Inspection·March 20, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm stating that this is the policy that the staff follows as their practice to notification and calling physician with any changes in their residents, such as fall incidents and change in medication upon return in the facility. Notification for Change in Condition Policy with a revised date of 12/17/23, reads in part: The facility will provide care to residents and provide notification of resident change in status. Residents Affected - Few The facility will immediately inform the resident, consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 2 of 7 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 03/20/2024 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow physician orders by not applying an antifungal cream to one resident. This affected one of three residents (R3) reviewed for medication. Residents Affected - Few Findings include: R3 readmission hospital paperwork dated 9/15/23 documents orders for: antifungal cream apply three times daily. R3's physician order dated 9/15/23 with start date of 9/16/23 for antifungal ointment apply to affected area three times a day for fungal infection R3 medication administration record for September 2023 documents: antifungal ointment apply to affected area three times a day (0600, 1400, 2100) for fungal infection with start date of 9/16/23 and discontinued on 9/19/23. The 0600 dose on 9/16/23- 9/19/23 documents NN (nurses notes) which indicates to see nursing notes. R3's nursing notes dated 9/16/23 documents: antifungal cream on order. R3's nursing notes dated 9/17/23 documents: medication unavailable. R3's nursing notes dated 9/18/23 documents order with no other documentation. R3's nursing notes dated 9/19/23 documents: medication unavailable. On 3/1/24 at 2:08PM, V13(Pharmacy tech) said R3's medicated ointment was never delivered to the facility due to needing clarification. The clarification was never received. On 3/1/24 at 12:44PM, V10 (MDS) said, R3 had an ordered for medicated ointment without a stop date on 9/16/23. V10 said, she canceled the existing order and input the order with a stop date. R3 had medical ointment ordered on 9/19/23 which was changed to an antifungal power on 9/20/23. On 3/1/24 at 1:44PM, V12 (Treatment nurse) said, during rounds R3 requested her medicated ointment be changed to an anti-fungal power. The anti-fungal power was a house stock that we need a doctor's order to implement. R3's anti-fungal powered was stated on 9/21/23. On 3/12/24 at 4:00PM, V2 (DON-Director of Nursing) said all residents readmitted from hospital will have their orders verified by nurse, one other nurse and nurse manger to ensure accuracy. The pharmacy will email nurse managers (DON, ADON, Restorative nurse) for any medication recommendation, clarifications or whatever the question. The DON or ADON would be responsible to ensure whatever the concern is addressed or changed at time email is received or within a day. V2 said all residents should have medication on hand to be administrated by staff. R3 physician order dated 9/20/23 with start date 9/21/23 documents: cleanse bilateral breasts with soap and water. Dust with house stock anti-fungal powder twice a day and as needed. Facility policy Following physician orders dated 05/2021 documents to correctly and safely receive and transcribe physician orders so correct order is followed and administrated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 3 of 7 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 03/20/2024 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on interviews and record reviews, the facility failed to notify the attending physician of one resident's urine culture and sensitivity results noting the antibiotic the resident was receiving for UTI (urinary tract infection) was ineffective in treating resident's UTI. This affected one of three residents (R10) reviewed abnormal labs on the sample list of 49. Findings include: On 3/12/24 at 1:07 PM, V51 (attending physician) stated that typically V51 will order macrobid (antibiotic medication) for UTI (urinary tract infection) until the urine culture and sensitivity results are known. V51 stated that it takes 3-4 days for culture results and V51 does not want to wait to start treatment. V51 stated that macrobid treats most UTIs. V51 stated that V51 expects the nurse to call him with the urine culture and sensitivity results once results are known so antibiotic can be changed if the current antibiotic is not effective in treating UTI. V51 stated that V51 does not recall R10. V51 was informed that R10 had urine for a urinalysis collected on 9/21/23 with results noting UTI on 9/21/23. V51 was notified of results and started on macrobid by mouth for 7 days. On 9/24/23 at 9:14 AM R10's urine culture and sensitivity results were reported to this facility. These results were not reviewed by nurse until 9/25/23 at 12:17 PM. On 9/29/23, V52 (former infection prevention nurse) notified V51 that R10 completed macrobid and urine culture does not note macrobid effective in treating R10's pseudomonas aeruginosa UTI. R10 was started on ciprofloxacin (antibiotic) by mouth x 7 days at that time. V51 stated that the nurse should have notified V51 on 9/24/23 so macrobid could have been discontinued and R10 started on appropriate antibiotic to treat UTI. On 3/8/24 at 1:55 PM, V21 IP nurse (Infection Prevention nurse) stated that the IP nurse is expected to review the resident's antibiotic after the third day as well as review culture and sensitivity results to ensure resident is receiving an effective antibiotic to treat the infection. On 3/8/24 at 2:49 PM, V47 RN (Registered nurse) stated that the nurse is expected to call the physician and relay all laboratory results and obtain new orders if needed. V47 stated that the nurse is expected to check and review laboratory results daily. V47 stated that the nurse reports to the oncoming nurse laboratory tests resulted and if orders were obtained and any pending laboratory results. V47 stated that the nurse marks the laboratory result(s) has been reviewed and the computer system notes name, date, and time result(s) reviewed. V47 stated that the nurse reviewing the results is responsible for contacting the physician and relaying results, and documenting in the resident's progress notes that physician notified and any orders received. R10's urine culture and sensitivity results were reviewed with V47. V47 acknowledged that V47's name appears at the top of this report with the date and time result was reviewed. There is no documentation found in R10's medical record noting V47 notified V51 of R10's urine culture and sensitivity results on 9/25/23 after V47 reviewed results. On 3/12/24 at 3:00 PM, V1 (Administrator) stated that this facility does not have a policy specific to notifying physician of laboratory results. V1 stated that this facility follows its notification for change in condition policy. R10's medical record, dated 9/21/23, V52 (former Infection Prevention nurse) noted urinalysis with culture and sensitivity ordered for R10's complaints of dysuria (painful or difficult urination) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 4 of 7 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 03/20/2024 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 0773 Level of Harm - Minimal harm or potential for actual harm with indwelling catheter, elevated white blood cell count result on 9/18/23. Urinalysis result called to V51 (attending physician), V51 aware culture pending. Orders recieved for macrobid 100mg (milligrams) by mouth twice daily x 7 days. 9/21, Macrobid Oral Capsule 100 MG Give 1 capsule by mouth every 12 hours for UTI for 7 Days. Residents Affected - Few On 9/29/23, V52 noted report called to infectious disease nurse practitioner and V51 regarding treatment for urine culture reported on 9/24/23. R10 finished Macrobid treatment on 9/28/23 but Macrobid was not included on sensitivity culture report. V51 orders received for ciprofloxacin (antibiotic) 500mg by mouth twice daily for 7 days. There is no documentation found in R10's medical record noting V51 was informed of R10's urine culture and sensitivity results prior to 9/29/23. This facility's notification for change in condition policy, revised 12/27/23, notes the facility must immediately inform the resident, the resident's physician, and resident's family member when there is a need to alter treatment significantly (need to discontinue an existing treatment or commence a new form of treatment). The Merck manual, reviewed/revised 05/2022, notes pseudomonas species are resistant to macrobid. According to the FDA (food and drug administration) noted macrobid has no activity against Pseudomonas species. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 5 of 7 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 03/20/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their covid 19 testing policy by not testing residents and staff following a covid 19 outbreak on 9/8/23 which had the potentially to affect all the 103 residents. In addition, the facility failed to test residents and staff for covid 19 for 14 days with no new positives during an outbreak that started on 2/5/24 which had the potential to affect all 96 residents at the facility reviewed for infection control. Residents Affected - Some Findings include: Facility staff covid line list dated August 1st until September 30 2023 documents: V48 (Speech) tested positive for covid 19 on 9/11/23. V49 (nurse) tested positive for covid 19 on 9/8/23. V48 (Speech) time punches document last day worked prior to positive testing was 9/7/23 8:38AM to 4:03PM. V48 provided speech services to 13 residents on 9/7/23 per daily labor report dated 9/7/23. On 3/12/24 at 12:02PM, V48 (speech) said on 9/10/23 he was symptomatic while at home and tested positive for covid using a rapid test. He informed facility on 9/11/23 of covid positive test. V49 (nurse) time punches document last day worked prior to positive testing was 9/5/23 11:00PM- 8:30AM. Facility covid line list for residents September 2023 documents: R3 tested positive for covid 19 on 9/13/23. On 3/12/24 at 330pm, V21 (Infection Preventionist nurse) said contact tracing would be tracked up to 72 hours prior to symptoms developing. Anyone who had contact would be tested for covid on day 1, 3 and 5 for contact tracing. On 3/8/24 at 3:06PM, V21(Infection Preventionist nurse) said the facility was unable to provide any contact tracing or resident testing for September. An outbreak of covid is one positive case in the facility for staff or resident. Facility census dated 9/5/23 documents: 103 residents. Facility resident covid line list documents: R48 covid positive on 2/11/24. Facility resident covid testing September 1, 2023 to March 1, 2024 documents resident testing conducted on 2/5/24 and 2/9/24. There was no other tests documented. Facility staff covid testing sheets was conducted on 2/6/24, 2/12/24 and 2/19/24 with no other testing conducted after 2/19/24 for staff. On 3/7/24 at 12:47PM, V21 (Infection Preventionist nurse) said residents were tested on [DATE], 2/9/24 and 2/16/24 with no positives test results. Staff were tested on [DATE], 2/12/24 and 2/19/24 with no positive test results. Testing was conducted for 14 days with no new positives. On 3/8/24 at 3:06PM, V21 said there was no additional testing for staff after 2/19/24 because staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 6 of 7 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 03/20/2024 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 Residents Affected - Some are able to tell us if they are sick. V21 said the residents were all tested on [DATE] with no new positives. No additional testing was done because it was within the 14 days. On 3/12/24 at 2:09PM, V21 (Infection Preventionist nurse) said she was unable to show the resident covid testing conducting on 2/16/24 because there was computer concerns with the program and they were not able to be submitted into the tracker. V21 was asked to provide the documentation or log of the resident testing conducted on 2/23/24. V21 said she did not know why the testing for the 2/23/24 was not under testing results and that the resolution column was the last day the resident was tested. Facility was unable to provide any documentation of testing conducted on residents 2/16/24 and 2/23/24. Facility policy Covid 19 Testing plan and response revised 12/26/23 documents: For facility experiencing an outbreak or that has identified its first case, the facility must promptly report to the LHD (local health department). Outbreak testing can be done in two ways: Contact tracing is a more focused approach and starts on the unit where the positive covid-19 case was identified. Contact tracing is done and all identified as exposed based on CDC definition of close contact or prolonged exposure are going to be tested three times (Day one, Day three and Day five). Once initial testing is completed and no positives then testing will stop. If results show positive recommended to change to broad based testing to continue every 3-7 days and test everyone until there are no longer positive cases x 14 days. Broad based testing requires testing of all residents and staff in either the unit or floor or entire facility. Testing is done every 3-7 days and test everyone until there are no longer positive cases x 14 days. Facility census on 2/25/24 documents 96 residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 7 of 7