Health inspection·March 28, 2025

F 0644 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. R95 is a [AGE] year-old male initially admitted in the facility on 04/20/2024 with diagnoses of not limited to Major Depressive Disorder and Bipolar Disorder. Residents Affected - Few R95's Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome dated 04/12/2024 indicated R95 is authorized to stay in the NF (nursing facility) 30 days or less. It also indicated that re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. On 03/26/2025 at 11:35AM during interview with V20 (Regional Director of Social Work), V20 stated that a new screening should have been requested for R95 before the 30 days had ended. Review of R95's admission Record dated 03/27/2025 indicated R95 was initially admitted on [DATE]. Review of R95's Order Summary Report dated 03/26/2025 indicated diagnoses of not limited to Major Depressive Disorder and Bipolar Disorder. Review of facility's policy entitled admission Criteria reviewed on 04/18/2024 indicated the following: Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Procedure: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorder (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The State PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 2 of 24 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 03/28/2025 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 0644 services of the potential resident that are outlines in the evaluation. Level of Harm - Minimal harm or potential for actual harm f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 3 of 24 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 03/28/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R34 face sheet shows diagnosis of schizophrenia. Residents Affected - Few 3/27/25 V20 (Consultant) said R34 has SMI (Serious Mental Illness) diagnosis, V20 said R34 was not referred for PASARR level one or level two assessment. R34's MDS (Minimum Data Set) dated 1/2/25 section I denotes diagnosis of schizophrenia. Section A 1500 denotes 0 for No for resident being considered by state for PASARR LEVEL 2 or related condition, section A1510 for level 2 preadmission screening nothing is checked for serious mental illness. R91's face sheet shows diagnosis of bipolar, major depression disorder, anxiety, and unspecified psychosis not due to substance. 3/27/25 V20 (Consultant) said R91 has SMI (Serious Mental Illness) diagnosis, V20 said R91 was not referred for PASARR level one or level two assessment. R91's MDS dated [DATE] section I denotes active diagnosis anxiety disorder, depression, bipolar disorder, and psychotic disorder. Section A 1500 denotes 0 for No for resident being considered by state for PASARR level 2 or related condition, section A1510 for level 2 preadmission screening nothing is checked for serious mental illness. Based on observation, interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 3 of 5 residents (R34, R87, R91) reviewed for PASARR in a total sample of 31. Findings Include: On 3/26/2025 at 10:30AM, V20 (Regional Director of Social Work) stated there was no PASARR completed for R87 prior to admission. A Level I was requested this morning. On 3/27/2025 at 9:30 AM, V1 (Administrator) stated PASARR needs to be completed prior to resident admission and if Level I is positive, Level II will have to be completed to ensure residents will receive appropriate services. R87's admission Record indicated an admission date of 10/29/2024. Diagnosis Information include Schizoaffective Disorder, Unspecified. Care Plan report state, Focus: R87 uses psychotropic medications r/t (related to) Behavior management, dementia, schizoaffective disorder. Review of Notice of PASARR Level I Screen Outcome, Notice date: March 26,2025 PASARR Level I Determination: Refer for Level II Onsite Policy and Procedure: Policy: admission Criteria, Reviewed 4/18/2024 Policy Statement: Our facility admits only residents whose medical and nursing care needs can be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 4 of 24 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 03/28/2025 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 0645 met. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Few 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 5 of 24 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 03/28/2025 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure to provide nail and foot care to dependent resident. This deficiency affects three (R60, R117, and R130) residents in the sample of 31 reviewed for Activities of Daily Living (ADL) Program. Residents Affected - Few Findings include: On 3/25/25 at 10:30AM, Observed R117 lying in bed uncovered. Fingernails on both hands are long and dirty with black matter inside the fingernails. Toenails on both feet are long, curved, and have thick yellowish-brown discoloration. Bilateral lower extremities have dry scaly skin. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said that Certified Nurse Assistants (CNAs) should provide nail care as part of ADL care. R117 has an admission date of 3/22/24 with diagnosis listed in part but not limited to Encephalopathy, Chronic kidney failure, Human Immunodeficiency Virus, Hospice care. Comprehensive care plan indicated she has an ADL self-care performance deficit secondary Impaired mobility, decreased in ADL, Physical limitations. She has a terminal prognosis, in hospice care. No indication in care plan that resident refused nail and foot care. She is alert, responsive and pleasantly confused. On 3/25/25 at 10:45AM, Observed R60 up in wheelchair in activity room. He is awake but nonresponsive. He has contractures on his right hand. Both fingernails on both hands are long and dirty with black matter underneath the nails. Showed observation to V10. V10 said that CNAs should provide nail care as part of ADL care. R60 has an admission date of 2/8/22 with diagnosis listed in part but not limited to end stage renal diseases, Type 2 Diabetes Mellitus with diabetic neuropathy, Aphasia following cerebrovascular disease, Dementia. Comprehensive care plan indicated he has an ADL self-care performance deficit secondary to impaired mobility, decrease in ADLs, physical limitations, and medical diagnosis. Has impaired cognitive function and thought processes. No indication in care plan that he refused nail care. On 3/27/25 at 1:07AM, V2 Director of Nursing (DON) said that CNAs and nurses are responsible for providing nail care to residents as part of the ADL program. The nurses should inform social services if a resident needs to be seen by the podiatrist. Social services is responsible for scheduling residents to be seen by the podiatrist. The podiatrist comes to the facility monthly. Facility's policy on ADL reviewed 7/20/2024 indicated: Policy statement: Facility ensures that residents receive ADL assistance and maintain resident's comfort, safety, and dignity. The goal is to maximize the residents and staff safety, confidence, independence, and ability to handle everyday activities. Procedures: 6. Assist the resident to be clean, neat, and well-groomed including nail care and having finger and toenails will be cut on shower days and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 6 of 24 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 03/28/2025 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 0677 Facility's policy on Foot care reviewed 5/2024 indicated: Level of Harm - Minimal harm or potential for actual harm General: Residents Affected - Few Foot care is given to promote cleanliness, prevent infection, control odor, provide comfort, monitor for skin breakdown, and promote healing. Guideline: 1. Foot care is provided routinely with the bath and PRN. It may also be done more frequently with a physician or nurse practitioner order. 8. Never cut toenails of resident with diabetes and circulatory disorders. 9. Residents with diabetes and circulatory disorders will be referred to the podiatrist as necessary. On 3/25/2025 at 10:33 AM, R130 is in bed and able to hold conversation. R130's fingernails were long. R130 said he would want his nails trimmed if there is someone who can do it. On 3/25/2025 at 10:35 AM, V25 (Licensed Practical Nurse/Agency) stated R130's fingernails were long and V25 will have the CNA assigned trim R130's fingernails. On 3/26/2025 at 8:55 AM, V2 (Director of Nursing) stated resident fingernails should be trimmed when long as this is part of their ADL care. V2 said staff should follow through. Review of R130's Care Plan (Revision date: 1/22/2025) read: R130 has ADL self-care performance deficit r/t (related to) dx (diagnosis) of dementia, lack of coordination, and muscle d/o. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 7 of 24 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 03/28/2025 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 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** 4. On 3/25/25 at 10:30AM, Observed R117 lying in bed with Low air loss (LAL) mattress uncovered. She is alert, responsive and pleasantly confused. Observed fitted sheet covering the LAL mattress with cloth pad over the mattress. R117 wears disposable briefs. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said that resident with LAL mattress should only have flat sheet over the mattress. Residents Affected - Some On 3/25/25 at 10:34AM, Observed V12 (WCC) prepare wound treatment/medication for R117's sacral wound, she left the treatment cart opened and unlocked In front of R117's room. V12 went inside the room and closed the door. No visual access of the treatment cart. V12 assessed R117 for pain. R117 said, she has on pain at her back with rate of 10/10. V12 said she will have the floor nurse administer R117's pain medication before she will perform wound care. Informed V12 of observation that she left the treatment cart opened and unlocked. V12 said, treatment cart should be closed and locked when not in use. On 3/25/25 at 11:41AM, Observed V12 (WCC) reposition R117 to her side and removed sacral wound dressing. Observed moderate amount of serosanguineous wound drainage. V12 cleansed the sacral wound with wound cleanser and gauze. V12 said R117 has a stage 4 pressure ulcer on sacrum with 20% yellowish greenish slough and 80% granulation tissue. V12 applied Medi honey and calcium alginate, then covered with dry dressing. R117 has an admission date of 3/22/24 with diagnosis listed in part but not limited to Encephalopathy, Chronic kidney failure, Human Immunodeficiency Virus, Hospice care. Active physician order sheet indicated Wound care: Sacral /coccyx - cleanse with Dakin's, wound cleanser or Normal saline, pat dry skin prep peri wound skin cover with honey and alginate and dry dressing every day shift and as needed. On low air loss mattress to prevent pressure ulcers. Wound assessment report dated 3/26/25 indicated Stage 4 Sacrum active pressure ulcer present on admission on [DATE] measures 2.2 centimeters (cm) x 6cm x 0.1cm. 90% bright beefy red and 10% necrotic soft adherent. Moderate amount of serosanguineous drainage. Comprehensive care plan indicated she has pressure ulcer related to disease process, history of ulcers, immobility. She has an ADL self-care performance deficit secondary Impaired mobility, decreased in ADL, Physical limitations. Braden scale/Skin assessment indicated that she is at risk for impairment. On 3/26/25 at 10:10AM, Informed V12 (WCC) that she did not follow R117's physician wound care treatment order when providing wound care to R117 yesterday. Informed V12 that she did not cleanse R117's sacral wound with Dakin's solution in addition to wound cleanser as indicated in physician order. V12 said that she forgot the Dakin's solution. V12 said they are expected to follow physician order in performing wound care. On 3/27/25 at 9:30AM, Reviewed R117 physician order sheet, indicated Dakin's solution for cleansing wound as part of wound treatment for R117 was discontinued. On 3/25/25 at 10:42AM, Observed R53 lying in bed with low air loss mattress with flat sheet and cloth pad over the mattress. He wears disposable briefs. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said that residents on LAL mattress should only have flat sheet over the mattress. R53 has a re-admission date of 8/30/24 with diagnosis listed in part but not limited on Stage 4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 8 of 24 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 03/28/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pressure ulcer sacral region, Type 2 Diabetes Mellitus with diabetic neurological complication and diabetic neuropathy, Morbid obesity, Peripheral Vascular disease, Congestive heart failure, Paraplegia. Active physician order sheet indicated Wound care: Sacrum cleanse with normal saline solution or wound cleanser, apply Hydrofera blue covered with dry dressing as scheduled every day shift MWF (Monday/Wednesday/Friday) and as needed. Comprehensive care plan indicated he has alteration in skin integrity/pressure injury. Intervention: Apply specialty mattress when in bed. No documentation in care plan that he is noncompliance with LAL mattress management of avoiding multi layers of linens over the mattress. Braden scale/Skin assessment indicated that she is at risk for impairment. On 3/27/25 at 9:54AM, Reviewed R53 and R117's medical records regarding wound care management with V12 (WCC). Informed concerns identified with R53 and R117. On 3/27/25 at 12:19PM, Informed V2 DON (Director of Nursing) of above concerns. V2 said that only flat sheet is placed over the LAL mattress as manufacturer's recommendation, no multi layers of linens. They are expected to follow physician orders in performing wound care to resident. Facility's policy on Skin Management: Specialty Mattress review date 6/2024 indicated: Low Air Loss: Stage 3, Stage 4, Unstageable, DTI to the buttocks, Multiple Stage 2, very high risk with multiple co-morbidities or residents who need this type of mattress for comfort. Procedure: 1. As per manufacture guideline, no more than 1 piece of linen will be placed between the mattress and the resident. Facility's policy on Wound Prevention and Healing reviewed on 6/1/2024 indicated: Policy statement: To provide wound care treatments/services (using multidisciplinary) based on evidence-based standards of care under the direction of a physician. 2. Wound assessment and documentation tool b. Goal will focus on the clinical status of the wound, guide the appropriate intervention for the wound. 9. Continued/Ongoing treatment a. Nurse/Therapist will provide wound care per physician order. Based on observation, interview, and record review, the facility failed to ensure that necessary treatment and services to promote healing and prevent development of pressure injury are implemented for 5 of 12 residents (R53, R117, R127, R136, R151) reviewed for pressure injury in a sample of 31. Findings include: 1. On 03/25/2025 at 11:30AM during unit rounds, R127's air mattress light indicator is on the 6th (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 9 of 24 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 03/28/2025 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 0686 light indicating the weight setting of the air mattress is between 210-320 lbs (pounds). Level of Harm - Minimal harm or potential for actual harm On 03/26/2025 at 9:32AM during unit rounds with V12 (Wound Care Coordinator/WCC), R127's air mattress light indicator is on the 6th light indicating the weight setting of the air mattress is between 210-320 lbs. V12 then proceeded to change the setting to the 5th light indicator. Residents Affected - Some On 03/26/2025 at 9:32AM during interview with V12, V12 stated that R127's weight is 183 lbs so the air mattress setting should be adjusted to the 5th light indicator. V12 also stated that air mattress settings should be according to R127's weight. Review of R127's Order Summary Report dated 03/26/2025 indicated admission date of 01/09/2025 and diagnoses of not limited to dependence on respirator (ventilator) status, dependence on renal dialysis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R127's Monthly Weight Report dated 03/27/2025 indicated R127's weight in March 2025 is 183.7 lbs. Review of R127's Patient Risk Profile indicated R127 was assessed for risk for acquiring pressure wounds on 03/13/2025 and scored 10 which is high risk. Review of R127's Wound Assessment Details indicated R127 has active sacral pressure ulcer on assessment date 03/25/2025. 2. On 03/25/2025 at 11:08AM during unit rounds, R136 was observed with air mattress. R136 had a flat sheet, folded linen, and reusable pad between R136 and the air mattress. R136 was also wearing disposable briefs. On 03/26/2025 at 9:27AM during unit rounds with V12 (WCC), R136 was observed with air mattress. R136 had a flat sheet, folded linen, and reusable pad between R136 and the air mattress. R136 was also wearing disposable briefs. On 03/26/2025 at 9:27AM during interview with V12, V12 stated that R136 should only have the flat sheet underneath her with disposable briefs on. Review of R136's Order Summary Report dated 03/26/2025 indicated R136 was admitted on [DATE] with diagnoses of not limited to morbid obesity due to excess calories. Review of R136's Patient Risk Profile indicated R136 was assessed for risk for acquiring pressure wounds on 01/24/2025 and scored 16 which is at risk. 3. On 03/25/2025 at 11:34AM during unit rounds, R151's air mattress light indicator is on the 7th light indicating the weight setting of the air mattress is between 260-400 lbs (pounds). On 03/26/2025 at 9:32AM during unit rounds with V12 (WCC), R151's air mattress light indicator is on the 7th light indicating the weight setting of the air mattress is between 260-400 lbs. V12 then proceeded to changing the setting to the 2nd light indicator. On 03/26/2025 at 9:32AM during interview with V12, V12 stated that R151's weight is 105 lbs so the air mattress setting should be adjusted to the 2nd light indicator. V12 also stated that air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 10 of 24 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 03/28/2025 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 0686 mattress settings should be according to R151's weight. Level of Harm - Minimal harm or potential for actual harm Review of R151's Order Summary Report dated 03/26/2025 indicated admission date of 03/03/2025 and diagnoses of not limited to focal traumatic brain injury and traumatic subdural hemorrhage. Residents Affected - Some Review of R151's Monthly Weight Report dated 03/27/2025 indicated R151's weight in March 2025 is 104.4 lbs. Review of R151's Patient Risk Profile indicated R151 was assessed for risk for acquiring pressure wounds on 03/24/2025 and scored 10 which is high risk. Review of facility's policy entitled Skin Management: Specialty Mattress reviewed on 06/2024 indicated the following: Guidelines for the Use of Specialty Mattresses: The following are guidelines for the use of specialty mattresses; however, the facility Wound Care Nurses, DON (Director of Nursing) and Physician will continue to use their professional judgement to determine the type of mattresses most appropriate for the individual resident. Procedure: 1. As per manufacture guideline, no more than 1 piece of linen will be placed between the mattress and the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 11 of 24 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 03/28/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure comprehensive restorative nursing evaluation and ongoing assessment is completed for a resident with limited range of motion/ contractures to upper extremities. This deficiency affects two (R60 and R79) of three residents in the sample of 31 reviewed for Restorative program. Findings include: 1. On 3/25/25 at 10:45AM, Observed R60 up in wheelchair in activity room. He is awake but nonresponsive. He has flexion contractures on his right hand. No splint applied. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said she does not know if he has an order for a splint. R60 has a re-admission date of 2/8/22 with diagnosis listed in art but not limited to End stage renal disease, dependence on renal dialysis, Type 2 Diabetes Mellitus with diabetic neuropathy, Aphasia following cerebrovascular disease, Cerebral infarction, Memory deficit, Anorexia. Physician order sheet indicated Caregiver will don/doff palm protector with rolled hand towel for right upper ordered 3/25/25 pending confirmation. No Comprehensive restorative assessment/Functional abilities were done for 2024 and 2025. Restorative assessment/Functional abilities completed on 9/30/23, 6/20/23, 2/20/23 and 1/31/22. MDS/resident assessment dated [DATE] indicated Section GG0115 Functional limitation in Range of Motion- 0 no impairment. Section GG0130 Self-care - Shower/Bathe, Upper and lower body dressing, putting on /taking off footwear and personal hygiene were marked 2 Substantial/maximal assistance. Toileting- was marked 1 Dependent. Eating was marked Supervision or touching assistance. On 3/27/25 at 11:07AM, V13 (Restorative Nurse) said that she has only been working in the facility for 2 months. She said that restorative assessment/functional abilities are done upon admission, quarterly assessment, annually and significant change of condition. Based on assessment the resident is placed on appropriate restorative program. R60's medical records were reviewed with V13. Informed V13 that R60 did not have restorative assessment for 2024 and 2025. The last restorative assessment done for R60 was 2023. V13 said that she has not uploaded her assessment due last month (2/20/25). R60's physician order sheet indicated order of splint to right hand (observed R60 with no splint). R60 was placed on bed mobility and splint program without having a comprehensive assessment. R60 was not evaluated for appropriate program based on comprehensive assessment. On 3/27/25 at 12:19PM, Informed V2 Director of Nursing (DON) of above concerns. V2 said that restorative nursing assessment is completed for resident upon admission, quarterly assessment, annually and significant change of condition. They (Restorative Nurse) are expected to follow their policy on Restorative Nursing program. On 3/28/25 at 9:55AM, Reviewed R60's MDS (Minimum Data Set)/Resident assessment Section GG Functional abilities and O Special treatments, procedures and programs dated 2/20/25 with V1 (Administrator), V2 (DON) and V13 (Restorative Nurse). R60 was marked for functional limitation in range of motion 0 -no impairment. All agree that R60 has impairment on his right arm due to contractures and will correct the MDS assessment. Informed V1 and V2 that no restorative assessment/functional abilities was done for 2024 and 2025. Most recent quarterly restorative assessment done on 9/30/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 12 of 24 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 03/28/2025 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 0688 Facility's policy on Restorative Nursing program reviewed on 8/18/24 indicated: Level of Harm - Minimal harm or potential for actual harm Intent: It is policy of the facility to assist each resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance with State and Federal Regulations. Residents Affected - Few Procedure: 1. Each resident will be screened and or evaluated by the nurse designated to oversee the restorative nursing process for inclusion into the appropriate facility restorative nursing program when it has been identified by the interdisciplinary team that the resident is in need or may benefit from such program. 3. The facility restorative nursing program will include but not limited to the following programs: b. Mobility- transfer and ambulation, including walking, prosthetic and or splint application with or without active and or passive range of motion, bed mobility. 4. The above program will be documented on the facility designated restorative care forms/tools in the resident's electronic medical records. 6. The designated nurse will be responsible for the following: a. Obtaining orders for the resident's restorative program b. Documentation on a monthly basis (at a minimum) and c. Initiation and updating restorative care plans. 7. Once in an appropriate restorative program, the designated nurse will continue to monitor the resident's progress. 8. The designated nurse will evaluate the restorative documentation monthly to determine if there are any changes needed to the existing program and make a monthly progress note, in the resident's electronic medical record related to this evaluation. Facility's policy on Managing resident with impaired physical mobility reviewed 3/16/2023 indicated: Policy statement: Facility will provide care and management of physical mobility impairment based on cause and nature of deformity. Facility will provide programs to prevent contractures and or further decline. Guidelines: 1. Mobility assessment will be completed by nurse upon admission, quarterly and as necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 13 of 24 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 03/28/2025 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 0688 2. Treatment of contractures: Level of Harm - Minimal harm or potential for actual harm a. Treatment guidelines for contractures will depend on the cause of the deformity. The following may be utilized in general. Residents Affected - Few b. Restorative program based on assessment. b. Facility will develop a plan of care to assess the patient's level of functional mobility and ability to perform ADLs, assist the patient during exercises and when performing ADLs. 2. On 03/25/2025 at 11:10AM during unit rounds, R79 had contractures on both of his upper extremities, without any brace, splint or carrot on. On 03/26/2025 at 9:43AM during unit rounds with V13 (Restorative Nurse), R79 had contractures on both of his upper extremities, without any brace, splint or carrot on. On 03/27/2025 at 11:27AM during record review with V13, R79 did not have a restorative nursing assessment. On 03/27/2025 at 11:27AM during interview with V13, V13 stated R79's restorative nursing assessment should be done quarterly to capture any changes within the quarter. V13 stated that restorative nursing assessments are done upon admission, quarterly, significant change and annually. On 03/27/2025 at 12:45PM V2 (DON) stated that restorative nursing assessments are done upon admission, quarterly, significant change and annually. Review of R79's Order Summary Report dated 03/26/2025 indicated admission date of 06/06/2023 and diagnoses of not limited to left hand contracture, other sequelae of cerebral infarction and right elbow contracture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 14 of 24 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 03/28/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident's environment is free of accident hazards and failed to perform ongoing smoking assessments for a smoking resident for two of three residents (R46, R95) reviewed for accidents in a sample of 31. Findings include: 1. R46 is a [AGE] year-old female initially admitted in the facility on 03/03/2023 with diagnoses of not limited to Nicotine Dependence, cigarettes, and other seizures. R46's most recent smoking risk assessment was completed on 08/09/2024. On 03/27/2025 at 9:45AM during record review with V3 (Social Worker), R46's most recent smoking risk assessment was noted on 08/09/2024. On 03/27/2025 at 9:45AM during interview with V3 (Social Worker), V3 stated that R46's smoking risk assessment should have been completed quarterly and should have a smoking risk assessment on November 2024 and February 2025. V3 stated that smoking risk assessment is done to determine if the resident is still safe to smoke independently and to capture if there are any changes in their smoking behavior. On 03/27/2025 at 10:15AM during interview with V20 (Regional Director of Social Work), V20 stated that smoking risk assessment should be completed upon admission, quarterly, annually, and as needed. Review of R46's Minimum Data Set (MDS) Section J dated 02/21/2025 indicated R46 currently uses tobacco. 2. R95 is a [AGE] year-old male initially admitted in the facility on 04/20/2024 with diagnoses of not limited to Major Depressive Disorder and Bipolar Disorder. On 03/25/2025 at 10:58AM during unit rounds, R95 has a 2-socket extension cord with the socket head placed on top of the right side of the head of the bed and is connected to the wall outlet. The extension cord has 2 plugs plugged into it. On 03/26/2025 at 10:50AM during observation with V6 (Maintenance Director), R95 was again observed with a 2-socket extension cord with the socket head placed on top of the right side of the head of the bed and is connected to the wall outlet. The extension cord has 2 plugs plugged into it. On 03/26/2025 at 10:50AM during interview with V6, V6 stated that R95 should not have an extension cord at bedside and should have not placed it on top of the bed because it is a fire hazard. On 03/26/2025 at 11:40AM during interview with V1 (Administrator), V1 stated that extension cords are not allowed in the resident care areas. On 03/28/2025 at 10:40AM, V1 stated that all staff should be aware that extension cords are not allowed in the resident care areas, and should report any fire safety concerns to any department heads if the resident refuses to remove it. Review of facility policy entitled Fire Safety and Prevention dated 06/01/2024 indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 15 of 24 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 03/28/2025 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 0689 following: Level of Harm - Minimal harm or potential for actual harm Intent: It is the policy of the facility to provide care and services related to Fire Safety and Prevention in accordance to State and Federal regulation. All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. It is the policy of this facility that personnel will follow facility established fire safety precautions in order to provide safety to all concerned. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 16 of 24 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 03/28/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow physician oxygen orders for 1 of 2 residents (R141) reviewed for oxygen administration in a total sample of 31. Residents Affected - Few Findings Include: On 3/25/2025 at 10:30 AM, R141 is laying flat in bed with oxygen on per nasal cannula. R141 stated he likes to lay flat in the bed even with oxygen on. Oxygen concentrator positioned at bedside with a setting of 4 liters (L)/minute. On 3/25/2025 at 10:35 AM, V25 (Licensed Practical Nurse/Agency) checked R141's physician order and indicated Oxygen (02) @ 2 Liters/Minute per nasal cannula/mask. V25 proceeded to R141's room and adjusted oxygen concentrator setting from 4L to 2L. V25 stated R141 should be on 2L per physician order. On 3/26/2025 at 9:00 AM, V2 (Director of Nursing) said oxygen administration should be followed according to physician order and raised head of bed at least 30 degrees. Review of admission Record (date: 2/8/2025) Diagnosis Information include CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), UNSPECIFIED, CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE, DEPENDENCE ON SUPPLEMENTAL OXYGEN Review of Care Plan indicate Focus: COPD: Noted to have an active diagnosis of COPD and avoids lying flat due to shortness of breath. Oxygen is in use to assist with symptoms of COPD. Interventions: Administer oxygen as ordered. Elevate the head of bed to promote optimal breathing and comfort. Policy and Procedure: Oxygen Therapy, 1/24/2021 Policy: Oxygen therapy is the administration of a FiO2 greater than 21% by means of various administration devices to: Raise the resident's PaO2 to an acceptable baseline using the lowest FiO2. To treat arterial hypoxemia. To decrease work of breathing. To reverse and prevent tissue hypoxia, and or to decrease myocardial work. Procedure: 1. Review physician's order 11. Start O2 flowrate at the prescribed liter flow FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 17 of 24 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 03/28/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview and record review the facility failed to follow their medication storage facility policy for 2 of 6 residents (R115, R79) reviewed for medication labeling and storage. Findings include: 1. R79 physician order sheet shows orders for Xalatan ophthalmic solution 0.005% (latanoprost), instill one drop in both eyes at bedtime related to glaucoma, order start date 6/7/2023. On 3/26/25 at 11:46am during a survey tour of the medication cart on the (unit) assisted by V2 (Director of Nursing), medication latanoprost 0.005% noted with R79's name, the box had one date of 3/15/25. V2 stated that 3/15/25 was the open date for the eye drops, V2 said the eye drops should be labeled with a second date for expiration. V2 said eye drops expire 30 days after opening. 2. R115 physician order sheet shows orders for Lokelma oral packet 10 GM (grams), give one packet by mouth one time a day for hyperkalemia, order start date 5/2/2024. On 3/27/25 at 8:22am during medication administration observation with V31 (Licensed Practical Nurse-LPN), V31 prepared and administered medication Lokelma 10 grams for R115, there was not a pharmacy label noted on the clear package, there was no label with R115's name, there was no instructions noted for administration. V31 did not respond when asked if the medication should have a pharmacy label. Facility policy titled Medication Storage In The Facility dated November 2021 denotes in-part medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications. The provider pharmacy dispense medication in containers that meet the regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kelp in these containers. Nurses may not transfer medications from one container to another or return partially used medications to original container. Expiration dating (beyond-use date), expiration dates (beyond-use date) of dispense medication shall be determined by the pharmacist at the time of dispensing. Drugs dispensed in the manufactures original container will be labeled with manufactures expiration date. Certain medication or package types, such as IV solutions, multiple dose injections vials, certain ophthalmic (per manufactures specifications; example latanoprost) nitroglycerin tablets, blood sugar testing solutions and strips, once opened, requires an expiration date shorter than manufacture's expiration date to insure medication purity and potency. Facility policy titled medication ordering and receiving from pharmacy dated November 2021 denotes in part each prescription label includes, resident name, specific directions for use, including route of administration, medication name, strength of medication, prescriber's name, date dispensed, quantity of medication, beyond use date (or expiration) date of medication, name address of dispensing pharmacy, and prescription number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 18 of 24 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 03/28/2025 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 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 observation, interview and record review, the facility failed to safely handle foods for all 144 residents receiving food from the kitchen. The facility also failed to ensure resident refrigerators are clean and the temperatures are monitored for two of two residents (R23, R46) reviewed for food safety in a sample of 31. Findings include: 1. On 03/25/2025 at 10:15AM during initial kitchen tour with V8 (Food Service Director) and V21 (Regional Director of Operations), reach-in cooler had a gallon of 2% milk with sell date of 03/24/2025, and walk-in cooler had an opened, undated half gallon of orange juice and an open box of bagels with dates 12/04/2024 and 12/18/2024 written on it. On 03/25/2025 at 10:18AM during interview with V8, V8 stated that the gallon of 2% milk with sell date of 03/24/2025 should have been discarded, the half gallon of orange juice should have been dated when it was opened. On 03/25/2025 at 10:18AM during interview with V21, V21 stated that box of bagels was frozen when it was delivered and should be pulled out from the freezer to the cooler to thaw 48 hours before it has to be used so there should be a clear date when it was pulled out from the freezer to the cooler to know when the bagels should be used. Review of facility's policy entitled Food Storage (Dry, Refrigerated and Frozen) reviewed on 08/12/2023 indicated the following: Policy: Food storage areas will be clean, dry and maintained at temperatures as required to ensure food safety. Procedure: 7. Goods that have been opened with no date, left on the floor, or not properly sealed will be discarded. 8. All out-dated goods will be discarded the day after expiration. Refrigerated Foods c. Open products are sealed, labeled and dated. Review of facility's policy entitled Labeling and Dating Foods reviewed 07/30/2023 indicated the following: Policy: To decrease the risk of foodborne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 19 of 24 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 03/28/2025 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 0812 - Level of Harm - Minimal harm or potential for actual harm Packaged or containerized bulk food may be removed from the original package and stored in an ingredient bin labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by. Residents Affected - Many 2. On 03/25/2025 at 11:14AM during unit rounds, R23 had a personal refrigerator in the room without a temperature log. On 03/26/2025 at 9:48AM during observation with V24 (Licensed Practical Nurse), R23 had personal refrigerator in the room without a temperature log, and the food items include 3 undated glasses of milk, undated resealable bag of fries, undated mixture of food in a glass, and opened, undated package of pancakes. On 03/26/2025 at 9:48AM during interview with V24, V24 stated that night shift usually checks the resident's refrigerator temperature and should be cleaning it out too. V24 also stated that food items in the refrigerator should be dated. V24 stated that there should be a temperature log to record the temperature of the refrigerator daily. On 03/26/2025 at 10:25AM during interview with V8 (Food Service Director), V8 stated that the glass of milk comes from the kitchen, and it should not be kept in the residents' refrigerator. Review of R23's Order Summary Report dated 03/27/2025 indicated admission date of 05/03/2024 and diagnoses of not limited to Major Depressive Disorder, Chronic Kidney Disease Stage 3B, Heart failure and Mixed hyperlipidemia. 3. On 03/25/2025 at 11:15AM during unit rounds, R46 had personal refrigerator in the room without a temperature log. On 03/26/2025 at 9:49AM during observation with V24 (Licensed Practical Nurse), R46 had personal refrigerator in the room without a temperature log or thermometer inside the refrigerator. On 03/26/2025 at 9:48AM during interview with V24, V24 stated that night shift usually checks the resident's refrigerator temperature and should be cleaning it out too. V24 stated that there should be a thermometer and temperature log to record the temperature of the refrigerator daily. Review of R46's Order Summary Report dated 03/26/2025 indicated admission date of 07/21/2024, and diagnoses of not limited to nicotine dependence, cigarettes, and other seizures. Review of facility's policy entitled Food Storage reviewed on 12/30/2024 indicated the following: Policy Statement: To ensure safe and sanitary storage of food in compliance with Illinois Department of Public Health (IDPH) regulations and federal food safety guidelines while allowing residents to keep personal food in designated areas, including their personal refrigerators. Procedure: 1. General Food Storage Guidelines (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 20 of 24 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 03/28/2025 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 0812 - Refrigerators: at or below 41F (5C), Freezers: at or below 0F (-18C) Level of Harm - Minimal harm or potential for actual harm - Expiration dates must be checked weekly; expired food must be discarded. - Label all food with resident's name and date of storage Residents Affected - Many 2. Resident-Specific Food Storage (Resident Refrigerators) - Personal refrigerators must be checked at least weekly for safety. - All food must be labeled with the resident's name and storage date. - Perishable food must be discarded within 3 days unless frozen. - Staff must check resident refrigerator temperatures weekly. 3. Enforcement & Compliance - Regular weekly inspections will be conducted by staff. - Spolied, expired, or improperly stored food will be discarded immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 21 of 24 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 03/28/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to grant the resident or his or her representative the right to rescind the arbitration agreement within 30 calendar days of signing it. This failure affected three (R7, R37, R67) out of three residents reviewed for arbitration agreement in the sample of 31. Residents Affected - Few Findings include: On 03/27/25 at 10:30 AM, V4 (Business Office Manager), said that all residents are offered arbitration upon admission. Surveyor reviewed the facility arbitration agreement with V4. V4 said that according to the facility arbitration agreement in section five, residents may cancel the agreement within seven (7) days. V4 said that after seven days, the agreement becomes binding. Review of the signed arbitration agreement by R7, R37 and R67 indicated that on section five: right of cancellation, these residents were only granted the right to rescind the agreement only within seven (7) days instead of 30 calendar days. R7 is a [AGE] year old male admitted on [DATE] with diagnosis not limited to Parkinson's disease, asthma, type 2 diabetes, and primary hypertension. R37 is a [AGE] year old male admitted on [DATE] with diagnosis not limited to vascular dementia, anxiety, major depression, and primary hypertension. R67 is an [AGE] year old female with original admission date of 12/15/2017 and diagnosis not limited to primary generalized osteoarthritis, vascular dementia, psychotic disturbance, mood disturbance, anxiety and primary hypertension. Policy: Health Care Arbitration Agreement Section Five. Right of Cancellation The health care arbitration agreement may be canceled by any signatory within seven (7) days of its execution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 22 of 24 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 03/28/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure most recent hospice plan of care specific to each resident is available and accessible to facility's staff for collaborated and coordinated care. This deficiency affects three (R24, R82 and R117) residents in the sample of 31, reviewed for Hospice care services. Findings include: On 3/25/25 at 10:15AM, V14 Registered Nurse (RN) said that R24, R82 and R117 are on hospice care. On 3/25/25 at 10:48AM, V10 (Nursing Supervisor/Infection Preventionist) said that hospice services provided hospice residents with binders for all their documentation. Reviewed R117's hospice folder. Observed hospice initial comprehensive admission assessment dated [DATE] in chart. No admission Plan of care (POC) upon admission and no updated POC. V10 said that Social Services is the one responsible for coordination with hospice care. Reviewed R82 and R24 hospice medical records with V10. R82's hospice service binder indicated Plan of care (POC) start of care 2/26/24 for certification period 8/24/24 to 10/22/24. R24's hospice service binder indicated start of care on 11/21/23 with certification period from 7/17/24 to 9/15/24. Both residents do not have updated POC in their hospice binders. On 3/25/25 at 11:09AM, V3 Social Service Director (SSD) said that she is in charge for coordinating hospice care between residents in the facility and hospice services. V3 said that hospice services have their own binder/folder for each resident. Hospice staff is responsible to provide the facility with the resident's plan of care and other hospice documents in binders. V3 said that she did not do audits or check if the hospice documentation was updated or if a plan of care was placed in the chart. Informed V3 that all three residents do not have updated hospice service POC. On 3/27/25 at 12:19PM, V2 Director of Nursing (DON) said that the social service is responsible to make sure that hospice services documentation such as updated plan of care (POC) and other documents are in placed in resident's hospice chart/binder. R117 is admitted on [DATE] with diagnosis listed din part but not limited to Palliative Care, Osteomyelitis, Human Immunodeficiency Virus disease, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease. Physician order sheet indicated she was admitted to hospice care on 3/25/24. Hospice service binder indicated the RN's initial comprehensive assessment was dated 3/22/24. No initial plan of care or recent updated plan of care is found. Comprehensive assessment indicated that he has a terminal prognosis, in hospice care. Intervention: work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. R82 is re-admitted on [DATE] with diagnosis listed in part but not limited to Palliative care, Polyarthritis, Dementia, Alzheimer's disease, Paroxysmal atrial fibrillation, Falls, Pacemaker. Physician order sheet indicated consult to hospice care dated 2/22/24. 3/25/25 indicated consult hospice and treat. Comprehensive care plan indicated she is enrolled in hospice. Intervention: Coordinate care and services between facility care givers and hospice company to ensure all resident needs are met. Hospice services binder indicated Plan of care (POC) start of care 2/26/24 with certification period 8/24/24 to 10/22/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 23 of 24 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 03/28/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R24 is admitted on [DATE] with diagnosis listed in part but not limited to Palliative care, adult failure thrives, Dementia, Age-related osteoporosis, Protein calorie deficit, Peripheral vascular disease. Physician order sheet indicated admit to hospice care dated 11/21/23. Comprehensive care plan indicated he has terminal prognosis and on hospice care. Intervention: Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physician and social needs are met. Hospice service binder indicated start of care on 11/21/23 with certification period from 7/17/24 to 9/15/24. Facility's policy on Hospice Program reviewed on 6/5/2024 indicated: Policy statement: The facility will make Hospice services available to residents at the end of life. Procedure: 7. It is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions including: a. Determining the appropriate hospice plan of care 10. Facility designates our Social Service Director/coordinator to coordinate care provided to the resident by our facility staff and the hospice staff. Responsibilities include: d. Obtaining the following information from the hospice: * Most recent hospice plan of care specific to each resident 12. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145946 If continuation sheet Page 24 of 24