Inspection·February 27, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/26/25 at 3:37PM, V6 stated R1 has rheumatoid arthritis and dermatomyositis and both conditions are autoimmune. V6 reported R1 has lesions on both hands and arms due to dermatomyositis. V6 stated the lesions present as swollen, inflamed, sores. V6 reported the physicians at an outside hospital put R1 on the immunosupressive medication and the topical steroid cream. V6 stated the immunosupressive medication helps decrease the swelling and prevent any further lesions from occurring. V6 reported the topical steroid cream helps with inflammation and healing of the lesions. V6 denied making any changes to the medication and reported the physicians at the outside hospital are responsible for managing both medications. V6 stated R1 reported being given medications late, but denied R1 reporting any missed doses of medication. V6 denied being aware of any missed doses of the topical steroid cream or the immunosupressive medication. V6 reported if either medication is not given as ordered the lesions could potentially become worse. V6 reported if a medication is not given for more than one dose as ordered than V6 would expect to be notified by staff to see if there is an alternative medication that should be prescribed instead. V6 stated the physician wants to be aware if R1 is taking the medication or not to see if the medication is working properly with R1's auto immune disease. The Physician Order Summary documents a medication order for a topical steroid cream (clobetasol) to be applied two times a day for dermatitis and an immunosupressive medication (mycophenolate mofetil) to be given twice a day for rheumatoid arthritis. The topical cream was ordered on 12/23/24 and the immunosupressive medication was ordered on 12/25/24. The Medication Administration Record (MAR) dated 01/2025 documents the topical steroid cream is to be given at 6 AM and 6 PM and applied to both hands. During 01/2025, six doses were not documented as being administered on the MAR. The following are the dates and times the topical steroid cream was not administered: 1/8/25 at 6AM, 1/8/25 at 6PM, 1/9/25 at 6AM, 1/15/25 at 6AM, 1/27/25 at 6PM, and 1/30/25 at 6PM. The immunosupressive medication is ordered to give three tablets by mouth two times a day at 9 AM and 5 PM. A total of four doses are not documented as being administered during this month. The following are the dates and times the immunosupressive medication was not administered: 1/20/25 at 9AM, 1/27/25 at 5PM, 1/30/25 at 9AM, and 1/30/25 at 5PM. The Medication Administration Record dated 02/2025 documents eleven doses of the steroid cream were not administered as ordered. The following are the dates and times the topical steroid cream was not administered: 2/10/25 at 6PM, 2/13/25 at 6PM, 2/14/25 at 6PM, 2/18/25 at 6PM, 2/19/25 at 6PM, 2/20/25 at 6AM, 2/20/25 at 6PM, 2/22/25 at 6AM, 2/23/25 at 6PM, 2/24/25 at 6AM, and 2/24/25 at 6PM. It also documents that ten doses of the immunosupressive medication were not administered as order. The following are the dates and times the immunosupressive medication was not administered: 2/4/25 at 5PM, 2/10/25 at 5PM, 2/13/25 at 5PM, 2/14/25 at 5PM, 2/18/25 at 5PM, 2/19/25 at 5PM, 2/20/25 at 9AM, 2/20/25 at 5PM, 2/23/25 at 5PM, and 2/24/25 at 5PM. The Hospital Records dated 2/3/25 document R1 presented to the hospital with bilateral hand ulcerations, pain, and swelling. Rheumatology was consulted and stated to continue the immunosupressive medication. Plan is to continue the immunosupressive medication and topical steroid cream. The Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment). The policy titled, Medication Administration Policy, dated 08/2015 documents, Policy: Level of Responsibility: . Documentation of medication administration is recorded on the medication administration record or treatment record and includes the date, time, and initials of the licensed nurse who administered the medication . Administration of Medications: Medication must be administered in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 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 145714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Oasis 625 North Harlem Oak Park, IL 60302 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. The policy titled, Physicians Orders, dated 06/2017 documents, These guidelines are to ensure that: 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Any orders given by the physician are carried out. Nurse Responsibilities: .6. Medication and/or treatment orders are to be scheduled to MAR/TAR as appropriate .Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received. B. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory, etc. The policy titled, Change in Condition Physician Notification Overview Guidelines, dated 04/2014 documents, . Nurse Responsibilities: The nurse should not hesitate to contact the attending physician anytime for a problem which is in his or her judgment requires immediate medical intervention. The frequency of physician contacts is based on nursing judgment and the following guidelines . Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received .E. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 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 145714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Oasis 625 North Harlem Oak Park, IL 60302 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a topical steroid ointment and an immunosupressive medication as ordered causing the resident to miss 15 doses of the topical steroid ointment and 14 doses of the immunosupressive medication over a two month period for one resident (R1) out of three reviewed for medication administration in a total sample of three. Residents Affected - Few Findings Include: R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin. On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. R1 reported the medication is supposed to be taken twice a day (once in the morning and once around dinner time) but it is only given usually once a day or not at all. R1 was unable to report the number of doses that were missed but R1 stated it was more than ten a month. R1 was unaware why the medication was not being given as scheduled. R1 stated the medication is used for healing the lesions on R1's hands from the autoimmune disease. R1 stated the lesions are painful but have not gotten any worse from not taking the medication as scheduled. On 2/26/25 at 12:30PM, V1 (Nurse) stated R1 takes a medication for an autoimmune disease because R1's fingers swell. V1 could not remember the names of the medications, but reported R1 also uses topical creams. V1 denied R1 refusing any medication. V1 reported R1 has a condition that causes swelling and lesions to the hands and fingers. V1 stated medications need to be administered as they are ordered. V1 denied being aware of R1 having multiple missed doses of the topical steroid cream and the immunosupressive medication. V1 reported that if a medication is not signed out on the MAR, then it is considered not to have been given. On 2/26/25 at 1:23PM, V2 (DON) stated R1 admitted to the facility with lesions to the hands and arms. V2 could not state what medications R1 was taking for the autoimmune disease. V2 reported all medication should be administered as ordered. V2 stated the nurse should document the medication when it is administered in the MAR. V2 denied R1 making any reports that R1 was not getting the topical steroid cream or the immunosupressive medication. On 2/26/25 at 3:37PM, V6 stated R1 has rheumatoid arthritis and dermatomyositis and both conditions are autoimmune. V6 reported R1 has lesions on both hands and arms due to dermatomyositis. V6 stated the lesions present as swollen, inflamed, sores. V6 reported the physicians at an outside hospital put R1 on the immunosupressive medication and the topical steroid cream. V6 stated the immunosupressive medication helps decrease the swelling and prevent any further lesions from occurring. V6 reported the topical steroid cream helps with inflammation and healing of the lesions. V6 denied making any changes to the medication and reported the physicians at the outside hospital are responsible for managing both medications. V6 stated R1 reported being given medications late, but denied R1 reporting any missed doses of medication. V6 reported if either medication is not given as ordered the lesions could potentially become worse. The Physician Order Summary documents a medication order for a topical steroid cream (clobetasol) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 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 145714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Oasis 625 North Harlem Oak Park, IL 60302 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to be applied two times a day for dermatitis and an immunosupressive medication (mycophenolate mofetil) to be given twice a day for rheumatoid arthritis. The topical cream was ordered on 12/23/24 and the immunosupressive medication was ordered on 12/25/24. The Medication Administration Record (MAR) dated 01/2025 documents the topical steroid cream is to be given at 6 AM and 6 PM and applied to both hands. During 01/2025, six doses were not documented as being administered on the MAR. The following are the dates and times the topical steroid cream was not administered: 1/8/25 at 6AM, 1/8/25 at 6PM, 1/9/25 at 6AM, 1/15/25 at 6AM, 1/27/25 at 6PM, and 1/30/25 at 6PM. The immunosupressive medication is ordered to give three tablets by mouth two times a day at 9 AM and 5 PM. A total of four doses are not documented as being administered during this month. The following are the dates and times the immunosupressive medication was not administered: 1/20/25 at 9AM, 1/27/25 at 5PM, 1/30/25 at 9AM, and 1/30/25 at 5PM. The Medication Administration Record dated 02/2025 documents eleven doses of the steroid cream were not administered as ordered. The following are the dates and times the topical steroid cream was not administered: 2/10/25 at 6PM, 2/13/25 at 6PM, 2/14/25 at 6PM, 2/18/25 at 6PM, 2/19/25 at 6PM, 2/20/25 at 6AM, 2/20/25 at 6PM, 2/22/25 at 6AM, 2/23/25 at 6PM, 2/24/25 at 6AM, and 2/24/25 at 6PM. It also documents that ten doses of the immunosupressive medication were not administered as order. The following are the dates and times the immunosupressive medication was not administered: 2/4/25 at 5PM, 2/10/25 at 5PM, 2/13/25 at 5PM, 2/14/25 at 5PM, 2/18/25 at 5PM, 2/19/25 at 5PM, 2/20/25 at 9AM, 2/20/25 at 5PM, 2/23/25 at 5PM, and 2/24/25 at 5PM. The Hospital Records dated 2/3/25 document R1 presented to the hospital with bilateral hand ulcerations, pain, and swelling. Rheumatology was consulted and stated to continue the immunosupressive medication. Plan is to continue the immunosupressive medication and topical steroid cream. The Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment). The policy titled, Medication Administration Policy, dated 08/2015 documents, Policy: Level of Responsibility: . Documentation of medication administration is recorded on the medication administration record or treatment record and includes the date, time, and initials of the licensed nurse who administered the medication . Administration of Medications: Medication must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. The policy titled, Physicians Orders, dated 06/2017 documents, These guidelines are to ensure that: 1. Changes in resident status/condition are assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Any orders given by the physician are carried out. Nurse Responsibilities: .6. Medication and/or treatment orders are to be scheduled to MAR/TAR as appropriate .Nursing Documentation: A. Any calls to or from physician will be documented in the nurse's notes, indicating information conveyed and received. B. The nurse shall indicate in the nurse's notes, ongoing conversations with the physician regarding response to notifications of changes in condition, laboratory, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 5 of 5