Health inspection·April 11, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hospital for either transfer. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and ombudsman notification. 2. R33's Face Sheet showed R33 was admitted to the facility on [DATE]. R33 had multiple diagnoses which included monoplegia of upper limb, Alzheimer's Disease, cerebral ischemia, diabetes, vascular dementia, and hypertension. R33's Change in Condition with SBAR Form, dated 12/20/24, showed R33 was observed sitting on the floor, next to her bed. The same form showed R33 was transferred to the hospital via emergency medical transport on 12/20/24. The form showed written notice for reason of transfer was not given to the resident and or/representative. The EMR contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and ombudsman notification. 3. R37's Face Sheet showed R37 was admitted to the facility on [DATE]. R37 had multiple diagnoses which included disorders of the brain, dementia, Alzheimer's Disease, chronic kidney disease, diabetes, hemiplegia, and hemiparesis. R37's MDS, dated [DATE], showed R37 had moderate cognitive impairment. R37's Change in Condition with SBAR Form, dated 01/24/25, showed R37's change in condition was an abnormal lab, potassium 6.7. The same form showed R37 was transferred to the hospital via emergency medical transport on 01/24/25. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for ombudsman notification. 4. R54's Face Sheet showed R54 was admitted to the facility on [DATE]. R54 had multiple diagnoses which included Parkinson's Disease with dyskinesia, weakness, muscle disorders, dementia, orthostatic hypotension, seizures, and congestive heart failure. R54's MDS, dated [DATE], showed R54 had severe cognitive impairment. R54's Change in Condition with SBAR Form, dated 09/15/24, showed R54's change in condition was more lethargic and less responsive. The same form showed R54 was transferred to the hospital via emergency medical transport on 09/15/24. R54's Change in Condition with SBAR Form, dated 12/27/24, showed R54's change in condition was altered mental status. The same form showed R54 was transferred to the hospital via emergency medical transport on 12/27/24. The form showed written notice for reason of transfer was not given to R54 and/or the representative. R54's Change in Condition with SBAR Form, dated 12/31/24, showed R54's change in condition was resident fell forward on dining room table, hitting head. The same form showed R54 was transferred to the hospital via emergency medical transport on 12/31/24. The EMR contained no documentation of written notice for reason of transfer or discharge to the hospital given to the resident and/or the representative for the transfer dated 12/27/24. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and ombudsman notification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm On 04/09/25 at 4:10 PM, V1 (Administrator) stated, The Ombudsman wasn't notified of the hospital transfers of the residents who returned to the facility starting September 2024 through March 2025. The Ombudsman should have been notified. It a regulation that they are notified. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of R80's electronic health record showed a 4/3/25 at 07:53 AM progress note that R80 was sent to the local community hospital for a dislodged G-tube (gastric tube). On 04/09/25 at 4:33 PM, V2, DON (Director of Nursing), said the family representative and R80 were not given the facility's Bed Hold policy because R80 was not admitted to the hospital, he was only sent to the ER (emergency room). V2 said both the resident and family are to get written notification of the transfer and the reason for transfer and the bed hold policy, along with notifying the Ombudsman. V2 said the facility's Bed Hold policy that is given to the resident and representatives does not notify about the facility's reserve bed payment. The facility's Bed Hold policy, dated 7/26/24, showed it is the facility's policy to adhere to the federal regulation on bed hold and on re-admission of resident transferred out of the facility. The Bed Hold policy did not show the facility's reserve bed payment. Based on interview and record review, the facility failed to provide the resident and/or their representative of the facility's policy for bed hold in writing. This applies to 3 of 3 residents (R33, R54, and R80) reviewed for discharge in a sample of 33. The findings include: 1. R33's Face Sheet showed R33 was admitted to the facility on [DATE]. R33 had multiple diagnoses which included monoplegia of upper limb, Alzheimer's Disease, cerebral ischemia, diabetes, vascular dementia, and hypertension. R33's Change in Condition with SBAR (Situation, Background, Assessment, Recommendation) Form, dated 12/20/24, showed R33 was observed sitting on the floor, next to her bed. The same form showed R33 was transferred to the hospital via emergency medical transport on 12/20/24. The form showed the facility's bed hold policy was not given to the resident and or/representative. The EMR (Electronic Medical Record) contained no documentation showing the bed hold policy was given to R33 and/or the representative. The facility was unable to provide documentation that the bed hold policy was given prior to the hospital transfer or after. 2. R54's Face Sheet showed R54 was admitted to the facility on [DATE]. R54 had multiple diagnoses which included Parkinson's Disease with dyskinesia, weakness, muscle disorders, dementia, orthostatic hypotension, seizures, and congestive heart failure. R54's MDS (Minimum Data Set), dated 04/09/25, showed R54 had severe cognitive impairment. R54's Change in Condition with SBAR Form, dated 12/27/24, showed R54's change in condition was altered mental status. The same form showed R54 was transferred to the hospital via emergency medical transport on 12/27/24. The EMR contained no documentation showing the bed hold policy was given to R54 and/or the representative. The facility was unable to provide documentation of the bed hold policy being given prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0625 the hospital transfer or after. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 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 observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who require assistance with their ADLs. Residents Affected - Some This applies to 7 of 7 residents (R23, R29, R33, R68, R75, R96, R116) reviewed for personal hygiene in a sample of 33. The findings include: 1. On 4/8/25 at 10:59 AM, R96 was lying in bed. His hair was disheveled and greasy. V33 (R96's wife) was beside him and she stated, They never wash or comb his hair. R96 confirmed what V33 had said. R96's care plan, dated 3/4/25, shows she has a ADL self care performance deficit and impaired mobility related to disease process. Intervention: Dressing and grooming (R96) .groom self and wash body and comb hair daily. R96's face sheet shows diagnoses of major depressive disorder, single episode, unspecified and suicidal ideations. 2. On 4/8/25 at 11:37 AM, R116 was lying in bed. He had a full beard and very long nails with a dark substance underneath on both hands. R116 stated, I've been asking to be shaved but the CNAs (Certified Nursing Assistants) say they don't have time. I don't know what my face looks like. I wanted to be shaved and I want my nails cut. R116's face sheet shows diagnoses of generalized anxiety disorder, spinal stenosis, cervicothoracic region, other cervical disc degeneration at C6-C7 level, encounter for orthopedic aftercare following surgical amputation, other reduced mobility, need for assistance with personal care. R116's care plan, dated 1/31/25, requires assistance with ADL's. Goal-(R116) will be assisted with ADL's as needed. Encourage participation in ADL's and help with grooming. 3. On 4/8/25 at 12:12 PM, R23 was lying in bed. R23's hair was not combed, and it was greasy. R23 stated, They are not washing my hair. Can't you see? It's greasy. I had a bed bath only a week ago. And I smell. R23's face sheet shows diagnoses of lymphedema, sepsis, lack of coordination, depression, morbid (severe) obesity due to excess calories, anxiety disorder. R23's care plan, dated 7/7/22, shows she has ADL self care performance and impaired mobility. Personal Hygiene-she requires extensive assist of 1 staff participation with personal hygiene. On 4/09/25 at 12:09 PM, V2 (DON-Director of Nursing) stated, CNA's under the supervision of the nurse are responsible for shaving, cutting nails, and washing the residents' hair. 6. On 4/8/25 at 2:26 PM, R68's fingernails were long, jagged, and with a brown substance under them. V11 & V12 (R68's daughters) were present at the time, and they both said that R68's nails always look like that, and they ask staff to provide nail care for R68, and it is still not provided. V11 and V12 said because staff does not provide nail care for R68, they do it for her, because they are afraid she will get and infection because she will scratch her skin to the point of bleeding. Then V11 and V12 provided nail care for R68. R68's 3/18/25 MDS showed her cognition is severely impaired, and she needs partial/moderate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 assistance with personal hygiene. Level of Harm - Minimal harm or potential for actual harm On 04/10/25 at 12:10 PM, V2, DON (Director of Nursing), said he expects nail care to be provided regularly to prevent infection and overall cleanliness to the resident. V2 said the facility policy says ADL (Activities in Daily Living) care should be given daily as needed. Residents Affected - Some The facility's Nail Care policy, dated 8/16/24, showed the purposes of the procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 7. On 4/8/25 at 12:21 PM, R75 had fingernails which were 1.5 inches long on all her fingers, and had a brown substance underneath them. R75 said the facility staff do not ask her if she needs them cut, and she would want the staff to cut them for her. On 4/10/25 at 10:02 AM, R75's fingernails remeined the same length, and still had a brown substance underneath them. On 4/10/25 at 10:40 AM, V23 (LPN/Licensed Practical Nurse) said the residents' nails should not be long and the residents should be offered clipping weekly. V23 said the residents' nails should be cleaned daily. V23 said the residents should have short nails to prevent scratching, which could cause infections. On 4/10/25 at 12:46 PM, V19 (CNA/Certified Nurse Assistant) said she had cared for R75 on 4/7/25 and had provided her a bed bath, but had not provided nail care. V19 said the residents' nails should be short and clean so they do not scratch themselves. V19 said long nails can cause skin breakdown, which can create a wound. On 4/10/25 at 12:54 PM, V18 (CNA) said every time the staff provide a bath, they should cut their nails if they are long. V18 said the nails should also be cleaned if they are dirty. V18 said long nails can cause the resident to scratch and cause infections. R75's face sheet showed diagnoses including osteoarthritis, anxiety disorder, and hypertension. R75's MDS, dated [DATE], showed she had moderate cognitive impairment. R75's care plan showed R75 has potential for impairment to skin integrity. R75's care plan showed she requires assistance with ADL's (Activities of Daily Living) (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Facility's policy titled General Care (7/30/24) shows: It is facility's policy to provide care for every resident to meet their needs. 1. Upon admission or readmission, the facility will evaluate the resident for physical needs. Physical needs would include, but are not limited to ADL .2. The facility will assist the resident to meet these needs. 4. On 04/09/25 at 10:00 AM, R29 was sitting in the dining room in a wheelchair. R29 was seated on a mechanical lift sling. R29 had a foul odor. V25 (CNA) and V26 (CNA) transferred R29 via mechanical lift from the wheelchair to the bed. V25 and V26 provided incontinence care to R29, assisted by V13, RN (Registered Nurse/Nurse Manager). R29's mechanical lift sling and wheelchair cushion had a strong foul odor. R29's incontinence brief was minimally wet. R29's Face Sheet showed R29 was admitted to the facility on [DATE]. R29 had multiple diagnoses which included cerebral ischemia, chronic obstructive pulmonary disease, psychotic disorder, mood disorder, and dementia. R29's MDS (Minimum Data Set), dated 03/03/25, showed R29 was cognitively impaired. The same MDS showed R29 required partial/moderate assistance with toileting hygiene and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 Residents Affected - Some dependent with transfers. R29's ADL care plan initiated 09/24/23 showed R29 requires assistance with ADL's (transfers and toileting). The ADL care plan goal showed resident will be assisted with ADL's as needed. On 04/09/25 at 10:00 AM, V13 (RN) stated, The resident should have not been placed on a soiled mechanical transfer sling. The slings should be changed when they are soiled, dirty, or smell like urine. The wheelchair cushions should be cleaned and wiped down twice per week. V13 stated R29's mechanical lift sling and the wheelchair cushion smelled like urine. 5. On 04/09/25 at 9:40 AM, R33 was sitting at the dining room table. R33's fingernails on both hands were long, jagged, and had a dirty substance underneath. R33 stated she would like her nails clipped and cleaned. On 04/10/25 at 2:26 PM, R33's fingernails remained long, jagged, with a dirty substance underneath. R33's Face Sheet showed R33 was admitted to the facility on [DATE]. R33 had multiple diagnoses which included monoplegia of upper limb, Alzheimer's Disease, cerebral ischemia, diabetes, vascular dementia, and hypertension. R33's ADL care plan, initiated 11/04/24, showed R33 requires assistance with ADL's (personal hygiene). The ADL care plan goal showed resident will be assisted with ADL's as needed. On 04/10/25 at 2:26 PM, V13 stated, Tesidents nails should not be long and jagged. Nails should not have a dirty substance underneath. Nails should be clipped on shower days and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 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 obtain vital information regarding residents' pacemakers, and ensure it was readily available in the resident's medical record. Residents Affected - Some This applies to out 5 of 5 residents (R20, R81, R96, R136, R529) reviewed for pacemakers in a sample of 33. The findings include: 1. R81's face sheet documents an admission date of 6/15/23. R81's POS (Physician Order Sheet) shows an order (6/16/23) for Pacemaker-Check for functionality and effectiveness. Check pulse rate and blood pressure daily and as needed. R81's face sheet documents the following diagnoses: presence of cardiac pacemaker, chronic combined systolic (congestive) and diastolic (congestive) heart failure, pure hypercholesterolemia, hyperlipidemia, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension, and hypertensive heart disease with heart failure. R81's medical record was reviewed. R81's progress notes, admission assessment, and care plan do not document the pacemaker serial and model number. It was also unknown as to when the pacemaker was last assessed. R81's care plan on pacemakers shows: Check upon admission/readmission and every 3 to 6 months in accordance to my physician's order. Check and document in chart: Heart rate, Rhythm, and Battery check. On 4/10/25 at 10:01 AM, V2 (DON-Director of Nursing) stated, The model and serial number should be in the care plan. It's notoriously difficult to get that information. I've tried myself. The families and residents don't know. The admission nurse is the first person who should try to get it. I'm the second person who follows up and tries to get that information. I've tried calling cardiology offices. There should be an order in the POS and how often it should be checked. The model and serial number of the pacemaker should be in the care plan. 2. R96's face sheet documents an admission date of 3/1/25. R96's face sheet documents the following diagnoses: presence of cardiac pacemaker, paroxysmal atrial fibrillation, acute on chronic systolic (congestive) heart failure, and hypotension. R96's POS did not have any orders for the pacemaker, or how often it should be checked. R96's medical record was reviewed. R96's progress notes, admission assessment, and care plan do not document the pacemaker serial and model number. It was also unknown as to when the pacemaker was last assessed. R96's care plan on pacemakers shows: Check for functionality and effectiveness. Check pulse rate and blood pressure daily and as needed. Check upon admission/readmission and every 3 to 6 months in accordance with physician's order. Checks per facility protocol and document in chart: Heart rate, Rhythm, Battery check.3. R529's face sheet documents an admission date of 10/21/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R529's face sheet showed diagnoses of presence of cardiac pacemaker, hypertensive heart disease with heart failure, hypertensive urgency, cardiomyopathy, chronic diastolic heart failure, acute on chronic diastolic heart failure, and syncope and collapse. R529's EMR (Electronic Medical Record) was reviewed. R529's POS (Physician Order Sheet) did not include any orders for a pacemaker. R529's care plan, dated 10/22/24, showed to Check upon admission/readmission and every 3 to 6 months in accordance to physician's order. 4. R20's face sheet documents an admission date of 7/14/22. R20's face sheet shows diagnoses of presence of cardiac pacemaker, hypertension, and heart failure. R20's EMR was reviewed, and R20's POS did not show the serial or model number of the pacemaker. R20's care plan also did not show a serial or model number. 5. R136's face sheet documents an admission date of 6/26/23. R136's face sheet showed diagnoses of presence of cardiac pacemaker, acute on chronic diastolic heart failure, hypertensive heart disease with heart failure, atherosclerotic heart disease, paroxysmal atrial fibrillation, personal history of transient ischemic attack, and cerebral infarction without residual deficits. R136's EMR was reviewed, and R136's POS did not show the serial or model number of the pacemaker. R136's care plan also did not show a serial or model number. Facility's policy titled Pacemakers (8/16/24) shows: Procedures-1. Residents who have pacemakers must have the following documented in their medical record: a. The date of insertion, physician who inserted it, and the place where it was inserted. b. Make, model and serial number of the pacemaker. c. Orders in the POS for how often the pacemaker is to be checked and by whom (physician office, cardiology clinic, by telephone, etc.). 2. The pacemaker remote follow-up/check should be done every 3-12 months for depending on the physician's orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure resident beds were kept at a safe height. Residents Affected - Few This applies to 2 of 4 residents (R167 and R173) reviewed for accidents in a sample of 33. Findings include: 1. On 04/10/25 11:59 AM, R167's bed and over bed table were in a very high elevated position. On 04/10/25 at 12:00 PM, R167 stated his bed was dangerous. V35, PTA (Physical Therapy Assistant/Therapy Director), entered R167's room and stated, The bed should not have been left that high. If (R167) had fallen from bed the impact of an injury would be worse. R167's diagnoses includes sequelae of cerebral infarction, hypertension, muscle wasting and atrophy. R167's care plan showed R167 was at risk for falls, with interventions include to provide a safe environment. 2. On 04/08/25 at 12:55 PM, R173's bed and over bed table were in a high position. On 04/08/25 at 12:57 PM, V29, Certified Nursing Assistant/CNA, stated R173 was a high fall risk. V29 stated she left R173's bed in the high position. R173's diagnoses includes displaced intertrochanteric fracture of left femur, type 2 diabetes, wedge compression fracture of fifth lumbar vertebra and dementia. R173's current care plan showed R173 is risk for falls related to recent falls. Interventions include to provide a safe environment. Resident is at risk for altered thought process related to her diagnosis of Lewy body dementia. The facility policy Fall Occurrence, dated 7/26/24, states those identified as high risk for falls will be provided fall intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 2. R119's face sheet shows diagnoses of multiple sclerosis, muscle wasting and atrophy, not elsewhere classified, unspecified lower leg, unspecified severe protein calorie malnutrition. On 4/8/25, review of R119's POS (Physician Order Sheet) shows no order for the Biofreeze and the Vitamin C. On 4/8/25 at 12:12 PM, R119 was in bed. On her dresser, there was a Biofreeze (Menthol-Pain Relieving Gel) roll on and Vitamin C 750 MG (Milligrams) Gummies. R119 stated, It's always kept here. I brought them from home. R119's MDS (Minimum Data Set), dated 3/18/25, shows she is cognitively intact. On 4/9/25 at 12:09 PM, V2 (DON-Director of Nursing) stated, All medications that are stored in resident rooms need an order by the doctor. If the resident and/or family wants them to take it or be at the bedside, it's the same thing. You need an order from the physician.3. On 04/08/25 at 11:33 AM, a tube of diclofenac sodium gel 1% 3.35 oz (Ounces) with R379's name was on her overbed table. On 04/09/25 at 3:39 PM, R379 stated she still had the diclofenac. R379 showed the tube of diclofenac gel 1% 3.35 oz in her wash basin. R379 stated a nurse gave it to her, and she applies it for a sciatic nerve problem. R379 stated she may use it twice a day as she needs it. On 04/10/25 at 11:04 AM, V32, LPN (Licensed Practical Nurse), assigned to R379, stated he did not have any residents assessed to keep medications at the bed side. V32 confirmed R379 was prescribed diclofenac topical, but it was not scheduled for administration during his shift. On 04/10/25 at 12:38 PM, V32 confirmed R379 had kept the tube of diclofenac at her bedside. Facility's policy titled Medication Storage, Labeling and Disposal (8/16/24) shows: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. 4. Medications will be secured in a locked storage area. Based on observation, interview, and record review, the facility failed to store medications securely. This applies to 3 of 3 residents (R125, R119, R379) reviewed for medication storage in a sample of 33. The findings include: 1. R125's face sheet showed R125 was admitted to the facility with diagnoses muscle wasting and atrophy, abnormalities of gait and mobility, aftercare following joint replacement surgery, intervertebral disc disorders with radiculopathy lumbar region, rheumatoid arthritis, unilateral primary osteoarthritis right knee, and osteoarthritis. R125's POS (Physician Order Sheet) did not have an order for Biofreeze Roll On Pain Relieving Gel. On 4/8/25 at 11:43 AM, R125's had a Biofreeze Roll On Pain Relieving Gel sitting on her bedside table. On 4/10/25 at 10:19 AM, R125's bedside table had the Biofreeze Roll On Pain Relieving Gel on it. R125 said she used the Biofreeze on her knees when she had pain. R125 said she puts the Biofreeze on, and she had put it on a few days ago. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm On 4/10/25 at 1:03 PM, V16 (Agency RN/Registered Nurse) said she did not have any residents who were allowed to keep medications at bedside, and if she saw a resident with medication at the bedside, she would remove them and report it to administration. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. Residents Affected - Many This applies to 162 residents in the facility receiving dietary services. Findings include: On 04/09/25 at 01:11 PM, V2, DON (Director of Nursing), confirmed 162 residents were being served from dietary services on 04/08/25. 1. On 04/08/25 at 10:24 AM, the coffee station drainpipe in the kitchen was wrapped in black tape that looked like electrical tape. The pipe was dripping over a silver container that had brown liquid with a gray furry film floating on top and white unidentifiable chunks. The stand mixer was covered with plastic. The mixer had white and yellow crusted drips. The vents over the stove cook top had a layer of dust. On 04/10/25 at 01:47 PM, V6, Dietary Director, stated the vents over the stove are cleaned by an outside company that comes out quarterly. They came out February 2025, and will return in May this year. V6 stated administration is responsible for setting up those visits, but he can put in a request for them to come out if needed. V6 stated the person who last used the stand mixer should have cleaned it thoroughly before covering it up. V6 stated he would inform maintenance about repairs needed in the kitchen. V6 stated he did not know the coffee station drainpipe was leaking prior to the survey. 2. On 04/08/25 at 10:24 AM, the ice machine did not have a log. V6 (Dietary Director) stated he was not responsible for the ice machine, and he was unaware of a log for its cleaning schedule. On 04/09/25 at 1:38 PM, V1, Administrator, stated the facility did not have a policy for the ice machine or cleaning logs for the ice machine. On 04/09/25 at 02:30 PM, V27, Executive Director, stated an outside company comes to the facility to clean the ice machines. V27 did not have documentation of services from the outside company. 3. On 04/08/25 at 10:03 AM, the walk-in cooler contained: *A 48 fl. (fluid) oz bottle of prune juice with a use by date of 4/7/25. *A 5lb container of cottage cheese with a use by date of 4/7/25. *A 5lb container of sour cream partially used without an open on or use by date. *A silver metal pan with viscous dark orange liquid and a thick dark orange frothy foam labeled JL identified by V6 as orange juice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many *A 5lb container of cottage cheese with a manufacture best by date of 3/30/25. The plastic seal and lid were bubbled out. V6 stated it should not be used because it is past the date printed on the container. On 04/10/25 at 1:47 PM, V6, Dietary Director, stated, Food should be labeled with a received date, opened on date, and use by date to assure no one becomes ill form eating outdated food. Food items are good for seven days in the cooler. Dry storage goods are good for six months and freezer items are good for up to a year. We wouldn't use food items past the best by date because that is the date set by the manufacturer. 4. On 04/10/25 at 11:13 AM, the first-floor unit refrigerator was reviewed with V33, Social Services. A bag of someone's personal food did not have any dates. No temperature log was on the refrigerator. On 04/10/25 at 11:19 AM, the second-floor unit refrigerator was reviewed with V34, Social Services, and it did not have a temperature log. On 04/10/25 at 11:25 AM, the third-floor unit refrigerator was reviewed with V38, LPN (Licensed Practical Nurse), and it did not have a temperature log. On 04/10/25 at 03:27 PM, V27, Executive Director, stated Housekeeping does the refrigerator logs for the unit refrigerator and some logs were missing. Three months of unit temperature logs were requested for each unit. V27 provided one temp log for each unit. The first-floor refrigerator on January 26, 2025, PM a reading of 42 degrees was logged with no documented corrective action provided. The third floor February 2025 had fifteen shifts with temperature log of 42 degree with no documented corrective action. 5. On 04/08/25 at 09:57 AM, the kitchen tour began in the dry storage withV6, Dietary Director. *A 5lb (Pound) bag of baking cocoa was open to air *A 6lb 10 oz (ounce) can of cream corn was dented *A 6lb 9oz can of pizza sauce was dented *A 25lb box of food thickener in clear plastic bag was open to air. On 04/10/25 at 01:47 PM, V6, Dietary Director, stated, Dented cans should be discarded to prevent food borne illness related to botulism. Food items should be wrapped up and sealed tight to prevent moisture, mold development, foreign object or pest contamination. The facility policy Maintenance, dated 8/16/24, states it is the facility policy to maintain equipment and the building environment. Any equipment that cannot be fixed will be replaced accordingly. The facility policy Food Handling, dated 7/26/24, states all food service equipment and utensils will be sanitized according to current guidelines and manufactures recommendations. The facility policy Kitchen, dated 8/16/24, states food should be free of slime mold. Refrigerated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many food should be covered, dated labeled and shelved to allow air circulation. Open containers or potentially hazardous food or leftovers should be dated and used within 3-5 days in the refrigerator. Dented cans will be returned to the food company and will not be utilized and served to residents The facility policy Food Handling, dated 7/26/24, stated functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state specific requirement. Federal standards require that refrigerated food be stored below 41 degrees Fahrenheit. The facility policy Food from the Outside, dated 7/26/24, states all food brought in by visitors and family members from outside of the facility will be labelled with the date it was brought to the facility. All undated food items will be discarded to ensure safety of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove expired items from resident refrigerators. Residents Affected - Some This applies to 4 of 4 residents (R36, R38, R47, R84) reviewed for refrigerators in a sample of 33. The findings include: 1. On 4/08/25 at 12:07 PM, inside R38's fridge, she had two cartons of yogurt (113 grams). One carton was raspberry flavored which expired on 12/3/24, and the other one was strawberry flavored that expired on 10/13/24. There was a carton of (gelatin) with a best by date of 10/8/24. R38 stated, I didn't know those were expired. You can throw those out. I won't eat those. I don't wanna get sick. R38's face sheet shows diagnoses of dysphagia, prediabetes, impaired glucose tolerance, cachexia and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R38's MDS (Minimum Data Set), dated 1/10/25, showed R38 is cognitively intact. 2. On 4/08/25 at 12:30 PM, inside R36's fridge, there were 2 cartons of yogurt (113 gram) mixed berry flavor that expired on 3/25/25, a bottle of freshly squeezed orange juice with a sell by date of 3/24/25, and a bottle of freshly squeezed mint, lemon, sugar alkaline water with a sell by date of 3/27/25. R36 stated, I didn't know they were not good. You can toss them out. It's not worth it to get food poisoning. R36's face sheet shows diagnoses of dysphagia, unspecified, mild protein-calorie malnutrition, and extended spectrum beta lactamase (ESBL) resistance. R36's MDS, dated [DATE], shows R36 is cognitively intact. On 4/09/25 at 12:09 PM, V2 (DON-Director of Nursing) stated, Housekeeping, nurses or CNA's (Certified Nursing Assistants) are responsible for removing expired food items from the residents' personal refrigerators.3. On 4/8/25 at 1:09 PM, R84's personal room fridge had a packet of pepperoni that expired on 3/16/25, and a packet of cracker barrel sharp white cheese which expired on 3/13/25. R84's face sheet showed she was admitted to the facility with diagnoses including nutritional deficiency, type 2 diabetes mellitus, osteoarthritis, muscle wasting and atrophy, and need for assistance with personal care. R84's MDS/ dated 3/26/25, showed she was cognitively intact. 4. On 4/8/25 at 11:41 AM, R47's personal room fridge had a blueberry yogurt/ which had a best by date of 3/26/25. R47's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis, muscle wasting, neuralgia and neuritis, hallucinogen use, and psychoactive substance abuse. R84's MDS, dated [DATE], showed she was cognitively intact. On 4/10/25 at 10:49 AM, V22 (CNA/Certified Nurse Assistant) said the housekeeping staff are supposed to throw away expired food and clean out the fridge. On 4/10/25 at 12:39 PM, V21 (Assistant Director of Housekeeping) said the housekeeping staff were the ones who should check the fridges. V21 said the staff are supposed to make sure everything was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated and if there was anything outdated, they should throw the food out. V21 said the housekeeping staff are supposed to clean the fridge out every week to make sure nothing was spoiled or rotten. On 4/10/25 at 12:40 PM, V20 (Director of Housekeeping) said the housekeeping staff are supposed to throw away expired food. V20 said there were no logs which showed the housekeeping staff had cleaned out the fridge. Facility's policy titled Food from the Outside Policy dated 7/26/24 shows: The facility will comply with sanitary food practices in storing, handling, and consumption of food brought by family and visitors from the outside of the facility 3. After 3-5 days, these food items will be discarded. 4. All undated food items will be discarded to ensure safety of the residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow infection control measures. Residents Affected - Some These failures apply to 5 of 5 residents (R27, R5, R529, R383, & R63) reviewed for infection control practices in a sample of 33 residents. The findings include: 1. On 04/08/25 at 12:35 PM, V3 (Restorative) was sitting at a table; R529 was to V3's left, and R63 was to her right. V3 was feeding R529 with her right hand, and then put down R529's fork, and V3 got up to move R63's wheelchair, touching the wheelchair. V3 then touched R63's lunch tray that R63 was eating his lunch from. After touching R63's wheelchair with both hands and touching R63's tray with her right hand, V3 then opened R529's mustard and ketchup packets with R529's fork, and then put a forkful of hamburger into R529's mouth. V3 never cleaned her hands between handling R63's wheelchair and tray and then feeding R529. At 12:54 PM, V3 was still feeding R529 with her right hand, and she reached over with her right hand and handed R63 his drink, and then turned back to R529 and put a forkful of hamburger in R529's mouth. V3 then picked up R63's coffee cup to give him a refill. V3 refills R63's cup, then cleans her hands with sanitizer and brings the cup of coffee back to the table and adds cream to the cup, and then hands the cup to R63 with her right hand. Then after handing the cup to R63, V3 touches the arm of R63's wheelchair with her right hand, and then picks up R529's fork and puts a forkful of hamburger into R529's mouth. On 04/10/25 at 12:15 PM, V2, DON (Director of Nursing), said his expectations are if staff is interacting with 2 residents, they should perform hand hygiene in-between the residents to prevent cross-contamination. 2. On 04/08/25 at 01:51 PM, V8, CNA (Certified Nurse's Assistant), was assisting R5 with toileting. V8, with gloved hands, pulled R5's pants down and removed her soiled brief, and then assisted R5 with sitting on the toilet. V8 then, with her dirty gloved hands, went to R5's closet, open the closet, got a new brief out of the closet, and brought the new brief back to the bathroom. V8, then with the same dirty gloved hands, cleaned R5's buttocks, had R5 stand, and V8 attached the new brief on R5. Then V8 pulled up R5's pants and R5 began to yell that her pants were wet. V8 then removed the soil pants from R5, removed the glove from her right hand, opened R5's closet with her bare right hand, then removes her left glove, picked up a clean pair of pants, came back to R5 in the bathroom, and put the clean pair of pants on R5 with her ungloved and unwashed hands. V8 then assisted R5 into her wheelchair and moved R5 out of the bathroom, and then V8 with her dirty ungloved hands, received R5's water pitcher from V9 (Restorative Aide), and hands it to R5, still with her bare and unwashed hands. On 04/10/25 at 12:07 PM, V2, DON (Director of Nursing), said his expectations of staff are once they have done a dirty task, they are to remove their gloves and perform hand hygiene and put on new gloves before doing the new task. V2 said this should be done to prevent infections. 3. On 04/08/25 at 1:51 PM, after V8 assisted R5 with toileting, V8 (CNA) and V9 (Restorative Aid) provided incontinence care for R27. V8 removed R27's saturated brief, wiped R27's buttocks, placed a clean brief under R27, then applied barrier cream to R27's buttocks wearing the soiled gloves, then opened R27's closet with her dirty gloved hands and put the barrier cream in the closet. V8 never (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some removed her gloves, cleaned her hands, or put on new gloves after leaving a dirty area and before going to a clean area. On 04/10/25 at 12:03 PM, V2 (DON) said his expectations of staff are once they touch a soiled brief, they are to remove their gloves, clean their hands, and put on new gloves before going to a clean area. V2 said staff are to also clean their hands after removing their gloves and before putting on clean gloves and they are to perform hand hygiene. V2 said staff must do this to prevent potential infections. The facility's Hand Hygiene policy, dated 7/30/24, showed hand hygiene is important in controlling infections. The policy shows hand hygiene should be done before and after direct resident contact, before and after assisting a resident with meals, before and after assisting a resident with toileting, and before moving from work on a soiled body site to a clean body site on the same resident.4. On 04/09/25 at 3:48 PM, R383's bedroom door was wide open. V31, Guest Services, entered R383 Covid isolation room with a surgical mask and gown. V31 exited R383 isolation room, removed gown, and did not change her mask and did not perform hand hygiene. V31 did not close R383's bedroom door. On 04/09/25 at 4:16 PM, V31 stated R383 was in isolation for Covid. V31 stated she had been educated on PPE (Personal Protective Equipment). V31 stated when she enters a covid isolation room, she should wear protective eye covering or face shield, mask, gown, and gloves. V31 stated she guesses she should have worn an N95 mask, but didn't remember. V31 states she changes her surgical mask every three hours. V31 stated she did not change the mask she had worn into R383's room until she went up to the second floor. V31 stated after she left R383's room, she went to the admissions office to retrieve a folder, then went to the second floor to see other residents. V31 stated she did hand hygiene when she went to the second floor, but did not do hand hygiene when she left R383's room. V31 stated she did not follow the proper procedure because she was in the middle of doing something and got distracted. On 04/08/25 at 3:01 PM, V30, CNA (Certified Nursing Assistant), stated, If a resident is in isolation for Covid, their bedroom door should be closed. On 04/10/25 at 1:14 PM, R383's bedroom door was left wide open. V36, Repair Vendor, was observed entering R383's room wearing a surgical mask and gown. V36 stated he was there to work on the call light. No one educated him on PPE use. On 04/10/25 at 2:30 PM, V15 (IP/Infection Preventionist) stated, Covid isolation room door should be closed to stop the spread of disease. Staff entering a Covid isolation room should ware an N95 mask. Vendors going into a Covid isolation room should be stopped and directed by staff to put on an N95 mask. Staff should be doing hand hygiene before the leave the isolation room to stop the spread of the disease. They should wear a shield or protective eye wear to keep the disease from getting inside the eye socket or conjunctiva and masks should be changed when they leave the room. It's an unsafe practice if they are not wearing the proper PPE and not doing hand hygiene. It puts other residents and staff at risk. The facility policy Covid 19 Guidelines and Emergency Preparedness Plan states the facility can place the positive resident in a single room with isolation signage. With staff wearing full Covid PPE (N95, face shield, gown and gloves) upon entering the room.5. On 4/8/25 at 11:48 AM, V18 (CNA/Certified Nurse Assistant) was in R63's room providing care to R63 with just gloves on for PPE (Personal Protective Equipment). R63's room door had signage which showed he was on EBP (Enhanced Barrier (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Precautions). V18 provided incontinence care, then changed his clothing and linen. At 11:58 AM, V24 (CNA) also entered R63's room with just gloves on for PPE to assist V18 with transferring R63 from the bed into his wheelchair using the mechanical lift. On 4/10/25 at 12:54 PM, V18 (CNA) said for EBP, gloves, gown, and a mask are worn for direct care for the residents. V18 said the PPE was worn to protect the staff and the residents. On 4/10/25 at 10:30 AM, V23 (LPN/Licensed Practical Nurse) said for residents on EBP, the staff need to wear PPE during patient care including toileting, dressing, and transferring. V23 said gloves and a gown need to be worn. On 4/10/25 at 10:49 AM, V22 (CNA) said for residents on EBP, a gown, gloves and a mask are worn. On 4/10/25 at 2:03 PM, V15 (IP/Infection Preventionist) said the staff would need to wear a gown and gloves when having direct contact with the patient. R63's face sheet showed he was admitted to the facility with diagnoses including hemiplegia and hemiparesis, cellulitis of the right lower limb, acute bronchitis, need for assistance with personal care, and chronic kidney disease. R63's POS (Physician Order Sheet) showed R63 had an order for Insertion of PICC (Peripherally Inserted Central Catheter) ordered 4/3/25. R63's MDS (Minimum Data Set), dated 3/21/25, showed R63 had moderate cognitive impairment and required supervision for personal hygiene, partial assistance for upper body dressing, substantial assistance for shower/bathing, and was dependent on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. The facility's Enhanced Barrier Precautions policy, dated 7/26/24 showed EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDROs (Multi-Drug Resistant Organisms) as well as residents with wounds and/or indwelling medical devices. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: a) Dressing .c) Transferring d) Providing hygiene e) Changing linens f) Changing briefs or assisting with toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to have documentation that staff were educated and offerred the Covid-19 immunization. Residents Affected - Many This applies to all 168 residents in the facility reviewed for immunizations in the sample of 33. The findings include: The CMS (The Centers for Medicare and Medicaid Services) form 671 titled Long-Term Care Facility Application for Medicare and Medicaid, dated 4/8/25, shows the facility has a census of 168 residents. On 4/9/25 at 3:01 PM, V15 (RN-Registered Nurse /Infection Control Nurse) stated, I don't have the documentation that shows where I offered the vaccine to staff. I think they offer the covid vaccines to staff through an outside company. They are not required to have covid boosters. I personally have not offered to them. I have to check with Human Resources if they have a log of it. On 4/10/25, V15 was unable to provide surveyor any logbook showing that the facility offered staff Covid-19 vaccines. V15's infection control binders did not have any documentation staff were educated regarding the benefits and potential side effects of the Covid-19 vaccine. The binders also did not contain any documentation staff accepted and/or received the vaccine, and there was no documentation to show the vaccination status of staff. On 4/11/25 at 12:49 PM, V1 (Administrator) emailed surveyor saying (V2-Director of Nursing) enters Covid data on employees into a tracker. She stated V2 would provide his staff covid vaccine tracker. As of 3:11 PM on 4/11/25, no tracker had been provided by the facility. Facility's policy titled Covid 19 Vaccination Policy (7/16/24) shows: The facility will comply with the applicable CMS, CDC (Centers for Disease Control and Prevention), and/or IDPH (Illinois Department of Public Health guidance on Covid-19 vaccination. As CMS had rescinded the mandatory Covid 19 vaccine requirement for staff and resident, the facility will continue to promote and provide Covid-19 vaccination whenever the vaccine is available, and individuals consent to Covid vaccination FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 If continuation sheet Page 22 of 22