Inspection·August 31, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 8/28/23 at 10:59 am, R136 was observed on Low Air Loss Mattress (LALM) with setting at 270 pounds. Again at 11:45 am, the LALM was still at the same setting of 270 pounds. R136's weight records show that R136 weighs only 90.8 pounds. Residents Affected - Some R136's care plan dated 5/10/23 states that R136 is a [AGE] year-old resident with potential for impairment to skin integrity related to multiple diagnoses. R136's Physician Order Sheet dated 2/14/23 states Low Air Loss Mattress for prevention and treatment of pressure injury. R136's pressure ulcer risk assessment dated [DATE] states that R136 had a score of 12 (high risk for pressure ulcer). Latest assessment dated [DATE] had a score of 13 (moderate risk). On 8/30/23 at 11:55 am, V11 (Wound Care Coordinator) was asked about the importance of correct weight settings for LALM in pressure ulcer prevention. V11 stated that the mattress should be at the correct weight settings. 2. R30 has a diagnosis of but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Benign Neoplasm of Cerebral Meninges, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Chronic Embolism and Thrombosis of unspecified Vein and Chronic Obstructive Pulmonary Disease with Acute Exacerbation. R30's Brief Interview for Mental Status is 07 that indicates Moderately impaired. On 8/28/2023 at 10:55 am, surveyor observed R30's low air loss mattress set at about 120lbs. On 8/29/2023 at 2:31 pm, surveyor reviewed R30's weights and vitals in PCC (Point Click Care Software) and R30's weight is 127.6lbs as of 8/04/2023. On 8/30/2023 at about 12:30 pm, R30's low air loss mattress was set at about 120lbs. R30's Order Listing Report with active orders as of 8/30/2023 documents, in part, LAL (Low Air Loss) pressure alternating mattress for offloading. R30's care plan focus for actual impairment to skin integrity dated 1/29/2023 documents, in part, alternating low air loss mattress in use. 3. R94 has a diagnosis of but not limited to Alzheimer's Disease, Major Depressive Disorder, Malignant Neoplasm of Colon, Type 2 Diabetes, and Protein-Calorie Malnutrition. R94's Brief Interview for Mental Status is 99 that indicates the individual chooses not to participate, or 4 or more items were coded 0 because the individual chose not to answer or gave a nonsensical response. On 8/28/2023 at 11:31 am, surveyor observed R94's low air loss mattress set at about 120lbs. On 8/29/2023 at 2:31 pm, surveyor reviewed R94's weights and vitals in PCC (Point Click Care Software) and R94's weight is 88.2lbs as of 8/4/2023. On 8/30/2023 at about 12:30 pm, R94's low air loss mattress was set at about 238lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0686 Level of Harm - Minimal harm or potential for actual harm R94's care plan focus for potential impairment to skin integrity date 3/30/2023 documents, in part, LAL (Low Air Loss) mattress for treatment and prevention of pressure injury. R94's Order Listing Report with active orders as of 8/30/2023 documents, in part, LAL (Low Air Loss) Mattress for treatment and prevention of pressure injury. Residents Affected - Some On 8/30/2023 at 12:39 pm, V11 (Wound Care Coordinator) stated the wound care staff initially do the settings for the low air loss mattresses and stated that the low air loss mattress should be set for comfort and the weight of the resident. Stated if the setting is high, based on the resident's weight, you are putting more pressure on the wound and if the setting is too low it would not provide enough support for the resident. Basedonobservations interviews andrecordreviews thefacilityfailedtoensure that thelowairlossmattressissetonthe appropriatesettingfor4 residents(R0, R2, R4, andR36) reviewedforpressureulcerpreventioninthetotalsampleof57 residents Findingsinclude 1. On08/28/23 10:34 AM R2 waslyingonalowairlossmattresswithasettingbelow80lbs ThisobservationwaspointedouttoV4 (CertifiedNursingAssistant. V4 statedsettingisbelow80 andnormalpressure On08/28/23 10:53 AM V1 (WoundCareCoordinator statedI(V1) amcheckingthesettingofthelowairlossmattresses I(V1) startedatthe4thfloorgoingdownto2ndfloor V1 checkedR2'sweightonthesheetofpaperV1 washoldingontherequestofthesurveyorandstatedshe(R2) weighs157lbs V1 thencheckedR2'ssettingoflowairlossmattressandstateditsbelow80lbs Thesupportsurfaceismuchsofter thelowairlossmattressisnotusedtothefullextent On08/30/2023 at12:45 pm V11 statedifthe residentweighs157 pounds thesettingofthelowairlossmattressshouldnotbebelow80lbs Itistoolow Thelowairlossmattressdoesnotprovideenoughsupporttotheresidentandmaycontributetoimpairedskinintegrity itmaycauseaskinbreakdown R2's(ActiveOrderAsOf 08/29/2023) OrderSummaryReportdocumented inpartDiagnoses (includebutnotlimitedto hypertension seniledegenerationofbrain andencounterforpalliativecare R2's(03/08/2021) BradenScaleforPredictingPressureSoreRiskdocumentedthatR2 scored16. IndicatingR2 wasatriskfordevelopingpressuresore R2's(08/29/2023) PreventiveInterventionsWorksheetdocumentedthatR2'sBradenscorewas15. Atriskfordevelopingpressuresore R2's(undated WeightsandVitalsExceptiondocumentedthaton08/15/2023, R2 weighed157.0lbs R2's(08/15/2023) MinimumDataSetdocumented inpartSectionC CognitivePatterns C500. BIMS(BriefInterviewforMentalStatus SummaryScore 'noentry. C700. ShorttermmemoryOK 1. Memoryproblem C800. LongtermmemoryOK 1. Memoryproblem SectionM SkinConditions M150. RiskofPressureUlcersInjuries Yes M200. SkinandUlcer InjuryTreatments B Pressurereducingdeviceforbed The(undated 8 AlternatingPressure& LowAirLossMattressSystemwithFoamBaseUserManualdocumented inpartIntendedUse Thepumpandmattressareintendedtohelpreducetheincidenceofpressureulcerswhileoptimizingpatientcomfort PressureAdjustKnobadjustablebypatientsweight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0686 Level of Harm - Minimal harm or potential for actual harm Turnthepressureadjustknobtosetacomfortablepressurelevelbyusingtheweightscaleasaguide OperatingInstruction 9. TurnthePressureAdjustKnobtosetacomfortablepressurelevelusingtheweightscaleasaguide Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to label and date oxygen tubing per the facility policy. This failure affected one resident (R90) reviewed for oxygen equipment, in a total sample of 57 residents. Residents Affected - Few Findings include: On 08/29/23 at 10:30 am, surveyor observed R90 in bed awake and alert. R90 was observed with 2 liters oxygen via nasal cannula with tubing in place unlabeled and not dated. When R90 was asked regarding R90's nasal cannula oxygen tubing, R90 stated, You would do better by asking the nurse when the oxygen tubing was last changed, I really do not pay attention when the nurse comes in to change the oxygen tubing. On 08/29/23 at 10:43 am, V17 (LPN/Licensed Practical Nurse) stated I don't see a label dated with a date that the oxygen tubing was changed. V17 stated the nurse should put a label on the oxygen tubing indicating the date the tubing was changed. V17 stated placing a date on the oxygen tubing avoids the tubing being in place too long and the resident getting an infection. V17 stated the nurse is responsible for changing the oxygen tubing every week or as needed. V17 stated the change of the oxygen tubing is usually done every Sunday on the 11pm-7am shift. On 08/30/2023 at 2:12 pm, V2 (DON/Director of Nursing) stated the nurses are responsible for changing the oxygen tubing. V2 stated the oxygen tubing should be changed every Sunday, at least weekly on the 11pm to 7am shift. V2 stated the nurses should label the oxygen tubing with a date on a label indicating the date the oxygen tubing was changed. V2 stated the oxygen tubing is labeled for infection control purposes and as a reminder for the nursing staff to change the oxygen tubing every seven days. R90's Face Sheet documents that R90 has the following diagnosis that include, but are not limited to, acute kidney failure, unspecified, cognitive communication deficit, cardiomegaly, chronic kidney disease, stage 3 unspecified, acute on chronic systolic (congestive) heart failure, constipation, unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, hydroureter, obstructive and reflux uropathy, unspecified, muscle wasting and atrophy, not elsewhere classified, unspecified site, difficulty in walking, not elsewhere classified, unspecified hydronephrosis, retention of urine, unspecified, ileus, unspecified, hypo-osmolality and hyponatremia, hyperkalemia, dehydration, other specified abnormalities of plasma proteins, repeated falls, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, type 2 diabetes mellitus with other specified complication, chronic viral hepatitis b without delta-agent, unspecified mental disorder due to known physiological condition, personal history of colonic polyps, other fatigue, other chest pain, presence of aortocoronary bypass graft, pure hypercholesterolemia, unspecified, essential (primary) hypertension, dermatitis, unspecified, tinea pedis, unspecified osteoarthritis, unspecified site, carpal tunnel syndrome, right upper limb, hyperlipidemia, unspecified. R90's Brief Interview for Mental Status (BIMS) dated 08/18/23 documents that R90 has a BIMS score of 12, which indicates that R90's cognition is moderately impaired. R90's MDS (Minimum Data Set) Section O. dated 08/18/2023 documents, in part, 00100. Special Treatments, Procedures, and Programs, Respiratory Treatments C. Oxygen Therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0695 Level of Harm - Minimal harm or potential for actual harm R90's Physician Order Summary Report dated 08/30/23 documents, in part, Oxygen (O2) at 2L(liters)/min(minute) every shift for hypoxia. R90's Physician Order Summary Report dated 08/30/23 documents, in part, change oxygen tubing/bubblers weekly and PRN (as needed) every night shift every Sunday. Residents Affected - Few The facility's policy dated 08/08/2016 titled Oxygen Therapy and Administration documents, in part, underneath Procedure: Date your equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change, failed to document dispensing of controlled medication, and failed to follow pharmacy instruction to refrigerate medications. These failures affected 4 residents (R27, R110, R140, and R141) reviewed for pharmacy services and records and have the potential to affect all 44 residents on 2nd floor Team 2 and 3rd floor Team 3. Findings include: The (08/31/2023) email correspondence with V1 (Administrator) documented that 2nd floor Team 2 include residents in rooms 214, 215-2, 217-229; and 3rd floor Team 3 include residents in rooms 303, 305, 306-312. The (08/28/2023) Daily Census documented that there were 27 residents in 2nd floor Team 2 and 17 residents in 3rd floor Team 3. On 08/29/2023 at 12:01 pm, on 3rd floor, during the medication storage and labeling task of the medication cart labeled as Team 3, surveyor along with V19 (Registered Nurse) observed that R141's Morphine Sul (sulfate) Tab 30 mg ER (extended release) Individual Controlled Substance Record indicated that there were 12 tablets left in the controlled cart. V19 (Registered Nurse) stated there were 11 tablets left in R141's dispensing card. I (V19) have not signed out yet the one I (V19) gave this morning. I (V19) am supposed to sign after I (V19) gave the medication. On 08/29/2023 at 12:33 pm, on 2nd floor, during the medication storage and labeling task of Team 2 medication cart along with V21 (Registered Nurse), surveyor observed R27's, R110's, and R140's Dronabinol's dispensing cards kept in the controlled medication box, and not in the refrigerator. R27's, R110's, and R140's Dronabinol's Controlled Drug Administration Record Tablet sheets had instruction to Refrigerate. V21 stated I (V21) kept these in the med cart this morning when (V21) counted the controlled medications with the outgoing nurse. The (08/2023) Controlled Substance Check Form on 2nd Floor Team 2 has missing signatures on day 3, 11-7 shift, Nurse On; day 4, 7-3 shift, Nurse Off and 11-7 shift, Nurse On; day 5, 7-3 shift, Nurse OFF, and 11-7 shift, Nurse On; day 6 7-3 shift, Nurse OFF; day 11, 11-7 shift, Nurse On; day 21, 7-3 shift, Nurse OFF; day 26 11-7 shift, Nurse On; day 27, 7-3 shift, Nurse OFF. The (08/2023) Controlled Substance Check Form in 3rd Floor has missing signatures on day 10, 11-7 shift, Nurse On; day 25, 11-7 shift, Nurse On; day 26, 11-7 shift, Nurse OFF. On 08/30/2023 at 12:00 pm, V2 (Director of Nursing) stated there should be a count of the controlled medications during the shift change between the incoming and outgoing nurses. The two nurses should sign after they counted the medications. These are controlled medication, there is a proper counting of controlled medications. It is part of regulation, to get accurate count of the controlled medication. Staff are expected to sign immediately after counting. On 08/30/2023 at 12:03 pm, V2 stated that immediately after they have dispensed the controlled medication, the staff is expected to document that the controlled medication is dispensed from the controlled by signing it off. For proper accounting of controlled medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 08/30/2023 at 12:12 pm, V2 stated if the pharmacy recommendation is to refrigerate the medication, then the medication should be refrigerated. To maintain the potency of the medication and to keep the consistency of the medication. Dronabinol gel could get soft. The expectation is to follow the pharmacy recommendation. R27's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) multiple sclerosis. Order Summary. Dronabinol Capsule 5mg give 5mg by mouth two times a day. R27's (Date Received: 08/15/23) Controlled Drug Administration Record Tablet documented, in part Dronabinol 5mg cap. Refrigerate. R110's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) heart failure, hypertension, and protein calorie malnutrition. Order summary. Dronabinol Capsule 2.5mg give 1 capsule by mouth one time a day. R110's (date received: 8/3/23) Controlled Drug Administration Record Tablet documented, in part Dronabinol 2.5mg cap. Refrigerate. R140's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) wedge compression fracture, hypertension, and spinal stenosis. Order Summary. Dronabinol Oral capsule 2.5mg give 2 capsule(s) by mouth one time a day. R140's (Date Received: 8/22/23) Controlled Drug Administration Record Tablet documented, in part Dronabinol 2.5mg cap. Refrigerate. R141's (Active Order As Of: 08/29/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) malignant neoplasm of lymph node, palliative care, and hypertension. Order Summary. Morphine Sulfate tablet 15mg. Give 2 tablets every 12 hours for severe pain. R141's (Schedule date: 08/29/2023 - 08/29/2023) Medication Admin (Administration) Audit Report documented, in part Order Summary. Morphine Sulfate Tablet 15MG Give 2 tablets by mouth every 12 hours. Schedule date. 08/29/2023 09:00 (9am). Administration Time. 08/29/2023 09:18 (9:18am). Doc'd (documented) by V19 (RN). R141's (Date Received: 8/10/23) Individual Controlled Substance Record for Morphine Sul (Sulfate) Tab 30MG ER documented that the last entry was on 'Date' 8/28, 'Time' 9pm, 'Amount Remaining' 12. The (7/2023) Controlled Medications Count policy and procedure documented, in part Policy Statement. It is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. Procedure. 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign of the accompanying controlled medication sheet indicating the medication is taken. The (08/2020) Storage of Controlled Substance policy and procedure documented, in part Policy. Medications classified by the Drug Enforcement Administration (DEA) as controlled substance are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures. 3. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. 5. Unless otherwise (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0755 Level of Harm - Minimal harm or potential for actual harm indicated in a facility policy and/or as required by state regulations, the following will be performed: a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented. 7. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and documented on a control count sheet (or similar form) or in accordance with facility policy and state regulation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure medication vials are contained in original packaging for 1 resident (R142), failed to discard expired flu vaccine, failed to check the temperature of vaccine refrigerator at a minimum of two times daily, and failed to ensure the refrigerator was within the required temperature. These failures have the potential to affect all the residents on 3rd floor. Findings include: On [DATE] at 11:48 am, on 3rd floor, during the medication storage and labeling task of the medication cart labeled as Team 3 along with V19 (Registered Nurse), surveyor observed 4 cyclosporin eye drop vials in the first drawer without labels and not contained in original packaging. This was pointed out to V19. V19 stated those are for (R142); they are not in original packaging. V19 opened the bottom drawer of the medication cart and showed this surveyor the original packaging of the cyclosporin eye drop vials. The original packaging had R142's identifier and inside the box were foil containers where the cyclosporin vials were stored. V19 stated these (referring to the cyclosporin vials not in original packaging) should be in original packaging to prevent contamination and to prevent giving to another resident because these are not labeled. On [DATE] at 12:13 pm, on 3rd floor during the medication storage and labeling task with V20 (Registered Nurse) of the 3rd floor medication storage room, surveyor observed that the medication refrigerator had 8 vials of pneumococcal vaccine polyvalent 23, 6 prefilled syringe pneumococcal 13-valent conjugate vaccines, and 1 prefilled syringe influenza Vaccine with expiration date of 2023-Apr-30. On [DATE] at 12:20 pm, the thermometer inside the medication refrigerator registered the temperature at 30F. V20 stated the temperature is not within the range. The purpose of keeping the medication refrigerator within the temperature range is to make sure the medications are still viable and effective. On [DATE] at 12:22 pm, surveyor inquired how often the facility checked the medication refrigerator temperature. V20 stated we check the temperature once a day by the night shift nurse. On [DATE] at 12:05 pm, V2 (Director of Nursing) stated the expectation is for the nurse to check the temperature of the refrigerator twice daily, if there are vaccines. The importance is to make sure the temperature is maintained during storage. To maintain the potency and effectiveness of the vaccines. It is not expected to store expired vaccines because it may be given to the resident. On [DATE] at 12:08 pm, V2 stated refrigerator temperature should be between 36F to 46F per manufacturing guideline. Thirty degrees Fahrenheit is too cold. It can affect the potency of the vaccines and medications. On [DATE] at 12:17 pm, V2 stated medications should be kept in original packaging because the identifier of the resident and the instruction on how to give the medication is in the original packaging. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 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 145775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Healthcare & Rehab Ctr 3919 West Foster Avenue Chicago, IL 60625 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R142's (Active Order As Of: [DATE]) Order Summary Report documented, in part Diagnoses: (include but not limited to) primary hypertension, osteoarthritis, and shortness of breath. Order Summary. Cyclosporine emulsion 0.05% instill 1 drop in both eyes every morning and at bedtime. The (08/2023) Daily Temperature Log in 3rd floor Nurses Station indicated the refrigerator temperature was checked once nightly. Refrigerator Temperature Range low- 34 degrees (F). High - 42 degrees (F). The (undated) Temperature Monitoring Best Practices for Refrigerated Vaccines-Fahrenheit (F) documented, in part 1. Store vaccines at ideal temperature: 40F. Within range 36F to 46F. 2. Record daily temperatures. 3steps daily: 1. Note: if your device does not display min (minimum)/max (maximum) temperatures, then check and record current temperature a minimum of 2 times (at start and end of workday). The (08-2020) Storage of Medications policy and procedure documented, in part Policy. Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. I. Procedures. 1. The provider pharmacy dispenses medications in containers that meet regulatory requirement, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. 3. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. 8. Outdated medications are immediately removed from inventory, disposed of according to procedures for medication disposal. II. Temperature. 1. All medications are maintained within the temperature ranges noticed in the USP and by the Centers for Disease Control (CDC). c. Refrigerated: 36F to 46F with a thermometer to allow temperature monitoring. 2. Medications and biologicals are stored at their appropriate temperature and humidity according to the USP guideline for temperature ranges. 3. Medications requiring refrigeration are kept in a refrigerator at temperature between 36F and 46F. 7. The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC Guidelines. III. Expiration Dating (Beyond-use dating). 8. All expired medication will be removed from the active supply and destroyed in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145775 If continuation sheet Page 11 of 11