Inspection·April 22, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm On 4/16/25 at 2:05pm, surveyor inquired if R2's insulin is administered as ordered R2 stated Not to me and my blood sugars are poorly controlled. The Nurses give me insulin sometimes and sometimes they don't. R2's (March 2025) MAR does not document R2's Glargine insulin was administered on 3/8/25, the entry is blank. Residents Affected - Some 3. R3's diagnoses include age related nuclear cataracts, osteoarthritis and neuropathy. R3's (4/8/15) care plan states resident is at risk for pain administer analgesia as per orders. R3's (4/4/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 4/15/25 at 2:54pm, surveyor inquired about concerns with medication administration R3 stated I (R3) requested a medication patch, she (Nurse) looked at my page and said you have nothing on the order for a pain patch. She gave me my (oral) medication but not the eye drops. I asked her about the eye drops, she said I don't have your eye drops. R3's POS includes Latanoprost 0.005% 1 drop both eyes at bedtime for glaucoma (start date: 2/17/25). (4/9/25) Lidocaine patch 4% apply to affected skin every 12 hours as needed for pain. R3's (February 2025) MAR affirms Latanoprost administration was not documented on 2/17/25, the entry is blank. R3's (April 2025) MAR excludes the prescribed Lidocaine patch. On 4/17/25 at 3:08pm, surveyor inquired about the requirements for entering physician orders V9 (ADON/Assistant Director of Nursing) stated It automatically populates to the MAR when entered under POS and should be entered by the pharmacy. Surveyor inquired if R3's (April 2025) MAR includes the 4% Lidocaine patch (prescribed 4/9/25) V9 stated No, I don't see it here. Usually, we (staff) put in the POS and the pharmacy give us (staff) a reminder for the 4% to be entered because it's a floor stock and affirmed that facility staff are required to enter the 4% Lidocaine patch orders on the MAR. 4. R4's diagnoses include dementia and encounter for palliative care. R4's (3/17/25) care plan states resident is at risk for pain related to dementia. R4's (3/20/25) BIMS determined that resident is rarely/never understood and altered level of consciousness is continuously present. R4's (3/19/25) POS includes Hydromorphone (Narcotic) 4mg (milligram) tablet give 0.25ml (milliliters) every 2 hours as needed for moderate pain and Hydromorphone 4mg tablet give 0.5ml every 2 hours as needed for severe pain. On 4/17/25 at 2:54pm, surveyor inquired about concerns with R4's Hydromorphone orders V9 (ADON) stated Hydromorphone 4 milligrams, oh I think it's a tablet and uh the dispensation is dispense as liquid. On 4/21/25 at 2:36pm, surveyor inquired if medication tablets are dispensed in milliliters V11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 2 of 6 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 (Medical Director) responded No. Level of Harm - Minimal harm or potential for actual harm The Physician Orders policy (revised 8/16/24) states it is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. Medication orders entered in the POS shall be reflected accurately in the MAR. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 3 of 6 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow facility polices and procedures, failed to ensure that residents are assessed for signs/symptoms of pain, failed to obtain physician orders, failed to follow physician orders, and failed to ensure that physician orders are transcribed on the MAR (Medication Administration Record). The facility also failed to administer pain medication timely to three of four residents (R1,R2, R4) reviewed for pain. These failures resulted in R2 crying due to experiencing excruciating pain. Residents Affected - Few Findings include: 1. R2 was admitted on [DATE] (9 months ago) with cervical radiculopathy (pinched or irritated nerve in the neck causing pain radiating into the chest or arm). R2's (7/12/24) care plan states resident is at risk for pain related to cervical radiculitis, interventions: monitor and record/report to Nurse any signs/symptoms of non-verbal pain. Resident will be able to tell you how much pain is experienced and tell you what increases or alleviates pain. Administer pain medication per request. R2's (April 2025) POS (Physician Order Sheets) exclude pain medication. R2's (2/7/25) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 4/16/25 at 2:05pm, surveyor inquired about concerns at the facility R2 stated I (R2) have debilitating RA (Rheumatoid Arthritis) that's in my hands and shoulders [R2's fingers were notably misaligned]. I have tried on multiple occasions to get them (facility staff) to prescribe me lidocaine patches because I've been on them for years. I can't get them here and I've sat here in excruciating pain, on a scale of 1 to 10 it's been 20. Surveyor inquired if R2 has prescribed pain medication R2 responded I should but no one's giving me one. There are times when the pain is so horrific, I will cry out for hours. Surveyor inquired about R2's current pain level R2 replied Right now, it's only about a 5. Surveyor inquired if R2 receives Tylenol R2 stated It doesn't do diddly, so I don't take it. It's like putting a bandaid on a sliced wound. Surveyor inquired if facility staff assess R2's pain level every shift R2 responded Oh, h*** no, they're (staff) very incompetent here (facility) in many respects. On 4/16/25 at 2:29pm, V8 (Registered Nurse) affirmed that she's assigned to R2. Surveyor inquired if a Lidocaine patch is prescribed for R2 V8 stated I'm looking through the orders, no I (V8) don't see any Lidocaine patch. Surveyor inquired if R2 is prescribed pain medication V8 responded No, no pain medication. Surveyor inquired why R2's physician orders exclude pain medication if she has pain related to RA V8 replied I'm gonna have to follow-up with the doctor for that. Surveyor inquired if R2's pain is assessed every shift V8 stated Yeah, I'm doing pain assessments on her. Surveyor inquired about R2's pain assessment conducted today V8 accessed R2's EMR (Electronic Medical Record) and responded, Today at 1:46, it was zero. Surveyor advised that R2 is currently experiencing pain and returned to the resident's room (with V8). Surveyor inquired if R2 reported that her pain level was zero today R2 replied That's not true, nobody's ever asked me about it and V8 failed to request R2's pain level at this time. Surveyor inquired why R2's pain was rated zero today (per EMR) V8 stated That was at 1:46am (over 12 hours ago), I haven't documented for my shift. I was gonna document it at 2:30 (7.5 hours after V8's shift started). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 4 of 6 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 0697 R2's (4/16/25) dayshift (7am-3pm) pain assessment (documented by V8) states 0 however this assessment was entered after surveyor record review/interview and clearly incongruent with actual findings. Level of Harm - Actual harm On 4/17/25 at 11:29am, V2 (Director of Nursing) stated We got orders for (R2) for the lidocaine patch. Residents Affected - Few R2's (April 2025) MAR affirms that 4% Lidocaine patch orders were received (the following day); start date 4/17/25. R2's Lidocaine patch was administered on 4/17/25 at 8am (roughly 17.5 hours after V8 was made aware of R2's reported pain) and 4% Lidocaine patches are (over the counter) facility floor stock therefore readily available. 2. R4's diagnoses include dementia, chronic peptic ulcer, and encounter for palliative care. R4's (3/17/25) care plan states resident is at risk for pain. R4's (3/20/25) BIMS determined that resident is rarely/never understood and altered level of consciousness is continuously present. R4's POS includes (3/17/25) pain assessment every shift. Acetaminophen (Analgesic) 650mg (milligrams) every 4 hours as needed for pain (pain scale 1-3). (3/19/25) Hydromorphone (Narcotic) 4mg tablet give 0.25ml (milliliters) every 2 hours as needed for moderate pain. R4's (March 2025) monitoring record affirms pain assessments were not documented on (dayshift) 3/21, 3/23, 3/25, (evenings) 3/21, 3/28 and (nights) 3/17, the entries are blank. On 4/15/25 at 2:27pm, R4 was observed lying in bed in a fetal position. R4 was noted to be grimacing and both hands were grasping the right shin. R4's right foot appeared severely bruised (dark purple) and notably edematous. Surveyor inquired if R4 was in pain however R4 did not respond. On 4/15/25 at 2:29pm, V4 (LPN/Licensed Practical Nurse) affirmed that she was assigned to R4. Surveyor inquired about R4's cognitive and functional status V4 stated He's bed bound, alert x1, and Yugoslavian speaking. Surveyor inquired how staff communicate with R4 V4 responded We have a service posted the language help desk, then we have a staff (V5/CNA-Certified Nursing Assistant) 5 days a week in the morning. Surveyor inquired if R4 injured his right foot V4 replied He came like this, he's here for 1 or 2 weeks [R4 was admitted on [DATE], roughly 1 month ago]. V4 subsequently assessed R4's right foot (as requested) and stated, Looks swollen, it's maybe looks like +4, we elevate with the pillow. Surveyor inquired if R4's foot also appeared bruised V4 responded Yeah, discolored. When V4 touched R4's right foot he jerked it away from V4 and placed it over the edge of the mattress (out of reach). Surveyor inquired if R4 has pain medication prescribed V4 replied He has Acetaminophen and Hydromorphone. Surveyor inquired if R4 received pain medication today V4 stated Hydromorphone was not recently taken. Surveyor inquired if R4 received Acetaminophen today V4 responded Not given today. During the assessment, V4 failed to utilize the language help desk and/or staff to determine R4's pain level. On 4/15/25 at 2:35pm, surveyor inquired what language R4 speaks V5 (CNA) stated Bosnian and affirmed that she's able to communicate with R4. V5 inquired if R4 was experiencing pain however received no verbal response and he was motioning towards his ears. Surveyor inquired if R4 is hard of hearing V5 responded He has a little bit hearing problem. V5 inquired (again) in a louder voice if R4 was experiencing pain R4 raised both hands in the air, shrugged his shoulders and appeared perplexed as if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 5 of 6 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 145634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place Living & Rehab 6300 North California Avenue Chicago, IL 60659 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 0697 Level of Harm - Actual harm Residents Affected - Few he didn't understand what was asked and/or didn't hear the question. Surveyor inquired if R4's foot appeared bruised V5 responded Probably, but like a little bit swollen however failed to determine R4's pain level. On 4/15/25 at 2:45pm, surveyor inquired when R4 was last medicated for pain V4 reviewed the EMR (Electronic Medical Records) and stated, Hydromorphone he never got, 3/21/25 was the Acetaminophen (several weeks ago). R4's (4/15/25) MAR affirms at 11:24pm (roughly 9 hours after V4's assessment) R4 received Acetaminophen 650mg for pain rated 4 however Acetaminophen was prescribed for pain scale 1-3 [Hydromorphone should have been administered]. 3. R1's diagnoses include dislocation of right hip, pain in left leg, and sciatica right side. R1 was discharged from the facility on 4/10/25. R1's (3/20/25) care plan affirms resident is at risk for pain, intervention: provide analgesic as ordered. R1's POS includes (3/20/25) Pain assessment every shift. (3/24/25) Lidocaine Patch 4% apply to right hip in the morning for pain. R1's (2025) monitoring record affirms pain assessments were not documented on 3/22, 3/26, 3/27, and 4/6 (dayshift). R1's MAR affirms the prescribed Lidocaine Patch was marked UV (Unavailable) on 4/5/25. On 4/21/25 at 3:16pm, surveyor inquired what UV indicates on the MAR V10 (Registered Nurse) replied I believe it's unavailable. The (2/28/25) resident counsel concern/response form includes the following: residents state they are having to wait a long time when requesting pain medication, in-service done however the (undated) pain medication administration in-service/training sign in sheet includes only 9 staff signatures. The pain policy (revised 1/30/25) states it is the policy to ensure that all residents are assessed for pain in every situation where there is a potential for pain. For pain complaints and for situations/incidents that might result to pain, the nursing staff may document it in any part of the resident's medical record that may include Nurses notes, incident report, medication record, etc. Upon admission, the nurse will assess resident for pain. For those identified with pain upon admission/readmission assessment, an order for pain medication will be obtained from the physician. Pain medication ordered will be administered to the resident as soon as possible. The physician orders policy (revised 8/16/24) states the facility shall ensure to follow physician orders as it is written in the POS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145634 If continuation sheet Page 6 of 6