Health inspection·April 5, 2024

F 0550 Review of facility's policy entitled Privacy and Dignity revised 7/28/2023 indicated the following: Level of Harm - Minimal harm or potential for actual harm Policy Statement: It is the facility's policy to ensure the resident's privacy and dignity is respected by the staff at all times. Residents Affected - Few Procedures: 4. Urine bags will be covered with the use of privacy bags. 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 04/05/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure privacy was maintained while applying a pain patch for one of one residents (R54) reviewed for privacy in a sample of 20. Residents Affected - Few Findings include: On 4/3/2024 at 8:40am, V16 (Licensed Practical Nurse-LPN) was observed applying a pain patch to R54's left shoulder with the resident's shirt pulled up over her shoulder, the room door was open and the privacy curtain was not closed. R54 said I prefer the pain patch on the left shoulder instead of the right shoulder as indicated. On 4/3/2024 at 8:45am, V16 said I should have closed the privacy curtain and the door then applied the pain patch. On 4/4/2023 at 9:20am, V2 (Director of Nursing-DON) said I would expect the nurses to always provide privacy. An Order Summary report dated 4/4/24 indicates that R54 has a diagnosis of spinal stenosis, lumbar region, with neurogenic claudication and low back pain unspecified, an order dated 3/28/2024 for a Lidocaine Pain Relief 4% Patch to right shoulder topically one time a day for pain and remove per schedule. Facility Policy: Privacy and Dignity Revised 7/28/23. Policy Statement: It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Procedures 1. During care that requires privacy such as incontinence care, the resident will be placed in the bed and the privacy curtain will be drawn to provide full visual privacy. If the privacy curtain is not sufficient to provide full visual privacy, the combination of the privacy curtain and privacy screen will be used. A privacy screen may also be used by itself if it will provide full visual privacy. Door may also be closed to provide additional layer or privacy during care. 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 04/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the fall care plan by failing to implement a fall intervention by not ensuring a resident's call light was in reach for a resident (assessed to be risk for fall and history of fall at the facility). This failure affected one resident (R57) of three reviewed for call lights in a total sample of 20. Findings include: On 4-2-24 at 8:05 AM, surveyors noted R57 clean, dressed, and groomed. R57 was up to her wheelchair parked at the side of her bed. Surveyors noted R57's call light in R57's side drawer and out of reach. Surveyor asked V20 (Certified Nurse Aide- Agency) to verify R57's call light and accessibility. V20 verified R57's call light inside of R57's side drawers and not in R57's reach. V20 proceeded to move tray table to retrieve R57's call light and place it in R57's reach. On 4-2-24 at 8:05 AM, R57 said she fell last week because she was reaching for her call light which was on the floor. R57 said she fell out of the bed and onto the floor. R57 denies any injury from that fall incident. R57 said she is not able to reach her call light at this time because the call light is in the side drawer and not in reach. On 4-2-24 at 8:05 AM, V20 (Certified Nurse Aide- Agency) said the call light should always be accessible for the residents. V20 said this is the first time working with R57 and is not aware of fall precautions or fall history. On 4-4-24 at 9:11 AM, V2 (Director of Nursing/ Fall Nurse) said R57 was assessed to be low risk for falls prior to the incident. V2 said fall investigation showed nurse found R57 on the floor in sitting position. V2 said no injury noted. V2 said R57 said she was reaching for something off the floor. V2 said staff asked R57 if she called for assistance. R57 said she pushed the call light after the fall. New interventions were to re-educate to ask for assistance. V2 said keeping R57's call light in reach was intervention prior to the fall incident. V2 said all staff are responsible for ensuring call light is in reach. Fall Care Plan (initiated 3-11-24) documents: Interventions: Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance (initiated 3-11-24). Nursing admission assessment dated [DATE] documents R5 is low risk for falls. Fall Risk assessment dated [DATE] documents R57 is high risk for falls. Progress Note dated 3-14-24 documents: fall evaluation. Date of Service: 03/14/2024 8:17 PM Primary Chief Complaint : Fall Without Injury History Present Illness : 51yo female with MS, was reaching to pick something up off of bed and fell. No trauma or injury. No blood thinners. Patient is at risk for falls due to the following, Loss of balance. 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 04/05/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and record review, the facility failed to place a urine collection bag below the bladder for one of two residents (R261) reviewed for catheter use in a sample of 20. Residents Affected - Few Findings include: On 04/02/2024 at 10:48AM during observation with V10 (Registered Nurse), R261 was observed sitting on his wheelchair with urine collection bag placed on the wheelchair seat on R261's left side. On 04/02/2024 at 10:48AM during interview with V10, V10 stated that R261's urine collection bag should be placed below the bladder. On 04/04/2024 at 9:29AM during interview with V2 (Director of Nursing), V2 stated that all urine collection bags should be placed below the bladder. Review of R261's Order Summary Report dated 04/04/2024 indicated admission date on 03/29/2024 and diagnoses of not limited to chronic kidney disease, stage3, and retention of urine. Review of facility's policy entitled Indwelling catheter revised on 7/28/2023 indicated the following: Procedures: 7. Indwelling catheter bag will always be positioned below the bladder region to prevent backflow if the foley (indwelling catheter) bag has no anti-backflow valve. 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 04/05/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, the facility failed to date and label the enteral tube feeding bottle for one of one resident (R264) reviewed for tube feeding management in a sample of 20 residents. Findings include: On 04/02/2024 at 7:48AM during unit rounds, R264 was observed lying on bed with unlabeled and undated tube feeding attached to gastrostomy tube. On 04/02/2024 at 10:52AM during observation with V12 (Licensed Practical Nurse), R264 was again observed lying on bed with unlabeled and undated tube feeding attached to gastrostomy tube. On 04/02/2024 at 10:52AM during interview with V12, V12 stated that R264's tube feeding bottle should be labeled and dated. On 04/04/2024 at 9:29AM during interview with V2 (Director of Nursing), V2 stated that all tube feeding bottle should be labeled and dated. Review of R264's Order Summary Report dated 04/04/2024 indicated admission date of 3/29/2024, diagnoses of not limited to encounter for attention to gastrostomy, order for enteral feeding with order date of 03/29/2024. Review of facility's policy entitled Enteral Tube Feeding Care revised 7/28/2023 indicated the following: Procedure: 3. Check that Feeding bag is properly labeled to include: a. Resident's name b. Formula (if it is not a closed system) and rate of feeding administration c. Date and time feeding was started 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 04/05/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to offer Influenza and Pneumococcal immunization as required for four of five residents (R25, R,27, R73 and R265) reviewed for immunization in a sample of 20 residents. Residents Affected - Some Findings include: On 4/4/24 at 11:45am, and V2 (Director of Nursing) and V22 (Infection Retentionist) both stated, all immunization given or refused should be documented. V22 stated that, she is responsible for checking that residents' s immunization are up to date once admitted into the facility. During record review on 4/4/2024 at 1:00 PM, R25, R27, R73 and R265' s immunization records did not indicate that these residents received or refused the Pneumococcal vaccine. R27's immunization record had no documentation to indicate that she received or refused the influenza vaccination. Facility policy reviewed 12/12/23 reads: Pneumococcal Vaccination. Policy statement: It is the policy of the facility to offer and administer Pneumococcal vaccination to each resident as recommended by CDC's Advisory Committee on Immunization Practices (ACIP), unless otherwise contraindicated or the resident or responsible party has refused the vaccine. Procedure. 4. Pneumococcal vaccination will be offered upon admission if recommended by ACIP. All current residents recommended by ACIP to received Pneumococcal vaccine shall received vaccination unless otherwise medically contraindicated or refused. 6. All administration and refusals will be documented. Facility policy reviewed: 8/8/2023 reads: Influenza Vaccination Policy statement: It is the policy of the facility to annually offer and administer vaccination against influenza to each resident unless otherwise medically contraindicated or the resident or responsible party has refused the vaccination. Procedure. 4. All current residents shall be offered vaccination during flu season unless otherwise medically contraindicated or the resident or responsible party refuses. All refusal will be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145363 If continuation sheet Page 7 of 7