Health inspection·June 5, 2024

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. Based on observation, interview, and record review the facility failed to ensure that inhaler medication was labelled appropriately, was ordered by physician, and locked in a medication cart when not in visual proximity of the nurse and not in use to prevent tampering and hazard for two residents (R4 and R5) in the sample of 8 residents. Findings include: On 05/30/24 at 10:29am, R5 was observed in bed with inhaler medication noted on the over the bed table. Symbicort budesonide 80mcg, Formoterol Fumarate Dihydrate 4.5mcg inhaler aerosol 80/4.5 and Latanoprost (4 tubes) not in manufacturer's package, without a name or pharmacy label. R5 stated R5 uses the inhaler and needs it. At 10:32am, when this observation was shown to V21 LPN (Licensed practical Nurse) and was asked about the facility policy and protocol on professional standard of medication storage, and medication administration, V21 stated no medication should be left at the bedside unless it is ordered, and it should be labeled with name of the patient and administration direction. V21 said, I should get a plastic bag to put them in and I will check for the inhaler and the eye drop order for whether it should be kept at the bed side. At 10:38am, the surveyor and V21 checked R5's physician order and MAR (medication Administration Record). There was no order for the inhaler and no order to leave at the bedside. On 05/30/24 at 10:53 am R4 was observed in bed, with Symbicort inhaler noted on the over bed table with no label, no name, not in manufacturer's package. R4 stated, I use it every morning. At 10 57am, when this observation was brought to R6 RN (Registered Nurse) case manager's attention, V6 stated the medication should not be stored at bed side unless ordered. After checking the MAR and physician order in R4's electronic medical record, V6 stated there is no order for the medication. V6 said, It may be that the family brought it for (R4). We don't randomly check their (residents) belongings so how can we know they have these medicines? When asked about the facility protocol/policy on medication storage and administration, V6 stated, If they have an order, then they can keep meds (Medicine) at the bed side but if they don't there is no way we will know if they have it or not. V6 stated, The medication storage should be kept locked in the cart and for wound care medications they are locked in the treatment cart. On 05/30/24 at 4:08pm, V2 DON (Director of Nurse's) stated in part that medication should be stored properly, locked away and it should be properly labelled with name and direction of use. The facility policy on Storage of Medications with effective date 10/25/24 documented in part that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only by licensed nursing personnel, pharmacy, personnel, or staff members lawfully authorized to administer medications. Listed procedures include but not limited to medication supplies are locked when not attended by persons with authorized access and medications labelled for individual residents are stored separately from floor stock medications when not in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649 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 provide a safe and functional environment by not ensuring the shower room floor tiles had non-skid tape attached to prevent accidental hazards. This failure has the potential to affect 142 residents residing on the 1st, 2nd, and 3rd, floor out of 193 residents. Findings include: On 05/30/24 at 11:52am, on the 3rd floor shower room in two shower stalls the six floor tiles were missing non-skid grip tapes and some were rolled up. V4 (Maintenance Director) who was present during this environment observation, stated there should be a non-skid tape on each of the tiles on the floor. At 12:02pm, 2nd floor shower room was observed with water puddle noted on the floor under the wash sink. The floors had two of the shower stalls with missing non-skid tapes. On 06/03/24 at 10:20am, the 1st floor shower stall was observed wet with peeling non-skid tape and some peeling off. V10 CNA (Certified Nurse's Aide) stated that all the residents' showers are done in the shower room. At 10:28am, V5 (Housekeeping) was made aware of the observation and was asked about the facility policy on wet floor and cleaning of the shower rooms. V5 stated that the housekeepers, and the flow tech are responsible for cleaning the shower rooms and if there is a problem the maintenance Director is called to see the problems for any repair. At 10:30am when the 1st floor shower room missing non-skid tape were shown to V4 (Maintenance Director), V4 stated V4 ran out of tape and there is no more non-skid tape to replace the missing ones. V4 stated V4 was not aware that these were missing. The surveyor asked V4 about the importance of the floor non-skid tape and what could happen if the floors are not repaired. V4 stated it is for the resident, so that they will not fall when the shower floors are wet. On the 2nd shower stall the drainage cover was coming loose. V4 stated this should be fixed. V4 stated that staff should let V4 know as soon as there is any needed maintenance work. V4 said, Some of them still use the maintenance book log on the floor but we are now switching to the computer form where I will check and correct whatever the problem is. Right now, I (V4) am trying to correct most of these things that are broken. At 11:30am, V2 DON (Director of Nurse's) stated that the bathroom's floor (referring to shower room floors) should have a non-skid floor. When asked about where the staff should the staff report any problem regarding maintenance, V2 stated they are to put it on a maintenance log located at the nurse's station. When asked about the importance of non-skid floor, V2 stated to keep people from slipping. As at 06/03/24 at 4:15pm, the facility was unable to provide any work order for the floor non skip tapes repair. The facility job description for Director of Maintenance documented that the purpose of the job position is to plan, organize, develop, and direct the overall operation of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulation governing the facility and as may be directed by the Administrator, to assure that (the) is maintained in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 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 145977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Shore Rehabilitation 2425 East 71st Street Chicago, IL 60649 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 safe and comfortable manner. Listed duties and responsibilities include but not limited to ensuring that supplies, are maintained to provide a safe and comfortable environment. Place orders for equipment and supplies as necessary or as may require. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 4 of 4