Health inspection·June 3, 2025

F 0602 footage from the gas station where the debit card was attempted to be used. Level of Harm - Minimal harm or potential for actual harm The facility's Abuse and Neglect policy (revised 7/12/2024) showed, Financial/Misappropriation of Property: Financial abuse includes, but is not limited to deliberate misplacement, misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently Residents Affected - Few 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 06/03/2025 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safely turn a resident in bed for cares. This failure resulted in R1 rolling off the bed and sustaining a right femur fracture. This applies to 1 of 3 residents (R1) reviewed for falls. The findings include: R1's Face Sheet showed she was originally admitted to the facility on [DATE]. R1's Face Sheet included diagnoses of functional quadriplegia, reduced mobility, muscle wasting and atrophy, morbid (severe) obesity, body mass index (BMI) 50-59.9, anxiety disorder, and need for personal care. R1's Activities of Daily Living (ADL) care plan focus statement (last revised 3/2023) showed R1 has an ADL Self Care Performance Deficit and Impaired Mobility [related to] impaired balance, weakness, decreased strength and endurance [due to] recent hospital stays. Needs assistance with self care and mobility; extensive assistance of 2 staff with mobility and transfers .May use full body lift machine with total assist of 2 staff .non ambulatory at this time. An intervention (last revised 10/1/2022, over two years ago) showed May require 2 staff assist with mobility and transfers depending on her level of participation and endurance. Another intervention (also not revised since 10/1/2022) showed BED MOBILITY: [R1] requires extensive assist of 1 staff participation to reposition and turn in bed, and scooting towards head of bed [due to bilateral lower extremity] weakness. A 3/20/2023 intervention showed TOILET USE: [R1] requires extensive assist of 2 staff participation with toileting needs. R1's 5/4/2025 nursing note from 9:16 AM (late entry) showed, At approximately 5:28 AM, writer responded to staff calling for nurse and resident was observed with right hand and knee on the floor, left leg was on the bed, and left arm was holding on to bed. [R1] let go of bed rail and placed left hand/leg onto floor. She then rolled onto right side, then onto her back to floor .the resident stated 'My leg slid over the bed while the CNA [Certified Nursing Assistant] was turning me and I rolled off the bed.' .resident remained on the floor .[R1] assisted to stretcher by 6 paramedics and was sent to [local] hospital. Under History of Present Illness in R1's 5/5/2025 Hospital admission note, it showed, Patient is a [AGE] year-old bedbound, non-ambulatory female with a BMI of 55 who presented after a fall from bed .she has a complex medical history, notably a severe COVID-19 infection three years ago that led to prolonged hospitalization, deconditioning, and eventual complete loss of ambulatory status. She has not stood or walked in over a year and has since experienced significant weight gain and progressive immobility. On presentation, radiographs and a CT (computed tomography) scan of the right lower extremity revealed a comminuted, supracondylar distal femur fracture with intra-articular extension into the lateral condyle . The Objective section in R1's 5/5/2025 hospital note showed R1 is 5' 9 tall and weighs 380 pounds. R1's 2/28/2025 Minimum Data Set (MDS) showed her cognition was moderately impaired. R1's April/May 2025 POC Response History 30-day lookback (from 4/29/2025 forward) asks for the (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 06/03/2025 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 - Actual harm Residents Affected - Few amount of assistance needed to Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. Seven documented staff entries were available up to R1's fall, one showing R1 needed Substantial/maximal assistance- helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. The other six entries showed R1 was Dependent- Helper does ALL the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. R1's 2/18/2025 MDS showed R1 was also dependent for toileting hygiene. On 5/28/2025 at 8:31 AM, R1 was in her bed wearing a hospital gown. R1 was alert and in a bariatric bed with a gel overlay. R1 stated staff took her stiches out the day before, and she was told there were three screws in her right knee. On 5/28/2025 at 9:36 AM, R1 stated V4 (CNA) was changing her by herself, when R1 fell. R1 stated when V4 was going to change R1's incontinent brief, V4 was standing on the right side of R1's bed, and V4 turned R1 away from her. R1 stated she told V4 her leg is going to fall. R1 stated V4 stood there and removed the soiled brief, and her leg slid off the bed. R1 stated she fell on her knees with her butt sticking up in the air. R1 stated 6-7 people came to her room after she fell. R1 stated her left leg has arthritis, and now her right knee was broken. On 5/28/25 at 2:51 PM, V4 (CNA) stated she worked on 5/4/2025 night shift, and she was taking care of R1 when she fell. V4 stated R1 turned herself towards the door. V4 stated as R1 was turning herself, one of her legs pulled out of the bed and R1 was on the floor. V4 stated she did not touch R1. V4 stated she yelled for the nurse. V4 stated R1 became a two person assist after she fell. V4 stated R1 never told her her leg is going to fall. On 5/29/2025 at 1:45 PM, V10 (Restorative LPN- Licensed Practical Nurse) stated R1 has never been on a bed mobility program, and she believed R1 has used a full-body mechanical lift for transfers for around two years. On 5/29/2025 at 2:25 PM, V3 (Therapy Director) stated R1 had a fall from bed resulting in a fracture. V3 stated, Staff should not roll residents away from them. V3 stated, If (R1's) leg started going off the side of her bed, she couldn't have stopped it .at 380 pounds the momentum would carry her leg over. On 5/29/2025 at 3:10 PM, V8, ADON (Assistant Director of Nursing), stated she completed the investigation into R1's fall. V8 stated R1 has full ROM (Range of Motion) to her arms, but not a whole lot of ROM to her legs as R1's baseline. V8 stated, You should not push a resident away from you in bed. You have more control of the patient if you roll them toward you. V8 stated the root cause of R1's fall was Resident stated, my leg slid over the bed and I rolled off the bed. V8 stated nobody was on that opposite side of the bed. The facility's General Care policy (revised 7/30/2024) showed, Policy Statement- It is the facility's policy to provide care for every resident to meet their needs 1 Physical needs would include, but are not limited to ADL .2. The facility will assist the resident to meet those needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145899 If continuation sheet Page 4 of 4