Inspection·August 17, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm was empty, I do not remember checking the tubing, I gave report to 3-11 nurse, I think it was an agency nurse and left for the day. My expectation regarding the urinary catheter care, is for the C.N.A to make sure to clean the tubing, check to see if is intact, and draining well. We do not document the urinary catheter care, we only document the reason for the urinary catheter catheter replacement and the urine the output, I do not remember why on 7-6-2024 I did not have any output documented. Residents Affected - Few Per local hospital documentation dated 7-7-2024 V13 (MD/Infectious Disease) documents: proteus bacteremia (2/2) secondary to (GU) genitourinary source, acute complicated (UTI) urinary tract infection in the setting of chronic urinary catheter. urinary catheter with ross pyuria (pus in the urine), also noted to have maggots in urinary catheter. (R5) presented to the emergency room with alter mental status and gross pus in urinary catheter, R5 is very disheveled with urine odor and unable to provide any history. On 8-17-2024 at 12:40PM V13 (MD/Infectious Disease) said, while R5 was in the emergency room R5's urinary catheter was noted to have maggots, the urinary catheter was immediately replaced in the emergency Room. We do not expect to see maggots in any urinary catheter, the maggots are caused by poor hygiene, by not receiving the proper care. Observing maggots in an indwelling catheter is very unexpected. R5 admitting diagnosis was sepsis, bacteremia secondary to urinary source and urinary tract infection. On 8-17-2024 at 2:20pm V14 (Medical Doctor/Medical Director) said, I know the patient, I saw R5 in the facility and in the hospital as well. I am looking at the computer because I do not want to say the wrong thing. R5 went to the hospital on 7-6-2024, and was admitted to the local hospital with Bacteremia, sepsis and pneumonia, the Maggots were identified in the emergency room in the urinary catheter when they removed it and replaced it. Maggots come based on the daily care R5 is receiving. It reflects that the catheter site is not being clean, is not being taking care properly, in summer it can take up to 24 hours for a fly's egg to hatch. The urinary catheter must be clean daily. On 8-17-2024 at 2:00pm V2 (Nurse Consultant) said, We do not document the urinary catheter care, urinary catheter care is part of the daily care and routine, we document if we have to irrigate, if we have to replace the urinary catheter, the intake and output. Is not normal to have maggots in the urinary catheter catheter. V2 presented R5's progress note dated: 6-7-2024 14:26 that reads: replaced (R5) urinary catheter, oral fluids encourage will endorse to on incoming nurse. V2 said I do not know why the nurse replaced the indwelling catheter and did not document the reason for the replacement, my expectation is to have a reason for the replacement, that was the last time it was replaced before R5 went to the hospital on 7-6-2024. On 8-17-2024 at 3:00PM V3 said, urinary catheter care is done every shift but we do not document because is the standard of care when we provide incontinence care we are to check the urinary catheter, if the C.N.A. sees anything abnormal my expectation is for them to report to the nurse and the nurse needs to intervene immediately. We need to make sure to check the urinary catheter after each incontinent episode. The C.N.A needs to clean the tubing, make sure the bag is clean and properly placed, the proper peri care is rendered. The nurse will document if the urinary catheter is not draining properly, urine is not yellow, if the urine has blood, if the urine has a foul odor, if the patient complaints of any pain if the tubing has any sediments or if the urine is milky/ cloudy. My expectation is that nurse documents the output from the urinary catheter every shift, also if the nurse replaces the urinary catheter they need to document the reason for the replacement and the outcome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 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 145946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Hillside,the 4600 North Frontage Road Hillside, IL 60162 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Per R5's treatment record dated July 2024 reads: catheter: record output due to catheter placement every shift, start date: 7-10-2023 15:00. On July 6 unable to identify any documented output. On 8-17-2024 at 3:15pm V3 (Assistant Director of Nursing) said, my expectation is for the charged nurse to document the output from the urinary catheter every shift, I do not see any documentation completed on 7-6-2024 for any shift. R5's care plan dated 5-19-2023 reads: (R5) has a urinary catheter due to Neurogenic Bladder, the goal is for (R5) will show no signs and symptoms of urinary infection. 8-17-2024 at 3:00pm facility presented policy titled: infection control: Indwelling catheter care dated: 1-22-2024 reads: it is the policy of the facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 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 145946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Hillside,the 4600 North Frontage Road Hillside, IL 60162 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 0791 Provide or obtain dental services for each resident. 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 residents are provided with the opportunity to receive annual dental exams as well as routine monitoring to identify any changes in dental care needs to the extent covered under the State health plan. This failure applied to five (R1, R4, R5, R6, and R7) of seven residents reviewed for dental services. Residents Affected - Some Findings include: R1 has been a resident at the facility since 8/3/2019. Review of R1's medical record documents last dental visit and exam on 7/18/23; no additional dental visits within the past year and no documentation to show that R1 declined to have any dental services provided by the facility. R1's primary payor source is Medicaid. R4 was originally admitted to the facility on [DATE]. Review of R4's medical record does not have any documented dental visits while in the facility nor was there any documentation to show that R4 declined to have any dental services provided by the facility. R4's primary payor source is Medicaid. R5 has been a resident at the facility since 5/19/23. Review of R5's medical record does not have any documented dental visits while in the facility nor was there any documentation to show that R5 declined to have any dental services provided by the facility. R5's primary payor source is Medicare A with Medicaid as secondary. R6 has been a resident at the facility since 8/24/22. Review of R6's medical record does not have any documented dental visits while in the facility nor was there any documentation to show that R6 declined to have any dental services provided by the facility. R6's primary payor source is Medicaid. R7 has been a resident at the facility since 6/13/24. Review of R7's medical record does not have any documented dental visits while in the facility nor was there any documentation to show that R5 declined to have any dental services provided by the facility. R7's primary payor source is Medicare A with Medicaid as secondary. During the course of this survey, the facility was asked to provide any additional documentation of any dental visits for the above sampled residents, and none were provided. 08/17/24 at 3:19PM V3 (ADON) said that the dentist sees the residents upon admission and as requested. When asked how often residents are seen by the dentist, V3 said, I'm not 100% sure; it depends on their insurance. 08/17/24 at 3:54PM V4 (Social Worker) said, there is an in-house dentist that comes in twice a month and as needed. Some people have outside dentist that they use, and we set up transport as needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 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 145946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Hillside,the 4600 North Frontage Road Hillside, IL 60162 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 0791 Level of Harm - Minimal harm or potential for actual harm for those visits. I have not run in to this issue with payor sources. We set it up if they need it. If a referral is received or the resident or family requests it, then we set them up to see the dentist. If there is a care plan meeting, then we do talk about the services that we provide here. Upon admission, I just make them aware that they can request a dental visit if they want. I don't know if it makes a difference on the payor source. It doesn't usually go in the care plan. Residents Affected - Some 08/18/2024 at 11:31AM, V1 (Administrator) stated that the facility will be working closely with their dental service provider to ensure the annual and as needed visits are completed. V1 added, I have spoken with our social services and nursing team to ensure long term residents or those requesting will be seen timely. We will be working to have all notes added to residents charts as well to help us with our overall goals of care and to avoid any delays in the future with requests. Illinois Medicaid plan coverage includes the provision of dental services for adults over the age of 21. Review of facility policy titled, Dental Services (last reviewed on 6/9/24) reads: POLICY STATEMENT: It is the policy of the facility to ensure that residents obtain needed dental services, including routine dental services. PROCEDURE: 1. The facility will provide from an outside source routine and 24-hour emergency dental services to meet the needs of each resident. 2. The facility will, if necessary or if requested, assist the resident: a. Making appointments; and b. Arranging for transportation to and from the dental services location; and c. Will promptly, at least within 3 days, refer residents with lost or damaged dentures for dental services. d. If a referral does not occur within 3 days, the facility will provide documentation of what they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 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 145946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Hillside,the 4600 North Frontage Road Hillside, IL 60162 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. 3. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. Event ID: Facility ID: 145946 If continuation sheet Page 6 of 6