Inspection·September 2, 2025

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interview with V16 (Nursing Supervisor) was also completed. V16 stated R4 was supposed to always wear the glove restraints according care plan. V17 stated that it was her first time working with R4 and was unaware that glove restraints were to be in place. Additionally, V17 reported that the facility online medical records database of R4 for physician orders and plan of care were inaccessible and V17 was not provided with updates, information or paperwork pertaining to R4 by the prior shift nurse. V16 informed V3 that there should be a binder at nurse station with R4's plan of care information. Report indicated V3 checked the binder and did not appear to be properly filled out.On [DATE] at 10:25AM, V3 ([NAME] Hills Police Department) stated he arrived at facility with R4 unresponsive and 911 paramedics working on her. Staff were interviewed and nurse on duty/ Agency nurse told V3 at approximately 5:55A - 6:05A R4 was observed with trach not in place (pulled out). V3 said while in the facility he did not observe R4's mittens in placed. V3 said employee informed him that electronic access to chart was down from a week to a week and half. V17 stated she did not get report from outgoing nurse regarding R4's mitten needs to be in placed at all times and V17 has no knowledge of facility restraint policy. V3 stated he believed there was neglect on facility as staff do not know their restraint policy and there was no hand off report from nurse to nurse according to his interview with agency nurse who was on duty.On [DATE] at 11AM, in separate interviews, V2 and V4 (Restorative Nurse) both stated R4 should have mittens on at all times to maintain trach patency because R4 has a history of pulling on trach tubes.On [DATE] at 10:28AM, V7 (Attending Physician/AP), stated he is the AP in facility only and not R4's community doctor. V7 said the last time R4 was seen was Friday, [DATE]. R4 was stable. He was aware that R4 has history of pulling on trach tube and the plan was to apply restraint (mitten) to prevent R4 from pulling trach. There was an order for mittens to be on at all times, staff to monitor, and may remove only when there is staff present and working with resident. V7 signed off on the Death certificate with cause of death, Respiratory Failure (not complete list). V7 stated the immediate cause of death was possibly R4's trach being pulled out since there was no oxygen being received by R4.On [DATE] at 11:34 AM, V8 (Certified Nursing Assistant/CNA) stated she work 11-7 shift on 8/23 thru 8/24 and was assigned to R4. V8 said she rounded on R4 every 2 hours and at 5:00AM she provided incontinence care. V8 said she did not visibly saw the mittens being on during her entire shift. V8 said no one communicated to her about R4's need of mittens. V8 stated she do not know the facility restraint policy and only received education today in the morning. V8 further state that during police investigation and interview with staff she was present and heard the nurse did not know anything about R4 needing mittens. V8 said there is no CNA to CNA shift to shift report or endorsement.On [DATE] at 1:42 PM, V11 (Respiratory Therapist/RT) stated he was the RT working with R4 on 8/23 -[DATE]. V11's shift is 7p - 7a. On [DATE] at 6:15AM nurse called stated R4 trach was out. When he went to the room V11 said R4 did not look like she was breathing and there was no pulse. V11 stated he do not re-call seeing R4's mittens on. V11 said there was an order for mittens as R4 have the history of self-decannulating behavior. V11 rounded 6X on R4 during his shift and at one point he reported to the nurse that mitten needs to be applied, however, V11 said he was unsure if nurse went to the room to check after acknowledging he was heard.On [DATE] at 10:25 AM, V14 (R14's Daughter) stated the incident of her mother pulling on tracheostomy tube occurred 3x since admission to facility. Stated facility was aware before admission that her mother was on restraints from another facility because of behavior. Requested for restraint but was told initially by V13 (Regional Nurse Consultant/ Interim DON) that facility is restraint free and that they do not use restraint in the building, but later it was decided that R4 needed it after the 2nd attempt and upon return from hospital. During this investigation, multiple call attempts to V17 (Agency Nurse) for an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145650 If continuation sheet Page 2 of 4 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 145650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nexus at Palos 10426 South Roberts Palos Hills, IL 60465 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interview was done with no success of a call back.Review of R4's medical records indicate an admission date of [DATE] with diagnosis information of aphasia following cerebral infarction, tracheostomy status and dependence on supplemental oxygen (not a complete list). Comprehensive assessment of MDS Section O, dated [DATE], indicated R4 with tracheostomy care, Section C, [DATE], indicated Brief Interview for Mental Status (BIMS) was not conducted. Order Summary Report, start date [DATE], read: Monitor left hand mitt for circulation, motion, sensation, PAIN, ROM. Every 2 hours for monitoring remove mitt for 10-15 period, CMS/ADL/ROM. Care Plan Report, date initiated [DATE] read: Focus- Physical Restraints: Requires physical restraint r/t pulling on mechanical equipment. Interventions include Check and remove restraints as per policy. Keep resident close to areas that are supervised. Provide hazard free environment. Special Instructions read: Apply MITT to LEFT hand to maintain patency of trach tubes due to patient chronic pulling of tubing. Ventilator/Aerosol Flowsheet indicated Trach care was done by V11 on [DATE] at 8:30 PM where trach inner cannula was changed. Consent for Use of Restraint/Device, effective date [DATE] read: 2. Benefits, a. Based on the resident's individual needs, restraints may be beneficial for the following. 2. Prevention of injury to self or other. Progress Notes, Effective Date: [DATE] 15:39 Type: Nurses Notes: Note Text: @ 0910 Pt., was observed by this nurse with her trach out, immediately RT was called to pt's room by CNA. 2 RT put the trach back in and SPO2 97 HR 66. Progress Notes, Effective Date: [DATE] 23:59 Type: Nurses Notes: Note Text: A Shiley 5XLTD decannulation occurred. Nurse notified the RT. Despite multiple attempts, the trach wouldn't reinsert. DON was notified. RT applied a 4x4 gauze over the stoma and a non-rebreather mask. R4 was stable at 95% oxygen saturation and 82 b/m HR. Ambulance left with her not in distress. Progress Note, Effective date [DATE] 20:08 Type: Nurses Notes: Note Text: Writer called resident daughter to inquire / inform of the use of hand restrain, daughter verbalized that she is aware of such order from the hospital and gave verbal Consent for the use of the hand mitten to restrain resident from pulling out her trach again. Nurse on Duty made aware. Facility did not provide progress note or completed incident report for [DATE] self-decannulation incident. Review of Illinois Certificate of Death read Cause of Death, Immediate Cause a. Nontraumatic Intracerebral Hemorrhage, b. Acute Respiratory Failure, c. Type 2 Diabetes. Certificate was signed and certified by the Attending Physician/Physician in Charge on [DATE]. Policy and ProcedureGuideline: Physical Restraint/Device, Review date 10/2021General: To provide guidance on the assessment for the use and documentation of physical devices including, but not limited to, position change alarms, bed rails, furniture positioning, concave mattress, reclining chairs, cushions such as wedge shaped, hand mitts, abdominal binders, etc. A physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff.Guideline:2. If is determined that the physical device is a restraint: a. A physician order will be obtained. b. Education will be provided to the resident/resident representative regarding the risks and benefits of the physical device. c. Informed consent will obtain from the resident/resident representative using the Consent for use of Restraint/Device Form3. If a resident or resident representative request the use of a restraint, then the facility will evaluate the appropriateness of the request and consult with the physician/NP to determine if resident has a medically necessary reason for the restraint.6. the effectiveness of physical device in treating the medical symptoms or as a therapeutic intervention and any negative impact on the resident shall be assessed by the facility throughout the period of time the physical device is being used and documented in the progress note.7. The behavior incident that prompted the use of the physical device will be documented in the progress note.8. The date and time the physical device was applied and released will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145650 If continuation sheet Page 3 of 4 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 145650 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nexus at Palos 10426 South Roberts Palos Hills, IL 60465 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented in the progress note.9. the name and title of the person responsible for the application and supervision of the physical device will be documented in the progress note. On [DATE] the surveyor verified by interview and record review that the facility implemented the following to remove the immediacy:Immediate Actions:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. All residents with tracheostomies were reviewed by DON/Unit managers. Completed on [DATE]. The review was done to ensure special instructions which includes mittens or other physical restraints were in place per physician orders and resident care plans. There was one resident to was identified with a physical restraint. No other concern was identified related to use of physical restraints during the review.The DON/Unit Managers provided education to nursing staff (nurses and nursing assistants), RT's (respiratory therapists) including Agency staff on special instructions such as use/application of mittens and other physical restraints for residents with Tracheostomy, following care plans and physician orders. Completion date: [DATE].The DON/Nurse Managers provided education to the nurses, including nurse agency staff, on change of shift reporting. The training also included notifying nursing assistants of any new special instructions at the start of the shifts. Completion date: [DATE].All nursing staff (nurses and nursing assistants) and RT's (respiratory therapists), including agency staff, who are not available and/or currently on vacation will also receive the same education upon their return to work. The DON/Unit Managers will provide the same training. Ongoing. Additional Interventions:The DON/Unit Managers will continue to audit new admissions with Tracheostomy to ensure that orders for physical restraints are care planned and are communicated with the nursing staff and RT's. Initiated on [DATE].The DON, Administrator, Unit Managers reviewed the policies and procedures related to physical restraints, tracheostomy, nursing rounds, care plan and following physician orders. There is no revision necessary. Completion date: [DATE].The QAPI committee held an Ad-Hoc QAPI meeting to discuss R4, and action actions described in this plan of removal. Completion date: [DATE].The DON/Unit Managers will conduct audit and observation of all residents with tracheostomy weekly for four (4) weeks to ensure compliance with special instructions, such use if mittens and physical restraints are being implemented, physician orders and care plan interventions are followed. Ongoing.The results of the audit/observation will be reviewed by the QAPI committee weekly for four (4) weeks. The QAPI committee will determine if additional corrective actions are necessary to maintain compliance. Ongoing.The facility asserts the likelihood for serious harm no longer exists on [DATE]. Event ID: Facility ID: 145650 If continuation sheet Page 4 of 4