Health inspection·April 11, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 follow its fall prevention policy by not implementing fall interventions for residents who are at high risk for falls. The facility failed to update a care plan based on a root cause analysis of post a fall investigation. These deficiencies affect seven of seven (R1, R2, R3, R4, R5, R6 and R7) residents reviewed for Fall Prevention Management. Findings include: R1 was re-admitted on [DATE], he was initially admitted on [DATE]. He has diagnosis listed in part but not limited to Hemiplegia and hemiparesis following Cerebrovascular accident affecting right dominant side, Hypertensive heart disease, Dementia, non-pressure chronic ulcer of left thigh, Muscle wasting and atrophy, History of falling, generalized muscle weakness, abnormal posture, Need for assistance with personal care. Fall assessment indicated he is at high risk for falls. He has history of falls on the following dates 9/21/18, 5/1/20,7/31/22, 9/20/22 and 12/4/22. Most recent fall dated 12/4/22 indicated: R1 was up in the nursing station and visitor saw him falling from wheelchair face down. Observed R1 on the floor in prone position. Assessment done, noted some redness on the right forehead with no swelling at this time. R1 was transferred to the hospital for evaluation. R1 was admitted to the hospital with a diagnosis of severe sepsis. Post investigation done dated 12/9/22 when R1 was still at the hospital. Indicated: R1 will be monitored while sitting up in his wheelchair and will be place near the nursing station where he can be monitored. Fall care plan was not updated. R1 was returned to the facility on [DATE]. Fall care plan was not updated. On 4/7/23 at 1:04pm, V2 DON said that she does the post fall investigation/root cause analysis immediately after a fall occurrence and V3 Care Plan Coordinator (CPC) does the fall care plan update based on a post investigation analysis. If resident is sent out to the hospital, fall care plan will be updated upon return. On 4/7/23 at 10:15am, Observed R2 lying in bed with oxygen via nasal cannula. She is alert and responsive but hard of hearing. Her Floor mat/bed mattress was standing against the wall and her bed was not in lowest position. Called V6 Restorative Aide to show observation made of R2. V6 said that R2's bed should be in the lowest position. V6 adjusted her bed in the lowest position. V6 said that the floor mat should be on the floor when R2 is on the bed for safety. On 4/7/23 at 1:10pm, Informed above observation to V2 DON and V3 CPC. Reviewed R2's medical records with V2 DON and V3 CPC. Informed both that fall care plan interventions are not implemented. R2 was admitted on [DATE] with diagnosis listed in part but not limited to Hypertensive heart disease, non-pressure chronic ulcer of skin, Senile dementia of brain, Palliative care, Generalized muscle weakness, Difficulty walking, Cataract. Fall assessment indicated at risk for falls. Fall care plan indicated: R2 is at risk for falls r/t to unsteady gait, use of assistive device, use of anti-depressant medication, Dx of hypertension, hyperlipidemia, cataract, depression, muscle weakness, impaired mobility and unsteadiness on feet. Intervention: Bed at its lowest position when resident in bed. Most recent fall incident dated 2/16/22 unwitnessed fall. On 4/7/23 at 10:20am, V7 LPN said that R3 had fallen yesterday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146176 If continuation sheet Page 2 of 6 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 146176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Senior Living Niles 7000 North Newark Niles, IL 60714 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 - Some On 4/7/23 at 10:23am, Observed R3 lying in bed, his call light is hanging by the wall, not within his reach. Showed observation made to V4 Social Service Director (SSD) who's making rounds in the unit. V4 said that the call light should be placed within R3's reach. She took the call light that is hanging on the wall and placed it within R3's reach. On 4/7/23 at 1:10pm, Informed above observation to V2 DON and V3 CPC. Reviewed R3's medical records with V2 DON and V3 CPC. V3 said that R3 is at high risk for falls. Informed both that fall care plan intervention is not implemented. R3 was admitted on [DATE] with diagnosis listed in part but not limited to Secondary Parkinsonism, Dementia with agitation, Traumatic Subdural hemorrhage, Atrial fibrillation, Presence of cardia pacemaker, generalized muscle weakness, Fall, Abnormality of gait and mobility, Lack of coordination, Unsteadiness in feet, Alzheimer's disease with late onset. Fall Assessment indicated that he is at high risk for falls. Fall care plan indicated: At high risk for fall related to history of falls, gait/balance problem, diagnosis of acute CVA, syncope, acute encephalopathy due to delirium, Dementia, BPH. Intervention: Be sure call light is within reach and encourage resident to use it for assistance as needed. R3's fall incidents history dated: 12/12/19, 9/19/21, 4/6/23 and 2/8/23. Most recent falls on 2/8/23 where he fell twice on the same day unwitnessed fall at 4am and 7:30am. On 4/7/23 at 10:20am, V7 LPN said that R4 had fallen yesterday. On 4/7/23 at 10:23am, Observed R4 lying in bed, his call light is hanging by the wall, not within his reach. Showed observation made to V4 Social Service Director (SSD) who's making rounds in the unit. V4 said that call light should be placed within R4's reach. She took the call light that is hanging on the wall and placed it within R4's reach. On 4/7/23 at 1:10pm, Informed above observation to V2 DON and V3 CPC. Reviewed R4's medical records with V2 DON and V3 CPC. V3 said that R3 is at high risk for falls. Informed both that fall care plan intervention is not implemented. R4 is re-admitted on [DATE] with diagnosis listed in part but not limited to Palliative care, Type 2 Diabetes Mellitus (DM) with hypoglycemia, Dementia with behavioral disturbance, Restless and agitation, Fall, Abnormalities of gait and mobility, Hypertensive heart disease. Fall assessment indicated that he is at high risk for falls. Fall care plan indicated: At risk for falls related to gait/balance problems, unaware of safety needs, wandering, cognitive impairment, fluctuating blood sugar, poor safety awareness, diagnosis of DM and dementia. Intervention: Be sure the call light is within reach and encourage him to use it for assistance as needed. Fall incidents history dated: 8/1/22, 10/11/22, 10/25/22, 12/3/22. 1/28/23, 2/4/23, 3/10/23 and 4/6/23. Most recent fall on 4/6/23 unwitnessed fall at 12:40pm. On 4/7/23 at 10:26am, Observed V8 CNA coming out from R5 's room. R5 has fall star sticker on his name by the door. V8 said that R5 is not on fall precaution or fall program because he does not move. Observed R5's bed in high position. V8 said that the bed should be in the lowest position when the resident is in bed. V8 took the bed remote and adjust the bed to the lowest position. No anti-slid material on bedside wheelchair. On 4/7/23 at 1:10pm, Informed above observation to V2 DON and V3 CPC. Reviewed R5's medical records with V2 DON and V3 CPC. V3 said that R5 is at high risk for falls. Informed both that fall precaution physician order and interventions are not implemented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146176 If continuation sheet Page 3 of 6 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 146176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Senior Living Niles 7000 North Newark Niles, IL 60714 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 - Some R5 is admitted on [DATE] with diagnosis listed in part but not limited to Heart failure, Type 2 Diabetes Mellitus, Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4, Abnormalities of gait and mobility, Repeated falls, generalized muscle weakness, Reduced mobility, difficulty in walking, unsteadiness on feet. Physician order sheet indicated: Fall precaution every shift. Fall assessment indicated he is at high risk for falls. Fall care plan indicated: at high risk for falls related to history of falls, unsteady gait, use of anti-depressant, anti-coagulant, use of assistive devices, muscle weakness, difficulty walking, unsteadiness on feet and current medical diagnosis. Intervention: Keep call light and desired personal items within reach. Anti-slid material on wheelchair cushion. Fall incidents history dated: 4/12/22, 7/26/22 and 11/14/22. Most recent witnessed fall on 11/14/22. On 4/7/23 at 12:04pm, Observed R6 lying in bed with floormat on the floor. She has oxygen via nasal cannula. Her call light is hanging on the wall. Called V7 LPN to show observation made. V7 took the call light hanging by the wall and placed it within R6's reach. V7 said that the call light should be placed within R6's reach. Asked V7 if R6's bed is in lowest position. V7 adjusted R6's bed in the lowest position. No anti-slid material on wheelchair at bedside. On 4/7/23 at 1:10pm, Informed above observation to V2 DON and V3 CPC. Reviewed R6's medical records with V2 DON and V3 CPC. V3 said that R6 is at high risk for falls. Informed both that fall care plan interventions are not implemented. R6 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic obstructive pulmonary disease, Heart failure, Type 2 Diabetes Mellitus with diabetic chronic kidney disease, unqualified visual loss both eyes, Dementia, Generalized muscle weakness, abnormal posture, unsteadiness on feet. admission fall assessment indicated she is at high risk for falls. Fall care plan indicated: At high risk for fall related to history of falls, unsteady gait, use of assistive devices, use of psychotropic medication, use of diuretics medication, fluctuating blood sugar, use of oxygen, needs assistance for transfers and ADLs and current medical Dx. Intervention: Keep call light and desired personal items within reach. Anti-skid material on wheelchair. Fall incidents history dated: 8/6/20 and 3/14/21. No recent fall incident for 2023. On 4/7/23 at 12 noon, Observed R7 lying in bed with oxygen via nasal cannula. She is alert and responsive but is hard of hearing. Her bed is pushed against the wall. She cannot find her call light. Called V7 LPN to R7's room. V7 searched for R7' call light and found it clipped at the side of the bed by the wall, but it fell on the floor at the side of the bed. V7 took the call light and placed it closer where R7 will be able to reach it. V7 said that the call light should be placed within R7's reach. On 4/7/23 at 1:10pm, Informed above observation to V2 DON and V3 CPC. Reviewed R7's medical records with V2 DON and V3 CPC. V3 said that R7 is at high risk for falls. Informed both that fall care plan intervention is not implemented. R7 is re-admitted on [DATE] with diagnosis listed in part but not limited to Paroxysmal atrial fibrillation, Hypertensive heart disease, Convulsions, Schizoaffective disorder, Abnormalities of gait and mobility, generalized anxiety disorder, Fall, Difficulty in walking, reduced mobility, need for assistance with personal care. Fall assessment indicated that she is at high risk for falls. Fall care plan indicated: At high risk for falls related to history of falls, unsteady gait, needs extensive assistance in ADLS, generalized weakness, limited ROM on BLE, use of assistive device, use of psychotropic medication and current medical diagnosis. Intervention: Keep call light and desired personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146176 If continuation sheet Page 4 of 6 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 146176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Senior Living Niles 7000 North Newark Niles, IL 60714 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 - Some items within reach. Most recent fall incident dated 3/11/23 unwitnessed fall at 11:30pm in her room. R7 found sitting upright with both lower extremities aligned straight on the floor beside her bed. R7 stated I was trying to go to the washroom then I slowly eased from bed. Assessment done. No injury noted. Assisted back to bed with 2 persons assist. Root cause analysis /Post investigation indicated: R7 re-educated on importance of asking for assistance when needed. R7 to be close to nurse's station when up. Frequent rounding on resident. Fall care plan updated on 3/15/23 but not consistent with the root cause analysis. New fall care plan interventions indicated: Reminded to press the call light when needing assistance with toilet use. Ongoing PT and OT. On 4/7/23 at 11:45am, V9 LPN said that they used to have list of residents on fall precautions, but she cannot find it. V9 said that fall prevention interventions are close monitoring, call light within reach, bed in the lowest position when in bed, floor mat when in bed as ordered. On 4/7/23 at 11:54am, V7 LPN said that they have the list of residents on fall precautions, but she cannot find it. Reviewed 24-hour nursing endorsement with V7. R3 and R7 are endorsed for fall precautions. V7 said that R4 should be endorsed for fall precaution because he fell yesterday. V7 said that fall prevention interventions are close monitoring, call light within reach, bed in the lowest position when in bed, floor mat when in bed as ordered. Facility's policy on Fall reduction program: Objectives: It is the policy of this facility to have Fall reduction Program that promotes the safety of residents in the facility. The program's intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks and the implementation of appropriate interventions, supervision, and or assistive devices deemed appropriate. Quality Assurance program will monitor the program to assure ongoing effectiveness. Program contents: The Fall Reduction Program includes the following components: 3. Use and implementation of profession standards of practice. 6. Communication with direct care staff members 8. Care plan incorporates: Identification of individualized risk/issues. Modification or implementation of care plan approaches based on newly identified risk or recent fall occurrences. Preventive measures. Standards: 3. Safety interventions will be determined and implemented based on the assessed, individualized risk and in accordance with standard of care, interventions to be documented within resident's care plan. 4. Assigned nursing personnel are responsible for ensuring that the ongoing precautions are put in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146176 If continuation sheet Page 5 of 6 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 146176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Senior Living Niles 7000 North Newark Niles, IL 60714 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 place and consistently maintained per the individual's plan of care. Level of Harm - Minimal harm or potential for actual harm 8. Attempts shall be made to implement new or modified interventions as needed to enhance safety and consistent with root cause analysis. New interventions to be communicated to the facility staff through revision of resident care plan and profile to maintain continuity of care. Residents Affected - Some 10. The Director of Nursing (DON) or designee is responsible for monitoring the Fall Reduction Program, including further staff education programs, purchase of additional equipment or other appropriate environmental alterations. In addition, DON is responsible for informing the administrator and the QA committee of program analysis. Examples of Standard Fall Safety Precautions that may be applicable: 2. The nurse call device to be placed within the resident's reach. 3. Monitoring bed height for appropriate level. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146176 If continuation sheet Page 6 of 6