Inspection·June 27, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Braden Scale for Predicting Pressure Sore Risk dated 06/26/25 document in part: Braden Scale of 14. (Moderate Risk). Wound Summary dated 06/20/25 document in part: MASD present on admission. Clinical stage: Erythema. Tissue Type: Bright pink or red =100%. Length 6.00 cm (centimeters) Width 3.00 cm and Depth 0.00 cm. Residents Affected - Few On 06/26/25 at 09:14 AM R6 was observed lying in bed on a low air loss mattress with a setting of 320. Gastric tube feeding Glucerna infusing at 70 ml/hr. On 06/26/25 at 09:16 AM V16 (Licensed Practical Nurse) entered R6 room. Surveyor asked V16 the setting of R6 low air loss mattress. V16 responded, a little after 320. Surveyor asked V16 the weight of R6 and how is the low air loss mattress setting determined. V16 responded, I am not sure what R6 weighs. I think the low air loss mattress is set based on the resident's weight. Surveyor asked V16 does R6 weigh 320 pounds. V16 responded. Not at all. On 06/26/25 at 09:17 AM V19 (Wound Care Tech) entered R6's room and said I am making my rounds now and I am about to update R6's weight. On 06/26/25 at 09:18 AM V19 (Wound Care Tech) stated I have a list downstairs, and I am going to have to print out a new weight label to put on the low air loss mattress machine. The label is put on the low air loss mattress machine so if the staff is done with patient care they can set it back to the correct setting. I know that is not set on R6's weight, that is why I am going to try and fix the issue now. The purpose of the low air loss mattress is to prevent wound break down on their body. If the weight is set to high, the bed will be a little too hard for their body. The low air loss mattress setting is set based on the resident's weight. On 06/26/25 at 09:32 AM V10 (Wound Care Nurse) stated R6 has a MASD (Moisture Associate Skin Damage) to the sacrum and the treatment is zinc daily. The area is open but not staged, just moisture with no drainage. R6 is on a low air loss mattress. R6 had a decline since readmission and does not move as much as he used to. The purpose of the low air loss mattress is for pressure relief and is set based on the resident's weight. It sounds like they just set up the low air loss mattress and it was put in place yesterday 06/25/25. The low air loss mattress should be set based on R6's weight. I would say the setting of 320 would be too firm and there is a potential of skin integrity and not getting the benefit of the low air loss mattress if it is too firm. I did not get the confirmation that R6 was on the low air loss mattress yet. V19 (Wound Care Tech) is the wound care technician, and her responsibility is to make sure the low air loss mattress was in place and on the correct setting. R6 is a readmission. I print the resident's weight on the label and put it on the machine. If the weight change, I will reprint a label. Housekeeping is putting the mattress in place and if they turn the setting up all the way it will fill up faster. Part of V19 role is to make sure the low air loss mattress is functioning properly, but everyone's responsibility is to make sure the low air loss mattress settings are correct. 06/26/25 at 10:29 AM V10 (Wound Care Nurse) stated R6's low air loss mattress was ordered on Monday 06/23/25 and I updated the care plan to include R6's mattress now that it is in place. The low air loss mattress is used if the person is immobile and have sacral wounds. Some residents come with orders or wound care determines if they need a low air pressure relief intervention. R6's low air loss mattress was not in place. We have the pressure relief mattress in house. I had to ask again yesterday where was R6's mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145661 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 145661 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ryze West 5130 West Jackson Boulevard Chicago, IL 60644 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 0686 Level of Harm - Minimal harm or potential for actual harm Document titled Proactive Medical Products undated document in part: Introduction: Indications; Mattress system, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Control Unit: Determine the patient's weight and set the control knob to that weight setting on the control unit. Operating Instructions: Step 6 Determine the patient's weight and set the knob to that weight setting on the control unit. Residents Affected - Few Policy: Titled Skin Care Prevention reviewed 01/25 document in part: All residents will receive appropriate care to decrease the risk of skin breakdown. 1. The Nursing Department will review all new admissions/readmissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 15. For residents who are bed or chair bound, a chair and pressure reducing mattress is needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145661 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 145661 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ryze West 5130 West Jackson Boulevard Chicago, IL 60644 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a system was in place for documentation of medication disposition. This failure resulted in R4s medication being unaccounted for. Findings Include: R4 was readmitted to the facility on [DATE] with diagnosis not limited to Personal History of Pulmonary Embolism, Cellulitis of Left Lower Limb, Respiratory Failure, Muscle Weakness, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, Morbid (Severe) Obesity due to Excess Calories, Depression, Anxiety Disorder, Obstructive Sleep Apnea, Lymphedema, Hypothyroidism, Binge Eating Disorder, Extreme, Adjustment Disorder with Depressed Mood, Lump in Unspecified Breast, Dependence on Wheelchair, Personal History of Other Diseases of the Musculoskeletal System and Connective Tissue, Abnormal Electrocardiogram, Essential (Primary) Hypertension, Personal History of other Diseases of the Respiratory System, Major Depressive Disorder and Tracheostomy Status. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R4's care plan document in part: Dietary: R4 is at nutritional risk as disease progresses, dx (diagnosis): morbid obesity, depression, lymphedema and hypothyroidism. R4 is taking schedule weekly medication Injections for weight loss management. R4 was receiving weight management medication since 04/25/25. R4's Order Summary Report document in part: Patient having tracheostomy placement at Medical Center 06/04/25 in preparation for bariatric surgery. Zepbound Subcutaneous Solution 2.5 MG (milligrams)/0.5ML (milliliter) (Tirzepatide (Weight Management)) Inject 1 pen needle subcutaneously in the afternoon every Wednesday for Weight Loss unsupervised self-administration. Progress note dated 06/04/25 07:32 document in part: Nursing Note: Patient out to an appointment (ENT) Ear, Nose, Throat VIA Ambulance. Progress note dated 06/04/25 15:07 document in part: Nursing Note: Writer spoke with Charge Nurse at Hospital who stated that the patient will be admitted overnight for Observation due to trach placement. Progress note dated 06/09/25 16:55 document in part: Nursing Note: Resident arrived on stretcher via ambulance from Hospital. Resident is in bed with trach 02 (oxygen) mask on. On 06/25/25 at 02:36 PM R4 stated the doctor from the outside prescribed weight loss medications that would be delivered to the pharmacy, my family would pick it up and bring it to the facility. I went to the hospital 06/04/25 - 06/09/25 to have surgery to put in this trach and when I came back the weight loss medication was nowhere to be found. I had received it previously and had 2 more shots left. The pharmacy sends four in the pack, and I got the shot on Fridays. I received a total of 6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145661 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 145661 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ryze West 5130 West Jackson Boulevard Chicago, IL 60644 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shots and the last 2 were never found, I told V21 (PM Supervisor/Licensed Practical Nurse) and V17 (Licensed Practical Nurse). They said they couldn't find them, so I missed 2 doses. They knew I was coming back to the facility. They did not replace the medication they just put in a new order. The medication needs to be in the refrigerator. On 06/25/25 at 02:51 PM V16 (Licensed Practical Nurse) stated I have not given R4 her shot for weight loss; it is kept in the refrigerator. If a resident is gone for a while we send the medication back to the pharmacy or discard it. I don't know what happened to R4's last 2 doses. On 06/25/25 at 02:57 PM V17 (Licensed Practical Nurse) stated R4 receives shots for weight loss and should have received the shot today. Normally when the resident goes to the hospital, they take the medications off the cart and discard them. I am not aware of what happen to R4's shots. We have the shots in my office in the refrigerator since this incident happened. R4 gets the shots once a week. I don't think R4 missed a dose. When R4 came back they ordered the shots, and she was getting them. R4's family was bringing the shots in prior to that. On 06/26/25 at 12:09 PM Per telephone interview V21 (PM Supervisor/Licensed Practical Nurse) stated I remember a conversation and R4 said she did not know where her injections are. I looked on the cart. Usually when a resident goes to the hospital, we send their medication back to the pharmacy. R4 did not tell me that the medication had to be refrigerated, and I was not aware the medication was brought in by the family. We will send the medication back to whatever pharmacy it came from. I told R4 the medication was sent back to the pharmacy and when R4 was readmitted we get orders from the doctor. The protocol is that all orders are discontinued if a resident spend a number of days in the hospital. I did not see any injections and I was not aware that R4 was in the hospital. It should be documented when the medication was sent back to the pharmacy in the electronic medical records. There should not be any documentation if the medication is discarded. Since there was a concern, about the missing medication we would do an investigation. On 06/26/25 at 11:27 AM V3 (Director of Nursing) stated V1 (Administrator) just told me 5 minutes ago that R4's Zepbound medication was missing. I spoke to R4 yesterday and she did not mention the missing medication. If family brought medication to the facility the staff should put the medication in zip lock bags and the manager can keep the injectable's or put them in the lock box. We knew R4 was coming back to the facility, but we did not know the eta (expected time of arrival) and R4's medication should have been put in the lock box. When the resident returns, we are supposed to put all new orders in. If the resident is gone more than 24 hours the orders will be discontinued. R4's procedure was planned. I did not know the medication was coming to the facility from the family. The medication should be on the cart and getting checked out each time it is being used. If the resident is discharged the medication should go back to the family or let the family know that we have the medication in our possession. I will start the investigation. On 06/26/25 at 12:20 PM Per telephone interview V22 (Licensed Practical Nurse) stated R4 injections were kept in the refrigerator in the medication room, and I never gave it to her. On 06/26/25 at 02:05 PM V16 (Licensed Practical Nurse) stated R4 was going to an appointment, they took R4 to the hospital from the appointment and R4 was admitted to the hospital. I did not send anything with R4, and I did not take R4's medication out of the medication cart. R4 was being admitted and they were going to observe her, so I did not remove any medication. I know the Zepbound was here, and it was in the refrigerator because we have to go in the refrigerator for insulin. It was not that particular day that I saw it, but I know it was in there because it was in a box. When I came (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145661 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 145661 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ryze West 5130 West Jackson Boulevard Chicago, IL 60644 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back, R4 asked me was the medication on the cart. I checked the cart, and it was not on the cart or in the refrigerator. I asked some of the nurses on the floor and V21 (PM Supervisor/Licensed Practical Nurse). V21 said she did not see it. V29 (Licensed Practical Nurse) said it was in the refrigerator. On 06/26/25 at 02:23 PM V29 (Licensed Practical Nurse) stated I saw R4's Zepbound in the refrigerator maybe a few days after R4's discharge to the hospital. I discarded it along with other insulin and medication for residents that were discharged in a sharp's container. After 72 hours we discard the medication. If there are pills, we send them back to the pharmacy. We cannot send back injectables and things like that. There is no sheet because it is not a controlled substance and there is no charting in the electronic medical records for the discarded medications. I administered the Zepbound to R4 on 06/18/25 and 06/25/25. Originally R4 was getting it on Fridays. I documented when I gave the Zepbound on the 06/18/25 but I did not document it on the MAR. R4 should have gotten the Zepbound on the 06/13/25 but I assume it was not here so R4 missed a dose on 06/13/25 and when it came in on the 06/18/25 on the 3-11 shift that is when I administered it to R4. No one asked where the medication was. R4 told me on 06/18/25 that she missed her dose. I told R4 that it just came in and I would administer it to her shortly. I was not aware that this was medication that R4's family had brought in. There is no process if a family member brings the medication in, we have all their medication here that they take. It was only one syringe of Zepbound in the refrigerator. On 06/26/25 at 02:46 PM V1 (Administrator) stated I have no policy on medication deposition. There is no policy for medication brought in by the family and I am not sure the nurses knew that R4's medication was brought in by the family. Resident census was obtained from the Midnight Census Report dated 06/24/25. Policy: Titled Medication Administration reviewed 01/24 document in part: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145661 If continuation sheet Page 6 of 6