Inspection·July 9, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the morning of [DATE], R2's nurse informed her R2's room was warm. V10 stated she went to check R2's room and it was hot, so she provided R2 with a fan. V10 stated R2 had heavy breathing and was asleep. V10 stated she was informed by V9 in the afternoon R2 was lethargic. V10 stated she told V9 to get R2's vital signs and inform the doctor. V10 stated she never told V5 nor V9 she would call to inform R2's doctor of his change in condition. V10 stated she did not call the doctor regarding R2's change of condition. V10 stated she never went to see R2 after she was informed of R2's change of condition.On [DATE] at 10:05am V11 (LPN) stated she was informed at the beginning of her shift (7pm) R2 did not look good. V11 stated she assessed R2, called the doctor and received orders to transfer R2 out to the hospital.On [DATE] at 12:44pm V2 (Director of Nursing/DON) stated a change in level of consciousness would be considered a change of condition. V2 stated after a true change of condition is identified, the doctor should be called immediately. V2 stated if there is a problem with a resident, the manager on duty should go look at the resident. V2 stated V5 (LPN) telling V8 (CNA) to continuously call R2's name was not an appropriate intervention. V2 stated the physician should have been made aware at the time R2's altered mental status was discovered.On [DATE] at 5:36pm V15 (Medical Doctor/MD) stated she was on call until 5pm on [DATE]. V15 stated she was never made aware of R2's change of condition. V15 stated if she would have been made aware, she would have had the nurse to triage R2 and depending on R2's vital signs and symptoms, gave orders.R2's progress note dated [DATE] at 8:05am documents in part, Resident is alert and oriented, able to make needs known.R2's progress note dated [DATE] at 7:54pm documents in part, Shortness of breath, unresponsiveness, seems different than usual .weak, confused, or drowsy at the time of evaluation.Review of R2's record shows no entry before the change of condition note dated [DATE] at 7:54pm for R2's change of condition. Review of R2's records show no indication R2's physician was notified before the change of condition note entered on [DATE] at 7:54pm.R2's hospital record dated [DATE] documents in part, Nursing home patient presents by the paramedics in cardiac arrest. Paramedics called the nursing home for mental status changes and found the patient lethargic, hypoxic and agonal breathing. Patient lost heart rate and respirations at the nursing home. Patient intubated en route . Present asystole with no pulse . Disposition: Expired.R2''s care plan dated [DATE] documents in part, Resident has the following advance directives: Living Will, POLST (Physician Orders for Life Sustaining Treatment) CPR (Cardiopulmonary Resuscitation) . Resident is a FULL CODE - if resident becomes unresponsive, call for help immediately and begin Basic Life Support sequence.Facility's policy titled Resident Rights Guideline dated 11/2024 documents in part, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times .Our facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility protects and promotes the resident of the residents .All residents have the right to equal access to quality care regardless of a diagnosis, severity of condition, or payment source.Facility's policy titled Acute Condition Changes - Clinical Protocol dated 08/2008 documents in part, Assessment and Recognition .1. As part of the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; the Nurse shall assess and document/report the following: a. Vital signs b. Neurological assessment c. Change in level of consciousness, memory, or mood . f. Onset, duration, severity .5. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145977 If continuation sheet Page 2 of 3 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 07/09/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete response.Facility's job description titled Licensed Practical Nurse (LPN) undated, documents in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations govern our facility, and as may be required by the Director of Nursing to ensure the highest degree of quality care is always maintained.Based on interview and record review the immediacy was removed on [DATE]. The facility took the following steps to remove the immediacy.1. On [DATE]rd, 2025, all 196 residents were immediately assessed by a licensed nurse, and attending physician immediately notified with any acute changes of condition. No additional residents were identified with an acute change of condition. These actions were completed by the DON (Director of Nursing) and all nurse managers.2. The DON and six nurse managers have conducted a comprehensive review on 196 residents to identify any other residents who may be at risk for change of condition.3. The facility has ensured all residents identified as at-risk, both new and readmitted , have individualized care plans specifically addressing any residents with an acute change of condition.4. Full house in-servicing (clinical, and non-clinical staff) and training on acute condition change, notification of change guidelines for recognizing a change of condition, and E-interact Stop and Watch. Any agency and nursing staff (nurses and aides) who have not been scheduled to work (PRN staff), vacation or medical leave must complete acute change in condition in-service/education prior to working. Agency staff will be educated prior to working. This training was initiated on [DATE] and completed by [DATE].5. Audit all transfers, both emergent, and non-emergent daily X 14 days then 3X weekly for 4 weeks to ensure staff have followed policy and procedure for resident acute change of condition, and MD notification. Audit process began on [DATE] and is ongoing. Audit will consist of resident name, date of transfer, type of transfer, change of condition, Stop/watch tool completion, timely notification of MD/NP (Nurse Practitioner) notification. These audits completed by DON and six nurse managers.6. Documentation will be reviewed daily through the facility's 24-hour report to monitor for any acute change of condition and ensure prompt provider notification. The audit will include the following: confirmation the 24-hour report was reviewed, whether any change of condition was noted, and if so, whether the Stop and Watch tool was completed, the eINTERACT assessment was completed. The audit process began on [DATE] and is ongoing for 14 days daily, then three times weekly for four additional weeks. Review will be done by DON and nurse managers.7. Ad Hoc (for this situation) QAPI will be completed upon acceptable abatement8. 1:1 training was done for V5 (LPN) regarding recognizing and reporting changes of condition, escalation process for emergent clinical changes, and timely documentation and physician notification and V9 (RN) regarding recognizing and reporting change of condition, and timely MD notification.9. All staff educated and in-serviced by DON and nurse managers on acute changes of condition, emergent clinical changes, and timely notification of MD with any acute resident changes. Employees who have not worked, will receive education prior to start of next shift. Event ID: Facility ID: 145977 If continuation sheet Page 3 of 3