family request and lack of an active restorative /mobility plan in the facility. Reviewed R1's medical records with V4 which indicated that V4 only did initial/admission restorative assessment of R1 on 8/13/24. V4 said he forgot to do follow up assessment as indicated in their policy. V4 said restorative assessment is done upon admission, quarterly, annual, and as needed. R1 was on ROM and walking program during her stay in the facility. V4 said he only selected 2 programs from therapy discharge recommendations to Restorative nursing. V4 said he did not complete restorative assessment when R2 was discharged from therapy to Restorative nursing. On 8/27/25 at 2:00PM, Informed V1 Administrator and V2 DON of concerns identified with Restorative program, On 8/28/25 at 11:30Am, Reviewed facility's policy on Restorative program and informed concerns identified with V4 Restorative Nurse. Facility's policy on Restorative Nursing Program reviewed 8/18/24 indicated: 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145803 If continuation sheet Page 4 of 5 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 08/29/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the Nurse designated to oversee the Restorative 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 programs. 2. The facility restorative nursing program will include but not limited to the following programs: a. Hygiene- bathing, dressing, grooming and oral careb. Mobility- transfer and ambulation, including walking, prosthetic and or splintc. Elimination- toileting, bowel, and bladderd. Dining- eating, including meals and snackse. Communication- including speech language, other functional communication systems.4. The above program will be documented on the facility designated restorative care forms/tools in the resident's electronic medical record. 5. Based on clinical evaluation and ongoing consideration residents may be placed in one or more of the above listed programs at one time.6. The designated nurse will be responsible for the following: a. Obtaining orders for the resident's restorative programb. Documentation monthly (at a minimum) and c. Initiation and updating restorative care plans7. Once in an appropriate restorative nursing program, the designated nurse will continue to monitor the resident's progress8. The designated nurse will evaluate the restorative documentation monthly to determine if there are any changes needed to the existing program and make a monthly progress note, in the resident's electronic medical record related to this evaluation. Event ID: Facility ID: 145803 If continuation sheet Page 5 of 5