Health inspection·July 2, 2025

F 0689 R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful. Level of Harm - Actual harm Residents Affected - Few On 06/30/2025 at 11:54 AM V6 (Licensed Practical Nurse) said, I wasn't here when R1 fell (04/06/2025). R1 ambulated with a walker, had steady gait back then; however, still required supervision prior to the fall. R1 is forgetful, there are times when you can have a conversation with him and other times when you cannot. R1 forgets to use a call light despite staff reminding him to do it. R1 was moved to a room closer to the nursing station after the fall for easier monitoring. On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions. Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025. On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself. On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, R1 had a fall in an early April (2025). I received a call from V9 (Registered Nurse) close to 3:00 PM notifying e of R1's fall. V9 (RN) said that R1 had a fall, while he was trying clean up a spilled water in the room. R1 didn't have a walker at the time of a fall. V9 (RN) said that R1 didn't have any injuries but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 2 of 11 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 07/02/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few complained of leg pain. V9 (RN) said he gave R1 pain medication and called V13 (Attending Physician) to get an x-ray order. It was a Sunday, so I didn't do anything else in relation to the fall, just spoke to V9 (RN). When I came in on 04/07/2025, V7 (Licensed Practical Nurse) told me that they are still waiting for an x-ray. I advised V7 (LPN) to follow up with the diagnostic company. V7 (LPN) told me that the diagnostic company will be coming in before the end of the day. I don't know what time they came in. When I came into the facility the next day (04/08/2025), I made my rounds and heard that R1 didn't come out of the bad. I had words with V7 (LPN), I told her that when a resident has a change in condition and cannot walk whereas he walked before, nurses should send them out to the hospital. I then started the process of sending R1 to the hospital and he was picked up around 10:20 AM (4/8/2025). R1 was a fall risk resident before the incident (04/06/2025). R1 required constant redirection. One of the issues was that R1 has OCD (obsessive compulsive disorder), trying to clean and rearrange the room all the time. R1 didn't use a call light or ask for assistance. We would find him walk without the walker all the time. R1 was already walking around or stayed in one of the dining rooms; however, Certified Nurse Assistant should monitor residents at least every two hours. R1's fall occurred because R1 was trying to clean up after his roommate and there was spilled water on the floor. R1 has an obsession with cleanliness. One of the reasons why R1 was moved to another room is to make sure the room is clean and close to the nursing station. Surveyor asked if V8 (Certified Nurse Assistant) was the only working CNA despite the need for two CNAs on the on the 2 Main unit on 04/06/2025, V2 (Director of Nursing/ Fall Coordinator) did not confirm nor deny it. On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, I don't recall getting notified of R1's call, I might have gotten a call. When the facility nursing staff call me, they emphasize if a resident hit the head, vital sign status, how a fall occurred, and based on that I give orders. The first step is in-house diagnostic. If there is a change in resident's mental status, head trauma, loss of consciousness, or complaining of severe pain, I send them out to the hospital. Surveyor asked what some of the signs and symptoms of a broken hip are, V13 (Attending Physician) stated, Some of the signs of broken hip is complaining of pain, bruising, deformity, and affected ROM (range of motion), such as extended leg. The nurse should try to obtain a STAT image order to determine if there is a fracture and need for hospitalization. If a resident has a mild pain, we start at over-the-counter pain medication, if it's excruciating pain we would send them out to the hospital. It a resident has continuous pain, not managed by the over-the-counter medications, they should be sent out to the hospital. Surveyor asked what some are of long-lasting results of a broken hip, V13 (Attending Physician) said, A broken hip with a subsequent surgery would affect a resident acutely, example: bed rest and physical therapy. There could also be long lasting effect, such as chronic pain and change in the ROM (range of motion). On 07/01/2025 at 12:19 PM V8 (Certified Nurse Assistant) said, On 04/06/2025, R1 was assigned to me. I don't recall R1 falling on my shift (7:00 AM - 3:00 PM). I was the only CNA on the main portion of the second floor on 04/06/2025, normally it's two. We do rounds are at least every two hours. R1 was not monitored in any special way, I don't think he was at risk for fall. I don't remember any special interventions that we had to do for R1. R1 was always adjusting and cleaning his room. Per record review, V8 (Certified Nurse Assistant) was an only CNA scheduled to work 7:00 AM - 3:00 PM on the 2 Main unit on 04/06/2025. R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 3 of 11 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 07/02/2025 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 0689 Level of Harm - Actual harm R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall. Residents Affected - Few R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 09:53 AM reads in part, The writer received (R1) in bed complaining of pain in left hip due to recent fall. The resident unable to come to a standing position. Md updated; orders given to send the resident to (local hospital). Currently awaiting transportation to arrive. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 10:20 AM reads in part, (Local) transportation arrived and transported (R1) via stretcher to (local medical center) per (R1's) request. (R1) received all scheduled medication and prn (pain medication) before leaving the facility and consumed 100% of his breakfast tray. Vitals upon (ambulance) arrival were (blood pressure): 138/76 (pulse): 86 (oxygen): 96% (temperature): 97.7 (pain): 6/10. Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well. The facility Fall policy (no date) reads in part, It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Standards: Safety interventions will be implemented for each resident identified at risk using a standard protocol. Standard Fall/Safety Precautions for All Residents: The resident's environment will be kept clear of clatter which would affect ambulation and remove hazards. Lighting will be appropriate for the time of day and in accordance to the resident's desire and the plan of care; Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet; All nursing personnel will be informed of residents who are at risk of falling. The fall risk classification will be identified on the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 4 of 11 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 07/02/2025 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 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 on interview and record review, the facility failed to timely administer a PRN (as needed) pain medications for post fall onset of pain for a one of one (R1) resident reviewed for pain in the sample of four. This failure resulted in R1 having ongoing, unaddressed pain for 44 hours before R1 was hospitalized for left hip fracture, and subsequent surgery of the left hip fracture. Residents Affected - Few Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure. On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful. 06/30/2025 11:54 AM V6 (Licensed Practical Nurse) said, If a resident complains of pain and has difficulty moving, I make sure the doctor knows all the details and gives order to send a resident to the hospital for further evaluation. On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions. Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025. On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I noticed the diagnostic company didn't come around midday, I called them, and they said they had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 5 of 11 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 07/02/2025 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 0697 Level of Harm - Actual harm Residents Affected - Few order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself. On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, The nurses should assess residents' pain, establish source, administer a PRN pain medication or order one if there is no order for it, and check within 30 minutes if administered pain medication was effective. If the medication is not effective, nurses should follow-up with a physician. The nurses should sign the medication out in a resident's MAR (Medication Administration Record) or document it in the progress note. The pain should be assessed at the time of a fall or if a resident exhibits pain. Other than that, pain should be assessed every shift and documented in a resident's MAR (Medication Administration Record). On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, I don't recall getting notified of R1's call, I might have gotten a call. When the facility nursing staff call me, they emphasize if a resident hit the head, vital sign status, how a fall occurred, and based on that I give orders. The first step is in-house diagnostic. If there is a change in resident's mental status, head trauma, loss of consciousness, or complaining of severe pain, I send them out to the hospital. Surveyor asked what some of the signs and symptoms of a broken hip are, V13 (Attending Physician) stated, Some of the signs of broken hip is complaining of pain, bruising, deformity, and affected ROM (range of motion), such as extended leg. If a resident has a mild pain, we start at over-the-counter pain medication, if it's excruciating pain we would send them out to the hospital. It a resident has continuous pain, not managed by the over-the-counter medications, they should be sent out to the hospital. R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall. R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. will continue to monitor as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 6 of 11 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 07/02/2025 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 0697 Level of Harm - Actual harm R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 09:53 AM reads in part, The writer received (R1) in bed complaining of pain in left hip due to recent fall. The resident unable to come to a standing position. Md updated; orders given to send the resident to (local hospital). Currently awaiting transportation to arrive. Residents Affected - Few R1's progress note written by V7 (Licensed Practical Nurse) dated 04/08/2025 10:20 AM reads in part, (Local) transportation arrived and transported (R1) via stretcher to (local medical center) per (R1's) request. (R1) received all scheduled medication and prn (pain medication) before leaving the facility and consumed 100% of his breakfast tray. Vitals upon (ambulance) arrival were (blood pressure): 138/76 (pulse): 86 (oxygen): 96% (temperature): 97.7 (pain): 6/10. R1's April 2025 Medical Administration Record pain assessment shows: 04/06/2025 (evening) pain 3/10; 04/07/2025 (day) pain 4/10; 04/07/2025 (evening) pain 1/10. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM shows R1's pain 5/10. Absent are any documents to show that R1 received pain medication between 04/06/2025 2:40 PM (time of the incident) and 04/08/2025 10:20 AM (as per progress note) indicating 44-hour delay in pain management. Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well. The facility Pain policy (no date) reads in part, It is the policy of the Nursing Department to respect and support the resident's right to optimal pain management. General Guidelines: A Pain Assessment tool will be used as a guide in determining a resident's pain level in addition to their descriptive words, and/or physical signs and behaviors; Assessments will be performed at the time of admission, quarterly in conjunction with the MDS schedule. admission diagnosis and other events during the resident's stay may initiate additional pain assessments, i.e., post falls or new or increased pain medications; Pain control effectiveness will be measured after PRN pain medication is administered and during each medication pass; Once pain rate scale is determined, all staff members are instructed to use the resident's identified scale for all assessments; Interventions for pain will be balanced with adequate response to provide comfort while maintaining functional status, when possible, in accordance with the residents; Documentation of each pain assessment will be recorded on the Pain Assessment form, in the nurses' notes or on the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 7 of 11 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 07/02/2025 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 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. 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 ensure diagnostic testing order was carried out and diagnostic testing results were reported in a timely manner for a resident with acute fracture for one of four (R1) residents (R1, R2, R3 and R4) reviewed for diagnostic testing in the sample of four. Residents Affected - Few Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including bit not limited to Ataxia; Epilepsy; Unspecified Abnormalities of Gait and Mobility; Abnormal Posture; Muscle Wasting and Atrophy; Schizoaffective Disorder, Bipolar Type; Schizophrenia; Bipolar Disorder; Essential (Primary) Hypertension; Type 2 Diabetes Mellitus with Diabetic Neuropathy; and Heart Failure. On 6/30/2025 at 11:48 AM Surveyor observed R1 laying in the bed. R1 clean and dressed appropriate, no shoes observed at this time. R1's room dark, call light out of R1's reach, no clutter observed. R1 said, Yeah I fell, I hurt my hip. I'm not sure when or how it happened. R1 unable to recall circumstances of the incident, sounds confused and forgetful. 06/30/2025 11:54 AM V6 (Licensed Practical Nurse) said, As far as an x-ray service, we use external diagnostic service. When the doctor gives an x-ray order, we call the x-ray company and order an x-ray. If it is a regular order, the company comes out within 24 hours, if it's a STAT order, the company comes out within 2 hours. On 06/30/2025 at 3:23 PM V9 (Registered Nurse) said, I worked on 04/06/2025, I don't remember what shift. I don't remember the time of R1's incident, but I think it was after breakfast. I heard R1 calling for help while I was passing medications. I went up to R1, R1 was sitting on the hallway floor, right by his room, leaning against the wall, with one of his legs stretched forward. R1 said he saw spilled water on the floor and was trying to wipe it. I don't remember if R1 was wearing shoes. R1 was not able to get up on his own. I called someone for help, I don't remember who came, we placed R1 in the wheelchair and put him in the bed. I notified the doctor, who recommend an x-ray. Upon my assessment, R1 was not able to move his left leg and it was in extended position. R1 was in a lot of pain, especially when trying to move his leg. I gave R1 pain medication, but I don't remember if I documented. After I received an x-ray order, I called the diagnostic company, and I was told they'll come out to do an x-ray but didn't say when. I don't remember whether this was a regular or STAT order. I didn't check on R1 nor reassessed R1's pain before the end of my shift. The x-ray company didn't come before I left. I didn't follow up with the diagnostic company. R1 would always use a call light when he needed anything. I don't know why he attempted to get up that day (04/06/2025). R1 would normally walk around the unit, he looked stable. I don't know if he used any mobility devices. R1 was walking like a normal person, so I'm not sure if R1 was at high risk for falls before the incident on 04/06/2025, so I'm not sure if R1 had any fall prevention interventions. Per record review, V9 (Registered Nurse) was scheduled to work 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM on the 2 Main unit on 04/06/2025. On 07/01/2025 at 10:45 AM V7 (Licensed Practical Nurse) said, When I came in to work on 04/07/2025 7:00 AM - 3:00 PM, it was reported to me that R1 fell the day before. I wasn't told any details of the fall. I looked at the report, and it showed that the x-ray was ordered per doctor's order. Once I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 8 of 11 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 07/02/2025 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 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few noticed the diagnostic company didn't come around midday, I called them, and they said they had no order for R1's x-ray. I placed a STAT x-ray order, and they came out after 3:00 PM (04/07/2025). R1 usually wakes up early and walks around with a walker. On 04/07/2025, during my initial rounds, I noticed R1 was in pain and couldn't move his left leg. R1 was not able to get up but wasn't able to rate the pain. I'm pretty sure I gave R1 pain medication and document it in the progress. I was thinking we were just waiting for an x-ray, and everything was arranged. I was trying to keep R1 comfortable, I gave R1 some ice. When I returned to work on 04/08/2025 (7:00 AM - 3:00 PM), I was told that the x-ray showed that he had a fracture, and I was supposed to send him out to the hospital and not wait for the x-ray. R1 was a fall risk resident, and we were supposed to make sure we assist and supervise R1 when he gets in and out of bed and that he has a walker with him. R1 would always use a call light but also, he would try to get up by himself. On 07/01/2025 at 11:07 AM V2 (Director of Nursing/ Fall Coordinator) said, The nurse should call the diagnostic company once they receive an order. Next, they should print an order and a resident face shift and get all documents ready. When we call the diagnostic company, we need to specify whether it is a regular or stat order. Regular x-ray is usually done within 24 hours, and STAT should be done with 4 hours. On 07/01/2025 at 12:02 PM V13 (Attending Physician) said, The nurse should try to obtain a STAT image order to determine if there is a fracture and need for hospitalization. On 07/01/2025 at 1:40 PM In the follow up interview, V2 (Director of Nursing/ Fall Coordinator) said, If an x-ray order was STAT, it would be indicated on the order, R1's x-ray it was a regular order. If there is an abnormality in the radiology report, the diagnostic company supposed to call the facility; however, all results are posted in the electronic medical record, as the company process them. The nurses should check for any posted results at least once per shift. R1's x-ray result was posted on 04/07/2025 at 5:48 PM, that means, at least night nurse should have caught it. I was never aware of R1's x-ray result. I don't know if any nurses saw the result. It was not reported to me. I don't know if nurses didn't check and were not aware of it or they just didn't report it to nor anyone else. I initiated R1's hospitalization on the morning of 04/08/2025 based on R1's declined condition. R1's progress note written by V9 (Registered Nurse) dated 04/06/2025 02:42 PM reads in part, Full body assessment done, no open injuries or active bleeding noted, able to move all extremities but with a lot of pain voiced when moved the left knee and unable to stand up. v/s bp 134/67, r 20 p 71, DON (V2) aware, on call md order Knee x-ray. R1's progress note written by V7 (Licensed Practical Nurse) dated 04/07/2025 03:38 PM reads in part, (R1) immobile due to pain to injury from recent fall; (R1) unable to come to an upright sitting position without assistance, greenish purple bruise noted on the left hip; pain level 5/10; Ambulatory status pre-change: ambulated with walker; Ambulatory status post-change: non ambulatory due to injury from previous fall. New orders: x-ray ordered by writer, currently awaiting x-ray tech to arrive. R1's progress note written by V2 (DON/Fall Coordinator) dated 04/08/2025 09:30 AM reads in part, Manager follow up: Writer made aware by floor nurse that (R1) was observed lying in bed awaiting x ray results, but (R1) continues to c/o pain to Left leg and is not getting out of bed as per his baseline. Writer observed (R1) in room lying in bed stating, it's hard for me to stand up it hurts. Floor nurse made aware and instructed to call MD and have (R1) sent out for further evaluation, no further issues at this time, call remains within reach and resident given pain medication as per MD order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 9 of 11 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 07/02/2025 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 0777 will continue to monitor as needed. Level of Harm - Minimal harm or potential for actual harm R1's x-ray physician order dated 04/06/2025 03:20 PM created by V2 (DON/Fall Coordinator) reads in part, x-ray left knee bil. Residents Affected - Few R1's Radiology Results Report reads in part, Examination Date: 04/07/2025 1:50 PM; Reported Date: 5:48 PM; Procedure: L-HIP W/PELVIS & FEMUR; Interpretation: Impacted transcervical fracture of the left neck with varus deformity. Hospital record initiated on 04/08/2025 11:30 AM reads in part, [AGE] year-old male with a (past medical history) of anemia, CAD (coronary artery disease), schizoaffective disorder, bipolar disorder, GERD, epilepsy, hypothyroidism, heart failure, hypertension, T2DM (diabetes mellitus type 2) presented to the ER due to a fall. (R1) unsure when he fell but thinks that he fell on Sunday (04/06/2025) on his left side. Since the fall, (R1) has been having left-sided hip and knee pain as well as adnominal pain. CT of the hip showed a moderately displaced and angulated fracture of the left femoral neck along with enlargement of the left iliac muscle. (R1) was admitted for further management. Left femoral neck hemi-arthroplasty on 04/09/2025. Tolerated procedure well. Diagnostic company ordering procedure (no date) reads in part, All non-stat orders are performed the same day, unless requested to be done another day. Results will also be available to you the same day the procedure was performed (please note that this is 100% possible if the orders are placed early, preferably before 5 pm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 10 of 11 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 07/02/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to adhere to sanitary requirements by not following its own hair restraints policy when a dietary aide was found not wearing a hair restraint while inside the facility's kitchen. This failure has the potential to affect the quality of food served to all residents at the facility. Findings include: On 07/01/2025 at 12:00 PM, This Surveyor visited the facility kitchen to verify if kitchen staff were wearing hair restraints. This Surveyor introduced himself to V14 (Dietary Supervisor). Before entering the kitchen, this Surveyor asked V14 for a hair restraint to wear, was given one, and placed it over his head. Both V14 and this Surveyor then proceeded to enter the kitchen. Upon entering the kitchen, this Surveyor observed V15 (Dietary Aide) to the immediate left, sitting by the wall, and not wearing a hair restraint. This Surveyor then observed V14 instruct V15 to place his hair restraint over his head. V15 was then seen walking outside the kitchen, holding a hair restraint in his hand, then returning to the kitchen a few seconds later, now wearing a hair restraint over his head. This Surveyor then left the kitchen. On 07/01/2025 at 1:15 PM, V14 told this Surveyor that, technically, V15 was not supposed be without his hairnet in the kitchen. When this Surveyor asked V14 what she meant by, technically, V14 said, it was not correct because I didn't want you to see it. V14 also said that V15 told her he had just sat down in the kitchen because it got hot, then wiped the sweat off his brow, and the hairnet slipped off. V14 reiterated that, technically, V15 was not supposed to be in the kitchen without wearing a hairnet, but because he was hot, she gave him the leeway. The facility's Hair Restraints policy, dated 2021, states in part, Food and nutrition services employees shall wear hair restraints. The facility's Hair Restraints procedure states in part, hairnets will be worn at all times in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145714 If continuation sheet Page 11 of 11