Inspection·April 18, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an abuse allegation to Illinois Department of Public Health (IDPH) for one resident (R1) out of 4 residents reviewed for abuse. Finding include: R1's Face sheet documents that R1 was admitted to the facility on [DATE] with diagnoses not limited to: Toxic encephalopathy, unspecified abnormalities of gait and mobility, other reduced mobility, type 2 diabetes mellitus without complications, acute kidney failure. Essential (primary) hypertension. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R1 has a Brief Interview for Mental Status (BIMS) score of 5, indicating that R1 has a severe cognitive impairment. Care plan (dated 04/14/2025) documents that R1 is noted with potential communication deficits- may have difficulty completing her thoughts, trouble with word choices. On 04/15/2025 at 11:06AM, during a complaint investigation survey, surveyor inquired for V1 (administrator) to bring the surveyor the facility reportable binder. At 11:31AM, surveyor received the reportable binder and after reviewing it, surveyor noted that R1's abuse allegation from 03/20/2025, was not in the facility's reportable binder. Surveyor interviewed V1 to determine why the reportable was not submitted to the state agency. On 04/15/2025 at 11:35AM, V1 (administrator) stated, R1 was admitted to the facility on [DATE]. On 03/20/2025, when R1's family came to the facility to visit R1, they noticed the discoloration to R1's left eye. V2 (director of nursing) and I, went to assess R1 and R1's son and V5 (R1's daughter) were present during the assessment. During the assessment, I saw R1 with a discoloration to the left eye, which looked different from the right eye. R1's skin is of dark complexion, and the discoloration did not appear red. We asked the resident what happened. R1 mentioned that during the ambulance transport to the facility, the night prior, something fell on R1's head inside the ambulance. R1 was not sure what fell on her head. R1 was explicit about saying that they did not mean for anything to fall on R1. R1 mentioned that the paramedics put back whatever fell on R1's head. R1 is alert and oriented. I told the family that I would call the ambulance for the ambulance to start the investigation. I did not have the ambulance transport form. I had to ask the hospital's case manager for the name of the ambulance company. I contacted the ambulance company and I spoke to the manager, and I informed them of the allegation that something had fallen on R1's head during transportation. The next day, on 03/21/2025, the manager from the ambulance company called me back and informed me that there (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145844 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 04/18/2025 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)