Health inspection·March 27, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few 02/20/25. V6 stated, On 02/20/25, it was V5 (CNA) who notified me to come to his (R3) room because he (V5) and V7 (CNA) were trying to assist him (R3) back to bed after dinner. I went to his (R3) room, he (R3) was agitated with them, said his left arm hurts, because they were trying to put him in bed. I did my assessment, no bruise, no open area. I called V14 (Nurse Practitioner), stat X-ray was ordered. I was off for 3 days, when I came back, I asked and was told that there was no fracture. Two to three days after, we got him up, V14 was trying to examine him and he couldn't move his (R3) arm, so he was sent out as ordered. V6 was asked if R3 has any limitations on his arms. V6 replied, Both arms are a bit contracted, unable to move his arms freely. He is dependent on staff for ADLs. He can still lift his arms a little. On 03/20/25 at 3:36 PM, V5 was interviewed regarding R3's incident on 02/20/25. V5 stated, I was one of the CNAs, I was helping V7. We were doing the care, taking his (R3) clothes off, and as we were taking his shirt off, he pulled away and that is when we heard a pop in his arm. He became agitated and that is when the pop came from his arm. I was the one taking his shirt off. Once I heard the pop, I immediately called the nurse. He did not complain of any pain. He was not agitated at first, he became agitated when I attempted to remove his shirt. This was the first time I worked with him (R3) and it happened. V5 was asked on how he removed R3's shirt. V5 continued, I tried to pull the shirt from the back when that didn't work, I grabbed the sleeve from his arm. I was holding his arm and I pulled the sleeve from his wrist and pulled it out. And that is when he became agitated and that's when the pop noise happened. On 03/20/25 at 3:47 PM, V7 was also asked regarding R3. V7 stated, We (V5 and me) were trying to take his (R3) sweater off. He kind of pulled back and we heard his arm popped and we go to get the nurse. It was the left that popped. He is alert and oriented. I don't know if his arms were contracted or not, that was my first time working with him. R3's Restorative Nursing Review Notes dated 12/24/24 recorded the following: Range of Motion: 2. Left shoulder - severe loss/less than 50% of norm 4. Left elbow - severe loss/less than 50% of norm 6. Left wrist and fingers - severe loss/less than 50% of norm Muscle strength and loss of functional movement: left shoulder, left elbow, left wrist - poor On 03/25/25 at 12:33 PM, V11 (CNA) was asked regarding R3 and range of motion. V11 stated, He has contracted upper extremities. He has stiffening on both arms, can bend elbows but shoulders are stiff. He is unable to move the upper extremities wide enough. If he gets agitated during dressing, depending on his mood, for the most part, he will kick his bed, [NAME] from side to side, he'll tell us to leave him alone. We will leave the room and come back later, otherwise he will not stop screaming. We will give him time to cool down and then attempt again later. When he gets agitated, he is not combative, he [NAME] from side to side and will scream. When we remove his shirt off, we don't hold the hand or arms. We will lay him in bed, we'll pull the shirt off by turning him from one side to another. When the shirt is on the upper chest, we will slide it over the head and slide out from the arms. We don't extend his arms at full length. For the most part, every CNA has had experience with him, knows how to do ADL care on him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 2 of 4 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 145220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Crest Health Care 3300 West 175th Street Hazel Crest, IL 60429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few On 03/25/25 at 1:01 PM, V12 (Licensed Practical Nurse, LPN) was interviewed regarding R3. V12 replied, He is alert. His upper extremities are contracted. He required total care; he is a feeder. He does not use his arms and hands; he could move them a little but not able to fully extend it to the sides or front. When we do ADL care, when removing shirt on R3, slide the shirt off from the back to head then slide it out from the sleeves. No need to pull or hold the hands. On 03/25/25 at 2:50 PM, V13 (Restorative Nurse) stated during interview, R3 had limitations to his bilateral shoulder. He could only extend his shoulders like less 50% of the norm. And any type of hyperextension, he cannot do it. His arms and shoulder cannot rotate. He usually wears loose fitting clothes. When you take his shirt off, pull the shirt off from the back, slide it over the head, slide it out to the arms, one arm at a time. You don't need to hold or grab his arms because his clothes are loose fitting and easy to take off. It is not necessary to hold his arm, just slide it off. He can be a little agitated especially when he wants something to do and he cannot do it, he become frustrated and agitated. He has a behavior of waddling himself and kind of pulling back, so any type of joint movement and when you are holding his hand or shirt can cause some resistance, and it could potentially lead to some type of pain or injury. That is why, when you are taking his shirt off, just let it slide off. He is alert enough to tell you what was going on. V3 (Director of Nursing) was also interviewed on 03/25/25 at 2:20 PM regarding R3. V3 stated, With the incident on 02/20/25 for R3, he pulled back while CNA was removing his shirt off from his left arm. The CNA said he had gotten agitated, resistive at that point. Whenever a resident gets agitated, let him cool down by not touching the resident, get another staff member involved, calm resident down. In other words, do not continue providing the care. V3 was also asked on how to remove R3's shirt. V3 verbalized, R3 is one of the residents with limited movements. His arms cannot go all the way up. He can move it to certain extent but not all the way. If you have a resident with contracted arms, you will pull the shirt off over the head first before pulling the shirt out to the arms. You don't have to hold the arm when pulling off the sleeves. If a resident has an impairment on one side, start with the normal side then to the impaired side. You should not hold the hand or arm when removing the shirt off. Let the sleeve slide out from the arms. On 03/25/25 at 11:38 AM, V9 (Social Services Director) was asked regarding R3's behavior. V9 stated, He is alert, oriented, no aggressive behavior, not overly delusional, gets agitated at times when refusing care, like he does not want to take shower or get out of bed. But not being difficult during assistance in ADL care, not that I am aware of. He is usually cooperative and compliant with care. He'll have those days that are not pleasant but most of the time, he is pleasant and cooperative. R3's care plan documented: Self-care deficit and requires assistance with ADLs to maintain the highest possible level of functioning as evidenced by the following limitations and potential contributing factors: limited bilateral shoulder and elbow range, poor bilateral hand grasp and dexterity, shoulder pain (revision dated 12/08/22) Intervention (02/05/2020) Explain all tasks prior to performing the ADL assistance. Use task segmentation and verbal cues as needed. Further review of R3's care plans showed that there were no interventions addressing behavior of agitation especially during ADL care and any special instructions on how to perform ADL care related to dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 3 of 4 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 145220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Crest Health Care 3300 West 175th Street Hazel Crest, IL 60429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few On 03/26/25 at 11:01 AM, V14 was asked regarding R3 and expectations on staff related to injury prevention during provision of care. V14 stated, R3 has limited mobility in his upper and lower extremities. I was notified that he had swelling and pain on the left arm and I sent him out to the hospital for further evaluation and treatment. I was told by V3 that when they were trying to dress him, he was resisting during ADL care, and they heard a pop. He was pulling away. He was resisting them while changing clothes and he pulled away. Usually, staff walks away or bring another staff member, give him a few minutes to calm down and try again. I expect staff to take into account what his behavior at the moment and how he respond, if not, step away and come back at a later time, give him time to cool down, this is the key in order to make him safe. He has some mental issues, in a minute they appeared to be cooperative then in a second they snap, behavior change, staff has to step back or redirect him. Facility's policy titled Behavioral Management for New or Worsening Behavior Symptoms dated 4/14 documented in part but not limited to the following: Purpose: To determine the cause of the behavior To prevent the resident from harming self or others To establish guidelines for reducing or preventing behaviors when possible Policy: It is the policy of the Nursing Department to determine the cause of behaviors when possible and initiate interventions to reduce, control, or prevent identified behaviors. Facility's policy titled Activities of Daily Living dated 4/14 stated in part but not limited to the following: Purpose: To preserve ADL function, promote independence and increase self-esteem and dignity. Implementation of Mobility Programs: Develop individualized care plan utilizing resident-centered goals. Provide special instructions and precautions. There was no other policy presented by facility related to prevention of accidents during ADL care or during provision of care upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 4 of 4