Inspection·June 3, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some needs. R3 stated she pressed her call light around 4AM this morning on 06/01/2024 and the assigned CNA (identified as V8) never came to answer R3's call light. R3 stated she was wringing wet and needed her incontinence briefs to be changed. R3 stated V3 (Licensed Practical Nurse/LPN) answered R3's call light and informed R3 that V8 (CNA) left the facility at 6:00AM. R3 stated she currently has her call light on, and it has been on for approximately one hour. R3 stated she pressed her call light because she must use the bathroom to be toileted. Surveyor located inside R3's room and observed a red light blinking on R3's call light system, no sound was audibly heard coming from the call light system. Outside of R3's room door a white light illuminated above R3's room door. On 06/01/2024 at 10:23AM, in the hallway on the three north unit R3's call light is observed still illuminated. Surveyor observed V4 (CNA) walk past R3's room but not answer R3's call light. At 10:26AM, V4 observed walking down the hallway past R3's room again and does not answer R3's call light. On 06/01/2024 at 10:27AM, V4 observed answering R3's call light and stated there is no sound that rings on the call light system, only the light illuminates. On 06/01/2024 at 10:28AM, V5 (CNA) stated the facility's call light system does not have an audible sound to alert staff that the resident's call light has been pressed. V5 stated there is only a light that illuminates above the resident's room when it is pressed. V5 stated this system allows the staff to constantly round on the residents to assist with resident's needs. On 06/01/2024 at 12:24PM, V2 (DON) stated she has been working at the facility since February 2024. V2 stated she learned in the second week of working at the facility that there is no sound for the facility's call light system. V2 stated there is only a light that illuminates when a resident presses their call light. V2 stated the facility staff taught her that the staff's call light protocol is to walk looking up to see the call light. V2 stated this is how the call lights are set up at the facility. V2 stated everyone is responsible for answering call lights even if they are not able to perform a specific task, they should answer the call light and refer the resident's needs to the appropriate person. V2 stated when agency staff work at the facility, there is a checklist that they sign off on acknowledging that the agency staff understands how the call light system works. V2 stated it is not okay to walk past a resident's illuminated call light unless it is an emergency. V2 stated she has not received any complaints of call lights not being answered in a timely manner since the end of February 2024. V2 stated nurses are allowed to administer medications one hour before and one hour after the scheduled administration times. On 06/02/2024 at 9:30PM, V7 (LPN) stated he was the nurse on duty on 05/31/2024 from 11PM-7AM on the third floor of the facility for this shift. V7 stated he was responsible for caring for residents on the three west unit and the three north unit. V7 stated there were two CNAs assigned on the third floor of the facility, one CNA assigned to the west unit and one CNA assigned to the north unit. V7 stated V8 (CNA) is an agency CNA whom he had never worked with before. V7 stated at the start of V8's shift, V8 informed V7 that V8 would be leaving the facility at 6AM in order to attend her next job. V7 stated he gave V8 her assignment and V8 was initially receptive and cooperative with her assignment. V7 stated later in the shift, V7 had a hard time locating V8 in the facility. V7 stated he observed V8 constantly on her phone during V8's assigned shift. V7 stated V8 would disappear off the unit and he did not know where V8 was located majority of the shift. V7 stated he observed multiple resident call lights illuminated throughout the shift. V7 stated he observed R1's call light illuminated also but he is unsure what R1's needs were because V7 did not get a chance to answer R1's call light. V7 stated he is not sure if R1's incontinence briefs were changed during the shift and could not answer R1's call light because V7 was administering medications to residents. V7 stated on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 2 of 6 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 06/03/2024 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 - Some 06/01/2024 at approximately 3:30AM, V7 was performing his medication administration pass and observed R7's call light illuminated. V7 stated he observed R7's call light illuminated for approximately 15 minutes. V7 stated this is the only facility he has ever worked for that has a silent call light system. V7 stated he does not feel the facility's call light system is an effective call light system for resident needs. V7 stated he then went to answer R7's call light and R7 stated he needed his incontinence briefs changed and needed some water. V7 stated he went to the third floor dining room to get water for R7 and observed V8 (CNA) sleeping in the dining room during her assigned shift. V7 stated when V4 (CNA) started her assigned shift on 06/01/2024 at approximately 7AM, V4 informed V7 that R5 and R6 were not changed, and their incontinence briefs were soiled. V7 stated once V8 left the facility at 6AM on 06/01/2024, no one was assigned to resume care for residents residing on the three north unit. V7 stated he did the best he could with answering resident call lights but V7 also had other nursing duties he was responsible for. V7 stated it is a problem if no one is assigned to care for residents and perform rounds on the residents because residents could potentially fall or be in distress if not monitored and rounded on. V7 stated when agency staff works at the facility, he encounters agency staff leaving the facility before their assigned shift is completed. V7 stated this happens approximately once or twice a month. V7 stated he has not encountered this behavior with regular staffing in the facility, only agency staff. V7 stated he has not informed anyone in management about the above occurrences and only gives report to the on-coming nurse when he completes his assigned shift. R1's Facesheet documents that R1 has diagnoses not limited to: secondary Parkinsonism, type 2 diabetes mellitus, heart failure, muscle weakness, need for assistance with personal care, reduced mobility, seizures, history of falling, urinary tract infection, and retention of urine. R1's Physician Order Sheet/POS documents in part the following orders: 1. Ativan 0.5mg- Give 1 tab by mouth at bedtime 2. Atorvastatin 40mg- Give 1 tab by mouth one time a day 3. Brilinta 90mg- Give 1 tab by mouth two times a day 4. Budesonide-Formoteral Fumarate 160-4.5mcg/ACT- 2 puff inhale orally two times a day 5. Buspirone 7.5mg- Give 1 tab by mouth three times a day 6. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 3 of 6 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 06/03/2024 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 Carbidopa-Levodopa 25-250mg- Give 1 tab by mouth four times a day Level of Harm - Minimal harm or potential for actual harm 7. Carvedilol 6.25mg- Give 1 tab by mouth two times a day Residents Affected - Some 8. Entacapone 200mg- Give 1 tab by mouth four times a day 9. Hydroxyzine 25mg- Give 1 tab by mouth at bedtime 10. Ipratropium-Albuterol Inhalation Solution 0.5mg-2.5mg (3) mg/3ml- 3ml inhale orally every eight hours 11. Lantus 100unt/ml- Inject 10 unit subcutaneously at bedtime 12. Midodrine 5mg- Give 1 tab by mouth three times a day 13. Mirtazapine 45mg- Give 1 tab by mouth at bedtime 14. Novolog FlexPen 100unit/ml- Inject per sliding scale 15. Pramipexole Dihydrochloride 0.125mg- Give 1 tab by mouth three times a day 16. Sacubitril-Valsartan 24-26mg- Give 1 tab by mouth two times a day 17. Tamsulosin 0.4mg- Give 1 cap by mouth one time a day R1's Medication Administration Audit Report reviewed for 05/12/2024 and documents that the above medications were not given as prescribed by the physician's orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 4 of 6 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 06/03/2024 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 - Some R1's MDS/Minimum Data Set, dated [DATE] documents that R1 is dependent with toileting hygiene needs. R1 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R1 is cognitively intact. R1's care plan documents in part, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Toileting: R1 requires one staff assistance with Toileting. Toileting Schedule: CNA to assist resident to the bathroom q2 hours while resident is awake. R3's Facesheet documents that R3 has diagnoses not limited to: Congestive heart failure, overactive bladder, anxiety disorder, Alzheimer's disease, dementia, legal blindness, polyarthritis, and left artificial hip joint. R3's MDS/Minimum Data Set, dated [DATE] documents that R3 requires partial/moderate assistance with toileting hygiene needs and is occasionally incontinent of bowel and bladder. R3's MDS documents that R3 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R3 is cognitively intact. R3's care plan documents in part, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Toileting Schedule: Assist resident to the toilet every shift and as needed. Check the resident and as required for incontinence. Wash, rinse, and dry perineum. CNA change clothing PRN after incontinence episodes. Toileting: R3 requires one staff assistance with Toileting. R4's Facesheet documents that R4 has diagnoses not limited to: Spastic hemiplegic cerebral palsy, spinal stenosis, encounter for attention to colostomy, malignant neoplasm of colon, and polyarthritis. R4's MDS/Minimum Data Set, dated [DATE] documents that R4 is dependent with toileting hygiene needs. R4's MDS documents that R4 has a Brief Interview for Mental Status/BIMS of 15/15, indicating that R4 is cognitively intact. R4's care plan documents in part, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Check resident every two hours and assist with Colostomy care if needed. Toilet Use: The resident requires total staff assistance with Toileting. R5's MDS dated [DATE] documents that R5 is dependent with toileting hygiene needs. R6's MDS dated [DATE] documents that R6 is dependent with toileting hygiene needs. Facility policy dated 03/20/2020 titled Medication Administration documents in part, 5. Check the medication administration record (MAR) prior to administering medication for the right medication, does, route, patient and time. 14. Document as each medication is prepared on the MAR. 18. If medication is not given as ordered, document the reason on the MAR. Facility policy dated 06/19/2020 titled Call Light Use documents in part, Intent: Facility aims to meet resident's needs as timely as possible. Call light system is used to alert staff of resident's needs. 4. Direct care staff will check these residents during, check and change, rounds and ADL care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 5 of 6 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 06/03/2024 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 Facility policy dated 10/29/2021 titled Supporting Activities of Daily Living (ADL) documents in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently ., including appropriate support and assistance with: Elimination (toileting). Residents Affected - Some Facility' CNA assignment sheet dated 05/31/2024 documents that V8 (CNA) was responsible for caring for residents residing on the three north unit of the facility. Facility nursing scheduled dated 05/31/2024 documents that V8 was scheduled to work at the facility from 11PM-7AM. Facility timecards dated 05/31/2024 documents that V8 left the facility at 6:06AM. Facility Census dated 06/01/2024 documents a total of 20 residents reside on the three north unit of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145844 If continuation sheet Page 6 of 6