Inspection·November 20, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few demonstrate how she wrapped the sheet around R1. V2 demonstrated for surveyor. V2 put the sheet around her upper body/waist, tied the sheet at the upper body area, leaving the lower part of the sheet to be open freely. V2 was shown the picture presented to surveyor. V2 said R1 should not be wrapped in the sheets like that, it a was a restraint. V2 said the sheet should not be tied around R1 legs. V2 said R1 has a right to move freely. V2 explained the facility has removed the rails off their beds because they don't use restraints. V2 described when the bed rails are in the up position it's considered a restraint (if the resident is not assessed for bed rails use and approved). V2 was made aware surveyor observed bed rails in the up position on R1 bed. V2 said R1 should not have the bed rails in the up position. V2 explained R1's bed was provided by the hospice company but staff knows how to put the bed rails in the down position and they should put the bed rails in the down position. V2 said R1 has down syndrome and has dementia. V2 explained R1 is a fall risk, R1 has boosters on her mattress for fall prevention intervention and R1 bed should be in a low position. V2 made aware R1 bed was not in the low position when observed by the surveyor at 8:45am. On 10.18.23 at 10:49am V6 (Hospice Aide) said she is the hospice aide was assigned to R1 care on 10.27.23. V6 said she visited R1 on 10.27.23 and observed R1 to be cradled in a bedsheet from upper body down to legs and at the legs the sheet was tied. R1 did not appear to be in distress at time. V6 said she had to literally unwrap R1 body from the sheets. V6 said she called her supervisor at the hospice company to inform them. V6 said she did not mention this to facility because she didn't know how to manage the situation with the facility. V6 said she took picture to show her supervisor. V6 said she untied R1 and provided care to R1. V6 said she did not see any bruises on R1. V6 said the facility has asked her not to return because she expressed concerns about the clients she was assigned to at the facility. On 11.18.23 at 10:49am V1 (case manager hospice company) said it was reported to her by V6 that V6 observed R1's legs tied up in a sheet on 10.27.23. V1 said the hospice company had a previous episode with R1 being restrained at the facility in April 2023. V1 said she asked V6 not to talk to the facility and she would inform the facility. V1 said she informed V3 on 10.27.23 of the issue and she showed V3 the photo image also. On 11.18.23 at 11:18am V3 (Administrator) V3 said it was reported to her on 10.27.23 by V1 that R1 was observed with the bed sheet tied around her legs. V3 said V1 showed V3 the picture of R1 but V3 couldn't recall what V3 observed in the picture because the angle was not clear. V3 said she interviewed staff and V4 reported that V4 wrapped R1 up in a sheet. At 2:15pm V3 was showed the photo of R1 wrapped in a bed sheet and the sheet was tied around R1 legs. V3 said the sheet should not be tied around R1 legs. V3 said the facility does not use restraints. Review of the photo presented by V1 shows a resident observed, resident has a ring on (R1 observed wearing ring on 11.18.23), the white bed sheet is around the resident body tightly, the sheet comes down to the legs and at the legs the sheet is tied. Facility concern form dated 10.27.23 denotes in-part, R1 name, report taken by V3, concern- hospice CNA stating resident's sheet is wrapped too tightly around her legs. Summary of pertinent findings- not substantiated, staff positioned sheet around legs so they would stay on comfortable. V4 notice of corrective action form dated 10.27.23 denotes in-part on 10.27.23, the employee stated during an investigation she wrapped a blanket around a resident in order to keep the blanket on. Those could be considered a restraint and all restraints must be approved by the IDT (interdisciplinary team). Using a restraint without approval is against the policy of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145839 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 145839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068 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 0604 Level of Harm - Minimal harm or potential for actual harm Facility records of in-service dated 5/18-5/23/23, topic- restraint free facility, side rails, summary of the presentation denotes: no side rails without orders, anything is attached to resident body and prevents them from free movement is a restraint. V4 name is noted on in-service report. R1 physician order sheet for the month of October 2023, does not reflect any order for use of restraints. Residents Affected - Few Review of R1 care plan presented by V3 as the most recent plan, target date of 02.24.23, 20 pages, there is not a plan of care denoting the use of restraints for R1, there is not plan of care denoting to tie bed sheets around R1 legs, there is no care plan denoting to cradle R1 inside a bed sheet because she touches her adult brief. Facility policy titled restraints with revision date on 4.24.18 denotes in part to ensure each resident is to attain and maintain his/her practicable well-being in an environment prohibits the use of restraints for discipline or convivence and limits restraint use to circumstance in which the resident has medical symptom warrant the use of restraints. Definitions: physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident body the individual cannot remove easily which restricts freedom of movement to normal access to one body. Physical restraints may include but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vest, lap cushions, and lap trays the resident cannot remove easily. The resident right for the people living in long term care denotes your facility must treat you with dignity and respect and must care for you in a manner promotes your quality of life. You have a right to be free from physical or chemical restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145839 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 145839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Ridge Healthcare Center 665 Busse Highway Park Ridge, IL 60068 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to follow their abuse prevention policy and report and allegation of abuse of using a physical restraint to the department for 1 of 1 resident (R1) for 22 days. Residents Affected - Few Findings include: R1 face sheet R1 has diagnosis of down syndrome, major depressive disorder, and anxiety. On 11.18.23 at 11:18am V3 (Administrator) said V3 did not report the allegation of the sheets being tied around R1's legs to the department because V1 (case manager of hospice company) said she did not think it was done with ill intent. V3 said it was reported to V3 on 10.27.23 by V1 that R1 was observed with the bed sheet tied around her legs. V3 said V1 showed V3 the picture of R1 but V3 couldn't recall what V3 observed in the picture because the angle was not clear. V3 said she interviewed staff and V4 reported that V4 wrapped R1 up in a sheet. At 2:15pm V3 was showed the photo of R1 wrapped in a bed sheet and the sheet was tied around R1 legs. V3 said the sheet should not be tied around R1 legs. V3 said the facility does not use restraints. V3 presented initial report to department on 11.18.23 for physical abuse, denoting in-part it was reported to her (V3) that R1's blanket was secured around her (R1) legs. Facility policy tiled abuse prevention and reporting with last revision date 10.24.22 denotes in-part, external reporting, when allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident representative and department of public health regional office shall be informed by telephone or fax. Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property has been reported and is being investigated. If there is reasonable suspicion that a crime has been committed that is not listed above and does not involve serious bodily injury, then a report to local law enforcement and department of public health as soon as possible but within 24 hours of when the suspicion was formed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145839 If continuation sheet Page 4 of 4