Inspection·July 10, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a functional sanitary environment for one (R1) of three residents reviewed functional and comfortable environment. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: diabetes, congested heart failure, atrial fibrillation, hypertension, acute kidney disease, osteomyelitis, right leg amputated on 10/7/2024 and left leg amputated on 2/22/2025. On the (MDS) Minimal data Set assessment of 5/1/2025 section C the BIMS (Brief Interviewed Mental Status) score was 15/15 and indicates cognitive intact. On MDS of 5/1/2025 GG section R1 can wheel 50 feet with two turns: Once seated in a wheelchair/scooter, the ability to wheel at least 50 feet and make two turns with Partial/moderate assistance. On 7/8/2025 at 2:41 PM, R1 said, my bathroom sink has been leaking for two weeks and staff placed a gray bucket under the sick because it was leaking on the floor. I notified the staff to call maintenance to get it fixed, but nothing was done. I cannot remember who I had notified. R1 accompanied the surveyor to the room. A gray bucket was ½ full of dirty water under the sink was observed. When the faucet is opened and the water is running, a few drips are observed dripping into the gray bucket under the sink. On 7/8/2025 at 3:43 PM, I asked V5 (Wound Care Nurse) to walk to R1's room to check the sink when V6 (Maintenance Director) was already in the room and started to fix the sink. V6 said, that once I get notified of anything that is not working or broken, I usually can fix it right away. I was just notified that the sink was leaking, and I am fixing it now. On 7/8/2025 at 4:38 PM V1 (Administrator)said, I was not notified of the sink leaking until today and staff can add a work order online and the maintenance director checks it daily and can fix broken equipment or leakages like the sink. I do not know why the staff did not report it. On 7/9/2025 at 2:30 PM V2 (Director of Nursing) said, I was not aware that R1's sink was leaking for two weeks, staff can add a work order for V6 (Maintenance Director) to fix. I will provide education for the staff to add work orders as soon as they are aware of anything requiring repair. On 7/9/2025 at 2:03 PM V1(Administrator) provided a policy titled, Work Orders, Maintenance review date 6/1/2025. Which reads in part (but not limited to): (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: 145946 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 07/10/2025 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)