Inspection·April 19, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/19/2024 at 11:01 AM, V5, Licensed Practical Nurse, stated R1 needs assistance with most Activities of Daily Living (ADLs). V5 stated, For eating R1 requires 1:1 assist except for pizza. For all other ADLs, grooming, we must provide everything but R1 can brush his teeth. R1 is incontinent of both bowel and bladder functions. For bed mobility, R1 is dependent on staff for repositioning. For showers, R1 is dependent on 1 staff for bed baths and showers. R1 requires a Hoyer lift with 2 staff for transfers. R1's shower schedule is Thursday PM shift and Sunday PM shift. The CNAs fill up the Shower Sheet and the Alma Palette, a newly created form for the CNAs to distinguish any new skin impairments. They would check it and let the nurse know and the nurse will do an assessment if there are any new skin changes. On 4/19/2024 at 1:26 PM, R1 was observed up in the Geri chair, wearing personal clothing with crumbs all over his upper garment, with spilled juice all over the floor, his lunch meal consisting of bun with a patty was spilled all over the table beside him. R1 was trying to reach for his food. R1 stated he is very hungry, and no one has come to assist him with his lunch meal yet. R1 stated he has been waiting for 45 minutes for the staff to assist him with his meal tray. R1 stated he tried to pick up his hamburger to eat but it just fell on top of the bedside table, and he knocked his cup of juice down while trying to reach for it. Surveyor summoned V5, LPN, and V4, CNA to R1's room. V4 stated his meal tray was delivered around 12:30 PM and then she went to check another resident. When asked why R1 has not eaten yet at this time and why no one is assisting R1 eat his lunch, V5 stated V4, Certified Nursing Assistant/CNA, knew R1 needed assistance with eating and V4 is not supposed to leave R1 while he is eating especially since the resident V4 mentioned she was helping was ready already. V5 stated, If I was given my lunch late and if nobody was assisting me with feeding, I would be upset and would feel helpless also. I will make sure R1 gets another tray and is assisted with feeding. R1 appeared distraught and kept saying, Leave me alone, I don't want to talk to anybody anymore, I just want to transfer to a different hallway. This keeps happening to me. Leave me alone, I don't want to talk anymore. Review of R1's Shower sheets exclude documentation R1 received a d bath or shower on 4/4/2024 and 4/11/2024 as scheduled. Review of Point of Care Documentation in R1's EHR excludes any documentation bed bath or shower was given for the whole month of April. Review of R1's progress notes excludes any documentation R1 was refusing showers, bed baths or shaving. 2. According to the Electronic Health Record (EHR) R2 had diagnoses including chronic obstructive pulmonary disease, muscle weakness, need for assistance with personal care, acute respiratory failure, acute kidney failure, localized edema, atherosclerotic heart disease of native coronary artery, hypertensive heart disease without heart failure, hyperlipidemia, dementia, bipolar disorder, generalized anxiety disorder, major depressive disorder, monoplegia of upper limb affecting left nondominant side, arthritis, psychotic disorder and personal history of COVID-19. The Minimum Data Set (MDS) dated [DATE], shows R2's cognition was moderately impaired with a nine out of fifteen points required on the Brief Interview for Mental Status (BIMS). Section GG documents R2 has an impairment on one side of the upper extremity. Care Plan showed R2 had an Activities of Daily Living (ADLs) self-care performance deficit related to impaired mobility, decrease in ADLs, Physical limitations: Balance problems, gait, strength, endurance. On 4/19/2024 at 10:02 AM R2 was observed sitting in her wheelchair. V2 stated she has not been receiving her showers and the only time she gets showers is when her friend comes to visit her. R2 stated, If the CNAs give her a shower, they don't do a good job, they just pour water over me and does not clean me up very well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 2 of 3 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 04/19/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Point of Care Documentation in R2's EHR excludes any documentation bed bath or shower was given for the whole month of April. Review of R2's progress notes excludes any documentation R1 was refusing showers or bed baths. 3. According to the Electronic Health Record (EHR) R3 had diagnoses including muscle weakness, osteomyelitis, chronic obstructive pulmonary disease, asthma, type 2 diabetes mellitus, hyperlipidemia, dementia, bipolar disorder, major depressive disorder, iron deficiency anemia, cocaine abuse, gastrointestinal hemorrhage, chronic kidney disease and gastritis without bleeding. The Minimum Data Set (MDS) dated [DATE], shows R3's cognition was intact with a fifteen out of fifteen points required on the Brief Interview for Mental Status (BIMS). Section GG documents R3 requires partial/moderate assistance with shower/bathing and supervision/touching assistance with upper body dressing. Care Plan showed R3 had an Activities of Daily Living (ADLs) self-care performance deficit related to impaired mobility, decrease in ADLs, Physical limitations: Balance problems, gait, strength, endurance. On 4/19/2024 at 10:10 AM, R3 was observed ambulating in the room, appeared disheveled, upper garment was worn inside out, hair disheveled. R3 stated she can't remember when the last time was, she got a shower. R3 stated nobody helped her dress up this morning. Review of Point of Care Documentation in R3's EHR excludes any documentation bed bath or shower was given for the whole month of April. Review of R3's progress notes excludes any documentation R3 was refusing showers, bed baths or assistance with grooming and dressing. V2, Director of Nursing/DON provided the shower sheets for the month of March and April, which excludes any shower sheets for R2 and R3. V2 informed surveyor did not find any completed shower sheets for R2 and R3, and R1 was missing shower sheets for 4/4/2024 and 4/11/2024 to which V2 responded, I will take a look and give you what I have. No additional shower sheets were provided by V2. On 4/19/2024 at 1:50 PM, V2, Director of Nursing/DON, stated the expectation is the CNAs will assist residents with their Activities of Daily Living (ADLs), and some residents require more assistance than other. V2 stated the CNAs are expected to complete the Shower Sheet and document in the Electronic Health Record (EHR) the shower or bed bath was completed, and agency staff should at least document in the Shower Sheets. If a resident is refusing showers or bed baths, V2 stated she expects to see documentation on the progress notes regarding the refusal. V2, DON, provided the facility policy titled, Activities of Daily Living dated 1/1/2021 which documents in part: Policy Statement: Facility ensures residents receive ADL assistance and maintains resident ' s comfort, safety, and dignity. The goal is to maximize the residents and staff safety, confidence, independence, and ability to handle everyday activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 3 of 3