Chicago Ridge Nursing Center

F-F600 Free from abuse and neglect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50036

Residents Affected - Some Based on interview and record review, the facility failed to ensure sufficient nursing staff were available to ensure medications were administered as ordered to 34 residents (Resident R1, Resident R4, and Resident R6-Resident R37). This failure has the potential to affect 34 residents ordered to received medication from third floor front cart.

Findings include:

The 3rd floor (12/25/2024) census of 72 residents was provided to surveyor by V1 administrator.

Resident R1's face sheet dated 12/30/2024 documents that Resident R1 is a [AGE] year-old resident with diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease.

Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that Resident R1 is moderately cognitively impaired.

Medication Administration Records (MAR) for December 2024 for (Resident R1, Resident R4, and Resident R6- Resident R37) all document that medications were not given 12/25/2024, day shift.

On 12/30/2024, at 10:06 am, Resident R4 stated we always have a nurse on shift to give medications except on Christmas Eve or Christmas Day that morning I did not get my medications.

On 12/30/2024, at 10:30 AM V7, Licensed Practical Nurse (LPN), stated, we are supposed to have two nurses on each floor for day (7am - 3:30pm) and evening (3:00pm - 11:30pm) and just one for nights (11:00pm-7:30am). Two nurses on nights on second floor only and one nurse on nights for 1st and 3rd floors.

On 12/30/2024, at 11:03 AM, Resident R1 stated, we did not have a nurse on the 3rd floor day of Christmas on day shift. So, we did not get medications for the day. Someone came up from another floor about 5:00 pm and gave medications then, just the evening medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 0725 On 12/31/2024, at 9:35 AM, V7 (LPN) stated, I worked Christmas Day (12/25/2024) by myself up on third floor. I did not give medications to the whole floor. I just gave medications to my side which was the back hall Level of Harm - Minimal harm or 312-325. The other cart covers rooms 301-311 and 326-334. Management knew I was not giving medication potential for actual harm to the whole floor. V6 DON (Director of Nursing) knew that I wasn't going to be giving medication to the whole floor because she was looking for a nurse. She said, they were missing a nurse on first floor as well Residents Affected - Some and the nurse down there was getting a bonus to pass meds for the whole floor. I told her I would not pass meds for the whole floor bonus or not. The other residents on the floor did not get their medications. V6 did not come up and pass meds for the other residents. There are 77 residents on this floor right now. I did not accept keys for that cart or anything. I came in and did my residents, passed medications, and did make sure everyone was safe and taken care of but did not pass medications for the other half of residents. This was

the only time this happened that I am aware of. V6 was well aware that I was not passing medications on the other cart. ADON (Assistant Director of Nursing) is on vacation and was on vacation at that time.

On 12/30/2024, at 12:27 PM, Surveyor Reviewed Daily Staffing sheets from 11/6/2024 - 12/30/2024. Date of 12/25/2024 is missing. All other dates show 2 nurses on dayshift per floor, 2 on pm shift per floor and 1 nurse

on night shift for 1st and 3rd floor and 2 on 2nd floor except for the following dates:

11/8/2024 only 1 nurse on nights on 2nd floor

12/6/2024 only 1 nurse on nights on 2nd floor

12/20/2024 only 1 nurse on pms on 2nd floor

12/29/2024 only 1 nurse on nights on 2nd floor

12/30/2024 only 1 nurse on pms on 2nd and 3rd floor and 1 nurse on nights on 2nd floor.

On 12/31/2024, at 11:36 AM, Schedule was provided to surveyor for 12/25/2024. Schedule documents only one nurse assigned to day shift on 3rd floor and only one nurse assigned to 1st and 3rd floor on second shift.

On 12/30/2024, at 3:20 PM V6 (DON) stated I have been the DON since December 4th, 2024. I am not aware of any issues with medications not being delivered by pharmacy or residents not getting medications. Resident R1 has not complained to me about not getting his medication. My expectation of my staff is that residents get their medications as ordered. If they run into any issues, to please let me know. I am aware of not having

a second nurse up on 3rd floor on Christmas day. There was a call off. I have not had anyone come to me to say they did not receive their medications on that day. I did only have one nurse up on 3rd floor. I have worked this floor by myself and that is not how we typically want it, but it can be done. I have not been made aware of anyone missing medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 0725 On 12/31/2024, at 11:52 AM surveyor interviewed V6 and V7 together. V6 stated, I would come in if we do not have enough nurses on the floor. Wound nurse, restorative nurse, IP (Infection Preventionist) nurse, Level of Harm - Minimal harm or ADON, MDS nurses and I can all fill in on the floor. Other nurses have come up on different occasions to potential for actual harm help pass medications. I was trying to get help to get some nurse to come in to help pass medications. It was

a holiday. (ADON) was on vacation. I was given schedules as if it was staffed. Someone quit on me. I was Residents Affected - Some working at another job and could not get a replacement for myself. I was under the impression that V7 was going to pass medications for the whole floor. A resident called the administrator and said V7 told resident

she wouldn't give her medications. V6 stated, I called (V7) and (V7) stated she was in process of passing medications and did not say that. V7 stated, I did not accept the keys for the other cart and made it clear I would not pass medications for whole floor. V6 stated, (V7) did say she would not accept a bonus to do the medications on the other half of the floor. V7 stated, I did not say I was passing medication all morning on

the other side of the floor. V7 stated, I passed my medications to my residents, on my cart, made sure people were safe and cared for. V6 stated, I understand it is a lot, I am new, and I am accepting responsibility for this. I understand approximately 77 residents is a lot and I was continuing to look for another nurse. This was an isolated incident. These are routine residents that the nurses are used to working with. I am not an office DON. I come in here in uniforms and I work the floors. The conversation was different, I take responsibility for the situation. Not one time did (V7) say she would not pass the medications for the other residents. I still pick up at my other job. My administrator is aware that I have another job and I just pick up as needed. I have not picked up anymore because my ADON is on vacation. I had promised to work at the other job months ago prior to taking this job. We staff two nurses on day shift and pm shift for all three floors. On nights it is only one nurse for first and third floors and two nurses on second floor.

On 1/2/2025, at 9:33 AM, V7 (LPN) stated I did not call the doctors for the residents that I did not pass medications to on 12/25/2024 and let them know that the residents did not get their medications. I was not

the nurse for that med cart. I did not accept keys for that cart. Management knew I was not passing medications on that cart.

On 12/30/2024, at 1:18 PM, V3 (Nurse Practitioner) stated, I did not get a call regarding Christmas Day or any residents not receiving their medications that morning. I am a contractor here. I do see the residents here. I was not here Christmas day.

On 12/31/2024, at 1:19 PM V1 (Administrator) stated, my expectation of staff is that staff completes medication pass and documents it. I do not know the answer to if V6 is allowed to have another job. We are going to have to try to create a holiday rotation. We do not have a holiday rotation set right now. The impression I was under was that V7 (LPN) was going to pass the medications for the whole floor of about 77 patients. I did not know anything about the bonus until after the fact. I do not have to approve the bonuses.

We don't give too many out. If it got crazy, yes but not in this case. We will have to come up with a holiday plan and whoever is on call for the holiday is going to have to come in and cover any call offs. My expectation is that medications are given as ordered to the residents. It could have been not so good of turnout as a lot of residents are on seizure medications, psych medications, etc. Thank God it wasn't. I am not aware of any other complaints of medications not being given as ordered except for now the issue with Christmas day on day shift.

On 12/31/2024, at 11:36 AM, nursing schedule provided to surveyor for 12/25/2024. Schedule documents only one nurse assigned to day shift on 3rd floor and only one nurse assigned to 1st and 3rd floor on second shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 0725 On 1/2/2025, at 12:05 PM, V1 Administrator stated, facility does not have a staffing policy.

Level of Harm - Minimal harm or On 1/2/2025, at 12:16 PM, V1 Administrator stated there were 72 residents total on third floor on 12/25/2024. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50036

Residents Affected - Some Based on interview and record review, the facility failed to provide medications to 34 residents (Resident R1, Resident R4, and Resident R6-Resident R37) as ordered by the prescriber to meet the needs of each resident. This failure has the potential to affect thirty-four residents receiving medication from third floor front cart.

Findings include:

Resident R1's face sheet dated 12/30/2024 documents that Resident R1 has a diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease.

Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents that Resident R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that Resident R1 is moderately cognitively impaired.

Medication Administration Records (MAR) for December 2024 for (Resident R1, Resident R4, and Resident R6- Resident R37) all document that medications were not given 12/25/2024, day shift.

On 12/30/2024, at 10:06 am, Resident R4 stated, we always have a nurse on shift to give medications except on Christmas Eve or Christmas Day that morning I did not get my medications.

On 12/30/2024, at 11:03 AM, Resident R1 stated (in part), we did not have a nurse on the third floor day of Christmas

on day shift. So, we did not get medications for the day. Someone came up from another floor about 5:00 pm and gave medications then, just the evening medications.

On 12/31/2024, at 9:35 AM, V7, Licensed Practical Nurse (LPN), stated I worked Christmas Day by myself up on 3rd floor. I did not give medications to the whole floor. I just gave medications to my side which was

the back hall (third floor). The other cart (front) covers residents (Resident R1, Resident R4, and Resident R6-Resident R37). Management knew I was not giving medication to the whole floor. V6 Director of Nursing (DON) knew that I wasn't going to be giving medication to the whole floor because she was looking for a nurse. She said that they were missing nurse on 1st floor as well and the nurse down there was getting a bonus to pass meds for the whole floor. I told her I would not pass meds for the whole floor bonus or not. The other residents on the floor did not get their medications. The DON did not come up and pass meds for the other residents. There are 77 residents

on this floor right now. I did not accept keys for that cart or anything. I came in and did my residents, passed medications, and did make sure everyone was safe and taken care of but did not pass medications for the other half of residents. This was the only time this happened that I am aware of. The DON was well aware that I was not passing medications on the other cart. The ADON (Assistant Director of Nursing) is on vacation and was on vacation at that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 On 12/30/2024, at 3:20 PM V6 (DON) stated (in part), I have been the DON since December 4th, 2024. I am not aware of any issues with medications not being delivered by pharmacy or residents not getting Level of Harm - Minimal harm or medications. Resident R1 has not complained to me about not getting his medication. My expectation of my staff is potential for actual harm that residents get their medications as ordered. If they run into any issues, to please let me know. There was

a call off. I have not had anyone come to me to say they did not receive their medications on that day. I did Residents Affected - Some only have one nurse up on 3rd floor. I have not been made aware of anyone missing medications.

On 12/31/2024, at 11:52 AM, surveyor interviewed both V6 (DON) and V7 (LPN) together. I (V6) was trying to get help to get some nurse to come in to help pass medications. It was a holiday. I was under the impression that (V7) was going to pass medications for the whole floor. Another (resident) called administrator and said (V7) told resident she wouldn't give her medications. I called (V7) and (V7) stated she was in process of passing medications and did not say that. V7 stated she did not accept the keys for the other cart and made it clear she would not pass medications for whole floor. V6 stated, V7 did say she would not accept a bonus to do the medications on the other half of the floor. V7 stated she did not say she was passing medication all morning on the other side of the floor. V7 stated I passed my medications to my residents, on my cart, made sure people were safe and cared for. V6 stated Not one time did (V7) say she would not pass the medications for the other residents.

On 1/2/2025, at 9:33 AM, V7 (LPN) stated, I did not call the doctors for the residents that I did not pass medications to on 12/25/2024 and let them know that the residents did not get their medications. I was not

the nurse for that med cart. I did not accept keys for that cart. Management knew I was not passing medications on that cart.

On 12/30/2024, at 1:18 PM, V3 (Nurse Practitioner) stated, I did not get a call regarding Christmas Day or any residents not receiving their medications that morning. I am a contractor here. I do see the residents here. I was not here Christmas day.

On 12/31/2024, at 1:19 PM V1 (Administrator) stated, the impression I was under was that V7 (LPN) was going to pass the medications for the whole floor of about 77 patients.

Administering Medications Policy & Procedure dated 1/1/2020 documents (in part): Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations.

2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications shall be administered in physicians written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the residents identity when no contraindications are identified and the medication is labeled according to accepted standards.

8. The individual administering the medication shall initial the resident's medication administration record (MAR) on the appropriate line and date for that specific day before administering the medication.

10. If it is discovered the person administering medications has forgot to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/treatment has been administered/performed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 If the response indicates the medication/treatment was administered the staff member shall return to the facility, initial and circle the MAR to indicate a late entry. A late entry note will be documented indicating the Level of Harm - Minimal harm or administrateion of the medication. If the medication was not administered the missed dose/medication error potential for actual harm protocol shall be followed.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50036 potential for actual harm Based on interview and record review, the facility failed to provide significant medications to five residents Residents Affected - Some (Resident R1, Resident R16, Resident R26, Resident R33 and Resident R37) on 12/25/2024 on day shift. This failure affected five of thirty-four residents reviewed for significant medication.

Findings include:

Complaint dated 12/25/2024 alleges Resident R1 is missing medications, given wrong medications and at times not all

the medications due to no nurse.

Resident R1's face sheet dated 12/30/2024 documents that Resident R1 is a [AGE] year-old resident with diagnoses including but not limited to: unspecified dementia, unspecified psychosis, seizures, depression, encephalopathy, essential hypertension, and chronic obstructive pulmonary disease.

Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents that Resident R1 has a Brief Interview for Mental Status (BIMS) score of 12, which suggests that Resident R1 is moderately cognitively impaired.

Medication Administration Records (MAR) for December 2024 for (Resident R1, Resident R16, Resident R26, Resident R33 and Resident R37) all document that seizure medication were not given on on 12/25/2024, day shift.

On 12/25/2024 Resident R1's December MAR documents (in part) Divalproex Sodium Oral Tablet Delayed Release 250 mg - Give 1 tablet by mouth two times a day for treat seizures was not given on at 8:00 AM. and Levetiracetam Oral Tablet 250 mg - give 3 tablets by mouth two times a day for seizures was not given at 8:00 AM

On 12/25/2024 Resident R16's December MAR documents (in part) Keppra Oral Tablet 250 mg (milligram) - give 5 tablet by mouth two times a day for seizure was not given on at 8:00 AM and Lacosamide Oral Tablet 100 mg - give 1 tablet by mouth every 12 hours for seizures was not given at 8:00 AM.

On 12/25/2024 Resident R26's December MAR documents (in part) Depakote Tablet Delayed Release 500mg - give 1 tablet by mouth two times a day for anticonvulsant was not given at 8:00 AM.

On 12/25/2024 Resident R33's December MAR documents (in part) Depakote Tablet Delayed Release 500 mg - give 1 tablet by mouth three times a day for prevent seizures was not given at 8:00 AM nor at 12:00 PM.

On 12/25/2024 Resident R37's December MAR documents (in part) Keppra Oral Tablet 1000 mg - give 1 tablet by mouth one time a day related to other generalized epilepsy and epileptic syndromes was not given at 8:00 AM.

On 12/30/2024, at 10:06 am, Resident R4 stated, we always have a nurse on shift to give medications except on Christmas Eve or Christmas Day that morning I did not get my medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 0760 On 12/30/2024, at 11:03 AM, Resident R1 stated, I have not had my seizure medicine for about 4 days. I take Keppra twice a day 750 mg. The facility ran out. I think it is an insurance issue. I had an issue when I was not here of Level of Harm - Minimal harm or not taking my medications when I was supposed to. I should have 90-day supply of Keppra here that I came potential for actual harm in with, but because I came in with it, I don't think the facility will give it to me because they can't verify what

the pills are. They were giving me Depakote from a previous facility and this facility continued it here until I Residents Affected - Some refused to take it. We did not have a nurse on the 3rd floor day of Christmas on day shift. So, we did not get medications for the day. Someone came up from another floor about 5 pm and gave medications then, just

the evening medications.

On 12/30/2024, at 2:27 PM, surveyor asked V8 (Licensed Practical Nurse/LPN) to see Resident R1 medication cards for Keppra. V8 stated, he took his last dose on the card this morning. I already reordered it. When he needs it, we can get it out of the (Medication Storage System) downstairs. Electronic medical record shows it was reordered 12/29/2024. V8 stated, she is going to call pharmacy right now to see when it is coming in. Surveyor stayed and V8 put phone on speaker. Pharmacy stated, there is an issue with insurance. The last time we sent was November 20th for 30 days. It was a 750 mg tablet and then it changed to 250 mg tablets x 3 tabs. That may be the issue. They are stating that they can send 500 mg tablet and a 250 mg and will send

it tonight and update the (Medication Storage System) for it to be pulled with new order this evening. Pharmacy needs new order sent over.

On 12/30/2024, at 4:05 PM, V8 (LPN) showed surveyor 3 tabs of Keppra 250 mg pulled from (Medication Storage System) for evening dose for Resident R1. She stated, the order was approved by pharmacy for the 750 mg oral tablet twice a day and will be delivered tonight.

On 12/31/2024, at 9:32 AM, V9 (LPN) showed surveyor the two medication cards for Resident R1 that came in of Keppra 750 mg of 30 pills each. She also showed surveyor the bottle of Keppra 750mg that Resident R1 came in with. Bottle is over half full approximately 75% full. V9 stated, I have not been made aware of him missing any medications or Keppra. That bottle has been here since he came.

On 12/31/2024, at 9:35 AM, V7 (LPN) stated I worked Christmas Day by myself up on 3rd floor. I did not give medications to the whole floor. I just gave medications to my side which was the back hall. The other cart covers (Resident R1, Resident R4, and Resident R6-Resident R37). Management knew I was not giving medication to the whole floor. V6 Director of Nursing (DON) knew that I wasn't going to be giving medication to the whole floor because she was looking for a nurse. She said that they were missing nurse on 1st floor as well and the nurse down there was getting a bonus to pass meds for the whole floor. I told her I would not pass meds for the whole floor bonus or not. The other residents on the floor did not get their medications. The DON did not come up and pass meds for the other residents. There are 77 residents on this floor right now. I did not accept keys for that cart or anything. I came in and did my residents, passed medications, and did make sure everyone was safe and taken care of but did not pass medications for the other half of residents. This was the only time this happened that I am aware of. The DON was well aware that I was not passing medications on the other cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 145639 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145639 B. Wing 01/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chicago Ridge Snf 10602 Southwest Highway Chicago Ridge, IL 60415

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 0760 On 12/30/2024, at 3:20 PM V6 (DON) stated (in part), I have been the DON since December 4th, 2024. I am not aware of any issues with medications not being delivered by pharmacy or residents not getting Level of Harm - Minimal harm or medications. Resident R1 did have a hospitalization and was out 12/16/2024-12/20/2024. So, he could have gotten his potential for actual harm dose for those days at the hospital prior to returning. We do have access to this medication in the (Automated Medication Storage/Dispensing System) and he will get the dose. If there is an insurance issue, Residents Affected - Some we can still get out of the (Automated Medication Storage/Dispensing System), and the facility will cover cost. That is a short-term fix, but we still need to figure out how we can get this medication. Whether it be getting an order for a different medication that does the same thing, or go to a different pharmacy, we just need to figure it out for the patient. He has not complained to me about not getting his medication. My expectation of my staff is that residents get their medications as ordered. If they run into any issues, to please let me know. I have not had anyone come to me to say they did not receive their medications on that day. I did only have one nurse up on 3rd floor. I have not been made aware of anyone missing medications.

On 1/2/2025, at 9:33 AM, V7 (LPN) stated I did not call the doctors for the residents that I did not pass medications to on 12/25/2024 and let them know that the residents did not get their medications. I was not

the nurse for that med cart. I did not accept keys for that cart. Management knew I was not passing medications on that cart.

On 12/30/2024, at 1:18 PM, V3 (Nurse Practitioner) stated, regarding Resident R1 is on Keppra 750 mg twice a day. I did not get a call regarding Christmas Day or any residents not receiving their medications that morning. The Keppra is used for seizure. The resident is prone to having seizures. If residents do not get seizure medication that will lower the seizure threshold and make them more susceptible to having a seizure. I am a contractor here. I do see the residents here. I was not here Christmas day.

Facility policy: Administering Medications Policy & Procedure dated 1/1/2020 documents:

Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations.

2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions.

3. Medications shall be administered in physicians written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the residents identity when no contraindications are identified and the medication is labeled according to accepted standards.

8. The individual administering the medication shall initial the resident's medication administration record (MAR) on the appropriate line and date for that specific day before administering the medication.

10. If it is discovered the person administering medications has forgot to initial in the appropriate space, the supervisor shall notify that person to investigate if the medication/treatment has been administered/performed. If the response indicates the medication/treatment was administered the staff member shall return to the facility, initial and circle the MAR to indicate a late entry.A late entry note will be documented indicating the administration of the medication. If the medication was not administered the missed dose/medication error protocol shall be followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 145639