Health inspection·August 22, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete intervention; And modifying the intervention as appropriate.Assessment of pressure injury risk. Licensed nurses will conduct a Braden scale tool form on all residents upon admission /re-admission, weekly times 4 weeks, then quarterly or whenever the residents condition changes significantly.The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Example of risk factors include but not limited to [NAME] impaired decreased mobility and decreased functional ability; Comorbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus, resident refusal of some aspect of care and treatment.Use of Support Surface Policy not dated, reads in part: Support surfaces will be used in accordance with evidence based practice for residents with or at risk for pressure injury. Support surfaces will be chosen by matching the potential therapeutic benefit with the resident specific situation. The goal and preferences of the resident and/ or authorized representative will be included in the plan of care and support surface selection. Support surfacess will be utilized in accordance with the manufacturer's recommendation including consideration for contraindication. Event ID: Facility ID: 145994 If continuation sheet Page 2 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services to maintain the highest level of mobility for one of six residents (R14) reviewed for mobility in a sample of 24. Findings include:R14 is an [AGE] year-old male with admission date of 11/24/2022 and diagnosis of not limited to chronic obstructive pulmonary disease and acquired absence of left leg above knee. During record review, R14 was not on any restorative nursing program. R14's Functional Abilities and Goals dated 06/03/2025 indicated R14 needs partial/moderate assistance with chair/bed-to-chair transfer and toilet transfer, and tub/shower transfer. Review of R14's Rehabilitation Screening Form dated 05/06/2025 indicated R14's current level of assistance with transfer was standby assist (SBA). Review of R14's Physical Therapy Discharge Summary on 01/23/2025 indicated R14's functional skills assessment revealed that R14 was independent with chair/bed-to-chair transfer and toilet transfer. On 08/20/2025 at 11:35AM during interview with V6 (Minimum Data Set Coordinator), V6 stated that the facility does not have a Restorative Nurse or Aides, and they currently do not have any residents on restorative nursing programs. On 08/21/2025 at 12:59PM during interview with V5 (Therapy Director), V5 stated that R14 was discharged from Physical Therapy on 01/23/2025 independent with chair/bed-to-chair transfer and toilet transfer. V5 also stated that she screens residents after 3-4 months from discharge to see if they had a decline or improvement with their functional abilities. V5 stated that when she screened R14 on 05/06/2025, R14 was on the same level of functional ability the reason why R14 was not picked up for therapy. V5 stated that she was not aware that R14 declined with transfer abilities, and if so, she could have screened R14 and determined if therapy is needed. Event ID: Facility ID: 145994 If continuation sheet Page 3 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to reduce accident hazards and risks for one of two resident (R100) reviewed for accidents in a sample of 24. Findings include:R100 is an [AGE] year-old female who was admitted in the facility on 10/17/2024 with diagnoses of not limited to history of falling, anxiety disorder, Alzheimer's disease and unspecified dementia. On 08/19/2025 at 9:51AM during unit rounds, V8 (Hospice Certified Nursing Assistant/CNA) was performing incontinence care and assisting R100 with personal hygiene. V8 called for assistance from facility staff to transfer R100 via mechanical lift in which V9 (CNA) responded. V8 placed the reclined chair on the corner at the foot of the bed with the head part closer to the bed. V9 stood on the left side of the reclined chair which was the farther side from R100. V8 controlled the mechanical lift, and no staff was guiding R110's body midair while being transferred by V8. On 08/19/2025 at 9:55AM during interview with V8, V8 stated that V9 should be by R100's leg guiding it while R100 is midair and in the process of being transferred to the reclining chair. On 08/19/2025 at 12:55PM during interview with V9, V9 stated that she was supposed to hold R100's legs to guide and support while R100 is midair and in the process of being transferred to the reclining chair. On 08/21/2025 at 1:10PM during interview with V5 (Therapy Director), V5 stated that there should be two people assisting the resident when being transferred using a mechanical lift. V5 stated that one person is to control the mechanical lift and another person touching and guiding the resident, moving at the same time as the mechanical lift is moved, until the resident is completely transferred to where the resident is to be transferred. Review of R100's Care Plan revised 08/06/2025 indicated that R100 has ADL self-care performance and mobility deficits and interventions include to transfer with mechanical lift with 2-person assist. Review of R100's Minimum Data Set Section GG dated 08/01/2025 indicated that R100 is dependent with chair/bed-to-chair transfer, and Dependent is defined as helper does all of 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. Event ID: Facility ID: 145994 If continuation sheet Page 4 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure infection control measures are implemented and prescribed oxygen inhalation was administered for 10 of 10 residents (R7, R14, R15, R23, R36, R45, R60, R63, R86, R98) reviewed for oxygen in a sample of 24. Findings include: Residents Affected - Some R7 is a [AGE] year-old female admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes mellitus type 2, chronic kidney disease, heart failure, hypertension, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris and peripheral vascular disease. On 8/19/2025 at 11:30 AM, R7 observed sleeping on the bed with oxygen concentrator @ 2LPM (liters per minute), humidification bottle not labeled, via nasal cannula (NC), oxygen tubing located on the floor with no date or labeling on the tubing. No oxygen sign located on doorway, nowhere visible. Oxygen via nasal cannula was not on R7. On 8/19/2025 at 1:00 PM V2 (Director of nurse), made aware of above findings and said it is expected for the nurses to ensure the nasal cannula is on R7 as ordered per physician's order and check R7s oxygen saturation level. Reviewed R7s medical records. R7 admitted on [DATE]. Active physician order shows 2L (2 LITERS) of oxygen O2 via NC continuously to keep SPO2 >92% every shift for oxygen, ordered on 6/23/2025. R7 admitted to Journey Care hospice diagnosis of congestive heart failure on 07/19/2025. Care plan revision date for 8/6/2025 with no respiratory/oxygen care plan. Weights and vitals summary report shows oxygen via nasal cannula was not administered daily per physician's order with no nurse's documentation of patient refusal to wear nasal cannula. Facility's policy on Oxygen AdministrationPurpose: oxygen will be safely administered per physicians' orders. Place oxygen in use sign at the door of the residence room when is use smoking prohibited. Nasal cannula procedure place the nasal cannula into position by having one prong in each nostril adjust the strap for proper fit if hermeneutic humidification is used change humidifier bottle every seven days or as needed may label with date and initial. Policy medication administration- Observe resident consumption of medication. Administer medication(s) according to physician order. 1.R14 is an [AGE] year-old male with admission date of 11/24/2022 and diagnosis of not limited to chronic obstructive pulmonary disease. On 08/19/2025 at 10:51AM during unit rounds, R14 has an undated nasal cannula connected to oxygen concentrator. On R14's nightstand, there is an undated and uncovered nebulizer mask. On 08/19/2025 at 10:54AM during unit rounds with V14 (Registered Nurse), R14 was again observed with an undated nasal cannula connected to oxygen concentrator. At the same time, an undated and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 5 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0695 uncovered nebulizer mask was again observed on R14's nightstand. Level of Harm - Minimal harm or potential for actual harm On 08/19/2025 at 10:54AM during interview with V14, V14 stated that R14's nasal cannula and nebulizer mask should be dated when changed. V14 also stated that the nebulizer mask should be stored in a bag at bedside after each use. Residents Affected - Some Review of R14's Order Summary Report dated 08/20/2025 indicated an order for nebulization treatment with order date of 07/23/2025 2.R63 is a [AGE] year-old male with admission date of 12/28/2014 and diagnosis of not limited to chronic obstructive pulmonary disease. On 08/19/2025 at 10:50AM during unit rounds, R63 has an undated nasal cannula connected to oxygen concentrator. On R63's nightstand, there is an undated and uncovered nebulizer mask. On 08/19/2025 at 10:54AM during unit rounds with V14 (Registered Nurse), R63 was again observed with an undated nasal cannula connected to oxygen concentrator. At the same time, an undated and uncovered nebulizer mask was again observed on R63's nightstand. On 08/19/2025 at 10:54AM during interview with V14, V14 stated that R63's nasal cannula and nebulizer mask should be dated when changed. V14 also stated that the nebulizer mask should be stored in a bag at bedside after each use. Review of R63's Order Summary Report dated 08/21/2025 indicated an order to change nebulizer and tubing weekly and as needed with order date of 10/14/2023, an order for changing oxygen tubing and humidifier bottle as needed and every Wednesday night shift with order date of 03/19/2023, and an order for oxygen at 2-3 liters per minute via nasal cannula at bedtime and day time with order date of 09/28/2020. 3.R86 is an [AGE] year-old female with admission date of 04/18/2025 and diagnoses of not limited to chronic obstructive pulmonary disease, sarcoidosis and obstructive sleep apnea. On 08/19/2025 at 10:04AM during unit rounds, there was an uncovered BiPAP (Bilevel Positive Airway Pressure) mask on R86's nightstand. (BiPAP machine is used to treat sleep apnea.) On 08/19/2025 at 10:58AM during unit rounds with V14 (Registered Nurse), an uncovered BiPAP mask was observed again on R86's nightstand. On 08/19/2025 at 10:58AM during interview with V14, V14 stated that R86's BiPAP mask should be kept in a bag after each use. Review of R86's Order Summary Report dated 08/20/2025 indicated an order for BiPAP while sleeping every evening and night shift with order date of 06/04/2025. 4.R98 is a [AGE] year-old male with admission date of 07/09/2025 and diagnoses of not limited to unspecified asthma and obstructive sleep apnea. On 08/19/2025 at 10:31AM during unit rounds, there was an uncovered CPAP (Continuous Positive Airway Pressure) mask hanging on the side of the metal shelf at R98's bedside. (CPAP machine is most (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 6 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0695 commonly used to treat sleep apnea.) Level of Harm - Minimal harm or potential for actual harm On 08/19/2025 at 10:58AM during unit rounds with V14 (Registered Nurse), an uncovered CPAP mask was observed again on hanging on the side of the metal shelf at R98's bedside. Residents Affected - Some On 08/19/2025 at 10:58AM during interview with V14, V14 stated that R98's CPAP mask should be kept in a bag after each use. Review of R98's Order Summary Report dated 08/20/2025 indicate an order for CPAP use with order date of 07/28/2025. Review of facility's policy entitled Oxygen and Respiratory Equipment- Changing/Cleaning revised on 09/19/2023 indicated the following: Guidelines Purpose: 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 1. Handheld nebulizer and mask, if applicable. a. The handheld nebulizer should be changed weekly and PRN (as needed). b. A clean plastic bag will be provided with each new setup 2. Nasal cannula a. Nasal cannulas are to be changed once a week and PRN. c. A clean plastic bag will be provided to store the cannula when it is not in use. R15 is a [AGE] year-old male resident with diagnoses of but not limited to: hemiplegia and hemiparesis, dementia, type 2 diabetes mellitus, obstructive sleep apnea, and dependence on other enabling machine and devices. On 8/19/25 at 10:20AM, R15 observed to be in bed. Awake and alert. CPAP not in used. On top of side cabinet drawers. Not in plastic bag and left open to air. Next to it is a Nebulizer mask and with tubing not dated. And not stored in plastic bag and left open to air. On 8/19/25 at 11:04AM, V4 (ADON) stated that V4 will change the whole tubing for Nebulizer, since it is not dated and not stored in plastic. V4 stated that without the date, they don't know how long it's been being used. V4 stated that the Neb tubing and Mask is changed weekly, and that is why putting the date is important on the tubing. V4 also stated they store CPAP Mask/and Neb mask in plastic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 7 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0695 bag and do not leave it open to air. To keep it clean. And to follow their infection control practices. Level of Harm - Minimal harm or potential for actual harm Physician order sheet reviewed. R15 has an order for Change nebulizer tubing and mask weekly and as needed dated 5/29/24. CPAP (Continuous Positive Airway Pressure) at bedtime dated 9/9/23. CPAP machine is a common treatment for sleep apnea, helping to keep airways open during sleep by delivering a continuous stream of air. Residents Affected - Some R23 is a [AGE] year-old male resident, with diagnoses of but not limited to: paraplegia chronic respiratory flare, heart failure, morbid obesity, anemia, and neurogenic bowel. On 8/19/25 at 11:40AM. R23 is in bed, alert and awake. Observation and confirmed with V4 (ADON) that the Oxygen Tubing and humidifier not dated and not in storge and not stored in plastic bag and is hanging on Right side rail of R23. Per R23 it was just changed today, and V4 made a comment that V4 is glad that R23 is alert and oriented and able to tell that it was just changed. V4 also stated that the oxygen tubing is changed weekly, and the reason for dating the equipment so the staff would know when to change the tubing. Physician Order Sheet reviewed and R23 has an order for Change oxygen tubing weekly and as needed with an order date of 11/23/24. On 8-19-25 at 10:20 AM, surveyor observed R60's nebulizer mask on the bedside table, open to air, and not stored in a plastic bag. At 10:32 AM, surveyor observed R36's nebulizer mask on the bedside table, open to air, and not stored in a plastic bag. At 11:09 AM, surveyor observed R45's nebulizer mask on the bedside table, open to air, and not stored in a plastic bag and R45's nasal canula on the floor and not stored in plastic bag. On 8-19-25 at 11:34 AM, V10 (Licensed Practical Nurse) said she was not aware of the mask and nasal canula laying open to air on the bedside table and V10 said she will ensure the nebulizer mask will be stored in plastic bag. V10 said the nebulizer mask and nasal tubing should be stored in plastic bag for infection control. On 8-21-25 at 11:01, V1 (Director of Nursing) said nebulizers masks and nasal tubing are stored in plastic bags for infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 8 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately account for controlled medications for four of four residents (R42, R63, R87, R98) reviewed for controlled medications in a sample of 24. Findings include:1. R98 is a [AGE] year-old male with admission date of 07/09/2025 and diagnoses of not limited to unspecified asthma and obstructive sleep apnea. Review of R98's Order Summary Report dated 08/20/2025 indicated an order for Pregabalin 100mg (milligram) one time a day with order date of 07/09/2025. On 08/20/2025 at 10:25AM during medication administration observation with another surveyor, V11 (Licensed Practical Nurse) removed a pill from R98's Pregabalin 100mg blister pack. At 10:40AM after giving the medications to R98, V11 went back to the cart and did not sign R98's Controlled Drug Receipt Record/Disposition Form of Pregabalin 100mg. 2. On 08/20/2025 at 11:38AM during review of controlled medications with another surveyor and V11, the following were noted:1. R42's medication blister pack of Lorazepam 1mg indicated there were 11 pills left and R42's Controlled Drug Receipt Record/Disposition Form of Lorazepam 1mg indicated there were 12 pills left on the blister pack2. R63's medication blister pack of Hydrocodone-Acetaminophen 5-325mg indicated there were 25 pills left and R63's Controlled Drug Receipt Record/Disposition Form of Hydrocodone-Acetaminophen 5-325mg indicated there were 27 pills left on the blister pack3. R63's medication blister pack of Pregabalin 100mg indicated there were 31 pills left and R63's Controlled Drug Receipt Record/Disposition Form of Pregabalin 100mg indicated there were 32 pills left on the blister pack4. R87's medication blister pack of Alprazolam 1mg indicated there were 33 pills left and R87's Controlled Drug Receipt Record/Disposition Form of Alprazolam 1mg indicated there were 34 pills left on the blister pack5. R98's medication blister pack of Pregabalin 100mg indicated there were 9 pills left and R98's Controlled Drug Receipt Record/Disposition Form of Pregabalin 100mg indicated there were 10 pills left on the blister pack On 08/20/2025 at 11:38AM during interview with V11, V11 stated that she has not signed the Controlled Drug Receipt Record/Disposition Form yet of those residents that she gave the medications already. V11 stated that she should have signed the Controlled Drug Receipt Record/Disposition Form after each administration of the medications to the residents. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that nurses are expected to sign the Controlled Drug Receipt Record/Disposition Form after each administration of the medication to the residents. V2 stated that V11 signed R42's R63's, R87's and R98's Controlled Drug Receipt Record/Disposition Form before making copies. R42 is a [AGE] year-old female with admission date of 07/23/2025 and diagnoses of not limited to borderline personality disorder, major depressive disorder, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder. Review of R42's Order Summary Report dated 08/21/2025 indicated an order for Lorazepam 1mg three times a day with order date of 07/23/2025. R63 is a [AGE] year-old male with admission date of 12/28/2014 and diagnosis of not limited to hereditary motor and sensory neuropathy. Review of R63's Order Summary Report dated 08/21/2025 indicated an order for Hydrocodone-Acetaminophen 5-325mg every 4 hours with order date of 04/02/2024 and an order for Pregabalin 100mg two times a day with order date of 06/25/2025. R87 is a [AGE] year-old female with admission date of 02/27/2025 and diagnoses of not limited to anxiety disorder, panic disorder, major depressive disorder and depression. Review of R42's Order Summary Report dated 08/21/2025 indicated an order for Alprazolam 1mg two times a day with order date of 08/19/2025. Review of facility's policy entitled Medication Administration implemented on 01/01/2025 indicated the following:Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 9 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 0755 professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines:21. If medication is a controlled substance, sign narcotic book. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 10 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications are stored securely for two of two residents (R80, R122) reviewed for medication storage in a sample of 14. The facility also failed to label multidose medication with open date which has the potential to affect all 24 residents currently residing in Unit 3, and all potential new admissions in Unit 3. Findings include: R122 is a 73- year- old male admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes mellitus type 2, adjustment disorder with depressed mood, hypertension heart disease without heart failure, atrial fibrillation and peripheral vascular disease. On [DATE] at 11:20 AM, observed a medication cup with multiple medications left at bedside in R122's room and no nurse in the room. On [DATE] at 11:00 AM R122 stated he did not know how long those medications have been sitting on the nightstand. R122 stated he had barely gotten out of his bed to sit in his wheelchair one hour ago. On [DATE] at 11:24 AM, V4 (assistant director of nurse, ADON) said medications should not be left on the nightstand by the nurse and medication administration should be administered by the nurse who prepared the medications. V4 (assistant director of nurse) went into R 122's room and removed the medications from his room. On [DATE] at 11:26 AM V7 (Registered nurse) had first stated she did administer R122 medications in the morning. After being told medications were just observed in R122s nightstand then V7 (registered nurse) said she left the medication at bedside and did not observe the patient take his medications. V7 (registered nurse) was made aware that V4 (ADON) had removed the medications from R122s room. On [DATE] at 1:00 PM V2 (Director of nurse) said V7 (Registered nurse) should have observed R122 take his medication and not leave the medications unsupervised at the bedside. Review of 122's order summary R122 does not have any medications scheduled for 6:00 am morning medications. The medication Admin Audit Report shows 14 medications were administered to the patient approximately 8:00 am. However, on [DATE] at 11:20 am medications were observed in R122's room on nightstand. Record Reviewed, there is no physicians order that states R122 may self-administer medication. Facility's Policy on Medication administration. Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. 18. Observe resident consumption of medication. 19. Administer medication(s) according to physician order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 11 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 1. On [DATE] at 9:56AM during unit rounds, there was medication cup with round, white pill and half of an oval, orange pill at R80's bedside table. On [DATE] at 10:05AM during unit rounds with V4 (Assistant Director of Nursing), there was again a medication cup with round, white pill and half of an oval, orange pill at R80's bedside table. Residents Affected - Some On [DATE] at 10:05AM during interview with V4, V4 stated that there shouldn't be any medications left at the resident's bedside. V4 stated that the pills on R80's bedside table looked like it was spit out. V4 also stated that nurses are expected to make sure that the resident completely swallowed their medications upon administration and before leaving the resident's room. 2. On [DATE] at 10:17AM during medication storage review with V15 (Licensed Practical Nurse), Unit 3 medication refrigerator had an open and undated vial of Tuberculin Purified Protein Derivative. The manufacturer container reads Once entered, vial should be discarded after 30 days. On [DATE] at 10:17AM during interview with V15, V15 stated that the open file of Tuberculin Purified Protein Derivative should be dated when it was opened and be discarded 30 days after it was opened. Review of facility's policy entitled Medication Storage implemented on [DATE] indicated the following: Policy: It it's the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines: c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of facility's policy entitled Medication Administration implemented on [DATE] indicated the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 13. Identify expiration date. If expired, notify nurse manager. 18. Observe resident consumption of medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 12 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review, the facility failed to ensure food items in the walk-in refrigerator were labeled or dated. This practice has the potential to affect all 116 residents residing in the facility who receives food from the kitchen. The facility also failed to document personal refrigerator temperature logs and discard expired food from the refrigerators for seven residents R23, R28, R43, R30, R43, R65 and R72 reviewed for refrigerator logs in a sample of 24 residents.During an initial tour of the kitchen on 8/19/25 at 10:00am, surveyor and V17(Food service Director) observed in the walk-in freezer a sandwich condiment tray containing coleslaw salad, egg salad, lettuce, tomatoes, and sliced turkey with a use by date of 8/15/25. During an interview, at 10:15 am, V17 stated that the condiments tray should not be in the refrigerator. Facility policy dated 1/25/2025 title: Date Marking for Food Safety reads, The facility adheres to a date marking system to ensure the safety of ready- to -eat, time/ temperature control for safety food. Policy explanation and compliance guidelines for staffing: 2.The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. On 8/19/25 at 11:10AM, observed R23's personal refrigerator temperature log sheet filled in up until the 12th of August and after that there is no entered temperature. On 8/19/24 at 11:40AM, observed and confirmed withV4 (ADON) that the temperature log sheet is not completed and that V4 confirmed that temperatures are checked daily. V4 is not aware who is the responsible person checking the personal refrigerators in residents' rooms. R30 is [AGE] year-old female who was admitted in the facility on 04/26/2025 with diagnoses of not limited to type 2 diabetes mellitus and morbid obesity. On 08/19/2025 at 10:24AM during unit rounds, R30's personal refrigerator temperature log for August 2025 indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 10:56AM during unit rounds with V14 (Registered Nurse), R30's personal refrigerator temperature log for August 2025 again indicated last entry of temperature on 08/12/2025. R30's personal refrigerator had undated cut watermelon in a resealable bag. On 08/19/2025 at 10:56AM during interview with V14, V14 stated that R30's food items should be labeled and dated. V14 also stated that he is not sure how frequent the residents' refrigerators are cleaned and temperatures are checked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 13 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that housekeeping staff checks the temperature of the residents' refrigerators daily and cleans it weekly. R65 is [AGE] year-old male who was admitted in the facility on 10/11/2022 with diagnoses of not limited to type 2 diabetes mellitus and chronic kidney disease stage 3. Residents Affected - Many On 08/19/2025 at 11:04AM during unit rounds, R65's personal refrigerator temperature log for August 2025 indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 11:04AM during unit rounds with V14 (Registered Nurse), R65's personal refrigerator temperature log for August 2025 again indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 11:04AM during interview with V14, V14 also stated that he is not sure how frequent the residents' refrigerators are cleaned and temperatures are checked. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that housekeeping staff checks the temperature of the residents' refrigerators daily and cleans it weekly. V2 stated that all food items in the resident's refrigerator should be discarded past the use by date. R72 is [AGE] year-old male who was admitted in the facility on 08/23/2022 with diagnoses of not limited to unspecified dementia and gastro-esophageal reflux disease. On 08/19/2025 at 10:11AM during unit rounds, R72's personal refrigerator temperature log for August 2025 indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 10:55AM during unit rounds with V14 (Registered Nurse), R72's personal refrigerator temperature log for August 2025 again indicated last entry of temperature on 08/12/2025. R72's personal refrigerator had unlabeled and undated food items in the dessert cup and soup bowl. It also had 8 peach yogurts, one each with use by dates of 12/30/2024, 07/05/2025 and 07/31/2025 respectively, two with use by dates 05/15/2025, and three with use by date 05/22/2025. On 08/19/2025 at 10:55AM during interview with V14, V14 stated that R72's food items should be labeled and dated, and R72's yogurts should have been discarded before the use by date. V14 also stated that he is not sure how frequent the residents' refrigerators are cleaned and temperatures are checked. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that housekeeping staff checks the temperature of the residents' refrigerators daily and cleans it weekly. Review of R72's care plan revised 08/18/2025 indicated R72 has the tendency to store and keep items/food items in his room or refrigerator with interventions including check items that should be discarded, check expiration date of food, and offer to throw away as he allows. Review of R72's Progress Notes from May 2025 to present did not indicate any refusal of discarding food items from R72's refrigerator. Review of facility's policy entitled Resident Refrigerators implemented on 08/01/2025 indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 14 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 Policy: This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary any resident-owned refrigerators. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: Residents Affected - Many 2. Staff shall record refrigerator temperatures weekly on a temperature log 3. Staff should clean the refrigerator weekly and discard any foods that are out of compliance. 4. Residents and staff shall comply with safe food handling and storage principles: b. Leftovers shall be dated upon receipt and discarded within three days. c. Foods with use-by dates shall be discarded accordingly. d. Any food with potential concerns (i.e. smell, packaging, appearance, frozen foods are not solid to touch) shall be discarded. 8. Noncompliance with safety and sanitation requirements of this policy will result in the removal of the refrigerator from the resident's room. On 8-19-25, surveyor observed R43's (at 10:27 AM) and R28's refrigerator logs with documented temperatures up to August 12,2025 with no further refrigerator temperatures documented. On 8-19-25 at 11:34 AM, V10 (Licensed Practical Nurse) said the refrigerator temperatures are checked and documented by the night shift nurse daily. On 8-22-25 at 11:01 AM, V2 (Director of Nursing) said the housekeeper is responsible for checking refrigerator temperatures and documenting on the log sheet. V2 said the refrigerator logs were overlooked when this task was not assigned when the housekeeper was not on duty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 15 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control measures during medication administration procedures for four of four residents (R3, R21, R30, R39) reviewed for medication administration in a sample of 24. Findings include:1. R21 is an [AGE] year-old male with admission date of 08/19/2025 and diagnosis of not limited to hyperlipidemia. On 08/20/2025 at 9:36AM during medication administration observation with another surveyor, V10 (Licensed Practical Nurse) disinfected a scissor with disinfectant wipes while wearing gloves then immediately proceeded to cutting the top of R21's Omega-3 fatty acids soft gel capsule without performing hand hygiene and changing gloves. On 08/20/2025 at 9:51AM during interview with V10, V10 stated that she should have performed hand hygiene and changed gloves before she cut R21's Omega-3 fatty acids soft gel capsule. Review of R21's Medication Administration Record for August 2025 indicated that V10 partially administered R21's crushed medications to R21 on 08/20/2025. Review of R21's Order Summary Report dated 08/21/2025 indicated R21 has orders for may crush medications and administer in food or liquids unless contraindicated with order date of 08/19/2025, and Omega-3 Fatty Acids Capsule 1000 mg (milligrams) one time a day with order date of 08/19/2025. 2. R3 is a [AGE] year-old male with admission date of 08/15/2025 and diagnosis of not limited to Klebsiella pneumonia as the cause of diseases classified elsewhere. On 08/20/2025 at 10:02AM during medication administration observation with another surveyor, V4 (Assistant Director of Nursing) while being observed by the facility's unit manager orientee, prepared the R3's intravenous (IV) antibiotic while wearing gown, gloves and mask. V4 was unable to remove air bubbles from the IV tubing so she asked the unit manager orientee to get her another bag of IV antibiotics. While waiting for the new bag of antibiotics, V4 patted R3 on R3's right arm apologizing for the delay. When the unit manager orientee came back and handed her the bag of IV antibiotics, V4 immediately proceeded with preparing the IV antibiotic without performing hand hygiene and changing gloves. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that V4 was expected to perform hand hygiene and change gloves after she touched R3 and before V4 prepared the new bag of IV antibiotics. Review of R3's Order Summary Report dated 08/21/2025 indicated R3 was admitted on [DATE] and has an order for Ertapenem sodium solution 1 gram intravenously in the morning with order date of 08/17/2025. Review of facility's policy entitled Hand Hygiene implemented on 01/05/2025 indicated the following:Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Policy Explanation and Compliance Guidelines:2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table conditions included after handling contaminated objects, before preparing or handling medications, and before and after handling clean or soiled dressings, linens, etc. 3. R30 is [AGE] year-old female who was admitted in the facility on 04/26/2025 with diagnoses of not limited to type 2 diabetes mellitus and morbid obesity. On 08/20/2025 at 11:32AM during medication administration observation with another surveyor, V11 (Licensed Practical Nurse) placed the blood glucose monitoring machine on R30's bedside table without placing a barrier before pricking R30. On 08/20/2025 at 11:37AM during interview with V11, V11 stated that she should have placed the blood glucose monitoring machine on the tray that she has instead of the bedside table. Review of R30's Medication Administration Record for August 2025 indicated that V11 performed blood glucose monitoring on R30 on 08/20/2025. 4. R39 is a [AGE] year-old female who was admitted in the facility on 06/19/2025 with diagnosis of not limited to type 2 diabetes mellitus. On 08/20/2025 at 11:51AM during medication administration Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145994 If continuation sheet Page 16 of 17 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 145994 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067 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 FORM CMS-2567 (02/99) Previous Versions Obsolete observation with another surveyor, V12 (Licensed Practical Nurse) placed the blood glucose monitoring machine on R39's bedside table without placing a barrier before pricking R39. On 08/20/2025 at 11:37AM during interview with V12, V12 stated that she should have brought a tissue with her and placed it on the bedside table then she could have placed the blood glucose monitoring machine on that tissue. Review of R39's Medication Administration Record for August 2025 indicated that V12 performed blood glucose monitoring on R39 on 08/20/2025. Review of facility's undated document entitled Blood Glucose Testing Competency indicated the following:Competency/Skill:5. Places clean paper towel or clean barrier and places supplies on surface. Event ID: Facility ID: 145994 If continuation sheet Page 17 of 17