Health inspection·November 21, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1 if he was scratching again? R1 said not that he was aware of. V19 wiped R1's palms and back of hands with a disposable wipe. V5 said, Every day we come in and his hearing aids and partial dentures are left sitting on the bedside table, no one puts them in or helps him. R1's nails were not cleaned, and the dark substance was still surrounding his nail beds. On November 15, 2023 at 11:01 AM, V4 (Family Member) and V5 (POA/Power of Attorney) were both in the room visiting at this time. V4 said she visited R1, and when she returned to the facility the next day, R1 was still wearing the same clothes he had on the day before. V4 said she asked the CNA (Certified Nurse Assistant) if someone could get him dressed; V4 said she even pulled clean clothes out of the closet and laid them on the bed. The CNA supervisor came to the room and said she would get the assigned CNA to come help R1. V4 left the facility around at about 4:00 PM that day, and V5 (POA/Power of Attorney) said she arrived at 6:00 PM. V5 said R1 was still wearing the same clothes from the day before, and the clean clothes that were laid by V4 was still on the bed. V5 said the staff have left him in the same undershirt for days, and the way they know is because when they have taken off R1's sweatshirt, there are coffee stains on it, so they know it is not a clean shirt. V5 said, (R1) is supposed to get a shower on Tuesday and Thursday, and this Tuesday he did not get a shower. We had a family member come to visit and they said (R1) smelled, so they went to the desk to see if someone could come help (R1). The family members said no one ever came. V5 said they are concerned with the fact R1 has had a dark substance under his nails, and around the nail beds, and no one has washed or cleaned his hands. On November 20, 2023, at 9:36 AM, V3 (DON/Director of Nursing) said it is his expectation that on a daily basis, the staff check and change a resident every two hour and/or as needed, provide oral care as needed, nail care as needed, and pass waters to the residents. V3 said even if it is not a resident's shower day, the staff still provide oral care and nail care. V3 said, Part of cleaning the resident up or getting ready for the day also includes washing face and hands, arm pits. Residents should not be in same clothes two days in a row, and anytime during the day if a resident's clothes become soiled, the staff should change the resident's clothing. The negative effects of a resident not getting cleaned up regularly would include risk skin breakdown, MASD (Moisture Associated Skin Damage), infection control issues, UTI (Urinary Tract Infection), comfort, also safety, because it can lead to resident squirming or trying to get up out of bed on their own. It is also a dignity issue. V3 said we don't want the resident to smell. 2). R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, speech, and language deficits, encounter for gastrostomy (G-tube), type 2 diabetes, metabolic encephalopathy, and chronic kidney disease stage 3. R2's MDS (Minimum Data Set), dated September 4, 2023, showed R2 had severely impaired cognition and required one staff's limited assistance for bed mobility, one staff extensive assistance for dressing, toileting, and personal hygiene. MDS showed transfers did not occur for R2. R2's care plan showed R2 has an ADL self-care performance deficit and impaired mobility. Interventions showed R2 requires one to two staff extensive assistance for repositioning, toileting, and bathing. R2 required one staff extensive assistance for personal hygiene and oral care. R2 has frequent bowel and bladder incontinence and interventions included check and change every two hours and as needed. On November 15, 2023, at 3:26 PM, R2 was in bed wearing a hospital gown. R2 had facial hair and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Orland Park 14601 South John Humphrey Dr Orland Park, IL 60462 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 long jagged nails. Level of Harm - Minimal harm or potential for actual harm On November 16, 2023, at 9:06 AM, R2 was in bed wearing a hospital gown laying sideways in the bed. When asked if his gown had been changed since yesterday, he shook his head no. R2's mouth had a thick white substance covering both upper lip, lower lips, and skin surrounding the mouth. R2 has long nails with a dark substance under them. R2 nodded his head yes when asked if he wanted his nails cut. R2 has a lot of whiskers/facial hair and when asked if he wanted shaved, R2 shook his head no. Residents Affected - Few On November 16, 2023 at 10:46 AM, R2 lying in the bed, still turned sideways with his legs over the side rail. Mouth is still coated with a thick white substance; teeth are coated with a thick white substance. When asked if they staff brushed his teeth, he shook his head no. On November 16, 2023, at 12:43 PM, R2 was still in the same position, laying crooked in the bed. Surveyor asked R2 if he was uncomfortable, he shook his head yes, when asked if he wanted to get up out of bed, he shook his head yes. Mouth and skin around the mouth were covered with a thick white substance. V1, Administrator, and V2, Executive Director, went into R2's room with the surveyor. They agreed R2 was in a poor position and should not be crooked in the bed like he was. V1 and V3, Director of Nursing, repositioned him to the center of the bed. V1 grabbed a wet paper towel and used it to wipe the thick white substance off R2's mouth. The substance was dried on and it took several wipes to get it cleaned off. V1 said, We will get some sponge tipped swabs to clean his mouth with. V1 went and asked a CNA (Certified Nursing Assistant), to get some for her. When she returned, V1 used a sponge tipped swab to clean his mouth. R2's teeth were also covered with a thick white substance.Incontinence brief was opened, and front of brief was dry. Once R2 was turned on his side, the incontinence brief was noted to be saturated with urine, and R2 also had a bowel movement. It took several wipes to clean the stool off his skin. V1 and V2 along with V17, CNA assigned to take care of R2, finished cleaning R2 up. When R2 was turned onto his right side, there was something in the bed; V1 picked it up and said it was a folded piece of gauze with tape on it, like they put on your arm after a blood draw. No one was sure when his last blood draw was. V13, Restorative CNA, came into the room to help V17 get R2 dressed into clothes and into his wheelchair. R2 was transferred with a mechanical lift. R2 was taken out to the dining room. R2's mattress had an indentation in the middle of the mattress where R2's bottom rested. It remained in that shape even after R2 was out of the bed for several minutes. 3). R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction, mild protein-calorie nutrition, Type 2 diabetes, seizures, nontraumatic intracranial hemorrhage, chronic kidney disease stage 3, encounter for gastrostomy, and weakness. R3's MDS (Minimum Data Set), dated September 20, 2023, showed R3 had moderately impaired cognitive skills for daily decision making and required one staff extensive assistance for bed mobility, transfers, and toilet use. R3 required one staff limited assistance for dressing and personal hygiene. R3's care plan showed R3 has potential for impairment of skin. Interventions included to keep clean and dry, turn and reposition every 2 hours and as needed, and apply lotion. R3 required assistance with ADLs (bed mobility, transfers, dressing, walking, personal hygiene, eating, and toileting) On November 15, 2023 at 11:23 AM, R3 was sitting in high backed wheelchair wearing a burgundy sweatshirt and had splints to bilateral hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Orland Park 14601 South John Humphrey Dr Orland Park, IL 60462 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 Level of Harm - Minimal harm or potential for actual harm On November 15, 2023, at 3:00 PM, R3 was still sitting in high backed wheelchair wearing a burgundy sweatshirt. Splints to bilateral hands. On November 16, 2023, at 9:01 AM, R3 was lying in bed wearing the same burgundy sweatshirt as yesterday. The sweatshirt had flaky substance all over it. Residents Affected - Few On November 16, 2023, at 10:44 AM, R3 was lying in bed on his back, wearing the same sweatshirt as mentioned above. On November 16, 2023 at 11:13 AM, V9 (CNA) and V10 (CNA) came into the room, followed by V15 (PTA/ Physical Therapy Assistant). V15 said she was there to take R3 to physical therapy, and said she had asked a CNA about getting R3 up and out of the bed close to two hours ago. V9 said they were here now and were going to get him dressed and up out of bed. When V9 pulled down the covers, R3's lower legs were very dark in color and had the appearance of tree bark. There was a dry, dark, flaky substance all over the bed surrounding R3's lower legs. V8 said she has complained to the staff before about his dirty linen, and said if they used the lotion like there were supposed to, then the bed wouldn't look like this. V8 (Family Member) said she is the one who cuts R3's fingernails because the CNAs have told her they are not allowed to cut fingernails. V9 (CNA) said they have been told they cannot cut resident fingernails. At 11:23 AM, V16 (LPN/Licensed Practical Nurse) came into the room to disconnect the IV and the G-Tube. V8 (Family member) asked V16 if he knew when R3 had a shower last. V16 said he believed it was on Tuesday when R3 was in the other hallway. When V16 was done disconnecting R3, V9 and V10 started to provide care. R3 was not able to help turn or help at all with care being provided. R3's incontinence brief was saturated with urine; V9 said he was last changed at 6:00 AM. Perineal care was provided When R3 was turned onto his left side, R3 was noted to have had a bowel movement. Care was provided. There was a dressing to his sacral area with the date 11/13 written on it. V10 (CNA) removed R3's hand splints. V9 and V10 were wondering why R3 was in a sweatshirt, and not pajamas or hospital gown. The CNAs removed his shirt and put on a new one. V9 only washed R3's face. V8 commented on R3's dry lips and peeling skin flakes on R3's lips. V8 asked the CNAs if they were going to put on the special lotion on R3's legs, and V9 said it should be in his drawer. When V9 looked it was not in there. V9 said she would go ask V16 (LPN) if he had the lotion. A short time later, V16 returned to the room with the lotion; he said it was ammonia lactate, and could be kept in the room, but V16 left the room with the lotion. V9 and V10 used the mechanical lift and placed R3 into his high-backed wheelchair and V8 (Family member) took R3 to physical therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 If continuation sheet Page 4 of 4