Inspection·September 8, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. Document the notifications and record any new orders received from the physician in the resident's medical record. When a change of condition occurs - the nurse will perform an appropriate assessment of the resident as well as then making the required notifications. The assessment and the notifications will be documented. Examples of situations/circumstances when the physician must be immediately notified: any critical lab value. Event ID: Facility ID: 145424 If continuation sheet Page 2 of 5 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to obtain physician orders for blood glucose monitoring/sliding scale insulin, failed to receive blood glucose parameters for physician notification, failed to follow physician orders, failed to ensure that medication was administered/documented within regulatory requirements, and/or failed to ensure that (critical) blood glucose levels were addressed by a physician/nurse practitioner for two of four residents reviewed for change in condition. These failures resulted in R1 sustaining critical blood glucose levels ranging from 413-500 (without intervention) for a total of 8 days within 1 month. These failures also resulted in R2 sustaining a critical blood glucose level of 400 (without prescribed sliding scale insulin) for 11 hours.Findings include:On 8/21/25, IDPH (Illinois Department of Public Health) received neglect allegations due to facility staff refusing to contact a doctor when resident blood sugars were elevated.R1 was admitted to the facility on [DATE] with diagnoses which include but not limited to morbid obesity due to excess calories and type II diabetes mellitus. R1 was discharged on 7/2/24 (prior to this survey).R1's (6/5/24) care plan includes potential for complications of metabolic functioning as evidenced by hyper/hypoglycemia, interventions: monitor blood sugars as ordered and cover as ordered per sliding scale. Report abnormal blood sugars to Medical Doctor. R1's (6/1/24) POS (Physician Order Sheets) include check blood glucose before each meal and at bedtime [parameters for physician notification are excluded]. Glargine (insulin) inject 85 units every morning and at bedtime. Humalog (Insulin) inject 50 units before meals. [Sliding scale insulin is excluded].On 9/3/25 at 1:19pm, surveyor inquired if any residents were recently sent out to the hospital due to blood sugar concerns V2 (DON/Director of Nursing) stated We haven't had anybody go out for hyperglycemia or hypoglycemia recently, not that I'm aware of. Surveyor inquired if any residents or family members recently reported concerns regarding blood sugars V2 responded No. Surveyor inquired when R1 was discharged from the facility V2 replied He (R1) has been gone a while, he discharged I wanna say back in 2024. He (R1) was short term stay; I (V2) don't believe he was sent out for blood sugar. I (V2) do remember him (R1) having issues with his blood sugar because the wife (V3) was bringing in all the wrong foods. She (V3/Wife) brought him (R1) whatever he wanted, and we (staff) had to have a meeting with her (V3) about it. She was educated on his diet. We (staff) also found out that she (V3) was giving insulin to him when she was here, and we have that care planned. R1's progress notes state (6/2/24) 9:22am, upon entering resident room, writer noted resident wife with a filled syringe in her hand about to administer it to resident but stopped when I entered the room. Writer made appropriate parties aware [R1's 6/2/24 blood glucose was 330 at 7:30am and 339 at 11am per MAR/Medication Administration Record]. (6/5/24) 3:47pm, Staff reports resident's wife was observed with a vial of insulin to administer to the resident [R1's 6/5/24 blood glucose was 202 at 4pm per MAR]. R1's (June 2024) MAR also affirms that blood glucose levels were (critical) high on the following dates: 6/1: 413. 6/7: 432. 6/15: 500. 6/18: 419. 6/20: 469. 6/23: 450. 6/24: 430. 6/27: 419 however R1's (June 2024) Nurses Notes exclude critical high blood glucose levels and physician notification of resident change in condition. On 9/4/25 at 1:01pm, surveyor inquired about resident blood glucose monitoring V6 (Medical Director) stated, If someone's uncontrolled we (staff) would probably be checking that with meals. Surveyor inquired what parameters should be inclusive for hyperglycemia V6 responded We have about 3 different options; it would be 350 or 400. Surveyor inquired about staff requirements if a resident's blood glucose is 400 or above V6 replied It should be whatever the order is [R1's Physician orders exclude sliding scale (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145424 If continuation sheet Page 3 of 5 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. insulin] and affirmed the physician should be contacted. Surveyor inquired about potential harm to a resident with a blood glucose level that's 400 or above V6 stated Medical comorbid conditions associated with hyperglycemia which could be infection, DKA (Diabetic Ketoacidosis), or hyperosmolarity.On 9/4/25 at 2:20pm, surveyor inquired if there was any documentation in R1's EMR (Electronic Medical Records) regarding notification for R1's (6/15/24) critical blood glucose level of 500 - per MAR V2 (DON/Director of Nursing) reviewed R1's EMR and stated No, there's no documentation that she (Nurse) called the Physician or Nurse Practitioner for the 15th. Surveyor inquired if there was any documentation that R1's Physician was notified for any of R1's (June 2024) critical blood glucose levels V2 reviewed the EMR to no avail and responded They (staff) were giving the insulin that was ordered but nobody thought about a sliding scale. He (R1) had no sliding scale the entire time he was here, everybody missed it [R1 resided at the facility for over 1 month]. __R2's diagnoses include diabetes mellitus with hyperglycemia however the (9/3/25) facility glucose monitoring log - excludes R2's name. R2's POS includes (8/27/25) Lispro (Insulin) 25 units before meals. Glargine (Insulin) 50 units two times daily. (8/29/25) Lispro inject per sliding scale 150-199 = 2 units, 200-249 = 4 units, 250-299 = 6 units 300-349 =8 units, 350-399 = 10 units at bedtime. [Blood Glucose Monitoring is excluded].R2's (11/7/18) care plan states resident has hyperglycemia related to disease process, interventions: monitor for signs/symptoms of hyperglycemia, report to Nurse and Physician as needed. R2's (7/31/25) BIMS (Brief Interview Mental Status) determined a score of 10 (moderate impairment).On 9/3/25 at 4:09pm, surveyor inquired if R2 has any facility concerns that she would like to discuss R2 responded No, I've always been with the Santa Clause therefore not appropriate for interview. R2's (9/2/25) MAR affirms the following: blood glucose level was 486 (at 5:00pm) and 9 (see nurse note) was documented. R2's blood glucose level was 400 (at 9:00pm) and 9 was documented. [R2's blood sugar was not rechecked until 8am the following day - 11 hours later]. On 9/4/25 at 9:19am, surveyor inquired what 9 indicates on the MAR V2 (DON) stated If they (staff) didn't give it for whatever reason they'll put in a 9 and put in a nurses note. Surveyor presented R2's (September 2025) MAR and inquired if R2 received insulin on 9/2 when the blood glucose was 400 and above V2 responded Let me (V2) see, I'll have to see if the Nurses made any note and did anything with that. The sliding scale only goes up to 399 so she (V5/Registered Nurse) should have called the doctor. They (staff) should know you follow the sliding scale, if the blood sugar is higher than what it is, you reach out to the physician and find out if they (Physician) want to give insulin. R2's (9/2/25) Medication Administration Note states (10:33pm) medicated with 25 units Lispro insulin for blood sugar of 486 per Nurse Practitioner (V7). (10:40pm) Medicated with 10 units Lispro insulin per (V7) however R2 was prescribed sliding scale insulin at 5pm and 9pm - therefore not administered within regulatory requirements (1 hour before or after the scheduled time). On 9/4/25 at 2:16pm, surveyor inquired why V5 (Registered Nurse) documented on 9/2/25 that R2 received Lispro (25 units) at 10:33pm and Lispro (10 units) at 10:40pm (7 minutes later) per electronic Medication Administration Note V2 (DON) responded She (V5) should have put it was given at 5pm or whenever it was given. On 9/4/25 at 3:23pm, surveyor inquired if the Physician was notified of R2's critical blood glucose levels on 9/2/25 V5 (Registered Nurse) stated The Nurse Practitioner (V7) gave the orders to the ADON (Assistant Director of Nursing/V8) she (V7) said to give the 25 units when she (R2) was 486 and then I (V5) gave the 25 units. She (V7) said recheck in 30 minutes, call her (V7) back and it was 400. She (V7) said follow the sliding scale and affirmed that R2 received Lispro 10 units at that time [R2's sliding scale only covers a blood glucose level up to 399 - therefore the sliding scale was not followed]. Surveyor inquired what time R2 received the 25 units and 10 units of Lispro on 9/2/25 V5 responded It was about 5pm but I didn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145424 If continuation sheet Page 4 of 5 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 145424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Richton Park Rehab & Nsg Ctr 22660 South Cicero Avenue Richton Park, IL 60471 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete sit down to chart it then. Surveyor inquired if insulin was administered to R2 on 9/2/25 (at 9pm) as prescribed V5 replied She (R2) gets Lantus at night, so I gave her the Lantus [Sliding scale Lispro scheduled for 9pm administration was excluded]. Surveyor inquired if V7 was notified of R2's (9/2/25) critical blood glucose level (at 9pm) V5 replied I called her (V7) twice (at 5pm and a half hour later) and during the 9pm, I didn't call her because she (R2) was within the limits to give her a sliding scale. At 9pm, I covered her with the sliding scale because she was under 400. For the 9pm, I just give her the insulin I didn't make a note [R2's blood sugar at 9pm was 400 - therefore not within sliding scale parameters and 9 was documented on the MAR which affirms Lispro was NOT administered as ordered]. Surveyor inquired (again) which insulin was administered to R2 on 9/2/25 at 9pm (due to inconsistent statements) V5 responded I gave her Lantus. The (undated) blood glucose monitoring policy states blood sugars found to be below 70 or above 400 will be reported immediately to the physician and the resident's representative. Any orders received from the physician will be implemented. Notify physician if blood glucose is outside resident's parameters for blood glucose as ordered by their physician. Nursing interventions for treatment of hyperglycemia: follow the sliding scale parameters for fast acting insulin and any additional orders received from the physician. Immediately notify the physician and the resident's representative any time the resident's blood sugar is outside the ordered parameter range as well as any interventions taken to address a hypoglycemic or hyperglycemic event. Complete all appropriate documentation. Event ID: Facility ID: 145424 If continuation sheet Page 5 of 5