Inspection·November 29, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm her CNA is. At 2:14 PM, R41 continues to yell out and crying she has to use the bathroom. V17 wheeled R41 to her room and told her I'm waiting for someone to take you. V26 (CNA) came to R41's room to assist. V26 said she is working on a different wing and was pulled to assist R41. V26 assisted R41 to the toilet and removed her stool soiled incontinent brief. At 2:25 PM, V16 (CNA) said she is R41's CNA and was on break. V16 said R41 was last toileted in the morning. Residents Affected - Few R41's Minimum Data Set assessment dated [DATE] shows she requires extensive assist with toileting. On 11/29/23 at 9:10 AM, V15 (CNA) said residents should be checked and changed every two hours for incontinence care. There should also be two staff in the dining room, one activity aide and one CNA to assist residents with toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 2 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm 3. On 11/27/23 at 10:10 AM, R84 was observed lying in bed with her heels resting on the mattress and not off-loaded. Her heel protector boots were on her chair in her room. V14 (RN) said R84 has no pressure ulcers, but had a history of pressure ulcers on her heels. Residents Affected - Few On 11/28/23 at 9:15 AM, R84 was observed lying in bed with her heels resting on the mattress. Her heel protector boots were on her chair. On 11/29/23 at 11:45 AM, V5 (Wound Nurse) said R84 has unstageable pressure ulcer to her right heel and her heels should be off-loaded or have her heel protector boots on. R84's Physician Progress note dated 11/22/23 documents she has unstageable pressure ulcer to the right heel measuring 5 cm (centimeters) x 7 cm x 0.1 cm and 100% necrotic (non-viable dead tissue). R84's Current Care Plan revised on 11/29/23 documents she has impairment to her skin integrity: right heel unstageable pressure ulcer and scored a 10 on the skin risk scale which categorizes her as having severe risk for skin breakdown with interventions to off load pillow while in bed with heel boots or pillows. The facility's Prevention of Pressure Ulcers Policy dated March 2020, states, The Purpose of this procedure is to provide information regarding the identification of pressure ulcer risk factors and interventions for specific risk factors .33. When in bed, every attempt to should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by the therapist and prescribed by the physician. 2. On 11/27/23 at 10:28 AM, R213's right heel was wrapped in gauze and had a sock over it. R213's right and left heels were flat on the mattress. R213 stated I got a sore on my foot, it's not getting better. They have been doing treatments awhile now. On 11/28/23 at 9:37 AM, R213 was in bed with both heels flat on the mattress. On 11/29/23 at 11:37 AM, V5 Wound Registered Nurse said R213 has a pressure injury to his right heel. V5 said R213's heels should be offloaded off the mattress or he should have heel boots on. R213's Wound Note dated 11/22/23 shows R213 has a Stage IV pressure injury to his right heel. Recommend honey and calcium alginate with dry dressing daily and prn. Offload as tolerated. Based on observation, interview, and record review the facility failed to ensure dressings and pressure relieving interventions were in place for residents with pressure injuries and at risk for pressure injuries. This applies to 3 of 8 (R3, R213, R84) reviewed for pressure in the sample of 35. Findings include: 1. On 11/27/2023 at 9:59 AM, R3 said she did not have a dressing in place on her right side. R3 said she hasn't had a dressing in place for a couple of days. On 11/27/2023 at 10:30 AM, V5 Wound Nurse and V31 Wound Nurse were observed providing wound care to R3. No dressing was observed on R3's pressure injury on her right gluteal fold when R3 was checked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 3 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by V5 and V31. V31 measured the area and stated it was 8cm (centimeters) x 6cm. V5 said a dressing should be in place. V5 said the order for dressing changes was every 3 days and as needed when soiled or loose. R3's 11/27/2023 Progress Note shows R3 had a deep tissue pressure injury to the right gluteal fold with no signs and symptoms of infection. R3's Order Summary Report Dated 11/28/2023 shows an order for the Right gluteal fold: Cleanse with normal saline, pat dry, apply hydrocolloid every 3 days and prn (as needed) if soiled/loose. R3 Treatment Administration Record (TAR) dated 11/1/2023 to 11/30/2023 shows daily skin checks completed daily from the order start date of 11/9/2023 to 11/27/2023. The facility's Prevention of Pressure Ulcers policy dated 2020 states, provide and administer medications and treatments as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 4 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to safely transfer residents. The facility also failed to supervise a resident who is at a high risk for falls and has history of falls for 3 of 35 residents (R76, R68, R41) reviewed for safety and supervision in the sample of 35. Findings include: 1. R76's electronic medical record accessed on 11/28/23 show R3 has diagnosis of dementia and in need of 2 plus staff for transfer. On 11/27/23 at 12:25 PM, V5 (Wound Nurse) and V6(Certified Nursing Assistant-CNA) were transferring R76 from his wheelchair to bed. V5 (Wound Nurse) applied a gait belt to R76 while V6 (CNA) held onto R76 who was unable to sit up in his wheelchair. R76 was leaning back. During the transfer, R76 was unable to bear weight. R76 was lifted under his arms and transferred to bed. When R76 was being transferred back to his wheelchair, R76 was unable to hold himself up and again kept leaning back. V5 held R76's back for R76 to sit upright. A gait belt was again applied. V5 and V6 transferred R76, held onto the gait belt in R76's waist but lifted R76 under his arms. R76 was unable to bear any weight. V5 said R76 had declined and now unable to bear weight and needs to be assessed for safe transfers. On 11/28/23 at 9:20 AM, V20 (Restorative Nurse) said R76 has poor trunk control and was not safe to transfer via a gait belt, R76 needs to be transferred via a mechanical lift. The facility Transfer Policy dated March 2000, shows Residents in the facility will be transferred safely from one location to another using the proper transfer technique. 2. R68's face sheet shows she is a [AGE] year old female with diagnoses including unspecified dementia with other behavioral disturbance, frontal lobe and executive function deficit following cerebral infarct, bipolar disorder and repeated falls. R68's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires partial/moderate assistance with sit to stand transfers and walking assistance. R68's Fall Risk assessment dated [DATE] shows she is a HIGH risk for falls. On 11/27/23 at 11:50 AM, R68 was observed in the dining room in her wheelchair. She has a black left eye with a laceration above her left eyebrow. She was attempting to stand from her wheelchair repeatedly. V14 (RN) assisted R68 back in the wheelchair. V14 said R68 had a recent fall and is high risk for falls. She needs continuous monitoring. On 11/28/23 at 9:18 AM, R68 was observed walking unsteady without staff assistance from the dining room into the hallway. V33 (RN) said she can not walk alone. V17 (Activity Aide) stated, I know I'm only one person. On 11/28/23 at 2:46 PM, V20 (Restorative Nurse) said R68 is a high risk for falls. She a history of falls with most recent she tripped and fell. She used to walk independently but now needs one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 5 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0689 person extensive assist with a gait belt. She should not be walking without staff assistance. Level of Harm - Minimal harm or potential for actual harm R68's Current Care Plan revised 11/24/23 documents she is at risk for falls related to gait/balance problems actual falls on 8/18/23, 10/17/23, 10/24/23, and 11/24/23 with interventions included downgrade to wheelchair use for ambulation, encourage resident to stay in the atrium after each meal and anticipate and meet the resident needs. The care plan did not include her transfer status or use of a gait belt with ambulation/transfers. Residents Affected - Few 3. R41's face sheet shows she is a [AGE] year old female with diagnoses including unspecified dementia, unspecified fall, urine retention, and obstructive reflux uropathy. R41's Minimum Data Set assessment dated [DATE] shows she requires extensive two person assist with toileting. R41's Fall Risk assessment dated [DATE] shows she is at risk for falls. On 11/27/23 at 2:03 PM, R41 was observed in her reclining chair in the dining room. She was yelling out in Spanish help me, help me. R41 had a indwelling urinary catheter in place. She said has to use the bathroom to have a bowel movement. V17 (Activity Aide) was notified R41 needed to use the bathroom. At 2:08 PM, R41 is yelling out help me, help me and crying she needs to use the bathroom. V17 said R41's nurse is on break, I'm going to get a CNA. At 2:14 PM, R41 continues to yell out and crying she has to the bathroom. V17 wheeled R41 to her room and told her I'm waiting for someone to take you. V26 (CNA) came to R41's room to assist. V26 asked V17 does R41 stand, V17 stated, I don't know. V26 said she is working on a different wing and was pulled to assist R41. V26 transferred R41 from her recliner chair to the toilet without using a gait belt. R41's gait was unsteady and she was unable to stand upright as V26 transferred her. On 11/29/23 at 9:26 AM, V34 (RN) said R41 is alert to self and communicate her needs. She is two person assist for transfers. The facility's Transferring a Resident from one location to another Policy dated March 2020 states, Residents in the facility will be transferred safely from one location to another using the proper transfer technique .transfer the resident; obtain help when necessary, or as identified on care plan/care card . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 6 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure a residents urinary catheter tubing and drainage bag was below the level of the bladder for 1 of 8 residents (R380) reviewed for urinary catheter care in the sample of 35. Findings include: R380's Face sheet shows R380 has diagnoses of hyrdonephrosis with ureteropelvic junction obstruction and retention of urine. R380's Care Plan shows R380 has a history of urinary tract infections requiring antibiotic treatment. On 11/27/23 at 10:16 AM, R380 was in bed leaning on her left side. R380's urinary catheter tubing was coming from R380's urethra and draped over R380's upper right leg close to her hip. There was yellow urine in the tubing that was unable to drain into the drainage bag. R380 said she had just returned from the hospital and had problems with the shunt in her kidneys and they put the urinary catheter in. On 11/28/23 at 9:12 AM., R380 was in bed with the urinary catheter drainage bag hanging on bed rail even with mattress. There was yellow urine in tubing all the way to R380's urethra. The tubing was level with drainage bag and at the entrance of the bag the tubing went upward before draining into the bag. The urine was unable to go up the tubing at this point to drain into the collection box attached to the urinary catheter bag. On 11/29/23 at 9:59 AM, V10 Registered Nurse said urinary catheter bags and tubing should be below the level of the bladder so the urine can drain into the bag to prevention urine retention and infection. The facility's Catheter Care Policy dated 3/2020 shows check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. The urinary drainage bag must be held or positioned lower then the bladder at tall times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 7 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 to ensure a resident with a diagnosis of dementia that is exhibiting behaviors,, was provided necessary care and services. This applies to 1 of 10 residents (R68) reviewed for dementia care in the sample of 35. Residents Affected - Few Findings include: 1. R68's face sheet shows she is a [AGE] year old female with diagnoses including unspecified dementia with other behavioral disturbance, frontal lobe and executive function deficit following cerebral infarct, bipolar disorder and repeated falls. R68's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, has little interest or pleasure in doing things, trouble concentrating on things, being so fidgety or restless that have been moving around a lot more than usual, being short tempered, easily annoyed, has behaviors of hallucinations, delusion, physical, verbal and other behavioral symptoms not directed towards others, and wandering behaviors daily. On 11/27/23 at 10:51 AM, R68 was observed in the dining room sitting in her wheelchair. She had a large left black eye with laceration above her left eyebrow. Several residents were in the dining room with two activity staff present. Music was playing in the background. R68 was making several attempts to stand up from her wheelchair. V17 (Activity Aide) re-directed her to sit back in her wheelchair. R68 attempted to stand from her wheelchair three times and V17 re-directed back into her wheelchair. After the third attempt V17 wheeled R68 around in her wheelchair then back into the activity room. R68 stood again from her wheelchair. V17 ambulated with R68 then placed her back in her wheelchair. On 11/27/23 at 11:50 AM, V14 (RN) was wheeling R68 in her wheelchair. R68 was making several attempts to stand from her wheelchair. V14 re-directed R168 back into her wheelchair. On /11/27/23 at 2:13 PM, V17 (Activity Aide) said she has battle wounds from R68. R68 scratched her chest and arms. V17's hands and chest with visible scratches and red marks. On 11/28/23 at 9:26 AM, R68 was combative and attempted to hit V19 (Transportation Aide) and then pulled her hair. V19 re-directed R68 back into her wheelchair. R68 remained standing behind R68's wheelchair. R68 attempted to stand up and V19 assisted her back into the wheelchair. At 9:28 AM, V19 said this is my first time with R68, I'm a transportation escort. She said staff did not let her know of R68's behaviors. I'm trying to calm her down, attempting to re-direct her but she keeps on getting up. She's bored and her mind is wandering. She asked another staff in the dining room if thee was something they could give R68. On 11/28/23 at 9:32 AM, V17 (Activity Aide) said R68 is combative and difficult to re-direct. We try to walk with her, wheel in her around in her wheelchair, try to color with her. There is no direction from nursing or how to handle her behaviors, I'm trying to figure things out on my own. I reported to the nurse about her behaviors but nothing happens. I reported to the DON about her behaviors, too. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 8 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/29/23 at 9:19 AM, V14 (RN) said she's been working at the facility for 14 years. R68 is alert to self, has behaviors of agitation, anxiety, wanders and needs continuous monitoring and direction. We will walk with and try to re-direct her as much as possible. We used to give her as needed medication when she gets anxious but the medication was discontinued. V14 confirmed staff reported R68's behaviors and reported R68 calmed down when her environment was changed. V14 said she did not notify the physician of her increased behaviors. V14 said the facility has a memory care director, but could not recall their name. On 11/29/23 at 10:15 AM, V2 (DON) said we don't have a memory care director. She said there should be someone over seeing the residents on the dementia regarding behavior management. V2 said she was not aware of any recent reports of R68 being combative. V2 said has behaviors of impulsiveness and combative. V2 said she is not sure if staff receive training on how to manage resident behaviors. R68's Psychiatry note dated 10/28/23 documented that R68 was seen in the day room, and that she appeared to be calm but was minimally enraged. No agitation or or aggressive behaviors were noted. R68's Current Care plan initiated on 10/2022 documents R68 has potential to be physically aggressive related to dementia, poor impulse control. She is very confused and has been refusing cares at times and wandering on the unit. She has been physically aggressive towards staff at times. Interventions include to analyze times of day, places and circumstances, triggers and what de-escalate behavior and document. Provide physical and verbal cues to alleviate anxiety, psychiatrist consult as indicated, when the resident becomes agitated; intervene, if response id aggressive towards staff walk away calmly and approach later. The facility's Dementia Care Protocol dated March 2020 states, For individuals with confirmed dementia, the physician will identify a plan to maximize remaining function and quality of life .The physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia .the physician will help staff adjust interventions and the plan depending on the individuals responses to those interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 9 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure a resident's narcotic controlled substance record for was in place for 1 of 1 residents (R213) reviewed for controlled substance medications in the sample of 35. Findings include: On 11/28/23 at 09:31 AM, V11 Registered Nurse was reviewing controlled substance medications in the medication cart with this surveyor. R213 had an opened bottle of liquid morphine (narcotic pain reliever) with approximately 25 ml (milliliters) left. There was no controlled substance proof of sheet/form for R213's morphine. V11 stated there is no sheet for this. There should be a sheet to sign off when the medication is given. R213 had a dose once and he did not like it so we don't give it to him. V11 said she did not reconcile/count R213's morphine with the night nurse at shift change. On 11/29/23 at 9:59 AM, V10 RN stated liquid morphine should have a medication reconciliation sheet to sign off when a dose is given and to verify that what's left in bottle matches the amount given. All narcotics are checked shift to shift with the oncoming nurse. R213's Medication Administration Record (MAR) for November 2023 shows an order hydromorphone HCL Solution (narcotic pain reliever) 2 mg (milligrams)/ml Give 1 mg by mouth every 1 hour as needed for pain with a start date of 10/17/23. This same MAR shows R213 received a dose on 11/8/23 at 9:40 AM. The facility's Controlled Substances Policy dated 3/2020 shows an individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance. The nurse has to document the resident's medical record and /or sign out the controlled substances proof of use sheet/form once the medication is administered to the resident. Nursing staff must count controlled medications at the end of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 10 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview, and record review the facility failed to ensure medication regimen reviews (MRRs) were being completed and documented on a monthly basis. The facility also failed to ensure those recommendations were being followed up on by a physician. This applies to 2 of 5 (R3, R50) reviewed for MRRs in the sample of 35. Findings include: On 11/29/2023 MRRs for the last 6 months was requested for R3 and R50 from V1 Administrator. 1. On 11/29/2023 at 1:15PM, V2 Director of Nursing (DON) attempted to pull up MRR records for R3 for the last 6 months in the computer charting under progress notes and was unsuccessful. V2 said the pharmacist was going to send the records for [R3]. The facility failed to provide copies of monthly medication reviews from individual months for R3. On 11/29/2023 at 12:22PM, V25 Pharmacist said the MRRs are completed monthly and should be visible in the computer charting system under progress notes under pharmacy. V25 said he is unsure why they wouldn't be showing up in the computer charting system. R3's MRRs provided were all dated 11/29/2023. On 11/29/2023 at 1:29PM, V3 Assistant Director of Nursing (ADON) said she was responsible for reviewing the MRRs once a month for the residents on her unit. V3 said the pharmacist provided copies of the MRRs and they noticed they were dated with the same date for [R3]. 2. On 11/29/2023 at 1:15PM, V2 Director of Nursing (DON) said the pharmacist was going to send the records for [R50]. On 11/29/2023 at 12:22PM, V25 Pharmacist said the MRRs are completed monthly and should be visible in the computer charting system under progress notes under pharmacy. V25 said he is unsure why they wouldn't be showing up in the computer charting system. R50's MRR dated 10/26/2023 shows a recommendation for GDR (Gradual Dose Reduction) by V25 Pharmacist to decrease [R50's] Duloxetine (Antidepressant) 120mg (milligrams) daily to 100mg daily. On 11/29/2023 at 1:29PM, V3 Assistant Director of Nursing (ADON) said she was responsible for reviewing the MRRs once a month for the residents on her unit. V3 said R50's MRR dated 10/26/2023 was faxed to the physician on 11/1/2023 and 11/9/2023 but no response. On 11/29/2023 at 3:20PM, V2 Director of Nursing (DON) said there was a response from the physician regarding [R50's] GDR that was identified on the MRR dated 10/26/2023. V2 said the physician had not responded to that request until 11/29/2023. The facility provided two copies of R50's MRR completed on 10/26/2023. One copy showed no response from the physician regarding the GDR request. The second copy of the MRR from 10/26/2023 shows a typed response which was signed by the physician and dated 11/29/2023 addressing the GDR request on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 11 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0756 MRR. Level of Harm - Minimal harm or potential for actual harm The facility failed to provide a policy for monthly medication reviews. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 12 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the failed to implement a pharmacy recommendation of a gradual dose reduction (GDR) for a resident who is receiving a antipsychotic medication. This applies to 1 of 5 residents (R185) reviewed for unnecessary medications in the sample of 35. Findings include: 1. R185's Physician Order Sheets (POS) shows he has diagnoses including unspecified psychosis, unspecified dementia, unspecified severity with other behavioral disturbance and generalized anxiety. The POS shows orders dated 8/3/2023 for Olanzapine (anti-psychotic) 15 mg (milligram) at bedtime for psychotic behavior. The Pharmacy Medication Report dated 11/21/23 shows R185 is due for a GDR and recommends to decrease Olanzapine 15 mg at bed time to Olanzapine 12.5 mg at bedtime. The form is not completed or signed by the physician regarding the recommendation. On 11/29/23 at 1:26 PM, V13 (ADON) said pharmacy sends the recommendation and we fax the form to the physician to review and sign. V13 confirmed R185's GDR was not sent over to the physician until today (11/29/23.) The facility did not provide a policy regarding GDR or for the use of unnecessary medications; upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 13 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure insulin administration pens were labeled with an opened date and failed to dispose of expired insulin for 2 of 8 residents (R160, R181) reviewed for medication storage in the sample of 35. Findings include: On [DATE] at 09:31 AM, the 3rd floor medication cart 2 contained R160's lantus insulin pen that was opened and not labeled with an open date or an expiration date. The same cart contained R160's insulin aspart solution bottle that was dated as opened on [DATE], which expired [DATE] and R181's levemir insulin solution bottle with an open date of [DATE] and an expired date of [DATE]. V11 Registered Nurse (RN) said R181's levemir and R160's insulin aspart are expired and should have been thrown out. V11 said R160's lantus insulin solution pen should be dated with the date is was opened. V11 said insulin is good for 28 days once opened. R160's Medication Administration Record (MAR) for [DATE] shows an order for lantus 30 units subcutaneous two times a day for diabetes and insulin aspart inject 10 units subcutaneous two times a day. This same MAR shows both lantus and insulin aspart was administered to R160 on [DATE]. R181's MAR for [DATE] shows an order levemir 50 units subcutaneous at bedtime. This same MAR shows R181 received levemir on [DATE]. On [DATE] at 9:59 AM, V10 RN said insulin should be dated when opened and labeled with the date opened and the expiration date. V10 said insulin is good for 28 days. The facility's Administering Medications Policy dated 3/2020 shows the expiration/beyond-use date on the medications label must be checked before administering. When opening a multi-dose container, the date opened shall be recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 14 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to ensure food was prepared in a form to meet a residents needs which applies to 5 of 5 residents (R76, R84, R153, R213, R222) reviewed for puree diets in a sample of 35. Findings include: The facility's weekly dietary menu showed the noon meal to be a chicken soft taco, Spanish rice, seasoned corn, and fruit mix on 11/28/23. On 11/28/23 at 10:00 AM, V32 [NAME] stated puree foods should have a smooth consistency like pudding. During the puree prepping, V30 Dietary Manager stated the food processor they have does run at a slower speed so it does take a while to puree the foods. After the puree foods were prepared V32 and V28 Assistant [NAME] did not sample the food items prior to packaging it for serving. On 11/28/23 12:31 PM, A test tray was sampled for the pureed food. The puree chicken was gritty with particulates in it. The puree corn still had parts of the corn kernal shells in it. On 11/28/23 at 1:00 PM, V30 Dietary Manager tried the pureed food, and said the chicken needed to be blended more, and the corn had pieces of husk in it. The Facility's Pureed Diet List printed on 11/29/23 showed R76, R84, R153, R213, and R222 require a puree consistency diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 15 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 the food service areas were sanitized prior to serving food. This failure affects 5 of 5 residents (R84, R124, R153, R213, R380) reviewed for food service in a sample of 35. Findings include: On 11/28/23 at 11:50 AM, V29 Dietary Aide opened the 3rd floor kitchenette where the steam tables are kept for meal serving. There were seven dirty meal trays in the kitchenette. The trays had used, dirty plates, cups, silverware, and paper garbage on them. V29 stated they had no idea why the trays were there. V29 removed the trays from the kitchenette, set up the steam tables, and started serving the noon meal without sanitizing the food serving area. On 11/28/23 at 1:00 PM, V30 Dietary Manager stated the dirty trays should not be stored/left in the kitchenette. They are supposed to be put on the dirty tray carts and brought down stairs to the dishwasher area. The dirty trays could cause cross contamination. The food serving areas should be kept clean. The facilities Kitchen Sanitation Policy dated 12/2015 showed the food service are shall be maintained in a clean and sanitary manner. Equipment, food contact surface, and utensils should be sanitized using hot water and/or chemical sanitizing solutions. R84, R124, R153, R213, and R380 Facesheets showed these residents reside on the third floor of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 16 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 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 ensure staff donned and doffed Personal Protective Equipment PPE when entering and leaving rooms with residents who were on isolation due to testing positive for the COVID-19 virus. The facility also failed to ensure doors were kept closed for rooms with COVID-19 positive residents, failed to ensure a COVID-19 positive residents remained isolated in their rooms. The facility also failed to implement enhance barrier precautions. These failures affect 16 of 35 residents (R129, R48, R73, R89, R18, R5, R139, R62, R79, R173, R159, R58, R6, R43, R134 and R100) reviewed for infection control in the sample of 35. Residents Affected - Some Findings include: 1. On 11/27/23 at 9:50 AM, R129, R48, R73's room had a sign on the doorway of droplet contact isolation precaution. V4 (Infection Control Nurse-IP) said the facility was in a COVID-19 outbreak and R129, R48 and R73 were all COVID-19 positive residents that were on isolation. V7 (License Practical Nurse-LPN) entered and exited the isolation room wearing only a surgical mask. V7 said he forgot to apply Personal Protective Equipment (PPE) which was respirator face mask, faceshield, gown and gloves. On 11/27/23 at 10:45 AM, R89, R18 and R5's room had a sign of droplet isolation precaution who were also identified as testing positive for COVID-19 infection by V3 (IP). The door to R89, R18 and R5's room was wide open. V8 (LPN) was inside this room, wearing only a surgical mask. V8's N95 mask was on her neck, talking to another nurse V9 (RN). V9 informed V8 to please close the door. V8 stated I was talking to the other nurse (V9) and if I wear my N95 mask, (V9) would not understand what I was saying. On 11/27/23 at 10:30 AM, R139, R62, R79 and R173's room door was wide open with a sign of droplet isolation precaution. These residents were identified as requiring isolation for testing positive for COVID-19. R139 was out of the room, and was in the doorway of R51's adjacent room who was not on isolation and had tested negative for the COVID-19 virus. There was no staff present at that time to redirect R139. V12 (Housekeeper) was going around looking for staff. V3 (Assistant Director of Nursing ADON) came to the unit15 minutes later and closed the door including another room with COVID-19 positive residents including R159, R58 and R6. V3 said all COVID-19 positive resident rooms should be kept closed to prevent the spread of the COVID-19 virus infection. On 11/27/23 at 11 AM, V4 (Infection Control Nurse-IP) said it has been a challenge to educate staff during this COVID-19 outbreak at the facility. V4 said she has been making rounds and reminding staff about the importance of wearing proper PPE, which includes a respirator face mask, a face shield, gown and gloves, closing doors of rooms with residents who tested positive and on isolation for COVID-19 and redirecting COVID-19 residents to remain in their room. The facility policy entitled Policy on The Core Principles of COVID-19 Infection Prevention dated 5/23 show b. If a resident is suspected or confirmed to have COVID-19 HCP (Healthcare Personnel) must wear a respirator face mask, eye protection gown and gloves. d. In addition, facilities should consider requiring a respirator face mask on all resident care on the affected floor. The Centers for Disease Control (CDC) guidelines dated May 2023 shows, Personal Protective Equipment: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 17 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID 19) infection should adhere to Standard Precautions and use a NIOSH (National Institute for occupational Safety and health) Approved particulate respirator with special particulate filters or higher, a gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). CDC Patient Placement-Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed. 3. R100's electronic face sheet printed on 11/29/23 showed diagnoses to include but not limited to encounter for attention to gastrostomy, Escherichia coli, and type 2 diabetes mellitus. R100's physician's order sheet printed on 11/29/23 showed enhanced barrier precautions (EBP) related to Gastrointestinal-tube, IV (intravenous) access, specialty female external urinary catheter every shift for infection control. (This was added during the survey process after interviews on 11/27/23.) R100's care plan printed on 11/29/23 and revised on 11/28/23 after interview with surveyor showed enhanced barrier precautions as ordered. R100's Minimum Data Set (MDS) assessment dated [DATE] showed R100 as cognitively intact. On 11/27/23 at 12:57 PM, R100 was sitting up in bed watching television. There was no enhanced barrier precautions signage on the door to R100's room. R100's gastrointestinal tube (g-tube) feeding was running, and a specialty female external urinary catheter machine sat on a bed side table on the far left hand side of the bed. On 11/28/23 at 8:55 AM, there was no enhanced barrier precautions signage on R100's entry door. The resident continued on g-tube feeding, specialty female external urinary catheter and had an IV access site. On 11/28/23 at 8:57 AM, V21 (Nurse Supervisor 2nd floor) said I am not sure if they should be on enhanced barrier precautions when they have a g-tube. I will check with the IP (Infection Preventionist -V4). Technically she should be on EBP. On 11/28/23 at 9:03 AM, V22 (Wound Care nurse) said I was told by IP to wear PPE when I go into her room. She has a specialty female external urinary catheter and a g-tube. On 11/28/23 at 10:20 AM, V4 IP (Infection Preventionist) said for (R100) who has g-tube, uses a specialty female external urinary catheter and has a PICC (peripherally inserted central catheter) (IV) line access, the enhanced barrier precautions sign should be on the door. There is a potential risk for staff or the resident to get an infection. I just got an order for EBP for (R100) this morning. I forgot to put the sign on her door yesterday. 2. On 11/27/2023 at 1:39 PM, R134's room door was open. R134's room had signs outside of the room indicating resident was on contact/droplet isolation. On 11/27/2023 at 1:09 PM, R43 was seen outside of his room without a mask on holding his lunch tray. On 11/28/2023 at 8:55 AM, V24 Registered Nurse (RN) was seen exiting a droplet/contact isolation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 18 of 19 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 145329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Norridge Gardens 7001 West Cullom Norridge, 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 room with her personal protective equipment (PPE) still on. Level of Harm - Minimal harm or potential for actual harm On 11/28/2023 at 9:00 AM, V24 said she had just finished passing medications in a room that COVID-19 positive residents reside in. Residents Affected - Some On 11/29/2023 at 10:46 AM, V4 Infection Control Preventionist (ICP) said staff should not exit isolation rooms with PPE still on. V4 said the doors should be closed for residents on droplet/contact for COVID. V4 said [R134's] door should have been closed. V4 said residents on COVID isolation should not be out in the hallways without a mask and staff should be redirecting them to their rooms. V4 said [R43's] door should have been closed and [R43] should not be in the hallway without a mask. The facility provided list Transmission Based Precaution Report dated 11/23/2023 lists [R134] on contact/droplet isolation with a start date of 11/23/2023 and lists [R43] on contact/droplet isolation with a start date of 11/22/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145329 If continuation sheet Page 19 of 19