Inspection·December 13, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm properly self-administer the medication but also follow the proper frequency of how often the medication is administered. R58 is alert and oriented x3. At this time, I cannot think of any reason that would prevent R58 from administering the medication in a safe manner. 2.) Residents Affected - Few R79's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic obstructive pulmonary disease, unspecified, major depressive disorder, recurrent, unspecified, hypertensive heart disease without heart failure, hyperlipidemia, unspecified, gastro-esophageal reflux disease without esophagitis. Care plan (dated 10/23/2024) documents that R79 has a diagnosis of chronic obstructive pulmonary disease (COPD) and exhibits the following symptoms; easily fatigued, periods of confusion due to low oxygenation, anxiety and requires medication, oxygenation, shortness of breath placing resident at risk for death. Minimum Data Set (MDS) section C (dated 10/29/2024) documents that R79 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R79's cognition is intact. On 12/09/2024 at 11:42AM, R79 stated, I have chronic obstructive pulmonary disease (COPD) and if I have an exacerbation of shortness of breath, I should have my rescue albuterol inhaler at bedside. I don't have the rescue inhaler because when I asked several different nurses if I can keep it with me, the nurses said that they are not allowed to leave any medications at bedside. If I have an exacerbation, by the time I call for assistance and by the time the nurse responds, I will be in trouble and that's why I should have my albuterol inhaler with me. I have told many different nurses at different times about wanting to keep my rescue inhaler and I was never assessed for self-administration of the inhaler. Nobody assessed me for proper self-administration, they just told me that I cannot have it. On 12/09/2024, at 11:52AM, surveyor performed an inspection of the nursing medication cart which contained the medications for R58 and R79. V8 (Licensed Practical Nurse) was present at the time that the surveyor inspected the medication cart. Surveyor observed that R58 and R79's albuterol sulfate HFA aerosol inhaler was being stored inside the nursing medication cart. On 12/9/24 at 2:43PM, V2 (DON) stated, R79 has COPD. To my knowledge, R79 did not request to have his rescue albuterol inhaler at bedside. We need to assess R79 for proper self-administration of the albuterol inhaler. Based on the outcome of the assessment, if R79 is able to self-administer the albuterol medication properly, then we have to call the doctor and get the order allowing the resident to have the medication at bedside. Medications are not left at bedside for safety purposes. If a resident wishes to keep the medication at bedside, the resident must be assessed, and the medication must be stored somewhere outside of the reach of other residents. R79 never mentioned to me that he wanted the rescue albuterol for his COPD at bedside. R79 is alert and oriented x3. At this time, I cannot think of any reason that would prevent R79 from self-administering the medication in a safe manner. R79's Physician Order (dated 10/23/2024) states: albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation: Every 6 Hours - PRN (as needed). Medication Administration Policy (dated 03/2022) documents in part: Residents who indicate a desire (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 2 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to self-administer medications will be assessed by the interdisciplinary care plan team using an assessment tool. Assessment results will be provided to the physician for approval. Residents will be allowed to self-administer medications only when the attending physician has written as order. Self-administered medications use and response will be monitored by licensed nurses. Self-Administration and Medication Storage Policy (dated 02/2014) states in part: To provide guidelines for self-administration of drugs/biologicals and their storage in the resident's room. Policy Specifications; (1.) Residents who request to self-administer drugs will be assessed at the time of admission or thereafter, to determine if the practice is safe, based on the results of the self-administration of medication form. (2.) The assessment results will be communicated with the attending physician and an order obtained to self-administer, if appropriate. Event ID: Facility ID: 146149 If continuation sheet Page 3 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a call light was within reach of one resident (R32) reviewed for the call light system. Residents Affected - Few Findings include: 12/9/24 at 12:00 PM, observed R32's bed and call light placement. R32's bed was placed along one wall lengthwise. R32's call light was placed on the adjacent wall of the bed on the other side of the closet that was at the foot of the bed in the corner of the two walls. Surveyor asked R32 if R32 could reach the call light. R32 said I have to get up to get it. V2 (Director of Nursing/DON) joined surveyor in R32's room. V2 stated there is no way for R32 to reach the call light. 12/9/24 at 3:00 PM, V2 (DON) stated the purpose of call lights is to alert the staff that the resident needs help. The resident pulls the cord to activate the call light. The cord needs to be in the resident's reach. If R32 were in bed R32 could not reach the call light to alert staff that R32 needs help. R32 can call out if she needs help. 12/11/24 at 2:25 PM, V1 (Administrator) stated I expect the call lights to be within reach and the resident to be able to use them. When a staff person goes into the rooms, they should check the call light is within reach and functioning. Facility policy Answering the Call Light, August 2008, documents in part: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 4 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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, facility failed to administer medications timely and failed to follow the facility's medication administration policy for 7 residents (R13, R48, R62, R64, R71, R90, R98) out of 7 residents reviewed for medication administration in a sample of 21 residents. Findings Include: On 12/09/2024 at 10:11AM V5 (Licensed Practical Nurse/LPN) was observed during medication administration. V5 had 7 residents (R13, R48, R62, R64, R71, R90, R98) that did not receive their scheduled 9:00AM medications. V5 stated, On a regular day, when I work a shift, I am usually done passing medications to all by residents by 10:15 AM. I try my best to finish my morning medication administration on time, but I work with many different residents who ask for things in a specific way. I always try to do my best to accommodate every resident's request and it takes more time to finish my medication administration by 10:00 AM. I keep my residents happy and accommodate their needs and that's why I can't finish the morning medication on time. Some residents want to talk to me and share things with me when I go in to administer their morning medications and I don't want to rush the residents and that is another reason why I am not done on time. On 12/10/2024 at 8:55 AM, V3 (Assistant Director of Nursing) stated, The medications that are scheduled at 9:00 AM, the nurse can give the medications starting at 8:00 AM, which is one hour before the scheduled time, and the nurse can give the medications up to 10:00 AM, which is one hour after the scheduled time. Anything that is administer past the 1-hour window of the scheduled time is considered late. If a nurse still has medications to pass after 10:00 AM, the nurse must go to the resident and explain why the medication is late. If a nurse needs help with the medication administration, they can call the director of nursing or myself (assistant director of nursing) for assistance. The physician must be notified when a resident is given medications past the regular window of 1 hour before/after the medication is scheduled. 1.) R13's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: hypertensive heart disease without heart failure, schizoaffective disorder, unspecified, pure hypercholesterolemia, unspecified, hypothyroidism, unspecified. Care plan (dated 08/01/2024) documents that R13 uses antipsychotic/mood stabilizing medication (clozapine and Depakote) due to schizoaffective disorder. Care plan documents that R13 has hypertension. R13's scheduled 9:00 AM medication as per the physician orders are: Atropine drops 1% amt: 1 drop; ophthalmic (eye) Benztropine tablet 1mg oral tablet Clozapine 100mg tablet 1 tablet Divalproex 500mg delayed release 1 tablet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 5 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 Dorzolamide drops 2% 1 drop in both eyes Level of Harm - Minimal harm or potential for actual harm Lisinopril 5mg tablet 1 tablet Timolol Maleate 0.5% drops Residents Affected - Some Flomax 0.4mg capsule 1 capsule 2.) R48's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Type 2 diabetes mellitus without complications, major depressive disorder, single episode, unspecified, alcohol use, unspecified with intoxication, unspecified, bipolar disorder, unspecified, anxiety disorder due to known physiological condition. Care plan (dated 10/04/2024) documents that R48 receives antianxiety medication related to major depression and alcohol intoxication. The care plan documents that R48 receives antidepressant medication R/T Major Depression and alcohol intoxication. R48's scheduled 9:00 AM medication as per the physician orders are: Sertraline 50mg tablet 1 tablet. Glipizide 10mg tablet 1 tablet Gabapentin 300mg capsule 1 capsule 3.) R62's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Multiple sclerosis, major depressive disorder, recurrent severe without psychotic features, epilepsy, unspecified, not intractable, without status epilepticus, hyperlipidemia, unspecified. R62's Care plan (dated 05/07/2024) documents that R62 has feelings of depression, isolative tendencies, hard time trusting others, anxiety, and history of engaging in substance abuse related to major depression disorder. R62's scheduled 9:00 AM medication as per the physician orders are: Propranolol 10mg tablet 1 tablet Sodium Chloride 1,000mg tablet 1 tablet Lexapro 20mg tablet 1 tablet Levetiracetam 500mg tablet 1 tablet Clonazepam 0.5mg tablet 1 tablet Gabapentin 300mg capsule 2 capsules Topamax 50mg tablet 1 tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 6 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 Wellbutrin XL extended release 150mg tablet, 1 tablet Level of Harm - Minimal harm or potential for actual harm 4.) R64's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, major depressive disorder, recurrent, unspecified, other specified chronic obstructive pulmonary disease, schizoaffective disorder, unspecified, bipolar disorder, unspecified, gastro-esophageal reflux disease without esophagitis. Residents Affected - Some Care plan (dated 09/11/2024) documents that R64 receives hypnotic medication related to major depression and generalize anxiety. R64's scheduled 9:00 AM medication as per the physician orders are: Amlodipine 5mg tablet 1 tablet Clonazepam 1mg tablet 1 tablet Escitalopram 10mg tablet 3 tablets [NAME] Thyroid 30mg tablet 1.5 tablet (45mg) Lipitor 10mg tablet 1 tablet 5.) R71's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Chronic obstructive pulmonary disease, unspecified, Major depressive disorder, recurrent, unspecified, Hypertensive heart disease without heart failure, Suicidal ideations. Care plan (dated 09/29/2024) documents that R71 receives antidepressant medication R/T Major depression. R71's scheduled 9:00 AM medication as per the physician orders are: Amlodipine 5mg tablet; 1 tablet Budesonide-formoterol HFA aerosol inhaler, 80-4.5mcg/actuation 2 puffs Escitalopram Oxalate 10mg tablet 1 tablet Escitalopram Oxalate 5mg tablet 0.5 tablet Lisinopril 20mg tablet 1 tablet Plaquenil 200mg tablet 1 tablet 6.) R90's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, generalized anxiety disorder, unspecified asthma, uncomplicated, hyperlipidemia, unspecified, major depressive disorder, recurrent, unspecified. Care plan (dated 01/30/2024) documents that R90 has shortness of breath (dyspnea) when lying flat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 7 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 related to asthma. Level of Harm - Minimal harm or potential for actual harm R90's scheduled 9:00 AM medication as per the physician orders are: Clopidogrel 75mg tablet 1 tablet Residents Affected - Some Venlafaxine capsule 150mg extended release 1 capsule. Rosuvastatin 10mg tablet 1 tablet Protonix 40mg tablet 1 tablet Metoprolol Succinate 25mg extended-release tablet 1 tablet 7.) R98's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Care plan (dated 08/15/2024) documents that R98 has a diagnosis related to hypertension. R98's scheduled 9:00 AM medication as per the physician orders are: Carvedilol 3.125mg tablet 1 tablet Clonidine HCL 0.1mg tablet 1 tablet Amlodipine 10mg tablet 1 tablet Amoxicillin 875mg tablet 1 tablet Baclofen 5mg tablet 0.5 tablet Bumetanide 1mg tablet 1 tablet Carvedilol 6.25mg tablet 1 tablet Clonidine HCL 0.1mg tablet 1 tablet Entresto 24-26mg tablet 0.5 tablet Isosorbide Dinitrate 10mg tablet 1 tablet Lantus U-100 unit/mL 15 units Loperamide 2mg capsule 1 capsule Metolazone 5mg tablet 1 tablet Metoprolol Succinate 25mg extended-release tablet 1 tablet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 8 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 Rosuvastatin 40mg tablet 1 tablet Level of Harm - Minimal harm or potential for actual harm Spironolactone 25mg tablet 1 tablet Gabapentin 100mg capsule 1 capsule Residents Affected - Some Medication Administration Policy (dated 03/2022) documents in part: Drugs will be administered in accordance with orders of licensed medical practitioners of the State in which the facility operates. Medications shall be administered one (1) hour before/after of the medication schedule unless specifically ordered otherwise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 9 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 - 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store insulin medications and gastrostomy tube (g-tube) feeding extension tubing supplies. This failure impacted 2 residents (R14 and R53) who had expired insulin inside the medication cart during inspection. This failure also resulted in expired gastrostomy tube feeding extension tubing supplies being found in the medication storage room. Finding Include: On 12/09/24, at 12:49 PM, the 1st floor Medication Cart # 3 was inspected with V20 (Licensed Practical Nurse/LPN). R14's Novolog FlexPen U-100 Insulin (insulin aspart u-100) was found in drawer, marked with the open date of 07/24/2024, and marked with the expiration date of 08/21/2024. Surveyor found 3 10mL (milliliter) syringes marked with the expiration date of 09/30/2024. On 12/09/24 at 1:14 PM, surveyor inspected 1st floor medication cart #2 with V9 (LPN). Surveyor found R53's Basaglar Kwik Pen (insulin glargine injection) in the drawer, marked with the open date of 11/21/2024, and marked with the expiration date of 11/29/2024. Surveyor found a second Basaglar Kwik Pen (insulin glargine injection), marked with the open date of 11/23/2024 and no expiration date. On 12/10/2024, at 9:50 AM, the 1st floor medication storage room was inspected by the surveyor. The surveyor found 9 expired (Brand Name) Nutrition Delivery System Safety Spike Plus Pump Set (g-tube connection tubing) with the expiration date of 03/28/2024. Surveyor found 1 expired pre-filled 0.9% Normal Saline Flush (10mL) with the expiration date of 11/21/2024. Surveyor found 5 expired (Brand Name) System Continu-Flo Solution Set (g-tube connection tubbing) with the expiration date of 10/16/2024. Surveyor found 3 expired (Brand Name) System Continu-Flo Solution Set (g-tube connection tubbing) with the expiration date of 11/25/2024. On 12/09/2024, at 3:02 PM, V2 (Director of Nursing) stated, When the nurses open the insulin, they have to label the insulin with the date it is opened, and they must label the insulin with the date that it expires. Lantus insulin is good for 28 days. I like to read the manufacturer's instruction. If the manufacturer instruction says to discard after 30 days, then the insulin is labeled accordingly. Insulin in general is either good for 28 days or 30 days and must be discarded after the date it expired. On 12/10/2024, at 11:55 AM, V2 stated, Different nurses and the manager on duty are the ones who I delegate to clean the medication storage room, and to remove any access supplies that are not in use. Also, the nurses go through the medication storage room so that they can let me know if they need any supplies. My expectation is that the nurses who complete the inventory in the medication room will go through the supplies to ensure that the supplies are not expired. All the supplies in general, including the tubing, catheters, syringes, normal saline flushes, and all other supplies are not expired and that all the supplies in the medication storage room are current. When the nurses perform the inventory at the end of the month and as needed, they must remove any remove any supplies that are expired, and they must turn the expired supplies to the nursing office. The nursing carts are cleaned monthly and as needed. When the nurses clean the medication carts, they are expected to go through the entire nursing cart and make sure that medications and supplies are not expired. When the nurses find expired medication or supplies, they must remove the expired items from the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 10 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 cart and turn it into the nursing office. Level of Harm - Minimal harm or potential for actual harm Storage of Medications Policy (dated 10/25/2014) documents in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. Residents Affected - Few 1.) R14's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Asthma, type 2 diabetes mellitus with unspecified complications, unspecified dementia, mild, with other behavioral disturbance, gastro-esophageal reflux disease without esophagitis, disorder of urea cycle metabolism, unspecified. R14's Physician Orders (dated 08/01/2024) states: Novolog FlexPen U-100 Insulin (insulin aspart u-100): Per Sliding Scale If Blood Sugar is less than 80, call MD. If Blood Sugar is 181 to 220, give 1 Units. If Blood Sugar is 221 to 261, give 2 Units. If Blood Sugar is 262 to 300, give 3 Units. If Blood Sugar is 301 to 351, give 4 Units. If Blood Sugar is 352 to 400, give 5 Units. If Blood Sugar is greater than 400, give 6 Units. If Blood Sugar is greater than 400, call MD. 2.) R53's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Major depressive disorder, recurrent, unspecified, chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene. R53's Physician Order (dated 07/09/2024) states: Basaglar KwikPen U-100 Insulin (insulin glargine); give 26 units at bedtime. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 11 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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. Based on observations, interviews and record reviews, facility failed to follow their policy to ensure foods were labeled and dated in the dry food storage. This failure has the ability to affect all the residents in the facility. Findings include: On 12/09/2024 at 09:26 AM, surveyor observed the dry food storage area. Food was kept on palates. The following food did not have dates on them: Bread, banana, potatoes, and frozen squash. V14 (Cook) stated that those should have dates on them. On 12/10/2024 at 10:00 AM, V10 (Food Services Director) stated that all food is supposed to be labeled when they arrive. They are supposed to be labeled so that we do not use expired food when preparing food for the residents. On 12/10/2024, at 10:15 AM, V11 (Dietician) stated that all food is supposed to be labeled when they arrive. V11 stated this is important so that we know when the food expire and should be thrown away. Facility's Labeling and Dating Foods policy (undated) documents in part: To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 12 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 ensure that a reusable blood pressure cuff device was properly cleaned and disinfected in between resident use for 3 residents (R17, R22, R62) out of 8 residents reviewed for infection control and prevention in a total sample of 21. Residents Affected - Few Finding Include: 1.) R17's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: primary generalized (osteo)arthritis, schizoaffective disorder, unspecified, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Care plan (dated 02/07/2024) requires a therapeutic diet related to type 2 diabetes mellitus and hypertension. Minimum Data Set (MDS) section C (dated 08/05/2024) documents that R17 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R17's cognition is intact. 2.) R22's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Hypertensive heart disease without heart failure, schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, unspecified, hypermetropia, unspecified eye, unspecified psychosis not due to a substance or known physiological condition. Care plan (dated 10/23/2024) documents that R22 has diagnosis related to hypertension and hyperlipidemia. Minimum Data Set (MDS) section C (dated 10/23/2024) documents that R22 has a Brief Interview for Mental Status (BIMS) score of 13, indicating that R22's cognition is intact. 3.) R62's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Multiple sclerosis, major depressive disorder, recurrent severe without psychotic features, epilepsy, unspecified, not intractable, without status epilepticus, hyperlipidemia, unspecified. R62's Care plan (dated 05/07/2024) documents that R62 has feelings of depression, isolative tendencies, hard time trusting others, anxiety, and history of engaging in substance abuse related to major depression disorder. Minimum Data Set (MDS) section C (dated 11/06/2024) documents that R62 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that R62's cognition is intact. On 12/9/2024 at 9:29 AM, observed V5 (Licensed Practical Nurse) using a reusable blood pressure device to obtain R17's blood pressure, failing to clean and disinfect the device prior to collecting the resident's blood pressure. After V5 obtained R17's blood pressure, V5 was observed placing the blood pressure device on top of the nursing cart, failing to clean and disinfect the blood pressure cuff after resident use. On 12/9/24 at 9:47 AM, V5 was observed utilizing the blood pressure device to collect R62's blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 13 of 14 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 146149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westwood Vlge Nrsg and Rhb Ctr 2444 West Touhy Avenue Chicago, IL 60645 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 pressure without cleaning and disinfecting the blood pressure device. Level of Harm - Minimal harm or potential for actual harm On 12/9/24 at 9:55 AM, V5 was observed utilizing the blood pressure device to obtain R22's blood pressure without cleaning and disinfecting the device. Residents Affected - Few On 12/9/2024 at 10:05 AM, V5 stated, I am supposed to clean and disinfect the blood pressure device before resident use and after resident. The device must be cleaned and disinfected in between residents but I did not do it. On 12/9/2024 at 3:10 PM, V2 (Director of Nursing) stated, Devices such as blood pressure monitoring machine must be disinfected before resident use and must be disinfected after resident use to prevent infection. On 12/10/2024 at 11:49 AM, V12 (Infection Control Preventionist) stated, The vital machines and the blood pressure puff should be disinfected after each resident use. The blood pressure machine should be disinfected in between each resident. Usually, the blood pressure cuff is the main part that should be disinfected in between each resident use. The purpose of disinfecting the blood pressure cuff after each resident use is to prevent the spread of infection from resident to resident. Cleaning and Disinfection of Resident-Care Items and Equipment Policy (revised 07/2014) documents in part: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146149 If continuation sheet Page 14 of 14