Health inspection·April 30, 2025

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 interviews and records reviewed the facility failed to offer showers for two (R60 and R5) of four residents in a sample of 72 reviewed for ADL assistance. Residents Affected - Few The findings include: On 4/28/25 at 1:53PM the surveyor checked the 2 facility shower rooms. South hall shower room had dry floor. The shower faucet was dry. The surveyor then checked the East/West shared shower room, upon entering the room, there was a foul odor and the bath tub was full of dead, winged, bugs. The shower area floor was dry and the shower head was dry. No drops of water were seen in the only two showers of the facility. On 4/28/25 at 2:02PM V8, Restorative Nurse, toured the south shower room with the surveyor. The floor was wet, but a housekeeper was in the room and said he just wet it. V8 said it's wet because I just wet it, it was dry. V8 and surveyor then checked East/West shower. V8 said I would not want to shower in here, there is a smell. V8 said it does not appear this shower was used, it is dry. V8 said she has worked in nursing home for years. V8 said I have not heard of a facility not using a shower on a Monday on day shift. On 4/29/25 at 2:42PM V13, Scheduler, said shower books were found, yesterday. V13 said I don't see that the staff is documenting if a bed bath or shower was given on the shower records. On 4/28/25 at 1:43PM V18, CNA, reported she gave showers in the morning around 7:00AM. V18 said she gave R7 and R6 a shower. Both R7 and R6 are cognitively impaired and unable to answer if they received a shower.) On 4/28/25 at 1:47PM V19, CNA, said she gave only bed baths today. V said I have not used the shower room on this unit (East/West) since last week. V said we have shower books but I have not been able to find them. On 4/28/25 at 1:51PM V6, CNA, said I only gave bed baths, I could not find the shower book today. On 4/28/25 at 1:50PM V4, LPN, said we have shower books, but we have not been able to find it today. .On 04/29/25 at 11:38 AM R5 said they haven't given me a shower, I haven't had a shower in . I don't know how long. R5 said I would take a shower if it was offered, they don't offer them. V5 said I'm supposed to have a shower on Tuesdays and Thursdays. I am given bed baths, but not offered a shower. On 4/30/25 at 1:38PM V19, CNA said R5 needs all the help from staff to shower. Shower sheets for April reviewed for R5. R5 is listed as Mon & Thurs shower. The sheet is not completed to identify if a shower was given. R5 MDS dated [DATE] section C identifies BIMS of15, cognitively intact. Section GG for shower/bathe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 2 of 22 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 04/30/2025 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 states requires substantial to maximal assistance. Level of Harm - Minimal harm or potential for actual harm R5 MDS dated [DATE] section C identifies BIMS of15, cognitively intact. Section GG for shower/bathe states requires substantial to maximal assistance. Residents Affected - Few No progress note or care plan was provided for R5 refusing showers. b.On 04/29/25 at 09:30 AM R60 said I haven't had a shower, except once this month. R60 said I am supposed to get one today. R60 said I would like to take a shower weekly.R60 said I have not been offered a shower. R60 said it is on my mind everyday, to wonder if today will be the day I get a shower. R60 said I get bed or sink baths, but not showers. On 4/30/25 at 1:38PM V19, CNA said R60 is dependent on staff to assist her to get into the shower chair safely for showers. Shower sheets for April reviewed for R60 has showers listed on Mondays and Thursdays. The sheet does not identify if shower given. The facility Bath/Shower Policy dated 2/2024 states to be completed for all residents at least twice weekly based on facility bathing schedule. Procedure: minimally twice a week resident will receive shower/bath. If resident refuses shower, CNA will notify nurse and will provide interventions or education of the proposed care or treatment. Documentation in clinical records. The care plan will be updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 3 of 22 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 04/30/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to transcribe and initiate a verbal order by not ordering an ultra sound as requested by the nurse practitioner for one of one residents (R30) review for quality of care in a sample of 72. Residents Affected - Few Finding Includes: R30's brief interview for mental status dated 4/22/25 documents a score of fifteen which indicates cognitively intact. Nurse Practitioner progress note dated 4/25/25 documents: infected cyst to right side of neck: Assessment and Plan: Local infection of skin and subcutaneous infection - R30 has a sebaceous cyst but it was noted today that cyst is reddened and swollen. Progress Note dated 4/25/25 documents: Writer (V11) notified by staff member of large bump on patients neck. Writer went to assess and observed large abscess on right side of patient's neck. Assess is tender to touch and painful. Patient describes pain level at a 5 when assess is touched. NP made aware, N/O (new order) for antibiotics and ultrasound of neck. On 4/27/25 at 1:13pm, R30 was observed with a golf ball size lump with a white circular area the size of a green pea located towards the bottom of the lump on the right lateral neck. R30 who was assessed to be alert and orient to person, place and time, said she was supposed to have an ultrasound but no one has come yet. On 04/29/25 11:16am, R30 said, she had not had the ultrasound yet. R30 said bump on her neck burst this morning, liquid was everywhere. V12 (treatment nurse) change the dressing. On 4/29/25 at 10:21am, V9 (radiology personnel) said, when there is an order for an ultrasound/test the nurse at the facility would called radiology to give information about the needed test, inform radiology of the verbal order via the phone and a tech will go to the facility and complete the test on the same day or the next day. V9 said, he did not have an order for R30 for an ultra sound of the neck. V9 said, the last order was in March for an ultrasound of the abdomen. On 4/29/25 at 10:27am, V11 (nurse) said, she ordered R30's ultra sound on Friday (4/25/25) to be completed on Monday (4/28/25). V11 said, she does not recall complete the medical imaging form but she wrote the progress note dated 4/25/25. V11 said, she did not see the order for R30 ultra sound of the neck in R30's electronic record. R30's physician order sheet and order history dated 3/25-4/25 did not document an order for April 2025 for an ultra sound of the neck. On 4/9/25 at 10:37AM, V10 (nursing supervisor) said, when an order is completed it will be listed under order history. V10 said, she did not see an order for R30 to have an ultrasound of the neck. Progress note dated 4/29/25 documents: R30 was admitted to the hospital for right neck abscess. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 4 of 22 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 04/30/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow their dressing policy by not providing an as needed dressing after who was diagnosis with a stage 4 sacral pressure ulcer after having an episode of diarrhea. This affected one of three residents (R11) reviewed for dressing changes. Residents Affected - Few Findings Include: R11 had the diagnosis of stage 4 sacral pressure ulcer. Physician orders sheet dated 3/30/25- 4/30/25 documents: Site-Coccyx: cleanse wound with wound cleanser. Apply calcium alginate to wound bed, apply bed skin prep to peri-wound cover with dry dressing daily and as needed (prn) if loose or soiled. On 4/28/25 at 12:33pm, during a body assessment with V4 (nurse), R11 was observed with a large amount of watery stool in her incontinence brief. V4 cleaned R11. R11 sacrum wound was observed without a dressing. R11 said, who was assessed to be alert and oriented to person, place and time said, V5 (treatment nurse) changed her dressing in the morning but she has had multiple episode of diarrhea and the dressing was removed with the last episode. V6 (cna) said, provided incontinence for R11 at 11:30am. V6 said, R11 had an episode of diarrhea and her sacrum dressing was soiled. V6 said, she removed the dressing and could not find V5 to reply the dressing. V4 (nurse) said, was not aware R11 did not have a dressing in place or that R11 needed one. V4 said, if a dressing is soiled during incontinence care, the wound should be cleaned and the dressing/treatment should be replaced. V4 said, V5 is no left for the day. On 4/30/25 at 3:54pm, V25 (nurse consultant) said, she expect the cna to informed the nurse and the nurse to reapply the dressing/treatment as prescribed. Dressing non-steile (aseptic) policy no date documents: Apply prescribe ointment and/or dressing per physician treatment order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 5 of 22 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 04/30/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility staff failed to ensure one resident who has a diagnosis of dementia with a history of falling, was safely positioned in bed before turning away from the resident while providing direct resident care. This affected one of one resident (R7) reviewed for safety while providing care. This failure resulted in R7 sustaining a fall from the bed to the floor with facial swelling and being transported to the hospital for one of two reviewed for falls. Findings include: R7 was admitted to the facility on [DATE] with a diagnosis of dementia, major depressive disorder, age related osteoporosis, glaucoma and history of falling. R7's brief interview for mental status score dated 2/19/25 documents a score of 3/15 which indicates cognitively impaired. R7 fall event dated 12/17/24 documents: R7 fall in the dining room unwitnessed, R was sleeping in the chair prior to falling. R7's fall event dated 4/19/25 documents: fall in R7's room. R7 was lying in bed with the aide preparing to reposition her. R7's fall was witnessed. Noted left eye lid and cheek swelling. R7's progress note dated 4/19/25 documents: The assigned aide reported to the writer that as dinner was being brought to the resident she was noted to be lying across the bed. That as she prepared the area to reposition the resident, turning her back towards her to remove clutter, the resident slipped to the floor on her face. Although the bed was already in a low position, the resident was still noted with a swelling to the left eye brow and cheek around her nose area. On 4/29/25 at 9:46AM, V8(restorative nurse) said R7 had a fall in December with no injury. R7 most recent fall occurred in R7's room. V8 said V33(Certified nursing assistant, CNA) was attempting to reposition R7 for dinner. R7 was laying horizontal in the bed. V8 was preparing area, removing clutter and turned her back to R7. When V33 turned around, R7 fell out of bed onto the floor. V8(restorative nurse) said V33 should have never turned her back to the residents and should have ensured she was safely positioned in bed first. V8 said staff was educated after the incident but unable to provide that documentation. On 4/30/25 at 2:20PM, V29(nurse) said he was the nurse on duty for R7's fall. V29 confirmed that V33(CNA) was present in the room at the time of R7's fall. V29 showed surveyor in R7's room. V29 said V33 reported that R7 was laying horizontally in low bed. V33 said she was getting R7 set up for dinner and when V33 was moving items in the room, she turned her back to R7 who then sustained a fall to the floor. V33 got V29 who observed R7 on the floor. R7's floor mat was not in place because V33 was attempting to set up bedside table for food tray. V29 said R7 had swelling to her face and was sent to the hospital for evaluation. R7's care plan dated 3/4/25 documents R7 is at risk for falls related to injury related to dementia with decreased cognition, poor judgement and decreased safety awareness, impaired balance and other diagnosis such as glaucoma, hypertension, osteoporosis and potential for pain. R7's hospital record dated 4/19/25 documents: R7 has history of dementia and reportedly fell out of bed and hit left side of head. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 6 of 22 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 04/30/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on interviews, observations, and records reviewed the facility failed to identify and evaluate nutrition interventions for one resident. This affected one of one resident R2 reviewed for nutrition in sample of 72. This failure resulted in R2 having a significant unplanned weight loss of 16.7% in 4 months. Residents Affected - Few The findings include: R2 is alert but has diagnosis including but not limited to Dementia, Major Depressive Disorder, Schizoaffect Disorder, Restless and Agitation, and Pseudobulbar Affect. R2 is difficult to understand his words. 04/27/25 10:08 AM R2 observed eating in bed, head of bed elevated, tray table over him, food spilt along left side of chest, leaning towards left in bed. Food cover, milk carton, and food debris on the floor along left side of bed. On 04/28/25 at 12:59 PM R2 in bed, feeds self in bed. R2 said he prefers to stay in his room. On 4/30/25 at 12:17 V26, Dietary Manager, said Restorative department does weights and enters it in the resident records. V26 said I do a review of re-weights. V26 said after the re-weight we notify the Registered Dietician if then they are seen and her recommendations are given to me and then we follow them. V26 said I told them in February that weights were not done. V26 said I told restorative about it. V26 said I noticed in March. V26 said they did not tell me why the weights were missing. V26 said when she completed R2's annual assessments dated 3/18/25related to weight she used the January 2025 weight, because she did not have a current weight to use. V26 said the Policy is for at least monthly weights for all residents. V26 said R2 should have been reweighed to confirm the weight from March. V26 said I do not have reweights for R2. V26 said that is a lot of weight loss for someone. V26 said the purpose of the Nutrition at Risk Observation is to alert us of resident changes and then I am to notify the dietician. V26 said we were not sure when R2's weight loss occurred. The surveyor asked V26 what has been done for R2 to maintain his weight and V26 said I will have to look. As of 3:17PM V26 did not return or provide additional information. On 4/30/25 at 12:26PM V8, Restorative Nurse, said we do weights monthly for all residents, per the policy. V8 said we did not get a weight for R2 in February.V8 said the aid said he refused, but I did not document it, I should have. V8 said we don't have documentation that we tried again. V8 said she looked in her office and did not find anymore weights for R2. On 4/30/25 at 12:54PM V27, Registered Dietician, said the Dietary Manager generally monitors weights, I do 2 visits a month. If there is no weight on my first visit I document and ask about it. V27 said with R2, I caught that he lost 20 pounds, but we were not sure when it occurred. V27 said I asked for reweight on Monday 4/28/25. V27 said I saw him on 4/24/25, last week. V27 said R2's weight loss since January 2025 is 16.7%, this is a significant loss. V27 said I was called and notified on 4/28/25, by phone, that R2 had a weight loss. V27 said every Thursday we have a weight meeting with Dietary Manager. V27 said I was in the facility on 4/10/24 and 4/24/24 and R2 had no weight. V27 said I was told R2 was eating ok. V27 said she doesn't remember if they discussed R2. V27 said we don't have any idea what has caused the weight loss. V27 said we will weigh R2 weekly to make sure he is stable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 7 of 22 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 04/30/2025 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 0692 On 4/30/25 at 2:09PM the surveyor observed as V8 and V20 Restorative Aide, obtained R2's weight utilizing the wheelchair scale. R2's weight is 168.9 pounds. R2 was calm and cooperative for this. Level of Harm - Actual harm Residents Affected - Few R2's weight report documents 12/4/24 204.1 pounds; 1/6/25 202.7 pounds; 3/28/25 184.5 pounds (18.2 pound loss); and 4/28/25 168.8 pounds (another 15.7 pounds). From January to March R2 went 11 weeks without a weight obtained or documentation of him refusing weights. R2 has lost an unplanned 33.9 pounds since January 2025. Review of R2's Nutrition at Risk has weight of 203 pounds and Nutrition Assessment list weight 202.7 pounds, both assessments dated 3/18/25. R2's diet is no concentrated sweets, mechanical soft texture with thin liquids. R2's Physician Order Report includes order dated 4/28/25 for Ensure 8 ounces twice a day between meals. R2's Dietary Progress Notes 4/24/25 state he is 70 inches tall. No weight for February. Unsure when weight loss occurred. No significant changes in care noted. Further weight loss not desired at this time. Recommend reweigh. Noted no April weight complete, will discuss with nursing. Question if resident is refusing weights. Dietary Progress Notes 4/28/25 Resident was reweighed. 168.8 pounds indicating an additional 15 pound loss in 1 month. Weight loss not desired and unplanned. Will have dining readdress food preferences. Add supplement to promote weight maintenance. Weekly weights recommended to monitor closely. These are the only 2 date Dietary has a progress note for R2 since January 2025. R2's Assessment for Swallowing and Nutritional Status list weight 203 pounds and says no weight loss or gain. R2's care plan dated 3/18/25 states he at risk for malnutrition. Goal for R2 states will maintain current weight +/- 3 pounds by next review. All interventions are dated 3/18/25. Facility Nutrition Impaired/ Unplanned Weight Loss Policy dated August 2008 includes assessment and recognition, cause identification, treatment & management, and monitoring. The policy states in part monitor and document the weight and nutritional status of residents in a format which permits readily available month to month comparisons. Assess current nutritional status and identify recent weight loss and risk for impaired nutrition. Consider whether testing is indicted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 8 of 22 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 04/30/2025 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 0725 Level of Harm - Potential for minimal harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interviews and records reviewed the facility failed to provide their designated number of staff to provide resident care. This failure has the potential to affect all 76 residents in the facility. Residents Affected - Many The findings include: On 04/29/25 at 10:40 AM V13, Scheduler, said the minimum CNAs for day shift is 5; the minimum CNAs on evening shift is 4; and 3 CNAs on night shift. V13 said for nurses on the weekend the minimum on day shift is 3; evening shift is 3 nurses; and night shift is 2 nurses. Review of time cards presented for day shift on 4/5/25 and 4/6/25 identify 2 nurses for day shift in the facility (V21 LPN and V22, RN). Night shift on 10/12/24 identifies 1 nurse ( V23, LPN) and on 10/13/24 1 nurse for night shift (V24, LPN) The [NAME] PBJ report for this survey identifies excessively low weekend staffing and 1 star staffing rating for the facility first quarter of 2025. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 9 of 22 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 04/30/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on interviews and records reviewed the facility failed to develop a plan of care to address behavioral health services for one resident after returning from a psychiatric evaluation. This affected one of two residents (R4) reviewed for behavioral services. Findings include: R4's diagnosis include, but are not limited to Spina Bifida, Bipolar Disorder, Current Episode Mixed, Sever With Psychotic Features, Suicidal Ideations, Hereditary Spastic Paraplegia, and Major Depressive Disorder. Progress notes dated 3/13/25 state R4 admitted to hospital with diagnosis of Spinal Bifida with Spastic Paraplegia and Acute Suicidal Ideation. On 04/29/25 at 1:41 PM V7 said Resident # 4 he expressed to the Nurse Practitioner (NP) that he had felt some kind of way. V7 said we sent him out anyway. V 7said I did not submit for a new PASSAR, I probably should have. V7 said upon R4's hospital return, I only did a BIMS and PHQ9. V7 said there is no care plan updated for that behavior; V7 said there should be. 04/29/25 01:37 PM V2, Assistant Director of Nursing, said the NP reported to me that he said something and I went to see R4 and he said it to me, as written, I want to end it all. We called the doctor and got an order to send him out for evaluation. R4's progress notes state on 3/12/25 writer was informed by the NP that R4 was having suicidal ideations. Writer (V2) asked if everything was ok, R4 said No, I want to end it all. R4 denied a plan but said it's just in my head. Orders to send for psych evaluation. R4's hospital records dated 3/12/25 note chief complaint violent behavior. R4 has longstanding history of what appears to be a very poorly controlled diagnosis of bipolar disorder. History and physical states R4 said he suddenly had the thought of going to meet his mom. He had plans of taking something this morning, though he now denies any specific suicide plan. Care plan for R4 dated 11/11/24 states he had an episode of (suicidal attempt, suicidal ideation, self-harm). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 10 of 22 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 04/30/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure they had insulin pen needles for resident's insulin administration for (R5, R28, R54, R55) four of four residents reviewed for pharmaceutical services. Findings include: R5 R5 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with other circulatory complications. R5s physician order sheet dated 9/5/ 24 documents: lantus (glargine) solostar insulin pen. Inject 40 units subcutaneously daily. R5's insulin medication administration record for April documents R5 was administered lantus insulin for the month of April. On 4/29/25 at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R5 had lantus insulin pen with no insulin vials observed. On 4/28/25 at 12:50PM, V31 (Nurse) said he has been working at the facility for the last three weeks and they have not had any pen needles for the insulin pens. V31 said he informed facility staff, but they never received any. V31 said he still is able to give the insulin to the residents by drawing the insulin from the pen insulin reservoir with a sterile syringe. V31 said that is not how you are suppose draw that type of insulin but there was no other way to administrate the medication without the pen needles. On 4/28/25 at 1:44PM , V4(nurse) said they have not had any insulin pen needles for over two months. On 4/30/25 at 2:54PM, V32 (pharmacist) said its not recommended for insulin to be drawn out of insulin pen. There is no harm but its not recommended for administration. Facility medication labeling policy revised11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Pharmacy documents undated titled insulin Humalog/lispro documents: insulin should never be drawn from insulin pen cartridge. R28 R28 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with unspecified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 11 of 22 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 04/30/2025 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 0755 complications. Level of Harm - Minimal harm or potential for actual harm R28's physician order sheet dated 3/20/25: lantus (glargine) insulin pen. Inject 50 units subcutaneously daily. Novolog flexpen sliding scale before meals. If blood sugar less than 60 or greater than 400 call the MD. If blood sugar is 150-200 give four unit, if blood sugar is 201 -250 give six units; 251-300 give eight units; if blood sugar is 301-400 give ten units. Residents Affected - Some R28's insulin medication administration record for April documents R28 received insulin for the month of April. On 4/29/25 at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R28 had novolog aspart insulin pen with no insulin vials observed. On 4/28/25 at 12:50PM, V31 (Nurse) said he has been working at the facility for the last three weeks and they have not had any pen needles for the insulin pens. V31 said he informed facility staff, but they never received any. V31 said he still is able to give the insulin to the residents by drawing the insulin from the pen insulin reservoir with a sterile syringe. V31 said that is not how you are suppose draw that type of insulin but there was no other way to administrate the medication without the pen needles. V31 administered R28's NovoLog flexpen by taking an insulin syringe and drawing the insulin form the NovoLog pen insulin reservoir cartridge. V31 drew up four units of insulin and administered insulin to R28 to left arm. Surveyor observed no insulin pen needle on medication cart. On 4/28/25 at 1:44PM , V4(nurse) said they have not had any insulin pen needles for over two months. On 4/30/25 at 2:54PM, V32 (pharmacist) said its not recommended for insulin to be drawn out of insulin pen. There is no harm but its not recommended for administration. Facility medication labeling policy revised11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Pharmacy documents undated titled insulin Humalog/lispro documents: insulin should never be drawn from insulin pen cartridge. R54 R54 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with hyperglycemia. R54's physician order sheet dated 6/1/24 documents: Humalog [NAME] kwikpen sliding scale before meals and at bedtime. If blood sugar less than 70 or greater than 400 call the MD. If blood sugar is 150-200 give one unit, if blood sugar is 201 -250 give two units; 251-300 give three units; if blood sugar is 301-350 give four units; if blood sugar is 351-400 give five units. R54's insulin medication administration record for April documents R54 required insulin for the month of April. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 12 of 22 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 04/30/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/29/25 at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R54 had Humalog insulin pen with no insulin vials observed On 4/28/25 at 12:50PM, V31 (Nurse) said he has been working at the facility for the last three weeks and they have not had any pen needles for the insulin pens. V31 said he informed facility staff, but they never received any. V31 said he still is able to give the insulin to the residents by drawing the insulin from the pen insulin reservoir with a sterile syringe. V31 said that is not how you are suppose draw that type of insulin but there was no other way to administrate the medication without the pen needles. On 4/28/25 at 1:44PM , V4(nurse) said they have not had any insulin pen needles for over two months. On 4/30/25 at 2:54PM, V32 (pharmacist) said its not recommended for insulin to be drawn out of insulin pen. There is no harm but its not recommended for administration. Facility medication labeling policy revised11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Pharmacy documents undated titled insulin Humalog/lispro documents: insulin should never be drawn from insulin pen cartridge. R55 R55 was admitted to the facility on [DATE] with a diagnosis of type II diabetes. R55's physician order sheet dated 6/1/24 documents: Humalog/lispro kwikpen sliding scale twice a day. If blood sugar less than 60 or greater than 350 call the MD. If blood sugar is 200 -250 give five units; 251-300 give six units; if blood sugar is 301-350 give eight units. R55's insulin medication administration record for April documents R55 required insulin for the month of April. On 4/29/25 at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R55 had lispro insulin pen with no insulin vials observed. On 4/28/25 at 12:50PM, V31 (Nurse) said he has been working at the facility for the last three weeks and they have not had any pen needles for the insulin pens. V31 said he informed facility staff, but they never received any. V31 said he still is able to give the insulin to the residents by drawing the insulin from the pen insulin reservoir with a sterile syringe. V31 said that is not how you are suppose draw that type of insulin but there was no other way to administrate the medication without the pen needles. On 4/28/25 at 1:20PM, facility staff V1 (Administrator), V2(ADON) and V10(nursing supervisor) were unable to show that there were any insulin pen needles in the facility. V11(nurse) and V4(nurse) verified that there were no pen needles on their nursing cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 13 of 22 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 04/30/2025 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 0755 On 4/28/25 at 1:44PM , V4(nurse) said they have not had any insulin pen needles for over two months. Level of Harm - Minimal harm or potential for actual harm On 4/30/25 at 2:54PM, V32 (pharmacist) said its not recommended for insulin to be drawn out of insulin pen. There is no harm but its not recommended for administration. Residents Affected - Some Facility medication labeling policy revised11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Pharmacy documents undated titled insulin Humalog/lispro documents: insulin should never be drawn from insulin pen cartridge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 14 of 22 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 04/30/2025 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 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 observation, interview and record review, the facility failed to follow their medication labeling, Storage of medications and insulin administration policies by not discarding expired insulin and eye drops, ensuring open date and expiration dates were labeled on insulin pens, and ensuring all insulin pens were labeled with residents name for four ( R5, R54, R64, R67) of four residents reviewed for medication storage. Findings include: R5 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with other circulatory complications. R5s physician order sheet dated 9/5/ 24 documents: lantus (glargine) solostar insulin pen. Inject 40 units subcutaneously daily. R5's insulin medication administration record for April documents R5 was administered lantus insulin for the month of April. On [DATE] at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R5 had lantus insulin pen with no insulin vials observed. There was no open or expired dates labeled on the insulin pens. On [DATE] at 9:53AM, V15(pharmacist) said that insulin should be given as ordered. There should be an open date along with an expired date (28-30 days). Insulin is stored in the cart and It can degrade. If expired insulin is administered, it will not be as effective. On [DATE] at 12:20PM, V25(consultant) said all medication carts should be checked daily by nursing staff and nursing manager. Insulin should be labeled with resident name, open date and expired date to ensure insulin is given appropriately. Facility medication labeling policy revised11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Certain medication or package types, such as Intravenous fluids solutions, multiple dose injectable vials, once opened, require an expiration date shorter than the manufacturers expiration date to insure medication purity and potency. When the original seal of a manufacturer container or vial is initially broken, the container or vial will be dated. No expired medication will be administered to a resident. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Under steps in the procedure documents check expiration date, if drawing from an opened multi-dose vial. If opening a new vial record expiration date and time on the vial. R54 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with hyperglycemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 15 of 22 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 04/30/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R54's physician order sheet dated [DATE] documents: Humalog [NAME] kwikpen sliding scale before meals and at bedtime. If blood sugar less than 70 or greater than 400 call the MD. If blood sugar is 150-200 give one unit, if blood sugar is 201 -250 give two units; 251-300 give three units; if blood sugar is 301-350 give four units; if blood sugar is 351-400 give five units. R54's insulin medication administration record for April documents R54 required insulin for the month of April. On [DATE] at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R54 had Humalog insulin pen with no insulin vials observed. There were no open date or expired dates on insulin pen. On [DATE] at 9:53AM, V15(pharmacist) said that insulin should be given as ordered. There should be an open date along with an expired date (28-30 days). Insulin is stored in the cart and it can degrade. If expired insulin is administered, it will not be as effective. On [DATE] at 12:20PM, V25(consultant) said all medication carts should be checked daily by nursing staff and nursing manager. Insulin should be labeled with resident name, open date and expired date to ensure insulin is given appropriately. Facility medication labeling policy revised11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Certain medication or package types, such as Intravenous fluids solutions, multiple dose injectable vials, once opened, require an expiration date shorter than the manufacturers expiration date to insure medication purity and potency. When the original seal of a manufacturer container or vial is initially broken, the container or vial will be dated. No expired medication will be administered to a resident. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Under steps in the procedure documents check expiration date, if drawing from an opened multi-dose vial. If opening a new vial record expiration date and time on the vial. On [DATE] at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that Three insulin pens, (novolog, basaglar, and glargine) were with no label/resident name. All three pens had been opened and used. There was no open date or expired date on any of the three insulin pens. V17 said they should have a label with residents name and be labeled when opened. On [DATE] at 9:53AM, V15(pharmacist) said that insulin should be given as ordered. There should be an open date along with an expired date (28-30 days). Insulin is stored in the cart and it can degrade. If expired insulin is administered, it will not be as effective. On [DATE] at 12:20PM, V25(consultant) said all medication carts should be checked daily by nursing staff and nursing manager. Insulin should be labeled with resident name, open date and expired date to ensure insulin is given appropriately. Facility medication labeling policy revised11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Certain medication or package types, such as Intravenous fluids solutions, multiple dose injectable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 16 of 22 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 04/30/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some vials, once opened, require an expiration date shorter than the manufacturers expiration date to insure medication purity and potency. When the original seal of a manufacturer container or vial is initially broken, the container or vial will be dated. No expired medication will be administered to a resident. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Under steps in the procedure documents check expiration date, if drawing from an opened multi-dose vial. If opening a new vial record expiration date and time on the vial. R64 had the diagnosis of diabetes mellitus. Physician orders sheet dated [DATE]- [DATE] documents: Humalog lispro 100unit/ml: Inject 8 units subcutaneous three time a day (8:00am, 12:00pm and 4:00pm). R67's physician orders sheet dated [DATE]- [DATE] documents: lantanoprost drops 0.005% 1 drop into both eye at bedtime. On [DATE] at 12:23pm, during medication pass with V4 (nurse) on the south unit medication cart, R64 was observed with a used bottle of Humalog Insulin with opened 3/22 and ex (expire) 4/19 written on the box. V4 (nurse) said, Humalog is good for thirty days after being open and must be discarded after thirty days. R67 was observed with used glaucoma eye drops dispensed on [DATE] and 3/20 written on the box. V4 said, the 3/20 is the date R67's eye drops where opened. V4 said, eye drops are good for thirty days after opening and must be discarded after thirty days. On [DATE] at 9:53AM, V15 (pharmacist) said that insulin should be given as ordered. There should be an open date along with an expired date (28-30 days). Insulin is stored in the cart and it can degrade. If expired insulin is administered, it will not be as effective. Facility medication labeling policy revised 11/2021 documents: Medications and biologicals are stored safely, securely and properly, following manufactures recommendations or those of the supplier. Certain medication or package types, such as Intravenous fluids solutions, multiple dose injectable vials, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. When the original seal of a manufacturer container or vial is initially broken, the container or vial will be dated. No expired medication will be administered to a resident. Insulin administration policy revised 4/2007 documents; to provide guidelines for the safe administration of insulin to residents with diabetes. Under steps in the procedure documents check expiration date, if drawing from an opened multi-dose vial. If opening a new vial record expiration date and time on the vial. Storage of Medication Policy dated 1/2024 documents: Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from use; disposed of according to procedure from medication disposal and reordered from the pharmacy, if current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 17 of 22 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 04/30/2025 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 0851 Level of Harm - Potential for minimal harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and records reviewed the facility failed to meet Payroll Based Journal requirements for staffing. This failure has the potential to affect all 76 residents in the facility. Residents Affected - Many The findings include: On 04/29/25 at 10:50 AM V1, Administrator, said corporate submits the Payroll Based Journal for us. The [NAME] PBJ report for this survey identifies excessively low weekend staffing and 1 star staffing rating for the facility first quarter of 2025. On 04/29/25 at 10:50 AM V1, Administrator, said corporate submits the Payroll Based Journal for us. Review of time cards presented for day shift on 4/5/25 and 4/6/25 identify 2 nurses for day shift in the facility (V21 LPN and V22, RN). Night shift on 10/12/24 identifies 1 nurse ( V23, LPN) and on 10/13/24 1 nurse for night shift (V24, LPN) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 18 of 22 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 04/30/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use for one resident. This affectes one of two residents (R28) reviewed for receiving antibiotic. Residents Affected - Few Findings include: On 04/28/25 at 10:32 AM V2, Infection Preventionist, said Urinary Tract Infections (UTI) were trending a couple months ago. V said residents were testing positive for ESBL in the urine, on readmission from the hospital. V2 said nurses will document infection symptoms in the resident's progress notes. V2 said while on antibiotics nurses will document any adverse reactions or symptoms. V2 said nurses should document on the resident while they are on antibiotic therapy. V2 said she completed the IP nurse training and received her certificate. On 4/29/25 at 2:27PM V2 said she reviewed R28's records and there are not enough symptoms documented, based on Mc Geer's criteria to treat R28 for a UTI. V2 said the nurse taking the order and the nurse completing the Infection Tracker should have caught it. V2 said I didn't review it well to catch the lack of symptoms. V2 said the Mc Geer criteria and Infection Tracker are used to prevent overuse of antibiotics. V2 said to treat UTI with antibiotics the criteria includes symptoms such as, burning, itching, positive urine analysis, or fever. V2 said you should know what symptoms R28 had from the assessment. V2 said this (Infection Tractor with Mc Geer's Criteria for R28) does not show the appropriate symptoms for UTI treatment. R28's Infection Tracker with McGeer's Criteria dated 1/5/25 identifies UTI criteria 1 and 2 have no symptoms marked. R28's order dated 12/31/2024 for Cipro 500mg twice a day until 1/7/25. Diagnosis is blank, special instructions list UTI. The facility Antibiotic Stewardship Program Guideline darted 4/29/24 states the purpose of antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance .to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use. the facility will utilize Mc Geer's criteria when considering initiation of antibiotics. Based on interviews and record review the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use for 1 resident (R28) with a UTI in a sample of 2 reviewed for receiving antibiotic. As a result, the potential exists for the resident to develop an adverse drug event or antibiotic resistance. The findings include: On 04/28/25 at 10:32 AM V2, Infection Preventionist, said Urinary Tract Infections (UTI) were trending a couple months ago. V said residents were testing positive for ESBL in the urine, on readmission from the hospital. V2 said nurses will document infection symptoms in the resident's progress notes. V2 said while on antibiotics nurses will document any adverse reactions or symptoms. V2 said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 19 of 22 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 04/30/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses should document on the resident while they are on antibiotic therapy. V2 said she completed the IP nurse training and received her certificate. On 4/29/25 at 2:27PM V2 said she reviewed R28's records and there are not enough symptoms documented, based on Mc Geer's criteria to treat R28 for a UTI. V2 said the nurse taking the order and the nurse completing the Infection Tracker should have caught it. V2 said I didn't review it well to catch the lack of symptoms. V2 said the Mc Geer criteria and Infection Tracker are used to prevent overuse of antibiotics. V2 said to treat UTI with antibiotics the criteria includes symptoms such as, burning, itching, positive urine analysis, or fever. V2 said you should know what symptoms R28 had from the assessment. V2 said this (Infection Tractor with Mc Geer's Criteria for R28) does not show the appropriate symptoms for UTI treatment. R28's Infection Tracker with McGeer's Criteria dated 1/5/25 identifies UTI criteria 1 and 2 have no symptoms marked. R28's order dated 12/31/2024 for Cipro 500mg twice a day until 1/7/25. Diagnosis is blank, special instructions list UTI. The facility Antibiotic Stewardship Program Guideline darted 4/29/24 states the purpose of antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance .to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use. the facility will utilize Mc Geer's criteria when considering initiation of antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 20 of 22 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 04/30/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to ensure shower room water was within normal temperature range between 100 -110 degree (fahrenheit) for one of two shower rooms. This failure has the potential to affect all 52 residents on the shared unit. Findings include: On 4/30/25 at 10:35AM, East/west shower room water temperature was checked with V16(maintenance director). V16 said the thermometer which was an infrared device did not need to be calibrated and was working properly at time of observation. Shower water temperature was temping between 80-82 degrees Fahrenheit. On 4/30/25 at 10:33AM, V16(maintenance director) said they had an issue with hot water tank sometime this month and parts were replaced. V16 said it affected the east/west shower room. V16 denied any current concerns with shower rooms or receiving any concerns related to the shower room temperatures. V16 said the shower temperature was checked this morning with no issue or concern. Facility water temperature log for April 2025 does not document any shower room temperatures taken. Facility daily water temperature policy undated documents it is the policy of this facility that the water temperature be taken each weekday and recorded on the daily water temperature log. Purpose to assure the water temperature in the facility do not exceed 110 degrees or drop below 100 degrees. Facility census dated 4/27/25 on east wing is 24 residents. Facility census dated 4/27/25 on west wing is 28. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 21 of 22 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 04/30/2025 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interviews and records reviewed the facility failed to provide staff with training for dementia care and cognitively impaired residents. This failure has the potential to affect 42 residents with diagnosis of Dementia or Cognitive Impairments in the facility, in a sample of 72 residents. The findings include: The facility presented Dementia & Alzheimer's Caregiving Post Test for 3 CNAs. V18 and V19 test are dated 8/9/23 and V20 is dated 9/28/23. On 4/29/25 at 12:37PM V3, Assistant Administrator, said we don't have any training for the CNAs for 2024 to including Dementia training or Care for Cognitive Impairments. The facility In service Training Program, Nurse Aid, undated, states annual in-service must ensure continuing competence of nurse aides, be no less than 12 hours per employment year, address the special needs of the residents with cognitive impairment. Enhance the skills of the nurse aids in providing care for residents with Dementia. All trainina attendance will be entered on the Employee Trainina Attendance Record. Records shall be filed in the employee's personnel file or shall be maintained by the department supervisor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145879 If continuation sheet Page 22 of 22