Inspection·January 21, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many of the situation. V2 stated that V2 made rounds on all the residents when V2 arrived. V2 stated that V2 asked the CNAs if residents were okay during the night. V2 stated that V2 in-serviced all staff present that if anything out of norm happens to call V2 immediately. V2 stated that this in-service is on-going. V2 stated that V16 and V17 called off or were no shows to work on 12/31/24. V2 stated that it is important for diabetic residents to have blood glucose levels monitored and insulin administered if needed. V2 stated that medication prescribed to be given before breakfast is because the medication is absorbed better on empty stomach. V2 stated that medications should be administered as ordered. V2 acknowledged that all residents' have a pain assessment that needs to be documented on by the nurse every shift. V2 stated that V2 notified the residents' physicians and completed a medication error details report for each resident on 1/1/25 regarding medications not administered on 12/31/24 11:00PM-7:00AM shift. V2 showed this surveyor the text message she received on her phone. It notes at 6:04AM, V2 sent a text message to V1 that V2 was on her way to facility now. R5's MAR notes to monitor and record vital signs once a day on the 11:00PM - 7:00AM shift. It also notes pain scale/evaluation every shift. There is no documentation noting R5's vital signs or pain assessment were performed. R6's MAR notes to monitor anti-psychotic medication use every shift. It also notes to assist R6 to elevate head of bed to prevent shortness of breath when lying flat due to COPD (chronic obstructive pulmonary disease), document oxygen saturation level. It also notes pain scale/evaluation every shift. On 01/01/25 at 9:25AM, V4 documented these assessments were performed on the previous shift. R7's MAR notes blood glucose monitoring three times a day (6:00AM, 11:00AM, and 4:00PM). Notify physician if blood glucose level is below 60 or above 300. Head of bed to be elevated to prevent shortness of breath due to bronchitis, document oxygen saturation level every shift. Administer short acting insulin per sliding scale three times a day. It also notes pain scale/evaluation every shift. On 01/01/25 at 9:28AM, V4 documented the above were done on the previous shift. R8's MAR notes budesonide-formoterol aerosol inhaler, 80-4.5 mcg (micrograms)/actuation, administer two puffs daily at 6:00AM and 6:00PM. Indwelling catheter, monitor output every shift. Head of bed to be elevated to prevent shortness of breath due to diagnosis of COPD, document oxygen saturation level. Levothyroxine 100mcg, administer one tablet once a day at 6:00AM. Monitor temperature, pulse, and respirations and record every shift. Pain scale/evaluation every shift. Pantoprazole 40mg (milligrams), administer one tablet daily at 6:00AM. Peripheral intravenous catheter, assessment every shift and as needed, document and notify physician of any abnormalities. There is no documentation noting the above were administered or assessed. R9's MAR notes levothyroxine 25mcg, administer one tablet once a morning at 6:00AM. On 01/01/25 at 12:31PM, R9 was administered this medication by V8. Pain scale/evaluation every shift. R9's pain was assessed by V8 on 01/01/25 at 1:39PM. R10's MAR notes levothyroxine 50mcg, administer one tablet once a morning at 6:00AM. On 01/01/25 at 1:39PM, PD was administered this medication by V8. R11's MAR notes fast acting insulin per sliding scale three times a day (6:00AM, 11:00AM, and 9:00PM). If blood glucose level is less than 60 or greater than 300, notify physician. R11's blood glucose level documentation on 01/01/25 notes the same level as documented on 12/31/24 at 9:00PM. Pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 2 of 6 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many scale/evaluation every shift. On 01/01/25 at 12:38pm, R11's night shift pain assessment was documented by V8. R12's MAR notes one liter fluid restriction daily, monitor every shift. On 01/01/25 at 10:07AM, R12's night shift documentation was done by V8. Indwelling catheter, monitor output every shift. On 01/01/25 at 12:36PM, R12's 12/31/24 night shift documentation was done by V8. Pain scale/evaluation every shift. On 01/01/25 at 12:36PM, R12's 12/31/24 night shift documentation was done by V8. R13's MAR notes blood glucose monitoring twice a day (6:00AM and 5:00PM). Notify physician if blood glucose level is below 60 or above 400. Fast acting insulin, administer 5 units subcutaneously once a day at 6:00AM. On 01/01/25 at 1:30PM, V8 documented R13 refused to have 6:00AM blood glucose level checked and insulin administered. Pain scale/evaluation every shift. On 01/01/25 at 1:30PM, V8 documented R13's night shift pain assessment was 0 out of 10. R14's MAR notes Novolin regular insulin 5 units subcutaneously three times a day (6:00AM, 11:00AM, and 5:00PM). On 01/01/25 at 12:28PM, V8 documented R14's 6:00AM dose of insulin was administered. Pain scale/evaluation every shift. On 01/01 at 12:28PM, V8 documented R14's night shift pain assessment was 0 out of 10. R15's MAR notes blood glucose monitoring three times a day (6:00AM, 11:00AM, and 5:00PM). R15's documented blood glucose level on 01/01/25 notes the same level as documented on 12/31/24 at 5:00PM. Fast acting insulin per sliding scale. Pain scale/evaluation every shift. On 01/01/25 at 2:34PM, V8 documented R15's night shift pain assessment was 0 out of 10. R16's MAR notes blood glucose monitoring three four a day (6:00AM, 11:00AM, 4:00PM, and 5:00PM). R16's documented blood glucose level on 01/01/25 notes the same level as documented on 12/31/24 at 9:00PM. Fast acting insulin per sliding scale. V8 documented R16 was administered 8:00AM at 12:03PM. Levothyroxine 100mcg, administer one tablet once a day at 6:00AM. Pantoprazole 40mg, administer one tablet once a day at 6:00AM. On 01/01/25 at 12:03PM, R16 was administered these medications by V8. Pain scale/evaluation every shift. On 01/01 at 2:34PM, V8 documented R16's night shift pain assessment was 0 out of 10. V6's timecard notes V6 clocked out at 1:59AM. The facility's staffing sheet notes V6 LPN, V16 LPN, and V17 LPN were scheduled to work 12/31 at 11:00PM until 1/1 at 7:00AM. V16 and V17's timecards do not note that they were in the facility on 12/31 as scheduled. V2 presented a medication error detailed report for each resident residing in this facility on 12/31/24 noting medication not administered on 12/31 11:00PM-7:00AM shift. This facility's staffing policy, dated 11/2017, notes our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services and provide supervision to CNAs. This facility's department duty hours, nursing services policy, dated 8/2008, notes nursing service is provided 24 hours per day, seven days per week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 3 of 6 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 0725 The facility assessment for staffing notes that licensed nurses providing direct care on the night shift is one RN and 3 LPNs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 4 of 6 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to follow its medication administration policy and consistently monitor the effectiveness of pain medication and accurately document the administration of controlled substances for four of residents (R3, R17, R18, and R19) out of four reviewed for receiving high alert medications in a sample of 19. Residents Affected - Some Findings include: On 1/16/25 at 11:45AM, V7 (nurse) stated that the nurse is expected to sign out in the resident's MAR (medication administration record) and controlled substance sheet when a high alert medication is administered. V7 stated that if a pain medication is administered, the nurse is expected to follow-up with resident regarding the medication's effectiveness. On 1/17/25 at 11:00AM, V2 DON (director of nursing) stated that the nurse is expected to make sure all high alert medications are signed out on resident's controlled substance sheet and MAR. V2 stated that the nurse is expected to follow up with the resident every time an as needed medication is administered to monitor the medication's effectiveness. V2 stated that the nurse is expected to document in the resident's MAR at the time the medication is administered to the resident. 1. R3: R3's MAR, dated 12/21/24-1/16/25, notes hydrocodone-acetaminophen 5-325mg oral three times a day as needed for pain. R3 received this medication on 12/24/24 at 9:46PM; 12/27/24 at 8:41AM; 12/31/24 at 11:23AM; 1/6/25 at 9:22PM; 1/7/25 at 9:56AM; 1/8/25 at 8:31PM; 1/10/25 at 8:26PM; 1/11/25 at 9:00AM; 1/13/25 at 1:01PM and 8:20PM; 1/15/25 at 8:17PM; and 1/16/25 at 9:20AM. R3's controlled substance sheet for hydrocodone-acetaminophen 5-325mg notes this medication was signed out on 12/21/24 at 9:00AM and 9:00PM; 12/22/24 at 9:00AM and 9:00PM; 12/24/24 at 9:00AM and 9:00PM; 12/25/24 at 9:00AM and 9:00PM; 12/26/24 at 9:00AM and 9:00PM; 12/27/24 at 9:00AM and 9:00PM; 12/31/24 at 9:00AM and 9:00PM; 1/1/25 at 9:00AM and 9:00PM; 1/2/25 at 9:00AM and 9:00PM; 1/3/25 at 9:00AM and 9:00PM; 1/4/25 at 9:00AM, 3:00PM, and 10:00PM; 1/5/25 at 9:00AM and 9:00PM; 1/6/25 at 9:00AM and 9:00PM; 1/7/25 at 9:00AM and 9:00PM; 1/8/25 at 9:00AM and 9:00PM; 1/9/25 at 9:00AM and 9:00PM; 1/10/25 at 9:00AM and 9:00PM; 1/11/25 at 9:00AM and 9:00PM; 1/12/25 at 9:00AM and 9:00PM; 1/13/25 at 9:00AM; and 1/14/25 at 9:00AM and 9:00PM. 2. R17: R17's MAR (medication administration record), dated 12/21/24-1/16/25, notes hydrocodone-acetaminophen 10-325mg (milligrams) oral every 4 hours as needed for pain. This medication was administered and documented on 12/23/24 at 10:33AM; 12/26/24 at 10:25AM and 8:43PM; 12/31/24 at 9:08AM; 1/2/25 at 2:16AM; 1/3/25 at 7:29PM; 1/4/25 at 7:29AM; 1/5/25 at 10:43AM; 1/6/25 at 8:29AM and 6:36PM; 1/7/25 at 6:00AM; 1/8/25 at 6:00AM; 1/10/25 at 9:38PM; 1/13/25 at 8:31PM; and 1/16/25 at 9:48AM. R17's controlled substance sheet for hydrocodone-acetaminophen 10-325mg notes this medication was signed out on 12/21/24 at 9:00AM and 6:00PM; 12/22/24 at 9:00AM and 6:00PM; 12/23/24 at 9:00AM and 6:00PM; 12/24/24 at 9:00AM and 6:00PM; 12/25/24 at 9:00AM and 6:00PM; 12/26/24 at 9:00AM and 9:00PM; 12/27/24 at 9:00AM and 6:00PM; 12/28/24 at 9:00AM and 6:00PM; 12/29/24 at 9:00AM; 12/30/24 at 1:00AM, 9:00AM, and 6:00PM; 12/31/24 at 9:00AM; 1/11/25 at 9:00AM and 9:00PM; 1/12/25 at 9:00AM and 6:00PM; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 5 of 6 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 145798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Nursing & Rehab Ctr 1635 East 154th Street Dolton, IL 60419 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 0760 1/13/25 at 9:00AM, 6:00PM, and 11:30PM; 1/14/25 at 9:00AM and 5:00PM; and 1/15/25 at 9:00AM. Level of Harm - Minimal harm or potential for actual harm 3. R18: Residents Affected - Some R18's MAR, dated 12/21/24-1/16/25, notes hydrocodone-acetaminophen 10-325mg oral twice a day as needed for pain. This medication was administered and documented on 12/31/24 at 12:46AM; 1/2/25 at 10:05AM; 1/3/25 at 8:57PM; and 1/7/25 at 9:19PM. R18's controlled substance sheet for hydrocodone-acetaminophen 5-325mg notes this medication was signed out on 12/27/24 at 10:50AM and an illegible time; 12/28/24, 12/29/24, and 12/30/24 4 tablets were signed out but no time is noted; 12/30/24 at 11:30PM; 12/31/24 at 10:00AM and 9:00PM; 1/1/25 at 9:00AM and 9:00PM; 1/2/25 at 9:00AM and 9:00PM; 1/3/25 at 9:00AM and 9:00PM; 1/4/25 at 9:00AM and 7:00PM; 1/5/25 at 9:00AM and 9:00PM; 1/6/25 at 10:00AM and 9:00PM; 1/7/25 at 10:00AM and 9:00PM; 1/8/25 at 10:00AM and 6:00PM; 1/9/25 at 9:00AM and 9:00PM; 1/10/25 at 9:00AM and 9:00PM; 1/11/25 at 10:00AM and 6:00PM; 1/12/25 at 10:00AM and 6:00PM; 1/13/25 at 10:00AM and 9:00PM; 1/14/25 at 9:00AM and 9:00PM; 1/15/25 at 9:00AM and 9:00PM; and 1/16/25 at 10:00AM. 4. R19: R19's MAR, dated 1/5/25-1/16/25, notes hydrocodone-acetaminophen 5-325mg oral every 6 hours as needed for pain. This medication was administered and documented on 1/12/25 at 5:32AM and 1/16/25 at 10:30AM. R19's controlled substance sheet for hydrocodone-acetaminophen 5-325mg notes this medication was signed out on 1/5/25 at 7:00PM; 1/6/25 at 7:00AM and 6:00PM; 1/7/25 at 5:30AM and 6:00PM; 1/8/25 at 6:00AM and 6:00PM; 1/9/25 at 9:00AM and 6:00PM; 1/10/25 at 9:00AM and 6:00PM; 1/11/25 at 10:00AM and 6:00PM; 1/12/25 at 5:30AM and 6:00PM; 1/13/25 at 6:00AM and 6:00PM; 1/14/25 at 5:00AM and 6:00PM; 1/15/25 at 9:00PM; and 1/16/25 at 10:50AM. The facility's medication administration policy, dated 3/2022, notes only authorized personnel are permitted access to the drug storage areas, medication room and/or cart. The same licensed nurse who prepares the medications shall also administer those medications to residents for whom they were ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145798 If continuation sheet Page 6 of 6