Inspection·September 28, 2023

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few eMAR and physician order), 3. Right Dose, including mathematic calculations using appropriate factors (e.g. mg/kg, mg/m^2, etc) and that is within the range for the patient population, 4. Right Route of administration, 5. Right Time/Frequency. After the 5 rights of medication administration and IV considerations are confirmed, the nurse documents the administration of the medication and indicates the name of the co-signer in the co-signature box of the eMAR. The co-signer will document in the electronic medical record that he/she has performed the independent double check. Policy titled Storage of Medications (Patient Care Areas) 01/18 states: Safe Handling of Medications from the Medication Storage Area to the Point of Administration: - Medications are removed from medication storage areas just prior to administration. Medications are taken directly from the medication storage area to the bedside for administration. Protective outer wrapper on medications and IV solutions are not removed until immediately prior to administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 2 of 13 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 09/28/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow their policy and procedures for providing assistance with activities of daily living by not ensuring resident nails were clean and cut, not ensuring a dependent resident's environment was clean and that he was was free of body odors, and failed to ensure a resident was raised out of bed for daily activities. These failures applied to five of five residents (R6, R7, R9, R18, and R68) reviewed for activities of daily living. Residents Affected - Few Findings include: 1. On 09/26/23 at 11:27 AM, R6 stated her physician told her the podiatrist comes to the facility every 10 days. R6 stated she wanted her toenails cut. R6 had long unclean fingernails. R6 stated no one offered to cut her nails. R6's current subacute rehabilitation conference sheet documents she is dependent on and requires assistance with activities of daily living. 2. On 09/25/23 at 1:11 AM, R7 had a sock on his left hand, right hand was heavily contracted, his toe nails were long, thick, and yellow, R7 had a strong body odor, and R7's skin was red on his right elbow. R7 was unable to communicate, answering only with the word yeah and nodding his head. On 09/26/23 at 11:18 AM, R7 was lying in his bed on his back. R7's right contracted hand when opened by V10 (Patient Care Tech) had long and dirty fingernails. R7's left hand had long, dirty fingernails. V10 stated R7 is not diabetic. V10 stated PCT's (Patient Care Techs) cannot cut residents nails. V10 stated R7 hasn't been observed out of bed by her since she's been at the facility. On 09/26/23 at 12:02 PM R7 was lying in bed, awake and alert. R7's call light remote was on top of his bed sheets covered with a light brown dry substance, which was also on small areas of his gown and draw sheet. On 09/26/2023 at 12:12PM, V10 PCT (patient care tech) arrived in the room to provide feeding assistance and confirmed R7 had a bowel movement, which she aided with earlier in the day. When R7's call light was pointed out to V10, V10 said she hadn't noticed it earlier and was unable to determine what the brown matter was. V10 the got a paper towel dampened with water, and attempted to wipe away the brown substance. R7's current subacute rehabilitation conference sheet documents he is dependent on staff for assistance with activities of daily living. 3. On 09/25/23 at 1:28 PM, R9's nails were long and unclean. V15 (Family Member) stated she had been asking if they could cut R9's fingernails. V15 stated R9 is diabetic, and she was not aware someone could cut her nails for her. R9's current subacute rehabilitation conference sheet documents she is dependent on staff for assistance with activities of daily living. 4. On 09/26/23 at 11:16 AM, R18's nails were long and unclean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 3 of 13 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 09/28/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm R18's current subacute rehabilitation conference sheet documents she is dependent on staff for assistance with activities of daily living. 5. On 09/26/23 at 11:39 AM, R68's nails were long. R68 stated no one offered to cut her nails for her, and her hand and toenails could use a trim. Residents Affected - Few On 09/26/23 at 1:17 PM, V2 (Director of Nursing) stated there is no set schedule for the podiatrist to come and service the residents. V2 stated the podiatrist is requested when needed. At times, family members opt to cut the residents nails, and when this happens it is documented in the residents medical records. V2 stated the facility does not provide nail care. V2 stated she is unsure if the therapy staff provides nail care, and she will follow up once she verifies this information. On 09/27/23 at 9:48 AM, V2 (Director of Nursing) stated the facility does not have a policy on nail care. V2 stated, If the resident or their family would like their nails clipped, or if we notice that the resident's nails are long and are causing scratches or issues, nursing would put in a request for the podiatrist to come in. V2 stated none of the in house staff provide nail care. V5 (Chief Nursing Officer) stated, We have attempted to find the right care for (R7( because he requires custodial care vs subacute care and we are not custodial care, but we have not found anything. V2 stated, (R7) is never out of bed and he's usually just sat up in bed. We could probably get clothes for him. V2 stated she doesn't know why R7 is not out of bed. On 09/27/23 at 11:27 AM, V5 (Chief Nursing Officer) stated R7 is not raised out of bed because it was assessed by therapy he was not safe to use a wheelchair due to his body being too contracted. V5 stated they don't have geriatric chairs. On 09/27/23 at 01:30 PM, V2 (Director of Nursing) stated the issue with R7 having a sock on his hand would be restriction of his hands and not being able to observe him for circulation. V2 stated nobody knows why R7 was wearing a sock on his hand. V5 (Chief Nursing Officer) stated, Placing a sock on (R7's) hand is definitely not a practice we encourage. On 09/28/23 at 11:15 AM, V2 (Director of Nursing) stated it's everyone's responsibility to ensure R7's call light is clean and free of substances. V2 stated after incontinence care, staff should ensure there are no substances left behind, and they should be observing for any substances that shouldn't be left in a residents care area. V2 stated, All staff providing assistance with activities of daily living should be checking for unclean nails and if observed, should soak and clean them. V2 confirmed all nursing and therapy staff are responsible for ensuring residents are clean. V2 confirmed if a resident is observed with a body odor even after receiving a bath, they should be cleaned again. On 09/28/23 at 1:56 PM, V2 (Director of Nursing) stated team conferences are conducted once monthly and documented on the subacute rehabilitation conference sheet, which contain the most updated information regarding the residents care needs. On 09/28/23 at 2:28 PM, V2 (Director of Nursing) stated they plan to work on providing R7 with care equipment that will possibly allow him to be raised out of bed. On 09/28/23 at 3:12PM, V2 (Director of Nursing) could not provide any therapy or other medical record documentation that indicated R7 could not be raised out of bed in a wheelchair or geriatric chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 4 of 13 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 09/28/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their fall prevention policy and procedures by not ensuring a chair alarm intervention was in place as required for a resident at risk for falls resulting in an unwitnessed fall. This failure applied to one of one resident (R9) reviewed for accidents/falls. Findings include: R9 is an [AGE] year-old female with a diagnosis history of Partial Paralysis due to Stroke, who was admitted to the facility 09/08/2023. On 09/25/23 at 1:28 PM, R9 was sitting in her room in her wheelchair. V15 (Family) was visiting R9. V15 stated R9 had a fall last Tuesday or so, at around 3PM. V15 stated the facility has known R9 is a fall risk since she was admitted and has provided her with a chair alarm since her admission. V15 stated during the incident, R9 was sleep in her chair. V15 stated R9 moves around a lot because in her mind she can still move. V15 stated R9 fell on her bottom. R9's physician progress note, dated 09/19/2023, documents per V15 (Family Member), R9 is debilitated with limited verbal expression; chief complaint includes impaired mobility and self-care. R9's progress note, dated 09/19/2023, documents a code was called at 3PM, per nursing R9 was calling out for help and tried to get out of her wheelchair. She was found having slid partially out of her wheelchair with her wheelchair tilted behind her. R9's Pre/Post Fall Reports, dated 09/19/2023, documents she was assessed to be at moderate risk for falls with a Morse Fall Risk Scale score of 35, she experienced an unwitnessed fall, per her report she was repositioning herself in the chair prior to the fall; V11 (Therapy Manager) was in the therapy office and heard a patient yelling out for the nurse, he responded to the patients call and observed her sitting up on the floor. Per R9 she was attempting to reposition herself in her wheelchair and slid forward out of the chair. R9's chair alarm pad was on her chair but was not plugged in. Upon further investigation, R9 was participating in group activity and was returned to her room by family. On 09/26/23 at 11:43 AM, V2 (Director of Nursing) stated when falls happen, there are reports completed and they are submitted to the Risk Manager. V2 stated she reviews these reports. V2 stated she reviewed R9's physician note from 09/19/2023, which documented she fell partially out of her wheelchair after trying to reposition herself in it. V2 stated R9's chair alarm was noted in place. V2 stated V6 (Registered Nurse) documented the pre and post fall reports for the incident, which are not located in her medical records. On 09/26/23 at 11:58 AM, V6 (Registered Nurse) stated, (R9) did have an incident last week where she slid to the floor out of her chair. (R9's) chair alarm activates if she stands up, or weight is removed from it, such as when turning or moving, or if the pad is removed from underneath her. V6 stated she believes R9 was in another room during the time of the incident. V6 stated the Physical Therapist found R9 after she had fallen, and notified everyone that it happened. V6 stated she didn't hear R9's chair alarm during her fall, possibly due to being in another location. V6 stated she may have been assisting another resident during the time of the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 5 of 13 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 09/28/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/26/23 at 12:07 PM, V11 (Occupational Therapy Manger) stated he discovered R9 on the floor when she had a fall last Tuesday 09/19/2023. V11 stated this happened approximately between 1-2 PM. V11 stated while working in the Physical Therapy office, he heard R9 calling out for a nurse and responded immediately. V11 stated he found R9 on the floor in a seated position. V11 then called out a code that indicates someone has fallen. V11 stated when he asked R9 what happened, she reported she was just trying to reposition herself. V11 stated at the time, there were no other staff present in the hall or otherwise. V11 stated R9 generally doesn't use the call light, and instead has on occasion called out for assistance. V11 stated he believes R9's family and brought her back from activities and her chair alarm was not reconnected by the family. V11 stated R9's family was not present during the incident. On 09/26/23 at 12:19 PM, V6 (Registered Nurse) stated, It is requested that family communicate to staff when they return a resident back to their room. When (R9's family) left her in her room on Tuesday (09/19/2023) after activities, they did not communicate to the staff that she was back in her room. V6 stated when she contacted V15 (Family Member) to inform her about the fall, she reported V15 reported she had just left R9. V6 stated the nursing staff usually monitor residents whereabouts themselves and don't solely rely on family to inform them when a resident has been returned to their rooms. V6 stated R9 is not typically impulsive and had not been that day. V6 stated R9's chair alarm was in place during the time of her incident. It is nursing responsibility to monitor the resident's whereabouts and who they are with. The activities coordinator should notify nursing when a resident is returned to their room after activities . Whenever staff escorts a resident who uses a chair alarm back to their room, staff reconnect it, especially therapy staff. V6 stated she is not sure if the activities coordinator or any other staff was with her when she returned back to her room after activities on 09/19/2023. V6 stated whenever she conducts rounds, she makes sure residents who require chair alarms have the device correctly in place. On 09/26/23 at 12:56 PM, V12 (Activities Coordinator) stated she was with R9 on Tuesday 09/19/2023 when conducting activities. V12 stated staff would normally escort a resident from activities back to their rooms. V12 stated staff would have escorted R9 back to her room after activities due to her cognitive status and using a wheelchair. V12 stated she did not escort R9 back to her room from activities 09/19. V15 (Family Member) stated she escorted R9 back to her room from activities without any staff present on 09/19. V15 stated she escorted R9 to and from activities without any staff accompanying them. V15 stated she stayed with R9 for a brief time after, but then left, and soon after was informed that R9 fell. On 09/27/23 at 09:48 AM, V2 (Director of Nursing) stated when R9 fell 09/19/2023 her family brought her back to her room, but staff were unaware. V2 stated R9 was was adjusting herself in the wheelchair, and while scooting, lost her balance. V5 (Chief Nursing Officer) stated good collaboration between family and staffing as well would help prevent accidents such as the one R9 experienced. V5 stated V12 (Activities Coordinator) could have also alerted staff that R9 was returning to her room after activities. V2 stated during rounds, the nurse or PCT (Personal Care Tech) would notice R9 had returned to her room. V2 and V5 stated they don't expect family to reconnect the resident's chair alarm upon returning to their room, and wouldn't expect family to prevent an accident. V2 and V5 stated better communication among staff would have help prevent R9's accident and activities staff could have notified the PCT 's that a patient was returning to room. The facility's Fall Risk Assessment and Prevention Policy, reviewed 09/28/2023, states: The Fall/Injury Prevention Program is designed to: Recommend interventions intended to prevent or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 6 of 13 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 09/28/2023 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 0689 reduce the risk of injuries associated with falls; Enhance patient/resident, family, and staff knowledge of potential safety issues; outline the responsibilities all staff in the prevention of or response to a patient fall. Level of Harm - Minimal harm or potential for actual harm Prevention of falls and injury to the patient/resident is the responsibility of every member of the staff. Residents Affected - Few The facility will maintain a safe environment to reduce the risk of injury for patients/residents. An RN (Registered Nurse) is responsible for implementation and oversight of individualized patient fall prevention care as follows: Provides oversight of delegated duties to ancillary personnel in the delivery of safe care. A fall is defined as a sudden, unintentional descent, with or without injury to the patient/resident, that results in the patient/residents coming to rest on the floor, on or against some other surface. A Morse fall risk assessment score between 25-50 indicates moderate risk. Chair alarms may be utilized for patients/residents identified as high risk for falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 7 of 13 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 09/28/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were six medication errors out of 25 medication opportunities, resulting in a 24% medication error rate. This failure affected two of five residents observed during medication administration. Residents Affected - Few Findings include: On 09/26/23 at 12:25PM, V7, RN (Registered Nurse), was observed for insulin administration for R9. V7 said the blood glucose was taken around 11:30AM, prior to lunch. V7 could not provide the exact blood glucose result, but said according to the result, R9 should have gotten some insulin according to a sliding scale as ordered by the Physician. V7 said before insulin was given to R9, she needed to be monitored for how much food was eaten. Later at 12:45PM, V7 said since R9 only ate 25% of her meal, she would be withholding the insulin, and this did not require notification of any provider, because she knows the blood sugar will decrease if given. According to results review in the electronic health record, blood glucose was not documented as taken prior to lunch. A result of 189 was documented at 12:59PM, after lunch had been served. Physician order and Medication Administration Record (MAR) included Order to administer 1 unit of insulin for a result of 189. On 9/27/23 at 1:30PM, V2, Director of Nursing (DON), and V5, Chief Nursing Officer (CNO), said although the facility does not have a policy specific to administering insulin, the nurses are expected to take blood glucose samples from residents close but prior to mealtimes, and the RN should follow the Physician order, which may include additional parameters that would also be noted within the order. The nurse is expected to provide insulin according to the sliding scale (range), not according to amount of food eaten, unless specified. On 09/27/23 at 9:42AM, V18 was observed during medication administration to R6. When completed, V18 returned to the nurse's station at 9:51 AM. V18, RN, produced a plastic zip bag with a plastic medicine cup and five loose pills that were scheduled to be given to R171. V18 said the medications had been prepared prior to this observation. V18 said, The medications were removed from the dispensing machine, scanned to be given. I knew that I was about to give them, so I just got them ready. Usually, I do this in the resident's room. Five pills were in a plastic bag unable to be identified by individual packaging. While pouring the medications from the bag into the cup, 1 oblong white pill was dropped on the floor, and needed to be replaced. V18 said they were familiar with the medications, and thought they knew which medication dropped, due to familiarity. V18 was followed into the medication room and observed to remove another pill out of the medication dispensary. V18 left the cup of all other medications unattended on the mobile computer station, and walked into the medication room to remove one atorvastatin pill. Returning to the nurse's station, V18 dropped the atorvastatin pill again, onto the nurse's station counter and computer area. It was replaced with another tablet, and the medications were verified by defining characteristics. V18 said according to the medication scanner, the medications that were being administered were Atorvastatin 40mg (milligrams), Azythromycin 250mg, Enalopril 2.5mg, Torsemide 10mg and Tamsulosin 0.4mg. V18 was observed providing medications to R171 at 9:58 AM. After exiting the room, V18 said the medication scanner required an additional scan from R171's wrist band to confirm that the medications were given, and then re-entered the room to obtain the scan. Review of Medication Administration Record notes medications were completed and given at 10:07AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 8 of 13 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 09/28/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Shortly after at 10:30AM, another nurse, V17, RN, was observed passing medications to other residents without concerns. V17 said, The policy of the facility is that medications should be pulled from the medication dispensary for one resident at a time, scanned in the presence of the resident to avoid mistakes. V17 also said that prepared medications should not be left unattended for safety. On 9/27/23 at 1:30PM, V2, DON (Director of Nursing), and V5, CNO (Chief Nursing Officer), said, The nurses are expected to follow the policies for medication administration which include the procedure of removing medications immediately prior to administration and scanning resident wristband, and medications at the bedside which translates electronically to the MAR (Medication Administration Record). Medication Administration Policy, revised March 2016, states: Medication Administration Procedure: Medications are prepared for one patient at a time. Unit-dose packages remain intact until immediately prior to administration. Medications are administered immediately after the medication is prepared without a break in process by the individual who prepares the dose. Document the exact time the medication is administered. Do not document prior to administration. Policy titled Storage of Medications (Patient Care Areas) 01/18 states: Safe Handling of Medications from the Medication Storage Area to the Point of Administration: Medications are removed from medication storage areas just prior to administration. Medications are taken directly from the medication storage area to the bedside for administration. Protective outer wrapper on medications and IV solutions are not removed until immediately prior to administration. Medications may not be stored in a pocket. The medication must remain within the control of the healthcare professional until administered, wasted or returned to a secured storage area. If the individual cannot immediately administer the medication, the medication will be handled as defined in the Product Disposition section below. Product Disposition Medications removed from the labeled package or container and not administered to the patient are discarded following the hospital's Pharmaceutical Waste Management Plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 9 of 13 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 09/28/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. On 09/27/23 at 12:40 PM, V16 (Infection Preventionist) stated the facility handles Legionella monitoring and she receives a report and she reports it to the infection committee. V16 stated the water has not been tested since she began working as the Infection Preventionist. V16 stated she is responsible for reviewing the water testing report and ensuring any necessary follow up is initiated. V16 stated this is also the responsibility of the Plant Operations staff. V16 stated she did not review the most recent results because she's been busy, and she has not asked for assistance with this. V16 stated she does not know when the next test will be conducted. Residents Affected - Some 09/28/23 12:53 PM V2 (Director of Nursing) reported she was not able to locate the results of Legionella Testing Reports, and she is ordering a stat test to be done. The facility's Water Management Plan, reviewed 09/28/2023, states: Control Measures for Legionella include: Regular monitoring including weekly and quarterly testing, and treatment of water as required. Based on observation, interview, and record review, the facility failed to follow infection control policies regarding 1. hand hygiene while passing meal trays 2. Droplet Plus isolation precautions, and 3. Legionella (water contamination) prevention; and failed to have a policy which includes COVID prevention. These failures have the potential to affect all seven residents residing on the subacute rehabilitation unit. Findings include: 1. On 9/25/23 and 9/26/23, lunch was observed on the unit. Dietary staff were observed passing meals to residents in their rooms, and no hand hygiene was observed at any time during this process. While passing trays, items were manipulated on several resident's bedside tables in order to make room for the meals. Facility Hand Hygiene states; If hands are not visibly soiled, use an alcohol based hand-rub (ABHR) or wash hands with soap and water for routine decontamination in the following clinical situations: 1.5 After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. On 9/27/23 at 1:30PM, V5, Chief Nursing Officer, said it was the expectation of staff to utilize hand sanitizer or wash hands upon entering and exiting patient rooms, and Dietary staff should be doing this while passing trays. 2. On 9/27/23 at 9:55 AM, while observing medication administration for R171, V18, RN/Registered Nurse, was seen going into the room without a face shield or eye protection. V18 said that R171 was on isolation Droplet precautions due to a positive COVID-19 result. The red isolation sign on the Door indicated: All healthcare workers entering the room must: wear a N95 mask with shield upon entry. On 9/27/23 at 12:50 PM, V16, Infection Preventionist, said the facility did not have a COVID prevention policy, but staff was expected to wear the PPE (Personal Protective Equipment) as stated on the appropriate (Droplet Plus) isolation sign. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 10 of 13 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 09/28/2023 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 0880 Infection Control Policy Isolation Precautions: General, revised May 2016 and reviewed August 2023, does not include isolation precautions for COVID-19 infection. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 11 of 13 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 09/28/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 follow their vaccine policy and procedures for flu and pneumonia vaccination by not ensuring a vaccine eligible long term care resident was offered and educated on or receiving a flu or pneumonia vaccination. This failure applied to one (R7) of five residents reviewed for vaccinations. Residents Affected - Few Findings include: R7 is a [AGE] year-old male, with a diagnoses history of Coronary Vascular Accident, Aphasia, Seizures, and Depression who has been residing at the facility for the past 5 years per nursing. On 09/27/23 at 12:40 PM, V16 (Infection Preventionist) stated she began working on the unit as the Infection Preventionist at the end of July, and has been working in that role a little over 2 months. V16 stated it wasn't documented R7 received any flu vaccines. V16 stated she educates the nurses on vaccines, and they handle ensuring residents are offered and educated on vaccines. V16 stated if the patient wants the vaccines, they would sign a consent, or if they refuse, it would be documented. On 09/28/23 at 1:56 PM, V2 (Director of Nursing) stated R7 has been on the Subacute Rehab Unit at least 5 years. V2 stated she reviewed R7's records as far back as she could, and he hasn't had a flu or pneumococcal vaccine and had only one COVID vaccine. V2 stated she isn't sure why he hasn't had an influenza vaccination, but he should have. R7's medical records do not include any documentation of receiving a flu or pneumonia vaccination since admission. The facility's Vaccine Policy reviewed 09/28/2023 states: The Skilled Nursing Facility (SNF) shall arrange for vaccination against influenza and pneumococcal in accordance with the recommendation of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, unless the resident has refused or it is medically contraindicated. Residents admitted October through February will be assessed to determine if they have received the influenza vaccine. It will be documented in the resident's medical record that the influenza vaccine was administered, refused or medically contraindicated. Residents admitted will be assessed to determine if they have received the pneumococcal vaccine within the last five years. It will be documented in the residents medical record that the pneumococcal vaccine was administered, refused or medically contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 12 of 13 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 09/28/2023 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow their COVID-19 policy and procedures for COVID vaccination, by not ensuring a vaccine eligible long term care resident was offered and educated on or received a COVID vaccination. This failure applied to one (R7) of five residents reviewed for COVID vaccination. Findings include: R7 is a [AGE] year-old male with a diagnoses history of Coronary Vascular Accident, Aphasia, Seizures, and Depression, who has been residing at the facility for the past 5 years, per nursing. On 09/27/23 at 12:40 PM, V16 (Infection Preventionist) stated she began working on the unit as the Infection Preventionist at the end of July, and has been working in that role a little over 2 months. V16 stated R7 received a COVID 19 vaccine 03/16/2021, which is likely an initial dose, based on when the vaccines became available in December 2020. V16 stated she is unable to find any other COVID vaccine information for R7. V16 stated the facility does not have a COVID policy. V16 stated she educates the nurses on vaccines, and they handle ensuring residents are offered and educated on vaccines. V16 stated if the patient wants the vaccines, they would sign a consent, or if they refuse, it would be documented. R7's medical records document he received only one COVID 19 vaccine in March 2021 since admission. On 09/28/23 at 1:56 PM, V2 (Director of Nursing) stated R7 has been on the Subacute Rehab Unit at least 5 years. V2 stated she reviewed R7's records as far back as she could, andR7 had only one COVID vaccine. V2 stated R7 may have had a one dose COVID vaccine, and he should have received a booster, but he hasn't received one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145743 If continuation sheet Page 13 of 13