Health inspection·June 28, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R7's care plan includes interventions for functional status and fall risk includes keep call light in reach at all times. Facility Call Light policy dated 5/17/24 state's objective: to respond to resident's request and needs. Procedure: answer call light in a prompt, calm, and courteous manner. Respond to request, it item is not available or request questionable, get assistance from the nurse. Return to resident with prompt reply. Event ID: Facility ID: 145879 If continuation sheet Page 2 of 7 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed the facility failed to provide assistance to a dependent resident wanting to change position into a sitting position. This affected one of three residents (R7) reviewed for staff assistance with activities of daily living. This failure resulted in R7 not receiving any assistance for 17 minutes. Residents Affected - Few Findings include: R7 diagnoses include but are not limited to adjustment disorder with mixed Anxiety and Depression Mood, and Spinal Stenosis. R7's cognitive assessment dated [DATE] notes a score of 15, cognitively intact. On 6/21/24 at 1:40PM observation of R7's call light on. Surveyor remained in view of the light. At 1:48PM the surveyor approached R7 and asked what help he needs. R7 was observed sitting with legs and feet out of the bed and torso and back laying back on the bed. R7 stated he wants to get into his wheelchair and is waiting for assistance to sit up. V21, CNA, observed walking in the hall near R7's room and did not answer the light. V22, Laundry, observed walking in the hall near R7's room and did not answer the light. At 1:57PM R7 light answered. During the time the call light was activated, V31, LPN was sitting at the nurses' station where the beep from the light is audible. On 6/26/24 at 11:45AM V27, CNA, stated R7 needs assistance with everything. V27 stated R7 needs help turning, sitting up, getting up, and changing. V27 stated R7 can stand and pivot with one person assist. V27 stated R7 can call when he wants assistance. On 6/25/24 at 2:19PM V4, Social Services, stated R7 is disabled. V4 stated I encourage R7 to call the facility or use the call light for assistance. V4 stated if R7 uses the call light they should answer it. On 6/25/24 at 2:36PM V12, Director of Nursing, stated call lights should be answered when you hear them. V12 stated call lights should be answered within 3-5 minutes. R7's Functional Abilities and Goals assessment dated [DATE] documents R7 has limitations in upper and lower extremities. R7 requires substantial to maximal assistance for toileting, bathing, upper body dressing, hygiene, and sitting up. According to the assessment R7 is not independent with any of his activities of daily living. R7's care plan includes interventions for functional status and fall risk includes keep call light in reach at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 3 of 7 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide, evaluate, and reevaluate the effectiveness of the motorized wheelchair safety/training/education to reduce the risk of injuries for one resident. This affected one of one resident (R1) reviewed for safe use of the motorized wheelchair. This failure resulted in R1 having multiple accidents attempting to maneuver the wheel motorized wheelchair. R1 sustained a fractured toe, and a laceration to the leg requiring 6 sutures. Findings include: On 6/18/24 at 11:11am R1 observed sitting in motorized wheelchair, R1 escorted to room for interview and observation assisted by V16 Licensed Practical Nurse (LPN). R1 observed alert with confusion. R1 observed to have healing scar to left lower leg. R1 was not able to recall what happened to her leg. R1 stated her toes were broken when the door hit her foot, R1 stated she was on her way out the room when the door hit her foot. R1 stated her feet were not on the footrest, (R1 demonstrated that her feet were on the floor when the door hit her foot). R1 stated she did go to the hospital. R1 wheelchair was observed to have a metal footrest. R1 was asked if the facility showed her where her feet should rest on the wheelchair when using the chair. R1 denied getting education. R1 observed with difficulty using the control arm on wheelchair, R1 not able to efficiently back up wheelchair and use control arm to turn wheelchair. V17 (certified nursing aide) assisted R1 with maneuvering wheelchair. Facility final investigation to the State Department dated 4/9/24 denotes in-part reportable event occurred 4/3/24. R1 expressed pain in the right foot while sitting in wheelchair. NP (Nurse practitioner) in-house physician notified. She states she opened a door and the door closed on her foot in her room. R1 is a [AGE] year-old resident with DX (diagnosis) of osteoarthritis, COPD (chronic obstructive pulmonary disease), osteoporosis with hx (history) of pathological fracture of vertebrae, myalgia. R1 uses a wheelchair for mobility. Per R1 interview, she states that her room door closed on her foot. Upon complaint of foot pain, R1 was assessed by nursing staff and contacted the nurse practitioner. The nurse practitioner gave orders to send R1 to the emergency room. Imaging was completed on her right foot, which showed a metatarsal fx (fracture). R1 returned from emergency room with a CAM boot and orders to see orthopedic specialist. Due to R1's DX of osteoarthritis, osteoporosis, R1 sustained metatarsal fracture. Pain assessment was done and monitored. Care plan updated. Facility final report to the State Department dated 4/25/24 denotes in-part, resident notified NOD (nurse on duty) of hitting her left leg on the bed. Observed open area on left lower leg. Resident stated she wants to go to the hospital. NP (Nurse Practitioner) and sent to ER (emergency room) for treatment and eval. Resident returned to facility with sutures and dressing on left leg. Investigation initiated. Upon investigation it was discovered that the root cause of the accident was that R1 was not proficient in her ability to navigate her wheelchair. R1 is to be assessed by the wheelchair company and the speed on her wheelchair will be lowered. R1 was also educated on how to safely use he electric wheelchair. R1 skin integrity event dated 4/23/24 denotes in-part type of injury -laceration, left lower leg, moderate depth, open area, blood and redness at the site, activity during skin tear/ laceration occurrencelocomotion, walking/ wheel in wheelchair. Taken to emergency room for hitting leg under the bed rail using motorized wheelchair. Resident reported that she hit her leg on the bed in her room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 4 of 7 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 - Actual harm Residents Affected - Few trying to backup with the electric wheelchair. Writer noted blooding running down the resident leg. Writer clean and compressed the left chin until bleeding stopped, covered with bandage, resident states that she wants to go to the hospital. Head to toe assessment completed, no c/o pain, discomfort at this time. NP and R1 daughter informed. Phone called hospital, spoke with Nurse. Ambulance states will pick up resident within 45 minutes. Resident returned to this facility from emergency room on stretcher with new orders, no related to event noted. Received sutures and 1 week appointment for wound re-check. No c/o pain or discomfort at this time. Will continue to monitor. On 6/20/24 at 11:36am V12 (Director of Nursing) said R1 received training/ education on use of motorized wheelchair. 6/20/24 V12 presents a document titled motorized wheelchair evaluation form-IL only dated 3/8/24, description motorized wheelchair training/ observation. Additional observation info, education given and understanding, acknowledged to seek assistance as needed, training by the wheelchair man, successful with nurse present, signed by V3 (Director of Rehab). There were no description of what training or education that was provided to R1. On 6/20/24 at 1:00pm V12 (Director of Nursing) presents another document titled Medical prior authorization request form and seating mobility evaluation stating, and Power mobility devices and custom manual wheelchairs physician form. V12 stated this is the education that was provided to R1 from the wheelchair company. Review of the documents presented by V12, the medical prior authorization request form and seating mobility evaluation, and power mobility devices and custom manual wheelchairs physician form there is no documentation denoting there was education provided to R1. There is no documentation denoting what education was provided to R1. 6/20/24 at 2:07pm V12 (Director of Nursing) was asked if there was any education/ training provided to R1 after R1 fractured her toes on the door. V12 was asked how did R1 fracture her toes when the foot plate is very large on the wheelchair, V12 was asked about the placement of R1's foot/ toes, if they were off the footrest when the door hit R1 foot/toes. V12 was asked was R1 educated on positioning of feet/toes when using wheelchair. V12 did not respond. V12 did not respond when asked if the facility provided R1 with any training on safe use of wheelchair after the two incidents where R1 sustained injuries. V12 was asked how's the facility reducing the risk of injuries for R1 when using the motorized wheelchair, V12 replied the wheelchair man provided R1 with education on use of wheelchair). V12 made aware that there were no documentation denoting any training provided to R1 in that packet that was presented to surveyor. On 6/21/24 at 9:49am V3 (Director of Rehab) stated the wheelchair man provided R1 with education on the use of the motorized wheelchair, V3 stated the education is in the packet that was presented to the surveyor. V3 stated the documents, in the packet that was presented to the surveyor yesterday the medical prior authorization request form and seating mobility evaluation was the education that was provided to R1 from the wheelchair company was the motorized wheelchair training. V3 stated the motorized wheelchair was new for R1. V3 stated R1 received the motorized wheelchair on 3/8/24. V3 was asked how's the facility reducing the risk of injuries for R1 when using the motorized wheelchair, V3 replied the wheelchair man provided R1 with education on use of wheelchair). V3 was asked what (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 5 of 7 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 the wheelchair man taught R1, V3 did not respond. Level of Harm - Actual harm R1 progress note dated 4/2/24 denotes in-part received patient on AM shift in bed. CNA informed writer that resident c/o (complaints of) pain to R (right) Foot. Writer assessed R1 and discoloration was noted. Writer informed NP (Nurse practitioner). NP assessed R1 in house during rounds. Awaits new orders. Residents Affected - Few R1 progress notes dated 4/3/24 denotes in-part resident returned to facility via Superior ambulance x (times) 2 attendants via stretcher, alert and responsive. No s/s of apparent pain. Resident DX (diagnosis) with Metatarsal fracture to right foot with new orders to d/c (discharge) current Norco dosage to increased Norco 10-325 mg per tablet. Follow up appt. with foot and ankle specialist within the next week or so. R1 progress notes dated 4/23/24 denotes in-part resident reported that she hit her leg on the bed in her room trying to backup with the electric wheelchair. Writer noted blood running down the resident leg. Writer clean and compressed the left chin with until bleeding stopped, covered with bandage, Resident states that she wanted to go to the hospital. Head to toe assessment completed, no c/o pain, discomfort at this time. NP (Nurse Practitioner) and (daughter) informed. Phone call to hospital, spoken to nurse. (Ambulance company name) ambulance states will pick-up resident within 45 minutes. R1 care plan dated 4.1.24 denotes in-part R1 currently has motorized related to COPD, R1 will use wheelchair throughout the facility as trained. R1 will safely maneuver throughout the facility. R1 care plan developed 26 days after receiving the motorized wheelchair. R1 emergency room records dated 4/23/24 denotes in-part patient reports to ER with c/o (complaints of) laceration of left lower leg. Chief complaint [AGE] year-old female arrives to the ED (emergency department) with EMS (emergency medical services) for left leg injury. Patient was driving motorized scooter for the first time and ran onto a wall. Patient has bruising and laceration to left lower leg. Denies hitting head/falling off, and LOC (loss of continuousness). Denies any other complaints or injuries at this time. Exam denotes in-part laceration left lower leg, 2 cm (centimeters), skin repair nylon 6 sutures. Clinical impression laceration of left leg, contusion of left leg. During this survey the facility failed to present education/ training provided to R1 related to the safe use of motorized wheelchair on or prior to 3/8/24, facility failed to present education/ training provided to R1 related to the use of motorized wheelchair after R1 hit toes on door when using wheelchair, facility failed to present education/training provided to R1 related to the use of motorized wheelchair after R1 hit leg on bed frame sustaining injury when using wheelchair. Facility failed to present any education provided to R1 related to preventing/ minimizing injures when using motorized wheelchair. Facility care plan policy with last update of 10/2022 denotes in-part an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. The facility care planning team develops and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may expect to attain. Each resident comprehensive care plan has been designed to incorporate risk factors associated with identified problems. Aide in preventing or reducing declines in the resident functional status and functional level. Care plans are revised as changes in the resident's condition dictates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 6 of 7 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 145879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-State Village Nrsg & Rhb 2500 East 175th Street Lansing, IL 60438 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 R1 referred to occupational therapy on 5/2/24. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 7 of 7