Inspection·January 12, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Residents shall be groomed as they wish to be groomed, and residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns. 3. On 01/09/24 at 11:03 AM, R16 was sitting in a wheelchair in his room. R16 was able to propel himself in the wheelchair. R16 had on a black pair of shoes. The shoes did not have any shoelaces and the tongues were hanging out, touching the floor. R16 said my shoes are very old, and I want new shoes. On 01/10/24 at 11:30 AM, R16 continued to wear the black shoes. The black shoes still did not have any shoelaces, and the tongues were hanging out touching the floor. R16 said I need a new pair of shoes. R16 said he had spoken with the facility staff about needing a new pair of shoes. R16 said the staff told him they could not get him a new pair of shoes. R16 does not remember which staff member he spoke with about getting new shoes. On 01/11/24 at 12:22 PM, R16 continued to be in his room sitting in a wheelchair. V2 (Director of Nursing) was in the room. R16 stated my shoes are too little, and I want another pair. The shoes continued to be without shoelaces, and the tongue of the left shoe was touching the floor. On 01/11/24 at 11:40 AM, V2 said she did not know R16's shoes were in the condition they are in. V2 said R16 needed a new pair of shoes after observing the condition the shoes were in. V2 said the staff were unsure of what happened to R16's shoelaces. V2 said if the staff notices residents' clothes and shoes are torn and not appropriate, they can get items from a donated box. R16's face sheet showed R16 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, weakness, malaise, muscle wasting and atrophy, difficulty in walking, lack of coordination, alcoholic hepatitis without ascites, cholelithiasis without obstruction, hyperlipidemia, schizophrenia, and hypertension. R16's MDS dated [DATE] showed R16 required substantial/maximal assistance with putting on and taking off socks and shoes that is appropriate for safe mobility. R16's risk for falls care plan, not dated, stated ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair as an intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 2 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R66 has diagnoses that includes Type 2 Diabetes, Parkinson's Disease, and Autistic Disorder. R66's Minimum Data Set, dated [DATE] shows severe cognitive impairment. R66 requires staff supervision or touching assistance with eating while using suitable utensils to bring food to the mouth and swallow. R66's Care plan dated 12/01/2023 states R66 has a nutritional problem or potential nutritional problem. Therapy provided a special silverware sponge grip that will allow silverware to be held better. Residents Affected - Few On 01/09/24 at 12:12 PM, R66 was served two egg salad sandwiches, diced beats served on a regular flat plate, a banana, and a pink drink. Resident attempted to scoop the beats up with a regular spoon and dropped them on her lap. R66 then ate the beats from her lap. R66's meal tray ticket listed a General Regular diet, double portions, and adaptive equipment starred and in bold font. The meal ticket did not list what adaptive equipment R66 was to have on her tray. 01/09/24 at 12:27 PM, V7 (Certified Nursing Assistant / Memory Care Coordinator) stated special adaptive equipment comes from the kitchen and if it is not on the tray staff should call the kitchen to get it. If a resident required special adaptive equipment, it would be listed on their meal ticket. V7 stated there were no residents in the dining room that required special adaptive equipment. On 01/10/24 at 12:58 PM, R66 was observed eating lunch. R66 was eating from a scoop plate. R66's utensils were a regular fork and regular spoon. On 01/11/24 at 12:12 PM, V3 (Director of Food and Nutrition Services) stated therapy services inform them what assistive meal devices residents require and dietary services add it to the meal ticket. V3 stated the only adaptive equipment being used by residents in the facility are scoop plates. On 01/11/24 at 12:37 PM, V15 (Physical Therapy Assistant / Director of Rehab Services) stated R66 was seen by the Occupational Therapist on 1/8/2024 for a post fall assessment. R66 was not assessed for eating devices at that time. If R66 assistive eating devices were to be changed she would need to be reassessed. V15 did not see any documentation of reassessment of assistive eating devices. On 01/09/24 at 12:56 PM, V2 DON (Director of Nursing) stated the assistive devices a resident requires should be listed on their meal ticket. If the device was not sent on the tray, staff should contact the kitchen to obtain it. The Restorative Nurse or Therapy Services determine what assistive devices residents require. A physicians order is not required. The assistive device a resident requires should be listed on their meal ticket and in their care plan. R66's care plan says she should have a sponge on her utensils. She will get a scoop plate or a flat plate depending on what she wants. The facility policy Assistance with Meals dated July 2017 states residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Adaptive devices will be provided for residents who need or request them. These may include devices such as silverware with enlarged / padded handles, plate guards and or specialized cups. Based on observation, interview, and record review, the facility failed to have an adaptive call light accessible for one resident and adaptive eating utensils for a dependent resident. This applies to 2 of 2 residents (R32 and R66) reviewed for accommodation of needs in a sample of 31. The findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 3 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. On 01/09/24 at 11:24 AM, R32 was sitting in a motorized wheelchair. R32's left arm was contracted to his chest. R32 was able to move his right arm. R32's thumb and fifth finger on his right hand was contracted in the downward position. R32's index, middle and ring fingers were in a straight position, and not able to move or flex. R32's left leg was contracted. R32 stated he needed to be repositioned. R32 attempted to press the call button in his room. R32 was unable to press the button due to the limited range of motion in both hands. The call light was pressed for R32 by the surveyor. On 01/10/24 at 12:10 PM, R32 still did not have the appropriate call light for him to use. R32 said he informed the staff of the need for another call light when he moved to the current room. On 01/11/24 at 09:40 AM R32 continued to have the call light he was not able to use in his room. R32 said he told the staff again he needed the touchpad call light from my old room. R32's face sheet showed R32 was admitted to the facility with diagnoses of diabetes mellitus, left knee contracture, right hip pain, dysphagia, weakness, right and left knee pain, personal history of transient ischemic attack and cerebral infarction, insomnia, major depressive disorder, hyperlipidemia, seizures, paraplegia, hypertension, neuromuscular dysfunction of bladder, and metabolic encephalopathy. R32's MDS dated [DATE] showed R32 was cognitively intact. The same MDS showed R32 was dependent upon staff for all ADL's (ADL's/Activities of Daily Living). R32's risk for falls care plan intervention stated, be sure my call light is within reach and encourage the resident to use it for assistance as needed. The same care plan showed another intervention to remind me to call for assistance needed. On 01/11/24 at 11:40 AM, V2 (DON/Director of Nursing) said all call lights should always be within reach and clipped to the bed. V2 said call lights should never be hanging and not within reach. V2 said residents who cannot push the call light should have a flat pad call light. V2 said if residents are not able to notify staff of needing assistance, there could be a delay in treatment or meeting their needs. All residents should have call lights that are accessible to them. The facility's Routine Resident Checks and Call Light Response policy revised 07/2013 stated 1. To ensure the safety and well-being for our residents, nursing staff shall make a routine resident check on each unit and to ensure the call-light is working and within easy reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 4 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R54 is dependent on toilet hygiene. Residents Affected - Some On 1/9/24 at 12:15 PM, R54 was in his bed, and V8 (Nurse) turned R54 to his right side per the surveyor's request. R54 was observed with a soaked incontinent brief with urine leaked onto the linen and mattress. Also, a piece of stool was observed between his inner buttocks. On 1/9/24 at 12:15 PM, R54 stated that the facility hadn't changed him yet. On 1/9/24 at 12:17 PM, V8 stated, The Certified Nursing Assistants are supposed to provide incontinent care. I will call the CNA to change him. Record review on R54's incontinent care plan document: Clean peri-area with each incontinent episode. On 1/9/24 at 1:48 PM, V2 (Director of Nursing / DON) stated that incontinent care should be provided to residents every two hours and as needed. The facility provided incontinent care policy revised 10/03 document: 5. Residents will be checked every two hours and prn (as needed) to provide care/incontinent care. 5.On 01/09/24 at 10:43 AM, R14 was observed in her bed with her nails long, jagged, and with brown substances under the nails. R14 said she would like for her nails to be cleaned. On 01/11/24 at 12:29 PM, V1 (Administrator/RN) said that there was no reason why R14's nail hygiene was not done. V1 looked on her computer at R14's EHR (Electronic Health Record) to see if she had refused care and said there was no documentation showing any refusal. V1 then said R14's nails should be cut and cleaned to avoid injury or infections. R14's EHR showed that she is a [AGE] year old female admitted to the facility on [DATE]. R14's 10/18/23 MDS (Minimum Data Set) Section GG showed that she is dependent for personal hygiene. The facility's Fingernails/Toenails, Care of policy (February 2018) showed that proper nail care can aid in the prevention of skin problems around the nail bed, and staff should trim and smooth nails to prevent the resident from accidentally scratching and injuring his or her skin. Based on observation, interview and record review the facility failed to provide personal care to dependent residents. This applies to 5 of 5 residents (R9, R14, R16, R32, and R54) reviewed for ADL's (ADL's/Activities of Daily Living) in the sample of 31. The findings include: 1. On 01/09/24 at 10:57 AM, R9 had stubble facial hair above the lip, under the chin, and both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 5 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cheeks. R9 stated he wanted to be shaved. On 01/10/24 at 11:25 AM, R9 continued to have stubble facial hairs above the lip, under the chin, and both cheeks. R9 said he still wanted to be shaved. On 01/11/24 at 10:20 AM, R9 still had stubble facial hairs. R9's face sheet showed R9 had the following diagnoses chronic obstructive pulmonary disease, emphysema, insomnia, unsteadiness on feet, abnormalities of gait and mobility, malaise, dementia with anxiety, low back pain, right hip pain, major depressive disorder, hypertension, muscle wasting and atrophy, schizophrenia, and bradycardia. R9's MDS (MDS/Minimum Data Set) dated 10/18/23 showed R9's cognition was mildly impaired. The same MDS showed R9 required substantial/maximal assistance with personal hygiene. R9's ADL self-care performance deficit care plan stated Personal hygiene/oral care: I need assistance. I am on the restorative program. 2. On 01/09/24 at 11:03 AM, R16 had an accumulation of facial hair. R16 said he had not been shaved in a while. R16 said he would like to be shaved. R16's left hand fingernails were short with a dark colored substance underneath. On 01/10/24 at 11:30 AM, R16 continued to have an accumulation of facial hair. R16 said all I need is a haircut and a shave. R16 said he informed the staff he wanted to be shaved. On 01/11/24 at 12:22 PM, R16 continued to have facial hair. R16's face sheet showed R16 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, weakness, malaise, muscle wasting and atrophy, difficulty in walking, lack of coordination, alcoholic hepatitis without ascites, cholelithiasis without obstruction, hyperlipidemia, schizophrenia, and hypertension. R16's MDS dated [DATE] showed R16's cognition was moderately impaired. The same MDS showed R16 required substantial/maximal assistance with personal hygiene. 3. On 01/09/24 at 11:24 AM, R32 had an accumulation of facial hair. R32 said it's been a while since I last had a shave. R32 said he would like to be shaved. On 01/11/24 at 09:40 AM, R32 continued to have facial hair. R32's face sheet showed R32 was admitted to the facility with diagnoses of diabetes mellitus, left knee contracture, right hip pain, dysphagia, weakness, right and left knee pain, personal history of transient ischemic attack and cerebral infarction, insomnia, major depressive disorder, hyperlipidemia, seizures, paraplegia, hypertension, neuromuscular dysfunction of bladder, and metabolic encephalopathy. R32's MDS dated [DATE] showed R32 was cognitively intact. The same MDS showed R32 was dependent upon staff for all ADL's (ADL's/Activities of Daily Living). R32's ADL self-care performance deficit care plan intervention showed, Personal Hygiene: I need limited-extensive assistance by 1-2 staff with personal hygiene and oral care. On 01/11/24 at 11:40 AM, V2 said nail care and shaving is done as needed and on shower days. V2 said it is expected that nail care is done with showers. V2 said dirty fingernails is a dignity issues and an infection control issue. On 01/11/24 at 12:18 PM, V10 (CNA/Certified Nursing Assistant) said shaving and nail care is done after showers or as needed. V10 said residents are showered two times per week. V10 said residents should not have dirt under their fingernails or long facial hair. V10 said it is the responsibility of the CNA's to clean the resident's nails and shave them. The facility's Care of Fingernails/Toenails policy revised 02/2018 stated The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection. The same policy's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 6 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 0677 general guideline stated 1. Nail care includes cleaning and trimming. Level of Harm - Minimal harm or potential for actual harm The facility's Shaving the Resident policy revised 02/2018 stated The purpose of this procedure is to promote cleanliness and to provide skin care. The facility's Activities of Daily Living (ADL's) policy revised 03/2018 stated Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). The same policy stated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 7 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, interviews and record reviews, the facility failed to provide non slip footwear to residents at high risk for falls. This applies to 2 of 2 residents (R50 and R75) reviewed for falls in a sample of 31. Findings include: 1. On 01/09/24 at 11:20 AM, R50 was observed in the dining room and hallway with no shoes or non-slip socks on. V14 CNA (Certified Nurse's Assistant) said she was R50's CNA for the day and she did not pay attention to her socks that she was wearing on this day. V14 said that they were the socks that R50 went to bed in the night before. On 01/09/24 at 11:23 AM, V7 (Memory Care Coordinator/CNA) said she had put R50's shoes under the storage unit in the dining room because R50 had taken them off. She said that around 10:45 am, she attempted to put R50's shoes back on her but R50 took them back off. V7 said she could have put on non-slip socks on R50, but she didn't do it because she knew R50 was going to get a shower that day. V7 said that she should have put on non-slip socks on R50 because she could have got up and fell. On 01/11/24 at 12:38 PM, V1 (Administrator) said staff should have replaced R50's shoes or put non-slip socks on her because R50 is a fall risk, and it would prevent her from slipping and falling. R50 EHR (Electronic Health Record) showed that she is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including high risk for falls, history of right knee pain, schizophrenia, and psychoactive drug use. R50's 11/22/23 care plan showed that she has had falls on 2/15, 2/25, 3/15, 3/27, 5/15, 6/8, 6/15, 7/7, 8/1, 8/20, 10/31, and 11/6. R50's interventions included non-skid socks, and staff to assist with resident getting up, dressing and ADLS (activities of daily living) before breakfast. 2. On 01/09/24 at 11:30 AM, R75 was observed in the dining room with no shoes on and non-slip socks not on properly. The non-slip sides were on the sides of her feet, not on the sole of her feet. At 11:32 AM, V13 (CNA) was showed R75's non-slip socks and V13 said that the non-slip socks should be on the sole of the foot, so the resident doesn't fall. V13 said that the way R75 was wearing the non-slip socks could cause her to fall. On 01/11/24 at 12:35 PM, V1 (Administrator) said that R75's sock should have been applied properly even if she dressed herself. V1 said staff should have ensured they were on properly to prevent R75 from slipping and falling. R75's 6/18 care plan showed high risk for falls related to diagnoses of Huntington's disease. R75's care plan showed R75 had falls on 5/14, 5/27, 5/31, 6/18, 6/28, 7/6, 7/25, 8/6, 8/21, and 11/14. The care plan showed interventions including put nonskid socks on resident daily. The facility's Falls Guideline (7/16) showed that the facility will identify and evaluate those residents at risk for falls and facilitate as safe an environment as possible, and staff will ensure interventions are implemented to prevent resident falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 8 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide humidification with oxygen therapy. This applies to 2 of 3 residents (R39 and R87) reviewed for oxygen therapy in a sample of 31. Residents Affected - Few The findings include: 1. R39 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. Record review on R39's Physician Order Sheet (POS) for 01/2024 documented oxygen therapy with nasal cannula at 2-3 liters per minute (L/M) and to change oxygen tubing and water bottle every week and as needed. On 1/9/23 at 11:04 AM, R39 was on his bed with a Nasal Cannula with no water in the humidifier bottle. R39 stated, My nose is dry, and it's better to have some water with a humidifier. 2. R87 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. On 1/9/23 at 10:42 AM, R87 was in his wheelchair with a Nasal Cannula with no water in the humidifier bottle. On 01/09/24 at 11:32 AM, V8 (Nurse) stated, The nurses are allowed to fill in water with a humidifier. I will take care of those empty humidified bottles. A review of the facility provided Oxygen Administration Policy revised in October 2010 document: Equipment and Supplies: The following equipment and supplies will be necessary for this procedure. 1. Humidifier bottle Steps in the Procedures: 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 14. Periodically recheck the water level in a humidifying jar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 9 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and address pain before and during wound care to a resident. This failure has caused severe pain for one resident during dressing changes. This applies to 1 of 2 residents (R54) reviewed pain management in a sample of 31. Residents Affected - Few The Findings include: R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/10/24 at 2:20 PM, observed V5 (Wound Care Nurse) and V7 (Certified Nursing Assistant CNA/Memory Care Director) begin to provide wound care to R54's coccyx wound without assessing for pain. Observed V5 and V7 using the mattress linen to pull him up on the bed and R54 complaining of pain, saying, I have too much pain. In response to R54's pain, V5 said to R54, I know your nurse gave you pain medication. On 1/10/24 at 2:25 PM, V5 and V7 turned R54 to his right side to provide wound treatment to his coccyx wound. V5 sprayed wound cleanser on his unstageable wound (as per V5) and wiped it. R54 again complained of pain, saying, Ohh .too much pain, it's hurting. In response to R54's pain, V5 replied, I am not touching you now. On 1/10/24 at 2:35 PM, in response to the surveyor's inquiry, R54 stated, I have pain all over the place. It is 7 out of 10. I was given Norco, and it is not helping. On 1/10/24 at 2:35 PM, V5 stated, R54 was given pain medication, and that's why I didn't ask him for his pain level before starting. I am not sure I should have stopped treatment when he complained of pain. I have to look at the policy to see whether I should have stopped when R54 complained of pain during treatment. On 01/11/24 at 10:37 AM, R54 stated, Every day, I have pain when they do wound care. They give me one Norco pill, and that doesn't do anything. 01/11/24 10:45 AM, V2 (Director of Nursing / DON) stated, Our standard of practice is assessing residents for pain before wound care. The wound care nurse should have assessed the resident for pain before she started with wound care and should have stopped the wound treatment when the resident complained of pain during treatment. 01/11/24 10:15 AM V6 (Wound Care Nurse Practitioner) stated, Pain assessment is crucial before wound care, and the pain should be managed well. If pain is not managed well, it can cause the resident to deny treatment and care. The patient should have been assessed for pain. If the patient complains of pain during wound care, she should hold it and manage the pain to have a pleasant experience for the resident. The facility presented a wound care policy revised in the October 2010 document: 2. Review the resident's care plan to assess for any special needs (including pain as per Administrator) of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 10 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 0697 A review of the Pain Assessment and Management Policy revised in March 2015) documented the steps in the procedure to recognize pain. Level of Harm - Actual harm 1. Residents Affected - Few Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain a. Verbal expressions such as groaning, crying, screaming. 4. Ask the resident if he/she is experiencing pain. Be aware .numbness or tingling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 11 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/9/24 documents that the total census was 94 residents. On 1/10/24 at 11:26 AM, V3 (Director of Food and Nutrition Services) said there are no NPO (Nothing by Mouth) residents and all 94 residents eat from the facility kitchen. On 1/9/24 starting at 10:32 AM, the facility kitchen was toured in the presence of V3 and the following was found: Dry Storage: 1. Twelve 2 pound bags of sun dried raisins with expiration date 8/25/23. 2. One 6 pound 9 ounce can of diced pears dated 11/15 with a large dent on rack of food to be served. V3 said the dented cans are supposed to be removed from circulation and not used because of the risk of botulism. 3. One 6 pound 9 ounce can of diced pears with no date. 4. Two 6 pound 9 ounce cans of diced peaches with no date. 5. Three 6 pound 9 ounce cans of fruit mix with no date. 6. Six 6 pound 9 ounce cans of mandarin oranges with no date. 7. Two 6 pound 8 ounce cans of apple sauce with no date. Meat Freezer: 8. 64 ounce bag of whole strawberries opened, not dated, and not sealed with freezer burn. V3 said freezer burn is a problems because it wilts the food and effects the taste. 9. Three 36 ounce cherry pies with no date. 10. 15 pound box of rib shaped pork patties, opened and not sealed with freezer burn. 11. Freezer floor dirty with approximately three 2 inch yellow colored puddles of unknown substance. V3 said that needed to be cleaned up. 12. 6 pound opened box of pork sausage patties, not sealed with freezer burn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 12 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 Walk-in Freezer: Level of Harm - Minimal harm or potential for actual harm 13. 3 inch yellowish brown puddle on right side wall by entrance. 14. Expired 12 ounce package of classic franks with expiration date of 10/21/23 Residents Affected - Many 15. 2 large boxes of pitas with delivery date of 7/7/23. V3 said they were defrosted sometime last week, but she is not sure when. There is no defrost date on boxes. Milk Cooler: 16. 7 pitchers of drinks that are unlabeled and undated. On 1/11/24 at 10:20 AM, V3 said all foods need to be labeled and dated so staff know the expiration date and type of food item. V3 said if a resident is given expired food they can get sick. V3 said when a food item is defrosted, it needs to be labeled with a use by date to prevent expired food from being served. V3 said dented cans need to be taken out of circulation due to the risk of botulism and resident death. V3 said all cans need to be dated with received by date and stocked using the FIFO (First In First Out) method to make sure older products are used first. V3 said FIFO cannot be followed if the cans are not dated. V3 said all opened foods need to be sealed before restocking to keep critters or debris from contaminating the food. V3 said freezer burn effects the quality of the food and could cause spoilage. V3 said food storage areas should be clean and free from spills due to the risk of falls and/or cross contamination. The facility's policy titled, Storage of Dry Foods/Supplies developed 4/2017 states, Policy: The facility will follow safe handling and storage of dry foods and supplies. Procedure: .The area should be clean, .dry and free from contaminants .Canned good will be removed from packaging, dated and stored using the First in, First out method. Opened products will be labeled and stored in tightly covered containers. Dented cans will be stored separately and marks for return or disposal . The facility's policy titled, Storage of Refrigerated/Frozen Items developed 4/2017 states, Policy: The facility will follow safe handling and storage of refrigerated and frozen foods. Procedure: .Foods in the refrigerator will be covered, labeled and dated. Foods will be used by its use-by-date, frozen or discarded . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 13 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 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 follow its isolation guidelines by cohorting isolation and non-isolation residents in the same room. The facility also failed to follow its standard precaution policy by not changing gloves and performing hand hygiene during incontinence care and when leaving an isolation room. This applies to 5 of 5 residents (R18, R41, R54, R145, and R344) reviewed for infection control in a sample of 31. Residents Affected - Some The Findings include: 1. R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. 2. R145 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. On 01/09/24 at 11:37 AM, V5 (Wound Care Nurse) stated, R54 has Methicillin-resistant Staphylococcus Aureus (MRSA) infection with his right stump. R145 is not in isolation. We are combining those residents because R54's stump wound is covered with a dressing and is contained. On 1/9/24 at 11:45 AM, contact isolation signage was observed at the room door shared by R54 and R145. R54's right stump was observed with an old dressing coming off with drainage on the dressing. Upon notification, V4 (Certified Nursing Assistant) reapplied the old dressing and stated that she would notify the wound care nurse. The facility presented Isolation - Categories of Transmission Based Precaution document: Contact Precaution: The individual on contact precaution will be placed in a private room if possible. If a private room is unavailable, the infection preventionist will assess various risks associated with other resident placement options. During an infection control interview on 1/10/23 at 11:10 AM, V9 (Infection Preventionist) stated, We can combine isolation residents with non-isolation residents as long as the source of infection is contained. R54's source of infection with the right stump should have a dressing intact to contain the infected wound to minimize the risk of MRSA infection to his roommate (R145). 4. R41 is a [AGE] year old female that was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of the bladder and an Indwelling catheter. On 01/09/24 at 10:49 AM, V11 CNA (Certified Nurse's Assistant) was providing incontinence care for R41. V11 put on gloves and opened R41's brief, wiped R41's perineal area with a washcloth, wiping areas twice before folding the washcloth. V11 went to R41's rectal area and did not wash or clean the washcloth before going to the new area. V11 was observed wiping the area three times before folding the washcloth and wiping again. After V11 completed incontinence care, V11 did not remove her gloves and clean her hands, she continued with attaching the clean brief, adjusting the resident, and adjusting the sheets and blankets with the same dirty gloved hands. V11, then with same dirty gloved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 14 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm hands, remove the soil brief and put it on the back of the toilet in the resident's bathroom, then she removed her dirty gloves, did not clean her hands, and then gave R41 her remote control. V11 then put gloves on her uncleaned hands, picked up the soil brief, put it in a plastic bag, carried it through the hallway to the soiled utility room, removed her gloves, did not clean her hands, and opened the door to the soiled utility room and went inside. Residents Affected - Some On 01/09/24 at 12:54 PM, V11 (CNA) said she should have only wiped once and then folded the towel, and she should have gotten a new towel before going to a different area. V11 said she should have removed her gloves and cleaned her hands when going from a dirty area before going to a clean area. On 01/10/24 at 11:41 AM, V12 (Nurse) was examining R41's urinary catheter and brief, checking to see if R41's catheter was leaking. V12 put on gloves, opened R41's brief, touched R41's perineal area and catheter tubing, closed R41's brief, pulled up the sheets, adjusted the bed with the bed control, adjusted the catheter bag, adjusted the resident in the bed, and then removed the dirty mattress pad with her gloved hands. V12 never removed her gloves and cleaned her hands after going from a dirty area before going to a clean area. V11 then removed her gloves did not clean her hands, put on new gloves and again adjusted the catheter bag. On 01/10/24 at 11:52 AM, V12 (Nurse) said she should have cleaned her hands before going to a clean area to prevent infections and cross contamination. On 01/11/24 at 12:24 PM, V1, Administrator said that the staff should have cleaned their hands when going from a dirty area to a clean area for infection control. V1 said staff should have only wiped one time then folded the towel, she said the staff should have cleaned the towel or got a new towel when she went to the new area, the front to back, one and done, for infection control. The facility's Catheter Care Urinary policy (September 2012) showed staff are to maintain clean techniques when handling or manipulation of the catheter, tubing, or drainage bag. The facility's Handwashing/Hand Hygiene policy (August 2015) showed that the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the hand washing hand hygiene procedures to prevent the spread of infections. The use of alcohol based hand rub or alternatively soap and water for the following situations: before and after direct contact with residents, before and after handling an invasive device (e. g. urinary catheters), before moving from a contaminated body site to a clean body site during resident care, after contact with residents' intact skin, and after contact with blood or bodily fluids. The facility's Perineal Care policy (February 2018) showed the purpose of this procedure is to provide cleanliness and comfort to the resident to prevent infections and skin irritations. The procedures in the policy show the staff are to wash the perineal area first then rinse washcloth apply soap or skin cleanser and wash the rectal area next. 5. On 01/09/24 at 11:41 AM, R18 was assisted with toileting by V13 C.N.A. (Certified Nursing Assistant). V13 pulled gloves from her pocket to put on, then applied a transfer belt to R18. V13 assisted R18 to stand at her bathroom handrail. V13 removed R18's soiled disposable undergarment and assisted her to sit on the toilet. V13 touched R18's right shoulder with her soiled gloves while speaking with R18. V13 C.N.A then assisted R18 to stand at the handrail using the transfer belt. V13 wiped R18's genitals and buttocks with a washcloth and placed it on the bathroom sink. V13 then pat R18 dry with a dry washcloth and placed it on the sink. V13 then applied a clean disposable undergarment and pulled R18's pants up with the same soiled gloves. R18 informed V13 her pants had urine on them. V13 pulled the pants with urine down. V13 assisted R18 to sit in the wheelchair using the transfer belt. V13 removed R18's shoes and pants with urine. V13 maneuvered R18's wheelchair out of the bathroom (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 15 of 16 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 145043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Kankakee 900 West River Place Kankakee, IL 60901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some doorway with her soiled gloves. V13 went to R18's drawer opened and closed it. V13 opened R18's closet door and pulled out a pair of leopard print pants with the same soiled gloves. V13 then maneuvered R18's wheelchair back into the bathroom. V13 C.N.A. put R18's clean pants on up to her knees and shoes back on. Using the transfer belt, V13 assisted R18 to stand at the handrail and pull her pants up. V13 assisted R18 to sit back in her wheelchair and removed the transfer belt with the same soiled gloves. V13 then opened the bedroom door, maneuvered R18 to the door. V13 then removed her soiled gloves and tossed them in the trash bin next to the door and exited the room without doing hand hygiene. On 01/09/24 at 11:55 AM, V13 stated she didn't do hand hygiene or change her gloves because she forgot her box of gloves and does not use the glove supplied in resident rooms. 3. On 01/10/2024 at 09:20 AM V10 (CNA/Certified Nursing Assistant) was observed coming out of R344's room with gloves on. V10 was observed in the hallway wearing the gloves. V10 did not perform hand hygiene. The facility had a sign posted on the wall next to R344's room. The sign stated R344 was on contact isolation. R344 had an isolation bin next to the room. V8 (Registered Nurse) stated R344 was on contact isolation for C-Diff (Clostridium Difficile). R344's face sheet showed R344 was admitted to the facility on [DATE] with the following diagnoses local infection of the skin and subcutaneous tissue, severe protein calorie malnutrition, enterocolitis due to clostridium difficile, anemia, and anal fistula. On 01/11/24 at 11:40 AM V2, DON (Director of Nursing) said gloves should not be worn in the hallways. V2 said when staff come out of isolation rooms, gloves should be removed. Staff members must wash their hands with soap and water after taking care of residents with C-Diff. On 01/11/24 at 12:18 PM, V10 said gloves should not be worn in the hallway when coming out of residents' rooms. V10 said I can transfer an infection if I don't remove my gloves when coming out of resident's rooms. On 01/11/24 at 12:31 PM, V9 (Infection Control Preventionist) said no one should come out of an isolation room with gloves on. The gloves should come off and the hands are washed with soap and water before exiting a room. It is cross contamination for a staff member to leave out of a room with gloves on. At no times should staff wear gloves in the hallway. The facility's Standard Precaution policy revised 10/2018 stated Gloves: gloves are removed promptly after use, before touching non contaminated items and environmental surfaces, and before going to another resident. The Contact Precautions sign the facility utilizes next to isolation rooms stated to discard gloves before room exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145043 If continuation sheet Page 16 of 16