Health inspection·December 22, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 12:50 PM, V2 (Director of Nursing) was interviewed regarding R103's BiPap machine and orders. V2 states admissions was notified at some point from the hospital liaison that R103 needed a BiPap. At this point, admissions did order a BiPap for R103, however when the resident arrived at the facility, the facility did not see an order on the discharge records for the BiPap, so the BiPap was not set for R103. R103 did not receive the BiPap on [DATE]. V2 stated she knew that the unit manager had been made aware that R103 needed a BiPap the following day on [DATE] and this is how the order was obtained. V2 stated she was not sure if the BiPap was one from home or the one admissions had ordered for R103 or who set the BiPap machine up for R103. On [DATE] at 1:30 PM, V35 (Unit Manager) was interviewed regarding R103's care while at the facility. V35 stated on [DATE] V35 spoke with V27 (Family Member) about concerns V27 had about R103's care. V27 told me at this time that R103 was previously found unresponsive and needs a BiPap when R103 sleeps. V27 stated she came to the facility and saw R103 sleeping without the BiPap. V27 was concerned this would happen again. V35 ensured V27 that the facility was able to care for R103. This was the first time we were made aware that R103 required a BiPap while sleeping. After this conversation, V35 looked into the situation and found that R103 did not have an order for the BiPap in place. V35 stated she contacted the doctor, confirmed the order, and obtained a written order. V35 stated she talked with the nurses on R103's unit to ensure R103 is wearing the BiPap at all times while sleeping. V35 stated, I am unsure of where the BiPap came from, if it was brought in by the family or it was one that we had ordered for the resident. On [DATE] at 12:10 PM, V29 (Registered Nurse) was interviewed regarding R103's admission to the facility. V29 stated she was the admitting nurse for R103 and believes R103 was admitted around 3:00 PM on [DATE]. We are made aware of new admission orders and status by both the hospital discharge records and by the hospital nurse's report. I remember R103 came in via transport with oxygen. I also received report from the hospital nurse that R103 was on oxygen. I did not get report from the hospital nurse that he was using a BiPap nor was it in his hospital discharge orders. Typically, if a resident is on a BiPap, the hospital nurse will report to us the settings of the BiPap or the settings will be on the discharge paperwork. I did not have any interaction with his family when R103 was admitted , R103 arrived by himself. Asked V29 how the admission orders are reviewed after the admitting nurse puts them in, V29 stated, two nurses verify the orders upon admission. The next day the unit manager would review the admission records, then the physician typically shows up the following day to verify the orders, notes, and to see the resident. V29 states, I have been disciplined in the past for transcribing medications incorrectly. The facility One-On-One Inservice Record, V29 (Registered Nurse) was disciplined on [DATE], [DATE], [DATE], and [DATE] for medication reconciliation and medication/treatment guidelines. Per nursing progress note written by V25 (Registered Nurse) on [DATE] at 8:45 AM states in part but not limited to the following: Approximately 2:50 AM, R103 noted on floor by side of bed, face down. Upon assessment, patient noted with skin cut on forehead with minimal bleeding, site cleansed with normal saline. Patient not responding to verbal or tactile stimuli, no carotid pulse noted, board placed, patient transferred to bed by staff, CPR (Cardiopulmonary Resuscitation) on going, 911 called, patient transferred to hospital per 911. On [DATE] at 4:30 PM, V25 was interviewed regarding the incident on [DATE]. At some time after 2 AM, I went in to check on R103 and found him face down on the floor. I called for help, there was another nurse on the floor, V26 (Registered Nurse). V26 and I both went into the resident's room; we called a code blue and I called 911. The CNA's and other nurses came in to help as well when the code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 2 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was called. V26 started CPR. 911 came at some point after and took him. Asked V25 why she documented the progress note at 8:45AM in which she responded I documented at the end of my shift. On [DATE] at 10:21 AM, V2 (Director of Nursing) was interviewed regarding the incident with R103. V2 stated I did do the investigation on the incident with R103. My understanding was that V25 was on his way to the room or passing R103's room and noticed the R103 on the floor, face down. R103 had a skin tear on the forehead with minimal bleeding. R103 was found unresponsive at that time. V25 called a code blue, started CPR, and called 911. V2 states that if a resident expired in a facility unexpectedly, we notify the doctor and family. We then investigate if there were any accidents that may warrant a call to the coroner. Asked V2 for the facility policy in regard to reporting incidents, in which V2 satates she does not believe the facility has one. We did not deem this incident a reportable incident since R103 expired from cardiac arrest, not related to the fall. R103 had a small laceration to his head that did not require sutures or staples, to my knowledge. I know after R103 left our facility, he went into cardiac arrest a couple times in the emergency room and later R103 was pronounced dead. Incident/Accident log states in part but not limited to the following: [DATE] at 2:40 AM, R103, fall resulting in serious injury in patient's room. Per witness statement from V25 dated [DATE] states in part but not limited to the following: At 2:50 AM, V25 went into the room to check on R103 and observed him laying lying on the floor, face down between the bed and the door. The BiPap machine was not on the patient. V25 called for staff assistance. V26 (Registered Nurse) came in and they rolled the patient over noting a small laceration to the forehead with minimal serosanguinous drainage. V25 then performed a sternal rub, R103 was non-responsive, no spontaneous breaths and no palpable heartbeat. He was transferred into the bed. V25 left the room to call 911 and grab the crash cart. V26 initiated CPR with the backboard in place and the AED on. 911 came in and took over. emergency room records dated [DATE] at 3:47 AM state in part but not limited to the following: History of Present Illness: [AGE] year-old male with history of hyperlipidemia, heart failure, dementia, COPD, pulmonary hypertension presents in cardiac arrest. EMS (Emergency Medical Service) reports that they were called by nursing home for patient in cardiac arrest. Nursing home reported patient last seen approximately 25 to 30 minutes prior to being found in cardiac arrest. Patient in asystole on EMS arrival. EMS estimates approximately 15 minutes ACLS (Advanced Cardiovascular Life Support) performed since they arrive on scene upon arrive in the emergency department, patient in asystole throughout. Death certificate obtained for R103 lists cause of death as organic cardiovascular disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 3 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: R504 was an [AGE] year-old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. Immediately prior to transfer, R504 underwent a surgical laminectomy of the spine after sustaining a fall in the home. According to the Minimum Data Set assessment dated [DATE], R504 was assessed to be totally dependent on staff for all activities of daily living, requiring extensive 2-person assistance with bed mobility, turning and toileting. R504 mobilized with a wheelchair and was not ambulatory. According to nursing progress note dated [DATE] at approximately 1:00AM, R504 was assessed by nursing staff to have multiple episodes of yellow emesis at start of the shift. During emesis R504 was observed to have fixed stare. Nurse assessed vital signs: Blood Pressure: 67/39 Heart Rate: 89 and blood glucose: 299. The nurse on duty called 911 for transport to the nearest hospital. According to hospital records dated [DATE], several hours after arriving to the Emergency Department, R504 received life resuscitation measures and expired. Death Certificate dated [DATE] lists cause of death: Cardiopulmonary Arrest and Massive Pulmonary Embolism. On [DATE] at 10:06AM V2 Director of Nursing said, we were made aware that R504 went to the hospital and passed away. When the hospital called, they asked for a medication list and the unit manager grabbed the chart and reconciled the notes. That is when she found that there was a discrepancy with how the admission medication orders were transcribed. It is possible that this could have contributed to blood clot development, and I began an investigation based off of this concern. The medication, Heparin was missed (upon admission to the facility) and was not documented on the Physicians Order Sheet. R504 did not receive Heparin at any time while in the facility. The nurse that transcribed the orders was from an agency and was asked not to return after this incident. On [DATE] at 9:58AM, V30 Medical Director and primary physician of R504 said, when patients come from the hospital, we are supposed to follow all the hospital orders. I was told by the facility that the nurses have a system in place where they call the physician and go over the medication list, and then another nurse will verify that all the medications have been ordered in the system correctly according to the discharge medication list. I round at the facility, and I also will review the hospital discharge orders when I do the initial visit. I don't know how an error could have occurred with these systems in place. Heparin is used to help prevent blood clots, such as DVT (deep vein thrombosis) and pulmonary embolism. Heparin is used to help prevent blood clots of all kinds, particularly in high-risk patients. It is possible that without the Heparin being given as ordered, a patient who is at risk of developing blood clots has a higher chance of developing them if they are unable to walk or move on their own. V30's Physician progress note dated [DATE] indicated that R504 was assessed, and all hospital records were reviewed. Hospital discharge forms and Physician Order sheet reviewed for [DATE]. Hospital discharge medication list included Heparin 5,000 units to be given every 8 hours which was not transcribed to the Physician Order Sheet at the time of admission to the facility. There is no record of R504 receiving this medication while in the facility at any time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 4 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 0726 Physician progress note dated [DATE] documented that R504 was at risk for developing DVT (deep vein thrombosis). Level of Harm - Actual harm Residents Affected - Few Facility policy titled, Admission, long-term care (Revised [DATE]) includes: Ensure that a complete list of the medications the resident was taking at home is documented in the resident's medical record. Compare this list with the resident's current medications. Reconcile and document any discrepancies in the resident's medical record to reduce the risk of transition-related adverse drug events. R73 is a [AGE] year-old male admitted to the facility [DATE] with diagnoses that include End Stage Renal Disease, Diabetes, Hypertension and Spinal Stenosis. R73 is alert and oriented as assessed on [DATE], with a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact). On [DATE] V6 (RN) wrote a progress note at 4:07PM that stated, Resident accidentally taken the wrong medication family aware and MD will continually monitor resident for side effect and reaction. Facility Witness statement for the incident of [DATE] states that V6 (RN) pulled medications for R73 and the roommate and entered the room with both medication cups in hand. When she set the medication in front of R73, he ingested one pill and then stated that the medications in the cup were not his meds. V6 took the remaining medicine from R73 and gave him the other prepared medications. Prior to going into the room, the medications were labeled with the resident's names. V6 (RN) could not be reached for interview during this investigation. Review of V6's Employee file reviewed and found to contain Employee Warning Notices that indicated V6 had received written notice of three additional medication administration related incidents since being hired in the facility in 2018. On [DATE] at 10:06AM V2 Director of Nursing said, I am aware that there have been multiple medication administration errors since I've been the Director of Nursing. Medication administration errors are avoidable by utilizing the 5 rights. When an incident like this occurs, the nurses are provided education in the form of an in-service that emphasizes the Rights of Medication Administration, such as right medication, right dose, right patient, right time, and right route. I was not aware that V6 (RN) had a history of documented medication errors or incidents. R73 did not require any hospitalization after the incident, and the physician was called with no further orders but to monitor for any reactions. Facility policy titled, Medication and Treatment Administration Guidelines, Long-Term Care (no revision date) includes: Medications are administered in accordance with the following rights of medication administration or per state specific standards: Right patient, right medication, right dose, right route, right time (including duration of therapy, right documentation, right of patient to refuse, right clinical indication). Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the required competencies when transcribing physician orders for newly admitted residents to ensure that care is being provided as ordered and to meet the needs of the residents; they also failed to ensure that standards of nursing practice were being followed during the administration of medication. This failure applied to three of three (R73, R103, and R504) residents reviewed for nursing services and resulted in (R73) receiving medication that was not ordered; (R103) not having a BiPap machine upon admission, that R103 was required to wear due to history of sleep apnea and respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 5 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 0726 failure; and (R504) did not receive medication that were needed for the prevention of blood clots upon admission to the facility. Level of Harm - Actual harm Findings include: Residents Affected - Few R103 was a [AGE] year-old male initially admitted to the facility on [DATE] and expired on [DATE]. His medical diagnoses include but are not limited to the following: respiratory failure, sleep apnea, severe protein calorie malnutrition, muscle wasting, altered mental status, history of falling, hyperlipidemia, heart failure, dementia, depression, and absence of lung, HTN, and COPD. Transition of care report from (facility) state in part but not limited to the following: Reason for hospitalization: fall, altered mental status, acute respiratory failure, and COPD. 4 liters of oxygen. Per hospital discharge records dated [DATE] state in part but not limited to the following: BiPap QHS per pulmonary recommendations Settings: 15/5, 50% FiO2. Venous blood gas improved with BiPap. Fast track report: Oxygen: 3 liters, has a BiPap from home and will bring. Physician Order Sheet dated [DATE] at 2:04 PM states in part but not limited to the following: BiPap; Oxygen 4 liters per minute; Settings: 12/5, set rate 12 breathing 25; FiO2 40% with tidal volumes 448 every evening and night shift and as needed for sleep apnea while sleeping. On [DATE] at 12:50 PM, V2 (Director of Nursing) was interviewed regarding R103's BiPap machine and orders. V2 states admissions were notified at some point from the hospital liaison that R103 needed a BiPap. At this point, admissions did order a BiPap for R103, however when the resident arrived to the facility, we did not see an order on the discharge records for the BiPap, so the BiPap was not set for R103. R103 did not receive the BiPap on [DATE]. I know that the unit manager was made aware that R103needed a BiPap the following day on [DATE] and this is how the order was obtained. I am not sure if the BiPap was one from home or the one admissions had ordered for him. I am unsure of who set the BiPap machine up for R103. On [DATE] at 1:30 PM, V35 (Unit Manager) was interviewed regarding R103's care while at the facility. V35 states on [DATE] she spoke with V27 (Family Member) about concerns V27 had about R103's care. V27 told me at this time that R103 was previously found unresponsive and needs a BiPap when he sleeps. V27 satated she came to the facility and saw R103 sleeping without the BiPap. V27 was concerned this would happen again. I ensured her we were able to care for R103. This was the first time we were made aware that R103 required a BiPap while sleeping. After this conversation, I looked into the situation and found that R103 did not have an order for the BiPap in place. I contacted the doctor, confirmed the order, and obtained a written order. I talked with the nurses on his unit to ensure he is wearing the BiPap at all times while R103 is sleeping. I am unsure of where the BiPap came from, if it was brought in by the family or it was one that we had ordered for the resident. On [DATE] at 12:10 PM, V29 (Registered Nurse) was interviewed about R103's admission to the facility. V29 says she was the admitting nurse for R103 and believes he was admitted around 3:00 PM on [DATE]. We are made aware of new admission orders and status by both the hospital discharge records and by the hospital nurse's report. I remember he came in via transport with oxygen. I also received report from the hospital nurse that he was on oxygen. I did not get report from the hospital nurse that he was using a BiPap nor was it in his hospital discharge orders. Typically, if a resident is on a BiPap the hospital nurse will report to us the settings of the BiPap or the settings will be on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 6 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 0726 Level of Harm - Actual harm Residents Affected - Few discharge paperwork. I did not have any interaction with his family when he admitted , he came by himself. Asked V29 how the admission orders are reviewed after the admitting nurse puts them in, in which V29 said two nurses verify the orders upon admission, the next day the unit manager would review the admission records. From there the physician typically shows up the following day to verify the orders, notes, and to see the resident. V29 says I have been disciplined in the past for transcribing medications incorrectly. Per facility One-On-One Inservice Record, V29 (Registered Nurse) was disciplined on [DATE], [DATE], [DATE], and [DATE] for medication reconciliation and medication/treatment guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 7 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. This failure applied to two residents (R60 and R74) and resulted in four errors out of 27 observed medication opportunities, resulting in a 14.81% medication error rate. Residents Affected - Some Findings include: 12/20/2022 at 9:20AM, V7 LPN, was observed during medication administration for R74. V7 noted that one medication, Methylphenidate 10mg, was not available in the medication cart. V7 was observed giving medications to R74 and immediately after contacted the unit manager to remove the medication from the convenience medication dispenser. The unit manager informed V7 that this medication was not available in the machine. V7 said, the medication will be missed, and I will update the pharmacy now in the system to re-order it. Upon medication reconciliation, it was noted that Polyethylene Glycol was also not administered per physician orders. This resulted in two observed medication errors. Physicians order sheet dated December 2022 lists Methylphenidate HCl Tablet 10 MG, give once daily by mouth scheduled at 8AM; Polyethylene Glycol 3350 17 Grams is ordered to be given daily at 8AM. 12/20/22 at 9:36AM, V7 LPN was observed giving morning medications to R60. After medication reconciliation, it was noted that R60 was not given two inhaler medications which were scheduled for 8AM. R60's Physician Order Sheet dated December 2022 includes orders for Fluticasone-Salmeterol Inhaler twice daily at 9AM and 9PM and Ipratropium-Albuterol Inhaler four times daily for shortness of breath at 8AM, 12PM, 4PM and 8PM. Facility Policy titled Medication and Treatment Administration Guidelines, Long-Term Care (no revision date) states in part; Medications are administered in accordance with the following rights of medication administration or per state specific standards: Right patient, right medication, right dose, right route, right time (including duration of therapy, right documentation, right of patient to refuse, right clinical indication). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 8 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe hospital discharge orders to ensure that a newly admitted resident received all medications needed for treatment and failed to prevent a medication administration error. These failures affected two residents (R504 and R73) reviewed for medication administration and resulted in one resident (R73) receiving medication that was not ordered and resulted in (R504) not receiving medication for the prevention of blood clots upon admission to the facility and then being emergently transferred to the hospital and subsequently expiring. Residents Affected - Few Findings include: R504 was an [AGE] year old male admitted to the facility [DATE] with diagnoses that included cerebral infarction and hypertension. Immediately prior to transfer, R504 underwent a surgical laminectomy of the spine after sustaining a fall in the home. According to the Minimum Data Set assessment dated [DATE], R504 was assessed to be totally dependent on staff for all activities of daily living, requiring extensive 2 person assistance with bed mobility, turning and toileting. R504 mobilized with a wheelchair and was not ambulatory. According to nursing progress note dated [DATE] at approximately 1:00AM, R504 was assessed by nursing staff to have multiple episodes of yellow emesis at start of the shift. During emesis R504 was observed to have fixed stare. Nurse assessed vital signs: Blood Pressure: 67/39 Heart Rate: 89 and blood glucose: 299. The nurse on duty called 911 for transport to the nearest hospital. According to hospital records dated [DATE], several hours after arriving to the Emergency Department, R504 received life resuscitation measures and expired. Death Certificate dated [DATE] lists cause of death: Cardiopulmonary Arrest and Massive Pulmonary Embolism. On [DATE] at 10:06AM V2 Director of Nursing said, we were made aware that R504 went to the hospital and passed away. When the hospital called, they asked for a medication list and the unit manager grabbed the chart and reconciled the notes. That is when she found that there was a discrepancy with how the admission medication orders were transcribed. It is possible that this could have contributed to blood clot development and I began an investigation based off of this concern. The medication, Heparin was missed (upon admission to the facility) and was not documented on the Physicians Order Sheet. R504 did not receive Heparin at any time while in the facility. The nurse that transcribed the orders was from an agency and was asked not to return after this incident. On [DATE] at 9:58AM, V30 Medical Director and primary physician of R504 said, when patients come from the hospital, we are supposed to follow all the hospital orders. I was told by the facility that the nurses have a system in place where they call the physician and go over the medication list, and then another nurse will verify that all the medications have been ordered in the system correctly according to the discharge medication list. I round at the facility, and I also will review the hospital discharge orders when I do the initial visit. I don't know how an error could have occurred with these systems in place. Heparin is used to help prevent blood clots, such as DVT (deep vein thrombosis) and pulmonary embolism. Heparin is used to help prevent blood clots of all kinds, particularly in high risk patients. It is possible that without the Heparin being given as ordered, a patient who is at risk of developing blood clots has a higher chance of developing them if they are unable to walk or move on their own. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 9 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 0760 V30's Physician progress note dated [DATE] indicated that R504 was assessed, and all hospital records were reviewed. Level of Harm - Actual harm Residents Affected - Few Hospital discharge forms and Physician Order sheet reviewed for [DATE]. Hospital discharge medication list included Heparin 5,000 units to be given every 8 hours which was not transcribed to the Physician Order Sheet at the time of admission to the facility. There is no record of R504 receiving this medication while in the facility at any time. Physician progress note dated [DATE] documented that R504 was at risk for developing DVT (deep vein thrombosis). Facility policy titled, Admission, long-term care (Revised [DATE]) includes: Ensure that a complete list of the medications the resident was taking at home is documented in the resident's medical record. Compare this list with the resident's current medications. Reconcile and document any discrepancies in the resident's medical record to reduce the risk of transition-related adverse drug events. R73 is a [AGE] year old male admitted to the facility [DATE] with diagnoses that include End Stage Renal Disease, Diabetes, Hypertension and Spinal Stenosis. R73 is alert and oriented as assessed on [DATE], with a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact). On [DATE] V6 (RN) wrote a progress note at 4:07PM that stated, Resident accidentally taken the wrong medication family aware and MD will continually monitor resident for side effect and reaction. Facility Witness statement for the incident of [DATE] states that V6 (RN) pulled medications for R73 and the roommate, and entered the room with both medication cups in hand. When she set the medication in front of R73, he ingested one pill and then stated that the medications in the cup were not his meds. V6 took the remaining medicine from R73 and gave him the other prepared medications. Prior to going into the room, the medications were labeled with the resident's names. V6 (RN) could not be reached for interview during this investigation. Review of V6's Employee file reviewed and found to contain Employee Warning Notices that indicated V6 had received written notice of three additional medication administration related incidents since being hired in the facility in 2018. On [DATE] at 10:06AM V2 Director of Nursing said, I am aware that there have been multiple medication administration errors since I've been the Director of Nursing. Medication administration errors are avoidable by utilizing the 5 rights. When an incident like this occurs, the nurses are provided education in the form of an in-service that emphasizes the Rights of Medication Administration, such as right medication, right dose, right patient, right time and right route. I was not aware that V6 (RN) had a history of documented medication errors or incidents. R73 did not require any hospitalization after the incident, and the physician was called with no further orders but to monitor for any reactions. Facility policy titled, Medication and Treatment Administration Guidelines, Long-Term Care (no revision date) includes: Medications are administered in accordance with the following rights of medication administration or per state specific standards: Right patient, right medication, right dose, right route, right time (including duration of therapy, right documentation, right of patient to refuse, right clinical indication). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 10 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for preparing food under safe and sanitary conditions and to prevent the spread of contamination by not using hand hygiene after touching contaminated surfaces, not labeling opened food with a used by date, not ensuring stored potentially hazardous food is free of spillage, not ensuring the kitchen environment is clean and free of debris and spatter, not ensuring meat slicer was cleaned and sanitized after use, not wearing hair restraints properly, not ensuring opened containers of foods were dated and used by discard date, not preventing potential contamination when preparing puree and using thickener, not ensuring ice machine was clean and sanitary, not preventing personal food containers from being stored with the facility's food used for residents, and not ensuring the kitchen remained adequately sanitary to prevent the attraction of insects. This failure has the potential to affect all 93 residents currently in the facility and receiving food items from the kitchen. Findings include: On 12/19/22 from 09:31 AM - 10:18 AM V11 (Dietary Manager) observed walking through the kitchen wearing her mask underneath her nose and with her hair exposed from underneath her hairnet. Observed V15 (Dietary Aide) moving carts and walking through the kitchen wearing her surgical mask underneath her chin and with hair exposed from underneath her hairnet on the sides of her head. Observed V11 touch her mask and did not perform hand hygiene while in the kitchen. Observed the meat slicer sitting uncovered with debris and buildup in crevices at various spots. V12 (Cook) stated the meat slicer had been sitting uncovered since yesterday. Observed garbage bin sitting near three compartment sink mostly covered with residue and spatter. Observed drain screen underneath prep sink with heavy buildup and heavy build up on floor underneath the prep sink. V18 (Maintenance Director) stated the drain screen should not have heavy build up and needed to be cleaned. Observed sugar and flour bin with spatter on the outside. V11 stated the bin storing the flour and sugar needs to be cleaned. Observed an individual container of fried rice stored in the walk in cooler. V11 stated the fried rice was someone's personal food and should not be stored in the cooler with the food stored for residents. Observed a bin with cabbage in the walk-in cooler with red liquid on it. Observed a 33.8-ounce juice container with juice spillage on the exterior sitting in the prep cooler to be dated as prepped on 11/06/2022 but without a used by date. V11 stated the juice container should have a used by date on it and should not have spillage on it. Observed the floor in the cooler with a heavy amount of debris. Observed several spices stored in a cart with their lids open and covered with residue. Observed cart with spices stored in it with heavy buildup in crevices throughout the cart and with debris and buildup on the racks underneath the spices. Observed two opened packages of gravy and one opened package of cream not labeled. V11 stated the open containers of gravy and cream should have been labeled to ensure they were discarded properly when due. V11 stated the storage cart with the spices in it should be cleaned. Observed the lid to a small freezer with ice cream stored in it to have a large amount of build-up. V11 stated the small freezer should be cleaned. Observed the ice machine dispenser area with a large amount of residue and spillage and with a heavy build-up of black spots on the bottom of the machine where the ice falls down. Observed the ice catch screen to be missing. V18 stated he cleans the ice machine once a month and the ice catch screen is missing. V11 and V18 agreed the ice machine should be free of residue and spatter. On 12/20/22 from 09:31 AM - 10:21 AM Observed V16 (Dietary Aide) walking through and working in the kitchen with his surgical mask underneath his nose. Observed V17 (Dietary Aide) plating cakes with her surgical mask underneath her nose. Observed several gnats in the dishwashing area. Observed V16 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 11 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many pick up a meal ticket off the floor with gloved hands and throw it away, then handle clean dish equipment and continue working in the kitchen without removing his gloves or performing hand hygiene. Observed walls throughout the kitchen with build-up and spatter. Observed V11 walking throughout the kitchen and past kitchen staff with hair mainly exposed from underneath her hairnet and wearing her surgical mask underneath her nose. Observed V16 walking through the kitchen past other dietary staff with the top of his mask not completely covering his lips or nose. Observed food temperature log book heavily covered in build-up sitting on top of a 4.5 pound bread mix container. V12 (Cook) stated the bread mix is used to prepare food. V12 stated the build-up on the food log is grease and he is not sure why it is not cleaned from the log book. Observed V17 adjust her surgical mask with gloved hands then continue preparing desserts and grab items from the dry storage area without removing her gloves or performing hand hygiene. Observed V17 touch her head with gloved hands then grab clean utensils without removing her gloves or performing hand hygiene. Observed V12 rinse a spoon, shake it off, then scoop out thickener and place the thickener in the corn puree he was preparing then scoop more thickener and place it in the corn puree. V12 stated the pureed corn was being prepared for approximately 24 people. V12 stated he was adding the thickener to the corn puree until he reaches the desired consistency. Observed while V13 (Prep Cook) wearing her mask underneath her nose while assisting V17 with preparing food for meal trays. Observed V11 instruct V13 to place her mask over her nose, observed V13 adjust her mask over her nose with gloved hands and did not remove the gloves or perform hand hygiene then continue to continue assisting with food prep. V11 stated masks should be worn completely covering the nose and mouth. V11 stated gloves should be changed and hands washed after touching clothed body or mask and in between tasks. V11 stated if a dietary staff pick up an item off the floor with their gloves hands, they should remove the gloves and wash their hands. V11 stated hair nets should completely cover the dietary staffs hair. Observed V13 pick up an oven rack covered in heavy buildup off the floor and place in the convection oven. Observed V17 with her hair exposed from underneath her hair net in the front of her head. Observed heavy build up and debris on the floor underneath the convection oven and various areas of the kitchen. Observed the ceiling in a few areas of the kitchen with food spatter and build up. Observed the kitchen floor was sticky. V11 stated the kitchen floors and walls should be clean and free of buildup and spatter for infection control and sanitation purposes. Observed V17 don gloves, throw away two face shields that were sitting on top of table outside of the dish washer where clean dishes are set, then grab clean dish racks and store them without removing her gloves or performing hand hygiene. V11 and V17 stated they were not sure who the face shields belonged to. V11 stated V17 should have removed her gloves and washed her hands after handling the face shields. On 12/20/22 at 11:29 AM - 12:08 PM Observed V12 (Cook) rinse a spoon, shake it off, then scoop out thickener and place the thickener in the squash puree he was preparing, then scoop more thickener and place it in the squash puree. Observed V12 touch his shirt, grab gloves and set them down on the dishwashing sink, wash and rinse his hands under 20 seconds, then don the gloves. On 12/21/22 at 12:52 PM V11 (Food Service Manager) stated the spoon used for thickener and puree should have been allowed to dry before being used to make puree to prevent contamination from organisms. V11 stated sanitation and infection control would be a concern if oven equipment is left with buildup. V11 stated if an oven rack is picked up off the floor and placed in oven this would be an infection control issue. V11 stated gnats in the kitchen are from poor sanitation and infection control. V11 stated the meat slicer should have been washed, sanitized, and covered with a plastic bag after previous use. V11 stated juice stored in the cooler left with spillage can be potentially hazardous if not stored properly and spillage on the outside of the container (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 12 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 can become contaminated. Level of Harm - Minimal harm or potential for actual harm 12/21/22 01:52 PM V11 (Food Service Manager) stated grabbing a new pair of gloves after touching clothes is cross contamination. V11 stated hand washing should occur for at least 20 seconds. Residents Affected - Many The facility's Hand Hygiene Policy reviewed 12/21/2022 states: Purpose: To decrease the spread of infection. The facility's Hair Restraints Policy reviewed 12/21/2022 states: Hair restraints are worn to keep hair away from food and to minimize touching or handling of hair during food production. Hair is considered to be foreign object and hair restraints help to avoid hair from falling into food. Hair restraints are worn in a manner that covers all hair including bangs and pony tails. The facility's Food Storage Policy reviewed 12/21/2022 states: Nonperishable foods are stored: In a clean, dry and cool storeroom. Label opened foods following date marking guidelines. Discard food that has exceeded the expiration date or when the use-by date is unclear. Store spices and herbs in airtight containers in cool dry places to preserve quality freshness and flavor. The facility's Cleaning Schedule Policy reviewed 12/21/2022 states: Cleaning schedules help frame a plan for cleaning tasks. Staff use and follow cleaning schedules to make sure that all areas, equipment and food contact surfaces are given a thorough cleaning on a routine basis, in addition to the clean as you go approach during day-to-day operations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 13 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to have a COVID-19 policy and procedure in place to mitigate the spread of COVID-19 and failed to have a policy in place with guidelines of how to respond during an active facility outbreak of COVID-19; failed to post visible signs or posters to notify visitors of the outbreak status; failed to ensure that staff properly wear personal protective equipment (PPE); failed to ensure that staff practice proper hand hygiene after touching contaminated substances. These failures have the potential to affect all 93 residents currently in the facility. Residents Affected - Many Findings include: On 12/19/22 upon entry to the facility at 09:25 AM, observed V4 (Receptionist) not wearing a mask while at the reception desk. V4 was asked if the facility had any COVID positive residents and she said yes, but she does not know how many since she was off over the weekend and the number may have changed. There were no signs posted to indicate that the facility is in an outbreak status, several staff members were observed wearing surgical masks and no eye protection in the patient care area. 12/19/22 at 1:03PM, V1 (Administrator) entered the conference room wearing a surgical mask under her cheek. V1 was asked if the facility is in an outbreak status and she said, Oh, I'm sorry, and then pulled up her mask. 12/19/22 at 12:05PM Observed lunch on the first floor and noted staff passing lunch trays to resident's rooms. Some staff members were observed handing N95 masks and face shield to other staff and asking them to switch their surgical mask with the N95 and put on the face shield. V3 (RN) was noted entering an isolation room with a lunch tray with no PPE, came out and proceeded to pull medications from her cart without performing any hand hygiene. At 12:10PM, Surveyor asked V3 (RN) who she gave lunch in that room, and she said bed one (R83), V3 was asked if the room is an isolation room and she said yes, V3 was asked if she wore any PPE and she said no, she was supposed to wear one but just didn't. On 12/19/22 from 12:00 PM - 12:42 PM, Observed V21 (Certified Nursing Assistant) while on the 1st floor hallway remove her N95 mask then grab a new one from the PPE (Personal Protective Equipment) bin outside an isolation room without performing hand hygiene. Observed V21 touch the front of her mask and hand a straw to staff to be passed to R92 without performing hand hygiene. Observed V21 enter an isolation room with her isolation gown untied at the top. Observed V21 touch R8's clothed arm without performing hand hygiene afterwards. 12/20/22 at 12:30PM, V4 (Receptionist) was asked what type of screening she provides for visitors and she said that visitors are required to get their temperature taken, they are informed that the facility is in an outbreak status, they make sure they wash their hands, and they are provided with a screening questionnaire. V4 was asked to provide a copy of the questionnaire that visitors use, and she did not have any at the desk. V4 was asked why none of the current survey team members were properly screened for two days now and she said, no reason. 12/20/22 at 1:23PM, V1 (Administrator) was asked about the facility visitation protocol and she said that they are allowing visitors right now and they do not need to make an appointment. V1 was asked who is considered a visitor and she said, everyone including physicians, contractors and even IDPH (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 14 of 15 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 145363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453 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 surveyors. V1 was asked what type of screening the facility provides to the visitors and she said that they take the temperature, provide them with PPE, and have them sign screening questions provided by the receptionist. V1 was informed that the facility did not have any sign on the door regarding their COVID outbreak status when surveyors entered on Monday and none of the surveyors were screened apart from getting their temperature taken. Residents Affected - Many 12/21/22 at 11:35AM, V34 (Family Member) said that she was not screened when she came in and was not informed that there is a COVID-19 outbreak in the facility. V34 also said that she has received phone calls from the facility from time to time regarding COVID-19 but she is not aware that they are in outbreak status at this time. At 1:30PM, the survey team requested to speak to the infection prevention nurse but were told that she left for the day. When contacted over the phone, V5 (Infection Prevention Nurse) stated she went home because she tested positive for COVID, she was having symptoms when she came to work this morning. On 12/21/2022 at 4:10PM, V2 (DON) said that employees with signs and symptoms of COVID-19 are screened and tested on day one, three, and, five. The facility has been in outbreak status since 12/19/2022 and currently have 25 residents that are positive and about eight staff members isolating at home. Employees are not being screened when they come in, they are just taking their temperatures. The facility is currently testing both staff and residents three times a week. The survey team requested for facility policy and procedure for COVID-19 outbreak but none was provided during the course of this survey. V1 stated that the facility does not have a policy, they are just following CDC and IDPH guidelines. She added that the facility is still supposed to inform visitors of the outbreak status and that staff are supposed to wear an N95 mask and face shield when the facility is in an outbreak. On 12/21/22 at 04:03 PM V2 (Director of Nursing) stated that staff should use hand sanitizer before and after meeting a resident, and after touching inanimate objects, clothed body, hair, face mask, face shield. V1 (Administrator) and V2 stated N95 masks and face shields should be worn by all staff during COVID outbreak status. V1 and V2 stated if a staff member enters an isolation room, their gown should be tied at the top and bottom. Document provided by V5 (Infection Prevention Nurse) titled, COVID-19 PPE Usage, (dated 10/18/2022) states in part: As community transmission levels increase, the potential for encountering asymptomatic or pre-symptomatic patients with .In these circumstances, healthcare facilities should consider implementing broader use of respirators and eye protection by health care professionals (HCP) during patient encounters. Under outbreak, employees are required to wear N95 mask and eye protection during all patient encounters in specific areas that are high risk of COVID-19 transmission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 15 of 15