Health inspection·January 18, 2026

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a thorough and credible investigation was conducted for 1 of 3 residents (R1) reviewed for abuse. Specifically, the facility's investigative process failed to: 1) Reconcile conflicting evidence between a staff member's motive and the resident's initial allegation of being 'hit'; 2) Include critical witness testimony from the first clinician on the scene (V4 Agency RN) in reports provided to law enforcement; 3) Conduct a clinical review to assess the feasibility of a catastrophic orbital globe rupture and depressed fracture being caused by a minor 'accidental' strike; and 4) Factor the resident's Mild Alzheimer's and high-risk use of Eliquis into the evaluation of the incident and subsequent 'recantation.' As a result of this incomplete investigative process, the facility provided a medically implausible and incomplete narrative to law enforcement, which contributed to the premature closure of an abuse investigation into a life-altering injury. Review of the facility's undated policy titled Abuse Prevention Training Program, stated in part but not limited to: Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. The policy further states that Abuse is most likely to happen in situations that result in frustration, annoyance, and anger, and directs staff to manage these situations with self-control and to remove themselves from the situation when in doubt. Residents Affected - Few Review of the facility's final investigative file regarding the incident on 11/08/25 revealed that the facility neglected to document or include critical testimony and clinical evidence: During an interview on 01/16/26 at 11:55 AM, V4 Agency RN stated he was the first clinician on the scene and documented R1's immediate allegation that the CNA hit me. V4 also observed the CNA's agitated state and perceived anger toward R1 over a broken necklace as a possible motive. V4 stated he reported these findings to the Administrator and management, yet the facility's formal report to Law Enforcement did not include these observations and the fact that a staff member had reported the incident as an assault via a 911 call. The facility concluded R1's injury was accidental, suggesting the resident's eye was struck by the resident himself and did not include the possibility that the necklace chain or pendent may have been the contributing blunt object. Review of the hospital discharge summary confirmed a depressed orbital floor fracture and left orbital globe rupture requiring emergent surgical intervention. There was no evidence the facility consulted a medical professional to determine if a swinging pendant or a self-inflicted blow from an elderly resident with Mild Alzheimer's could generate the force required to fracture the bony orbit. (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 01/18/2026 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)