Inspection·February 27, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm the slippers could containment things. V2 stated that offering and assisting R12 into stool-stained slippers and not having them washed is considered a dignity issue. The facility's Resident Rights policy dated January 17, 2025 showed the following: procedure: 9. Each resident will be treated with dignity and respect. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 2 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the dining room in a sanitary condition during meal service and failed to clean a resident room. This applies to 8 of 18 residents (R1, R7, R12, R27, R51, R58, R125 and R126) reviewed for environment in the sample of 18. The findings include: 1. On February 25, 2025 at 8:40 AM, V9 (Restorative Aide) was seen taking breakfast meal trays from a free standing cart in the small dining room that served residents that needed supervision or assistance. V9 set up each tray before handing it out to the residents. The dining room tables appeared very dirty with smears of unknown substance and crumbs/debris on it. The floor also was littered with covers of the straws, bits and pieces of paper and food crumbs. R1 was seen seated in a wheelchair wiping the soiled table she was seated at with a disposable wipe. Other residents in the dining room included R7, R27, R51, R58, R125 and R126 who were seated at tables that were soiled with above mentioned unknown smears and debris. R7 and R125 had already started eating as they were served their breakfast trays by V9. V9 was notified that the meal tables were unsanitary and V9 stated that she will clean the same before passing out the trays to the other residents in the dining room. On February 25, 2025 at 1:35 PM, V12 (Housekeeper) stated that he usually cleans the dining room after meals. When asked if the dining room has been cleaned the night before after the dinner meal, V12 stated We were running low [on housekeeping staff]. On February 26, 2025 at 01:56 PM, V1 (Administrator) stated that the facility does not have a policy related to cleaning general areas. On February 26, 2025 at 3:46 PM, V21 (Maintenance Director) stated that after the meal, the meal tables are supposed to be cleaned by kitchen staff and the floor by housekeeping. V21 stated that when this was brought to his notice today, he discussed the matter with V4 (Regional Dietary Director) and was told that some staff were not aware of the same. 2. R12's Face Sheet showed R12 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation, abdominal aortic aneurysm without rupture, Partial intestinal obstruction, Ileostomy Status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. R12's Minimum Data Set, dated [DATE] showed R12 was cognitively intact. On February 24, 2025 at 10:32 AM, at the bottom of R12's bed, there a white blanket that had brown stains on it. There was also garbage, miscellaneous pieces of crumbled napkins and paper, smears of a sticky substance, and crumbs on the floor. R12 stated they do not clean he room on the weekends and she has not had her floor cleaned since last week. On February 25, 2025 at 1:52 PM, R12 stated the floor still has not been mopped or cleaned. The same stains were on the floor and more balled up tissue and a towel was on the floor. On February 25, 2025 at 1:54 PM, V24 (Housekeeper) stated she had cleaned all the rooms except R12's room, but she was going to clean R12's room now. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 3 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On February 25, 2025 at 3:39 PM, R12's room had the same garbage and sticky smears on the floor, in addition more was under the resident's bed and on the floor. On February 25, 2025 at 3:43 PM, V21 (Housekeeping Director) went to R12's room and looked at the dirty floor, with all the same tissues, salt packet, crumbs, and garbage on the floor. Surveyor mentioned to V21 that the housekeeper said she would clean the room yesterday, but it had not been done. V21 stated that V24 works 7-3 PM and will be working double duty today because another housekeeper called off. Surveyor informed V21 that stool was spilled on the floor yesterday. V21 stated R12's room should have been cleaned and if stool had spilled on the floor, then the floor should have been mopped and disinfected. On February 26, 2024 at 9:57 AM, R12's floor still had not been cleaned and had the same sticky smear and trash on it. On February 26, 2024 at 10:16 AM, surveyor asked V21 why the room was not cleaned yet. In the evening, they only have housekeepers that does the laundry. V21 stated the housekeepers that mop the floors are only at the facility from 7-3 PM, so that is why the rooms are just now getting cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 4 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide grooming and hygiene for residents who requires assistance with Activities of Daily Living (ADL) care. This applies to 5 of 18 residents (R12, R41, R51, R125, and R225) reviewed for ADL care in the sample of 18. Residents Affected - Some The findings include: 1. Face sheet shows that R51 is 92 years-old who has multiple medical diagnoses which include dementia and legal blindness. R51's Minimum Data Set (MDS) dated [DATE], shows that she is cognitively impaired and requires substantial/maximal assistance for grooming and hygiene. On February 24, 2025, at 11:21 AM, R51 was sitting in the dayroom, staring in space. R51 displays long jagged fingernails with black/brown substance underneath. 2. Face sheet shows that R125 is 89 years-old has multiple medical diagnoses which include dementia, malignant neoplasm of prostate, and secondary malignant neoplasm of bone. R125's MDS dated [DATE], shows that he is cognitively impaired and requires substantial/maximal assistance for grooming and hygiene. On February 24, 2025, at 11:20 AM, R125 was in the dining room sitting in his wheelchair hunched forward sleeping, with uncombed/unkempt hair, and he displayed black/brown substances underneath the fingernails and brownish to yellowish discoloration on the nail beds. On February 26, 2025, at 3:55 PM, V22 (Certified Nursing Assistant/CNA) stated that R51 and R125 are cooperative during provisions of care. Though R125 is a little bit more confused, all they had to do was explain the procedure to him and he readily cooperates. 3. R41 Face sheet shows that R41 is 70 years-old who has multiple medical diagnoses which include abnormal gait and mobility. R41's MDS dated [DATE], shows that he requires assistance for grooming and hygiene. On February 25, 2025, at 1:25 PM, R41 was sitting in his wheelchair drooling, with his drool resting on his beard. R41 displayed long unkempt/untidy facial hair and jagged fingernails with black/brown substances underneath, and brownish/yellowish discoloration on the nail beds. V19 and V20 (both CNAs) assisted R41 back to bed and provided peri-care. At 1:25 PM, when surveyor asked, R41 stated that he wanted his facial hair trimmed and nail care done. After the peri-care was completed, V19 and V20 left the bedroom without offering to provide facial hair care and nail care. On February 26, 2025, at 3:58 PM, V2 (Director of Nursing/DON) stated that ADL care is to be provide as scheduled and as needed which include provisions of peri-care, nail, oral, and facial hair care, to ensure comfort and dignity for residents. 4. R12's Face Sheet showed R12 was admitted to the facility on [DATE], with diagnoses that include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 5 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 Level of Harm - Minimal harm or potential for actual harm chronic obstructive pulmonary disease with acute exacerbation, abdominal aortic aneurysm without rupture, Partial intestinal obstruction, Ileostomy Status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. R12's Minimum Data Set, dated [DATE], showed R12 was cognitively intact. Residents Affected - Some On February 24, 2025 at 10:42 AM, V18 (Licensed Practical Nurse/LPN) changed R12's ileostomy appliance and applied the belt around R12's back that was wet with stool. After attaching the belt, V18 stated the ileostomy was leaking again already and it was open on the top right. V18 then reinforced it with some white cloth tape. V18 stated she would send the (CNA) to help R12 get cleaned up. On February 24, 2025 at 11:07 AM V19 (CNA) entered R12's room and told her she would help her get cleaned up. R12 brought with her a gown and sheets. V19 helped R12 into a clean gown and removed the one that was soiled with brown stains on the inside of the gown. R12's right side of her back and the bed was still wet with what R12 said was stool from her leaking ileostomy bag. V19 did not clean her skin. V19 then picked up R12's slippers (Beige teddy bear material) that had dried brown and black rounds stains on the tops of them and offered them to R1. V19 then then pulled up the elastic waist of R12's incontinence pull-up brief. A brown smear could now be seen on the top right of the incontinence pull up brief. R12 said to V19, can you put something in the chair so that I don't screw up the chair. Once R12 was out of the bed, R12's back was wet and a large wet and brown area about 14 inches in diameter could be seen on the fitted sheet. R12's back was visibly wet. V19 removed the sheets and made the bed with clean linens, R12 did not wash R12's skin nor the bed. V19 also did not offer or change R12's incontinence brief that was wet in the back with brown stain on it. At 11:25 AM, V19 said she was done and left the room. R12 stated she asked for the staff to change her earlier, but they couldn't. R12 stated they don't usually wash her skin after stool spills on her, they just change her clothes. R12 stated she waited so long for someone to help her this morning to go to the restroom and no one came, so she grabbed the garbage can and peed in it. 5. R225's Face Sheet showed R225 was admitted to the facility on [DATE] with diagnoses that include aftercare following joint replacement surgery, presence of right artificial knee joint, and chronic obstructive pulmonary disease. R225's Minimum Data Set, dated [DATE] showed R225 was cognitively intact. On February 24, 2025 at 9:56 AM, R225 stated he has only been offered a shower once at the facility and the last shower he had was a couple weeks ago. R225 skin on his face was dry and there were sheets of dry skin on his forehead. R225 had on a black shirt, and it was filled with white flakes of skin. R225's hair looked greasy, and his beard was long. R225 stated he should be getting showers twice per week. R225 stated he would like a shower. On February 25, 2025 at 1:41 PM, V20 (CNA) stated that residents are offered showers twice per week. V19 showed surveyor the shower schedule that showed R225 showers are on Monday and Thursday mornings. V19 (CNA) stated she has not offered R225 a shower yesterday or today. V20 stated she thought R225 had an appointment at 9:30 AM yesterday. Surveyor mentioned he didn't go anywhere and asked if V20 had asked R225 later on during the day if he wanted a shower. V20 stated I didn't ask him because I was overwhelmed. I take accountability for that. V20 then stated she had 3 other people to help with showers that day. On February 25, 2025 at 3:00 PM, V2 (DON) stated residents are offered showers on their shower day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 6 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and if they refuse that morning they are offered a shower later in the same day and as needed. V2 stated staff should document each time a shower is offered or refused. At 3:15 PM, V2 said according to V20 she did offer R225 a shower in the morning of February 24, 2025 and R225 refused. On February 25, 2025 at 4:08 PM, R225 stated no one still has not offered him a shower. R225 stated no one had offered him a shower on the days of his appointment either (2/17/25, 2/20/25, and 2/24/25). R225 stated no one had asked him if he wanted a shower and he did not go anywhere yesterday. R225 was wearing the same black shirt he had on yesterday that was covered with white flakes of skin, he was unshaven, and his face was still flaky. On February 26, 2025 at 10:05 AM with V2 (DON) present, R225 stated no one has asked him if he would like to shower since he had his last shower 2 weeks ago. R225 stated, he needed a shower and wanted a shower today. R225 was still wearing the same black shirt he has had on for 3 days with white flakes of skin on it. R225 face was still flaking, and his hair still looked oily. Surveyor and V2 left R225's room and V2 stated she did not ask R225 yesterday or today if he wanted a shower. V2 stated maybe V18 (LPN) did. At that moment, V18 approached and V18 stated she did not ask R225 yesterday or today if he wanted a shower. R225's Care ADL care plan dated 2/11/25 and revised on 2/15/2024 showed the following: R225 has an ADL self-care performance deficit, and he requires 1 assist with bathing and hygiene. The facility's electronic medical record shower sheet for R225 showed he received one shower since he had been in the facility. The facility did not produce any other shower sheets by the end of the survey. The facility's Supporting Activities of Daily Living (ADL) policy dated 12/5/2024 showed the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 7 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the indwelling urinary catheters of residents were secured, and the urinary bag was not resting on the floor. This applies to 3 of 6 residents (R11, R41, and R57) reviewed for indwelling urinary catheters in the sample of 18. The findings include: 1. Face sheet shows, R57 is 66 years-old who has multiple medical diagnoses including chronic kidney disease, stage 3B, urethral stricture, male, unspecified site, obstructive and reflux uropathy, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, presence of urogenital implants. R57's Minimum Data Set (MDS) dated [DATE], shows, R57 is alert and oriented and requires assistance for toileting. R57's Care Plan with revision date of February 11, 2025, shows: R57 has chronic indwelling catheter related to BPH and urethral stricture. The goal is for R57 to be free from complications related to the use of catheter. The same care plan shows multiple interventions which include Retention Strap in place to assist in maintaining catheter tubing alignment as tolerated. On February 24, 2025, at 11:06 AM, during initial rounds with V23 (Certified Nursing Assistant/CNA), R57 was resting in bed. R57's had an indwelling urinary catheter that was not anchored or secured to his thigh. R57 stated that his catheter tube has been unsecured for a while now but was unable to tell how long. There was no sign of anchor or retention strap on the tube or on his thighs. On February 25, 2025, at 1:40 PM, R57's indwelling urinary catheter remained unsecured, with the urinary catheter bag resting directly on the floor. 2. Face sheets shows, R41 is 70 years-old who has multiple medical diagnoses including infection and inflammatory reaction due to indwelling urethral catheter, and obstructive and reflux uropathy, unspecified. R41's MDS dated [DATE], shows that R41 requires assistance for toileting. R41's Care Plan which has a target date of April 14, 2025, shows: R41 has indwelling urinary catheter due to urinary retention related to uropathy. The same care plan shows that R41 has two prior hospitalizations in 2024, due to gross hematuria, urinary tract infection (UTI), end stage bladder, bladder fungus ball and sepsis. On February 25, 2025, at 1:17 PM, V19 and V20 (both CNAs) assisted resident back to bed for peri-care. R41 had an indwelling urinary catheter which was not secured. The catheter tubing was pulling while R41 was being repositioned or when care was being provided. There was no sign of anchor or strap on R41's catheter tubing or on his thighs. 3. Face sheet shows, R11 is 70 years-old who has multiple medical diagnoses including benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, chronic kidney disease stage 4, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 8 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 neuromuscular dysfunction of bladder, and unspecified hydronephrosis. Level of Harm - Minimal harm or potential for actual harm R11's Care Plan with a target date of March 7, 2025, shows R11 has suprapubic catheter related to sacral wounds and recurrent UTI. The goal is to be free from complications related to use of catheter. Residents Affected - Few On February 25, 2025, at 1:32 PM, R11 was sleeping in his bed. Upon assessment of R11's indwelling (suprapubic) catheter with V18 (Licensed Practical Nurse), it was observed that R11's catheter tube was detached from the anchor, leaving the tube unsecured. On February 26, 2025, at 3:19 PM, V2 (Director of Nursing) stated that the resident's indwelling urinary catheter must be always secured to prevent from getting pulled and being dislodge. V2 added, the catheter bag must be always off the floor to prevent infection. Facility's Policy for Perineal Care/Indwelling Catheter Care dated 11/1/2018 shows: 7. Ensure Foley Catheter is positioned correctly and secured. and 10. Ensure the bag is off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 9 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0694 Provide for the safe, appropriate administration of IV fluids 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's order for management of Peripherally Inserted Central Catheter (PICC) line. This applies to 1 of 2 residents (R57) reviewed for care of intravenous catheter in the sample of 18. Residents Affected - Few The findings include: On February 25, 2025, at 9:37 AM, V15 (Registered Nurse) administered an IV (Intravenous) antibiotic (Ceftriaxone 2 grams) medication to R57 who had a PICC line on his right upper arm. The PICC line dressing, which was dated February 3, 2025, was loose and opened halfway. Physician Order Summary (POS) Report dated February 9, 2025, shows PICC line dressing change once a week and as needed one time a day every 7 days for infection prevention. R57's care plan with revision dated of February 11, 2025, shows R57 has PICC line on the right basilic for IV antibiotic infusion. The goal is for the PICC line to remain free from signs of infection. This same care plan shows multiple interventions which include to change dressing weekly, or sooner, if it is soiled, loose, or damp. Use sterile aseptic technique when changing the dressing. On February 25, 2025, at 12:06 PM, V15 provided dressing change to R57's PICC line. V15 stated that the dressing must be change every 7 days and as needed. V15 confirmed that the dressing was dated 2/3/25. V15 changed the dressing, however, V15 did not measure the length of the catheter and arm circumference. On February 26, 2025, at 3:12 PM, V2 (Director of Nursing) stated, when staff are changing the PICC line dressing, the staff must measure the length of the catheter to check for migration of catheter and measure arm circumference, to check for swelling. V2 also stated PICC line dressing must be change every 7 days and as needed to prevent infection. V2 further stated the staff must ensure that dressing is always intact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 10 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have a physician order and care plan for oxygen administration in accordance with their policy. Residents Affected - Few This applies to 1 of 1 resident (R325) reviewed for oxygen use in the sample of 18. The findings include: R325 was admitted to the facility on [DATE], with multiple diagnosis including chronic obstructive pulmonary disease, dependence on oxygen, chronic respiratory failure with hypoxia, centrilobular emphysema, influenza A, and cyst of the pancreas. On February 24, 2025, at 12:10 PM, R325 was observed with oxygen infusing via nasal cannula. R325's Health Status note dated February 24, 2025, at 11:12 PM showed continuous oxygen was administered at 3L (Liters) per NC (Nasal Cannula). On February 26, 2025, at 10:10 AM, R325 was observed with oxygen infusing via nasal cannula. V15 (RN/registered Nurse) stated the oxygen was infusing at 3L per NC and R325 can have 4L per NC if R325 gets anxious. R325's hospital H&P (History and Physical) dated February 16, 2025, showed under history of present illness R325 baseline oxygen use at 2L per NC continuously. R325's physician order summary dated February 23, 2025, through February 25, 2025, showed there was no order for oxygen administration. R325's care plan initiated on February 26, 2025, for the problem of shortness of breath, had no specified settings for the use of oxygen in the care plan interventions. On February 26, 2025, V2 (DON/Director of Nursing) provided a list of all residents in the facility who utilize oxygen and R325 was not identified on that list. On February 26, 2025, at 4:30 PM, V2 stated there should be physician orders to administer oxygen and the order should include the amount of liter flow and method of delivery. The Facility's policy titled Oxygen, dated April 2024, showed Policy Statement .it is the facility's policy to ensure that oxygen .use is compliant with acceptable standards of practice .Procedures .4 .Physician's order will be obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 11 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to provide lunch meal options of similar nutritive value and failed to accommodate a resident's dietary intolerances. Residents Affected - Some This applies to 4 of 4 (R35, R43, R58, R59) residents reviewed for dining in the sample of 18. The findings include: 1. Facility daily production sheet for February 24, 2025 lunch meal included Italian Herb chicken (3 oz/ounce), buttered noodles (4 oz), Brussels sprouts (4 oz) dinner roll, and cake of the day. On February 24 at 12:22 PM, V6 (Chef) was seen making a grilled cheese sandwich with 2 slices of bread and 2 slices of cheese for R58 whose tray card showed a diet order of Vegetarian diet. R58 received the same with a 4 oz portion each of noodles and Brussels sprouts and a side of cake for dessert. V10 (Cook) who was on the tray line, stated that R58 gets grilled cheese every day. Facility daily production sheet for February 25, 2025 lunch meal included pork fried rice (8 oz), oriental vegetables, dinner roll, tropical fruit mix. Facility provided information that each 8 oz serving of pork fried rice contained 3 oz of pork. On February 25, 2025 at 12:11 PM, R35 received a grilled cheese sandwich made with 2 slices of cheese. R43 also received a grilled cheese sandwich and V10 stated that she put 4 slices of cheese in the sandwich. V10 stated that R35 and R43 received the same as their diets are no pork. On February 26, 2025 at 9:19 AM, V4 (Regional Dietary Director) stated that the facility uses American cheese to make grilled cheese sandwiches. Nutrition facts on the label for cheese slices used for grilled cheese sandwich showed 4 grams of protein for 2 slices of cheese. On February 26, 2025 at 11:51 AM, V15 (Dietitian) stated that 1 oz of meat =7 grams of protein and therefore a 3 oz portion of pork/chicken = 21 grams of protein. V15 stated that as 2 slices of cheese contained only 4 grams of protein, the facility should consider adding other items like cottage cheese when serving grilled cheese sandwich. Facility policy titled Menu Alternates(revised May 31, 2021) included as follows: Policy: Nutritionally comparable menu items shall be available to accommodate resident food preference. 2. R59's diet order on POS (Physician Order Sheet) showed GLUTEN RESTRICTED diet, Regular texture, Regular (Thin) consistency. On February 24, 2025 at 1:03 PM, R59 stated that she did not receive a lunch meal tray. This was relayed to V7 (Registered Nurse) who went and got a tray from a meal cart and delivered the tray without a meal ticket. The lunch meal consisted of Italian fried chicken, noodles, Brussels sprouts, dinner roll and cake. When asked where the meal ticket was, V7 stated that R59 told her that she is on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 12 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0806 Level of Harm - Minimal harm or potential for actual harm regular diet. R59's meal ticket was located crumpled up in the meal cart and showed Regular, Gluten free. Next to the items noodles, dinner roll and cake listed on meal ticket it showed no sub (substitute) found. On returning to the room, R59 was in tears and pointing to the noodles, dinner roll and cake, stated I cannot eat all this. I am going to get a stomachache. I am always getting a stomachache as they serve me foods I am not supposed to eat, which I eat as I am hungry. I can't keep buying my own foods. Residents Affected - Some On February 24, 2025 at 1:14 PM, V5 (Dietary Manager) was notified and V5 stated that R59 should not have got the above items with gluten and should have got gluten free items instead. On February 26, 2025 at 11:16 AM, V15 (Dietitian) stated that the facility should serve R56 the diet as shown on the diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 13 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide high calorie nutrition supplement as ordered by the Physician. This applies to 4 of 4 residents (R19, R27, R20 and R326) reviewed for supplements in the sample of 18. The findings include: 1. R19's face sheet included quadriplegia, other acute osteomyelitis, left femur, dysphagia, unspecified. R19's quarterly MDS dated [DATE] showed that R19 was cognitively intact and was dependent on staff for eating. R19's diet order on POS (Physician Order Sheet) included General diet, Regular texture, Regular (Thin) consistency, High Calorie Drink four times a day for (Brand Name) Plus High Protein with meals and at bedtime (start date October 11, 2024). On February 24, 2025 at 11:00 AM, R19 was lying in bed watching television with head propped up on a pillow. R19 stated that he is unable to use arms as both were contracted. Stated that he is fed by staff, regular consistency food and did not get any (Brand Name) nutrition supplement for breakfast. Multiple cans of (Brand Name) nutrition supplement was seen on a chair in a corner of R19's room. On February 24, 2025 at 1:12 PM, R19 was fed by V11 (Certified Nursing Assistant/CNA) in his room and no High Calorie Drink was seen with meal tray. On February 24, 2025 at 3:13 PM, V7 (Registered Nurse/RN) stated that she gave R19 one can of (Brand Name) earlier and that R19 took a few sips. When R19 was asked again if he received any (Brand Name) supplement from V7, R19 emphatically stated that he did not get any and stated When? R19 glanced towards the box containing (Brand Name) supplements placed on the chair and added They are still there. On February 25, 2025 at 8:56 AM, R19 was fed breakfast in his room by V11 and no High Calorie Drink was seen with breakfast meal. V11 stated that he fed R19 breakfast on February 24, 2025 and R19 did not get (Brand Name). 2. R20's face sheet showed unspecified Dementia, unspecified severity, with other behavioral disturbance, senile degeneration of brain, gastro-esophageal reflux without esophagitis. R20's diet order on POS included Regular diet, Regular texture, Regular (Thin) consistency High Calorie Drink (Brand Name) one time a day Give 237 ml/milliliter (start date February 10, 2025). On February 24, 2025 at 12:57 PM, R20 was served Regular meal in the dining room. Staff provided a grilled cheese sandwich as R20 refused the meal but R20 did not receive a High Calorie Drink. On February 24, 2025 at 9:02 AM, R20 was served breakfast tray in the dining room which she did not eat, but R20 did not receive a High Calorie Drink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 14 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0808 Level of Harm - Minimal harm or potential for actual harm On February 25, 2025 at 12:55 PM, R20 was seen wheeling self away from her table with her lunch meal untouched and it did not include a High Calorie Drink. 3. R27's diet on POS included General diet, Pureed texture, Nectar consistency, High Calorie Drink (Brand Name) two times a day 237 ml (Brand Name) (start date February 18, 2025). Residents Affected - Some On February 24, 2025 at 1:00 PM, R27 received a pureed meal at lunch and was fed in dining room by V8 (Restorative Aide). R27 did not receive a High Calorie Drink with his meal. On February 25, 2025 at 8:49 AM, R27 received a pureed meal at breakfast with nectar thick liquids and was fed in dining room by V9 (Restorative Aide). R27 did not receive a High Calorie Drink with his meal. On February 25, 2025 at 12:57 PM, R27 had finished eating lunch and V9 stated that she fed him a pureed meal and that R27 did not get a high calorie supplement. R27's meal tray checked and verified the same. On February 24, 2025 at 3:13 PM, when asked why R20 and R27 did not receive (Brand Name) supplement during days observed, V7 (RN) stated that only R19 has a stock of (Brand Name) supplement in his room that is provided by family. V7 stated that the facility does not have any (Brand Name) supplement currently as the orders were changed from medication pass supplement to (Brand Name) recently. V7 stated that the facility used to have a box of medication pass supplement before but currently have none. V7 went into the medication storage room to verify and stated that there is no High Calorie Drink in there. On February 26, 2025 at 11:08 AM, V14 (Dietitian) stated that she recommends High Calorie Drink to those residents who have inadequate intake, poor appetite and/or weight loss. V14 stated that she was made aware by email on February 10, 2025 that the facility was switching over from the previous nutrition supplement given at medication pass to (Brand Name). V14 added that the switch took over last week (unknown date). 4. The EMR (Electronic Medical Record) showed R326 was admitted to the facility on [DATE], with multiple diagnoses including stroke, type 2 diabetes mellitus, heart failure, and chronic kidney disease. On February 25, 2025, at 8:36 AM, V15 (RN) said R326 is to receive a diabetic high-calorie protein drink, but the facility does not have any. V15 did not administer a diabetic high-calorie drink to R326. R326's Order Summary Report dated February 26, 2025, showed an order dated February 17, 2025, for Diabetic [High-Calorie Protein Drink], one time a day 237 mL (milliliters). On February 26, 2025, at 8:46 AM, V15 documented R326's high-calorie protein drink was not given due On order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 15 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 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 follow sanitary practices in the facility kitchen. This applies to 74 residents that received foods prepared in the facility kitchen. Residents Affected - Many The findings include: Facility's CMS Form 671 dated February 24, 2025 showed that the facility census was 76 residents. Facility provided information that there were 2 residents on NPO (nothing by mouth). On February 24 at 9:15 AM, during initial tour of the facility kitchen, the following observations were made. At the side of the ice machine there was a plastic scoop placed inverted (scoop handle up) in a plastic scoop holder that was attached to the wall. Inside the bottom of the scoop holder there was some pooled water with blackish substances that was touching the inverted top of the scoop. V5 (Dietary Manager) who had come into the vicinity was notified of the same. On a counter in the kitchen, there were several cardboard boxes of various types of breaded items. One box contained four plastic packets (12 count each packet) of hot dog buns with whitish substance noted on some of the hot dog buns. The delivery date marked on the box showed January 15, 2025 and V5 stated that the breaded products should have been refrigerated. On the spice rack, the following opened containers of spices were seen Ground allspice (16 oz/ounce) delivery date of September 13, 2023 with no open on or use by date, Ground Oregano (12 oz) with delivery date of May 31, 2021 and with no open on or use by date. The thermometer that was placed inside the reach in freezer in the kitchen showed 25 degrees Fahrenheit. A packet of frozen vegetables had condensations on it and the vegetables were soft to touch. Another box containing frozen peas were also soft to touch. There were several boxes that contained individual cups of ice cream and gelato that were soft when lids were opened and tested. A cardboard container with waffles was also tested and were soft to touch. Other boxes of food stored in the freezer were not opened to check and V5 was notified that the same freezer will be tested again in a few hours after food prep is completed. On February 24 at 12:22 PM, the same reach in freezer was checked again and the inside thermometer showed 20 degrees Fahrenheit. V4 (Regional Dietary Director) who had come to the area stated that the freezer should be at 0 degrees Fahrenheit. Both V4 and V5 were notified that the freezer will be checked again after meal service. On February 24 at 1:13 PM, the same reach in freezer was checked again and the inside thermometer showed 30 degrees Fahrenheit with the items stored inside the freezer showing further defrosting stages. V5 stated that she will notify maintenance and take necessary action. Facility policy titled Ice Machine, Scoop and Tray (undated) included as follows: Policy: The ice machine and equipment (scoops and trays) will be cleaned on a regular basis to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 16 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 maintain a clean, sanitary condition. Level of Harm - Minimal harm or potential for actual harm Procedure: 8. Store ice scoop beside or on top of the machine in a clean non-porous container, that allows water to drain off (and not pool around the scoop). Residents Affected - Many Facility policy titled Labeling and Dating (reviewed July 30, 2023) included as follows: Policy: Leftovers and opened foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use. Procedure: 2. 30-day shelf life, usually applies to items that are shelf stable until opened. Label includes: b. Discard date (i.e. opened 4/30, discard 5/30). Facility policy titled Freezers and Refrigerators (undated) included as follows: Policy: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. Procedure: 1. Acceptable temperatures should be 35- 41 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 17 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The electronic medical record shows that R57 was placed on contact isolation for C-Diff (Clostridium difficile). R57's bedroom door has a posting which showed that R57 is on contact isolation. Residents Affected - Some On February 25,2025, at 9:37 AM, V15 (RN) administered IV (intravenous) antibiotic to R57. V15 was wearing gloves and mask, however, she was not wearing an isolation gown. On February 25, 2025, at 12:06 PM, V15 entered R57's bedroom and started setting up the PICC line dressing wearing only her gloves and mask. After she set up the dressing materials, V15 went outside the bedroom to wear a gown, when she saw surveyor entered the bedroom with an isolation gown. Throughout the dressing change V15 sanitized her hands with alcohol-based hand rub in between tasks and glove changing. V15 used a pillow from another bed to prop up R57's right arm during the dressing change. Afterwards she returned the pillow to the other bed without removing the soiled pillowcase and without ensuring the pillow was sanitized after use. 3. On February 25, 2025, at 1:17 PM, V19 and V20 (both CNA) assisted R41 back to bed to render peri-care. V19 and V20 removed R41's shoes and pulled his pants down. V20 proceeded to provided peri-care, applied new incontinence brief, pulled pants back in place while wearing same gloves. After completion of the peri-care, V19 and V20 removed their gloves and carried the soiled items outside the bedroom without performing hand hygiene. 4. On February 26, 2025, at 12:41 PM, V20 and V26 (CNA) rendered incontinence care to R44 who was wet with urine and had a bowel movement. V26 wiped R44 from front to back. V26's gloves made direct contact with the fecal matter during care. When V26 finished cleaning R44's peri-area, she applied new incontinence brief, repositioned R44, straightened bed linens, and adjusted the privacy curtain, while wearing the same soiled gloves all throughout the procedure. On February 26, 2025, at 3:01 PM, V2 (DON) stated, the staff must perform hand hygiene before start of care, in between tasks and glove changes and after completion of the provision of care. The staff must wear complete PPE (gown and gloves, and mask if needed) when providing any care to a resident on contact isolation or EBP (Enhanced Barrier Precaution) to protect the resident and employees from potential infection. The staff must wash their hands in between tasks when dealing with C-Diff cases. Facility's Hand Hygiene Policy dated April 27, 2024, shows: Policy Statement: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure: 1. Soap and water is required for hand hygiene when: -Before and after entering isolation precaution settings. - After caring for resident with diarrheal infection such as C. difficile. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 18 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0880 - After removing gloves or aprons. Level of Harm - Minimal harm or potential for actual harm 2. Alcohol-based hand rub may be used for all other hygiene opportunities (e.g., when soap and water is not indicated per #1 above). Hand hygiene is to be performed: Residents Affected - Some - When moving from one contaminated body site to a clean body site such as when changing a brief or a wound dressing. - After caring for a resident including after removing gloves. - After contact with the resident environment. Based on observation, interview, and record review, the facility failed to follow their policies for EBP (Enhanced Barrier Precautions), TBP (Transmission Based Precautions), and hand hygiene during provisions of care. This applies to 4 of 18 residents (R41, R44, R57, and R326) reviewed for infection control in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R326 was admitted to the facility on [DATE], with multiple diagnoses including stroke, type 2 diabetes mellitus, congestive heart failure, and chronic kidney disease. R326's hospital records dated February 13, 2025, showed R326 had a history of Carbapenem-resistant Pseudomonas aeruginosa (a drug resistant organism). On February 25, 2025, at 8:29 AM, V15 (Registered Nurse/RN) said R326 needed to be repositioned in bed. V15 and V16 (Certified Nursing Assistant/CNA) entered R326's room. V15 and V16 did not wear an isolation gown while repositioning R326 in bed. On February 26, 2025, at 11:02 AM, V2 (Director of Nursing/DON) said R326 should have been place on EBP since admission to the facility. On February 26, 2025, at 3:32 PM, V2 said repositioning a resident is considered a high contact activity. V2 continued to say V15 and V16 should have worn gowns while repositioning R326 in bed. The facility's policy titled Enhanced Barrier Precautions dated 7/22, showed General: Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmissions of Staphylococcus aureus and Multidrug Resistant Organisms (MDRO). EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; Infection or colonization with an MDRO . Examples of MDRO's Targeted by CDC (Centers for Disease Control and Prevention) include: Carbapenemase-producing Pseudomonas spp . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 19 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 offer and provide education regarding the seasonal influenza and pneumococcal vaccines. This applies to 4 of 5 residents (R1, R53, R57, R58) reviewed for immunization in the sample of 18. Residents Affected - Some The findings include: 1. R1's medical record showed R1 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including cerebral palsy, anemia, and essential hypertension. There was no documentation to show R1 was offered or provided education regarding the seasonal influenza vaccine for 2024-2025 season. 2. R53's medical record showed R53 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis due to cerebral infarction, cardiac arrythmia, myalgia and essential hypertension. There was no documentation to show R53 was offered or provided education regarding the seasonal influenza vaccine for the 2024-2025 season. 3. R57's medical record showed R57 was [AGE] years old, admitted to the facility on [DATE], with multiple diagnosis including chronic obstructive pulmonary disease, interstitial lung disease with progressive fibrotic phenotype, chronic diastolic heart disease, and chronic kidney disease stage 3B. The facility provided a consent dated October 16, 2022, for PPSV23 (Pneumococcal Polysaccharide Vaccine) that R57 signed consenting to vaccine administration. There was no documentation that R57 was administered the vaccine. The facility provided documentation that R57 was offered the pneumonia vaccine 20 on January 12, 2023, that showed the family refused the vaccine, but also showed no education was provided regarding the vaccine. 4. R58's medical record showed R58 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including acute on chronic congestive heart failure, hemiplegia and hemiplegia following cerebral infarction, neuromuscular dysfunction of the bladder with urogenital implants, and chronic kidney disease stage 3. There was no documentation to show R58 was offered or provided education regarding the pneumococcal vaccine for the 2024-2025 season. There was no documentation to show R58 was previously vaccinated with a pneumococcal conjugate vaccine. The CDC (Center for Disease Control and Prevention) recommendation dated October 26, 2024, showed for adults aged 50 or over it is recommended to receive a pneumococcal conjugate vaccine if not previously vaccinated or if vaccination status is unknown. On February 24, 2025, at 2:20 PM, V3 (Infection Preventionist) stated V3 reviews resident's immunization status upon admission and influenza vaccine should be offered annually and pneumococcal offered to eligible residents. V3 stated there was a vaccination clinic for influenza offered on December 18, 2024, and provided a list of 29 residents who received the influenza vaccine. There was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 20 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0883 Level of Harm - Minimal harm or potential for actual harm documentation offered that residents who did not receive the vaccine were educated and offered the opportunity to decline the vaccine. CMS Form 671 completed on February 24, 2025, showed the facility census was 76, which indicated only approximately 38% (percent) of the residents were offered the influenza vaccine. Residents Affected - Some The Facility's policy titled Influenza and Pneumococcal Immunizations for Residents, dated June 3, 2024, showed Intent: It is the policy of the facility to ensure that the resident receives Influenza and Pneumococcal immunizations in accordance with State and Federal Regulations and national guidelines .Procedure .Influenza Immunization .2. Each resident is offered an influenza immunization October 1 through March 31 annually, .Pneumococcal Immunization .2. Each resident is offered pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 21 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide education and obtain consent or declination for the COVID-19 booster vaccine for the 2024-2025 vaccine. This applies to 5 of 5 residents (R1, R47, R53, R57, and R58) reviewed for immunizations in the sample of 18. The findings include: 1. R1's medical record showed R1 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including cerebral palsy, anemia, and essential hypertension. There was no documentation to show R1 was offered, or education provided regarding the COVID-19 booster vaccine for 2024-2025. 2. R47's medical record showed R47 was [AGE] years old, and was admitted to the facility on [DATE], with multiple diagnosis including human immunodeficiency virus, anoxic brain damage, hemiplegia, and hemiparesis due to cerebral infarction, unspecified asthma, and presence of cardiac pacemaker. There was no documentation to show R47 or representative was offered, or education provided regarding the COVID-19 booster vaccine for 2024-2025. 3. R53's medical record showed R53 was admitted to the facility on [DATE], with multiple diagnosis including hemiplegia and hemiparesis due to cerebral infarction, cardiac arrythmia, myalgia and essential hypertension. There was no documentation to show R53 was offered or provided education regarding the COVID-19 booster vaccine for 2024-2025. 4. R57's medical record showed R57 was [AGE] years old, admitted to the facility on [DATE], with multiple diagnosis including chronic obstructive pulmonary disease, interstitial lung disease with progressive fibrotic phenotype, chronic diastolic heart disease, and chronic kidney disease stage 3B. There was no documentation to show R57 was offered or provided education regarding the COVID-19 booster vaccine for 2024-2025. 5. R58's medical record showed R58 was [AGE] years old and admitted to the facility on [DATE], with multiple diagnosis including acute on chronic congestive heart failure, hemiplegia and hemiplegia following cerebral infarction, neuromuscular dysfunction of the bladder with urogenital implants, and chronic kidney disease stage 3. There was no documentation to show R58 was offered or provided education regarding the COVID-19 booster vaccine for 2024-2025. The CDC (Center for Disease Control and Prevention) COVID-19 booster guidelines dated January 7, 2025, showed getting the 2024-2025 COVID-19 vaccine is extremely important if you have never received a COVID-19 vaccine, are age [AGE] years old or older, and live in a long-term care facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 22 of 23 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On February 24, 2025, at 2:20 PM, V3 (Infection Preventionist) stated there was a COVID-19 vaccine clinic held on December 18, 2024, and provided a list of residents who received the COVID vaccine, which totaled 25. There was no documentation provided regarding other residents' education or declination of the COVID vaccine. Form 671 completed on February 25, 2025, showed the facility census was 76, which indicated only approximately 32% of residents were offered the COVID vaccination for 2024-2025. The Facility's policy titled COVID 19 Guidance dated May 20, 2024, showed The Facility will encourage residents, staff, and families to remain up to date with COVID 19 vaccination, including all eligible booster doses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145980 If continuation sheet Page 23 of 23