Inspection·October 19, 2022

F 0600 The abuse investigation was substantiated and resident to resident abuse did occur. Level of Harm - Minimal harm or potential for actual harm The local police department report was reviewed and shows that they arrived to the facility at approximately 9:00 PM on 9/3/22. That report shows both R102 and R331 were interviewed by the police. R102 communicated with the police by showing them previously typed messages on his cell phone about the incident. R102 admitted to throwing the cans at R331 because the TV was too loud. R331 told police he had recently been moved into the room with R102 (10 hours earlier) and was watching a football game on TV when R102 began throwing cans at him. One can hit him in the back of the head, and one knocked his phone to the floor cracking the phone screen. The investigation shows R102 was issued a citation for criminal damage and battery. Residents Affected - Few On 10/18/22 at 2:38 PM, V11 (Licensed Practical Nurse/LPN) said the night the altercation happened between R102 and R331 she was alerted by a CNA who came frantic saying that R102 was throwing cans at R331. V11 said when she arrived, there were several soda cans on the floor and in the hallway, and R331 was covered in soda. V11 said she immediately separated the 2 residents (both were still on their side of the room) and called V1 to alert him of the incident. She said when she asked R331 what happened, he told her he was watching TV and R102 just started opening and throwing cans at him. R102 told her that he had been hit with a can and his phone was also broken. V11 said R102 can become childish if he does not get his way, but to her knowledge, he has never started a physical altercation with any other roommates. On 10/19/22 at 8:04 AM, V8 (Unit Manager) said she was notified of the altercation between R102 and R331. She said R331 was not injured but he was very upset the incident happened, and he was moved to another room and discharged a few days later. V8 said that R102 is very particular about people and also doesn't like certain staff at the facility and refuses care from them. She said that there has been issues between R102 and roommates in the past, but to her knowledge, he has never become physical with anyone else. V8 said she went to try and talk with R102 after the incident, and he responded by giving her the middle finger. She said to communicate with R102 they use a writing board, an interpreter, or he types the words into his phone, and they read it. On 10/19/22 at 8:22 AM, V12 (Medical Records/Interpreted for R102) R102 communicated with the surveyor via writing on an erase board and via V12 interpreting. R102 said he deliberately was trying to hit R 331 with the cans he threw at him because his TV was too loud. R102 said he did not try to alert staff about the TV issue and asked this surveyor, Am I going to jail. On 10/19/22 at 9:01 AM, V1 said he was contacted by staff at the facility about the incident between R102 and R331, and he came into the facility and began the investigation. He said he was upset that the police did not take R102 with them after this incident occurred because it was considered a battery to another resident. V1 said he has not had any other physical abuse allegations involving R102, but he has had other roommate issues, which are typically the other residents requesting to move away from R102 because his TV is too loud. V1 said that R102 does not have any dementia and his acts were deliberate. He said when he sent the final report to IDPH he forgot to check the box that abuse was substantiated, but battery is abuse and the allegation of abuse was substantiated against R102. V1 also said R1 has not had a private room because of space at the facility. On 10/19/22 at 9:59 AM, R331 was interviewed via phone. He said he was only in the room a short time with R102, but on the night of the incident (9/3/22) he was watching the bears game on TV, and his roommate (R102) had turned his TV off and went to bed. Shortly after, he hears a pop can open up and it comes flying by him hitting the side of his head. He said he was covered in soda, and R102 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 2 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete threw 4 cans at him in total. He said one of the cans knocked his phone off the bedside table and cracked the back of it. R331 said he was moved out of the room to another room but did in fact see R102 in the hallway and in the dining area of the facility. He said even though he was not injured he was Not thrilled that this happened to him. The facility provided policy titled SG ANE and Investigations (abuse policy) revised on 9/8/22 states, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Event ID: Facility ID: 145821 If continuation sheet Page 3 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 identify restraining a resident by restricting their movement which applies to 1 of 24 residents (R44) reviewed for restraints in the sample of 25. Residents Affected - Few The findings include: R44's Facility assessment dated [DATE] showed R44 being an [AGE] year old cognitively impairment resident admitted to the facility with diagnoses which include: dementia, history of falls, sequela for pelvis/pubis fracture. On 10/17/22 at 9:05 AM, R44 was sitting inside the nurses' station with no staff present at the desk. R44 was pushed all the way up to the desk counter with both brakes on the wheelchair locked. R44 attempted to get up and push away from the desk but could not move with the wheels locked. On 10/17/22 at 9:10 AM, V22 (Certified Nursing Assistant/CNA) stated R44 is kept at the nurses' station because she is a fall risk. R44 will attempt to get up from her chair by herself. We (staff) keep her at the nurses' station to keep an eye on her, but she cannot be left by herself. On 10/18/22 at 12:30 PM, V22 stated putting her up against the nurses' station with the wheelchair locked does restrict her from getting up. On 10/17/22 at 10:30 AM, V19 (Certified Nursing Assistant/CNA) stated R44 will try to get up from her chair if she is not occupied with an activity or being redirected. R44 is a fall risk. On 10/18/22 at 11:35 AM, V2 (Director of Nursing/DON) stated R44 should not have been placed where she could not move. The facility's Restraint Policy revised 3/27/22 showed .Restraints shall only be used to treat the resident's medical symptom(s), and never for discipline or staff convenience .Definition of Restraint: Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 4 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 identify, assess, and apply pressure relieving interventions for residents who are high risk for pressure injuries. This applies to 3 of 11 residents (R76, R103 & R106) reviewed for pressure injuries in the sample of 25. Residents Affected - Few 1. R76's electronic medical records (EMRs) list her diagnoses to include: cognitive communication deficit, urine retention, chronic kidney disease, disorientation and dementia. R76's EMR shows she was admitted to the facility on [DATE]. The facility's pressure ulcers as of October 17, 2022 provided on October 17, 2022 shows, R76 has two pressure injuries. Her left heel- DTI (deep tissue injury) and sacrum- DTI. Both were acquired at the facility. R76's initial admission/re-admission nursing note dated August 30, 2022 shows, she was admitted with redness on her sacrum. There was nothing listed about her heels. Additional comments/observations: heels intact, groins intact, Foley catheter 16 fr(french-size)/10ml (milliliter), perineum intact, scabs to left lower buttock, skin is warm to touch, turgor tenting, pink in color. R76's weekly skin integrity review dated September 6, 2022 shows, Site: Sacrum, Description: excoriation. R76's weekly skin integrity review dated September 13, 2022 shows, Site: sacrum, Description: Shear wound. R76's newly identified skin condition dated September 17, 2022 shows, Site: sacrum, Type: other MASD (moisture associated skin damage), 1.0 X 1.0 X 0.1 cm (centimeters) (length X width X depth). 1a. If Other selected for site and/or type, describe: 100% superficial skin, no drainage, discomfort during cleansing of the wound. 2. Additional narrative of findings: incontinence of stool (has a catheter). R76's weekly skin integrity review dated September 20, 2022 shows, Site: sacrum, Description: shear wound related to incontinence. There are no measurements or assessment of the wound. R76's progress note dated September 24, 2022 shows, Late entry (entered on October 18, 2022 during the survey process): Weekly wound assessment: sacrum shear (MASD) wound, 1.5 X 0.6 X 0.0 cm, 100 % superficial skin, scant drainage, no pain, peri-wound intact, current treatment continues. R76's weekly skin integrity review dated September 27, 2022 shows, Site: sacrum, Description: shear wound- MASD related. There are no measurements or assessment of the wound. R76's progress note dated October 1, 2022 shows, Late entry (entered on October 18, 2022 during the survey process): weekly wound assessment: sacrum shear (MASD), 0.5 X 0.5 X 0.1 cm, no drainage, no pain, peri-wound intact. R76's weekly skin integrity review dated October 4, 2022 shows, Site: sacrum, Description: shear/MASD wound. There are no measurements or assessment of the wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 5 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R76's newly identified skin condition dated October 6, 2022 shows, Site: left heel, Type: pressure, 2.5 X 2.6 X 0.0 cm (length X width X depth), Stage: suspected deep tissue injury. R76's wound evaluation and management summary from the wound physician dated October 6, 2022 shows, History: Chief Complaint: This patient has multiple wounds. History of present illness: At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has an unstageable DTI of the left heel for at least 1 day duration . Focused wound exam: unstageable DTI of the left heel partial thickness, etiology: pressure, wound size (L X W X D): 2.3 X 2.5 X not measurable cm . Focused wound exam: unstageable DTI sacrum partial thickness, etiology: pressure, Wound Size (L X W X D): 1.5 X 0.3 X not measurable cm . R76's progress note dated October 6, 2022 shows, Late entry (entered on October 18, 2022 during the survey process): Weekly wound progress: left heel: unstageable DTI (deep tissue injury), 2.3 X 2.5 X 0.0 cm, no exudate, denied pain, peri-wound intact . Sacrum: unstageable DTI with intact skin: 1.5 X 0.3 X 0.0 cm, linear in shape, no exudate, peri-wound normal, denied pain. On October 18, 2022 at 11:25 AM, V4 (Wound Care Nurse) was doing R76's dressing to her right heel. R76 had a half dollar size closed dark purple pressure injury to her left heel. On October 18, 2022 at 1:21 PM, V4 (Wound Care Nurse) stated, a wound care physician did not see R76 until October 6, 2022. When the wound care physician saw R76,she said V4's identification of R76's wound was not correct and was being treated incorrectly. She labeled it a DTI and changed the treatment. V4 also stated that she was the one who found R76's left heel wound. Every time I do my rounds, I do skin checks. The wound was not identified on October 4, 2022, when V4 did a weekly skin review. She stated, I can't tell you why it wasn't found until me. She also added that she totally forgot to enter her assessments of the sacral wound every week. On October 19, 2022 at 1:00 PM, V2 (Director of Nursing/DON) stated, R76 was high risk for pressure injuries at the time of admission. R76's current order summary report provided on October 19, 2022 shows, (Brand) low air loss mattress, order date: October 7, 2022. Approximately one month after admission. R76's Minimum Data Set, dated [DATE] shows, she is not cognitively intact. She requires extensive assist of 1-2 people for ADL's (activities of daily living). R76's care plan date initiated October 1, 2022 (approximately 1 month after admit) shows, Focus: Resident is at RISK for skin impairment/pressure injury. Altered nutritional status, incontinence. Interventions: Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration, edema noted during bathing or daily care. Offload pressure to heels as needed. Provide pressure relieving mattress. R76's care plan date initiated October 17, 2022 (11 days after identifying wound) shows, Focus: The resident HAS PRESSURE INJURY to left heel- incontinence, limited/impaired mobility. The facility's wound care last revised on March 27, 2021 shows, Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 6 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0686 Level of Harm - Minimal harm or potential for actual harm The facility's repositioning and support structures last revised on March 27, 2021 shows, Standards: It will be the standard of this facility to provide evaluation of the resident's repositioning needs, to aid in the development of a care plan for repositioning as needed, to promote comfort for all bed-bound or chair-bound residents, to attempt to prevent skin breakdown, promote circulation and provide pressure relief for residents. Residents Affected - Few 2.) R103's face sheet shows she has diagnoses including unspecified dementia, cerebral infarction, muscle weakness and need for assistance with personal care. R103's 9/18/22 facility assessment shows her cognition is impaired and she requires extensive assistance from staff for bed mobility. R103's care plan initiated on 3/12/2020 shows she is at risk of developing pressure ulcers. The same care plans show she should use heel float devices or pillows to prevent her heels from rubbing on the mattress and to help reduce pressure. R103's active order summary shows she should have her heels floated and pressure prevention boots on when she is in bed. On 10/17/22 at 10:32 AM, R103 was lying in bed her heels were resting flat against the mattress. She did not have any pillows underneath her feet and did not have pressure prevention boots on. On 10/18/22 at 8:44 AM, R103 was lying in bed and a Certified Nursing Assistant (CNA) was in the room feeding her breakfast. R103 had her heels flat against the mattress with no pillows underneath her feet and no pressure prevention boots on. On 10/19/22 at 8:20 AM, R103 was again lying in bed and had her heels flat against the mattress with no pillows underneath them and no pressure prevention boots on. On 10/19/22 at 9:51 AM, V4 (Wound Care Nurse) said R103 is at high risk for pressure ulcers to develop and she should have her heels off-loaded and pressure prevention boots on when she is in bed. 3.) R106's face sheet shows he has diagnoses including hemiplegia and hemiparesis following cerebral infarct, muscle weakness, and need for assistance with personal care. R106's care plan revised on 8/15/22 shows he requires extensive assistance from staff for bed mobility and turning and repositioning. The same care plan shows R106 is at risk to develop pressure ulcers and should have his heels off loaded and heel protectors on when in bed. R106's active order summary shows he should have heel protectors on when in bed. On 10/17/22 at 2:10 PM, R106 was lying in bed. His heels were resting against the mattress with no pillows underneath and no heel protectors on. 2 green heel protector boots were seen in his room, one boot was on the floor in front of his bed side stand and the second was on his bed side stand. V15 (R106's fiancee) was present in room and said she was not even sure if he was supposed to have heel protectors on in bed or not. On 10/18/22 at 10:47 AM, V4 said that R106 is at a extremely high risk for developing a pressure ulcer due to multiple medical conditions. V4 said R106 should have his heels off-loaded or heel protectors on at all times when he is in bed. The facility's Skin and Wound policy revised on 3/27/21 states, It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment . Preventative measures, such as barrier creams, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 7 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0686 can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots and use of positioning devices . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 8 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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** 2.) R9's face sheet shows she has diagnoses including hemiplegia and hemiparesis following a cerebral infarction. R9's 7/22/22 facility assessment shows her cognition is mildly impaired, and she requires extensive staff assistance with her activities of daily living (ADL's) R9's mobility care plan revised on 8/11/2021 shows that R9 has limited mobility to her left hand and a hand towel roll should be put in her hand each shift. R9's restorative range of motion task charting shows R9 should receive a hand rolled towel in her left hand to prevent further contractures. The chart for R9 is checked off on 10/17/22 at 10:36 AM, and again on 10/18/22 at 11:05 AM, indicating that R9 did have a hand roll towel put into her left hand. On 10/17/22 at 9:56 AM, R9 was in bed her left arm was positioned in front of her and her left hand was in a clenched position with no hand roll in it. On 10/18/22 at 9:24 AM, and again at 1:24 PM, R9 was in bed with her left hand clenched and no hand roll in her hand. On 10/18/22 at 1:24 PM, when R9 was asked if the staff put a hand roll towel in her hand, she replied that they do not to that for her. On 10/18/22 at 1:17 PM, V8 (Unit Manager) said R9 is being seen by restorative therapy and part of the therapy for her is to have a rolled wash cloth put in her left hand to prevent it from developing any further contractures. The facility's Contracture Management policy revised on 3/1/21 states, It will be the standard of this facility that the facility must ensure that a resident with a limited range of motion (ROM) receives appropriate treatment to increase range of motion and/or to prevent further decrease in ROM .Treatment may include positioning or splinting to prevent further loss of ROM . Based on observation, interview, and record review, the facility failed to ensure restorative devices were being implemented as prescribed. This applies to 2 of 5 residents (R19 & R9) reviewed for restorative in the sample of 25. The findings include: 1. On October 17, 2022 at 10:43 AM, R19 was in her room in her wheelchair. Her arms were bent with her hands up on her chest. Her hands were severely contracted. She did not have on any splints. At 11:10 AM, she was still in her room in the same position with no splints on. At 2:04 PM, she was in bed taking a nap. She did not have any splints on. On October 18, 2022 at 8:48 AM, R19 was in the main dining room being fed by staff. She did not have any splints on her hands. At 11:38 AM, she was back in her room, in her wheelchair. She did not have on any hand splints. On October 18, 2022 at 2:06 PM, V6 (Unit Manager) stated, R19 does have hand splints. They are applying her splints up to 8 hours a day. They put her splints on in the AM and remove them after lunch before they go home. R19's current order summary report provided on October 19, 2022 shows, Arm/Hand splint brace (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 9 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 contractures,12 hours on in AM and off at night. Right blue hand splint on at night, remove in the morning. Red/White palmar protector on when in bed during the day. May remove for ADL's and skin check. Monitor for signs and symptoms of redness. R19's care plan last revision on March 7, 2022 shows, Focus: Resident participates in restorative nursing programs: splinting- palm protector right hand. Interventions: Provide restorative programs/interventions as ordered/indicated (see POS (physician order sheet)/physician orders/restorative program). R19's Minimum Data Set, dated [DATE] shows, she requires extensive to total dependence of two people for transfers, bed mobility, dressing, eating, toilet use, and personal hygiene. The facility's contracture management last revised on March 1, 2021 shows, Standard: It will be the standard of this facility that the facility must ensure that a resident with a limited range of motion (ROM) receives appropriate treatment to increase range of motion and/or prevent further decrease in ROM. A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable . Guidelines: 3. Treatment may include positioning or splinting to prevent further loss of ROM. 4. If splinting is used a schedule for wearing the splint must be developed. The time frame for wearing the device should allow for freedom of choice by the resident and application by the staff, such as applying after morning care, remove before HS (hours of sleep) care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 10 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 2 staff were present during resident care to prevent resident injury for 2 residents (R9 and R77), and failed to ensure 2 staff were present for a resident transfer for 1 resident (R46). This failure resulted in R77 rolling out of bed, sustaining subdural hematomas requiring emergency care and hospitalization. This applies to 3 of 25 residents (R9, R77, R46) reviewed for safety/supervision in the sample of 25. The findings include: R77's Facility assessment dated [DATE], 5/23/22, and 8/22/22 showed R77 being [AGE] years old, being cognitively intact, and needing two-person assistance with bed mobility, transfers, dressing, toileting, and bathing. The facility's Final Incident Report dated 5/10/22 showed On 5/3/22 .resident was turned on her side by CNA staff during incontinence care, Resident rolled over and fell on the floor .paramedics arrived and transported resident to ER for evaluation. On 10/18/22 at 8:35 AM, R77 was noted to have multiple contractures of both arms and hands. R77 was unable to self-turn in bed. R77 stated, A few months ago I had to go to the hospital. One of the CNAs was cleaning me up by herself. She turned me on my side to clean my backside, and I rolled off the bed away from her. I hit my wheelchair on the way down, and basically landed on my face. On 10/18/22 at 2:35 PM, V21 (R77 Daughter) stated the facility contacted me when mom fell. They told me [R77] was receiving peri-care by one staff member, and she rolled off the bed. At the hospital they said [R77] had some blood between her skull and brain from the fall. R77's Hospital Records dated 5/3/22 showed R77 admitted to the hospital. R77's head CT scan results showed two acute subdural hematomas. On 10/18/22 at 2:00 PM, V18 (Therapy Director) stated, she has assisted with turning R77 in the past. Due to her contractures, and inability to move herself, she needs to have two people turn her with care. On 10/18/22 at 11:35 AM, V2 (Director of Nursing/DON) stated if a resident is designated as a two-person assist, there should be two staff members providing the care. R77 should not be turned with only one person for care. The facility's Activities of Daily Living (ADL) Policy revised 3/27/21 showed .Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the resident, while ensuring the needs and desired goals of the resident are met safely. R9's face sheet shows she has diagnoses including hemiplegia and hemiparesis following a cerebral infarction. R9's 7/22/22 facility assessment shows her cognition is mildly impaired, and she requires extensive 2-person staff assistance with bed mobility and turning from side to side. R9's Activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 11 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 of Daily Living (ADL) care plan, revised on 8/11/21, shows R9 has limited mobility due to left sided hemiparesis and hemiplegia, and requires extensive 2 staff assist with her bed mobility. R9's fall risk care plan revised on 10/18/22 shows she is at risk for falls and has a history of falls. On 10/17/22 at 9:56 AM, R9 said she was rolled out of bed by a Certified Nursing Assistant (CNA) who had come in the room alone to turn and change her. R9 said the CNA was turning her alone and she rolled right out of bed hit her face on the floor and had to go to the emergency room. On 10/17/22 at 9:59 AM, V9 (Certified Nursing Assistant/CNA) said R9 does require 2 CNAs to turn and re-position her. A fall incident report dated 9/4/22 at 5:20 AM, shows that a CNA identified as (V13) was turning R9 and she suddenly moved and fell out of bed landing on the floor on her right side. The fall incident report shows that R9 was taken to the hospital and had no apparent injury A nursing progress note dated 9/4/22 at 11:39 AM, shows R9 returned from the hospital with no apparent injury and states, educated CNAs to have 2 persons assist when providing care. On 10/18/22 at 1:36 PM, V8 (Unit Manager) said there is (Trade name) storage/file system in the computer that staff can look at to see how resident transfers or how many staff are needed to turn or lift a resident. On 10/18/22 at 2:09 PM, V13 said he was the CNA in the room changing R9 alone when she suddenly rolled out of bed. V13 said he had not worked with R9 that much and he did not realize she needed 2 staff to turn and re-position her. V13 said he was not familiar with a (Trade name) storage/file system in the computer to look for how many staff are needed to turn or transfer a resident. 3.) R46's face sheet shows he has diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting his left side. R46's 8/10/22 facility assessment shows his cognition is intact and he requires extensive 2-person staff assistance for transfers and toileting. R46's active fall prevention care plan, revised on 2/17/21, shows R46 is a fall risk. R46's active ADL care plan, revised on 5/14/21, shows he requires extensive 2 person staff assistance with transfers and toileting. On 10/17/22 at 9:16 AM, V7 (Certified Nursing Assistant/CNA) took R46 into the bathroom to toilet him. She was the only CNA present, and she had R46 grab the bar and stand up and transferred R46 onto the toilet alone. V7 said that R46 is a 1-person transfer and she gets the information communicated to her from the nurse how each resident transfers. On 10/18/22 at 1:36 PM, V8 (Unit Manager) initially said that R46 was a 1 person staff transfer and went to check the (Trade name) storage/file system in the computer. V8 returned and said it was her mistake but R46 does require 2 staff to transfer him. V8 showed this surveyor R46's (Trade name) storage/file system that indicates he requires 2 staff for transfers and toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 12 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure residents on mechanical soft and pureed diets received the same menu as the regular diet. This applies to 24 of 24 residents (R6, R27, R127, R19, R64, R22, R82, R80, R43, R75, R44, R60, R38, R24, R182, R93, R3, R15, R88, R115, R51, R90, R36, & R103) reviewed for mechanical soft and pureed diets in the sample of 25. The findings include: The facility's menu with the noon meal for October 17, 2022 shows, Orange glazed chicken, fried rice, oriental vegetable blend, and bread pudding. On October 17, 2022 at 11:22 AM, V17 (Cook) was preparing the pureed diets for the noon meal. He stated, he did not have a pureed recipe for the orange chicken, so he was going to follow the recipe for chicken ala king. He put baked chicken bites in the blender and added some chicken broth. The chicken bites did not have any orange sauce on them. On October 17, 2022 at 12:01 PM, V16 (Food Service Director) was serving the noon meal. Residents' with a mechanical diet (R64, R22, R82, R80, R43, R75, R44, R60, R38, R24, R182, R93, R3, R15, R88, R115, R51, R90, R36, & R103) were served the ground chicken bites and a California blend vegetable (carrots, cauliflower & broccoli). There was no orange sauce on the chicken. They did not receive the oriental vegetables (green beans, broccoli, onion, red peppers & mushrooms). At 12:23 PM, V17 (Cook) stated, the mechanical soft chicken was just chicken with no orange sauce. The vegetables were different because he didn't have enough of the oriental vegetables to serve everyone. The facility's chicken orange glazed recipe dated January 5, 2021 shows, Ingredients: chicken breast boneless skinless 4 ounce, orange juice, granulated sugar, corn starch, sunglow butter blend, and mandarin oranges in juice. The facility's chicken a l'orange pureed thick dated July 28, 2021 shows, Ingredients: Chicken a l'orange, beef base, water, & food thickener. The facility's therapeutic spread report for the noon meal on October 17, 2022 shows, Mechanical Soft: Asian orange chicken- ground 4 ounce, rice, oriental vegetable, & bread pudding. Puree: Asian orange chicken, rice, oriental vegetable, bread pudding- no raisins. On October 18, 2022 at 10:20 AM, V1 (Administrator) and V16 (Food Service Manager) stated, the mechanical soft and pureed diets should have received the same as the regular diets. The facility diet type report provided on October 17, 2022 lists R6, R27, R127, & R19 as having a pureed diet. The same report lists R64, R22, R80, R82, R43, R75, R44, R60, R38, R24, R182, R93, R3, R15, R88, R115, R51, R90, R36, & R103 as having a mechanical soft diet. The facility's menus planning last revised February 19, 2021 shows, Guidelines: .2. Menus are followed daily . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 13 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure pureed diets were served in a smooth, soft texture. This applies to 4 of 4 residents (R6, R27, R127 and R19) reviewed for pureed diets in the sample of 25. The findings include: The facility's menu for the noon meal on October 17, 2022 shows, Orange glazed chicken, fried rice, oriental vegetable blend and bread pudding. On October 17, 2022 at 12:01 PM, the noon meal was served to all of the residents. At 12:46 PM, all residents were served the noon meal. R6, R27, R127, & R19 were served pureed diets. On October 17, 2022 at 1:01 PM, the pureed oriental vegetables were not smooth. There were pieces of the vegetables in it. The pureed rice was not smooth and there were also pieces of rice in it. On October 18, 2022 at 10:20 AM, V16 (Food Service Manager) stated, the pureed diets should be smooth and no chunks of food in it. The facility diet type report provided on October 17, 2022 lists R6, R27, R127, and R19 as having a pureed diet. The facility's liberalized diets last revised on February 19, 2021 shows, Guidelines: .5. The following diets may be served: e. Pureed- regular diet that is processed to a smooth, mashed potato or pudding consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 14 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food prep areas were free of food debris. The facility also failed to ensure plates were clean and dry before using them for the noon meal. This applies to all 124 residents residing in the facility. The findings include: The CMS 672 census and conditions report dated October 17, 2022 shows, there are 124 residents residing in the facility. On October 17, 2022 at 8:47 AM, during the initial kitchen tour, the stand mixer sitting next to the food prep area by the oven and steamer was dirty with some white powder like substance. The attachments were sitting in the bowl and were dirty with this white powder like substance. There was an opened boxed of barley that appeared to be dusty sitting next to the stand mixer. The table was dirty with a white powder like substance and dried food debris. Underneath the prep tables held the clean pots, pans, and cutting boards. The cutting boards were sitting on top of a baking sheet that was full of food crumbs, debris and old French-fries. The shelf with the pots and pans were also dirty with dried food debris and crumbs. The rolling cart that held the cereal was dirty with spilled cereal and food crumbs/debris. The other food carts that held condiment packets were thrown all over, and there were food crumbs all over. The food prep area table next to the rolling carts held the bread. There were papers, bread crumbs, dried food debris spread all over the counter. The steam table had noodles and carrots floating in the water. There was a salt-like substance spilled on top of the steamer. There was also a pair of tongs and a used glove behind the steamer. On October 17, 2022 during the noon meal, there were multiple plates that were still dirty with food debris stuck on them. Some of the dirty plates were used to serve the noon meal. Some of the plates and lids were wet with water from being washed and not allowed to air dry. On October 17, 2022 at 2:50 PM, V16 (Food Service Manager) stated, they didn't have a cleaning schedule or cleaning logs. She agreed that the kitchen was very dirty and had not been cleaned over the weekend. The facility's cleaning and sanitizing of food and non-food contact surfaces policy last revised March 4, 2021 shows, Standard: Food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent foodborne illness and minimize bacterial growth . Guidelines: 1. Food contact surfaces (i.e. countertops and other food preparation areas) are washed and sanitized before and after use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 15 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 Based on observation, interview, and record review, the facility failed to ensure a resident with COVID symptoms was placed on isolation precautions. This applies to 1 of 25 residents (R93) reviewed for infection control in the sample of 25. Residents Affected - Few The findings include: On October 17, 2022 at 9:41 AM, R93 was in his room. He was not on any isolation precautions. A CNA (Certified Nursing Assistant) was in the room helping him get up. At 10:45 AM, R93 was still in his room. Therapy was working with him. He practiced walking in the hallway. He was not on isolation precautions. On October 17, 2022 at 2:29 PM, R93 had an isolation bin outside his room and a sign on his door that said contact/droplet precautions. V20 (Registered Nurse/RN) stated, R93 was now positive for COVID-19. He had a cough and loose bowel movements that started last night. Around lunch time they rapid tested him for COVID-19, and he was positive. R93's progress notes dated October 17, 2022 at 7:00 AM show, Resident with LBM x2 (loose bowel movements) and occasional cough . rapid test administered and received negative results . R93's progress notes dated October 17, 2022 at 11:50 AM show, Resident noted coughing in the morning. Refused to eat breakfast this morning. Resident noted not his usual this morning. COVID-19 test done and positive. Floor nurse aware . isolation precaution set up. On October 18, 2022 at 11:03 AM, V2 (Director of Nursing/DON) and V3 (Infection Control Nurse) stated, if a resident develops COVID-19 symptoms they do a rapid COVID test. If the test is negative, they do a PCR to follow up. The facility's transmission-based precautions last revised on September 1, 2022 shows, TransmissionBased Precautions: COVID-19 Specific: Per the direction of CDC (Centers for Disease Control), special contact/droplet precautions are to be carried out for residents identified as having SARS-CoV-2 virus (COVID-19), COVID-19 PUI (persons under investigation), or new admission preventative precautions . Transmission-based precautions are used for residents who are known to be or suspected of being infected or colonized with infectious agents, including pathogens that require additional control measures to prevent transmission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 16 of 17 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 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to ensure that the kitchen, cooler and freezers were clean and sanitary. This applies to all 124 residents residing in the facility. Residents Affected - Many The findings include: The CMS 672 census and conditions reports dated October 17, 2022 shows, there are 124 residents residing in the facility. On October 17, 2022 at 8:43 AM, both stand-up freezer door handles and doors had dried food debris on them. Inside both freezers, on the floor, were frozen food and food debris (peas and green beans). The cooler had onion peels and other food debris on the floor. A red substance was dried on the wall. The floors were sticky and had a black film on them. There were packets of salt, mayonnaise, coffee creamer on the floor in random places. There were french fries on the floor. The floors appeared to not have been swept and mopped in sometime. On October 17, 2022 at 2:50 PM, V16 (Food Service Manager) stated, they didn't have a cleaning schedules or cleaning logs. She agreed that the kitchen was very dirty and had not been cleaned over the weekend. The facility's cleaning and sanitizing of food and non-food contact surfaces last revised on March 4, 2021 shows, Standard: .Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment. Guidelines: 3. Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule- or as visually necessary. These are then wipes down with sanitizer solution (bleach at 100 parts per million). The facility's kitchen floors policy (no date) shows, It is the dietary managers responsibility to assure that after every meal pass the floor is swept and damp mopped. The floor will be wet mopped with a degreaser daily after the last meal pass. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 17 of 17