Inspection·January 15, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and push R6 out of the room when R6 pushed R7 to the ground. R7 stated he hit the back of his head on the bathroom door and showed a lump on the back right of his head, a reddened knuckle of his left thumb, and a broken fingernail. R7 stated he started yelling for help and R6 walked out of the room yelling for staff and saying that R7 was attacking R6. On [DATE] at 12:27 PM, R6 was very agitated, speaking in a loud voice, and showed threatening body posture when speaking to staff and the state surveyor. R6 stated he witnessed R7 going through other residents' belongings several times over the last several months. R6 stated he was walking in the hall and walked inside the door of R7's room. R6 stated he told R7 not to mess with other people's stuff. R6 stated he did not inform staff of his concerns regarding R7 because he felt staff would not believe him. R6 stated he utilized a jiu-jitsu move to make R7 fall to the ground. R6 stated R7 then began hitting R6 but R6 denied any injuries. R6 stated R7 previously walked into R6's room but not at that time. R6 stated, He's lucky I didn't break his neck when he walked into my room. Progress note, dated [DATE], shows after R7 returned from the hospital he complained of discomfort of his left hand and a red/bluish area was noted on his left hand near his thumb. On [DATE] at 12:07 PM, V7 (Police Officer) stated two days prior R6 and R7 were involved in an altercation in which R7 told R6 to leave his room and R6 tripped R7 and pushed him to the floor where R7 hit his head. V7 stated R7 had a bump on his head, a swollen left finger, and a cut on his hand. V7 stated the facility revived the cameras which showed R7 had not left his room for at least 45 minutes prior to the incident. V7 stated she cited R6 with a ticket referencing a local ordinance. Initial police report, dated [DATE], shows V7 (Police Officer) was informed R7 had dementia but found him coherent and able to relate details about the incident accurately. The report shows at about 8:30 AM on [DATE], R6 began yelling at R7 and R7 did not know why. R7 told V7 he was smaller than R6 and tried to tell R6 to leave the room but R6 continued to approach R7 and continued to yell at R7. The report shows R6 then grabbed R7 and threw him to the ground and into the bathroom door. R7 stated R6 then began to exit the room and threatened R7 stating he would punch him and would kill him. The report shows there was a witness who heard R6 threaten to punch R7 out and kill R7. The report shows R7 had a small cut on his left thumb and the top of his head was sore. The report shows R6 was interviewed and claimed R7 was chronically entering other residents' rooms and going through their belongings without permission. The report shows R6 alleged that morning R7 entered R6's room and began looking through R6's roommate's belongings and R6 decided to take a stand and confront R7. The report shows R6 entered R7's room and R7 charged at R6 telling him to leave the room. The report shows R7 attempted to push R6 away and R6 then threw R7 to the ground. Police report, dated [DATE], shows V7 returned to the facility because R7 wished to press charges for battery. The report shows the facility reviewed video surveillance showing R6's claim that he followed R7 from R6's room and confronted him was false and showed R7 was in his room no less than 45 minutes prior to the altercation. The report shows V8 (Social Services) and R7 both felt R6's aggression was unprovoked. The report showed R7 had a lump and some discoloration on the top of his head as well as a small laceration on his left thumb. The report showed R7's thumb nail was broken and there was bruising where the laceration had been. The report shows V7 interviewed R6 who also made a threat to a nurse that morning which included shooting someone, which R6 denied. The report shows R6 was issued a local ordinance citation for assault/fights for the incident which occurred [DATE] between R6 and R7. Final facility Incident report, dated [DATE], shows R6 and R7 were separated at the time of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 2 of 8 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 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 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 0600 Level of Harm - Minimal harm or potential for actual harm altercation and the police were called. The report shows R7 complained of pain, but no injuries were identified and both residents were sent to the hospital. The report shows R7 confronted R6 in his room about rummaging through R7's personal items and the police were called and left without further action. The report shows R6's room was moved to the other side of the facility and R7 was placed on continuous monitoring. Residents Affected - Few Progress note, dated [DATE], shows, Staff observed a verbal altercation between this resident and a co-peer. Staff separated the resident and co-peer. Resident placed on 1:1 [supervision] pending a transfer to the ER (Emergency Room) for evaluations. Behavior progress note, dated [DATE], shows R6 was demonstrating physical and verbal conflicts with peers, made idle threats and expressing intentions of violence when faced with challenges or inconveniences, and R6 required immediate hospitalization. Facility Abuse Prevention Program policy and procedure, revised 1/2019, shows, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. Facility Abuse and Crime Reporting Policy and Procedure, revised 1/2019, shows, 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm 4. Physical Abuse: Hitting, slapping, pinching, kicking, etc 2. Review of R4's care plan shows R4's diagnoses include bipolar disorder, depression, anxiety, schizophrenia, and cerebral infarction. Care plan, dated [DATE], shows R4 had a history of misinterpreting interactions/situations and responding with verbal and physical aggression toward others. MDS, dated [DATE], shows R4's cognition was severely impaired. Review of R5's care plan shows R5's diagnoses included depression, heart failure, epilepsy, and chronic kidney disease. The care plan, dated [DATE], shows R5 had poor frustration tolerance and maladaptive coping as manifested by aggression when agitated and/or conflicts/altercations with others. R5's behaviors included verbal aggression when challenged or redirected. MDS, dated [DATE], shows R5's cognition was moderately compromised. On [DATE] at 1:51 PM, R5 stated R4 approached him as they were both attempting to take pizza from a pizza box in the dining room. R5 stated R4 became upset with R5, pulled R4's arms back in attempt to keep him from the pizza, swung at R4 several times causing a scratch on his right cheek, and then pulled R5's sweatshirt hood back trying to pull him away from the pizza. MDS, dated [DATE], shows R2's cognition was intact. On [DATE] at 1:37 PM, R2 stated she was sitting in the dining room when she heard a commotion and saw R4 slap R5 in the face. R2 stated R4 then pulled backward on R5's sweatshirt hood trying to keep him away from a box of pizza on a table. R2 stated the altercation between R4 and R5 was traumatic and scary to watch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 3 of 8 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 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 12:35 PM, V9 (Psychologist) stated she was in the dining room with a client when she saw a resident in a wheelchair move toward a box of pizza and R4 began to approach the resident. V9 stated she tried to redirect R4 away from the resident but R4 grabbed the resident by the shirt neck. V9 stated the residents were slapping at each other but V9 was unclear how much physical contact occurred. V9 stated she saw R4 grab the resident but the collar and pull him backwards in his wheelchair. V9 stated she was the only non-resident in the room when the altercation began and when left the room to retrieve staff to help. V9 stated when she returned to the room R4 again moved aggressively toward the resident in the wheelchair bur V9 stood between the two residents to de-escalate the conflict. V9 stated another resident witnessed the altercation and was screaming. Psychologists note, dated [DATE], shows V9 (Psychologist) witnessed R4 exhibiting physical and verbal aggression towards another resident, alerted staff, and attempted to assist in de-escalation and redirection. On [DATE] at 12:07 PM, V10 (Licensed Practical Nurse) stated she heard R2 screaming in the dining room and when she arrived at the dining room R5 was sitting in motorized wheelchair and R4 was pulling R5 backwards from a box of pizza. V10 stated the side of R5's cheek had a small laceration and there was blood on his cheek. Progress note, dated [DATE], shows R4 was witnessed pulling/tugging and attempting to strike at a resident. The note shows R4 expressed the other resident was taking someone's pizza and R4 felt it was not right. The note shows R4 held R5's hand which initiated an altercation and R4 then attempted to pull R5 away from the table using R5's sweatshirt. Progress notes, dated [DATE], shows R5 stated R4 came toward him when he wanted to see what was in the box. R5 reported R4 began striking R5 out of nowhere. R4 was noted to have a small abrasion (0.5 centimeters) near his right bilateral nose with oozing. The note shows the area was cleaned and treated. Final Incident Report, dated [DATE], shows R5 approached a pizza box in the dining room and R4 thought R5 was stealing pizza and R4 attempted to pull R5 away from the table by pulling R4's sweatshirt. The report shows R4 scratched R5, and staff witnessed the incident and separated the residents. The report shows small scratch was noted on R5's cheek and right wrist, the police were notified, investigated and a report filed. The report shows R4 was sent to the hospital and did not return to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 4 of 8 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 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11. Residents Affected - Few The findings include: 1. Face sheet, dated 1/10/25, shows R2's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, congestive heart failure, osteoarthritis, and muscle wasting. MDS (Minimum Data Set), dated 1/1/25, shows R2's cognition was intact and R2 was dependent on staff for bathing. Care plan, dated 5/27/22, shows R2 required extensive assistance and one person support from staff for bathing. On 1/9/25 at 11:58 AM, R2 stated, It's not fair! I deserve my shower! It's all I have. I don't get my shower if there isn't enough staff. I didn't have a shower last week. I don't know the last time I had a shower. I am a very clean person. Shower sheets, dated 11/1/24 to 1/10/25, showed R2 was only offered 9 showers (11/8/24, 11/12/24 refused, 11/19/24, 11/22/24 refused, 11/26/24, 12/10/24 refused, 12/17/24 refused, 12/27/24, and 1/7/25 requested bath next day) during the 10 weeks reviewed. On 1/13/25 at 12:32 PM, V2 (Director of Nursing) stated the facility schedules two showers a week for each resident and staff are expected to offer residents showers twice weekly. Facility first floor shower schedule, provided 1/13/25, shows each resident was scheduled to receive two showers each week. 2. Face sheet, dated 1/10/25, shows R3's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, muscle wasting, paraplegia, seborrheic dermatitis, depression, and dependence on wheelchair. MDS, dated [DATE], shows R3's cognition was intact and R3 was dependent on staff for bathing. On 1/9/25 at 12:03 PM, R3 stated the facility did not have enough CNAs (Certified Nursing Assistants) to provide her scheduled showers. R3 stated she was supposed to receive two showers a week on Mondays and Thursdays but there were not enough staff to provide her showers twice weekly. Shower sheets, dated 11/1/24 to 1/10/25, showed R3 was offered only 9 showers (11/7/24, 11/14/24, 11/18/24, 11/21/24, 11/25/24, 11/28/24, 12/9/24, 12/30/24 refused and 1/3/25) during the 10 weeks reviewed. 3. Review of R8's care plan showed R8's diagnoses included heart failure, muscle wasting and atrophy, osteoarthritis, and lymphatic disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 5 of 8 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 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS, dated [DATE], shows R8's cognition was intact and R8 required substantial/maximum assistance from staff for transfers from chair to bed. Care plan, dated 11/14/24, shows R8 required extensive assistance from staff for bathing and dressing. Resident Council Meeting minutes, dated 11/13/24, shows residents stated, We feel ignored when we are asking them to do something. The residents also expressed concern that call lights were not answered in a timely manner especially on the second shift. On 1/9/25 at 11:57 AM, R8 stated two weeks prior she waited four hours for staff to transfer her to bed because there were not enough staff to help residents. R8 stated a CNA (Certified Nursing Assistant) came in and told R8 she needed to give a shower to another resident and would return to put R8 back in bed but the CNA left at the end of her shift and did not return to R8. R8 stated when the new CNA came in R8 asked if she could be transferred to her bed but the CNA never came back to transfer her because that CNA was having a problem with another resident. R8 stated after four hours she called the nurse on the phone and asked the nurse to transfer her to bed. R8 stated I was stuck there! R8 stated she gets very dizzy when she sits up to long and stated she was very dizzy when she became stuck in her chair and had to wait to be transferred to bed. Shower sheets dated 11/1/24 - 1/20/25, show R8 was offered only 7 showers (11/3/24, 12/7/24, 12/11/24, 12/25/24 refused, 12/28/24, 1/1/25 refused, 1/4/25) during the 10 weeks reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 6 of 8 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 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11. The findings include: 1. Face sheet, dated 1/10/25, shows R2's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, congestive heart failure, osteoarthritis, and muscle wasting. MDS (Minimum Data Set), dated 1/1/25, shows R2's cognition was intact and R2 was dependent on staff for bathing. On 1/9/25 at 11:58 AM, R2 stated, It's not fair! I deserve my shower! It's all I have. I don't get my shower if there isn't enough staff. I didn't have a shower last week. I don't know the last time I had a shower. I am a very clean person. Shower sheets, dated 11/1/24 to 1/10/25, showed R2 was only offered 9 showers (11/8/24, 11/12/24 refused, 11/19/24, 11/22/24 refused, 11/26/24, 12/10/24 refused, 12/17/24 refused, 12/27/24, and 1/7/25 requested bath next day) during the 10 weeks reviewed. On 1/13/25 at 12:32 PM, V2 (Director of Nursing) stated the facility schedules two showers a week for each resident and staff are expected to offer residents showers twice weekly. Facility first floor shower schedule, provided 1/13/25, shows each resident was scheduled to receive two showers each week. 2. Face sheet, dated 1/10/25, shows R3's diagnoses included multiple sclerosis, neuromuscular dysfunction of bladder, muscle wasting, paraplegia, seborrheic dermatitis, depression, and dependence on wheelchair. MDS, dated [DATE], shows R3's cognition was intact and R3 was dependent on staff for bathing. On 1/9/25 at 12:03 PM, R3 stated the facility did not have enough CNAs (Certified Nursing Assistants) to provide her scheduled showers. R3 stated she was supposed to receive two showers a week on Mondays and Thursdays but there were not enough staff to provide her showers twice weekly. Shower sheets, dated 11/1/24 to 1/10/25, showed R3 was offered only 9 showers (11/7/24, 11/14/24, 11/18/24, 11/21/24, 11/25/24, 11/28/24, 12/9/24, 12/30/24 refused and 1/3/25) during the 10 weeks reviewed. 3. Review of R8's care plan showed R8's diagnoses included heart failure, muscle wasting and atrophy, osteoarthritis, and lymphatic disorder. MDS, dated [DATE], shows R8's cognition was intact and R8 required substantial/maximum assistance from staff for transfers from chair to bed. Care plan, dated 11/14/24, shows R8 required extensive assistance from staff for bathing and dressing. Resident Council Meeting minutes, dated 11/13/24, shows residents stated, We feel ignored when we are asking them to do something. The residents also expressed concern that call lights were not answered in a timely manner especially on the second shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 7 of 8 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 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/9/25 at 11:57 AM, R8 stated two weeks prior she waited four hours for staff to transfer her to bed because there were not enough staff to help residents. R8 stated a CNA (Certified Nursing Assistant) came in and told R8 she needed to give a shower to another resident and would return to put R8 back in bed, but the CNA left at the end of her shift and did not return to R8. R8 stated when the new CNA came in R8 asked if she could be transferred to her bed, but the CNA never came back to transfer her because that CNA was having a problem with another resident. R8 stated after four hours she called the nurse on the phone and asked the nurse to transfer her to bed. R8 stated I was stuck there! R8 stated she gets very dizzy when she sits up to long and stated she was very dizzy when she became stuck in her chair and had to wait to be transferred to bed. Shower sheets dated 11/1/24 - 1/20/25, show R8 was offered only 7 showers (11/3/24, 12/7/24, 12/11/24, 12/25/24 refused, 12/28/24, 1/1/25 refused, 1/4/25) during the 10 weeks reviewed. On 1/9/25 at 11:34 AM, V3 (CNA - Certified Nursing Assistant) and V4 (CNA) both stated they were often working short of staff on the first floor with only four CNAs (Certified Nursing Assistants) assisting approximately 88 residents. V3 stated she had eight residents requiring two staff for transfers and five residents who required feeding assistance. On 1/9/25, V5 (CNA) stated the facility was sometimes short of staff and had only four CNAs for the first floor and the staff are not able to give showers or turn and reposition residents in a timely manner. On 1/9/25, V6 (Licensed Practical Nurse) stated the first floor sometimes only had four CNAs for approximately 85 residents and they were sometimes not able to give residents showers. On 1/9/25 at 3:00 PM, V1 (Administrator) stated the average census for the first floor December 1, 2024 to January 9, 2025 was approximately 86 residents. Review of facility schedules, dated 12/13/24 to 1/8/24, show 14 (28%) of the 50 AM/PM first floor shifts reviewed had only 4 CNAs working on the first floor (1 CNA caring for 21 residents). On 1/13/25 at 10:00 AM, V2 (Director of Nursing) stated the facility was not allowed to use agency staff and the facility was experiencing resident/staff illnesses mid-December which resulted in many call-offs at the facility. V2 stated the facility goal was to staff the first floor with 6 CNAs (1 CNA caring for 14 residents) but 5 CNAs was the minimum the first floor should have working for an average census of 86 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 8 of 8