Inspection·September 12, 2025

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 follow professional standards and administer medications in a timely manner for two (R11 and R31) out of a total sample of 10 residents reviewed for medication times.Findings include: 1.On 9/09/2025 at approximately 10:20 AM, V6 (Licensed Practical Nurse) prepared R11's morning medications. These included Hydroxyzine Pamoate (given for restless leg syndrome), Lamotrigine (antianxiety), Levetiracetam (anticonvulsant), Metoprolol Succinate Extended Release (for high blood pressure), and Potassium Chloride (for low potassium). At 10:32 AM, V6 stated V6 will not administer the Metoprolol because R11's blood pressure was low. R11 took the other morning medications at 10:32 AM. R11's ‘Medication Administration Record (MAR)' documents R11's morning medications are to be given at 9:00 AM. R11's ‘Medication Admin Audit Report' documents on 9/03/2025, R11's morning medications were also administered late. R11's received the 9:00 AM medications at 12:08 PM. On 9/04/2025, R11 received the morning medications at 10:57 AM. On 9/08/2025, R11 received the morning medications at 12:40 PM. 2.On 9/09/2025 at 12:44 PM, R31 stated there were incidents a week to two weeks ago in which a new nurse gave R31's evening medications late. R31 stated nurses usually give R31's evening medications an hour after dinner. R31 stated during the mentioned incidents, it was almost 11:00 PM, and R31 still hadn't received the evening medications. R31's current MAR documents R31 is to receive Haloperidol (for agitation) and Vitamin C (supplement) at 5:00 PM. R31 is also to receive Donepezil Hydrochloride (for dementia) at 9:00 PM.R31's ‘Medication Admin Audit Report' documents in August, R31 had Naproxen (for pain) and Vitamin C scheduled at 5:00 PM. On 8/06/2025, R31 received the medications at 7:03 PM. On 8/07/2025, R31 received the medications at 6:25 PM. On 8/09/2025, R31 received the medications around 8:28 PM. On 8/12/2025, R31 was no longer receiving Naproxen in the evening; however, R31 remained scheduled to receive Vitamin C at 5:00 PM. On this evening, R31 received it at 9:34 PM. There were multiple evenings afterwards in which staff administered it late (8/13/2025, 8/15/2025 - 8/17/2025, 8/20/2025, 8/21/2025, 8/23/2025 - 8/25/2025).R31's ‘Medication Admin Audit Report' also documents in August, R31 had Donepezil Hydrochloride and Haloperidol scheduled at 9:00 PM. On 08/07/2025, R31 received the medications at 10:22 PM. On 8/20/2025, R31 received them at 11:14 PM. R31's ‘Medication Admin Audit Report' documents on 8/26/2025, R31's 5:00 PM medications were now Vitamin C and Haloperidol. On this evening, R31 received them late at 8:01 PM. R31 also received them late on 8/27/2025 - 8/29/2025, 9/02/2025 - 9/04/2025, and 9/06/2025 with the latest one being at 8:45 PM on 8/29/2025. On 9/10/2025 at 11:23 AM, V2 (Director of Nursing) stated V24 (outside Social Worker) spoke with facility staff at the end of August to report R31 had complained about late or missing evening medications. V2 stated with some of the new nurses such as V13 and V25, it's possible medications were given late, since the residents were new to them. V2 stated all nurses were in-serviced on medication timeliness to make sure medications are administered within one hour before or one hour after the scheduled time. Facility's ‘Medication Administration Policy' (8/15) documents: Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145765 If continuation sheet Page 2 of 4 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 145765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Rehab Center 5888 North Ridge Chicago, IL 60660 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 ensure a medication error rate of less than 5%. This affected five (R1, R11, R30, R107, R110) out of nine residents during medication administration task. The facility had six errors out of 25 opportunities, resulting in a 24% medication error rate.Findings include:1.R107's ‘Order Summary Report' and ‘Medication Administration Record' document in part: RisperDAL Oral Tablet (Risperidone) Give 1.25 mg by mouth in the morning related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE.On 9/09/2025 at 9:52 AM, V6 (Nurse) prepared R107's medications. V6 read R107's Medication Administration Record (MAR) on the laptop. V6 stated R107 was scheduled to receive Risperidone (Risperdal) 1.25 MG (Milligram) every morning. V6 pulled out two different unit-dose blister packs/bingo cards for R107's Risperidone. One blister pack read Risperidone Tab 3 MG take 1/2 tablet (1.5 MG) by mouth at bedtime. Each individual slot contained half tablets (1.5 MG dosing). The other blister pack read Risperidone tab 0.25 MG with instructions to take 1 tablet by mouth daily - give [with] 1 MG (total dose = 1.25 MG). V6 popped out two half tablets from the first blister pack (1.5 MG + 1.5 MG = 3 MG) and one 0.25 MG tablet from the other blister pack (totaling 3.25 MG of Risperidone). V6 popped the three tablets into the medicine cup with all the other morning medications for R107. V6 put away the rest of the medications and started cleaning up the medication cart. V6 stated V6 will administer the medications to R107. V6 was asked to review R107's orders and Risperidone blister packs. After reviewing the order, V6 removed a Risperidone 1/2 tablet (1.5 MG). The total in the cup was now 1.75 MG (1.5 MG + 0.25 MG). At a9:58 AM, V2 (Director of Nursing) was near the nurses' station. V2 motioned for V3 (Infection Preventionist) to assist. V3 instructed V6 to hold Risperidone until V2 and V6 obtained the correct dosage from the electronic medication dispensing system. 2.R11's ‘Order Summary Report' and ‘Medication Administration Record (MAR)' documents: Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 25 mg by mouth one time a day for [Hypertension] related to ESSENTIAL (PRIMARY) HYPERTENSION. There were no parameters to hold the medication.R11's ‘Care Plan Report' documentsR11 is at risk for elevated blood pressure related to hypertension (last revised 1/22/2025). Interventions include to administer medications as ordered by the doctor (initiated 1/22/2025). On 9/09/2025 at 10:20 AM, V6 prepared R11's medications. One of the medications included Metoprolol Succinate ER (Extended Release) 25 MG (blood pressure medicine) and Lamotrigine 200 MG (given for anxiety). At 10:29 AM, V6 went into R11's room and checked R11's blood pressure via an electronic blood pressure machine to R11's right wrist. V2 (Director of Nursing), who was standing at the doorway, stated there was no parameters for the blood pressure medicine. V2 stated it was okay for V6 to administer the Metoprolol. R11's blood pressure was 98/63, with a heart rate of 85 beats per minute. At 10:32 AM, V6 stated V6 will not administer the Metoprolol to R11 because the blood pressure was low. V6 stated, It's for hypertension [high blood pressure] and I don't want [R11] to bottom out. V6 stated V6 will put in a progress note to read that it did not apply. R11 took the other morning medications at 10:32 AM. At 10:37 AM, V6 stated R11's morning medication pass was complete and proceeded to administer medications to other residents. V6 did not call to inform R11's physician about not administering Metoprolol.R11's MAR documents V6 charted ‘9' under the 9/09/2025 9:00 AM dose meaning Other / See Nurse Notes. R11's orders and MAR also document: LamoTRIgine Oral Tablet 200 MG (Lamotrigine) Give 1 tablet by mouth every 12 hours for antianxiety. The MAR documents it was due at 9:00 AM. V6 administered the medication at 10:32 AM. R11's progress note, dated 9/9/2025, 10:34 AM reads dna hypotension (low blood pressure). V6 stated ‘dna' stood for ‘did not apply.'On 9/09/2025 at 10:41 AM, V4 (Physician) stated no one called to inform V4 about R11's blood pressure or holding the morning dose of Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145765 If continuation sheet Page 3 of 4 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 145765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Rehab Center 5888 North Ridge Chicago, IL 60660 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Metoprolol. V4 stated the nurses need to inform V4 when they are holding or not administering a medication because it is a complicated decision. V4 stated V4 will need to trend R11's blood pressures, heart rates, and symptoms in the last three to four days prior to deciding whether to hold the Metoprolol Succinate ER or change it. When asked about R107's Risperidone, V4 stated it ‘definitely' would not be good if the nurse increased the dosage and administered more than what was ordered. V4 stated R107 would have increased sedation and systemic slowing.3.R1's ‘Order Summary Report' documents Sucralfate Oral Suspension 1 GM (Gram)/10 ML (Sucralfate) Give 10 ml by mouth three times a day related to GASTROINTESTINAL HEMORRHAGE.R1's ‘Care Plan Report' documents R1 has gastritis and duodenitis (initiated 9/05/2025). Intervention initiated on 9/05/2025 documents in part to administer medications per physician orders. On 9/10/2025 at 12:03 PM, V13 (Nurse) prepared R1's noon medications. One of the medications was Sucralfate 100 MG / ML (milliliter) oral suspension. V13 stated the order was for 1 gram / 10 ML of Sucralfate. V13 held a medication cup in the air and poured the medication into the medicine cup. The medication when held in the air was at the 10 ML mark; however, when V13 placed the medicine cup on top of the medication cart, the medicine cup read 15 ML. At 12:10 PM, V13 went into the room and told R1 which medications V13 had prepared. V13 was asked to review Sucralfate medicine cup on a flat, stable surface. V13 took out 5 ML and administered 10 ML to R1. 3.On 9/10/2025 at 12:19 PM, V13 prepared medications for R110. V13 did not locate R110's blister pack for Hydroxyzine in the medication cart or medication room. V13 stated V13 administered the last pill from the blister pack in the morning. V13 reordered it from pharmacy via the electronic medical record. V13 then went to R110's room. V13 informed R110 the Hydroxyzine was not in the medicine cup, but V13 had reordered it from pharmacy. V13 informed R110 that pharmacy will deliver it in the evening and R110 will get it during the evening dose. V13 checked 9 in the MAR, and stated V13 will let the oncoming nurse know the medication was not there, but it was reordered. V13 stated R110's medication pass was complete and proceeded to prepare another resident's medications. V13 did not inform R110's physician the medication was not available. 4.R30's ‘Order Audit Report' documents: Simethicone Tablet 80 MG Give 2 tablet by mouth three times a day for bloating, give with meals.On 9/10/2025 at 12:32 PM, V13 prepared R30's noon medications. Reading off the MAR on the computer, V13 stated R30 was scheduled to get two Simethicone 80 mg chewable tablets. V13 stated it was a house stock medicine and pulled a bottle of Simethicone on the top right drawer of the medication cart. V13 stated there were two pills left in the bottle, which was exactly how many R30 needed. The bottle read Simethicone 125 MG tablets. V13 was notified of the dosage difference. V13 stated V13 did not notice the dosage difference. V13 searched the medication cart, medication room, and facility stock on the other floors. At 1:12 PM, V13 stated the facility did not have Simethicone 80 MG in the building. V13 stated V13 did administer two pills from the same bottle during morning administration. V13 stated V13did not know the dosage was different. On 9/10/2025 at 11:37 AM, V2 (Director of Nursing) stated the nurses are to administer medications based on the doctors' orders. V2 stated residents' rights with medications include the right patient, right medication, right dosage, right route, and right time. V2 stated nurses have one hour before and one hour after the scheduled time to administer the medications. V2 stated the nurses should reorder medications when they are running low so that there is ample medications and no issues with administration. V2 stated the pharmacy can deliver medications when needed as long as the nurses reorder them. V2 also stated if a nurse holds or does not administer a medication, the nurse is supposed to inform the physician. Facility's ‘Medication Administration Policy' (8/15) documents: Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. Event ID: Facility ID: 145765 If continuation sheet Page 4 of 4