Inspection·August 25, 2022

F 0578 Directives in place. Level of Harm - Minimal harm or potential for actual harm On 08/23/22 at 1:10pm, V14 (Social Worker) stated R159 does not have an Advance Directive in place at this time and stated, I still need to see this resident. V14 also said R7 does not have an Advanced Directive in place at this time. Residents Affected - Some On 08/24/22 at 10:50am, V1 (Administrator) was interviewed in regards to Advanced Directives. V1 stated, The admitting nurse is responsible to ask the resident upon admission if they have an Advance Directive in place. This is done within their admission paperwork in the EMR (electronic medical record) system. If the resident does not have an Advanced Directive in place, it is the responsibility of our Social Worker, (V14), to ensure they obtain one. On 08/24/22 at 12:23pm, V2 (Chief Nursing Officer) was interviewed in regards to Advanced Directives. V2 said it is the responsibility of the admitting nurse to obtain an Advanced Directive, or provide them with paperwork to fill out to complete an Advanced Directive. Asked V2 what is done after the resident is provided with paperwork and she said, It is then the responsibility of the Social Worker to follow up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 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 145743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Medical Ctr 3 Erie Court 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have an active order for oxygen administration for one resident (R9) prior to administration; failed to follow facility policy and accepted standards of care related to medication administration by not pulling residents' medications at the time of administration; and failed to safely secure controlled class drug medications. These failures apply to nine of nine (R8, R9, R10, R11, R109, R158, R159, R161, R209) residents reviewed for medication administration and storage, and has the potential to affect all 22 residents currently on the unit. Residents Affected - Many Findings include: On 08/23/2022 at 10:03am, observed a closed binder laid on top of V3's (Registered Nurse) mobile nursing cart. V3 (Registered Nurse) took a small cup of packaged medications from the top of her mobile cart, walked away from cart, and headed down the opposite end of hallway. Mobile cart with binder on top of cart was left unsecured, plugged into an outlet near opposite end of hallway, and not under constant surveillance by V3. At 10:07am, V3 (Registered Nurse) administered orally to R209: amlodipine 5mg, vitamin B12 1000mcg, and metoprolol tartrate 25mg. She then returned to her mobile cart, and said the morning medication pass is at 10:00am, so they have from 09:00 to 11:00am to administer. Reconciled administered medications with R209's physician's orders with active date of 08/23/2022, no discrepancies found. On 08/23/2022 at 10:38am, V3 (Registered Nurse) removed several packaged medications from a plastic bag within binder on top of cart, and then placed them into a small cup. She walked away from her cart and proceeded to head down the opposite end of the hallway. Mobile cart with binder on top of cart was left unsecured, plugged into an outlet near opposite end of hall, and not under constant surveillance by V3. At 10:41am, R9 was sitting in a high back chair next to the bed. He had a nasal cannula in place and was receiving oxygen at 2 liters per minute. At 10:42am, observed V3 (Registered Nurse) administer orally to R9: gabapentin 600mg, apixaban 5mg, pantoprazole 20mg, multivitamin tablet, thiamine 100mg, Seroquel 50mg and folic acid 1mg. On 08/23/2022 at 10:54am, V3 (Registered Nurse) returned to her mobile cart and took a nicotine patch from a small plastic bag within the binder on top of mobile cart. She then headed back down the opposite end of the hallway. Mobile cart with binder on top of cart was left unsecured, plugged into an outlet near opposite end of hallway, and not under constant surveillance by V3. At 11:00am, V3 applied a new nicotine patch 14mg to R9's left upper arm. She then checked his oxygen tubing for kinks, checked the flow rate, and informed R9 he is still receiving oxygen at 2 liters per minute. Reconciled administered medications with R9's physician's orders, with active date of 08/23/2022, showing R9 has current orders for Seroquel and Gabapentin, both of which are significant medications per regulatory body. No current order for oxygen (significant medication) at 2 liters found, no other discrepancies noted. On 08/23/2022 at 11:08 am, V3 (Registered Nurse) removed two patches, a pre-filled syringe, and several packaged medications from a plastic bag within binder on top of cart and placed the packaged medications into a small cup. She then walked away from her cart and headed down the opposite end of the hallway. Mobile cart with binder on top of cart was left unsecured, plugged into an outlet near end of hallway, and not under constant surveillance by V3. At 11:11am, V3 (Registered Nurse) applied one pain patch to R158's right knee, then a second pain patch to his left upper back. At 11:13am, V3 (Registered Nurse) administer orally to R158: atorvastatin 10mg, acetaminophen 650mg and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 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 145743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Medical Ctr 3 Erie Court 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many pantoprazole 40mg. At 11:15am, observed V3 (Registered Nurse) inject Lovenox 40mg from a pre-filled syringe into R158's right abdomen. Reconciled administered medications with R158's physician's orders, with active date of 08/23/2022, no discrepancies found. On 08/23/2022 at 11:22am, V3 (Registered Nurse) walked away from her mobile nursing cart with binder on top of cart, and headed across the hallway. Mobile cart left unsecured, plugged into an outlet near end of hallway, and not under constant surveillance by V3. At 11:26am, V3 (Registered Nurse) administered orally to R161 a onetime dose of diphenhydramine 25mg. Reconciled administered medications with R161's physicians (completed and current) orders, with active date of 08/24/2022, no discrepancies found. On 08/23/2022 at 11:32am, V3 (Registered Nurse) opened the binder on top of her mobile cart, and observed multiple bags within the binder that contained packaged medications separated within chart dividers. When asked whose medications were inside the bags, V3 (Registered Nurse) said she pulls all medications for my shift at one time and keep them in here. V3 (Registered Nurse) then informed surveyor the medications within the bags were for R161's evening medications, along with Tramadol and Tylenol; R159's 12:00pm dose of vancomycin; R9's 12:00 PM nebulizer breathing treatment; R8's pre-filled syringe of insulin glargine 10 units 08:00 PM dose that pharmacy left this morning that needs to be given to R8's nurse. When asked if it was safe practice to keep the medications on top of her cart and unsecured, V3 said No, that is why I keep my cart in the locked medication storage room. Then surveyor observed V3 (Registered Nurse) proceed to push her mobile cart into the medication storage room. Reconciled R161's bagged medications with her active physician's orders, dated 08/24/2022, showing current orders for acetaminophen (Tylenol) 650mg every 4 hours as needed for pain, Tramadol 50mg (significant medication) every 6 hours as needed for pain, aspirin 325mg twice daily, metoprolol tartrate 25mg every 12 hours, and pregabalin 50mg twice daily. On 08/23/22 at 2:47pm, V2 (Chief Nursing Officer) said R9 came to facility on oxygen at 2 liters, but does not have a current active order for oxygen. She then said the facility is currently attempting to obtain an order for oxygen. On 08/23/2022 at 3:11pm, V3 (Registered Nurse) said she works every other day 7a-7p, and is currently responsible for the residents on one side of the hall. She also said there are no set sides on the unit, staff assignments vary on number of nurses present and their work schedule. V3 (Registered Nurse) said all nurses are assigned to work both sides of hallway weekly. On 08/24/2022 at 9:56am, a mobile nursing cart with a binder on top of cart was in R109's doorway. Surveyor entered room and observed V11 (Registered Nurse) at the bedside facing resident with her back towards the door. Mobile nursing cart not under constant surveillance by V11. At 9:58am, V11 (Registered Nurse) injected heparin 5000 units via syringe to R109's right upper arm. Reconciled administered medications with R109's physician's orders, with active date of 08/24/2022, no discrepancies found. On 08/24/2022 at 10:18am, observed a mobile nursing cart with a binder on top of cart in R10's doorway. Surveyor entered room and observed V11 (Registered Nurse) next to chair facing resident with her back towards the door. Mobile nursing cart not under constant surveillance by V11. At 10:20am, V11 (Registered Nurse) administered to R10: plavix 75mg, aspirin 81mg, atorvastatin 40mg, fluoxetine 20mg, gabapentin 100mg, and memantine 5mg. She then returned to her mobile cart, and said she is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 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 145743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Medical Ctr 3 Erie Court 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 0658 Level of Harm - Minimal harm or potential for actual harm assigned to residents on one side of hall and that she pulls all medications for all of her residents at one time for the current scheduled medication administration time. V11 then opened the chart, and surveyor observed two plastic bags that contained medications for R8 and R11; per V11 both were 10:00 AM medications. Reconciled administered medications with R10's physician's orders, with active date of 08/24/2022, no discrepancies found. Residents Affected - Many On 08/24/2022 at 12:00pm, V1 (Administrator) said his understanding and expectation is for nurses to pull the medication for each resident one at a time, because if the nurse pulls multiple residents' medication at one time, they may sit out unsecured for an undesignated period. He then said, Residents' medication should be pulled one at a time before administration, and not pulled for the entire shift. Reviewed facility's medication administration policy, last reviewed June 2022, that showed under purpose is to ensure medications are administered in a safe and timely manner to meet the needs of the patient. Policy also showed under policy that medications and biologicals are administered in accordance with state law, including scope of practice laws and regulations, and hospital policy and procedures. Policy then showed under procedure that personnel authorized to administer medications receive training during orientation and ongoing throughout employment about topics related to safe medication handling, preparation, and administration of medications. Under medication administration procedure, the policy showed medications are prepared for one patient at a time, unit-dose packages remain intact until immediately prior to administration and to return unused medications to the automated dispensing system. Reviewed facility's storage of medications (patient care areas) policy, last reviewed June 2022, that showed under purpose to ensure safe and secure handling and storage of medications in patient care units, including the storage of medication between receipt by a healthcare provider and the medication administration to the patient. Under policy showed to ensure that medications stored outside of the pharmacy department are stored safely and securely and in accordance with this policy and procedure. Under secure medication storage requirements, policy showed that all medications are stored in a secure environment that limits access to authorized personnel as defined by hospital policy; medication storage areas secured with a lock must always remain locked unless being accessed; medications not securely locked must be under constant surveillance; mobile nursing carts containing drugs or biologicals are locked in a secure area when not in use; medications received from the pharmacy are immediately placed in an approved and secure storage area or remain under constant surveillance until placed in medication storage or taken directly to the patient for immediate administration; and medications removed from a storage area must remain with the individual at all times and are not to be left unattended. Under safe handling of medications from the medication storage area to the point of administration, policy showed medications are removed from medication storage areas just prior to administration; medications are removed for only one patient at a time; medications are taken directly from the medication storage area to the bedside for administration; medications may not be stored in a pocket; and the medication must remain within the control of the healthcare professional until administered, or returned to a secured storage area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 5 of 5