Inspection·August 14, 2025

F 0550 R10's face sheet documents diagnoses that include but are not limited to legal blindness. Level of Harm - Minimal harm or potential for actual harm R10's Minimum Data Set (7/19/25) documents, in part, that R10 has a brief interview of mental status summary score of 3, indicating that R10 has cognitive impairment and requires substantial/maximal assistance with eating. Residents Affected - Some R10's care plan, revised date 7/21/25, documents, in part, (R10) has a Self-Care Deficit and requires assistance with ADL's (activities of daily living) to maintain the highest possible level of functioning. following limitations and potential contributing factors: Impaired Cognitive Status, Requires Limited to Extensive Assistance with most ADL's, with interventions that document, in part, . Provide assistance with all ADL's as required per the residents need dependence: Eating, Transferring, Bed Mobility, Bathing, Dressing, Personal Hygiene, Ambulation and Personal Hygiene. On 8/11/25 at 12:10pm, V18 (certified nursing assistant/CNA) was observed standing over and feeding R10 while R10 was seated in the dining area. V18 was not positioned at eye level with R10 while assisting R10 with eating. On 8/11/25 at 12:18pm, V18 (Certified Nursing Assistant/CNA) acknowledged that, when assisting residents with eating, they should be seated at eye level with the resident to promote a respectful and dignified interaction, and to support the resident's individuality, dignity, and comfort. V18 said, I (V18) know I (V18) should be sitting with (R10), but I (V18) am also the sitter for the 2 residents over there (putting to another table). On 8/13/25 at 11:30am, V2 (Director of Nursing/DON) affirmed that urinary drainage bags must be stored in accordance with practices that promote and preserve resident dignity and privacy. V2 said, They (residents) should have a privacy bag even when in their room. V2 confirmed that staff should be seated at eye level with residents during assisted feeding in order to promote a respectful and dignified interaction. V2 said, Staff should be sitting at eye level with residents when assisting with meals. Facility policy titled, Urinary Catheter Care, dated 5/14, documents, in part, . 19. The catheter drainage bag will be marked with the date inserted or when changed and stored in privacy bag. CNAs (certified nursing assistants) may change the drainage and/or leg bag. Facility policy titled, Feeding and Assisting Residents to Eat, revised date 6/14, documents, in part, . Nursing personnel assisting should be positioned/seated at eye level with the resident to provide a relaxed and comfortable environment, and to avoid a standing over image. Facility policy titled, Resident Rights, dated 11/18, documents, in part, Policy: Employees shall offer all residents privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self-image. These rights include the residents' rights to:. n. Privacy and confidentiality. ee. The right to an environment that preserves dignity and contributes to a positive self-image. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. Findings include: R24's minimum data set (6/9/2025) documents in part a brief interview of mental status (BIMS) summary score of 14, indicating that R24 is cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 2 of 21 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 08/14/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/11/2025 at 10:46 AM, observed R24's buttocks/genitals from the hallway. R129 (R24's roommate) was observed with no pants on, sitting in his wheelchair within the room from the hallway. R129's incontinence brief was fully exposed. No privacy curtain or other devices/interventions were used to maintain dignity. R24 utilized a thin blanket to cover himself and stated, Please I really need to talk to you. I don't have any clothes. Yesterday, I had to go to the nurse's station naked because I have no clothes. I have to walk around the facility naked all the time because there are no clothes for me. It just makes me look stupid having to be naked—I want to wear clothes. No clothing was observed in R24's room. On 8/11/2025 at 10:57 AM, V25 (Certified Nursing Assistant) was observed physically assisting R129 with dressing and putting on pants. No privacy curtain was pulled, and the assistance provided could be seen from the hallway. V25 affirmed that V25 was assigned to care for R24 and R129. V25 affirmed that R24 was currently only wearing a blanket and was naked without clothing under the blanket. V25 explained that R24 does not have clothes and when V25 is assigned to R24, V25 has to go to laundry where there are spare clothes to find clothing that might fit R24. V25 did not know why R24 did not have clothes. V25 pulled pants, a shirt, and a incontinence brief from the linen cart and placed them on R24's bed. Facility policy titled, Dignity (1/2015) documents in part, Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .1. Residents should be treated with dignity and respect at all times; even cognitively impaired residents .10. Staff shall promote, maintain and protect resident's privacy, including bodily privacy during assistance with personal care and during treatment procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 3 of 21 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 08/14/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 follow physician orders and care plan for enteral feeding; failed to follow physician's order and resident's care plan to ensure that hip abduction pad is applied to a post hip replacement resident; failed to follow physician orders related to continuous oxygen use; failed to obtain physician orders/consultation for podiatric care and failed to provide podiatric care. These failures affect 4 residents (R6, R39, R75, R150) in a sample of 70 reviewed for quality of care. Findings include:On 8/11/2025 at 11:21 AM, observed R39 lying in high fowlers position sleeping in bed. R39's gastrostomy tubing (g-tube) was connected to an enteral feeding pump that was turned off. Approximately 250 mL less of tube feeding was observed in the feeding bottle in comparison to the total volume of the carton (1000 mL). Additionally, the tube feeding was dated for 8/11/2025 at 5:00 AM, indicating that the tube feeding had been started on 8/11/2025 at 5:00 AM. Residents Affected - Some R39's physician orders documents in part an order for two times a day Glucerna 1.2 85 mL/hr x 20 hours until 1700 mL is infused. Up at 4pm, down at 12 pm. Based on this physician order and the date/time of the tube feeding administration, approximately 510 mL of tube feeding should have been infused from the bottle and the tube feeding should have been on at the time of the observation. On 8/11/2025 at 11:25 AM, V24 (Wound Care Nurse) observed R39's enteral feeding pump and tubing and affirmed that the pump was off. V24 observed the tube feeding bottle, dates/times and affirmed that 250 mL of tube feeding had been administered. V24 accessed and reviewed R39's electronic health record and stated, no it (the tube feeding) should be on right now. It doesn't get turned off until 12. There is no reason why it is off right now. V24 accessed R39's enteral feeding pump and resumed the feeding at 85 mL/hr. R39's enteral feeding care plan (12/29/2023) documents in part R39's tube feeding is unavoidable and the only source of (R39's) nutrition and hydration. Additionally, the enteral feeding care plan documents in part an intervention, Infuse feeding as ordered on the POS (Physician Order Sheet). Findings include: R6's face sheet documents an initial admission date of 3/20/25, with diagnoses that include but are not limited to type 2 diabetes mellitus and muscle weakness. R6's Minimum Data Set (7/15/25) documents, in part, that R6 has a brief interview of mental status summary score of 7, indicating that R6 has cognitive impairment. R6's care plan, revised date 4/7/25, documents, in part, The resident (R6) has Diabetes Mellitus, with interventions that document, in part, Check all of body for breaks in skin and treat promptly as ordered by doctor; Monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs and symptoms) of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. R6's care plan, date initiated 3/21/25, documents, in part, Resident (R6) is at risk for muscle weakness and rigidity R/T: Parkinson's Disease, with interventions that document, in part, Monitor for need of assistance with ADL's (activities of daily living). On 8/11/25 at 10:34am, R6 was observed lying in bed, on R6's right side. R6 said, My (R6) major concern is my (R6) feet. They (feet) hurt so bad. I (R6) think my (R6) toenails are digging in my skin. Especially my (R6) right baby toe. And the bottom of my feet just throb all day. There is something (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 4 of 21 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 08/14/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some going on and I (R6) have asked the nurses for the past 3 months since coming here to have the doctor look at them, but nothing. They (staff) just worry about my butt sore. On 8/11/25 at 10:41am, V16 (Licensed Practical Nurse/LPN) removed R6's socks during foot and skin observation. Upon removal, a significant amount of dry, flaky skin was noted within the socks and on the resident's bed linens. Examination of both feet revealed all toenails to be markedly overgrown, thickened, and discolored with a brownish hue. The nails exhibited sharp and irregular edges. Further assessment of the plantar surfaces revealed the presence of multiple areas of concern: the right foot exhibited two quarter-sized and one nickel-sized areas of hardened, dry, and scaly skin, while the left foot presented with a nickel-sized area of similar characteristics. V16 said, The podiatrist comes here (to the facility) once a month. R6 chimed in stating, That's a lie. I've (R6) been here 3 months, and no one has looked at my (R6) feet. V16 said, Let me check to see when (R6) was last seen by the podiatrist. Upon checking R6's EMR (electronic medical record), V16 stated, I (V16) just put an order for (R6) to see the podiatrist. There was never an order placed for podiatry. Yes, (R6) most definitely needs to see a podiatrist to address her (R6's) toenails and callouses. She (R6) will be seen at the next visit. On 8/12/25 at 10:20am, V17 (Medical Records Coordinator) said, I'm (V17) the contact person for the podiatrist. He (podiatrist) works on his own list, and I (V17) add residents to the list when staff tell me (V17). The next time the podiatrist is coming here (facility) is 8/27 (8/27/25), but I (V17) still don't see her (R6) on the list. I (V17) honestly don't know. I'm (V17) going to call them and find out. On 8/12/25 at 10:55am, V17 (Medical Records Coordinator) said, I (V17) called podiatry and was told she's (R6) not in the system. They (podiatry) just need a consent form and face sheet, and she (R6) will be added to the podiatry list for 8/27 (8/27/25). On 8/13/25 at 11:30am, V2 (Director of Nursing/DON) confirmed that any concerns regarding a resident's feet—particularly for residents with a diagnosis of diabetes—should be addressed promptly, with the resident being evaluated without delay. Record review of R6's most recent MDS (Minimum Data Set), 7/15/25, failed to document existing skin conditions—specifically hard, dry, and patchy areas—present on both of R6's feet, as required in Section M: Skin Conditions. R6's MDS and care plan did not reflect the need for skilled foot care, nor were there documented interventions in place to mitigate the risk of complications related to poor foot condition. Despite the identified risks associated with diabetes and foot conditions, there was no evidence in the medical record of a podiatry consult, referral, or treatment plan. Interviews with staff confirmed that podiatry services had not been scheduled or provided for R6. R6's physician order, ordered date 8/11/2025, documents, in part, Needs podiatrist consult. R6 did not have an order to see a podiatrist until surveyor brought concerns to R6's nurse (V16/LPN/Licensed Practical Nurse). Facility policy titled, Activities of Daily Living (ADLS), dated 4/14, documents, in part, Grooming: Maintaining personal hygiene, including planning the task and gathering supplies, combing and/or styling hair, face and hands, brushing teeth, shaving or applying makeup, oral hygiene, self-manicure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 5 of 21 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 (X3) DATE SURVEY COMPLETED A. Building 08/14/2025 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 0684 (safety awareness with nail care), and/or application of deodorant or powder. Level of Harm - Minimal harm or potential for actual harm Facility policy titled, Resident Rights, dated 11/18, documents, in part, Policy: Employees shall offer all residents privacy and treat all residents with respect, kindness and dignity. To provide an environment of care that supports a positive self-image. Follow instructions, policies, rules, regulations in place to support quality care for residents. Residents Affected - Some Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Findings include: R150 is [AGE] years old admitted to the facility on [DATE], past medical history includes, but not limited to hyperlipidemia, Alzheimer's disease unspecified, unspecified fracture of right femur initial encounter, presence of right artificial hip joint, etc. Per record review, R150 complained of pain to the right leg on 6/15/2025, X-ray revealed right femur fracture, resident was admitted to the hospital, underwent surgical intervention on 6/19/2025 and was readmitted to the facility on [DATE]. Active physician order for R150, reads as follows: Hip Abductor: Place device in place when in bed, Remove during ADL care and prn. Care plan initiated 6/24/2025 states, resident needs Hip Abductor due to limited ROM to RLE r/t Hip Fracture. Goal: Resident will wear abductor daily until next review date. Interventions: Abductor should be placed at hip to ankle level. Staff to ensure device is clean. Staff to ensure straps on each leg are not with tight fit but with and able to place finger in place. 08/11/2025 11:25AM, R150 was observed in bed sleeping on his back, a big mattress was noted on the right side of the bed, resident did not have any hip abduction pad. 08/12/2025 12:15 PM R150 was observed in his room in bed, alert, and oriented x 1 to 2, stated that he is doing okay. Resident did not have any abduction pad between his leg, when asked where his abduction pad is he said that he does not have one. Surveyor asked resident if he ever have a pillow since his surgery and he said no. On 8/13/2025 at 9:35A, R150 was observed again in his room with V21 (C.N.A) who just finished providing resident ADL care. Survey asked V21 about resident's abduction pad and she said, I don't know, resident have not had it for a while, and I cannot say the last time he had it on. At 9:45AM, surveyor presented this observation to V22 (Restorative) who sad that resident no longer need the adduction pad, it was discontinued the last time he went to the doctor. V22 added that he forgot to discontinue the order in the system and to remove it from his care plan. Surveyor requested to see the discontinuation order, and none was presented. At 1:48PM, V22 (Restorative) said that he could not find an order to discontinue the resident's hip abductor, he called the doctor and received an order today. R75 is [AGE] years old and have resided at the facility since2023, past medical history includes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 6 of 21 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 08/14/2025 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 0684 chronic obstructive pulmonary disease, encephalopathy, obstructive sleep apnea, hyperlipidemia, etc. Level of Harm - Minimal harm or potential for actual harm Per record review, R75 have the following active physician order dated 7/2/2025, Oxygen 3LNC continuously. Residents Affected - Some 08/11/2025 10:55AM, R75 was observed in his room, awake and alert and stated he is doing okay. R75 on 3 liters of oxygen via nasal canula, a portable oxygen tank also noted at the bedside. 08/12/2025 12:31PM, R75 was observed in the dining room eating lunch with other residents, did not have any oxygen. 08/12/2025 2:00PM, surveyor followed up with resident who was not in his room and, oxygen concentrator and the portable oxygen tank was still set at 3 liters and was on, portable oxygen tank was at bedside, but the resident was not in the room. Surveyor asked V13 (LPN) where the resident is, and she pointed at him in the still in the dining room. Resident was observed still without oxygen. Surveyor presented this to V13 (LPN) who said that the resident's oxygen is supposed to be continuous, she does not know why the C.N.A did not put it on him. V13 then went to resident's room, bought out his oxygen tank to the dining room and applied oxygen to resident. Oxygen therapy policy (undated) presented by V2 (DON) states in part: to administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Procedures #8. States; Administer oxygen per physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 7 of 21 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 08/14/2025 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor and provide effective supervision to ensure that a resident with a history of alcohol abuse was able to get access to alcohol while in the facility. This affected one resident (R143) reviewed for supervision and monitoring. This failure resulted in R143 being able to obtain alcohol on two separate occasions in the resulting hospitalizations. [NAME], [NAME] (143) OLADINI, BOSEDE (32338) - Hazards/SupervisionR1's records show the following:Face sheet shows that R143 was admitted to the facility on [DATE] with diagnoses which include but are Alcohol Abuse, Opioid Abuse, Bipolar Disorder, Schizoaffective Disorder, Hypertension, Acute Kidney Failure, And Acute Respiratory Failure.Progress notes dated 6/6/25 at 6:55pm written by V13(LPN/Licensed Practical Nurse) states: While writer was passing medications, she heard a loud noise from 2204 from the CNA (Certified Nurse Assistant). On getting there, CNA told writer that resident was almost on the floor and that he assisted him back to chair. Upon assessing resident, he was drowsy and disoriented. the room was in disarray, everything was on the floor. resident v/s taken, wnl. as resident call light was moved closer to him to use to call for assistance writer saw an empty bottle of brandy wine on the bed. resident was asked where he got the bottle from. he became upset and annoyed, saying all kind of F word. resident came out of room to nurses station, threw one of his shoes at a staff. POA called and made aware of behavior. Administrator and nursing manager made aware. MD called order received to send resident out to the hospital for evaluation. Progress notes dated 6/7/25 at 2:56pm written by V12(RN/Registered Nurse) states in part: Resident returned to the facility on stretcher via two escorts from the Hospital where he was seen for aggressive behavior, alcohol intoxication and chronic tremors. Progress notes dated 7/3/25 at 7:30pm written by V14(LPN) states in part: Writer was informed that resident has alcohol in his room under his pillow. Writer went down to residents' room and discovered that there was a liquor bottle under resident's cover. Writer informed appropriate staff. Resident went down to his room and noticed that the bottle was gone. He then proceeded to the nurse station, where his roommate was standing and began to argue with him, shouting and cursing at him. Resident was asked to calm down to which resident refused and continued to argue with roommate.On 8/13/25 at 2:25pm, V27(Medical Director) was interviewed about residents getting access to alcohol and becoming intoxicated and being sent to the hospital two times in a row within 4 weeks interval. V27 was also asked about the possible effects on the residents. V27 stated They notified me about the situation. When we find out, we ensure that the resident is monitored more closely. V11 added Alcohol intake will affect the resident's medications like antipsychotics and blood pressure medications. Not only a resident, but anyone also who gets intoxicated with alcohol. The person will also be at high risk for falling, and the risks of intoxication. We try to get the resident to attend AA (Alcohol Anonymous), and we do closer monitoring.On 8/13/25 at 1:30pm, V29(Social Services Director) was asked about the interventions as listed on the alcohol abuse care plan for R143. V29 stated that R143 has a serious alcohol abuse issue and has been having 1:1 therapy session with a Licensed Clinical Social Worker, and the staff will continue to monitor R143 closely.R143's other records:Care Plan dated 6/16/25 states in part that resident has a history of substance abuse/chemical dependency related to: Resident has a diagnosis of opioid abuse and alcohol use Intervention states: Work with the resident to establish a verbal or written behavioral contract specifying what is and what is not allowed. Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances & intoxication.Face sheet shows diagnoses which include but are not limited to Major Depressive Disorder, And Generalized Anxiety Disorder.BIMS (Basic Interview for mental status) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 8 of 21 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 08/14/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete score dated 6/16/25 shows 15(Cognitively Intact).Community Survival Skills assessment dated [DATE] states in #4 that resident appears to be able to refrain from self-harmful and socially inappropriate behavior while in the community, including abstaining from alcohol and illicit drugs. Correct commendations and outcomes states that the resident appears to be capable of outside past privileges at this time.On 8/12/25 at 12:38pm, V1(Administrator) was notified about the concern that a resident at the facility had access to alcohol and got intoxicated, almost falling, and was sent to the hospital, and that this same resident was found with a bottle of alcohol that was provided by a staff member without doctor's order just 4 weeks later. V1 responded that now, if a resident is found with alcohol, or drugs, they would take their pass away.On 8/12/25 at 12:00pm, V7(Assistant Administrator) stated that's the facility did not know how the resident got the alcohol that intoxicated him on 6/6/25, but that the bottle of alcohol that was found on him on 7/3/25 was purchased for him by a staff member and that the staff members had since been terminated after investigation. V7 later presented the documents titled Corrective Action dated 7/8/25.R143's hospital records dated 6/7/25 written by V8 (Hospital Physician) shows a diagnosis of alcohol intoxication, aggressive behavior, and chronic tremor. The hospital physician further stated that the patient's aggressive behavior was related to alcohol intoxication.R143's hospital records dated 7/9/25 shows admission diagnoses of Aggressive Behavior, Alcohol Intoxication, Chronic Tremor, Hypertension, Hypothyroidism, And COPD (Chronic Obstructive Pulmonary Disease).Facility's Contraband Items list shows that Glass Bottle and Rubbing Alcohol are on the list of Contrabands.Facility's document titled House Rules #6 states: Drug and Alcohol use are strictly prohibited while living at the facility. Residents should not use drugs or alcohol while out on pass or living at the facility. #7 states: Illegal or non-prescribed drugs or alcohol may not be brought into the facility premises. Event ID: Facility ID: 145220 If continuation sheet Page 9 of 21 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 08/14/2025 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the required daily nurse staffing information was accurately completed and consistently posted. These failures have the potential to affect all 161 residents residing in the facility.Findings include:On 08/11/25 at 9:20 AM, upon entry into the facility, surveyor observed the Daily Nurse Staffing information posted near the receptionist area. The most recent posting was dated 08/06/25, indicating that accurate and current staffing data had not been posted for five consecutive days. The facility's daily nursing staffing also lacked the required unit-specific information. This prolonged lapse reflects a failure to maintain essential information required for public review and resident rights.On 08/11/25 at 11:30 AM, V2 (Director of Nursing) confirmed that the facility is required to post accurate and up-to-date daily staffing information each day. V2 stated, It (daily nursing staffing) needs to be posted daily.Record review of the facility's Daily Nursing Staffing form posted on 8/11/25, documents in part, (Name of facility); Date: 8/06/25, showed that it not only reflected an incorrect date but also lacked unit-specific information, further indicating a failure to ensure completeness and accuracy of the required posting.Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 10 of 21 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 08/14/2025 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 0759 Ensure medication error rates are not 5 percent or greater. 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 five percent (5%) or lower medication error rate. There were 3 medication errors out of 25 medication opportunities resulting in an 11% medication error rate. This failure affected two residents (R47 and R52) of five residents reviewed for medication administration. Findings include:On 8/12/2025 at 8:30AM, observed medication administration with V20 (LPN) on the first floor of the facility. The first resident observed was R47, a [AGE] year-old female who have a diagnosis of polyneuropathy among others. V20 administered 10 medications to R47, among the medications given was:Gabapentin Oral Tablet 600 MG (Gabapentin) 1 tablet by mouth.Active physician order for R47 shows the following. Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy; reducing dose due to weight gain. Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy give in addition to 600mg=700mg TIDUpon medication reconciliation, V20 signed the gabapentin 100mg as given in the medication administration record (MAR), though she only gave 600mg, not 700mg as ordered.8/12/2025 at 8:50AM, V20 also gave medications to R52 who is [AGE] years old and have a diagnosis of essential primary hypertension among others.V20 took a blood pressure for R52 which read 101/63, heart rate of 97.V20 administered 5 medications to R52 and held the Chlorthalidone 25 mg oral tablet due to the systolic blood pressure of 101. Review of active physician order for R52 showed the following:Chlorthalidone Oral Tablet 25 MG (Chlorthalidone) Give 1 tablet by mouth one time a day for htn Hold if SBP<120.Valsartan Tablet 40 MG Give 2 tablet by mouth one time a day for HTN 2 tabs=80mg: HOLD IF SBP<110Amlodipine Besylate Tablet 5 MG Give 5 mg by mouth in the morning for hypertension 1 tab=5mg: HOLD IF SBP<110.Per medication reconciliation, a review of medication administration record showed that amlodipine 5mg ad Valsartan 40mg were both signed out as given by V20, with a documented blood pressure of 101/63. Both medications were omitted during medication administration observation and should have been held due to resident's blood pressure as ordered.On 8/13/225 at 11:35AM, V2 (DON) said that her expectations from nurses during medication administration is to the five rights of medication administration, (right resident, right medication, right time, right route, and right order) as well as maintaining proper hand hygiene and resident's privacy.Medication administration policy (undated) presented by V2 (DON) states in part that only a licensed nurse is permitted to administer medications to residents.Medications should always be prepared, administered, and recorded by the same licensed nurse.Documentation of medication administration is recorded in the medication administration record (MAR) or treatment record and includes date, time and initials of the licensed nurse who administered the medication.Under administration, the policy states tin part that medications must be administered in accordance with a physician's order, e.g. right resident, right medication, -------, and right time. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 11 of 21 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 08/14/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to refrigerate medications as instructed, failed to destroy discontinued narcotic medications, and failed to label medications with an appropriate open/expiration date in accordance with accepted professional standards. This failure affects 6 residents (R42, R51, R70, R107, R136, and R137) in a sample of 70 residents reviewed for medication storage.Findings include:On [DATE] at 11:14 AM, observed R136's Lorazepam Injection Solution 2 mg/mL within the controlled substance narcotics drawer in the medication cart unrefrigerated. A sticker on the packaging of the medication instructed staff to keep the medication refrigerated. V13 (Licensed Practical Nurse) observed the Lorazepam and its packaging and affirmed that the Lorazepam should be kept in the refrigerator per the manufacturer's instructions to maintain the medication's patency.R136's physician orders document in part that the Lorazepam Injection Solution 2 mg/mL was discontinued on [DATE].On [DATE] at 11:21 AM, observed R137's Lorazepam Oral Concentrate 2mg/ML within the controlled substance narcotics drawer in the medication cart unrefrigerated. A sticker on the packaging of the medication instructed staff to keep the medication refrigerated. V23 (Licensed Practical Nurse) observed the bottle of affirmed that the Lorazepam should be kept in the refrigerator per the manufacturer's instructions to maintain the medication's patency.R137's physician orders document in part that the Lorazepam Oral Concentrate 2mg/mL was discontinued on [DATE].On [DATE] at 11:25 AM, the following medications were observed in the medication cart with V23 (Licensed Practical Nurse) without an open date or an expiration date: R70's opened Humalin solution vial, R42's opened Humalog vial, R51's opened insulin lispro vial. R107's opened vial of Insulin Aspart was noted with a discard date of 7/23. V23 affirmed that all multi-dose insulin vials and pens are to be labeled with the open date and discard date to ensure the insulin remains potent. V23 stated that insulin is good for 28 to 30 days after opening. V23 stated that R170's insulin is expired and removed R170's insulin from the medication cart.On [DATE] at 10:36 AM, V2 (Director of Nursing) affirmed that the facility expectation is that liquid lorazepam is stored in the refrigerator and that all multi-use insulin containers are labeled and dated when opened. V2 stated that when medications are discontinued, they should be removed from the cart.Facility policy titled, Labeling/Dating Meds (8/2018) documents in part, Purpose: to ensure that medications are being used timely in accordance to manufacturer's recommendations .the following medications MUST be dated when first opened: Insulin - opened date - expiration date (generally 28 days) - nurse initials .Facility policy titled, 3.1: MEDICATION STORAGE IN THE FACILITY (7/2017) documents in part, .11. Medications requiring refrigeration or temperatures between 36 and 46 degrees Fahrenheit are kept in a refrigerator . 14. Outdated, contaminated or deteriorated drugs and those in containers which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists . Event ID: Facility ID: 145220 If continuation sheet Page 12 of 21 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 08/14/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services in the facility's kitchen by failing to: remove ice from the ice machine, clean the visible dirt on the ice machine, clean the food mixer, and failing to clean the debris left on the floor of the kitchen by the grease trap backing up from under the kitchen floor. These failures have the potential to cause food borne illness in all 159 residents that receive food from the facility's kitchen.Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen.On 8/11/25 between 10:10am and 10:41 am during kitchen observation, the following were observed with V6(Dietary Manager):The floor of the kitchen close to the wall was observed with debris left on the floor of the kitchen from the grease trap backing up from under the kitchen floor. V6 stated that this happens frequently, and Maintenance has been aware of this for a long time. When the surveyor observed that there were only 2 staff working in the kitchen with V6 and asked V6 to be sure that the floor was cleaned as soon as possible because grease trap back-up is like sewer back up and that was an unsanitary condition in the kitchen, V6 explained that there should have been 3 staff working with her (V6), but someone had a scheduled sick-day off. V6 stated that the kitchen was running behind but that she would ensure that the floor was cleaned.The ice machine was observed with visible dirt on the left, right and front sides. The ice machine also was overflowing with ice and the cover (which V6 stated had been broken for a while) was observed on the wet blankets placed on the floor to catch the water dripping from the ice. V6 stated that staff should have emptied the ice into the ice cooler this morning and taken it to the 1st floor and 2nd floor for residents. Inquired from V6 why there were only 2 staff working with her(V6) in the kitchen, V6 stated that a staff member had a sick day off that had been requested for a while and on the schedule; V6 later showed the surveyor the schedule. V6 explained that she(V6) was working the position of the staff who is off and that usually, the ice machine should have been almost empty after taking ice to the floors. The food mixer that was covered with transparent plastic wrap was observed to have accumulated food particles. V6 stated that it should have been cleaned before being covered but they were running behind due to her (Dietary Manager) functioning in the position of absent staff. V6 stated that she would ensure to clean the food mixer.On 8/12/25 at 10:30am, it was observed that 4 staff were working in the kitchen. The kitchen was clean without blankets on the floor to catch water/grease trap leaks, and the ice machine was not overflowing to the floor with ice and water and there was no wet blanket on the floor of the ice machine.On 8/12/25 at 11:34am, V6 stated Today, we have enough staff and everything is going smooth.On 8/13/25 at 11:30am, V7(Assistant Administrator) presented the Dietary staff Job Description for the staff that works 6:30am-3:00pm. This document shows that the Dietary Aide was supposed to Make sure all hydration stations are filled. The Job Description for the AM [NAME] that works 5:30am to 2:00pm includes cleaning the cook area.Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers. Event ID: Facility ID: 145220 If continuation sheet Page 13 of 21 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 08/14/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 ensure that refrigerated milk cartons are stored at a temperature to protect against food spoilage(below 41 degrees), failed to clean the air vent/vent return above the food prep table, failed to clean the ice machine, failed to clean the food mixer, and failed to clean the debris left on the floor of the kitchen by the grease trap backing up from under the kitchen floor. These failures have the potential to cause food borne illness in all 159 residents that receive food from the facility's kitchen.Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen.On 8/11/25 between 10:10am and 10:41 am during kitchen observation, the following were observed with V6(Dietary Manager):The floor of the kitchen close to the wall was observed with debris left on the floor of the kitchen from the grease trap backing up from under the kitchen floor. V6 stated that this happens frequently, and Maintenance has been aware of this for a long time. When the surveyor observed that there were only 2 staff working in the kitchen with V6 and asked V6 to be sure that the floor was cleaned as soon as possible because grease trap back-up is like sewer back up and that was an unsanitary condition in the kitchen, V6 explained that there should have been 3 staff working with her (V6), but someone had a scheduled sick-day off. V6 stated that she would ensure that the floor was cleaned.The air vent/vent return above the food prep table was observed with accumulated dust. V6 stated that she(V6) would call maintenance to clean the air vents.The ice machine was observed with visible dirt on the left, right and front sides. The ice machine also was overflowing with ice and the cover (which V6 stated had been broken for a while) was observed on the wet blankets placed on the floor to catch the water dripping from the ice. V6 stated that staff should have emptied the ice into the ice cooler and taken it to the 1st floor and 2nd floor for residents. Inquired from V6 why there were only 2 staff working with her(V6) in the kitchen, V6 stated that a staff member had a sick day off that had been requested for a while and V6 later showed the surveyor on the schedule.The food mixer that was covered with transparent plastic wrap was observed to have accumulated food particles. V6 stated that it should have been cleaned before being covered.The milk cooler temperature thermometer showed 55 degrees Fahrenheit. V6 stated that the milk cooler did not read the correct temperature because staff have been opening and closing it so frequently. Two hours later, the surveyor and V6 used the ice point calibration method to calibrate a new thermometer brought out by V6. After the thermometer calibration, V6 brought out one carton of milk that had been supplied 4 days earlier (Thursday) and had been in the same refrigerator. V6 explained that it was better for us to check the milk that had been there for four days rather than checking the milk that was just supplied today. 2 out of the twelve 8-ounce cartons of Whole Milk (all stored in a plastic milk crate) that were received from the supplier 4 days earlier were found to be 51 F. V6 stated that the milk temperature should be less than 41 F. V6 proceeded to dump all the 12 cartons of milk in the garbage can.On 8/13/25 at 1:35 PM, V6 told the surveyor that she (V6) cleaned out the milk refrigerator and the milk refrigerator was not used the previous day and that it is now working well and maintaining the milk to the correct temperature below 41 .Facility's monthly resident council meeting minutes dated 2/27/25 and 3/27/25 both show that residents were complaining about spoiled milk. Facility's undated policy on food storage stated in part: Protect food from contamination, to ensure wholesomeness, and to prevent the spread of infections and communicable diseases. #3 states: Perishable foods shall be stored at the specified temperatures to protect against spoilage. This policy shows that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 14 of 21 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 08/14/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete dairy products and eggs are supposed to be stored at between 33 to 41 F. Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers.Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers. Event ID: Facility ID: 145220 If continuation sheet Page 15 of 21 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 08/14/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide sufficient personal protective equipment to meet the needs of residents that require enhanced barrier precautions. This failure has the potential to affect 4 residents (R5, R6, R24, R110) residents in a sample of 70 residents reviewed for infection control.Findings include:Facility document titled Enhanced Barrier Precautions (8/2025) documents in part the following residents require enhanced barrier precautions: R24 (gastrostomy tube), R110 (wound), R5 (wound), and R6 (wound).On 8/11/2025 at 10:58 AM, observed signage indicating enhanced barrier precautions on R5, R6, R24's, R110's room door. The signage indicated that gloves and gown were required when performing resident care. One isolation bin was observed within the 2400 and no gowns were noted within the bin. No other PPE was noted within the 2400 unit. V25 (Certified Nursing Assistant) affirmed that V25 is assigned to care for the residents within the 2400 unit. V25 observed the PPE bin and affirmed that there were no gowns for the unit for residents that require enhanced barrier precautions. V25 stated, I (V25) wouldn't be able to care for the residents properly without a gown and gloves. It (enhanced barrier precautions) requires a gown and gloves to provide care to the resident. On 8/13/2025 at 10:34 AM, V2 (Director of Nursing) affirmed that the facility's expectation is that personal protective equipment is readily available for staff as indicated for resident needs.Facility policy titled, ENHANCED BARRIER PRECAUTIONS (revised 9/2023) documents in part, Purpose: Recommendations from CDC to protect residents from multidrug resistant organisms. Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of acquiring MDRO . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 16 of 21 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 08/14/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that essential kitchen equipment such as the 3 Compartment sink water-drain works correctly to drain water without causing a drain back-up of grease/dirty water to the floor, failed to ensure that the milk refrigerator works efficiently to keep milk below 41 degrees Fahrenheit, and failed to fix the broken cover of the ice machine. These failures have the potential to affect all 159 residents that receive food from the facility's kitchen.Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen.On 8/11/25 between 10:10am and 10:41 am during kitchen observation, the following were observed with V6(Dietary Manager):The floor of the kitchen close to the wall was observed with debris left on the floor of the kitchen from the grease trap backing up from under the kitchen floor. V6 stated that this happens frequently, and Maintenance has been aware of this for a long time. V6 stated that she would ensure that the floor was cleaned.The ice machine overflowing with ice and the cover could not fit properly to cover the ice. V6 stated the Ice machine cover had been broken for a while. V6 was observed placing the broken ice machine cover on the wet blankets placed on the floor to catch the water dripping from the ice. V6 stated that the broken ice machine cover had been reported several times and added that the ice machine would need replacement.The milk cooler temperature thermometer showed 55 degrees Fahrenheit. V6 stated that the milk cooler did not read the correct temperature because staff have been opening and closing it so frequently. Two hours later, the surveyor and V6 used the ice point calibration method to calibrate a new thermometer brought out by V6. After the thermometer calibration, V6 brought out one carton of milk that had been supplied 4 days earlier (Thursday) and had been in the same refrigerator. V6 explained that it was better for us to check the milk that had been there for four days rather than checking the milk that was just supplied today. 2 out of the twelve 8-ounce cartons of Whole Milk (all stored in a plastic milk crate) that were received from the supplier 4 days earlier were found to be 51 F. V6 stated that the milk temperature should be less than 41 F. V6 proceeded to dump all the 12 cartons of milk in the garbage can.V6 added that the refrigerator should be cold enough to keep milk below 41 degrees.On 8/12/25 at 2pm, V10(Maintenance Director) stated that for him to fix the issue with the grease trap and prevents the back up so the kitchen floor, here we would have to open the wall of the kitchen and turn off water supply for the whole building. V10 stated that he could do that whenever it is possible to turn off water supply to the whole building.On 8/12/25 at 11:15am, with V1(Administrator) and V6 in the kitchen, V1 explained to the surveyor that the kitchen staff should not empty the three compartment sink all at the same time. V1 explained that if the whole water in the three-compartment sink is not emptied all at the same time, the grease trap under the kitchen floor would not overflow and back up on to the kitchen floor. V1 stated that he would continue to monitor how the kitchen staff empty the three-compartment sink and see whether or not the drain would back up onto the kitchen floor again. Facility's maintenance log sheets for July and August 2025 show that V6 and other dietary staff logged in several maintenance issues with kitchen equipment dated 7/3/25, 7/22/25, with kitchen equipment including the three-compartment sink leaking and Ice machine lid needs to be replaced. No evidence on the log sheet that these issues were addressed or resolved.Facility's preventative maintenance program policy says in part: to conduct regular environmental tours safety audits to identify areas of concern within the facility. #3 States preventative maintenance program will review the following areas during random rounds: #5 stats: All facility areas are kept clean and in safe condition. #17 states: Drains are cleaned and free of debris.Facility's document Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 17 of 21 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 08/14/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete titled Maintenance Director- Job Description states in #2: Maintains the building in good repair and free of hazards such as those caused by electrical, plumbing, heating, and cooling systems, life safety, etc.Facility's policy on dietary services states in #8f: All food equipment, utensils, dishes, steam tables, should be cleaned and sanitized daily. #8h: Ice machines are used and maintained in a manner that eliminates contamination during ice manufacture, storage, and dispensing. #8L: All floor surfaces should be cleaned daily and as appropriate using appropriate cleansers.Facility's undated policy on food storage stated in part: Protect food from contamination, to ensure wholesomeness, and to prevent the spread of infections and communicable diseases. #3 states: Perishable foods shall be stored at the specified temperatures to protect against spoilage. This policy shows that dairy products and eggs are supposed to be stored at between 33 to 41 F. Event ID: Facility ID: 145220 If continuation sheet Page 18 of 21 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 08/14/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the call lights in 2 out of 3 shower rooms on the second floor were functioning properly. This deficient practice has the potential to affect all 91 residents that reside on the second floor of the facility.Findings include:Facility census, dated 8/11/25, documents 91 residents residing on the third floor.On 8/11/25, at 11:08 a.m., during an observation of the second-floor shower rooms conducted with V13 (Licensed Practical Nurse/LPN), it was identified that the call lights in 2 of the 3 shower rooms were nonfunctional. V13 confirmed the issue, stating, Maintenance is working on fixing them (call lights in the showers). Any of the shower rooms can be used by any of the residents on this (second) floor. They (call lights in the showers) haven't been working since Friday (8/8/25). Yes, the call lights are important for patient safety. On 8/13/25 at 11:20am, V10 (Maintenance Director) stated that an external company had been contacted to repair the inoperative call lights in the second floor shower rooms. V10 was unable to confirm the duration for which the call lights had been nonfunctional.On 8/11/25 at 11:30am, V2 (Director of Nursing/DON) said, It wasn't long since the call lights in the second floor shower room weren't working. Like 2 or 3 days. An outside company was had to be called out to fix them. V2 affirmed that the call lights must be operable and functioning properly in the event a resident requires immediate staff accessibility.Facility policy titled, Call Light, dated 4/14, documents, in part, Purpose: To respond to residents' requests and needs in a timely manner. 3. Bathroom lights should be viewed as emergencies and immediate attention should be give. 6. Call bell system defects will be reported promptly to the Maintenance Department for servicing. Facility policy titled, Resident Rights, dated 11/18, documents, in part, . Follow instructions, policies, rules, regulations in place to support quality care for residents and a safe environment for all individuals in the facility. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 19 of 21 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 08/14/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to clean and maintain the dryer lint screens thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 161 residents at the facility.Findings include:Facility census, dated 8/11/25, documents 161 residents residing at the facility.On 8/12/2025 at 10:57am, during a tour of the laundry area with V19 (Housekeeping Supervisor), three dryers were observed. V19 opened the lint compartment dryer #1. The lint compartment floor was clean however the lint screen was fully covered with lint. V19 opened the lint compartment dryer #2. The lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. V19 opened the lint compartment dryer #3. The lint compartment floor had a large amount of loose lint on the floor and the lint screen was fully covered with lint. V19 said, This (lint) needs to be cleaned up right away. They (lint screens/compartments) are cleaned out every shift. Not cleaning the lint out can cause a fire.On 8/13/25 at 11:30am, V2 (Director of Nursing/DON) acknowledged that failure to regularly clean dryer lint compartments poses a significant fire hazard and jeopardizes the safety of residents, staff, and the facility. V2 said, The dryer lint should be cleaned out, just like home, after each load.Facility policy titled, Laundry Services, revised date 8/17/23, documents, in part, . Note: It is the responsibility of the Laundry Staff to maintain cleanliness of the laundry room and its equipment. Machines should be cleaned and disinfected minimal daily. Facility policy titled, Resident Rights, dated 11/18, documents, in part, . Follow instructions, policies, rules, regulations in place to support quality care for residents and a safe environment for all individuals in the facility. Event ID: Facility ID: 145220 If continuation sheet Page 20 of 21 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 08/14/2025 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that handrails were secured along the resident corridors. This failure has the potential to affect 21 residents that reside within the 2400 unit.Findings include:Facility provided census documents in part that 21 residents reside within the 2400 unit.On 8/12/2025 at 9:39 AM, observed the handrail near the elevator in the 2400 unit detached from the wall and hanging down approximately 6 inches. A hole approximately 4 inches long was observed where the handrail was anchored to the wall. When pressure was applied to the bottom and top of the handrail, the handrail was loose and was able to move approximately 6 inches. V3 (Assistant Director of Nursing) observed the handrail and affirmed that the handrail was not secured to the wall. V3 stated, it (the handrail) could be tightened, I'll call maintenance.On 8/13/2025 at 10:33 AM, V2 (Director of Nursing) affirmed that the expectation of the facility is that handrails are securely affixed to the walls in case a resident needs assistance with ambulation.Facility policy titled, Preventative Maintenance Program (4/21/21) documents in part, Purpose: To conduct regular environmental tours/safety audits to identify areas of concerns within the facility. 5. All facility areas are kept clean and in safe condition. 8. Are hand rails present and in working condition. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145220 If continuation sheet Page 21 of 21