Inspection·September 8, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The Electronic Medical Record (EMR) shows that R33, an [AGE] year-old female, with diagnoses of bilateral osteoarthritis, peripheral neuropathy, chronic obstructive pulmonary disease exacerbation, diabetes mellitus type 2, major depressive disorder, obesity, and cerebral infarction. R33 was admitted to the facility on [DATE]. Residents Affected - Some The MDS (Minimum Data Set) assessment dated [DATE] showed that R33 was cognitively intact with a BIMS (Brief Interview Mental Status) score of 14/15. The MDS also showed that R33 required extensive assistance from 1-2 staff for bed mobility, transfer, dressing and hygiene. On 9/05/23 at 10:43 AM, R33 was observed in her room. R33 was sitting in her wheelchair. R33 was observed with a long facial hair surrounding her chin and upper lip and looked like a moustache. When asked how R33 feels about her facial hair, R33 responded I do not like it, I like to have it shaved and I have been asking for it for a while, I even asked for a razor, they (staff) never did anything about it. V11 (Unit Charge Nurse) was present during this observation and said, I will ask a CNA (Certified Nurse Assistant) to shave her. R33 was also observed with long, and jagged fingernails. The fingernails were noted with black substance under the nails. V11 said she will have a CNA to cut R33's nails. The care plan dated 3/19/2022 showed that R33 has an ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance, impaired balance, and weakness. The care plan showed that R33 currently requires assistance with ADLs. Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and incontinence care. This applies to 9 of 9 residents (R31, R33, R39, R48, R49, R51, R84, R88 and R90) reviewed for ADLs (activities of daily living) in the sample of 24. The findings include: 1. R39 had multiple diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, based on the face sheet. R39's quarterly MDS (minimum data set) dated 8/22/23 showed that the resident was severely impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 11:26 AM, R39 was sitting in her wheelchair alert and verbally responsive. R39 had accumulation of facial hair above her lips. R39 wanted the staff to shave her. R39 stated, I do not want any of these, referring to the facial hair above her lips. V10 (Licensed Practical Nurse/LPN) was made aware and confirmed the facial hair above R39's lips. R39's active care plan last revised on 9/1/23 showed that the resident had an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance during personal hygiene. 2. R48 had multiple diagnoses which included Parkinson's disease, Alzheimer's disease, dementia without behavioral disturbance and generalized muscle weakness, based on the face sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 2 of 30 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 09/08/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R48's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 10:31 AM, R48 was sitting in his wheelchair inside his room. R48 was alert and verbally responsive. R48 had accumulation of long facial hair and his pants had dried food debris on the front area. R48 stated that he wanted the staff to shave him and help change his pants because he needed assistance. V19 (LPN) was present during the observation. R48's active care plan last revised on 9/1/23 showed that the resident had an ADL self-care performance deficit. 3. R49 had multiple diagnoses which included generalized osteoarthritis and dementia without behavioral disturbance, based on the face sheet. R49's quarterly MDS dated [DATE] showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 1:54 PM, R49 was sitting in her wheelchair by the hallway in front of the main dining room. R49 had scattered long and curling chin hair. R49 stated that she wanted the staff to shave her. R49 commented, They should shave me, I do not know why they don't. V10 (LPN) was made aware of R49's request to be shaven. R49's active care plan last revised on 7/3/23 showed that the resident had an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance during personal hygiene. 4. R90 had multiple diagnoses which included rheumatoid arthritis and dementia without behavioral disturbance, based on the face sheet. R90's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required extensive assistance from the staff with personal hygiene. On 9/5/23 at 10:52 AM, R90 was inside the main dining room, watching television. R90 was alert, verbally responsive but confused. R90 had accumulation of facial hair on the chin. During the observation, R90's daughters came to visit the resident. R90's daughters stated that they wanted the staff to shave/remove R90's chin hair. V19 made aware of the chin hair. R90's active care plan last revised on 8/30/23 showed that the resident had an ADL self-care performance deficit. The same care plan showed multiple interventions including extensive assistance during her personal hygiene. On 9/7/23 at 12:40 PM, V2 (Director of Nursing) stated that it is part of the nursing care and services to provide personal hygiene to the residents. V2 stated that the resident's unwanted facial hair should be removed or shaven especially for those residents needing assistance with ADL. 6. On 9/5/23 at 1:31 PM during Resident Council group meeting, the following residents expressed concerns regarding not receiving ADL (Activities of Daily Living) assistance in a timely manner: - R33 stated getting timely care was a problem at the facility and she has waited hours for ADL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 3 of 30 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 09/08/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm care. R33 stated days prior she sat an hour in bowel movement and waited for staff to answer her call light to assist her in toileting. - R31 stated the CNAs (Certified Nursing Assistants) will pass her room while her call light was on because they were not specifically assigned to her. Residents Affected - Some - R84 stated when she needs help with ADLs, staff sometimes come in her room, turn off her call light, and but do not provide assistance. R84 stated she has waited 30-45 minutes for ADL care and sometimes 50 minutes in the middle of the night. - R88 stated she has waited an hour or more on the toilet waiting for staff to assist her. R88 stated she recently felt trapped in the bathroom for over and hour waiting for staff to answer her call light to assist her with toileting. R88 stated she was banging on the door to try to get staff attention. - R51 stated she has waited almost an hour for ADL assistance MDS (Minimum Data Sheet), dated 7/19/23, shows R31 was cognitively intact, was frequently incontinent of bowel, required total assistance of staff for transfers and toileting, and required the extensive assistance of staff for bed mobility, dressing and hygiene. MDS, dated [DATE], shows R33 was cognitively intact, was always incontinent of bowel and bladder, and required extensive assistance for bed mobility, transfers, dressing and personal hygiene. The MDS shows R33 was totally dependent on staff for toilet use. MDS, dated [DATE], shows R84 was cognitively intact, was occasionally incontinent of bowel/bladder, and required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. MDS, dated [DATE], shows R88 was cognitively intact, was occasionally incontinent of bowel/bladder, and required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. MDS, dated [DATE], shows R51 was cognitively intact, was occasionally incontinent of bowel/bladder, and required extensive assistance for bed mobility, transfers, dressing, toileting use, and personal hygiene. Review of facility Resident Council Meeting minutes showed the following: 5/25/23 - CNA's take a long time to answer their call lights. 3/23/23 - Other CNAs are answering other CNAs lights, but they do not help. 2/23/23 - CNAs don't answer call lights overnight in a timely manner. 12/29/23 - CNAs take a long time to answer lights, when they do they turn the light off and say they will be back and never do. 10/27/22 Overnight CNAs don't do their rounds. When they do, they only ask one roommate by the door (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 4 of 30 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 09/08/2023 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 0677 and not the roommate by the window. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 5 of 30 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 09/08/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 physician order regarding the use of compression stockings and compression wrap to treat and manage edema. This applies to four of four residents (R1, R70, R80 and R102) reviewed for edema in the sample of 24. Residents Affected - Some The findings include: 1. On 9/05/23 at 10:53 AM, R1 was observed in the dining room. R1 was sitting in her wheelchair. R1 was wearing a pair of pants and lower legs were visible. R1 was wearing a pair of socks and shoes. R1 was noted with edema to the lower legs/ankles. R1 was not wearing compression stocking. V11 (Unit Charge Nurse) was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R1 was supposed to wear a pair of compression stocking during the day. The compression stockings were to be applied in the morning and removed at night. Review of the POS (Physician Order Sheet) for the month of 9/2023 shows a physician order for R1 to apply the compression stocking in the morning and to take it off at night. The current care plan initiated on 9/23/2021 showed that R1 has impaired circulation related to edema. The goal was for R1 to be free from signs and symptoms of complications of poor circulation. The interventions included but not limited to administer physician orders, elevate legs as needed, and apply elastic stockings (compression stockings) to BLE (bilateral lower extremities) one time a day for BLE edema. Apply in the AM and remove at bedtime. The EMR (Electronic Medical record) shows that R1, a [AGE] year-old with diagnoses of disorder of muscle. congestive heart failure, asthma, respiratory diseases. morbid obesity, depressive disorder, and localized edema. The MDS (Minimum Data Set) dated 8/4/2023 showed that R1 was cognitively intact with BIMS score of 13/15 (Brief Interview Mental Status). R1 required assistance from staff for mobility, transfer, hygiene, and dressing. 2. On 9/05/23 at 10:01 AM, R70 was observed lying in bed. R70 was observed with swollen right hand, forearm, upper arm all the way towards the under arm. There was no compression wrap to R70's right arm. V11 was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R70 was supposed to have ace wrap (compression elastic wrap) to the right hand, starting from the palm to the elbow. The care plan 7/1/2023 showed that R70 has an ADL self-care performance deficit related to ADL needs, due to cerebral infarction with right hemiplegia, impaired mobility and balance and morbid obesity. The care plan intervention included but not limited to Ace wrap on the right hand, starting from the palm to the elbow in the morning and remove in the evening. Refer to POS/MAR (Physician Order Sheet/Medication Administration Record) for current orders. Please leave her fingers out and elevate afterwards. Apply per MD orders and monitor skin condition for changes, elevate right arm when in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 6 of 30 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 09/08/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm The EMR showed that R70, a [AGE] year-old with diagnoses that included but not limited to cerebral infarction, peripheral neuropathy, congestive heart failure, and morbid obesity, The MDS dated [DATE] showed that R70's cognition was severely impaired. R70 also required extensive to total assistance for mobility, transfer, dressing and hygiene. Residents Affected - Some On 9/6/2023 at 4:03 PM, V11 said that R70 has chronic swelling on the right arm and must have the ace wrap/compression wrap as ordered by the physician. 3. On 9/05/2023 at 10:30 AM, R80 was observed in the dining room. R80 was sitting in her wheelchair. R80 was noted wearing a pair of socks and shoes. R80 was observed with swollen lower legs and ankles. R80 was not wearing compression stockings. R80 said I guess they (staff) forgot to put it (compression stockings) on. V11 was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R80 was supposed to wear the compression stockings on during the day, apply in the morning and remove at night. The EMR showed R80's diagnoses that included but not limited to osteoarthritis, peripheral vascular disease, morbid obesity, diabetes mellitus, atherosclerosis of arteries of extremities, and localized edema. The current care plan that was initiated on 8/9/2021 showed that R80 has impaired circulation related to edema to the lower extremities. The goal for plan of care was for R80 to be free from signs and symptoms of complications of poor circulation. The care plan included interventions such as to elevate legs when resting and to apply compression stockings/TED Hose per orders. The POS for the month of 9/2023 shows a physician order for the compression stocking on during the day, apply in AM and remove at night. On 9/07/23 at 11:00 AM, V11 (Charge Nurse) said R80 must use the compression stockings for the edema to the lower extremities. V11 said the edema was related to R80's medical condition. 4. On 9/05/2023 at 11:11 AM, R102 was in the dining room R102 was sitting in her wheelchair. R102 was noted wearing a pair of socks and shoes. R102 was observed with swollen lower legs and ankles. R102 was not wearing compression stockings. V11 was present during this observation. The Nurses Shift Report dated 9/5/203 shows that R102 was supposed to wear the compression stockings on during the day, apply in the morning and remove at night. The POS for the month of 9/2023 shows a physician order 5/9/2023 for compression stockings to be applied to the BLE. It also showed to apply the compression stockings in the morning and remove at night. The EMR shows R102's diagnoses that included but limited to osteoarthritis, peripheral neuropathy, osteoporosis, and cerebral infarction. The physician progress notes dated 6/5/2023 showed that R102 was admitted to the facility on [DATE] after recent hospitalization for left hip ORIF (open reduction internal fixation). The notes also showed that the A/P (Assessment and Plan) included to continue compression stockings as ordered to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 7 of 30 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 09/08/2023 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 0684 treat and manage edema to the BLE. Level of Harm - Minimal harm or potential for actual harm On 9/07/23 at 11:00 AM, V11 said R102 must use the compression stockings for BLE edema due to medical condition. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 8 of 30 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 09/08/2023 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. Based on observation, interview, and record review the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility. This applies to 1 of 6 residents (R55) reviewed for limited range of motion (ROM) in the sample of 24. The finding include: R55's EMR (Electronic Medical Record) showed R55 has been in the facility since 8/26/22. R55's diagnoses included unspecified injury at C7 level of cervical spinal cord resulting in paraplegia, major depression, muscle generalized weakness, contracture of right knee, contracture of left knee, and polyneuropathy. R55's MDS (Minimum Data Set) dated 8/8/2023 showed R55 was cognitively intact and required two staff extensive assistance for bed mobility, transfers, and toilet use. R55 required one staff extensive assistance for dressing and personal hygiene. R55's MDS indicated he was receiving restorative services but did not indicate splint or brace assistance. R55's care plan initiated on 1/6/23 showed [R55] had an ADL (Activities of Daily Living) performance deficit related to paraplegia and neuropathy. The interventions included bilateral contracture braces- on for 4 hours. On 5/3/23 a new focus was added. [R55] participates in restorative nursing programs. Interventions included provide restorative programs/interventions as ordered/indicated and report and document any declines in ability. R55's POS (Physician Order Set) showed an order on 6/8/23 for assistance brace left resting hand splint on for up to eight hours at a time. Monitor skin. Left elbow contracture brace on for eight hours at a time. Monitor skin integrity every day and evening shift R55's restorative recommendations made by Physical Therapy dated 5/3/23 showed PROM (Passive Range of Motion) was recommended. Description of plan showed gentle passive range of motion to bilateral hip and knee joints 15 repetitions times two sets. Restorative nursing program three to six times a week as tolerated. R55's restorative recommendations made by Occupational Therapy dated 5/12/23 recommended AAROM (Active Assisted Range of Motion), PROM, and splint/brace. Description of plan showed left elbow AAROM and left-hand PROM, two sets of 10 repetitions three to six times a week as tolerated for contracture management. Left resting hand splint and left elbow extension splint on up to eight hours at a time, monitor skin, done three to six times a week as tolerated. On 9/5/23 at 12:40 PM, R55 was in bed. R55's left was contracted into a closed fist. R55 said he cannot open his left hand. R55's right hand was visibly contracted and R55 said he could not straighten out his fingers. R55 said his right hand is worsening and facility is not doing anything about it. R55 said he should be getting ROM exercises. R55 also reported his left leg is starting to contract more. On 9/6/23 at 2:00 PM, R55 said he has not had his splint on his hand/arm for several days. On 9/7/23 at 10:28 AM, V11 (Restorative Nurse/Nurse Manager) said that R55 has an order for ROM (Range of Motion) to his left elbow, has a left resting hand splint which he is to wear for 8 hours a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 9 of 30 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 09/08/2023 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 day. R55 was on the other end of the building and so V11 said she did not know what was being done for him when he was on the other side of the building because we really don't have a restorative program. V11 said [R55's] orders in the computer showed restorative started on 9/14/22. V11 said no one has mentioned to her that R55's right hand is contracted. When there is a concern, the CNA (Certified Nurse Aide) or RA (Restorative Aide) needs to make the nurse aware and then PT (Physical Therapy) will be consulted. Residents Affected - Few On 9/7/23 at 10:43 AM, V22 (Restorative Aide) said R55 wears a left brace to hand and elbow three to six times a week. He last wore it two weeks ago. When asked why 2 weeks ago, V22 said she has been really busy. R55 will usually wear his brace after lunch. V22 said [R55] has not said anything to her about his right hand being contracted and continued to say that R55 has not been getting any restorative to his right hand because he can move his right arm himself. V22 said R55 exercises his right arm, and we do ROM to his left arm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 10 of 30 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 09/08/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to clean a resident during incontinence care in a manner that would prevent potential infection. This applies to 1 of 1 resident (R34) reviewed for incontinence care in the sample of 24. The findings include: R34's EMR (Electronic Medical Record) showed R34's most recent admission date was 7/4/22 with diagnoses that included Parkinson's disease, dementia without behavioral disturbances, and peripheral autonomic neuropathy. R34's MDS (Minimum Data Set) dated 7/20/23 showed R34 had severe cognitive impairment and required two staff extensive assistance for all ADLs (Activities of Daily Living). R34's care plan showed [R34] had an ADL self-care performance deficit and was dependent on two staff for toilet use. On 9/6/23 at 1:23 PM, V15 (Certified Nurse Assistant/CNA) came to assist V14 (CNA) with changing R34's incontinence brief. V14 left the room to get some supplies. V16 (Registered Nurse/RN) came to help V15. R34's pants were removed and V15 unfastened and opened up R34's incontinence brief. V15 used a wipe to clean left groin area and then right groin area. With a new wipe, V15 wiped down the middle from front to back without separating the labia. V15 removed her gloves and put on new gloves to turn R34 onto her left side. R34 had small bowel movement. V14 had returned to the room and V16 left the room. V15 cleaned the bowel movement from front to back. V15 asked V14 to lift R34's top leg. After V14 lifted R34's left leg, V15 used a wipe to clean from the front vaginal area back to the rectal area. V15 repeated this motion for a total of three times with same wipe folded over. On 9/7/2023 at 10:31 AM, V2 (Director of Nursing) said when providing incontinence care, the staff should clean from clean to dirty. When providing incontinence care to a female, the staff must separate the labia and clean from front to back, after done cleaning the front, the resident needs to be positioned onto their side so the buttock area can be cleaned. When asked if it is appropriate for a staff member to lift the resident's top leg when in the side lying position so another staff can use a wipe and clean from the front vaginal area back to the rectal area, V2 said no they cannot do that. Facility provided policy titled Perineal/Incontinence Care dated 10/24/22 showed, It will be the standard of this facility to provide cleanliness . to prevent infection . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 11 of 30 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 09/08/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to evaluate and put interventions in place to prevent weight loss. This affects 1 resident of 3 residents (R71) reviewed for significant weight loss in the sample of 24 residents. Residents Affected - Few The findings include: According to the facility Face Sheet, R71 had diagnoses that included respiratory failure, congestive heart failure, type 2 diabetes, severe chronic kidney disease, and other diagnoses. R71 was recently discharged from kidney dialysis. R71 is [AGE] years old. On 9/6/23 at 3:13 PM, R71 stated he has not seen the Dietician from the facility. The facility medical record for R71 shows a weight loss of 28 pounds between 6/27/23 and 9/2/23 as shown: 6/27/23 2:44 AM 219.0 pounds 7/5/23 12:27 PM 213.0 pounds 8/2/23 1:47 PM 206.2 pounds 8/2/23 1:53 PM 209.4 pounds 8/14/23 1:35 PM 198.2 pounds 8/28/23 2:43 PM 195.5 pounds 9/2/23 4:34 PM 191.0 pounds This represents an average of 3.1 pounds per week loss. This is a loss of 12.78% of total body weight in 9 weeks. On 9/7/23 at 12:44 PM, V20 (RD - Registered Dietician) stated R71's weight loss was significant, it was above 5% at one month and above 10% at three months. V20 stated a nutritional supplement was ordered prior to the R71's significant weight loss. V20 typified R71's weight as fluctuating but acknowledged there was mainly just a weight decrease. V20 stated R71 is obese and weight loss is desirable but R71's weight loss was not planned. On 9/7/23 at 11:51 AM, V25 (NP - Nurse Practitioner) stated she works with the primary physician for R71 and stated 3 pounds per week loss is concerning, given that R71 is eating 75-100% of meals. V25 stated she will order blood and other tests to assess for any medical reason that could contributing to this weight loss. V25 stated without further assessment we cannot say if the weight loss was unavoidable. There were three progress notes in the medical record from V20 (RD) during the period of R71's weight loss, however there were no interventions in place to prevent significant weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 12 of 30 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 09/08/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow physician's order with regards to administration of continuous oxygen. This applies to 2 of 2 residents (R50 and R61) reviewed for oxygen therapy in the sample of 24. Residents Affected - Few The findings include: 1. R61 had multiple diagnoses which included COPD (chronic obstructive pulmonary disease), asthma, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, based on the face sheet. R61's quarterly MDS (minimum data set) dated 7/6/23 showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with most of her ADLs (activities of daily living). On 9/5/23 at 11:21 AM, R61 was in bed, awake but confused. R61 was receiving five liters of continuous oxygen via nasal cannula as shown in the oxygen concentrator gauge. On 9/6/23 at 1:15 PM, R61 was in bed with the head of the bed elevated. R61 was receiving five liters of continuous oxygen via nasal cannula as shown in the oxygen concentrator gauge. V10 (Licensed Practical Nurse) was called to check the oxygen of R61. V10 confirmed that the resident was receiving oxygen at five liters per minute and commented, I have checked the order and she should be on three liters per minute continuously. V9 (Assistant Director of Nursing) who was in the room assisting R61 with the lunch meal stated that R61 should receive the three liters per minute oxygen, because the resident's oxygen therapy is like medications and should be given as ordered by the Physician. R61's active order summary report showed an order dated 9/5/23 to administer oxygen at 3 (three) liters via nasal cannula continuously. R61's active care plan last revised on 7/18/23 showed that resident had altered respiratory status. The same care plan showed multiple interventions which included administration of oxygen via nasal cannula at 3 (three) liters per minute as ordered by the physician. On 9/7/23 at 12:43 PM, V2 (Director of Nursing) stated that for any residents receiving oxygen therapy, the physician's order should be followed. The facility's standards and guidelines regarding oxygen administration last revised on 3/27/21 showed, It is the standard of this facility to provide guidelines for safe oxygen administration. Under the guidelines it showed in-part, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration and 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as ordered by the physician or required to provide for the needs of the resident. 2. R50's EMR (Electric Medical record) showed R50's initial admission to the facility was 6/25/20 with diagnoses that included unspecified sequelae of cerebral infarction, monoplegia of lower limb following cerebral infarction affecting left non-dominant side, pneumonia, acute and chronic respiratory failure with hypoxia and hypercapnia, tracheostomy, obstructive sleep apnea, chronic kidney disease, and congestive heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 13 of 30 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 09/08/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R50's MDS (Minimum Data Set) dated 7/8/23 showed R50 was cognitively intact and required two staff extensive assistance for all ADLs (Activities of Daily Living). MDS also showed R50 is receiving oxygen therapy, tracheostomy care, and non-invasive mechanical ventilator (BiPAP/bilevel positive airway pressure) R50's care plan showed R50 had a tracheostomy related to chronic respiratory failure and altered respiratory status. R50's POS (Physician Order Set) dated 7/3/23 showed administer 10 liters oxygen via trach continuously and aerosol trach collar. On 9/7/23 new order showed to deliver oxygen 6 liters via nasal cannula continuously. On 9/5/23 at 12:19 PM, R50's oxygen concentrator showed R50 was receiving 8 liters of oxygen via trach. On 9/6/23 at 2:45 PM, R50's oxygen concentrator showed R50 was receiving oxygen at 8 liters via trach. On 9/7/23 at 10:40 AM, R50 was receiving oxygen at 4 liters via nasal cannula. V16 (Registered Nurse) said his oxygen has been 10 liters via trach and today the Nurse Practitioner changed it to 6 liters via nasal cannula. V16 entered room with the surveyor and said it is supposed to be at 6 liters, but when she looked at concentrator, she confirmed that R50 was receiving only 4 liters of oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 14 of 30 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 09/08/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to employ and schedule a sufficient number of competent food service staff to safely and adequately serve resident meals. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/5/23 at 10:00 AM, the only food service staff working in the kitchen were V3 (Dietary Aide), V4 (Dietary Aide/Cook), and V5 (Cook). V3 stated the day prior the food service had only two employees in the morning working to prepare and serve breakfast to the facility residents. V3 stated the food service often only has a total of three people working in the morning in the food service however the operation requires a total of four staff to be able to effectively prepare and serve food to the residents. 2. On 9/5/23 during observations in the kitchen, several sanitation concerns were identified including: - There were 4 slabs of cooked ribs uncovered sitting on a sheet pan. The sheet pan of ribs was placed in a rolling rack and above the cooked ribs was a sheet pan of raw ground beef thawing. - A green cutting board was soaking in the third compartment of the three-compartment sink. V5 (Cook) stated the third compartment contained chemical sanitizing solution. V5 tested the chemical sanitizing solution concentration which measured 100 ppm (parts per million). V5 stated the concentration should measure 200 ppm. - At 10:20 AM, six frozen packages of diced beef were sitting on a sheet pan thawing on counter. V5 stated the packages of meat arrived in a delivery earlier that morning and the product needed to be thawed for 9/7/23 dinner service. V5 stated the packages of diced beef had been sitting on the counter less than one hour and stated he did not have time to put them in the cooler when he unpacked them. V5 then took the tray of diced beef to the walk-in cooler. At 10:33 AM on the wheeled rack in the walk-in cooler, the tray of diced beef was stored under a tray of uncooked chicken. The tray of uncooked chicken had uncooked juice in the sheet pan. Eight packages of thawing ground beef were also stored on the wheeled rack above the packages of diced beef. - V5 filled a bucket with chemical sanitizing solution from the three-compartment sink. V5 placed the sanitizing bucket at the cook station. V5 measured the concentration of the chemical sanitizer which measured only 100 ppm. - During lunch service, V5 twice removed his gloves, touched garbage lid that was on the garbage to dispose of the gloves, and then performed other food service duties without washing his hands. - There was no hot water available at the hand washing sinks located in dish room and next to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 15 of 30 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 09/08/2023 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 0802 cook's preparation area. Level of Harm - Minimal harm or potential for actual harm - The ice scoop was stored in a clear ice scoop holder mounted to wall. There was dried, brown debris inside bottom of ice holder and the bottom of the ice scoop edge was touching bottom of scoop holder and brown debris. Residents Affected - Many - There were two green buckets on the floor on the dirty side of three compartment sink which were filled with damp, soiled rags. There were also several damp towels and rags were stored behind the handwashing sink handles in dish room. - There was an open package of cookies in storage room sitting on top of food boxes with unwrapped cookies sitting on the boxes and cookies on the floor - A mop with a wet mop head was stored on the floor to left of the cook area handwashing sink. There was also a wet mop head with no handle attached on floor under stove in cook's area. There were no mop buckets located in the area. - There was food debris build up below counter mixer and a smear of red/brown dried food on the clean plate warmer near the tray line. 3. On 9/07/23 at 10:02 AM, V20 (Dietitian) stated her duties at the facility included performing monthly sanitation audits of the facility food service. V20 stated she was unable to perform sanitation audits at times because of a lack of staff in the kitchen causing the Dietary Manager to be unavailable to assist with the audit. V20 stated she was aware that the staffing in the food service department was inconsistent. V20 stated she was able to perform a sanitation audit on 8/22/23 and identified several sanitation concerns in the kitchen. 4. On 9/5/23 during lunch service, the food service staff failed to serve warm food at a palatable temperature to residents. On 9/5/23 during initial tour, several facility residents expressed concerns regarding being served facility food which was cold and unpalatable. Residents also expressed concerns regarding not receiving menu items as planned on the facility menu. 5. On 9/5/23 at 11:00 AM during observation of pureed pork preparation for lunch, V5 (Cook) prepared pureed pork roast for six pureed residents with pureed diet orders. The pureed pork roast tasted dry and had lumps of unpureed pork in the mixture. 6. On 9/5/23 during lunch service, the food service staff failed to serve four residents double protein servings and supplements per physician orders. 7. On 9/5/23 during lunch service, six residents receiving pureed diets were served an inadequate amount of pureed pork as their lunch entrees. 8. On 9/5/23 during lunch service, the food service staff failed to provide two residents adaptive equipment per physician orders during lunch service. 9. On 9/5/23 during Resident Council meeting, the facility residents expressed concerns that the facility failed to serve palatable meals at acceptable temperatures. The residents also stated the facility failed to serve food items at meals as per the planned facility menu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 16 of 30 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 09/08/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 10. Review of facility Resident Council Meetings and Grievances showed residents expressed concerns regarding unpalatable food temperatures and residents not receiving food items as planned on the facility menus. Facility Worked Schedule, dated 8/20/23 to 9/2/23, shows the facility had only three or less dietary staff working on the AM shift (at least until 8 AM) on seven of the fourteen days reviewed. On four of those seven days there were only two dietary staff working in the kitchen from 6:00 AM to 8:00 AM. On 9/07/23 at 10:41 AM, V1 (Administrator) stated only three total kitchen staff working from 6:00 AM to 8:00 AM were insufficient to meet the dietary needs of the residents in the facility. V1 stated the kitchen should have no less than four staff (three dietary aides and one cook) working during the entire AM shift from 6:00 AM to 2:30 PM for safe and effective food service to residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 17 of 30 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 09/08/2023 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 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 serve the facility menus as planned. This has the potential to affect all 119 residents receiving oral diets in the facility. Residents Affected - Many The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. Tray tickets, dated Week 3 Tuesday Lunch, show R10, R104, R5, R82, R15, R34 all received pureed diets. Facility Therapeutic Spread Report 2023 Winter Menu, dated 1/20/23, shows one serving of pureed pork roast was to be served with a #10 scoop (2.75 ounces volume) to equal one regular 3-ounce weight portion of pork roast. On 9/5/23 at 1:00 PM at the conclusion of lunch service, V6 (Corporate Food Service Manager) weighed one serving of pureed of pork as served to pureed diets during the lunch service. The serving of pureed pork weighed a total of only 1.75 ounces. V6 stated the pureed serving should contain no less than three ounces weight of pureed pork not including any liquid that was added during the pureed process. V6 stated the food service staff mistakenly utilized a #16 scoop (2 ounces volume) instead of the #12 scoop (2.75 ounces volume) as planned on the facility menu. 2. On 9/05/23 at 1:31 PM during Resident Council meeting, R84 stated some residents get the menu items and some do not during a given meal. R88 and R31 both stated the planned general menu items are often not served at the facility at meals and R88 stated the foods listed on her meal ticket are often not served on her plate during meals. R84 stated the facility often did not serve the planned menu items because the items are missing, they do not have enough of the product, or they did not make enough for all the residents. R7 stated she was usually served dinner around 6:30 PM and they are often missing out on the planned menu items because the food service runs out of the food products. 3. On 9/5/23 at 10:37 AM, R274 stated he was not receiving food items at meals that were to be served per the facility menu. On 9/5/23 at 11:19 AM, R107 stated he was not getting served items that were on the menu. 4. Resident Council Meeting Minutes- Dietary Concerns, dated 7/27/23, shows, Portions are irregular: some get too little, and others get too much When residents make changes to their tickets, kitchen staff however still give the resident what is being served. Resident Council Meeting Minutes - Dietary Concerns, dated 5/4/23, shows Kitchen staff have been missing things on the tray that is on the ticket. Standards and Guidelines Menus and Nutritional Adequacy, dated 8/24/17, shows, 2. Menus are followed daily . Extensions are written for all diets, specifying the serving size and consistency of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 18 of 30 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 09/08/2023 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 item for each diet. Level of Harm - Minimal harm or potential for actual harm Standards and Guidelines Diet Meets Needs of Each Resident, issued 8/24/17, shows the purpose of food and nutrition services (FNS) department is to provide high quality, nutritious, palatable, and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerances, religious and cultural preferences, based on reasonable efforts. Therapeutic diets will be served as prescribed by the attending physicians or their designee . 1. To provide food that is prepared by methods that conserve nutritive value, flavor, and appearance. 2. To provide food and drink that is nutritious, palatable, attractive and at a safe and appetizing temperature to meet individual needs. 3. To promote optimal nutritional status of each resident through medial nutrition therapy in accordance with written orders for nutrition care and consistent with each individual's physical, cultural, and religious needs and personal preferences . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 19 of 30 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 09/08/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to serve palatable meals to facility residents. This has the potential to affect all 119 residents receiving oral diets in the facility. Residents Affected - Many The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/5/23 at 12:02 PM with V6 (Corporate Food Service Manager) in the kitchen during lunch service, the food service staff prepared eight full plates of lunch and left them uncovered sitting on the shelf waiting for lunch servers to arrive to serve the plates to residents. At 12:04 PM, V7 (Food Service Aid) prepared three more plates and placed them on the shelf without lids next to the first eight pre-made plates. At 12:05 PM, V7 requested more tickets and began plating more plates of food and placed them on the shelf with no lids. On 9/5/23 at 12:10 PM, one of the plates sitting on the shelf was removed as a test tray. The foods were tasted, and the vegetables and noodles tasted room temperature. V6 checked the temperature of the plates in the clean plate warmer and stated the plates in the left side of the unit were not hot enough. V7 stated the plates that were in the warmer were just finished being washed in the dish room and did not have time to heat up yet. Facility staff then began passing the plates which had been sitting uncovered to the residents in the dining room without lids on the plates. 2. On 9/5/23 between 10:02 AM and 10:27 AM, the following residents stated they received cold food served at the facility: R15, R58, R71, R98, R106, R274 and R275. On 9/5/23 between 12:03 PM-12:27 PM, R49 stated the food served at the facility was served cold, R67 stated the food was no good and tasted terrible and R45 stated the food tasted terrible most of the time. 3. On 9/05/23 at 1:31 PM during the Resident Council meeting, R88 stated the facility food is sometimes very unappetizing and her eggs were usually served cold and watery. R33 stated the recently served macaroni was unpalatable and her oatmeal and eggs were served cold every day. R31 stated her eggs were cold at breakfast that morning. R84 stated her ice cream was melted and like soup when she received it on her trays. R84, R88, R31, R33, and R51 all stated the residents who were served first during meal services received hot foods, but the 500 hall residents were served last, and the trays often sat waiting to be passed which causes food to become cold. 4. On 9/07/23 at 10:02 AM, V20 (Dietitian) stated she was aware of reports of cold food temperatures at the facility and discussed the concerns with V1 (Administrator). V20 stated the food service staff were not using the plate warmer during meal service and that was the cause of the cold temperatures. V20 stated temperatures of the food on the steam table were meeting requirements, but the food service it took time and the foods lost temperature in the process. 5. Grievance, dated 3/14/23 by R320, shows a concern regarding the food being consistently served (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 20 of 30 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 09/08/2023 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 0804 cold. Level of Harm - Minimal harm or potential for actual harm 6. Resident Council Meeting Minutes- Dietary Concerns, dated 7/27/23, shows, Kitchen staff should work on their presentation. Residents Affected - Many Resident Council Meeting minutes, dated 5/25/23, show, Toast is soggy when put on top of eggs, can there be an alternative? Standards and Guidelines Diet Meets Needs of Each Resident, issued 8/24/17, shows, The purpose of food and nutrition services (FNS) department is to provide high quality, nutritious, palatable and attractive meals in a safe, sanitary manner. Food will be prepared in a form to accommodate resident allergies, intolerance's, religious and cultural preferences, based on reasonable efforts. Therapeutic diets will be served as prescribed by the attending physicians or their designee . 1. To provide food that is prepared by methods that conserve nutritive value, flavor, and appearance. 2. To provide food and drink that is nutritious, palatable, attractive and at a safe and appetizing temperature to meet individual needs. 3. To promote optimal nutritional status of each resident through medial nutrition therapy in accordance with written orders for nutrition care and consistent with each individual's physical, cultural, and religious needs and personal preferences FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 21 of 30 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 09/08/2023 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 puree resident food to a smooth consistency per facility policy. This applies to 6 of 6 residents (R5, R10, R15, R34, R82, and R104) reviewed for pureed diets. The findings include: Tray tickets, dated Week 3 Tuesday Lunch, show R5, R10, R15, R34, R82 and R104 all received pureed diets. On 9/5/23 at 11:00 AM during observation of pureed pork preparation for lunch, V5 (Cook) placed portions of ground pork roast into the blender. V5 added broth and pureed the mixture in the blender. V5 turned off the blender and began transferring the pork product from the blender into a steam table pan without tasting the product. V5 stated he was finished with pureeing the product. A sample of the product was tasted, and the sample tasted dry and had lumps of unpureed pork in the mixture. On 9/7/23 at 2:15 PM, V1 (Administrator) stated it was his expectation that purees were to be pureed until smooth (with no lumps) and served at an applesauce to mashed potato consistency. Standards and Guidelines Liberalized Diets, revised 2/19/21, shows, 5. e. Pureed - Regular diet that is processed to a smooth, mashed potato or pudding consistency. Diet and Nutrition Care Manual Dysphagia Puree, dated 2019, shows All foods must be the consistency of moist mashed potatoes or pudding. Standards and Guidelines Dry Food Storage, revised 3/2/21, shows, .All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase All dry foods will be covered and labeled with dates and when to be discarded by FNS staff FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 22 of 30 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 09/08/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to serve residents double protein servings and supplements per physician orders. This applies to 4 residents (R5, R31, R68 and R83) reviewed for therapeutic diets. The findings include: 1. Care plan, revised 9/5/23, shows R5 had a pressure injury on her sacrum, right and left ischium, and right lateral ankle. The care plan intervention, initiated 6/2/23, shows R5 was to be provided supplemental protein, amino acids, vitamins, and minerals as ordered by the physician to promote wound healing (see physician orders). Order Summary Report, dated 9/6/23, shows R5 has a physician order (dated 5/31/23) for Double the protein portions in lunch and dinner. On 9/5/23 at 12:38 PM during lunch service, the food service staff served R5 only one portion of pureed pork and two portions of pureed pasta. On 9/5/23 between 12:45 PM and 1:20 PM, R5 was served a single portion of pureed pork at her lunch table. R5's meal ticket showed R5 was to be a double portion of protein at the meal. 2. Care plan, revised 7/31/23, shows R83 had specific nutritional needs and needed an additional nutritional support to promote wound healing. The care plan shows R83 also experienced weight loss. The care plan interventions included, Provide diet and serve as ordered Provide supplements as ordered. Order Summary Report, dated 9/6/23, shows R83 had a physician order (dated 5/4/23) for Double the protein portion in his meals for wound healing. On 9/5/23 at 12:43 PM during lunch, R83 was served only one scoop of ground meat on her plate. 3. Face sheet, dated 9/7/23, shows R31's diagnoses included protein-calorie malnutrition. Order Summary Report, dated 9/7/23, shows R31 had a physician order (6/12/23) for double protein at dinner. On 9/5/23 at 1:31 PM during Resident Council group meeting, R31 stated she was supposed to receive double protein servings at every dinner meal. R31 stated she often did not receive the double portions and had to remind staff to serve them to her at dinner. 4. Face sheet, dated 9/6/23, shows R68's diagnoses included severe protein-calorie malnutrition. Order Summary Report, dated 9/6/23, shows R68 had a physician order (dated 5/19/23) for Frozen Nutritional Treat three times a day for nutritional need - weight loss (Brand name of shake). On 9/5/23 between 12:45 PM and 1:20 PM, R68 was served her lunch tray and no supplement was provided to R68. R68's meal ticket showed R68 was to receive a supplement during her meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 23 of 30 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 09/08/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/6/23 at 2:31 PM, V6 (Corporate Food Service Director) stated it was her expectation that double servings of protein and supplements were to be served per the instructions on the resident tray tickets. On 9/7/23 at 10:02 AM, V20 (Dietitian) stated some residents needed more protein for wound healing or malnutrition. V20 stated she tries to supply the additional protein from food and supplements. V20 stated she expected the food service staff to serve the double protein or supplements as ordered by the physician. Standards and Guidelines Diet Meets Needs of Each Resident, issued 8/24/17, shows, Therapeutic diets will be served as prescribed by the attending physicians or their designee. 3. To promote optimal nutritional status of each resident through medical nutrition therapy in accordance with written orders for nutrition care and consistent with each individual's physical, cultural, and religious needs and personal preferences Standards and Guidelines Menus and Nutritional Adequacy, dated 8/24/17, shows, 2. Menus are followed daily . Extensions are written for all diets, specifying the serving size and consistency of the item for each diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 24 of 30 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 09/08/2023 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide adaptive equipment to residents as per physician orders. This applies to 2 residents (R10 and R11) reviewed for adaptive equipment. Residents Affected - Few The findings include: Order Summary Report, dated 9/6/23, shows R11 had a physician order (dated 4/17/23) for Plate guard with all meals. Order Summary Report, dated 9/6/23, shows R10 had a physician order (dated 2/6/23) for use plate guard. On 9/5/23 at 12:00 PM with V6 (Corporate Food Service Manager), the food service staff were preparing lunch trays for facility residents. At 12:24 PM, R11's lunch plate was prepared and served. At 12:45 PM during lunch service, R10's lunch tray was prepared and served. Neither resident's plate/tray had a plate guard as per her lunch tray ticket instructions. On 9/06/23 at 2:31 PM, V6 (Corporate Food Service Manager) stated resident assistive devices (such as plate guards) used during meals should be placed on their trays/plates during meal service in the kitchen. Standards and Guidelines Assistive Devices, revised 3/4/21, shows The facility will provide residents requiring special eating equipment and utensils as well as appropriate assistance and needed to ensure the resident can use the assistive device when consuming meals and snacks 3. Upon receiving an order or recommendation for an assistive device for the resident, the dietary manager or designee verifies to ensure the proper device is in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 25 of 30 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 09/08/2023 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 the facility food preparation and storage was performed in a sanitary manner and under sanitary conditions. This has the potential to affect all 119 residents receiving oral diets in the facility. The findings include: Facility Census and Condition of Residents, dated 9/5/23, show the facility census was 122. Diet Type Report, dated 9/7/23, shows three residents had physician orders for NPO (nothing by mouth). 1. On 9/05/23 at 10:00 AM the following observations were made during tour of the kitchen: - There were 4 slabs of cooked ribs uncovered sitting on a sheet pan. The sheet pan of ribs was placed in a rolling rack and above the cooked ribs was a sheet pan of raw ground beef thawing. - A green cutting board was soaking in the third compartment of the three-compartment sink. V5 (Cook) stated the third compartment contained chemical sanitizing solution. V5 tested the chemical sanitizing solution concentration which measured 100 ppm (parts per million). V5 stated the concentration should measure 200 ppm. - There was no hot water available at the hand washing sinks located in dish room and next to cook's preparation area. - The ice scoop was stored in a clear ice scoop holder mounted to wall. There was dried, brown debris inside bottom of ice holder and the bottom of the ice scoop edge was touching bottom of scoop holder and brown debris. - There were two green buckets on the floor on the dirty side of three compartment sink which were filled with damp, soiled rags. There were also several damp towels and rags were stored behind the handwashing sink handles in dish room. - There was an open package of cookies in storage room sitting on top of food boxes with unwrapped cookies sitting on the boxes and cookies on the floor. - A mop with a wet mop head was stored on the floor to left of the cook area handwashing sink. There was also a wet mop head with no handle attached on floor under stove in cook's area. There were no mop buckets located in the area. - There was food debris build up below counter mixer and a smear of red/brown dried food on the clean plate warmer near the tray line. 2. On 9/5/23 at 10:20 AM, there were six frozen packages of diced beef sitting on a sheet pan thawing on counter. V5 stated the packages of meat arrived in a delivery earlier that morning and the product needed to be thawed for 9/7/23 dinner service. V5 stated the packages of diced beef had been sitting on the counter less than one hour and stated he did not have time to put them in the cooler (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 26 of 30 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 09/08/2023 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 when he unpacked them. V5 then took the tray of diced beef to the walk-in cooler. Level of Harm - Minimal harm or potential for actual harm On 9/5/23 at 10:33 AM on the wheeled rack in the walk-in cooler, the tray of diced beef were stored under a tray of uncooked chicken. The tray of uncooked chicken had uncooked juice in the sheet pan. Eight packages of thawing ground beef were also stored on the wheeled rack above the packages of diced beef. Residents Affected - Many 3. On 9/5/23 at 10:24 AM, V5 filled a bucket with chemical sanitizing solution from the three-compartment sink. V5 placed the sanitizing bucket at the cook station. V5 measured the concentration of the chemical sanitizer which measured only 100 ppm. 4. On 9/5/23 at 12:20 PM, V5 removed his gloves, touched garbage lid that was on the garbage to dispose of the gloves, and then walked to dry storage without washing his hands. V5 then returned to the lunch tray line and grabbed a soup bowel without washing hands. At 12:27 PM, V5 again removed his gloves, touched a garbage lid when disposing the gloves, walked to dry storage to get tomato juice, and returned to tray line with tomato juice without washing hands. 5. On 9/07/23 at 10:02 AM, V20 (Dietitian) stated she performed a sanitation once a month. V20 stated she was unable to perform some sanitation audits due to lack of staff in the kitchen. V20 stated on 8/22/23 she did have sanitation concerns during her sanitation audits and forwarded a copy of the sanitation audits to the dietary manger. On 9/06/23 at 9:53 AM, V1 stated the facility purchased a new chemical sanitizer and the sanitizing pump had not been correctly calibrated to the new chemical which caused the chemical sanitizing concentration to be too low. Chemical Sanitizing Solution product information showed the quaternary ammonium solution concentration was to measure 200 ppm. Facility Standards and Guidelines, revised 3/23/11, shows, FNS (Food and Nutrition Services) staff will demonstrate no cross contamination at mealtimes 1. Gloves should never be used in place of hand washing. Hands must be washed before putting on gloves and when changing to a new pair 5. Hands must be washed between any contaminations. Gloves must be changed as often as soon as they become soiled or torn, and before beginning a different task. Facility Standards and Guidelines, revised 3/23/11, shows, 3. Fill third sink with hot water . or a chemical sanitizing solution used according to manufacturer's instructions. Dispense quaternary sanitizer according to manufacturer directions. Vendor will provide a dispenser that automatically measures the correct amount of sanitizer. Test the sanitizer strength using the quaternary test strips Hold the strip under the water for at least 10 seconds. Sanitizer strength should be approximately 200 ppm, adjust the amount of water or sanitizer accordingly until the correct strength is obtained Facility Standards and Guidelines Cleaning and Sanitizing of Food and Non-Food Contact Surfaces, revised 4/17/09, shows, Food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent foodborne illness and minimize bacterial growth 3. Fill second bucket with cool to lukewarm water Add chlorine bleach sanitizer to achieve a concentration of 100 parts per million. Use chlorine sanitizer test strips to verify the correct concentration. Submerge clean cloth in sanitizer solution and wipe down the freshly cleaned surface. 4. Cloths used for cleaning and sanitizing food contact surfaces are laundered daily. Buckets of soap and sanitizer solutions are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 27 of 30 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 09/08/2023 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 changed/refreshed at least 4 times a day 5. Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule - or as visually necessary. These are then wiped down with sanitizer solution (bleach at 100 parts per million). Standards and Guidelines Thawing Foods, revised 3/2/21, shows, 1. Food and Nutrition staff will thaw frozen food items using one of the following recommended methods to avoid rapid bacterial proliferation: a. In the refrigerator, in a drip-proof container and in a manner that prevents cross contamination b. Completely submerge the item under cold water . that is running fast enough to agitate and float off loose ice particles, c. In a microwave . d. As part of a continuous cooking process. Standards and Guidelines Refrigerated Storage, dated 3/2/21, shows, FNS staff will store raw food (e.g., beef, fish, lamb, pork, and poultry) separate from each and on shelves below fruits, vegetables, or other ready-to-eat foods to prevent meat juices from dripping onto these foods. Standards and Guidelines Ice Chests, revised 3/27/21, shows The tray and the scoop should be run through a dishwasher or sterilized daily. Standards and Guidelines Environmental Services Cleaning Guidelines, revised 5/16/21, shows Mop head Mop head should be laundered after each use and allowed to dry before re-use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 28 of 30 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 09/08/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review the facility failed to identify and implement interventions for performance improvement regarding kitchen sanitation and ADLs (Activities of Daily Living) care. This applies to all 122 residents who reside in the facility. The findings include: On 9/7/23 at 11:35 AM, V1 (Administrator) identified rehospitalization as the only PIP (Performance Improvement Plan) that the facility is currently working on. V1 further stated that during the facility's mock survey in June 2023, by the corporate staff, concerns with sanitation, staffing and following the menus were identified in the kitchen. V1 stated there was no PIP developed nor a plan developed to improve conditions in the kitchen. V1 further stated the Quality Assurance program is not effective and could be improved. On 9/7/23 at 12:00 PM, V21 (Nurse Consultant) stated the facility has one PIP currently for rehospitalization. V21 stated when making rounds in the facility, V21 has identified ADL concerns, specifically grooming, and stated there is no PIP or working plan to address this concern. V21 stated the facility did have a mock survey completed by the corporate staff and concerns in the kitchen were identified. V21 further stated she has attended the facility's QA (Quality Assurance) committee meeting since March of 2023. V21 also stated that during the QA meeting following the mock survey on 7/24/23, neither the concerns in the kitchen nor the concerns with ADLs were discussed. On 9/7/23 at 10:02 AM, V20 (Registered Dietician) stated she performed the most recent sanitation audit in the kitchen was on 8/22/23, and identified problems with food labeling, cleaning, and sanitary storage of silverware. V20 stated she had missed the opportunity to do more sanitation audits in the kitchen previously due to lack of staff in the kitchen. V20 also stated she had relayed concerns from the residents regarding cold food to V1. Throughout this survey from 9/5/23, through 9/7/23, concerns with sanitation, staffing, and following the menus were identified in the kitchen as well as concerns with ADLs (Activities of Daily Living). The facility's policy Standards and Guidelines: Quality Assurance and Performance Improvement (QAPI) program. dated 11/28/19, showed 4. The facility shall design its QAPI program to be ongoing, comprehensive, and to address the range of care and services provided by the facility; address all systems of care and management practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 29 of 30 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 09/08/2023 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 and interview the facility failed to change gloves and perform hand hygiene during provisions of care. This applies to 1 of 2 residents (R34) reviewed for incontinence care in the sample of 24. Residents Affected - Few The findings include: R34's EMR (Electronic Medical Record) showed R34's most recent admission date was 7/4/22 with diagnoses that included Parkinson's disease, dementia without behavioral disturbances, and peripheral autonomic neuropathy. R34's MDS (Minimum Data Set) dated 7/20/23 showed R34 had severe cognitive impairment and required two staff extensive assistance for all ADLs (Activities of Daily Living). R34's care plan showed [R34] had an ADL self-care performance deficit and was dependent on two staff for toilet use. On 9/6/23 at 1:23 PM, V15 (Certified Nurse Assistant/CNA) came to help V14 (CNA) provide incontinence care to R34. V15 washed her hands with soap and water and put on gloves when V14 said he needed to go get some wipes and more gloves since the box in the room was now empty. V14 returned to the room and put on gloves without washing his hands or using hand sanitizer. V14 started going through R34's drawer to find barrier cream but could not find any. V14 removed his gloves, did not do hand hygiene, and left the room again. R34's pants were removed and V15 opened R34's incontinence brief which was saturated with urine. V15 cleaned the front perineal area, removed her gloves, did not do any hand hygiene, and put on new gloves. V14 (CNA) returned to the room. V14 put on gloves without hand hygiene. V14 assisted V15 to turn R34 onto her left side. R34 had a small bowel movement. V15 cleaned R34's bottom, removed her gloves, did not perform hand hygiene, and put on new gloves. V15 applied barrier cream to resident's back side, V15 removed her gloves, washed her hands, put on new gloves to turn resident back towards her. V15 put barrier cream in groin area, removed gloves, no hand hygiene was performed, and put on new gloves. R34's incontinence brief was fastened closed, and she was repositioned. On 9/7/23 at 10:31 AM, V2 (Director of Nursing) said before starting care, the staff need to wash their hands with soap and water or use hand sanitizer before putting on gloves. After the front area is cleaned, the staff need to remove their gloves and perform hand hygiene and put on new gloves before turning the resident. After the resident is turned onto their side the staff can clean the back side. After they are done cleaning that area, they need to wash their hands and put on new gloves before applying barrier cream. After they have finished applying the barrier cream V2 said the staff member needs to remove their gloves and put on new ones. V2 said at this time the staff member does not need to wash hands with soap and water, they just need to put on new gloves to reposition the resident. Facility was asked to provide a policy on hand hygiene but was policy was never provided to the surveyor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145821 If continuation sheet Page 30 of 30