Inspection·September 11, 2025

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when my [outside insurance vendor] coverage begins, I must get all of my medical and prescription drug benefits from [outside insurance vendor] plan. Benefits and services provided by [outside insurance vendor] and contained in my [outside insurance vendor] Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor [outside insurance vendor] Health Plan will pay for benefits or services that are not covered. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person legally authorized to act on my behalf on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), the signature certifies that: 1. This person s authorized under State law to complete this enrollment, and 2. Documentation of this authority is available upon request by Medicare. V19's (Significant Other) signature is typed in a cursive font as the signature on the Enrollment Form acknowledging V19 read and understood the Enrollment Form for R6. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only.The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R6 has severe cognitive impairment, with a BIMS score of 5, on July 8, 2025. The facility does not have completed POA paperwork for R6. The POA paperwork in R6's medical record shows a Power of Attorney for Health Care form, signed by V19 on May 19, 2025. The paperwork does not show R6's name anywhere on the paperwork to indicate the POA paperwork belongs to R6. The POA paperwork was witnessed by V3 (SSD) on May 19, 2025.2. R7's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R7's name, date of birth , gender, permanent address as the facility, and her Medicare Number. V20's (Daughter of R7) signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging V20 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only.The facility did not have POA paperwork in the medical record for R7 on August 20, 2025, the date the Medicare Advantage plan paperwork was signed by V20. Facility documentation shows POA paperwork was completed for R7, with R7's signature, on August 22, 2025, two days after the consent for enrollment in the Medicare Advantage plan was signed. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R7 has severe cognitive impairment, with a BIMS score of 7, on August 14, 2025. 3. R10's Medicare Advantage Plan Enrollment Form dated August 1, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R10's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V21's (Spouse of R10) electronic signature on the Enrollment Form, acknowledges V21 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V21 is the POA or health care surrogate for V21. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R10 has moderate cognitive impairment, with a BIMS score of 10, on July 21, 2025. 4. R11's Medicare Advantage Plan Enrollment Form dated August 6, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R11's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V22's (Brother of R11) electronic signature on the Enrollment Form, acknowledges V22 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 2 of 14 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 09/11/2025 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 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V22 is the POA or health care surrogate for R11. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R11 has moderate cognitive impairment, with a BIMS score of 11, on June 18, 2025. 5. R12's Medicare Advantage Plan Enrollment Form dated August 11, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R12's name, date of birth , gender, permanent address as the facility, and her Medicare Number. V23's (Son of R12) electronic signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging V23 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V23 is the POA or health care surrogate for R12.R12's MDS dated [DATE] shows R12 has moderate cognitive impairment, with a BIMS score of 8. 6. R15's Medicare Advantage Plan Enrollment Form dated August 28, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R15's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V24's (Brother of R15) electronic signature on the Enrollment Form, acknowledges V24 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V24 is the POA or health care surrogate for V24. R15's MDS dated [DATE] shows R15 has severe cognitive impairment, with a BIMS score of 7. 7. R16's Medicare Advantage Plan Enrollment Form dated August 19, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R16's name, date of birth , gender, permanent address as the facility, and his Medicare Number. V25's (Sister of R16) electronic signature on the Enrollment Form, acknowledges V25 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows V25 is the POA or health care surrogate for R16. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R16 has moderate cognitive impairment, with a BIMS score of 8, on June 23, 2025. 8. R18's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R18's name, date of birth , gender, permanent address as the facility, and her Medicare Number. R19's (Father of R18) signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging R19 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. The facility does not have legal paperwork in the medical record shows R19 is the POA or health care surrogate for R18. The undated roster provided by the facility of all residents enrolled in the new Medicare Advantage plan shows R18 has moderate cognitive impairment, with a BIMS score of 8, on August 15, 2025. On September 4, 2025 at 12:15 PM, V9 (Son of R19) said, V9 is not the POA for R18, did not sign the consent form for the change to R18's Medicare Advantage plan, and does not trust R19 could make an informed decision for changing R18's health plan. V9 said, English is not [R19's] first language, and I would not be confident he understood what he was signing. He speaks Polish. Guidance from CMS (Centers for Medicare and Medicaid) entitled, Medicare Advantage and Part D Enrollment and disenrollment Guidance Updated: 2024 shows: This guidance update is effective beginning with contract year 2025. All enrollments with an effective date on or after January 1, 2025, must be processed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 3 of 14 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 09/11/2025 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 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete in accordance with the revised requirements. Plans are expected to use the updated model enrollment form for enrollment requests received on or after January 1, 2025. Organizations may, at their option, implement any new requirement consistent with this guidance prior to the required implementation date. 10.1 Definitions: The following definitions relate to topics addressed in this guidance. Authorized Representative - An individual who is legally able to act on behalf of the beneficiary, as allowed by applicable state laws, in order to execute an enrollment or disenrollment request. A representative may be appointed by the individual (consistent with the standards under applicable law) or may be authorized under law without a specific or explicit appointment. 50 - Enrollment processing: The following should also be considered when processing an enrollment: .E. Signature and Date - The individual must sign the enrollment form or complete the enrollment request mechanism. If the individual is unable to do so, an authorized representative must sign the enrollment form or complete the enrollment request mechanism. If an authorized representative enrolls an individual, the authorized representative must attest to having the authority under State law to do so, and confirm that a copy of the proof of court-appointed legal guardian, durable power of attorney, or proof of other authorization required by State law that empowers the individual to effectuate an enrollment request on behalf of the applicant is available and can be presented upon request by the plan or CMS. On September 4, 2025 at 11:57 AM, V1 (Administrator) said the facility does not have a policy regarding obtaining consents. V1 provided the undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities brochure provided to every resident upon admission. The brochure shows, Your rights to participate in your own care: You have a right to complete information about your medical condition and treatment in a language that you can understand. Your rights as a citizen and a facility resident: If a court of law has appointed a legal guardian for you, your guardian may exercise your rights for you. If you have named an agent under a Power of Attorney for Health Care, our agent may exercise your rights for you. Event ID: Facility ID: 145333 If continuation sheet Page 4 of 14 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 09/11/2025 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were informed in a language and terminology they understood when a third-party vendor enrolled residents in a new Medicare Advantage plan at the facility. This situation resulted in R23 displaying psycho-social symptoms including emotional upset and crying when discussing the changes to his insurance he was not aware of. This applies to 3 of 17 residents (R1, R19, and R23) reviewed for changes to Medicare Advantage plans in the sample of 23. The findings include:1. On September 2, 2025, at 12:36 PM, R1 was sitting in his room. R1 said several weeks ago he signed up for a new insurance plan. R1 said, I didn't understand what I was signing up for. [V3] (SSD-Social Service Director) talked me into it. Then after I signed up for it, I found out I wouldn't be able to get my cancer medication and I was panicking because I need my medication. I didn't understand the new insurance would change what was covered. Then I had to just keep begging them to change my insurance back to what I had. I've been very upset about this situation. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dementia, generalized anxiety disorder, hypertension, anemia, insomnia, history of skin cancer, major depressive disorder, epilepsy, cognitive communication deficit, lack of coordination, leukemia, toxic encephalopathy, urine retention, bipolar disorder, and psychosis. R1's MDS (Minimum Data Set) dated June 19, 2025 shows R1 has moderate cognitive impairment, is independent with bed mobility, requires setup assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. On September 2, 2025, at 10:02 AM, V2 (DON-Director of Nursing) said, Our facility is working with [outside insurance vendor] Managed Care plan and they take over Medicare and Medicaid. [R1] is no longer part of the new plan. He signed up for the new plan, and there was a window of time where we couldn't do much with it. His doctor was able to get [R1's] cancer medications through his old insurance plan. They did not think they would be able to get the cancer medications through the new Managed Care plan at the facility. [R1] wanted his old insurance plan reinstated, and so we had to help with that. There were a few days of time for that transition to occur. 2. On September 9, 2025 at 10:35 AM, R19 was lying in bed in his room. R19 was speaking with a very thick accent and said his first language is Polish. R19 said Signing up for that new [Medicare Advantage plan] was a joke. [V3] (SSD) brought an insurance guy around, and asked if I would meet him. The insurance guy told me if I signed up, I would get a visit from a nurse practitioner every other week. The guy cheated me and didn't tell me everything, like the fact that I don't get to keep my doctor. He made it sound like we were going to get more services, not less. I don't want to be signed up for that insurance. I didn't understand what I was signing. The EMR (Electronic Medical Record) shows R19 was admitted to the facility on [DATE] with multiple diagnoses including, mononeuropathy of left lower limb, PVD (Peripheral Vascular Disease), hypertension, heart disease, spleen infarction, depression, anemia, spinal stenosis of the cervical region, post-laminectomy syndrome, low back pain, thoracic aortic aneurysm, anxiety disorder, adjustment disorder, and presence of prosthetic heart valve. R19's MDS (Minimum Data Set) dated July 8, 2025 shows R19 is cognitively intact, requires setup assistance with eating and lower body dressing, supervision with oral and personal hygiene, substantial/maximal assistance with showering and personal hygiene, and is dependent on facility staff for all other ADLs. R19 is frequently incontinent of urine, and always incontinent of stool. R19's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP- Health Maintenance Organization Institutional Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 5 of 14 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 09/11/2025 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 0552 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Special Needs Plan). The Enrollment Form continues to show R19's name, date of birth , gender, permanent address as the facility, and R19's Medicare Number. R19's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging R19 read and understood the Enrollment Form. The Enrollment Form continues to show V15 (Agent) as the individual helping enrollee with completing this form only. On September 4, 2025 at 12:15 PM, V9 (Son of R19) said, I did not know [R19's] Medicare Advantage plan was changed. No one ever called me. I have Power of Attorney for [R19]. I do not trust that my father could make a decision for changing his health plan. English is not his first language, and I would not be confident he understood what he was signing. He speaks Polish.The facility does not have the documentation to show R19 has a Power of Attorney or Healthcare Surrogate form, or that V9 (Son of R19) was contacted regarding R19's Medicare Advantage plan. 3. On September 9, 2025, at 1052 AM, R23 was sitting in a wheelchair in the hallway outside of his room. R23 said, I signed some papers the other day, but they didn't tell me it meant I was getting a new doctor and a new nurse practitioner. I didn't understand it. I want to go back, but I have to wait. They lied to us. R23 became tearful and started crying out loud, saying he has many health problems including Parkinson's disease and depression and this insurance change was causing him to feel sadder and more depressed. The EMR shows R23 was admitted to the facility on [DATE] with multiple diagnoses including, degenerative disease of the basal ganglia, Parkinsonism, Type 2 diabetes, anxiety disorder, depression, repeated falls, abnormalities of gait and mobility, and Parkinson's disease. R23's MDS dated [DATE] shows R23 is cognitively intact. R23's Medicare Advantage Plan Enrollment Form dated August 19, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form continues to show R23's name, date of birth , gender, permanent address as the facility, and R23's Medicare Number. R23's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging R23 read and understood the Enrollment Form. The Enrollment Form continues to show V15 (Agent) as the individual helping enrollee with completing this form only. On September 3, 2025 at 9:41 AM, R23 was sitting in the hallway in his wheelchair. R23 said he was approached by V3 (SSD) to ask if R23 wanted to hear a presentation regarding insurance. R23 said he would gladly hear about it, but decided not to do it because he didn't like the sound of it. R23 said he has had the same insurance company his whole life and he did not want to change from that. R23 said, Then when I said no, [V3] came back to my room and was asking me why I didn't want the new insurance. I felt like he was pressuring me to change to their preferred insurance, which seemed unethical and makes me not trust [V3] anymore. R23's MDS dated [DATE] shows R23 is cognitively intact. On September 4, 2025 at 11:57 AM, V1 (Administrator) said the facility does not have a policy regarding obtaining consents. V1 provided the undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities brochure provided to every resident upon admission. The brochure shows, Your rights to participate in your own care: You have a right to complete information about your medical condition and treatment in a language that you can understand. Your rights as a citizen and a facility resident: If a court of law has appointed a legal guardian for you, your guardian may exercise your rights for you. If you have named an agent under a Power of Attorney for Health Care, our agent may exercise your rights for you. Event ID: Facility ID: 145333 If continuation sheet Page 6 of 14 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 09/11/2025 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 protect the residents' right to be free from exploitation when the facility allowed an outside vendor to come into the facility and make unauthorized changes to cognitively impaired residents' Medicare Advantage plans. This applies to 3 of 17 residents (R5, R9, and R17) reviewed for changes to Medicare Advantage plans in the sample of 23.The findings include:On September 2, 2025 at 10:02 AM, V1 (Administrator) said, Our company is working with [outside insurance vendor] and that vendor takes over Medicare and Medicaid. On September 2, 2025, at 11:04 AM, V3 (SSD-Social Service Director) said, The [outside insurance vendor] chosen by our company, goes into the long-term care buildings owned by our company and offers residents to change their Medicare coverage to the [outside insurance vendor's] Medicare Advantage Plan. The SSD has to do the first point of contact between the residents and the insurance representative. My role was to say this is a new thing coming to our building. I took the rep around and introduced him to the residents. I called the POA (Power of Attorney)/guardians of the non-responsive people and had the same conversation. We, the staff, were told they were coming into our facility, and we are offering the residents this plan. I had to identify who was cognitively intact. The decision was based on the BIMS score (Brief Interview for Mental Status) score, and I used a BIMS score of 12 or higher to say the resident is decisional. They needed to be oriented to person, time, and place. [V15] was the representative from the [outside insurance vendor] who spoke to the residents and got the consents to change the residents' Medicare Advantage plans. V3 continued to say he was not present in the room when V15 (Insurance Agent) presented the Medicare Advantage information to the residents or to witness the residents signing the enrollment forms. V3 also could not say why he provided the names of R5, R9 and R17 to the insurance agent when they have a BIMS score of less than 12. The facility provided a list of residents whose Medicare Advantage Plan has been changed to an I-SNP (Institutional Special Needs Plan) Medicare Advantage Plan with the new insurance vendor. The undated list shows R5, R9, and R17 with an effective date in the I-SNP Medicare Advantage plan as September 1, 2025. 1. On September 9, 2025, at 10:49 AM, R5 was lying in bed in his room. R5 was not able to say what year it is, what day of the week it was, what time it was, or how long he had lived at the facility. R5 said he believed he had lived at the facility for two weeks, and asked if this surveyor was here to take him to his Alcohol Anonymous meeting. R5 said he did not know anything about signing papers to change his Medicare Advantage plan and could not recall if anyone had explained a new Medicare Advantage plan to him. R5 said, I'm on Medicaid, that's all I know. The EMR (Electronic Medical Record) shows R5 was admitted to the facility on [DATE] with multiple diagnoses including trans-cerebral attack, hemiplegia and hemiparesis of the left side, bipolar disorder, lack of coordination, weakness, and major depressive disorder. The EMR shows multiple MDS (Minimum Data Set) assessments for the period of December 2024 to July 2025 with documentation of R5's cognitive impairment, including: R5's MDS dated [DATE] shows R5 has severe cognitive impairment. R5's MDS dated [DATE] shows R5 was rarely/never understood, and therefore unable to complete the brief interview for mental status. The MDS shows R5 had moderate cognitive impairment at the time of the MDS assessment. R5's MDS dated [DATE] shows R5 had moderate cognitive impairment. R5's MDS dated [DATE] shows R5 had severe cognitive impairment at the time of his MDS assessment. R5's care plan, revised July 7, 2025 shows: My comprehensive assessment reveals a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase my susceptibility to abuse/neglect. The resident demonstrates: depression, diagnosis of mental illness, high level of hostility or irritability, history of drug and/or alcohol abuse, difficulty in Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 7 of 14 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 09/11/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few adjustment and generalized mood distress. Symptoms may be manifested by behavioral symptoms. The facility does not have documentation to show R5 has a POA (Power of Attorney) or a legal healthcare surrogate decision maker. The facility does not have documentation to show R5's family members/emergency contacts were contacted regarding the changes to R5's Medicare Advantage plan or that the insurance agent would be speaking to R5. R5's Medicare Advantage Plan Enrollment Form dated August 19, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO-Health Maintenance Organization I-SNP). The Enrollment Form shows R5's name, date of birth , gender, permanent address as the facility, and R5's Medicare Number. The Enrollment Form shows: Important: Read and sign below: I must keep both Hospital (Part A) and Medical (Part B) to stay in the [outside insurance vendor's] Health Plan. By joining this Medicare Advantage Plan, I acknowledge that [outside insurance vendor] will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement blow). Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan. I understand that I can be enrolled in only one MA (Medicare Advantage) plan at a time - and that enrollment in this plan will automatically end my enrollment in another MA plan. I understand that when my [outside insurance vendor] coverage begins, I must get all of my medical and prescription drug benefits from [outside insurance vendor] plan. Benefits and services provided by [outside insurance vendor] and contained in my [outside insurance vendor] Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor [outside insurance vendor] Health Plan will pay for benefits or services that are not covered. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person legally authorized to act on my behalf on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), the signature certifies that: 1. This person s authorized under State law to complete this enrollment, and 2. Documentation of this authority is available upon request by Medicare. R5's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging R5 read and understood the Enrollment Form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. On September 8, 2025 at 12:56 PM, V16 (Physician) said he is the primary care physician for R5 and R5 has severe cognitive impairment and would not be able to read and understand a consent form. 2. On September 4, 2025 at 11:18 AM, R9 was sitting in his room. R9 said, Some people came in and talked to me. I don't know what they were doing! I didn't understand it at all. Something about insurance, I think. Did I want my insurance to change? No. I don't know why I signed the papers or what they said. The EMR shows R9 was admitted to the facility on [DATE] with multiple diagnoses including, prostate cancer, recurrent major depressive disorder, bipolar disorder, cocaine abuse in remission, and hypertension. R9's MDS dated [DATE] shows R9 has moderate cognitive impairment. R9's care plan revised on April 20, 2025 shows: My comprehensive assessment reveals a history of suspected abuse, neglect, exploitation, past trauma and/or other factors that may increase my susceptibility to abuse/neglect. The resident demonstrates: delusions/hallucinations, difficulty in adjustment and generalized mood distress. Symptoms may be manifested by behavioral symptoms. The facility does not have documentation to show R9 has a POA or a legal healthcare surrogate decision maker. The facility does not have documentation to show R9's family member/emergency contact was notified regarding the change of R9's Medicare Advantage plan or that the insurance agent would be speaking to R9. R9's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 8 of 14 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 09/11/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medicare Advantage Plan Enrollment Form dated August 15, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R9's name, date of birth , gender, permanent address as the facility, and his Medicare Number. R9's signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging R9 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. 3. On September 4, 2025, at 1:58 PM, R17 was lying in bed in his room. R17 was not able to say what year it is, what day of the week it was, what time it was, where he currently lives, or how long he has lived at the facility. The EMR shows R17 was admitted to the facility on [DATE] with multiple diagnoses including, dementia, convulsions, repeated falls, alcohol abuse, schizoaffective disorder, bipolar disorder, and major depressive disorder. R17's MDS dated [DATE] shows R17 has severe cognitive impairment. R17's care plan, revised January 25, 2023 shows: Potential Abuse Neglect: My comprehensive assessment reveals factors that may increase my susceptibility to abuse/neglect related to diagnosis of dementia, mental illness (bipolar disorder, schizoaffective disorder and depression), current or history of conflict between/with co peer. Given [R17's] poor and compromised health status, cognitive issues, physical decline and need for 24-hour care, the IDT (Interdisciplinary Team) recognizes that he is considered a vulnerable adult. R17's Medicare Advantage Plan Enrollment Form dated August 20, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form shows R17's name, date of birth , gender, permanent address as the facility, and his Medicare Number. R17's signature is typed in a cursive font as the signature on the Enrollment Form, acknowledging R17 read and understood the Enrollment Form and signed the form. The Enrollment Form shows V15 (Agent) as the individual helping enrollee with completing this form only. R17's Power of Attorney for Health Care dated June 30, 2022 shows the POA for R17 as V17. The facility does not have documentation to show V17 (POA for R17) was contacted regarding the change of R17's Medicare Advantage plan or that the insurance agent spoke to R17. On September 11, 2025 at 9:13 AM, V17 (Son/POA for R17) said, I am the POA for [R17]. We set that up because my dad (R17) is not able to make his own decisions. I was not aware he (R17) consented to changing his insurance on August 20, 2025. I was not present for the presentation by the insurance agent, and I did not give my consent for that change to the new Medicare Advantage plan he is now enrolled in. Yesterday, [V3] (SSD) contacted me and told me they signed my dad up for a wellness program. It was not presented to me as a whole new insurance plan during the conversation; it was presented as a wellness plan. It is upsetting to think the consent for that insurance change happened on August 20, 2025 and yesterday is the first time the facility contacted me about it. How did [R17] even sign the paperwork? He can't even sign his own name. On September 8, 2025 at 12:56 PM, V16 (Physician) said he is the primary care physician for R17 and R17 has severe cognitive impairment and would not be able to read and understand a consent form. V16 continued to say he is the Medical Director of the building and, I was just told about the [outside insurance vendor] process and Medicare Advantage enrollment changes. I have no clue what they are doing. On September 4, 2025 at 9:51 AM, V18 (Compliance Officer Outside Insurance Vendor) said, the sales process for the Medicare Advantage plan from the outside insurance vendor starts with a designated person in the facility, in this case V3 (SSD), obtaining permission to contact the residents residing in the facility or the resident's POA/Healthcare Surrogate. Once the insurance agent receives permission to contact someone, the sales agent in the building does a presentation. V18 said the insurance company is not allowed, by law, to receive any information regarding any medical diagnosis or cognitive status of the resident. If the insurance agent is given permission to contact by the facility, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 9 of 14 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 09/11/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete then the resident is considered to be a self-signer and that information cannot be validated against any medical record until the insurance plan is in place. V18 continued to say a sales agent would not know if a resident had any cognitive deficit and relies solely on the facility to ensure the residents the insurance agent is talking to are cognitively intact and able to understand and sign the paperwork. V18 said, there are financial incentives, and the outside insurance vendor does quality bonuses. We reward quality care. When [outside insurance vendor] contracts with anyone, there are metrics of quality. For example, if the [outside insurance vendor's] member (resident) has hypertension, and it is controlled in the building over time; I cannot speak of a dollar amount but is a shared savings program. The money does not come back to the residents. The money is dispersed to the ownership. On September 9, 2025 at 4:43 PM, V1 (Administrator) said, The [outside insurance vendor] asked us for a list of who is conversational, and we gave it to them. We weren't there to hear what they presented to the residents or who signed what. The facility's Abuse Prevention Program Policy revised 3/1/21 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. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party.VII. Prevention: The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. Event ID: Facility ID: 145333 If continuation sheet Page 10 of 14 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 09/11/2025 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 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 interview and record review, the facility failed to follow physician orders to obtain an appointment for a neurology consult. This applies to 1 of 3 residents (R19) reviewed for appointments in the sample of 23. The findings include:On September 9, 2025 at 10:35 AM, R19 was lying in bed in his room. R19 said he went to see his neurologist about leg weakness a few months ago and the physician said R19 should get a second opinion from another neurologist. R19 said he is still waiting to see the neurologist and facility staff said it could be as long as February 2026 before the facility staff can find R19 an appointment. R19 said, Maybe I'll just give up and not go by the time they find me someone to go to. I can't wait this long. My legs won't work by that time. The EMR (Electronic Medical Record) shows R19 was admitted to the facility on [DATE] with multiple diagnoses including, mononeuropathy of left lower limb, PVD (Peripheral Vascular Disease), hypertension, heart disease, spleen infarction, depression, anemia, spinal stenosis of the cervical region, post-laminectomy syndrome, low back pain, thoracic aortic aneurysm, anxiety disorder, adjustment disorder, and presence of prosthetic heart valve. R19's MDS (Minimum Data Set) dated July 8, 2025 shows R19 is cognitively intact, requires setup assistance with eating and lower body dressing, supervision with oral and personal hygiene, substantial/maximal assistance with showering and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R19 is frequently incontinent of urine, and always incontinent of stool. The EMR shows the following order for R19 dated June 18, 2025 at 12:13 PM and signed by V14 (Physician): Order summary: Neurologist order: 2nd opinion for spine consultation at tertiary care center. On September 4, 2025 at 12:57 PM, V8 (Scheduler) demonstrated how she makes appointments for residents and sets up transportation to and from the appointments. V8 opened the facility's appointment calendar on the computer for the period of September 4, 2025 through February 28, 2026. V8 was unable to show a scheduled appointment for R19 to see the neurologist. R19 did not have a system in place to keep track of resident appointments, and went through many papers in her office, including sticky notes, scratch paper, and binders full of notebook paper, and was unable to find the appointment scheduled for R19. V8 said, Maybe the paper is in my backpack out in my car. The facility's policy dated 5/14/23 shows: Guidelines for Resident Appointments Outside the Facility shows: Purpose: While the facility has in-house physician visits to residents per policy and State/Federal regulatory mandates, there are times when the resident may need to be seen outside of the facility by a provider that does not physically travel to the nursing home. Procedure: Procedure: Upon receiving a physician's order for a situation or event that will require the resident to need transport services, the nurse who processes the order will notify the staff member who coordinates transport orders so that appropriate transport can be scheduled. The transport will be secured according to medical necessity-such as a medical emergency or an acutely ill resident requiring an ambulance, while a routine non-emergency situation could require the transport services of a local or facility provider. The nursing staff will be aware of the appointments that require residents to be transported from the facility. There will be a calendar/log to inform them of this. Residents who will be transporting on a given day/date will have their personal care done and their medications given in accordance with the time they will be away from the facility for the appointment. Dialysis residents will have a meal sent with them as indicated. If for any reason an ordered/scheduled appointment is missed, it will be re-scheduled as appropriate, unless there has been some change, and the order is cancelled. All parties to include the ordering physician, transport provider, resident and resident's responsible party/POA (Power of Attorney) will be notified of the re-scheduling or the cancellation of an appointment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 11 of 14 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 09/11/2025 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident requesting to see an audiologist, received assistance to make an appointment to see an audiologist. This applies to 1 of 3 residents (R1) reviewed for audiology services in the sample of 23. The findings include:On September 2, 2025, at 12:36 PM, R1 was sitting in his room. R1 said he has been having a difficult time hearing and has been asking to see an audiologist for a long time. R1 continued to say he would be happy to go out in the community if he could see an audiologist sooner, but facility staff have not assisted him with making an appointment to see an audiologist. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dementia, generalized anxiety disorder, hypertension, anemia, insomnia, history of skin cancer, major depressive disorder, epilepsy, cognitive communication deficit, lack of coordination, leukemia, toxic encephalopathy, urine retention, bipolar disorder, and psychosis. R1's MDS (Minimum Data Set) dated June 19, 2025 shows R1 has moderate cognitive impairment, is independent with bed mobility, requires setup assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The facility's Concern Form dated May 16, 2025 completed by V7 (Ombudsman) shows multiple concerns including, Needs to be seen by an audiologist. Has been asking since January 2025 and hasn't seen one. On September 8, 2025, at 3:37 PM, V7 (Ombudsman) said she completed the grievance form for R1 on May 16, 2025 but did not submit R1's grievances to V1 (Administrator) until May 19, 2025 at 8:45 AM via email. V7 provided documentation to show V1 received her grievance on behalf of R1 on May 19, 2025 at 11:25 AM. V7 continued to say she spoke to V11 (RN-Registered Nurse) regarding referrals to the audiologist in mid-June 2025. On June 16, 2025 at 1:59 PM, V11 (RN) documented, Writer called [V12] (Insurance Case Manager) to fax doctor list for urologist, eye doctor, dental, audiologist doctor. He said he will fax the doctor list for urologist, eye doctor, dental, audiologist doctor. Will f/u (Follow up). Writer provided the fax number for the facility. On September 9, 2025 at 11:05 AM, V11 (RN) said, I notified the social worker back in June that [R1] needed to see an audiologist. I used the communication tool in our EMR to communicate with him. I can tell you the exact date I communicated the request to see the dentist and audiologist to [V5] (SSD-Social Services Director). It was June 16, 2025. I can tell by looking at my documentation in the medical record. V11 continued to show the process of using the communication feature in the EMR and also showed her nursing progress note dated June 16, 2025. The facility does not have documentation to show facility staff followed up on the list of providers from R1's insurance company. As of September 2, 2025, the facility did not have documentation to show R1 was assisted with making an appointment to see an audiologist or had seen an audiologist. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 12 of 14 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 09/11/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy to ensure a resident received routine and emergency dental services in a timely manner. This failure resulted in R1 experiencing severe pain and requiring a tooth extraction. This applies to 1 of 3 residents (R1) reviewed for dental services in the sample of 23.The findings include:On September 2, 2025, at 12:36 PM, R1 was sitting in his room. R1 had a piece of rolled up gauze in his mouth and said he had a tooth pulled on August 30, 2025. R1 said, I lost the filling back in May (2025) and have been telling so many people here that I needed to see the dentist, including [V3] (SSD-Social Service Director). I even called [V7] (Ombudsman) to help me because the pain has been so bad. When they finally got me to see the dentist, he wasn't able to replace the filling and my only choice was to have the tooth pulled. If only they would have let me see him sooner. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dementia, generalized anxiety disorder, hypertension, anemia, insomnia, history of skin cancer, major depressive disorder, epilepsy, cognitive communication deficit, lack of coordination, leukemia, toxic encephalopathy, urine retention, bipolar disorder, and psychosis. R1's MDS (Minimum Data Set) dated June 19, 2025 shows R1 has moderate cognitive impairment, is independent with bed mobility, requires setup assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of bowel and bladder. The facility's Concern Form dated May 16, 2025 completed by V7 (Ombudsman) shows multiple concerns including, .3. Needs to see a dentist. On September 8, 2025, at 3:37 PM, V7 (Ombudsman) said she completed the grievance form for R1 on May 16, 2025 but did not submit R1's grievances to V1 (Administrator) until May 19, 2025 at 8:45 AM via email. V7 provided documentation to show V1 received her grievance on behalf of R1 on May 19, 2025 at 11:25 AM. V7 said she spoke to V11 (RN-Registered Nurse) regarding referrals to the dentist in mid-June 2025. On June 16, 2025 at 1:59 PM, V11 (RN) documented, Writer called [V12] (Insurance Case Manager) to fax doctor list for urologist, eye doctor, dental, audiologist doctor. He said he will fax the doctor list for urologist, eye doctor, dental, audiologist doctor. Will f/u (Follow up). Writer provided the fax number for the facility. On September 2, 2025 at 11:04 AM, V3 (SSD) said, Anytime a resident, nurse, or anybody asks, I will reach out to the dentist. He comes every Tuesday. Last week, he wasn't able to make it, so he came this past Saturday. I email the dentist if someone needs to be seen. On September 9, 2025 at 11:05 AM, V11 (RN) said, I notified the social worker back in June that [R1] needed to see a dentist. I used the communication tool in our EMR to communicate with him. I can tell you the exact date I communicated the request to see the dentist and audiologist to [V5] (SSD). It was June 16, 2025. I can tell by looking at my documentation in the medical record. V11 continued to show the process of using the communication feature in the EMR and showed her nursing progress note dated June 16, 2025. The facility's Admission/re-admission Screener for R1 dated July 2, 2025, signed by V10 (RN-Registered Nurse) shows 12. Teeth/Dentures: 1. Own teeth - yes.4. Broken or carious teeth? Yes. The facility does not have documentation to show facility staff followed up on the list of providers for R1 from his insurance provider. The facility does not have documentation to show R1 was seen by the dentist following the grievance dated May 16, 2025, or following the communication by V11 to social services on June 16, 2025, or following the assessment of dental concerns on the nursing assessment documentation dated July 2, 2025. The undated dental list provided by the facility does not show R1 was seen by the dentist during the dental visits at the facility from January 2025 through July 2025. Facility documentation shows R1's last dental visit at the facility was April 26, 2024. The Dental Consult form, dated April Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145333 If continuation sheet Page 13 of 14 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 09/11/2025 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 0791 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 26, 2024, shows V13 (Dentist) documented R1 received a dental exam and needed extractions of teeth number 8 and 9, asap (as soon as possible). The facility does not have documentation to show R1 was seen by the dentist following the dental exam on April 26, 2024, or that R1 refused to have the two teeth extracted as recommended by V13. The Dental Consult form dated August 27, 2025 shows R1 received a dental exam by V13, and R1 had red, puffy tissue, lost a filling in tooth number 19, and had continuing pain. V13 ordered an antibiotic for R1 and recommended an extraction of the tooth at the next visit. The Dental Consult form dated August 30, 2025 shows R1 had an extraction of tooth number 19, and recommended extractions of two teeth, number 9 and 10 at the next visit. On September 9, 2025 at 9:28 AM, V13 (Dentist) provided a timeline of his dental visits with R1, beginning on August 27, 2025. V13 said he visits the facility weekly. V13 said he sees residents routinely who are signed up for the dental program, and will see any resident in the facility, upon request, including residents who are not enrolled in the dental program. V13 said the last time he examined R1 prior to August 27, 2025 was on April 26, 2024, when V13 recommended extraction of two different teeth (8 and 9). V13 said, when he examined R1 on August 27, 2025, R1 had a lot of pain, swelling, and infection present due to a lost filling in tooth number 19. V13 was not able to extract the tooth on August 27, 2025 due to the swelling and infection and prescribed antibiotics with the plan to return to the facility in a few days to extract the tooth. V13 said he returned on August 30, 2025 to extract tooth number 19, and returned to the facility on August 31, 2025 for a post-operative follow-up and found R1 was experiencing a condition called dry socket. V13 said he again returned to the facility on September 2, and 7, 2025 due to R1 experiencing pain, and again on September 8, 2025 due to pain. V13 said if R1 had received prompt dental care when he voiced concerns regarding the lost filling, the tooth pain and infectious process R1 experienced could have been prevented. The facility's undated policy entitled Dental Services shows: Policy: it is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This includes meeting any need for dental/denture care to include routine as well as emergency indicated services. Procedure: 1. A licensed nurse will conduct a comprehensive, accurate, standardized assessment of each resident's functional capacity to include dental status. Note: Dental condition status refers to the condition of the teeth, gums, and other structures of the oral cavity that may affect the resident's nutritional status, communication abilities or quality of life. The assessment should include the need for and use of dentures or other dental appliance(s). 2. These assessments will be conducted initially upon admission, quarterly, annually, and when there is a significant change in the resident's condition that affects the oral cavity.6. The assessing nurse will physically inspect the resident's mouth (oral cavity) for any abnormalities. 7. The assessing nurse will monitor for: .Darkness on a tooth (likely decay) or broken natural teeth, bleeding or loose teeth, mouth, or facial pain - discomfort or pain when chewing. Note: Negative findings will be immediately addressed. The attending physician will be notified as well as the facility's dental provider. The DON (Director of Nursing), MDS (Minimum Data Set) Coordinator, and SSD will also be notified as well as the resident or their responsible party. 8. SSD will work with the resident, family, physician, and the dental provider to coordinate timely care. This includes arranging transportation and staff accompaniment as needed. Event ID: Facility ID: 145333 If continuation sheet Page 14 of 14