Bethesda Rehab & Senior Care

F-F700 CITATION FOR DETAILS.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 44103 potential for actual harm FACILITY Residents Affected - Few Medication Administration

F-F759

Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate of less than 5% for 1 (Resident R51) of 3 residents reviewed for medication administration. There was a total of 32 opportunities with 2 errors observed, which resulted in a medication error rate of 6.25%.

Findings Include:

On 3/11/25 at 9:45 AM, after V8 (Registered Nurse) checked Resident R51's blood pressure and heart rate, V8 started to prepare Resident R51's morning medications. V8 started Resident R51's nebulizer treatment Ipratropium-Albuterol and then prepared the oral pills Amlodipine 10 mg, Ferrous Sulfate 325 mg, Finasteride 5 mg, Fluoxetine 20 mg, Folic Acid 1 mg, Nebivolol 10 mg, Oxybutynin 5 mg, Senna 1 tablet, Sodium Bicarb 650 mg, and Vitamin B12 1000 mcg. At 9:56 AM, Resident R51's nebulizer treatment was completed and took all his oral pills. At 9:57 AM, V8 stated she completed Resident R51's medication pass and signed the Electronic Medication Administration Record (EMAR) indicating Resident R51's medications were administered.

Resident R51's 3/11/25 Medication Administration Record (MAR) shows Advair Diskus Aerosol Powder 1 puff inhaler and Lisinopril 20 mg 1 tablet by mouth to be given to Resident R51 scheduled on DAY1 (between 7:00 AM to 11:00 AM). Resident R51's Medication Administration Audit Report documents in part a 7:00 AM dose of Advair Diskus Aerosol Powder 1 puff inhaler and Lisinopril 20 mg 1 tablet by mouth that were documented administered at 9:57 AM by V8. Surveyor did not see V8 administer these medications during the medication administration

observation with Resident R51 on 3/11/25 completed at 9:57 AM.

On 3/11/25 at 3:08 PM, interviewed V2 (Director of Nursing) and stated that for medication administration,

the nurses should be following the right resident, right route, right medication, right time, and right dose. V2 stated nurses are supposed to be following physician orders when administering medications to the residents. V2 stated that after a resident takes their medications, the Nurses are documenting the time they administered the medications in the EMAR. V2 stated that they have to document what are given, what's missed or refused.

The facility's Medication Administration policy dated 8/1/24 documents in part: An order is required for administration of all medication. Check medication administration record prior to administering medication for

the right mediation, dose, route, patient and time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 40061

Residents Affected - Few Based on observations, interviews, and record reviews, the facility failed to follow their menu and failed to follow cooking instructions. This affected all 108 residents receiving nutrition from the kitchen.

Findings include:

Surveyor conducted an initial kitchen tour with V11 (Dietary Manager) on 3/11/2025 at 9:03 AM.

At 9:29 AM, there were multiple boxes of pies sitting on the kitchen counter. V11 stated the pies were frozen and are defrosting for lunch.

Facility's Week at a glance menu documents in part that the facility was to serve lemon meringue pies for lunch on 3/11/2025.

At 11:40 AM, V14 (Cook) began plating the lunch meal for the residents. Did not observe V14 slice or plate any pies. V11 stated the dessert for lunch was now a 4-ounce serving of pears. Later that day, V11 stated that the pies did not defrost in time for the lunch meal and the facility could not serve them.

During a Resident Council meeting on 3/12/2025 at 1:24 PM, Resident R67 and Resident R88 stated that the facility does not follow the menus. Resident R88 stated the menu will say one thing but the facility will serve a different food item instead.

Facility's undated Accuracy of Quality of Tray Line Service policy documents in part: The director of food and nutrition services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time. Tray line and/or meal service positions for breakfast, lunch and dinner will be planned and determined: according to the menu. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu.

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On 3/12/2025 at 10:01 AM, V14 (Cook) started the pureed mashed potatoes. Surveyor asked how many portions V14 was going to make. V14 asked V11 (Dietary Manager) how many residents were on pureed diet. V11 answered about 15 residents. V14 grabbed a deep pan and filled it halfway with regular water. Surveyor asked how much water was in the pan. V14 did not know. Surveyor asked the capacity of the pan and V14 did not know. V11 stated it was a 6-inch pan. V11 stated the facility uses powdered mashed potatoes and V14 only needs to reconstitute it. V14 opened the lid of the mashed potato granules and started pouring unmeasured amounts of it into the water. V14 stirred it with a whisk and then added more granules until V14 got a pureed consistency. V14 did not add salt.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 0803 Surveyor reviewed the label on the mashed potato container. It documents in part that for 35 servings, the preparer should use a fourth of the can or 3 cups of the granules with three quarts water and two teaspoon Level of Harm - Minimal harm or salt. Instructions read to use boiling water and mix on low and slowly add all potato granules over one potential for actual harm minute.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 40061

Residents Affected - Few Based on observations, interviews, and record reviews, the facility failed to follow physician orders for nectar-thick liquids for one resident (Resident R40) out of a total sample of 22 residents.

Findings include:

Resident R40's Order Summary Report documents in part an active diet order for nectar-thick consistency for liquids (order date 2/26/2024).

Resident R40's Care Plan Report documents in part that Resident R40 has swallowing/chewing difficulties and requires mechanically altered diet with thickened liquids (last revised 1/09/2025).

Intervention initiated on 1/09/2025 documents in part to Provide and serve diet as ordered.

On 3/11/2025 at 12:15 PM, V15 (Certified Nurse Aide) assisted Resident R40 with lunch meal. Resident R40 had a 114-milliliter carton of apple juice with lunch meal. V15 fed the apple juice thin and not nectar thick to Resident R40.

Facility's undated Accuracy of Quality of Tray Line Service policy documents in part: All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. Staff will refer to the meal identification (ID) card/ticket for food dislikes, allergies and other details and substitute appropriately for those items. Each meal will be check for correct name, room number, and diet order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 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. Level of Harm - Minimal harm or potential for actual harm 46342

Residents Affected - Some Based on observations, interviews, and record reviews, the facility failed to provide oral supplements on meal trays as part of the therapeutic diet prescribed by the physician for five (Resident R15, Resident R32, Resident R40, Resident R92, Resident R106) residents reviewed for dining services in a total sample of 22.

Finding include:

Resident R15, Resident R32, Resident R40, Resident R92, Resident R106's Order Summary Reports document in part dietary supplement order for High Calorie Frozen Dessert to be given at lunch.

Resident R15, Resident R32, Resident R40, Resident R92, Resident R106's lunch meal tickets document in part for Frozen Nutritional Treat to be served as

a daily item.

Resident R15, Resident R32, Resident R40, Resident R92, Resident R106's nutrition care plan documents in part, provide and serve supplement as ordered and/or as needed.

On 03/11/25 at 11:45 AM, observed Resident R106 eating lunch in main dining room. Resident R106 did not receive a High Calorie Frozen Dessert (Frozen Nutritional Treat) on her tray. Resident R106 said, I didn't get it today and I don't get it every day, only sometimes.

On 03/11/25 at 12:35 PM, V19 (Resident R32's Guardian) stated she had fed Resident R32 lunch and there was no Frozen Nutritional Treat on Resident R32's lunch tray. V19 showed surveyor Resident R32's lunch tray. There was no Frozen Nutritional Treat on it. V19 stated she feeds Resident R32 on a regular basis and cannot remember if she has seen

the Frozen Nutritional Treat on Resident R32's lunch tray or not.

On 03/11/25 at 12:40 PM, V13 (Dietary Aide) stated she was serving lunch in the main dining room and did not give out any Frozen Nutritional Treats. V13 said, I have not seen those in a couple of days. I think we are waiting for a delivery. If the kitchen had the Frozen Nutritional Treats, I would have given them out.

On 03/11/25 at 12:50 PM, V11 (Dietary Manager) stated the kitchen receives orders for Frozen Nutritional Treats based on the doctor's orders. V11 stated once she receives the order the item gets added to the residents' meal ticket so the staff knows who to give the supplement to. V11 stated the kitchen has Frozen Nutritional Treats in stock. V11 showed surveyor inside freezer and observed 12 cases of Gelato High Calorie which V11 stated is what they serve as the Frozen Nutritional Treat. Cases were dated 1/21. V11 stated that is the date the cases were delivered. V11 stated she does not know why the supplements were not given out. V11 stated they have enough in stock so they should have been given out. V11 stated the Frozen Nutritional Treats are used for residents who need extra calories so the potential problem of the residents not receiving the supplements is that they could lose weight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 On 03/12/25 at 11:52 AM, V33 (Registered Dietitian) stated oral supplements are ordered by the doctor and are considered to be part of the resident's therapeutic diet. V33 stated that some of the reasons she might Level of Harm - Minimal harm or put someone on an oral supplement could be to increase calorie intake because weight loss has occurred, or potential for actual harm if they are not eating well to prevent weight loss, or for wound healing if they require more calories and protein. V33 stated the Frozen Nutritional Treats should be given as ordered by the doctor and the potential Residents Affected - Some problem of the supplement not being given is that weight loss can continue or occur and/or the resident's wound may not heal because wounds require energy and protein for healing. V33 stated Resident R32 is underweight and has a poor appetite. V33 stated Resident R106 has a pressure ulcer and needs extra calories and protein for wound healing.

Facility provided list of residents with physician orders for Frozen Nutritional Treat dated 03/11/25 including Resident R15, Resident R32, Resident R40, Resident R92, Resident R106.

Facility provided policy titled, Fortified Foods/Supplements undated which documents in part, Fortified foods and supplements are used to promote adequacy of the diet as a nutrition intervention for at risk patients/residents and patient/residents who are at nutritional risk are considered for fortified foods/supplements to increase their overall calorie and nutrient intake.

Facility provided policy titled, Accuracy of Quality of Tray Line Service undated which documents in part, the director of food and nutrition services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time and each tray will be checked for food and beverage preferences, allergies, intolerances and special food requests.

40061

Findings include:

On 3/11/2025 at 12:15 PM, V15 (Certified Nurse Aide) assisted Resident R40 with lunch meal. V15 stated Resident R40 did not get a high calorie frozen dessert with the meal. V15 stated [V15] hasn't seen any high calorie desserts in a while. V15 stated usually assisting Resident R40 with meals. V15 stated during the times V15 fed lunch to Resident R40, Resident R40 has not received the high calorie frozen dessert.

On 3/11/2025 at 12:18 PM, Resident R92 sat at a lunch table on own. Resident R92's lunch meal did not include a high calorie frozen dessert.

On 3/11/2025 at 12:33 PM, V11 (Dietary Manager) stated Resident R40 and Resident R92 are supposed to get a high calorie frozen dessert based on the residents' meal tickets. V11 does not know why kitchen staff failed to provide them to Resident R40 or Resident R92.

On 3/11/2025 at 12:50 PM, Resident R40 had a high calorie gelato sitting on the table in front of Resident R40. Staff was not present to assist Resident R40 eat it. At 1:00 PM, V16 (Certified Nurse Aide) stated [V16] wasn't aware that Resident R40 needed the high calorie frozen dessert or that it was physician ordered due to Resident R40's nutritional risk and weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40061

Residents Affected - Many Based on observations, interviews, and record reviews, the facility failed to follow their policies and dispose of food items past their expiration/best buy/use by dates, label opened food item, store food and food related items away from cleaning solutions, perform hand hygiene during dishwashing, and cover prepared food to prevent contamination. This has the potential to affect all 108 residents that receive nutrition from the kitchen.

Findings include:

On [DATE REDACTED] at 9:03 AM, surveyor conducted an initial tour of the kitchen and food storage areas with V11 (Dietary Manager).

During the tour of the facility's dry goods stock room on [DATE REDACTED] at 9:05 AM, there was a gallon of maraschino cherries that expired on [DATE REDACTED] in the bottom shelf. In the same bottom shelf, there was an opened jug of soy sauce with the 'best by' date of [DATE REDACTED]. The label reads to refrigerate after opening. V11 did not know it had to be refrigerated. In the same bottom shelf, there was an additional jug of unopened soy sauce with a 'best by' date of [DATE REDACTED]. There was also an unopened gallon of Caesar dressing with a 'use by' date of [DATE REDACTED]. V11 stated that the facility's policy is to move all the old stock to the front of the shelves and

the incoming stock to the back of the shelves. V11 stated V42 (Dietary Aide) and the other kitchen staff are supposed to check all the labels and toss the expired items. V11 stated when there is no written expiration date, the facility follows the 'use by' or 'best by' date to discard them.

In a separate shelf there was an opened clear bag with brown powder inside it. The bag was tied manually and did not have a label. V11 stated it was brownie mix. V11 stated staff were supposed to label the bag when they opened it.

In the back of the dry storage room, there was a shelf against the wall perpendicular to the large can racks against the window (contained cans of fruits). In the bottom shelf, there were opened bags of food lids next to two 1-gallon bottles of bleach cleaning solution. V11 stated the lids were for cups and bowls used during residents' meals. Additionally, underneath the shelf (resting on the floor), there was a case of six 1-gallon bottles of bleach cleaning solution.

On [DATE REDACTED] at 9:21 AM, V12 (Dietary Aide) and V13 (Dietary Aide) were cleaning up the breakfast trays. V12 was tossing the food waste and handing over the trays, dishes, and utensils to V13. V13 loaded the dirty dishes through the hot-temperature dishwasher. V13 then pulled out the washed trays, dishes, and utensils out the other end of the dishwasher without performing hand hygiene or changing gloves. V13 touched the clean dishes with the same dirty gloves throughout the washing process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 On [DATE REDACTED] at 9:29 AM, there was coffee grounds in a coffee liner lying on top of the metal table next to the coffee machine. The coffee grounds were open to air and located next to two buckets with solution. V11 Level of Harm - Minimal harm or stated the kitchen staff uses the buckets to sanitize and clean the kitchen. V11 stated staff opened the coffee potential for actual harm grounds that morning and shouldn't have left them out next to the sanitation station. V11 verbally acknowledged that there could be cross contamination from the cleaning solutions splashing on the coffee Residents Affected - Many grounds. The open coffee grounds remained on top of the metal table during return observations later that day at 11:40 AM.

During the initial tour, there were also trays of uncovered, pre-portioned pears on the top counters. V11 stated they were 4-ounce servings of pears that one of the dietary aides prepared earlier that morning. Facility will serve them for lunch. The facility's heating and air conditioning unit was blowing over the uncovered pears. The pre-portioned pears were on the counter uncovered during return observations later that day at 11:40 AM.

On [DATE REDACTED] at 9:36 AM, V11 took the surveyor to the basement where the facility's walk-in refrigerator and freezer were located. In the refrigerator, there was a box of cucumbers in one of the top shelves. Multiple cucumbers were mushy, soft to touch, and had multiple black spots. V11 took the box out and stated staff should have tossed them out. In the freezer, there was a large, opened bag of ice in the bottom, left shelf. There was ice recrystallization (freezer burn) throughout the ice block. V11 stated the large bag of ice was there when V11 started working for the facility, which was seven months ago. V11 does not know what the facility used it for or why the facility purchased it.

On [DATE REDACTED] at 11:40 AM, V14 (Cook) started serving food from the kitchen tray line. Did not observe V14 check the temperatures of the food prior to plating. V11 showed the surveyor the kitchen's daily food temperature logs. The form for the current meal was empty. Surveyor asked V11 if V14 took the food temperatures. V11 did not know and asked V14. At 11:47 AM, V14 stated taking the temperatures prior to surveyor's arrival (before 11:30 AM) but forgot to write them down.

Facility's undated General Infection Control in Dining Services policy documents in part: The Dining Department follows all local, state and federal regulations in order to assure a safe and sanitary department.

Facility's undated Food Storage policy documents in part: All food stock and food products are stored in a safe and sanitary manner. All food stock is dated and used on a first in, first out basis.

Facility's Labeling and Dating policy (last reviewed [DATE REDACTED]) documents in part: 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.

Facility's undated Chemical Storage Guidelines documents in part: Poisonous and toxic materials are to be stored only in areas designated for such use and for no other purpose, or in a storage area outside the food, equipment and utensil storage area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 Facility's undated Dish Room - Safe Handling policy documents in part: Potential cross-contamination is prevented in the Dish Room. The task of loading the dirty dishes and utensils into the dishwashing machine Level of Harm - Minimal harm or is handled by one person. The task of removing the clean dishes and utensils from the dishwashing machine potential for actual harm is handled by a different person. If there is only one person working in the dish room, the person will remove their gloves, wash their hands and put on fresh gloves whenever they cross over to the clean side of the Residents Affected - Many dishwashing machine to unload the sanitized dishes and utensils.

Facility's undated Food Temperatures policy documents in part: Temperatures of TCS (temperature controlled for safety) foods shall be recorded before being served from the steam table. Food temperatures shall be checked at the end of cooking and recorded before meal service on the Food Temperature log or production sheet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 49486 potential for actual harm Based on observations, interviews and record reviews, the facility: Residents Affected - Some 1. Failed to follow Contact Precautions guidelines by not wearing appropriate Personal Protective Equipment (PPE) for one (Resident R4) resident.

2. Failed to ensure that there was an Enhanced Barrier Precautions (EBP) sign and PPE outside of Resident R16's room and failed to don PPE prior to incontinence care.

3. Failed to don PPE prior to incontinence and wound care to 2 (Resident R15, and Resident R28) residents.

These failures could potentially affect 4 (Resident R4, Resident R15, Resident R16, and Resident R28) of 8 residents reviewed for Transmission-Based Precautions in a sample of 22.

Findings Include:

On 03/11/25 at 10:21 AM, Resident R15 observed lying in bed with V3 (Certified Nursing Assistant/CNA) providing incontinence care to Resident R15 without donning a gown as Personal Protective Equipment/PPE. V3 stated that V3 should be wearing a gown before providing incontinence care to Resident R15 because she has sacral wound and an enhanced Barrier Precautions (EBP) signage by her door. V3 stated that providing care to Resident R15 without donning a gown exposes her to germs and transmission of infection.

On 03/12/25 at 9:41 AM, Resident R28 observed lying in bed, with V9 (Wound Care Licensed Practical Nurse) assisted by V29 (CNA) providing wound care to Resident R28 without donning gown as PPE. V9 and V29 both stated that failure to don the gown as the appropriate PPE while providing high contact care can cause cross contamination. V9 stated that Resident R28 has EBP signage by the door, so V9 should always wear a gown before providing wound care.

On 03/12/25 at 10:38 AM, V2 (Director of Nursing/Infection Preventionist) stated that staff and visitors should not enter contact isolation room without donning the appropriate PPE (gown, gloves, and mask). V2 also stated that it is V2's expectation that staff will don gown when providing high contact care like, wound and incontinence care to residents with EBP and contact precaution signage to prevent cross contamination.

Resident R15 and Resident R28's Physician Order Sheet (POS) with active orders as of 3/11/25 shows Enhance Barrier Precaution due to wounds every shift.

The facility policy on EBP dated 10/23 documents read in part: EBP is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and multidrug Resistant Organisms (MDRO). Transmission Based Precautions (TBPs) include airborne, droplet, contact, and EBP. TBP are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 Resident R16's Order Summary Report documents in part an active order for Enhance Barrier Precaution due to: wound every shift (order date 1/29/2025). Level of Harm - Minimal harm or potential for actual harm Resident R16's Care Plan Report documents in part that Resident R16 is on Enhanced Barrier Precautions related to wound (initiated 1/29/2025). Intervention initiated 1/29/2025 documents in part for staff to clean/wash hands, Residents Affected - Some including before entering and when leaving the room. Staff are to wear gloves and a gown for high contact resident care activities such as changing briefs or assisting with toileting.

On 3/11/2025 at 10:40 AM, there was no Enhanced Barrier Precaution (EBP) sign outside of Resident R16's room or

on the door. There was no Personal Protective Equipment bin readily accessible near Resident R16's room. After the surveyor interviewed Resident R16, V37 (Certified Nurse Aide) provided incontinence care and dressing assistance to Resident R16. V37 did not don a gown during the high touch care activities.

Resident R16's room remained without EBP signage and PPE bin during additional observations on 3/11/2025 at 2:58 PM and on 3/12/2025 at 9:34 AM.

On 3/12/2025 at 9:36 AM, V23 (Nurse) stated [V23] is assigned to care for Resident R16. V23 stated [V23] works on

an as needed schedule and does not work often with Resident R16. During interview, V23 did not know which residents would qualify for EBP or why residents would be on EBP. V23 stated the facility would usually have signs on the doors to alert staff which residents were on EBP. V23 guessed that V2 (Director of Nursing) was

the one responsible to put the signs up. V23 stated [V23] was not aware that Resident R16 had orders for EBP because Resident R16 didn't have signs on the door or outside the room.

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Findings include:

On 03/11/25 at 11:34 AM, observed signage posted for Contact Isolation outside of Resident R4's room with adequate supply of Personal Protective Equipment (PPE) located outside Resident R4's room including gowns, masks, gloves.

On 03/11/25 at 11:48 AM, observed V17 (Nursing Supervisor/Licensed Practical Nurse) enter Resident R4's room without gown or gloves. V17 only wore a mask.

On 03/11/25 at 11:50 AM, V18 (Licensed Practical Nurse) stated Resident R4 is on Contact Isolation for c. diff (Clostridium Difficile) and anyone going into Resident R4's room whether they are providing care or not needs to wear

a gown, mask, and gloves.

On 03/11/25 at 11:54 AM, V17 said, I didn't do any touching. V17 stated she did not wear a gown or gloves but should have and the reason for wearing gown, gloves and mask is prevent the transfer of c.diff to other residents. V17 stated c.diff is contagious and the problem with her not wearing the correct PPE is she could transfer c.diff to other residents.

Resident R4's diagnosis included but not limited to Enterocolitis Due to Clostridium Difficile, Sepsis, Urinary Tract Infection, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, Malignant Neoplasm of Prostate, Malignant Neoplasm of Lung, Hypertensive Heart Disease without Heart Failure, Iron Deficiency Anemia, Obstructive Sleep Apnea.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 28 145844 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145844 B. Wing 03/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

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 Resident R4's Order Summary Report dated 03/12/25 documents in part, active order for Contact Isolation for C. Diff every shift ordered 03/07/25 and Vancomycin HCl Oral Capsule 125 mg give 4 capsule by mouth every 6 Level of Harm - Minimal harm or hours for c.diff ordered 03/06/25. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 28 145844