Health inspection·June 7, 2025

F 0657 for R1-R6's care plan meeting for the past year. V9 stated care plan meetings had not been held. Level of Harm - Minimal harm or potential for actual harm On 6/6/25 at 4:41 PM, V2 DON (Director of Nursing) stated social services is responsible for arranging residents care plan meetings. Care plan meetings are attended by the residents if they are alert, their family member, social services, wound care infection preventionist, unit manager, dietary, nurse practitioner or physician. V2 stated if nursing is unable to attend the meeting the Social Worker will call nursing after the meeting for clinical input. Residents Affected - Some On 6/6/25 at 5:50 PM, V1 (Administrator) stated care plan meeting should be held on admission, quarterly and as needed for long term care residents. V1 stated care plan meeting are done in real time and includes the resident and family member. Families can participate by phone if they choose. Care plan meetings are to include the Interdisciplinary team. V1 stated she was unaware care plan meetings were not being held. The facility policy Care Planning - Interdisciplinary Team dated September 2013 states the care plan is based on the resident's comprehensive assessment and is developed by a care planning / interdisciplinary team which includes, but is not limited to the resident's attending physician, the registered nurse who has responsibility for the resident, the dietary manager, dietician, social worker, activity director, therapist, charge nurse, nursing assistants and others as appropriate or necessary to meet the needs of the resident. The resident, resident's family and / or legal representative, guardian or surrogate are encouraged to participate in the development and revision of the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to have physician-ordered medications available. This applies to 3 of 7 residents (R1, R2 and R3) reviewed for medication availability in a sample of 6. Findings include: 1.On 6/6/25 at 7:55 AM, V3 (Family Member) stated she refills R1's medications from an outside pharmacy. V3 stated most of the medications are on auto-refill, but there are times the facility runs out of medication and don't notify her that a refill is needed. On 6/6/25 at 12:24 PM, the medication cart was reviewed with V5 LPN Licensed Practical Nurse assigned to R1 and R2. R1's regularly scheduled medications Ammonium Lactate 12% cream that are to be applied to the bottom of both feet every evening, and propylene glycol-glycerin 1-0.3% that are scheduled one drop to both eyes two times per day were not available. R1 had orders for Albuterol Sulfate inhalation aerosol solution 108 (90 base) MCG (Micrograms) that is taken every four hours as needed for wheezing related to chronic obstructive pulmonary disease that was also unavailable. V5 LPN stated for R1 refill prescriptions are printed out signed by the physician and given to V3 Family Member to have medications filled. V5 stated when nursing sees the medications are running low, they should inform the V3. 2. On 6/6/25 at 11:25 AM, R3 stated the facility has run out of her pain medication in the past. On 6/6/25 at 1:03 PM, the medication cart was reviewed with V6 LPN assigned to R3. R3's unavailable medications that were scheduled were lidocaine 5% cream the is applied once per day to the AV (arteriovenous) fistula Monday thru Friday, and fluticasone- umeclidinium vilanterol 100-62.5-25 MCG inhalation aerosol powder administered daily. R3's unavailable as-needed medications were guaifenesin extended release 600 mg (Milligrams) given every 12 as needed for cough, and hydrocortisone 1% cream applied twice per day and every 6 hours as needed for hemorrhoid. V6 LPN stated medication refill request can be reordered in the electronic medical record or faxed to the pharmacy. V6 stated she hadn't reordered any medications that day. 3.On 6/6/25 at 10:25 AM, R2 stated the facility has previously run out of her hydrocodone/ acetaminophen in the past. On 6/6/25 at 12:24 PM when the cart was reviewed with V5, R2's unavailable medications were Menthol topical analgesic 2.5% that is applied every four hours as needed for pain, guaifenesin extended release 600 mg (Milligrams) given every 12 hours as needed for cough, lidocaine 4% external patch applied every 24 hours as needed for pain, Miconazole Nitrate 2% cream applied twice daily and as needed, sodium chloride nasal solution 0.65% that is given every eight hours as needed for congestion and polyethylene glycol 0.4-0.3% that is given every six hours as needed. V5 stated R2's medications are ordered through the electronic medical record by clicking a button. On 6/6/25 at 4:41 PM, V2 DON (Director of Nursing) stated residents should have a three-day supply of medications available. The nurses should reorder medications. As needed medications should always be available to administer when needed. Nursing should inform family members if a refill is needed on prescriptions three days to a week in advance of them running out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 6/6/25 at 5:50 PM, V1 (Administrator) stated nurses should order medications before they run out. Her expectation was that outside medications are provided only when the resident is there for a respite stay, but she would need to review the policy. The facility policy Reordering, Changing and Discontinuing Orders dated 10/31/16 states facilities are encouraged to reorder medications electronically. Reorders can be written and submitted on the refill order form, submitted verbally or faxed if permitted by applicable law. Event ID: Facility ID: 146093 If continuation sheet Page 4 of 4