Inspection·April 12, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the middle of the dining room. At 11:54 AM, V22 provided R26's lunch tray. R53 did not receive lunch tray until 12:05 PM and R91 at 12:07 PM. On 04/10/2024 at 12:20 PM, V22 stated staff are supposed to serve the meal trays at the same time to those residents sitting at the same table. V22 stated it is difficult to do so because the kitchen does not have the trays in order. V22 stated there are a lot of missing items from the meal trays so they find themselves going back and forth to the kitchen to retrieve those items. Missing items include cream, sugar, water, milk, gelato, or silverware. On 04/10/2024 at 12:34 PM, V19 (CNA who was also passing out lunch trays) stated they could not serve all the residents at the same time because there were missing meal trays. V19 stated CNAs go to the kitchen a lot during most meals because there are missing trays, drinks, or substitutes. On 04/11/2024 at 11:35 AM, V46 (CNA Supervisor) stated the expectation is to serve all the residents sitting at the same table at the same time. Facility's Meal Service policy, dated 11/03/2021, documents in part: Trays are delivered to the residents at the same table at the same time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 2 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide language support to non-English-speaking residents in accordance with professional standards of practice and facility policy. This failure impacts seven residents out of a total facility census of one hundred and nine residents. Residents Affected - Some Findings: On 4/9/2024 at 10 AM, observed staff speaking English to R106. No communication board was at bedside. On 04/09/24 at 10:56 AM during interview V4 confirmed R106's primary/preferred language is Spanish. V4 stated that to communicate with R106, One of the CNAs speaks Spanish. Otherwise, she will touch the area of her body to tell us what is bothering her. On 04/10/24 at 9:20 AM during interview, V28 (CNA) stated she did not receive an orientation before providing resident care. R106 speaks Spanish but knows a little English. V29 (CNA) stated to speak with R106, staff find a coworker who speaks Spanish. There are no other services or resources available. On 04/10/24 at 9:30 AM V21 (CNA) stated there are 2 residents on the 2nd floor who speak Spanish. V21 stated that to speak with the residents, we get a coworker, but she is off today. The housekeeping staff also help. A coworker is our only resource. On 04/10/24 at 9:39 AM during interview V40 (LPN) was asked if she received an orientation prior to starting or prior to providing patient care. V40 responded absolutely not. When asked what language services resources are available, V40 said Most facilities have a communication board, but I have not encountered one here. On 04/10/24 at 03:44 PM R106's care plan was reviewed. The care plan was dated 3/14/2024 and states in part that the resident has a communication problem related to medical conditions. Resident's daughter states R106 understands English and Spanish and declined communication cards. On 4/10/2024 at 3:45 PM, the admission documents of R106 state, Patient Registration Data from outside source dated 3/4/2024 at 17:27 stated: Patient Language: Language that patient prefers to speak: Spanish. Needs interpreter. On 04/10/24 at 11:31 AM during interview, V3 (Director of Social Services) stated staff have language line available to them. V3 stated they are rolling out an external vendor interpreter service in the next few months. V3 stated she reaches out to the family to interpret if needed. V3 stated staff have communication cards available, and staff should also read the resident's gestures. V3 did not know if staff have received education about language support services and resources. On 04/10/24 at 08:08 AM a communication resource list was presented by V3 (Social Services Director). The list is not dated and included Widget Health, language line services, Coalition of Limited English-Speaking Elderly, Cross Cultural Interpreting Services, Freetranslations.com, Google Translate, Chicago Hearing Society, Chicago Area Interpreter Referral Service, Eastern health (Australia), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 3 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0676 Illinois Language Services, PHQ-9 Translations and Communication Boards. Level of Harm - Minimal harm or potential for actual harm On 4/12/2024 at 9:34 AM, V47 (Minimum Data Set Coordinator) presented a list of Resident Responses to the question, What is your preferred language? Residents R364, R56, R10, R86, R109, R3 and R106 responded, Spanish. Residents Affected - Some Reviewed policy titled Communication - Foreign Language / Difficulty Expressing Self dated 11/4/2021 and last reviewed 4/1/2024. The policy stated in part: Policy Statement: Facility will ensure that resident will communicate through assistance from a translator or have access to use an augmentative communication device like communication book/language line to improve reception and/or expression. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 4 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 provide needed care or services by not ensuring compression stockings or compression wrap were applied, midline dressing was dated, educate, and assess residents who decided to apply compression wrap and develop a plan of care. These failures affected 3 (R20, R70 and R83) residents reviewed for quality of care in a final sample of 22. Residents Affected - Few The findings include: R20's health record documented admission date on 12/20/2021 with diagnoses with not limited to Secondary parkinsonism, Chronic systolic (congestive) heart failure, Type 2 diabetes mellitus, Other asthma, Cardiomegaly, Hypertensive heart disease with heart failure, Atherosclerotic heart disease of native coronary artery without angina pectoris, Nonrheumatic aortic valve disorder, Spinal stenosis, Obstructive sleep apnea Vascular dementia, Anxiety disorder, Major depressive disorder, Hyperlipidemia, Obesity, Repeated falls, Pain in left knee, Other seborrheic dermatitis, Gastro-esophageal reflux disease without esophagitis, Personal history of covid-19, Dysphagia, Chronic kidney disease, Unspecified osteoarthritis, Benign prostatic hyperplasia without lower urinary tract symptoms. MDS dated [DATE] showed R20's cognition was impaired. R20 needed supervision/touching assistance with oral hygiene and toilet transfer; Partial/moderate assistance with toileting and personal hygiene, shower/bathe self, upper and lower body dressing; Set up/clean up assistance with chair/bed transfer. R20's physician order sheet (POS) dated 4/10/24 with active order not limited to: TED hose on at 6am and off at 6pm one time a day apply to bilateral lower extremities and remove per schedule. R20's ETAR reviewed with missing signature / initial on 4/2/24, 4/3/34 and 4/6/24 for TED hose on at 6anm and off at 6pm one time a day apply to bilateral lower extremities and remove per schedule. R70's health record documented admission date on 11/22/23 with diagnoses not limited to Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, Cutaneous abscess of abdominal wall, Unspecified cirrhosis of liver, Morbid (severe) obesity due to excess calories, Systemic lupus erythematosus, Enterocolitis due to clostridium difficile, Unspecified atrial fibrillation, Unspecified diastolic (congestive) heart failure, Hypertensive heart disease with heart failure, Venous insufficiency (chronic) (peripheral), Ventricular tachycardia, Insomnia, Gout, Orthostatic hypotension, Other ascites, Umbilical hernia with obstruction, Vitamin d deficiency, Restless legs syndrome, Lymphedema, Hypothyroidism, Hyperlipidemia, Anemia. MDS dated [DATE] showed R70 was cognitively intact. R70 needed total assistance or dependent with toileting hygiene; Substantial/maximal assistance with shower/bathe self; Partial/moderate assistance with upper body dressing and chair/bed transfer; Supervision/touching assistance with lower body dressing and personal hygiene. R70's POS dated 4/10/24 with active order not limited to Bilateral legs swelling apply ace wrap from ankle towards above the knee ON at 6AM, OFF at HS (bedtime) one time a day for swelling. R70's TAR reviewed with missing signature on 4/2/24, 4/3/24, 4/6/24 for order of Bilateral legs swelling apply ace wrap from ankle towards above the knee ON at 6AM, OFF at HS (bedtime) one time a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 5 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 for swelling. No care plan found for lymphedema or compression wrap use. Level of Harm - Minimal harm or potential for actual harm R83's s health record documented admission date on 7/18/2023 with diagnoses not limited to Unspecified sequelae of cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Encephalopathy, Altered mental status, Type 2 diabetes mellitus without complications, Dysphagia pharyngoesophageal phase, Gastro-esophageal reflux disease, Hyperlipidemia, Anemia, Long term (current) use of anticoagulants, Other specified arthritis, Claustrophobia, Depression, Anxiety disorder, Hyperkalemia, Hypertensive heart disease without heart failure. Residents Affected - Few On 4/9/24 at 10:53am R70 observed sitting up on wheelchair, alert, and oriented x 3, verbally responsive, with compression wrap on both lower extremities not applied properly, with skin showing in between wrap. Both lower extremities are edematous or swollen. R70 said, My biggest concern is my ongoing lymphedema on both legs. R70 said she was the one doing the compression wrap on both legs every day and removing it at nighttime. At 11:28am R83 Observed lying in bed, alert and verbally responsive, with IV (Intravenous) antibiotic infusing (Cefepime) via single lumen midline on left arm, dressing peeling off and with no date. Requested V8 (Licensed Practical Nurse / LPN) in R83's room, checked midline dressing and stated there was no date. V8 said midline dressing should be dated when inserted or changed. V8 said midline dressing is changed every 3 days and as needed. MDS dated [DATE] showed R83's cognition was impaired. R83 needed substantial/maximal assistance with eating, oral hygiene; Dependent with toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, chair/bed transfer. R83's POS dated 4/10/24 with active order not limited to: Cefepime HCl Intravenous Solution 1 GM/50ML (Cefepime HCl) Use 1 gram intravenously every day and night shift. Order to have midline in place to run antibiotic for diagnosis of UTI (urinary tract infection). No care plan found for midline catheter use in R83's health record. At 2:28pm R20 Observed sitting up on wheelchair in the day room, alert and verbally responsive. No TED (Thromboembolic deterrent) hose / compression stockings on both lower extremities. R20 stated nobody is applying a compression stocking, and not sure if I need it. On 4/10/24 at 10:32am R20 Observed lying in bed, alert and verbally responsive. No compression stockings observed on both lower extremities. At 4:05pm V2 (Director of Nursing / DON) said TED hose stockings are applied as ordered and should be signed in ETAR (Electronic Treatment Administration Record) that it was provided, if not signed it means that it was not done. V2 said TED hose stockings or compression are used for swelling to help with edema. Reviewed ETAR with V2 and V2 said TED hose order was not signed on 4/2/24, 4/3/24, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 6 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/6/24 meaning it was not done or provided. V2 said midline when inserted or changed, dressing should be dated to know when it needs to be changed. V2 said policy for midline dressing should be changed and external catheter should be measured weekly and as needed and documented. Midline should be flushed before and after medication administration to keep the line patent and should be documented. Reviewed R83's electronic health record (EHR) with V2 and V2 stated no order for flushing and midline care dressing change and external catheter measurement. V2 said no documentation found that midline was flushed, dressing was changed, or external catheter was measured. V2 said use of antibiotic or midline catheter should be care planned but no care plan found. V2 said ace wrap or compression wrap is used for edema management and needs an order. V2 said if resident is cognitively intact and decided to apply the compression wrap, the resident needs to be educated and perform return demonstration to make sure that resident is doing it correctly or properly. V2 said education provided should be documented. Reviewed R70's EHR with V2 and V2 said no documentation or education, and no care plan regarding compression wrap found. V2 said care plan is to communicate with staff of what services is needed for the resident. Facility's physician order policy and procedure dated 1/20/24 documented in part: Licensed Profession Nurses / Registered Nurses will follow orders from physician and documented in a timely manner. Facility's policy for Midline catheters dated 1/2022 documented in part: Measure mid-arm circumference at baseline and PRN (as needed). NOTE: Measure the mid-arm halfway between the midline insertion site and the tip of the shoulder. Measurement in centimeters. Measure external midline length at baseline, weekly and PRN with dressing changes. Measure in centimeters. Document the following information in the resident's electronic health record: Date and time, Measurement of mid-arm circumference, Measurement of external midline length, Site condition, Dressing / cap change. On treatment administration record (TAR): Document dressing change. Schedule measurements for mid arm circumference and external midline length. On Medication administration record (MAR): Document and initial date and time for routine saline flushes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 7 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Facility's policy for TED (compression) stockings dated 12/18/23 documented in part: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few To apply even pressure to the lower legs in order to support blood vessels and prevent pooling of blood in lower extremities. The stockings are applied by an RN (registered nurse), LPN (licensed practical nurse), PT (Physical Therapist) or certified nursing assistant. Facility's policy for comprehensive care plan dated 12/18/23 documented in part: To meet the resident's physical, psychosocial and functional needs, facility will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and target goals. A resident's care should have the appropriate interventions and provide a means of interdisciplinary communication to ensure continuity in resident care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 8 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 observations, interviews, and record reviews, the facility failed to ensure the low air loss mattress was in the correct setting for 1 (R47) resident and failed to ensure the left heel boot protector was in place for 1 (R14) out of 2 dependent residents reviewed for pressure wound prevention in a final sample of 22. Residents Affected - Few Findings Include: R47's clinical records show R47 has diagnoses not limited to hemiplegia following cerebral infarction affecting left non-dominant side, dementia, and type 2 diabetes mellitus. R47's minimum data set (MDS) dated [DATE] shows R47 requires substantia/maximal assistance with rolling left and right on the bed. R47's Risk assessment dated [DATE] shows R47 is at risk in developing pressure wounds. R47's weight records show R47 weighs 196.6 pounds dated 4/4/24. R14's clinical records show R14 has diagnoses not limited to dementia, type 2 diabetes mellitus, and hypertensive heart diseases with heart failure. R14's MDS dated [DATE] shows R14 is cognitively impaired and requires substantia/maximal assistance with rolling left and right on the bed. R14's Risk assessment dated [DATE] shows R14 is at moderate risk in developing pressure wounds. R14's physician order sheet (POS) with active orders as of 4/10/24 shows an order to apply left heel boot at all times every shift. On 4/09/24 at 11:09 AM, R47 was lying in bed and noted on a low air loss mattress. R47's low air loss mattress weight control knob was set to 400 pounds. R47 stated that R47 has a wound on R47's buttocks. Surveyor asked V48 (Certified Nursing Assistant/CNA) to assist with R47 and noted R47 has redness on the left buttock. On 4/10/24 at 10:42 AM, R47 was lying in bed and noted R47's low air loss mattress weight control knob was still set to 400 pounds. On 4/10/24 at 11:40 AM, R14 was sleeping in bed and noted no heel boot was applied on R14's left heel. At 12:40 PM, R14 was being fed by V41 (Activity Director) and noted R14 left heel boot was not applied. On 4/10/24 at 11:09 AM, V2 (Director of Nursing) stated that when taking care of residents, staff should be following the doctor's orders. On 4/11/24 at 9:44 AM, V42 (Wound Care/Psychotropic Registered Nurse) stated R47 is on the low air loss mattress to prevent R47 from developing pressure wounds due to R47 is total assist with bed mobility. V42 stated the purpose of the low air loss mattress is to relieve pressure on the bony prominence. V42 stated the low air loss mattress is set based on the current resident's weight. V42 stated the nurses and CNAs should be checking the correct setting of the low air loss mattress every shift. If too low the mattress would deflate. If it's too high, it's too hard and it depletes the purpose of it. V42 stated R14's left heel boot is to offload the heel to prevent from getting pressure ulcer on the heel. V42 stated, For people who have weakness on their legs it's skin preventative measure so [R14] does not get any skin breakdown on [R14's] heels. [R14] has no history of refusing the boot so the CNAs should be applying that at all times except during shower and therapy. The facility's policy titled; Skin Management: Specialty Mattress dated 5/23 reads in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 9 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Settings will be observed every shift to ensure mattress is functioning properly. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled; Physician Orders dated 1/20/24 documents that all Licensed Professional Nurses/Registered nurses will follow orders from physicians and documented in a timely manner. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 10 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record reviews, the facility failed to ensure that a staff member supervised residents (R4, R7, R12, R26, R37, R53, R60, R63, R65, R86, R90, R91) sitting in the dining room. Findings include: On 04/09/2024 at 11:44 AM, V22 (CNA - Certified Nurse Aide) stated a CNA is supposed to watch the dining room when there are residents there, but it is difficult to do so if the CNAs also have their regular assignments involving residents' activities of daily living (ADL) care to carry out. On 04/10/2024 at 11:27 AM, multiple residents were in the dining room. Residents included R4, R7, R12, R26, R37, R53, R60, R63, R65, R86, R90, and R91. Residents R65, R90, R7, R37, R60, R86, R63, and R12 were sitting at the side with the television. R26 and R91 were talking in the middle of the room. In the smaller, activity side of the room, bingo concluded and V20 (Activity Aide) started cleaning up and assisting other residents back to their rooms. V20 left the room at 11:29 AM to take a resident to their room. No other staff in the dining room. Prior to leaving, V20 told residents including R4 and R53 who sat in the smaller, activity side of the room to wait, not move, and V20 will be back. V20 returned at 11:30 AM. V20 left the room again at 11:33 AM, came back seconds later. Left again at 11:35 AM and came back. Left again at 11:36 AM. R37 who was sitting in a specialized chair was leaning forward towards left side. No staff in the room. V20 returned at 11:38 AM and instructed R37 to sit back. V20 left the room at 11:41 AM with no staff in the room and returned 11:42 AM. At 11:47 AM, V20 stated [V20] supervised the residents during activities. V20 stated a CNA (Certified Nurse Aide) is supposed to watch the residents on the larger side of the room (side with the television) while V20 conducts activities on the smaller side. V20 stated V20 does not have clinical training and does not know which residents are high-fall risk residents. On 04/10/2024 at 12:20 PM, V22 (CNA) stated there should always be a CNA or nurse in the dining room, but it is difficult sometimes because the CNAs must also complete all ADL care for their assigned residents. V22 stated there isn't a CNA specifically assigned to monitor the residents, but CNAs are expected to take turns watching the dining room. V22 stated R86 is a high fall risk and recently had a fall last week. V22 stated R90 is also a high fall risk and needs supervision. On 04/10/2024 at 12:34 PM, V19 (CNA) stated [V19] was not sure who was supposed to watch the residents in the dining room. No specific CNA was assigned to be in the dining room to supervise the residents. V19 stated V19 can't do ADL care for given assignment and watch the dining room at the same time. On 04/10/2024 at 2:12 PM, V21 (CNA) stated V21 is not assigned to watch the dining room. V21 stated there should always be a staff member in the dining room supervising the residents. CNAs are supposed to take turn watching the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 11 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm On 04/10/2024 at 2:13 PM, V8 (Nurse) was sitting in dining room with the residents. V8 stated a staff member needs to always be in the dining room to supervise the residents for safety reason. On 04/11/2024 at 11:29 AM, V47 (Minimum Data Set Nurse) stated if there are residents in the dining room, staff needs to supervise them. Residents Affected - Some On 04/11/2024 at 11:35 AM, V46 (CNA Supervisor) stated facility always assigns a specific CNA to be in the dining room to supervise the residents. The CNAs are supposed to rotate blocked times during the day to supervise the dining room when there's no activities. V46 stated there should always be staff in the dining room supervising the residents. R26's comprehensive care plan documents in part R26 is at high risk for falls related to weakness, impaired mobility, psychoactive medications use, need for assistance with ADLs, and multiple diagnoses including dementia. R26 had six falls since April of 2023. Intervention initiated 09/23/2022 documents in part: Resident to be closely monitored when participating in activities in the sunroom. R53's comprehensive care plan documents in part that R53 is at high risk for falls related to impaired mobility, muscle weakness, need for assistance with ADLs, and related diagnoses. R53 had a recent fall on 04/07/2024. Intervention initiated on 02/03/2022 documents in part: Anticipate resident's toileting needs. Staff re-educated to not leave the resident unattended. Facility's Fall Prevention and Management policy, dated 10/29/2021, documents in part: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Universal Fall Precautions/Facility Fall Protocol will be implemented to all residents admitted to the facility regardless of risk scores. High-Risk Precautions will be implemented to residents and patients whose scores on Resident/Family Notification Fall Risk screen shows high risk will be considered on this precaution. Reviewed facility's undated Dining Room Service Tray Service policy. It documents in part: Edit this procedure to show actual responsibilities of dining and nursing staff in your community. Policy does not notate how facility ensures resident safety or prevent falls in the dining room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 12 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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** 4. R14's clinical records show R14 has diagnoses not limited to Type 2 Diabetes Mellitus, Dementia, Anemia, and Congestive Heart Failure. R14's Minimum Data Set (MDS) dated [DATE] shows R14 is cognitively impaired. R14's physician orders show R14 is to receive high calorie frozen gelato dessert with lunch ordered on 4/1/24. R14's nutritional care plan shows that R14 is malnourished and is to receive the high calorie frozen dessert every day for weight loss. R14's weights documented in part: 4/4/24 102.0 pounds, 3/14/24 104.6 pounds, and 2/7/2024 107.6 pounds. Residents Affected - Some On 4/09/24 at 1:05 PM, R14 was being assisted by V51 (Certified Nursing Assistant/CNA) for lunch in the 3rd floor dining room. R14 received chopped cheesy lasagna, green beans, juice, and chocolate bread for lunch. R14 did not receive the high calorie gelato dessert. R14's meal ticket does not indicate the high calorie gelato dessert. On 4/10/24 at 12:40 PM, V41 (Activity Director) was feeding R14 for lunch in R14's room. V41 stated that V41 is also a CNA and is certified to feed the residents. R14's lunch tray consisted of ravioli, garlic bread, peas and carrots, mandarin oranges, apple juice and coffee. R14 did not receive the high calorie gelato dessert. R14's meal ticket does not indicate the high calorie gelato dessert. On 4/10/24 at 2:49 PM, V18 (Consulting Registered Dietician) stated that R14 is underweight and had triggered for weigh loss. V18 stated that R14 should be getting the high calorie gelato dessert with lunch to help with weight gain or for maintenance. V18 stated that the gelato should be indicated in R14's meal ticket because it's a tool that the facility uses to communicate with the staff what R14 should be getting for meals. On 4/11/24 at 11:17 AM, V2 (Director of Nursing) stated V2 entered the order for the high calorie gelato dessert for R14 because dietary recommended it for weight loss. Based on observation, interview and record review the facility failed to a.) provide thickened liquids as prescribed by physician affecting 1 resident (R71), b.) provide physician ordered oral nutritional supplements affecting 1 resident (R14), and c.) assess residents with a significant weight change and adjust nutrition interventions affecting 3 residents (R36, R71, R100) out of 6 residents reviewed for nutrition and weight loss in a final sample of 22. Findings include: 1. On 04/09/24 at 1:05 PM, observed R71 in room consuming lunch. R71 did not receive any liquids on R71's lunch tray. R71's lunch ticket read nectar thick liquids and had the following items listed on the meal ticket: nectar thick water, nectar thick juice, 4 ounces nectar thick dairy choice of milk, and nectar thick beverage of juice. V13 (Certified Nursing Assistant) stated the kitchen is supposed to send the thickened liquids on the tray because there are no thickened liquids available on the nursing unit. V13 stated this has happened before and all V13 can do is call down to the kitchen to let them know. V13 stated R71 would drink the thickened liquids if they were provided. On 04/10/24 at 2:00 PM, V18 (Consulting Registered Dietitian) stated residents may be on thickened liquids if there are at risk for aspiration. V18 stated the Speech Language Pathologist would give these recommendations to the physician and once the order was obtained the information would be on the meal ticket as part of the diet order. V18 stated residents on thickened liquids could potentially (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 13 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be at increased risk for dehydration if they do not like the thickened liquids and/or if they are not provided with thickened liquids. V18 stated if a resident has an order for thickened liquids but are not receiving the thickened liquids, then they may not be meeting their fluid needs which could contribute to under hydration. V18 stated R71's diet order is mechanical soft with nectar thick liquids. V18 stated R71 should be provided with liquids at meals that have been thickened to nectar consistency per R71's physician order. V18 stated if R71 was not given nectar thickened liquids it would put R71 at risk for underhydration. On 04/09/24 at 3:44 PM, V37 (Contracted Regional Director of Operations) stated the only oral supplement served by the kitchen is the Frozen Gelato which is a high calorie ice cream type high calorie supplement. V37 stated if a resident has an order for the Thrive Gelato or Frozen Nutritional Treat then the kitchen would put it on the resident's tray at mealtime depending on the order. V37 stated anyone requiring thickened liquids per their diet order receives pre-thickened nectar thick juice or water from the kitchen on their trays as part of their meal. R71 was admitted to the facility on [DATE] and has diagnosis which includes but not Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Alzheimer's Disease, Personal History of Other Malignant Neoplasm of Bronchus And Lung. R71's Order Summary Report printed 04/10/24 documents in part General Diet - Mechanical Soft texture, nectar consistency ordered 10/20/23 and High Calorie Drink four times a day for nutritional supplement 120 ml ordered 02/26/24 and High Calorie Frozen Dessert one time a day for nutritional supplement Thrive Gelato at lunch ordered 02/26/24. R71's Speech Therapy Discharge summary dated [DATE] documents in part diagnosis moderate oropharyngeal dysphagia and recommendation to continue with mechanical soft with nectar thick liquids. R71's MDS (Minimum Data Set) dated 01/19/24 BIMS (Brief Interview for Mental Status) was 10 out of 15 indicating moderately impaired cognition. R71's Weight and Vitals Summary printed 04/10/24 documents R71's weights as follows: 04/04/2024 158.2 pounds 03/01/2024 162.5 pounds 02/15/2024 165.0 pounds 01/09/2024 161.4 pounds 12/04/2023 167.0 pounds 11/03/2023 170.8 pounds 10/01/2023 174.2 pounds 09/05/2023 190.0 pounds 08/06/2023 191.2 pounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 14 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Weight Warnings documents in part -27.5 pounds (-14.5%) from 09/05/23 to 03/01/24 (6 months). Level of Harm - Minimal harm or potential for actual harm Calculated weight change from 08/06/23 to 02/15/24 (6 months) -26.2 pounds (-13.7% change). Residents Affected - Some R71's most recent Dietary Progress Note titled, Dietitian Note- Weight Update dated 01/23/24 documents in part, significant weight loss x6 months - negative weight loss, underweight range according to geriatric guidelines, and oral supplement 120 ml three times per day. No Registered Dietitian documentation completed 2/2024 or 03/2024. R71 MNA Mini Nutritional Assessment completed 01/21/24 documents in part score 7.0 = malnourished. On 04/10/24 at 1:40 PM, V18 (Consulting Registered Dietitian) stated V18 has been covering the facility since the middle of February 2024 and sees the nutrition high-risk residents such as those who trigger for significant weight loss, pressure wounds, tube feedings, and dialysis. V18 stated significant weight loss triggers are defined as 5% in 1 month, 7.5% in 3 months and 10% in 6 months. V18 stated it is V18 responsibility to address the weight loss triggers. 2. R36 was admitted to the facility initially on 09/01/21 and has diagnosis which includes but not limited to Dementia, Atherosclerotic Heart Disease, Generalized Muscle Weakness, Abnormalities of Gait and Mobility, Repeated Falls, Need for Assistance With Personal Care, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Polyarthritis, Age-Related Osteoporosis, Hyperlipidemia, Anxiety Disorder, Myalgia, Palmar Fascial Fibromatosis, Anemia, Hydronephrosis. R36's Order Summary Report printed 04/10/24 documents in part General Diet - Regular diet texture, thin consistency ordered 10/19/22 and Two Calorie per ml Supplement three times a day 120 ml ordered 12/12/23. R36's MDS (Minimum Data Set) dated 02/22/24 BIMS (Brief Interview for Mental Status) was 05 out of 15 indicating severe cognitive impairment and weight loss 5% or more in the last month or loss of 10% or more in the last 6 months documents in part, yes, not on prescribed weight-loss regimen. R36's Weight and Vitals Summary printed 04/10/24 documents R36's weights as follows: 04/04/24 136 pounds 03/01/24 136.8 pounds 02/15/24 140.4 pounds 01/04/24 147 pounds 12/04/23 144 pounds 11/03/23 149.8 pounds 10/03/23 153.5 pounds 09/05/23 156.9 pounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 15 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 08/06/23 162.7 pounds Level of Harm - Minimal harm or potential for actual harm 07/02/2023 161.5 pounds Residents Affected - Some R36's most recent Dietary Progress Note titled, Dietitian Note - Weight Updated signed 12/12/23 documents in part significant weight loss x3, 6 months and recommendation to increase oral supplement to 120 ml three times per day. R36's Dietary Profile Form completed by 02/27/24 by V26 (Diet Technician) documents in part BMI underweight for age, weights times 6 months down 22.3 pounds (13.7% change), significant/unplanned weight loss times 6 months, at risk for malnutrition, and Registered Dietitian to follow for weight change. On 04/10/24 at 2:15 PM V18 (Consulting Registered Dietitian) reviewed R36's electronic health record and stated, I don't have a recent note for her. V18 stated the last Registered Dietitian assessment was done on 12/12/23 at which time R36 had a weight loss trigger and oral supplement was increased from 120 ml twice per day to three times per day. V18 stated R36's weight in 12/2023 was 144 pounds. V18 calculated R36's percent weight change from 08/06/23 to 02/15/24 and stated the percent change was -13.7% change indicating a weight loss trigger over this 6-month period. V18 stated 02/2024 weight was 140.4 pounds and since 12/2023 R36 had lost an additional 3.5 pounds. V18 stated is no Registered Dietitian note in 02/2024 addressing R36's weight loss trigger which occurred from 8/2023-02/2024 and there was no change in nutrition interventions since 12/2023. V18 calculated R36's percent weight change from 09/05/23 to 03/01/24. V18 stated the percent change was (-12.8% change) over the 6-month period indicating a weight loss trigger. V18 stated there is no Registered Dietitian assessment addressing the weight loss trigger and no change in nutrition interventions since 12/2023. V18 stated R36's 03/2024 weight was 136.8 pounds so R36 was still losing weight. V18 stated R36 should have been documented on to address the weight loss trigger. V18 stated R36 has a care plan for potential nutrition problem including risk for malnutrition and weight loss with goal was for weight maintenance, not loss. V18 stated that from a nutritional standpoint R36's weight loss was not planned. V18 stated given R36's weight loss triggers and continued weight loss trend V18 needs to look into another intervention for R36. V18 stated V18 would like to know how much of the supplement R36 is drinking and/or if another type of supplement should be offered. V18 stated when V18 was reviewing the monthly weights V18 saw that R36 already had a supplement, so she went to the bottom of my list. 3. R100 was admitted to the facility on [DATE] and was hospitalized between 02/17/24-03/06/24 and 03/26/24-04/02/24. R100 has diagnosis which includes but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Human Immunodeficiency Virus Disease, Type 2 Diabetes Mellitus Without Complications, Systolic (Congestive) Heart Failure, Heart Failure With Reduced Ejection Fraction, Anemia, Chronic Lymphocytic Leukemia Of B-Cell Type In Remission, Secondary Hyperparathyroidism, Diffuse Large B-Cell Lymphoma, Viral Hepatitis C Without Hepatic Coma. R100's Order Summary Report printed 04/11/24 documents in part Renal Diet - Regular diet texture, thin consistency ordered 12/19/23 and Liquid Protein three times a day 30 ml ordered 03/24/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 16 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 R100's MDS (Minimum Data Set) dated 03/12/24 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. Level of Harm - Minimal harm or potential for actual harm R100's Weight and Vitals Summary printed 04/11/24 documents R100's weights as follows: Residents Affected - Some 03/08/2024 206.2 pounds 02/15/2024 200.64 pounds 02/10/2024 203.4 pounds 02/07/2024 213.8 pounds 02/5/2024 213.8 pounds 01/27/2024 217.6 pounds 01/25/2024 212.96 pounds 01/13/2024 241.0 pounds 01/9/2024 247.2 pounds 01/6/2024 248.4 pounds 12/30/2023 248.4 pounds 12/24/2023 241.4 pounds 12/24/2023 244.2 pounds 12/23/2023 251.2 pounds 12/18/2023 251.4 pounds Weight Warnings documents in part -45.2pounds (-18%) from 12/18/23 to 03/08/24 (3 months). R100's most recent Dietary Progress Note titled, Dietitian Note - HD (Hemodialysis) signed 12/19/23. R100's dietary progress note dated 03/22/24 by V18 documents left voicemail for RD at Fresenius requesting call back, in addition to labs and recent pre/post hemodialysis weights for (R100). No Registered Dietitian documentation addressing weight loss trigger in 03/2024. R100's Dietary Profile Form completed 04/08/24 by V26 (Diet Technician) documents in part reentry weight pending, resident is at risk for malnutrition per Mini Nutritional Assessment (9.0), goal maintain weight and RD following for hemodialysis. No changes made to nutrition interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 17 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 04/11/24 at 12:44 PM, V2 (Director of Nursing) stated the Registered Dietitian (V18) manages the weights and coordinates care with the Dialysis Registered Dietitian. V2 stated the RD is the one who should be assessing R100's weights because R100 is at higher nutritional risk due to being on dialysis. Facility provided Job Description for Diet Technician/Diet Clerk dated 2021 which documents in part, duties include to Refer clients with significant weight loss, skin breakdown, or those on tube feeding or dialysis to the dietitian for further nutritional assessment. Facility policy titled, Weight and Weight Change Management undated documents in part, 1.) significant weight changes will be monitored and will be addressed by the dietitian/designee and interdisciplinary care team, 2.) the dietitian/designee will reassess the nutritional needs and intake of any resident with significant weight change and appropriate recommendations will be documented in the medical record. Facility policy titled, Supplements undated, documents in part supplements are used to promote adequacy of the diet as a nutrition intervention for at risk residents and residents who are at nutritional risk are considered for supplements to increase their overall calorie and nutrient intake. Facility policy titled, Thickened Liquids undated, documents in part residents with impaired swallowing ability will receive liquids that are thickened to the degree ordered by the physician or speech therapist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 18 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident receiving enteral feeding received appropriate care and services, enteral feeding was not administered as ordered and g-tube dressing was not changed daily for 1 (R1) resident reviewed for Tube feeding in a final sample of 22. The findings include: R1's health record documented admission date on 9/11/2021 with diagnoses with not limited to Dysphagia following cerebral infarction, Unspecified sequelae of cerebral infarction, Encephalopathy, Encounter for attention to gastrostomy, Type 2 diabetes mellitus with other circulatory complications, Gout due to renal impairment right hand, Other seizures, Vascular dementia, Heart disease, Atherosclerotic heart disease of native coronary artery without angina pectoris, Peripheral vascular disease, Hyperlipidemia, Chronic kidney disease, Hypothyroidism, Unspecified osteoarthritis, Personal history of covid-19, Essential (primary) hypertension. On 4/9/24 at 4:01pm Observed R1 lying in bed alert and verbally responsive, spoke in Tagalog interpreted by surveyor. Observed GT (Gastrostomy Tube) site covered with dressing dated 4/4/24. Observed blackish material on the G-tubing near the stopper. R1 stated he eats by mouth and receives formula and water via GT. R1 stated he's had the GT for 6-8 months and complains of pain at the GT site. R1 stated he becomes bloated after nursing administers formula via GT. R1 stated he does not refuse the formula feedings, but that nursing is not giving the g-tube feeding formula daily. V15 (Certified Nursing Assistant / CNA) stated R1's dressing at GT site was dated 4/4/24. Observed G-Tube site with slight redness and brownish drainage or stain on the dressing. On 4/10/24 at 4:05pm V2 (Director of Nursing / DON) said Enteral feeding should have an order and given as ordered. Dietician is consulted for residents with G-tube and if there is a recommendation for G-tube feeding and flushing, will be communicated, or confirmed to MD. V2 said G-tube dressing is changed daily and as needed. V2 said nurses are expected to sign EMAR (electronic medication administration record) and ETAR (electronic treatment administration record) if g-tube feeding was administered and G-tube dressing was changed to confirm that it was administered and services were provided, if not signed it means it was not done. Reviewed R1's EHR with V2 and stated with missing signature on eMAR for enteral feeding administration and eTAR for G-tube dressing changed. V2 said it was not given or provided because there was not signature or initial. Minimum Data Set (MDS) dated [DATE] showed R1's cognition was impaired. R1 needed supervision/touching assistance with eating, oral hygiene; Dependent with toileting hygiene, shower/bathe self; Partial/moderate assistance with upper body dressing and personal hygiene; Substantial/maximal assistance with lower boy dressing, chair/bed and toilet transfer. MDS showed R1 had feeding tube. R1's physician order sheet (POS) dated 4/10/24 included active order but not limited to: Clean feeding tube site and change dressing daily every day shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 19 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0693 G-tube site: cleanse with nss (normal saline solution), pat dry, apply dry gauze around, cover with dry dressing and secure it with tape every shift and as needed one time a day. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few Enteral feed order: Jevity 1.2 400ml bolus feeding two times a day. Enteral feed order: 150ml water flush 4x a day after each bolus feeding. R1's treatment administration record (TAR) showed order for G-tube site: cleanse with nss (normal saline solution), pat dry, apply dry gauze around, cover with dry dressing and secure it with tape every shift and as needed one time a day was not signed on 4/4/24, 4/5/24, 4/6/24 and 4/8/24 that was done. R1's medication administration record (MAR) showed order Enteral feed order: Jevity 1.2 400ml bolus feeding two times a day was not signed on 4/6/24 and 4/8/24 that was given. Facility's physician order policy and procedure dated 1/20/24 documented in part: Licensed Profession Nurses / Registered Nurses will follow orders from physician and documented in a timely manner. Facility's enteral feeding policy dated 5/19/23 documented in part: It is the policy of the facility to provide adequate nutrition and hydration to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with state and federal regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 20 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that oxygen tubing and bubbler were dated, changed, and oxygen tubing was placed in a bag when not in use. These failures affected 2 (R65 and R106) residents reviewed for respiratory care in a final sample of 22. Residents Affected - Few The findings include: R65' s health record documented admission date on 4/11/2023 with diagnoses with not limited to unspecified atrial fibrillation, Acute kidney failure, Retention of urine, Heart failure, Obstructive and reflux uropathy, Cardiomegaly, Atrioventricular block complete, Type 2 diabetes mellitus, Neurocognitive disorder with Lewy bodies, Polyarthritis, Gout, Tremor, Hyperlipidemia, Hypertensive heart disease with heart failure, Dementia in other diseases classified elsewhere, History of falling, Personal history of covid-19, Anemia, Insomnia. On 4/9/24 at 1:21pm Observed R65 sitting up on wheelchair in the dining room, alert and verbally responsive, with oxygen inhalation via nasal cannula at 3L/min, oxygen tubing no date, humidifier bottle dated 3/27/24. Requested V8 (LPN / Licensed Practical Nurse) to check on R65 oxygen and stated oxygen tubing has no date and bubbler was dated 3/27/24. V8 said oxygen tubing and bubbler should be changed weekly and as needed. On 4/10/24 at 4:05pm V2 (Director of Nursing / DON) said Oxygen administration should have an order including liter flow. V2 said oxygen tubing and bubbler are changed every week (Sunday) and as needed for sanitation purposes and should be dated to know when to change it. V2 said Oxygen tubing should be stored in the bag if tubing is not used to keep it clean. V2 said oxygen use should be care planned or incorporated in medical diagnoses like COPD (Chronic Obstructive Pulmonary Disease), emphysema, etc. R65's electronic health record (EHR) reviewed with V2 and said no care plan found for oxygen use. V2 stated care plan is to communicate with staff of what services are needed for the resident. MDS dated [DATE] showed R65 was cognitively impaired. R65 needs partial/moderate assistance with oral and toileting hygiene, shower/bathe self, upper body dressing; Substantial/maximal assistance with lower body dressing and personal hygiene; Supervision/touching assistance with chair/bed and toilet transfer. MDS shows R65 received oxygen therapy treatments. R65's physician order sheet (POS) dated 4/10/24 included active order but not limited to: Change oxygen nasal cannula/mask tubing and humidifier bottle weekly every night shift every Sunday. Oxygen, continuous at 3L/min via nasal cannula. Facility's oxygen policy dated 4/2023 documented in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 21 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 It is the facility's policy to ensure that oxygen equipment use is compliant with the acceptable standards of practice. Residents Affected - Few Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis. On 04/10/24 at 10:56 AM R106 was in bed without oxygen on. No tracheostomy in place. Oxygen tubing was noted to be in lying in a chair and not in a bag. During interview with V4 (RN) on 4/10/2024 at 11 AM, V4 stated the oxygen tubing was not in a bag but should be stored in a bag. V4 stated she would clean the tubing with alcohol and place it in a bag. On 04/09/24 at 11:25 AM record review included an order for oxygen dated 3/9/2024. Order stated Oxygen therapy: aerosol t-collar FiO2 : 30% titrate oxygen to maintain O2 saturation of 94%. Keep head of bed elevated more than thirty degrees. On 04/10/24 at 03:52 PM record review included care plan of R106 dated 3/10/2024. Next review date was 3/28/2024. Care plan stated in part that R106 has oxygen therapy related to tracheostomy. Order dated 3/29/2024 by V23 (Medical Director) stated Respiratory Therapy to remove trach on Saturday 3/30/2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 22 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, interviews, and record reviews, the facility failed to provide adequate staffing to ensure that nurses administer medications on time, staff supervise the dining rooms when fall-risk residents are present and provide residents' care needs. This has the potential to affect all the residents that reside on the second and third floors. Findings include: On 04/09/2024 at 11:44 AM, V22 (CNA - Certified Nurse Aide) stated the facility needs more staff. V22 stated a CNA is supposed to watch the dining room when there are residents there, but it is difficult to do so if the CNAs also have their regular room assignments and activities of daily living (ADL) care to carry out. V22 stated there are also a lot of residents on [V22's] assigned unit that requires total assistance and mechanical lifts for transfers. Two staff are required to do the mechanical transfers, so it is difficult to monitor the dining room if two are doing a transfer and the other CNA is rounding in the hall or doing ADL care. On 04/09/2024 at 1:32 PM, V45 (Family Member) stated the facility is short-staffed for nurses and CNAs. It takes a long time, sometimes an hour, for care since the staff are taking care of others. V45 stated R12 requires two staff assistance and a mechanical lift for transfer. It takes a long time for staff to get R12 in and out of the bed and wheelchair since R12's CNA needs to wait for another staff to become available to help with the transfer. During a resident council meeting on 04/10/2024 at 10:47 AM, R70 stated when there is one nurse on the unit, the nurse must cover all the residents on the floor. When the nurse passes out medications, the nurse can't stop to answer questions or come check on the residents. R70 stated the CNAs help but they can't handle nursing stuff, so residents have to wait until the nurse finishes everyone's medications first. At 10:52 AM, V29 stated, if they're short, we have to wait longer. Sometimes I've had to wait 40-50 minutes before they answer the call light. On 04/10/2024 at 12:34 PM, V19 (CNA) stated it is difficult to perform regular CNA duties such as ADL care and watch the residents in the dining room. Facility's Staffing policy, created 11/18/2021, documents in part: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Staffing number and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Please refer to F689E regarding supervision in the dining room. On 4/10/24 at 12:45 PM, R13 stated that last Monday and Sunday 11-7 shift, R13 stated R13 rang R13's call button at 12 midnight and asked for pain medications but did not receive. R13 stated R13 was up all night in pain. R13 stated R13 does not remember the nurses' names, but they were both agency nurses. R13 stated both nurses were upset staffing were so short and that they had to cover the entire floor by themselves. R13 stated during Easter there was only one nurse that worked night shift and covered two floors. R13 stated R13 always has to wait for hours at night for the nurse to come. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 23 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed (a) to follow their policy and procedure to ensure consents were obtained prior to administering psychotropic medications to 3 residents (R27, R74, R76), (b) to ensure Abnormal Involuntary Scale (AIMS) were completed every six months for 2 residents (R14, R76), (c) to follow physician recommendation to attempt a gradual dose reduction (GDR) for 1 (R27) resident, and (d) to provide adequate documentation to support that a GDR was attempted or if contraindicated for 1 (R14) out 4 residents reviewed for psychotropic medications in a final sample of 22. Findings Include: On 4/10/24 at 2:47 PM, R27's electronic health record (EHR) reviewed. R27's physician orders show R27 is on antipsychotic medication Quetiapine 25 mg by mouth at bedtime related to diagnosis of Psychosis ordered on 11/15/21, on antidepressant medication Escitalopram 20 mg by mouth one time a day related to diagnosis of Major Depressive Disorder ordered on 4/27/20, and antianxiety medication Ativan 1 mg by mouth at bedtime related to diagnosis of Generalized Anxiety ordered on 3/23/20. R27's Minimum Data Set (MDS) dated [DATE] shows R27 received antipsychotic, antianxiety, and antidepressant medications. There were no psychotropic medications consents found in R27's EHR. R27's progress notes dated 2/29/24 at 2:48 PM documented by V50 (Psychiatrist) reads in part: Attempt GDR Quetiapine 12.5 mg at bedtime. No documentation shows that this was followed. On 4/10/24 at 3:05 PM, R74's EHR reviewed. R74's physician orders show R74 is on antipsychotic medication Seroquel 25 mg by mouth in the morning and 50 mg at bedtime related to diagnosis of Psychotic disorder with delusions ordered on 3/9/23 and 6/28/22, and on antidepressant medication Mirtazapine 15 mg by mouth one time a day related to diagnosis of Major Depressive Disorder ordered on 6/28/22. R74's MDS dated [DATE] shows R74 received antipsychotic and antidepressant medications. There were no psychotropic medications consents found in R74's EHR. On 4/10/24 at 3:12 PM, R14's EHR reviewed. R14's physician orders show R14 is on antipsychotic medication Seroquel 12.5 mg by mouth one time a day related to diagnosis of Psychotic Disorder ordered on 4/12/23 and antidepressant medication Trazodone 50mg by mouth at bedtime related to diagnoses of Psychosis and Insomnia ordered on 12/17/22. There was no documentation found in R14's EHR related to any attempt for a gradual dose reduction (GDR) in the last year. R14's recent Abnormal Involuntary Scale (AIMS) assessment was last completed on 6/23/23. On 4/10/24 at 3:22 PM and on 4/11/24 at 12:30 PM, Surveyor requested for R14's documentations for GDR, but facility never provided. On 4/11/24 at approximately 10:00 AM, facility provided R27 and R74's psychotropic medications consent dated 4/11/24. On 4/11/24 at 9:44 AM, reviewed R27 and R74's EHR with V42 (Wound Care/Psychotropic RN) and no psychotropic medications consents were found. V42 stated that any psychotropic medications are not to be administered to the residents until consents are obtained. V42 stated that AIMS should be completed every 6 months for residents on antipsychotic medications to make sure they are not having side effects with the medications. V42 stated that GDRs should be done quarterly or every 6 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 24 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R76's health record documented admission date on 5/18/2023 with diagnoses with not limited to Chronic obstructive pulmonary disease, Pneumonia, Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere, Type 2 diabetes mellitus without complications, Moderate protein-calorie malnutrition, Ulcerative colitis, Acute ischemic heart disease, Other specified disorders of brain, Unspecified dementia, Major depressive disorder, Anxiety disorder, Unspecified psychosis not due to a substance or known physiological condition, Hyperlipidemia, Hypothyroidism, Paroxysmal atrial fibrillation, Peptic ulcer, Squamous cell carcinoma of skin of nose, Anemia, Vitamin d deficiency, Cerebrovascular disease, Gastro-esophageal reflux disease without esophagitis, Polyarthritis, Hypertensive heart disease without heart failure, Peripheral vascular disease. On 4/11/24 at 11:24am V42 (Registered Nurse/RN wound care / psychotropic nurse) stated consent is needed for psychotropic medication use before giving it. Consent will provide family or resident education with psychotropic medication use, understanding the purpose / reason and potential side effects of medication. V42 stated AIMS (abnormal involuntary movement scale) assessment is done every 6 months and as needed for all psychotropic medications. R76's electronic health record (EHR) reviewed with V42 showed R76 has an active order of Risperidone 1mg twice a day, start date 8/29/23. Diagnosis: unspecified psychosis. V42 stated no consent found in EHR, consent was obtained today 4/11/24. V42 said last AIMS assessment done on 5/18/23, it was not done in November 2023 and was signed today 4/11/24. V42 said AIMS assessment is done to monitor side effects of the psychotropic medications, would be able to assess physical symptoms like tremors or involuntary movement. MDS dated [DATE] showed R76's cognition was impaired and had received antipsychotic medication. R76's POS (physician order sheet) dated 4/11/24 included active order but not limited to: Risperidone Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth two times a day. Care plan dated 8/22/2023 documented in part: R1 takes psychotropic medications (Escitalopram/Risperidone) r/t Dementia, Depression. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of the psychoactive medication drugs being given. Facility's psychotropic drug use policy dated 6/11/23 documented in part: If an order is obtained for a psychotropic medication, the resident, family, or POA (power of attorney) must be informed of the risks and benefits of the medication. The facility must obtain an informed consent. A baseline AIMS test may be done prior to starting a new psychotropic medication. After initiating a new drug, the test will be repeated every 6 months. Residents on psychotropic drugs may be seen and evaluated by facility's psychiatrist and or PCP initially and at least quarterly for follow up. The psychiatrist / PCP (Primary Care Physician) will review the continued need for the medication and monitor side effects. This information will be noted in the progress note section. If the resident is eligible for potential GDR (gradual dose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 25 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 0758 reduction), the health care provider will review and document the reasons for not reducing the medication. 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: 145844 If continuation sheet Page 26 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews and record reviews, the facility (a) failed to properly discard multi-dose inhaler and insulins on expiration dates for 6 residents (R68, R362, R8, R56, R1, R89), (b) failed to date opened multi-dose insulins for 3 residents (R17, R34, R61), and (c) failed to follow their policy and procedure for medication storage and labeling to ensure medications were secured in a locked storage area from one out of three carts inspected for medication storage and labeling that could potentially affect all 53 residents residing on the second floor. Findings Include: On 4/09/24 at 9:03 AM, Surveyor observed a medication cart on the 2nd floor hallway left unattended and unlocked. There were house stocks medications sitting on top of the medication cart which include: Aspirin, Vitamin C, Vitamin B12, Cranberry, Calcium, Iron, Multivitamin, Stool Softener, Vitamin B1, Vitamin D, and Magnesium Oxide. At 9:07 AM, V7 (Agency Registered Nurse) came out of R88's room and stated that V7 was taking R88's blood pressure reading. At 9:15 AM, after preparing R88's medications, V7 went inside R88's room and did not lock the medication cart. The same house stock medications and R88's individual medication blister packs were left unattended on top of the medication cart. At 9:20 AM, V7 went to the other medication cart located by the nurses' station and left the other medication cart unattended in the hallway with the house stock medications sitting on top. At 9:27 AM, V7 prepared R76's medications. At 9:30 AM, after V7 prepared R76's medications, V7 went to R76's room to take R76's blood pressure reading and left the medication cart unlocked and unattended with the house stock medications and R76's individual medication blister packs sitting on top of the medication cart. On 4/09/24 at 12:08 PM, 2nd floor medication cart center odd was inspected with V8 (Licensed Practical Nurse). The following were noted: R68's opened Aspart insulin vial with date opened 3/5/24 written on the label. The label shows the medication is good for 30 days after opening. R362's Lantus insulin vial with date opened 4/3/24 written on the label. The label shows to discard after 28 days of opening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 27 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 R8's Incruse inhaler with date opened 3/8/24 and with expired date of 4/7/24 written on the label. Level of Harm - Minimal harm or potential for actual harm On 4/09/24 at 12:33 PM, 3rd floor medication cart north was inspected with V17 (Agency Registered Nurse). The following were noted: Residents Affected - Some R17's Humalog insulin vial without the date opened written on the label. R56's Novolog insulin pen with date opened 4/5/24 written on the label. The label shows to discard 28 days after opening. On 4/10/24 at 10:22 AM, 3rd floor medication cart west was inspected V12 (Licensed Practical Nurse). The following were noted: R34's Tresiba insulin pen without the date opened written on the label. R61's Lantus insulin vial without the date opened written on the label. R61's Lispro insulin pen without the date opened written on the label. R1's Glargine insulin vial with dated opened 3/4/24 and expiration date of 4/1/24 written on the label. R89's Novolog insulin vial with date opened 3/4/24 and expiration date of 4/1/24 written on the label. On 4/10/24 at 11:09 AM, V2 (Director of Nursing) stated that the expectation during medication administration is that the medication cart is locked in between resident's medication pass and once the nurse walks away from the cart. V2 stated that all medications should be securely stored inside the cart locked when the nurse walks away from the cart. V2 stated that insulin vials, insulin pens, and inhalers should be dated with the date of opening once opened and should be discarded the day after the expiration date. V2 stated that the days are indicated on the label how long they are good for. R89's physician order sheet (POS) with active orders as of 4/10/24 shows R89 is on Insulin Aspart (Novolog) injection sliding scale. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 28 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 R362's POS with active orders as of 4/10/24 shows R362 is on Insulin Glargine (Lantus) injection 22 units at bedtime. Level of Harm - Minimal harm or potential for actual harm R8's POS with active orders as of 4/10/24 shows R8 is on Incruse inhaler one time a day. Residents Affected - Some R17's POS with active orders as od 4/10/24 shows R17 is on Humalog insulin injection sliding scale. R34's POS with active orders as of 4/10/24 shows R34 is on Tresiba insulin injection 20 units one time a day. R61's POS with active orders as of 4/10/24 shows R61 is on Lispro insulin injection sliding scale and 10 units before meals and on Lantus insulin injection 15 units in the afternoon. The facility's pharmacy manufacturer's guidelines for insulins dated 9/12/20 documents the following: Novolog (Aspart) insulin vial/pen to discard 28 days after opening/use. Lantus (Glargine) insulin vial/pen to discard 28 days after opening/use. Humalog (Lispro) insulin vial/pen to discard 28 days after opening/use. Tresiba (Degludec) insulin pen to discard 56 days after use. The facility's policy titled; ID1 Storage of Medications dated 10/25/14 reads in part: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. Expiration Dating C. Certain medications or package types, such as multiple dose injectable vials once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 29 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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. On 4/09/24 at 1:14 PM, noted R56's lunch tray was untouched. R56 stated that R56 did not eat anything because R56 did not like the food and did not like the alternatives. R56's lunch tray consisted of cheesy lasagna, green beans, and chocolate cake. R56 stated that R56 wanted milk but the staff doesn't bring it to R56. R56's 4/9/24 lunch meal ticket indicates R56 was supposed to receive 4 ounces of choice of milk. On 4/10/24 at 12:36 PM, R56 was eating lunch in R56's room. R56's lunch tray consisted of half of garlic bread, cheese ravioli, peas and carrots, diced peaches, and coffee. R56 stated R56 wanted the milk but did not get it. R56's 4/10/24 lunch meal ticket indicates R56 was supposed to receive 4 ounces of choice of milk. On 4/10/24 at 1:40 PM, V18 stated V18 reviews the menu and stated, I see milk on the menu all 3 meals. V18 stated if a resident does not like to consume milk, up to 8 oz. milk can be substituted by hard cheese (1.5 ounces), or processed cheese (2 oz.) or yogurt (1 cup), or cottage cheese (1 cup). V18 stated that milk is a good source of protein. V18 stated, My main concern with a resident not receiving milk listed on their ticket would be the potential of lowering their protein intake. We have Lactaid milk for those residents who don't like milk or are intolerant. If they don't like milk, it would make sense for milk to be removed from their meal tickets and substituted for an alternative (yogurt, cottage cheese, hard or processed cheese). The facility has an obligation to offer, the residents have the right not to accept. By putting the item on the tray, I would consider that being offered. I would rather milk be on the tray and waste it, than not provide it at all. R56's clinical records show the following weights: 4/04/2024 201.8 pounds, 3/5/2024 190.2 pounds, and 2/29/2024 192.0 pounds. R56's progress notes dated 3/26/24 at 6:12 PM documented by V18 (Consulting Registered Dietician) reads in part: R56 had unintended weight loss potentially related to inadequate by mouth intake over time as evidenced by weight loss of -7.4% in one month, -2.3% in 3 months, and -10.8% in 6 months. The facility's policy titled; TRAY CARDS/MEAL TICKETS dated 2021 indicates that tray cards/meal tickets are placed on each tray for identification and the diet is served as indicated on the tray card/meal ticket. Based on observation, interview, and record review the facility failed to a.) ensure resident menus, individual food plan and preferences were followed affecting four residents (R29, R56, R75, R87), b.) provide menus that provide a variety of entrees which are not repetitive affecting three residents (R44, R70, R87), c.) communicate menu changes and/or food substitutions to residents affecting one resident (R70) out of 7 residents reviewed for menus in a final sample of 22. Findings Include: On 04/10/24 at 10:02 AM, during interview with Resident Council participants R29, R75, R87 all stated the kitchen was out of coffee this morning and no one received any coffee. R29 stated R29 did not receive any coffee this morning on R29's breakfast tray and when R29 asked the staff for a cup of coffee the staff told R29 there was no coffee to give her. R87 stated, I love coffee and want to get it at my meals and they run out of coffee all the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 30 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 On 04/10/24 at 10:10 AM, R87 stated, We always get pasta. There is too much pasta on the menu. R87 stated the menu repeats a lot. R44 stated, We want something a little different, not the same food all the time. On 04/10/24 at 10:11 AM, R70 stated yesterday for lunch R70 received lasagna for the main entrée at lunch and then for dinner received a grilled cheese sandwich with a scoop of same lasagna R70 received a lunch that day. R70 stated R70 did not request to receive lasagna for both lunch and dinner and does not know why she (R70) received the same thing two meals in a row. R70 stated there is no variety in what the kitchen serves for meals. On 04/10/24 at 10:12 AM, R70 stated the kitchen does not follow the posted menus and does not give an explanation to the residents ahead of time when changes are made to the menu. R70 stated for example on Monday of this week the menu listed Barbeque Chicken Sandwich for dinner which R70 said, I was looking forward to. R70 stated a Barbeque Chicken Sandwich was not served. R70 stated instead R70 received a dry chicken breast. R70 stated R70 was disappointed R70 did not receive the Barbeque Chicken Sandwich R70 was expecting. R70 stated there is no sign posted identifying any changes to the menus and R70 was not told about the menu change by any staff. On 04/10/24 at 11:52 AM, V35 (Dietary Aide) stated V35 was working this morning during the breakfast meal and that the residents were given hot chocolate instead of coffee because there was no coffee in stock. V35 stated someone had to run out to the store after breakfast to buy some so the kitchen would have coffee for lunch today. On 04/10/24 at 11:54 AM, V36 (Dietary Aide) stated V36 has been working in the kitchen since last week and makes the coffee to be served with the meals. V36 stated sometimes the kitchen does not have any coffee grounds to make coffee which is the problem we had this morning. V36 stated someone went out to buy some coffee so V36 had coffee grounds to make coffee for everyone at lunch today but none of the residents received coffee at breakfast. On 04/10/24 at 11:58 AM, V11 (Food Service Director) stated V11 does all the food ordering and food gets delivered once a week on Tuesdays. V11 stated sometimes the supplier does not send all the food ordered and this has been an issue especially with receiving coffee. V11 stated that was the situation that happened yesterday. V11 ordered coffee but no coffee was delivered. V11 stated V11 was not made aware that the coffee was not delivered on Tuesday and there was enough coffee to serve at dinner but not any for breakfast this morning. V11 stated no one tried to text V11 to let V11 know the coffee was all used up at dinner last night. V11 stated if they had V11 would have ordered coffee through a food delivery service and had it delivered so there was coffee for breakfast this morning. V11 stated when the kitchen does a substitution like that the kitchen does not send out any type of notification to the residents on the unit. V11 stated hot chocolate is not what they were expecting or supposed to have, and the residents want coffee with meals which does not make them happy when they don't receive coffee. On 04/10/24 at 12:27 PM, V11 stated on Monday a Barbeque Chicken Sandwich with lettuce/tomato was on the menu to be served however because the supplier did not send the chicken thighs ordered V11 served chicken breast instead with a hot vegetable on the side in place of the lettuce/tomato. V11 stated V11 let the corporate department and V11's manager know V11 did not receive the correct product and they approved the substitution. V11 stated V11 knew the residents were not going to be happy with the substitution because it was different than what they expected. V11 stated the kitchen does not send any kind of notification up to the nursing units or change the posted menus. V11 stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 31 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 is a disconnect, a breakdown in communication. Level of Harm - Minimal harm or potential for actual harm On 04/11/24 at 9:43 AM, V37 (Contracted Regional Director of Kitchen Operations) stated V37 does not know if V11 communicates information about food substitutions to the residents. V37 stated anytime there is a substitution needed because of lack of product the kitchen keeps substitution log to track changes. V37 stated V11 should change the menus posted on the unit so the residents would know what the change is so the residents can adjust their expectation of the meal. Residents Affected - Some On 04/11/24 at 11:42 AM, V37 stated there was no Food Substitution Log completed V37 could find. V37 stated the assumption was it was not being done since V37 cannot find any. R29 was admitted to the facility 06/01/21 and has diagnosis which includes but not limited to Multiple Sclerosis, Type 2 Diabetes Mellitus, Polyarthritis, Atherosclerotic Heart Disease, Chronic Kidney Disease. R29's MDS (Minimum Data Set) dated 03/20/24 BIMS (Brief Interview for Mental Status) was 12 out of 15 indicating moderately impaired cognition. R44 was admitted to the facility 02/24/15 and has diagnosis which includes but not limited to Heart Failure, Mild Cognitive Impairment of Uncertain or Unknown Etiology, Osteoarthritis, Dementia, Osteoarthritis, Other Specified Peripheral Vascular Diseases. R44's MDS (Minimum Data Set) dated 03/25/24 BIMS (Brief Interview for Mental Status) was 5 out of 15 indicating severe impaired cognition. R70 was initially admitted to the facility 02/20/21 and has diagnosis which includes but not limited to Surgical Aftercare Following Surgery on the Skin & Subcutaneous Tissue, Muscle Weakness, Reduced Mobility, Need for Assistance with Personal Care, Cirrhosis of Liver, Morbid (Severe) Obesity Due to Excess Calories, Systemic Lupus Erythematosus Lymphedema. R70's MDS (Minimum Data Set) dated 01/14/24 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. R75 was admitted to the facility 01/21/21 and has diagnosis which includes but not limited to Chronic Systolic (Congestive) Heart Failure, Atherosclerotic Heart Disease, Chronic Kidney Disease, Hyperlipidemia, Anxiety Disorder. R75's MDS (Minimum Data Set) dated 03/13/24 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. R87 was admitted to the facility 04/26/22 and has diagnosis which includes but not limited to Bilateral Primary Osteoarthritis of Hip, Spinal Stenosis, Cardiomyopathy, Asthma, Morbid (Severe) Obesity Due to Excess Calories, Acute Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Chronic Atrial Fibrillation, Chronic Kidney Disease Stage 3, Anemia. R87's MDS (Minimum Data Set) dated 03/18/24 BIMS (Brief Interview for Mental Status) was 14 out of 15 indicating intact cognition. Week At a Glance Menu dated from Sunday, 04/07/24 to Saturday, 04/13/24 documents Italian Sausage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 32 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Pasta for Sunday Lunch, BBQ Chicken Sandwich for Monday Lunch, Cheesy Meat Lasagna for Tuesday Lunch, Cheese Ravioli for Wednesday Lunch, Beef Mac (Macaroni) Casserole for Thursday Lunch, Pasta Salad as side for Friday Lunch, and Macaroni & Cheese for Friday Dinner. Kitchen policy titled Tray Service-Centralized dated 2021 documents in part, the director of food and nutrition services or person in charge checks the trays to ensure that the food is served according to the menu and clients' requests and food preferences will be honored. Kitchen policy titled Menu Substitutions undated documents in part, changes in the planned posted menu shall be made only, when necessary, changes to the posted menu shall be made when menu item is not available for service, changes to the menu shall be recorded on the Menu Substitution Log, and substitution logs will be retained with the menu for one year or the period between surveys. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 33 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 observation, interview and record review the facility failed to ensure food was served at a palatable temperature, and an appetizing appearance and taste. This deficient practice has the potential to affect all 107 residents receiving food prepared in the facility's kitchen. Residents Affected - Many Findings include: On 04/09/24, during lunch meal rounds observed meat lasagna being served. The appearance of the meat lasagna was not visually appealing because it looked very soft and mushy and was spreading across the plates. Some residents complained the lasagna tasted cold. No heated bases observed under the plates of food on lunch trays. On 04/10/24 at 10:09 AM, during interview with Resident Council participants R29, R64, R70, R75, and R87 complained of frequently receiving cold hot food and food that does not taste good. R64 stated the hot food is always cold and if I was at home, I wouldn't eat cold food and food tastes better when it's hot. On 04/10/24 at 10:23 AM, R87 stated R87 keeps a jar of peanut butter, jelly, and a loaf of bread in R87's room which R87 asked R87's son to bring because I often cannot eat the food. On 04/10/24 at 10:24 AM, R75 stated when R75 receives cold food or food that is not appealing or appetizing R75 calls R75's family to tell them R75 could not eat what was served and R75's family must go out and buy something so R75 can eat. On 04/10/24 at 10:29 AM, R87 stated, The food here stinks. On 04/10/24 at 10:30 AM, R29 said, When you ask us what we had to eat we are trying to forget it because the food is not appealing here. On 04/10/24 at 12:14 PM, test tray left the kitchen and was transported in a closed metal chart to 3 North nursing unit. The test tray was covered in a dome cover. There was no heated base underneath the plate of food. On 04/10/24 at 12:39 PM, after the last tray was passed from the chart, test tray temperatures were taken by V11 (Food Service Director) using a probe thermometer. Temperature results were as follows: Cheese Ravioli (114 degrees F), peas/carrots (121 degrees F), and mandarin oranges (77 degrees F). On 04/10/24 at 12:41 PM, V11 stated the hot food temperatures should be 145 degrees and the cold food temps should be 41 degrees or less. On 04/10/24 at 12: 42 PM, surveyor tasted the food items on the test tray. The cheese ravioli tasted cool and was a very mushy, thick consistency. Not able to view individual raviolis because the raviolis were stuck together in one large clump. The cheese ravioli also had an unappealing taste. The peas/carrots tasted lukewarm, and the mandarin oranges tasted warm. On 04/10/24 at 12:43 PM, V11 (Food Service Director) tasted the cheese ravioli and stated, it is warm but not hot. V11 tasted the mandarin oranges and stated, they are not chilled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 34 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 04/11/23, at 11:45 AM, V37 (Contracted Regional Director of Kitchen Operations) stated that acceptable food temperatures are subjective to the resident's preference. V30 stated that if the temperature is not acceptable to the resident, then their food can be reheated, or they can request a menu alternative. On 04/09/24, facility provided list of diet orders for all residents in the facility printed 04/09/24 at 11:09 AM from the facility electronic health system and V37 provided a list of diet orders for all residents in the facility printed 04/10/24 from the kitchen computer system. Both diet order lists indicated there are two residents who receive nothing by mouth (NPO). Kitchen policy titled Palatability and Nutritive Value dated 06/27/23 documents in part, food will be prepared, held, and served in a manner that preserves nutritive value and palatability, best efforts will be made to present hot food hot and cold foods cold at point of service using thermal lids and bases, heated or chilled plates and thermal pellets as necessary and food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns. Kitchen policy titled Food Temperatures at Point of Service dated 07/14/23 documents in part, food will be prepared, held, and served in a manner that preserves nutritive value and palatability, best efforts will be made to present hot food hot and cold foods cold at point of service using thermal lids and bases, heated or chilled plates and thermal pellets as necessary and food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns. Kitchen job description for Dietary [NAME] undated, documents in part prepare meals that are palatable and appetizing. Facility job description for Food Service Director undated, documents in part supervises and may assist in preparation of all products and meals so they are plateable and appetizing in appearance by following planned menus and using the standard recipes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 35 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated per facility policy, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) properly store uncooked meat, f.) clean ice machine, g.) do proper hand hygiene during meal preparation, h.) reheat pureed foods to 165 degrees before serving, i.) use tongs when serving bread to avoid direct hand contamination. These failures have the potential to affect all 107 residents receiving food prepared in the facility's kitchen. Findings include: On 04/09/24 at 9:00 AM, during initial kitchen tour V9 (Regional Food Service Manager) stated V9 has been in this position for three months and that prior to this V9 had been a Food Service Manager for 23 years. V9 stated that everything that goes in/out of the coolers/freezer must be labeled and dated. V9 stated all items should be labeled with a delivery date, an opened date, and a use by date. V9 stated the use by date is three days for prepared food with DAY 1 being the date it was prepared. V9 stated they follow the manufacturer guidelines for use by dates and storage printed by the manufacturer on the product. V9 stated whoever opens or prepares the item is responsible for labeling/dating the item and whoever sees the item past its use by date is responsible to discarding that item. On 04/09/24 at 9:15 AM, observed the following items in the kitchen walk-in cooler located on the lower level: 1.) One case of celery stalks 50% full labeled with packing date 02/23/24. The celery stalks inside the box appeared wilted and soft. V9 picked up one of the celery stalks. V9 stated the celery had gone bad based on the look and feel of it. V9 stated this celery will be discarded because it is not good anymore and they do not want to use it because of the highly susceptible patient population in the facility. 2.) One case of green peppers 25% full labeled with packing date 02/02/24. [NAME] peppers inside the case were observed to be wrinkled and soft and some of the green peppers had dark black spots on them. V9 acknowledged that some of the green peppers had gone bad and should not be used. 3.) Unopened deli turkey labeled with packed date 12/29/23 and labeled with sell or freeze by date 04/07/24. Surveyor pointed out that today is 04/09/24. V9 stated they can still use this item because with the way they make things now with so many preservatives it is still okay to use. On 04/09/24 at 9:24 AM, observed fans in the walk-in cooler blowing cold air enclosed by plastic covers which were covered in large clumps of dark gray fuzzy dust like material. Also, observed this material adhered on the ceiling of the walk-in cooler near the fans. V9 viewed the fan covers, and ceiling and stated that looks like dust coming from the fan and it should not be there because it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 36 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 could cross contaminate the food by falling on the fresh vegetables which are in open containers. Level of Harm - Minimal harm or potential for actual harm On 04/09/24 at 9:37 AM, observed the following items in the reach in cooler #3 located in the main kitchen: 1.) Residents Affected - Many Opened one-gallon container of Separating Italian Dressing dated with delivery date 03/17/24, and manufacturers use by date 03/05/24. V9 stated this product is beyond the manufacturer's use by date and should have been tossed on 03/05/24. V9 noted this product was delivered after the manufacturer's use by date. 2.) Opened one-gallon container of Sweet Relish dated with delivery date 03/17/24. There was no open date or use by date documented on the container. 3.) Opened one-gallon container of Creamy Caesar Dressing dated with delivery date 03/11/24. There was no open date or use by date documented on the container. 4.) Opened one-gallon container of Thousand Island Dressing dated with delivery date 03/19/24. There was no open date or use by date documented on the container. 5.) Opened one-gallon container of Mayonnaise dated with delivery date 03/06/24. There was no open date or use by date documented on the container. V9 stated these products are good for 30 days once they are opened but the items should have been labeled with an open date so that the staff knows when to discard the product(s). On 04/09/24 at 9:49 AM, observed inside ice machine black and light brown wet substance along the plastic lip of the inside of the ice machine and water dripping inside the ice machine. V9 stated V9 did not know what the substance was. V9 stated, it looks dirty. Observed V9 get a rag and wipe along the plastic lip inside the ice machine and V9 was able to wipe away the substance. V9 stated it should be colder in the ice machine because V9 could see dripping water inside the ice machine. V9 stated the ice inside the ice machine was used for the residents. On 04/09/24 at 9:54 AM, observed the following items in the reach in cooler #4 located on the main kitchen: 1.) Five-pound bag of shredded mozzarella cheese identified by V9 with 10-20% left in the bag. There was no open date or use by date documented on the bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 37 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 2.) Level of Harm - Minimal harm or potential for actual harm Sliced Swiss cheese slices identified by V9 wrapped in plastic wrap. There was no open or use by date documented on the plastic wrap. Residents Affected - Many 3.) Sliced American cheese slices identified by V9 wrapped in plastic wrap. There was no open or use by date documented on the plastic wrap. 4.) Opened number 10 can of [NAME] Chiles dated with delivery date 02/22/22. There was no open or use by date documented on the can. 5.) Unopened defrosted 5-pound package of uncooked ground pork with no date stored on the top shelf grate. Not in a container. Observed pink liquid pooling around the edges of the package. 6.) Unopened defrosted 5-pound package of uncooked bulk sausage with no date stored on the top shelf grate. Not in a container. Observed pink colored liquid pooling around the edges of the package. 7.) Prepared red gelatin dated 03/20/24 stored in a metal pan covered in plastic stored on the 2nd shelf directly underneath the uncooked ground pork and bulk sausage. V9 stated the ground pork and bulk sausage were brought up to defrost but should have been placed on the bottom rack, not the top rack because they do not want bacteria from the raw product dripping on ready to eat foods such as the gelatin. V9 stated this could make the resident's sick. On 04/09/24 at 10:05 AM, V9 stated V9 was the cook for the day and had to start preparing the lunch meal. V9 introduced surveyor to V10 (Regional Food Service Manager) who would be continuing the kitchen tour. On 04/09/24 at 10:10 AM, observed the following items in the reach in the Dietary Aide reach-in cooler located on the main kitchen near the coffee maker: 1.) Seven pitchers of various juices. None of the pitchers of juice were labeled or dated. 2.) A bowl containing cottage cheese with no label or date. 3.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 38 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 A chef's salad with no label or date. Level of Harm - Minimal harm or potential for actual harm V10 stated V10 does not know how long those items have been in there because they are not labeled or dated. V10 stated the items should be labeled with use by dates so the staff knows when they should be discarded. Residents Affected - Many On 04/09/24 at 10:20 AM, observed the following items in the food preparation area near the stoves (not refrigerated): 1.) Opened 1.25-quart Sesame Oil dated by manufacturer with best by date 03/28/24. 2.) Opened 1-gallon Teriyaki Marinade & Sauce not dated with a delivery, opened date, or use by date. Printed on the bottle manufacturer printed directions refrigerate after opening. V10 stated the Teriyaki Sauce should have been dated and stored in the refrigerator per manufacturer guidelines. 3.) Opened 1-gallon container of Soy Sauce dated with opened date 07/12/23. Printed on the bottle manufacturer printed direction refrigerate after opening for quality. V10 stated the product had expired and should have been stored in the refrigerator because the quality drops if not refrigerated. 4.) Opened 1-gallon container of Hickory Smoke dated with opened date 10/20/20. V10 stated this product should have been discarded 6-months from the opened date. 5.) Opened 1-gallon container of Dijon Mustard dated with delivery date 03/17. No year specified. Not dated with an opened date. Printed on the bottle manufacturer printed directions refrigerate after opening. 6.) Opened 1-quart bottle of lime juice not dated. Printed on the bottle manufacturer printed directions refrigerate after opening. Observed an excessive amount of sediment collecting at the bottle of the bottle. 7.) Opened 1-quart bottle of lemon juice not dated. Printed on the bottle manufacturer printed directions refrigerate after opening. V10 stated the kitchen should be following the manufacturer guidelines for refrigerated storage when specified, items should be labeled with a delivery, open and use by date and expired items should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 39 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 be discarded to avoid food poisoning because everyone is this facility is sick so it's a very weak population. Level of Harm - Minimal harm or potential for actual harm On 04/10/24 at 11:31 AM, during pureed preparation observed V9 remove lid from the blender and dip a spatula into the pureed carrot mixture in the blender. Then, observed V9 dribble some of the pureed carrot mixture from the spatula on to the opened palm side of V9's gloved hand. Then, observed V9 use V9's tongue to lick the pureed carrot mixture off V9's glove. V9 then using the same gloved hand V9 had just licked picked up the blender lid and placed on top of the blender and turned the blender back on. V9 stated the carrots were not pureed enough and that is why he was pureeing the carrots more. V9 did not remove cloves or wash V9's hands. Residents Affected - Many On 04/10/24 at 11:36 AM, observed V9 take the temperature of the pureed carrots using a probe thermometer. The thermometer read 142 degrees F. V9 stated V9 wants the temperature to be 140 degrees or higher. Observed V9 place the pureed carrots into a metal pan and place the pan directly on the steam table without reheating to 165 degrees F. On 04/10/24 at 11:38 AM, observed V9 take the temperature of the pureed ravioli using a probe thermometer and it read 145 degrees F. Observed V9 place the pureed ravioli in a pan and place the pan on the steam table without reheating to 165 degrees F. On 04/10/24 at 11:43 AM, observed lunch tray line in progress. Observed V34 (Dietary Aide) plating pureed foods for designated residents on pureed diets. On 04/10/24 at 11:47 AM, observed V34 (Dietary Aide) using gloved hand to grab individual slices of garlic bread and place the garlic bread onto the plates of food. No tongs were used. V34 was the only kitchen staff working on the tray line serving food and was observed handling multiple serving utensils and plate ware. On 04/09/24, facility provided list of diet orders for all residents in the facility printed 04/09/24 at 11:09 AM from the facility electronic health system and V37 (Contracted Regional Director of Kitchen Operation) provided a list of diet orders for all residents in the facility printed 04/10/24 from the kitchen computer system. Both diet order lists indicated there are two residents who receive nothing by mouth (NPO). On 04/11/24 at 9:33 AM, V37 stated V34 should have used tongs when serving the garlic bread on the tray line because V34 was handling multiple serving utensils when serving food on the tray line. V37 stated direct hand contact (gloved or not gloved) can only be done if there is one staff designated to only serve the bread and performs hand hygiene before/afterwards. On 04/11/24 at 9:38 AM, V37 stated everything is wrong with V9 licking V9's palm of hand during pureed meal preparation. V37 stated that was unacceptable and V9 should have used a tasting spoon to taste the pureed food for appropriate consistency. V37 stated V9 is going to contaminate all the pureed product prepared and that V9 should have discarded V9's gloves, washed hands and put on a new pair of gloves before proceeding with pureed preparation. Facility provided kitchen policy titled, Food Storage (Dry, Refrigerated and Frozen) undated documents in part food storage areas will be clean, goods that have been opened with no date will be discarded, all out dated goods will be discarded the day after expiration, open products are sealed, labeled and dated and raw food is stored below cooked or read-to-eat-foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 40 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Facility provided kitchen document titled, Labeling and Dating undated documents in part leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use (i.e., salad dressings, pickles). Seven day shelf life including date of preparation - label includes: name of food item and discard date. 30 day shelf life usually applies to items that are shelf stable until opened - label includes: name of food product and discard date. Facility provided document titled Shelf Life - Fresh Fruits and Vegetables undated, documents in part do not use fresh fruits and vegetables past their expiration date and 7 days/1 week for celery and peppers. Facility provided policy titled Ice Dispensing undated documents in part, the ice machine is cleaned necessary to preclude accumulation of soil or mold. Facility provide policy titled Food Handling undated, documents in part the kitchen and equipment shall be cleaned according to cleaning charts, prepared food items will be served with clean serving utensils to avoid hand contamination of food, tasting of food should be done with a clean plastic spoon or fork and all meats are to be thawed according to thawing policy/procedure. Facility provided policy titled Hand Washing undated, documents in part when to wash hands after touching any part of the body and after engaging in any other activity that contaminates the hands. Facility provided recipe titled Peas & Carrots undated, documents in part pureed process if temperature falls below 150 degrees F during processing, reheat to 165 before serving. Facility provided recipe titled Cheese Ravioli with Marinara Sauce undated, documents in part 165 degrees F including pureed foods all are reheated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 41 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 On 04/09/24 at 1:32 PM, V45 (Family member) stated the facility used to have masks and hand sanitizers that were readily available on the unit but now [V45] must ask for staff where it is or walk around for a while to look for it. V45 stated sometimes not being able to find hand sanitizers in the hallways. Residents Affected - Many Based on observation, interview and record review, the facility failed to follow standards of professional practice and facility policy relative to infection prevention and control. This failure has the potential to impact every resident in the facility. The facility census of one hundred and nine residents. Findings: On 04/09/24 at 09:10 AM it was noted that R95 had a sign for contact precautions while R363 had signage on the door for enhanced barrier precautions (EBP) and contact precautions. During interview on 4/9/2024 at 9:11 AM, V4 (RN) stated that isolation requirements are different. For R95, staff did not have to gown or glove unless they are going to touch R95. During Interview with V2 (Director of Nursing and Infection Prevention Nurse) on 4/10/2024 at 1 PM, V2 was asked about the fact that some resident rooms have EBP signs, some rooms have contact precautions, and some rooms have both. V2 stated, I have told staff not to do that. I reeducated the staff again today because I saw it on the first floor too. On 04/09/24 at 09:17 AM R364 was observed to be on EBP with signage on room door. V4 (RN) and V5 (CNA) entered room. V4 donned gloves. V5 did not don gown or gloves. V5 placed gait belt on resident. V4 and V5 transferred resident from wheelchair to bed, and V5 moved floor prevention mat and placed it beside the bed. On 04/09/24 at 09:28 AM, V5 exited R364's room, V5 did not wash hands or use alcohol-based hand sanitizer, and entered the room of R366 who also had a sign for EBP on the door. On 04/09/24 at 09:32 AM, V5 did not wash hands or use alcohol-based hand sanitizer, exited the room of R366 holding a water pitcher, went to central kitchen area, filled the water pitcher with ice and water and returned it to R366's room. On 04/09/24 at 09:36 AM, V5 was interviewed. V5 stated that V5 is allergic to latex and hand sanitizer so she does not use either. V5 stated that she did not wash her hands after exiting the room of R364 and entering the room of R366 because the call light was going off and she did not want the resident to wait. On 04/09/24 at 10:18 AM, surveyor observed one bottle of hand sanitizer in the hallway on 2 Central unit. During interview with V22 (CNA), she stated that there is one bottle of hand sanitizer in the hallway. V22 stated that there was a bottle by the Nurses Station, but she could not locate it. On 04/09/24 at 01:50 PM record review included an order dated 3/12/2024 for R106 that stated: PPE Use During high-contact resident care activities: Dressing? Bathing/showering? Transferring? Providing hygiene? Changing linens? Changing briefs or assisting with toileting? Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator? Wound care: any skin opening requiring a dressing. On 04/09/24 at 01:50 PM surveyor observed that there was no sign for EBP outside of R106's room. Interviewed V4 (RN) who stated that the resident does not need precautions and there is no need to gown or glove during contact activities with resident. Surveyor and V4 reviewed provider order dated 3/12/2024. V4 stated We are not doing this. We don't gown up. On 04/10/24 at 9:26 AM R106's room door was observed as having no EBP signage. V7 (RN) was asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 42 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many about whether R106 had any precautions or isolation PPE requirements. V7 walked to the door of R106's room and stated, There is no isolation sign, but she should probably be on precautions. V7 and surveyor reviewed the order dated 3/12/2024 which stated: PPE Use During high-contact resident care activities:? Dressing? Bathing/showering? Transferring? Providing hygiene? Changing linens? Changing briefs or assisting with toileting? Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator? Wound care: any skin opening requiring a dressing. V7 stated I believe that these are EBP orders. I will place a sign on her door for EBP. On 04/10/24 at 10:57 AM, R106's room was observed to have no EBP signage on door. On 4/10/2024 at 9:03 AM, V27 (Phlebotomist) was observed entering R365's room which had an EBP sign on door. V27 did not don a gown before entering room. V27 was observed donning gloves and drawing blood. V27 then assisted resident to the wheelchair and exited the room with gloves still on and no hand hygiene performed. Before entering the next resident's room, V27 was asked by surveyor if she should have worn a gown when drawing blood on R365. V27 stated, I would normally gown up before drawing blood. I did not see the sign on the door. These are the gloves that I drew his blood in. On 04/10/24 at 1 PM, V2 (Director of Nursing and Infection Prevention Nurse) was interviewed. V2 stated she did an in-service on hand hygiene and about a month ago began doing spot checks of staff's hand washing compliance but has no data regarding compliance. The results of NICL Laboratories' preventative surveillance were reviewed which included two positive eye cultures and six positive urine cultures from January 1, 2024 to January 31, 2024 and no negative cultures, as well as one positive urine catheter culture and five positive urine cultures during the period of February 1, 2024 to February 29, 2023. V2 stated, These results were before I started. I would have to track it. I don't know if anything was done. When V2 was asked about hand sanitizer availability, V2 stated that hand sanitizer used to be available on the walls throughout the hallways. V2 stated she is not sure why hand sanitizer is no longer wall-mounted in the hallways. V2 was asked about the order for PPE Use During high-contact resident care activities: Dressing? Bathing/showering? Transferring? Providing hygiene? Changing linens? Changing briefs or assisting with toileting? Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator? Wound care: any skin opening requiring a dressing. V2 stated that this is a template order that the physicians are supposed to use to individualize their EBP orders, but they don't. V2 stated that for new hires, Human Resources started an education program upon hire last month. Agency staff also receive orientation and tour of the facility and V2 states that she discusses expectations and spot-checks documentation. Surveyor asked if there was documentation of orientation. V2 responded that orientation is .aways verbal. There is no documentation. On 4/11/2024 at 10:34 AM, a random sample of resident rooms was observed for compliance with V2's statement that she has advised staff not to place both EBP and contact precaution signage on a resident's room door or near the resident room plaque. Findings included: Room of R106 - Had signage for EBP on room door. Room of R363 - Had signage for EBP and contact precautions on room door. Room of R 95 - Had signage for contact precautions on room door. Room of R366 - Had signage for EBP and contact precautions on room door. On 04/10/24 at 2:45 PM during interview with V1 (Administrator) and V24 (Maintenance Supervisor), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 43 of 44 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 145844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many V1 stated that water testing is done twice a year. Quarterly shower head cleaning/Legionnaires Prevention is done annually. On 4/11/2024 at 8:55 AM, V24 stated Weekly Water Temperature Log/Chlorine Test Log is completed monthly. Reviewed policy titled: Enhanced Barrier Precautions which was dated July 2022 with a review date of 3/28/2024. The policy stated in part: General: Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. Aureus and Multidrug Resistant Organisms (MDRO). EBP may be applied (when contact precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status, infection or colonization with an MDRO .Examples of high contact resident care activities: Dressing, Bathing/Showering, Transferring, Providing hygiene, Changing Linens, Changing briefs or assisting with toileting, device care or use (central lines, urinary catheter, feeding tube, tracheostomy), and wound care: Chronic wounds, to include, but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous status ulcers. Reviewed policy titled Water Management Plan dated July 1, 2023 which stated in part that the facility will put in place a water management plan to ensure water is safe along all distribution points. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 44 of 44