Inspection·November 3, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the company in order to prevent the facility from incurring any charges when not in use. V2 said that it was believed that the air mattress and bed were returned when R8 went to the hospital, which is why it was not available at the time of readmission. V2 provided an invoice sent 9/7/23 and email conversations from the rental company and the facility. On 9/8/23, the company representative wrote to V2, [R8]- Mattress misplaced when patient was out of facility. [R8] had one dropped off on 8/28/23. It was never picked up after she left the hospital. Tag 00782 should be in your building for her. [The facility] needs a new mattress for one they have misplaced [Low Air loss] 00782 for patient [R8]. V2 said, based on this conversation, it was indicated that R8 was readmitted to the facility, and without the needed equipment available. V2 was unable to provide further information regarding when the equipment arrived at the facility. Progress note dated 8/18/2023 7:30PM states Resident refused to be transferred to the [reclining wheelchair], to allow the air mattress to be set up. This note indicates that the bed was not available on admission, but two days after. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 2 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its policy related to notification related to a resident room change. This failure applied to one (R11) of three residents reviewed for room transfers. Findings include: R11 is a [AGE] year old, male, admitted in the facility on 10/07/23 with diagnoses of Senile Degeneration of Brain, Not Elsewhere Classified; Traumatic Subdural Hemorrhage with Loss of Consciousness Status, Known Sequela and Acute Respiratory Failure with Hypoxia. According to census report, he was placed on the second floor in the facility upon admission. Progress notes dated 10/09/23 recorded that R11 was moved to first floor. There was no documentation regarding room change and family notification of the room change as noted upon review of his medical records. On 11/01/23 at 10:05 AM, V2 (Director of Nursing) was interviewed regarding R11's room transfer. V2 replied, He (R11) was admitted and was placed on the second floor. He was only up there on the second floor temporarily until there will be an available room on the third unit first floor. I was not aware that documentation is needed for any residents who need to be transferred. His family was not notified of the transfer from one floor to another. Facility's policy titled Resident/Family Notice Regarding Room/Roommate Change dated 1/2020 stated in part but not limited to the following: A.Policy 1.Resident/Representative shall be given notice when a room change is necessary. B.Procedure 1.Prior to changing a resident's room (in non-emergency situations) or introducing a new roommate, resident, or the resident's representative when applicable, will be notified by a facility designee. 2.The designee will document a room change on the Room Change Notification assessment. 3.Additionally, a written notice will be provided about either of these changes listed above, to the resident, or resident's representative when applicable, using the Resident room Change/Roommate Written Notification /Form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 3 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to release resident's medical record to resident's guardian/power of attorney as requested. This failure affected one (R5) of one resident reviewed for release of medical records. Findings include: R5 is a [AGE] year-old man who resided at the facility from [DATE] to [DATE], with past medical history of Type 2 diabetes, Heart failure, Hyperlipidemia, Essential Primary Hypertension, Dysphagia, Gastro-Esophageal Reflux disease without Esophagitis, etc. During the complaint investigation into the allegation of the facility not assisting resident's family with the process of obtaining medical record, a social services progress note dated [DATE] documented that a family member who is not the POA was requesting the resident's medical record, facility informed him that the POA needs to sign the medical record request from which was provided, the family member later returned the documents signed by the POA and the document is being forwarded to the medical records department. [DATE] at 10:10AM, V18 (Social Service Director) stated that R5 went to the hospital, and she understood that he eventually passed away, she spoke to the resident's nephew who was requesting medical records for the resident, she told him that he was not the POA and not listed as a contact person on the face sheet. The facility provided him with a medical record request form which he completed and returned to the facility; the form was given to the staff in charge of medical records. [DATE] at 11:26AM, V22 (Medical Records) said that she received a medical record request from the family of R5, she forwarded it to the corporate office on [DATE], she then received a document from the corporate office indicating additional documents that the family needs to complete. V22 said that she called the resident's POA and told her of the additional documents in form of a court order that is needed before the records will be released, the family have not submitted the additional documents. V22 was asked if she documented the phone conversation with the POA and she said no. [DATE] at 4:22PM, V40 (Attorney) said that the family did not receive the requested hospital record because they did not submit the requested court papers. Surveyor pointed out that the request was signed by the resident's POA, and they submitted the power of Attorney document. V40 stated that the request was made after the resident died, surveyor also pointed out that the POA has the right to request the documents even after the resident died as stated in the POA paper work, V40 then said, Oh, I just started in August, I was not here when the request was made, I will talk to my supervisor and get back to you. [DATE] at 10:23AM, V40 called surveyor back and said that it was an oversight on their own part. She added that the family should have received the requested documents and said that they can send them out today. Surveyor requested for facility policy on release of medical records, but none was provided during the course of this survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 4 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/30/2023 1:23 PM R33 stated she has complained to maintenance several times about the window being broken and that it won't stay closed. R33 stated the window needs to be fixed from the outside not the inside and they keep fixing it from the inside and it never stays closed. R33 stated when she told this to the maintenance staff he asked her what do you want me to do about it? Observed the window in R16, R32, and R33's room to be open and the crank that allows the window to be opened or closed missing. R33 stated her television channels 19 and 20 are always frozen and she has reported this to maintenance as well, but they wont do anything about it. On 10/31/2023 at 3:49 PM V21 (Maintenance) stated he contacts vendors to fix windows and cable. When asked what repairs he personally makes in the facility V21 stated he fixes leaks but did not provide any additional information. On 11/01/2023 at 8:45 AM Observed water stains on the ceiling and a puddle of water in a bed under the water stains in R34 and R35 's room. R34 stated he has been here a week and anytime it rains theirs water leaking from the ceiling. R34 stated he has informed the staff about this. R35 stated he has been at the facility for a month and the ceiling has been consistently leaking during the entire time he has been at the facility. R35 stated he did not report it because he figured the staff should know about it because they can see the stains in the ceiling and the water leaking when they are in the room. On 11/01/2023 at 8:50 AM Observed R32 window boarded up. V6 (Assistant Director of Nursing) stated she wasn't aware R32's window was boarded up and it's boarded because the window is missing. R32 stated the window has been boarded up since the summer and she has discussed it with maintenance. V6 stated she would inform maintenance about the window and it shouldn't be that way. R16 stated she does not like it that the window in her room is boarded up. On 11/01/2023 from 12:16 PM - 2:10 PM V6 (Assistant Director of Nursing) stated staff are responsible to document any maintenance concerns on the maintenance logs if they observe issues or receive reports from residents. V1 (Administrator) stated staff should have been aware of the leaky ceiling in residents room and a contractor would have to be requested to address it. V1 stated we wouldn't leave residents in rooms with leaky ceilings. V1 stated there are 12 RN's and they are scheduled for at least 8 hours a day seven days a week. Maintenance Logs from - October 2023 documents resident room leak as of 09/03/23, dining room leaking as of 09/10/2023, ceiling tiles near 2nd floor room as of 10/01/23, R33's room window keeps opening, and complaining of channel 19 and 20 not working as of 10/17/23, 2nd floor resident wheelchair squeaking as of 10/19/23, 1st floor resident bed is broke (September no report date given). Maintenance Work Orders from June - October 2023 documents a work order was submitted 10/31/2023 during the complaint survey for cable channels 19 and 20, for hole in wall for hole in R8's room and frozen television channels 19 and 20 for R33. On 11/02/2023 at 11:06 AM V1 (Administrator) stated the restorative nurse is responsible for making sure the wheelchairs are in good working condition. V1 stated the walls will be patched by the end of day. V1 stated her corporate maintenance guy came down today and assisted her with putting in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 5 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0584 Level of Harm - Minimal harm or potential for actual harm work order for the broken windows documented in the maintenance logs from June - October 2023 and he is contacting a contractor for the window repairs and the roof. V1 stated she and the corporate maintenance personnel did observe water-stained ceiling panels in the 2nd floor dining room and water leaking in a 2nd floor room. V1 stated the corporate maintenance personnel is contacting a vendor to have these issues quickly resolved. Residents Affected - Some On 11/02/2023 at 2:24 PM V1 (Administrator) stated the squeaky wheelchair that was referenced as a maintenance concern was replaced today. The facility's Maintenance Policy reviewed 11/02/2023 states: Building Manager will prioritize and schedule work in a timely manner. Based on observation, interview, and record review, the facility failed to follow their maintenance policy by 1. not responding to maintenance requests timely 2. not ensuring the residents rooms and communal areas were in good condition and 3. Maintaining Resident room equipment to work properly. These failures affected six (R8, R16, R32, R33, R34, R35) of eleven residents reviewed for homelike environment. Findings include: R8 is a [AGE] year old female admitted to the facility 8/16/23 with diagnoses that include Quadriplegia. R8 is alert, oriented and totally dependent on staff for activities of daily living. On 10/30/23 at 11:55AM, R8 was observed in bed receiving care from V5 CNA (Certified Nursing Assistant). The room was disheveled- pillows were in the sink, personal items in general disorder. Cool air was coming from the window which was not fully closed, however the crank mechanism was missing in order to operate opening and closing. Three large holes were noted in the walls near the bed. V5 said, he believed that the holes were made by the bed hitting the wall, but that it was likely caused by staff because R8 is unable to operate the remote to move the bed. R8 said that she previously requested for weeks to have the walls repaired and no one has cared to come and fix them. R8 also said that she believed that vermin was scratching in the walls at night, and she was afraid that they would eat through if not covered. R8 also said that she had to yell for extra blankets one night because it was so cold, and the bed is placed directly under the window. V5 said, R8 had mentioned that concern to him before, and that the holes have been there for a while but V5 didn't know if there was anything he could do about them. Facility Maintenance logs were reviewed from June 2023 to current and did not indicate anyone reported these concerns. On 10/31/23 at 1:45PM V1 said, she noticed the holes in the wall previously and was not certain why they were not repaired. V1 also believed that R8's bed was causing the holes, but unable to speculate how they occurred. V2 also went on to discuss the window, saying that at one point, the window was hyperextended which caused it to come off the track and the window had to be closed or pushed from the outside. V2 said staff told her to be sure not to over extend the window in the future, and Surveyor inquired if it was physically possible for R8 to operate the window, when R8's medical condition renders her incapable of most motor function in her hands. V1 said, that the staff and visitors would have to be educated as well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 6 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/31/23 at 4:18PM V21 Maintenance Director said that he was aware of the holes in the walls but was unable to note how long he was aware because he was new to the facility. V21 said that he would have to call upon a company provided by Corporate to repair and paint the drywall, and that a work order would be placed later that day. Facility provided work order request dated 10/31/23 at 4:35PM which states: Description: room [ROOM NUMBER] has a hole in the wall need repair service tech . Event ID: Facility ID: 145173 If continuation sheet Page 7 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R15 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder, Unspecified Convulsions, End Stage Renal Disease, Type II Diabetes Mellitus with Complications, Diaper Dermatitis (August 2023), Legal Blindness, and Amputations of Fingers and Lower Limbs who was admitted to the facility 07/31/2017. R15's current care plan initiated 07/20/2022 has a history of physical aggression towards others due to poor impulse control with interventions including validated his feelings and ensured his safety; remove resident form any potential situation which could precipitate aggressive behavior. Final Facility Reported Investigation Report dated 05/13/2023 documents on 05/03/2023 a staff member reported that R15 made an allegation of abuse toward a staff member with the specific allegation against staff being unclear in the report; documents his allegations were inconsistent and range from verbal abuse to denying all allegations; R15 reported that he thought a staff member was speaking about him in the hallway about him not needing any help with his care; The CNA (Certified Nursing Assistant) in question (name not included in report) was interviewed by the charge nurses regarding R15's claims that he requires no assistance and when the CNA asked R15 if he had any concerns about his care he became verbally abusive, used profanity against the staff and requested she leave his room stating he does not want her to provide him with care; R15 has a history of false allegations and verbal aggression toward staff; Staff denied witnessing any form of abuse against R15; R15 did not have any roommates at the time of the alleged incident; R15's provided inconsistent accounts of the alleged incident; The allegation was not substantiated. Investigation statement dated 05/03/2023 documents R15 reported that V31 (Certified Nursing Assistant) was negligent in her care towards him, she never brought him his food and he heard her in the hallway stating R16 was bitching about his food, to another CNA and when he confronted her she stated she was just playing with him; R15 then reported another incident in which he asked her to go to his closet and give him a shirt out of his bag and she told him that she wasn't going to do it because these were too many clothes to go through so first shift staff can do it. R15's investigation statement dated 05/03/2023 documents V31 (Certified Nursing Assistant) went off on him because he reported to V33 (Certified Nursing Assistant) that she won't change him or give him his food and the CNA stated she didn't appreciate him informing V33; R15 felt it was retaliation from reporting her to V33. Investigation statement dated 05/04/2023 documents V27 (Licensed Practical Nurse) reported V33 CNA (Certified Nursing Assistant) came to report how rude and unruly the CNA was with herself, the nurse on duty and the resident and V27 advised she write a statement and leave it with the Director of Nursing. Resident Post Occurrence Follow Up report dated 05/12/2023 documents R15 reported his CNA approached him asking if everything is ok and asked if he told people that she's not doing her job, he didn't appreciate her questioning him, so he went off on her. Investigation statement dated 05/03/2023 from V33 (Certified Nursing Assistant) documents Attn V34 (Former Director of Nursing): Today R15 asked me to report V31 (Certified Nursing Assistant) negligent behavior towards him, he stated that she never brought him his food and he heard her in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 8 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0600 Level of Harm - Actual harm Residents Affected - Few hallway stating R16 was bitching about his food, to another CNA and when he confronted her she stated she was just playing with him; R15 then reported another incident in which he asked her to go to his closet and hive him a shirt out of his bag and she told him that she wasn't going to do it because these were too many clothes to go through so first shift staff can do it. R15 states that he doesn't want her to come in his room or care for him, upon notifying V32 (Registered Nurse) of what R15 stated V31 walks up and asks if R15 was talking about her and what was said, I asked V32 if it was ok to repeat what R15 stated and he said it was ok, upon hearing what R15 had to say V31 went in the room and confronted him and made him furious, I went in the room and calmed him down, moments later she walked in to another 1st floor room and stated she is gonna spaz out on everybody report people to the state and anybody can get it just loud unprofessional and rude, I spoke to V27 (Licensed Practical Nurse) about this and she advised to inform you (V32). On 11/01/2023 from 12:16 PM - 2:10 PM V1 (Administrator) stated V33 (Certified Nursing Assistant) initially reported R15's allegation regarding V31 (Certified Nursing Assistant). V1 stated the investigation report documents V31 stated to R15 regarding his allegation, did you tell people that I wasn't doing my job, but V31 was not hostile or confrontational when using those words and asking that question. V1 stated she could see it being offensive for a resident to be asked that question by staff. V1 stated V31 wasn't privy to R15's history of being aggressive and hostile towards staff because that wasn't her experience with him. V1 stated staff are responsible to familiarize themselves with residents based on their care plans. V1 stated it's not appropriate for staff to ask residents about allegations made against them and it could trigger R15. V1 stated she would train staff on resident rights and behavior management to address these issues. On 11/01/2023 at 2:45 PM V1 (Administrator) stated it is subjective as to whether a resident would feel intimidated by staff when being asked about an allegation the resident reported against them. The facility's Abuse Policy reviewed 11/02/2023 states: This facility affirms the right of our residents to be free from abuse. This facility prohibits mistreatment or abuse of it's residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment or abuse of our residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This facility is committed to protecting our residents from abuse by anyone including but not limited to facility staff. Abuse means any mental injury inflicted upon a resident other than by accidental means in a facility. Abuse is intimidation with resulting mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the harm. Mental Abuse may occur through verbal contact which has the potential to cause the resident to experience intimidation, fear, agitation or degradation. Mistreatment is inappropriate treatment or exploitation of a resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 9 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0600 Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to follow their Abuse Prevention Policy by not keeping residents free from physical and verbal/mental abused by staff. These failures applied to two (R15, R19) of seven residents reviewed for abuse and resulted in R15 experiencing mental abuse by feeling retaliated against by a staff member and R19 was physically abused by staff hitting R19 with a hanger to the right buttock, leaving a red discoloration. Findings include: R19 is a [AGE] year old male admitted to the facility 7/17/2020 with diagnoses of Alcohol abuse with alcohol-induced anxiety disorder, Unspecified Dementia, Hypertension and dysphagia. According to R19's health record, he is dependent on staff for activities of daily living. On 9/16/23 R19 made an allegation of physical abuse against V4 CNA. Progress note dated 9/16/23 stated, The writer was at the nurse's station and heard a loud popping sound and I traced the sound in the hallway. I then saw the above resident frantically stumbling toward his bed and I asked him if he is ok and then he stated The CNA hit me I stat pulled the cna off the floor and approached her at the nursing station in regard to the accusation. The assistant administrator/MOD [Manager on Duty] at that time was notified immediately. Administrator, POA (Power of Attorney), [NAME] [Director of Nursing], Np [Nurse Practitioner], and [Medical Doctor] made aware. I immediately did a full body assessment on the resident, and I observed a red discoloration on the Rt buttock. The resident denies pain and refuses pain medication at this time. This incident was reviewed and investigated by V1 Administrator shortly after the incident occurred. On 10/31/23 at 11:44AM V1 said when the event occurred, the assistant administrator was on duty and in the building. V39 Assistant Administrator removed V4 from the building immediately and called me. He said, there was an allegation which V4 admitted to. I came to the facility shortly after and began my investigation. I interviewed V4 a few days later and she admitted to hitting R19 with the hanger as well. I told her that she was terminated for not adhering to the abuse policy. She did not return to the facility since the incident occurred. Facility Abuse Policy revised 9/2020 states in part; This facility affirms the right of our resident to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. This facility is committed to protecting our resident from abuse by anyone including, but not limited [NAME] facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individual. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 10 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Willful mean the individual acted deliberately, not that the individual must have intended the injury or harm. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and /or maintain physical, mental and psychosocial well-being. This includes suspicion of a crime. Assuring that physical restraints re used sparingly and properly and that chemical restraints are not used. This assumes that all instances of abuse of resident, even those in a coma cause physical harm or pain or mental anguish. Event ID: Facility ID: 145173 If continuation sheet Page 11 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its policy related to wound care documentation for residents being treated for pressure ulcers. This failure affected one (R9) of four residents reviewed for pressure ulcers. Residents Affected - Few Findings include: R9 is a [AGE] year old male, admitted in the facility on 05/08/23 with diagnosis of Pressure Ulcer of Sacral Region, Stage 4. According to TAR (Treatment Administration Record) dated May 2023 to July 2023, the following were documented: Maxorb II AG 4x8 external apply to sacral topically everyday shift for pressure ulcer of sacral region use calcium alginate packing QD (everyday) if wound vac is NA (not available) - 05/18, 05/19, 05/20 were not signed for Days. Sacral wound cleanse with NS (normal saline), apply moisturizing cream. Secure with calcium alginate, apply with wound vac at 120 to 125 mm (millimeters) one time a day every Monday Wednesday Friday (MWF) for wound care - missing signatures on 05/19; 06/28, 06/30 and 07/10 at 1200. Sodium Chloride Solution 0.9% apply to sacral topically every night shift every MWF for skin condition. Cleanse wound with NS, then apply negative pressure wound treatment (wound vac) at 125mm Hg continuous pressure, and change dressing 3 times per week and PRN (when needed) until healed - no signatures on 05/19; 05/29 and 07/07 for nights. On 11/01/23 at 1:06 PM, V2 (Director of Nursing) was asked regarding unsigned treatment orders in the TAR. V2 replied, I don't know why it was not signed out not until I talked to the nurse on duty at the time. V25 (Registered Nurse, RN) was interviewed on 11/01/23 at 1:15 PM regarding treatment orders. V25 stated, Wound care is here in the facility Mondays through Fridays. If they are not here, floor nurses do wound treatment and as needed. Typically, once wound care is rendered, we signed it off. If it is not signed, it could possibly be due to nurses forgot to sign or the treatment was not done. R9's care plan dated 05/09/23 regarding actual alteration in skin integrity documented: Intervention: Treatment as ordered. Facility's policy titled Prevention and Treatment of Pressure Injury and Other Skin Alterations dated 03/02/21 documented in part but not limited to the following: Policy: 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Facility's policy titled Non-Sterile Dressing Change dated 03/2021 stated in part but not limited to the following: Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 12 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 0686 24. Document the dressing change on the TAR (treatment administration record) or EHR (electronic health record). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 13 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R16 is a [AGE] year-old female with a diagnoses history of Partial Paralysis, Cerebrovascular Disease, Contracture of Muscle Right Upper Arm, COPD, and Schizophrenia who was admitted to the facility [DATE]. On [DATE] at 12:46 PM R16 stated V35 (Certified Nursing Assistant) pushed her right hand into the left bed rail when turning her over and injured her hand. R16's Minimum Data Set assessment dated [DATE] documents she requires extensive one person assistance with bed mobility and totally dependent on two-person assistance for transfers. R16's current care plan initiated [DATE] documents she is noted to resist care with interventions including Accept residents right to refuse and show respect for residents decision. R16's progress notes dated [DATE] at 12:21 PM documents she reported to nursing staff that she was abused by a CNA (Certified Nursing Assistant); at 12:50 PM V28 (Licensed Practical Nurse) documented she was made aware that R16 was bleeding from her right hand, her right hand fifth finger area was bleeding, pressure was applied to stop the bleeding and area cleaned and wrapped with gauze. Final Incident Investigation Report submitted to the state agency [DATE] documents R16 made an allegation against V35 (Certified Nursing Assistant) concerning delivery of care; The incident occurred in R16's room and V35 was immediately sent home; Her roommates are alert and oriented and did not witness any abuse against R16, other residents interviewed expressed no concerns regarding the care rendered; R16 has given various reports in the past of her hand being broken years ago by her husband and her hand being broken from her bed when she was younger: R16 denies feeling intimidated by staff and has a history of hallucinations, delusions, erratic behavior, and bizarre thoughts. Resident Services Screening Tool dated [DATE] documents R16 reported her husband broke her hand and it had been broken for years, she broke her hand when she was a little girl, and she told them her CNA broke her hand too. Undated statement included in Final Incident Investigation Report submitted to the state agency [DATE] from V28 (Licensed Practical Nurse) documents a CNA (Certified Nursing Assistant) came to her and reported R16 was upset with her while performing activities of daily living care and she hit her, V28 went to R16's room and R16 stated she pushed me so hard, she hit me and broke my finger, she threw my pop away, right finger observed bleeding, area cleaned and bandage applied. Investigation statement from V29 (Scheduler) dated [DATE] documents V28 (Licensed Practical Nurse) notified me that R16 informed her that a CNA broke her finger and pushed her. Investigation statement included in Final Incident Investigation Report submitted to the state agency [DATE] from R33 (Resident) documents she reported she saw a CNA shove R16. Investigation statement dated [DATE] from V35 (Certified Nursing Assistant) documents when providing activities of daily living care to R16 she became upset and became physical with staff, during this incident R16 tore her skin in between her fingers with her long nails; V35 informed the nurse and was advised by the nurse that whenever R16 denies care to leave her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 14 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 - Actual harm R16's undated investigation statement on allegation included of abuse included in Final Incident Investigation Report submitted to the state agency [DATE] documents a Certified Nursing Assistant jumped on her while she was taking care of her; her jaws and fingers are hurting; the person's name is V35 (Certified Nursing Assistant) pronounced in a different manner. Residents Affected - Few On [DATE] from 12:16 PM - 2:10 PM V1 (Administrator) stated she believes she received two allegations involving resident care for V35 (Certified Nursing Assistant). V1 stated one resident reported he didn't like the way V35 was providing feeding assistance and she received another report from R16 with an allegation that V35 broke her hand. V1 stated CNA's (Certified Nursing Assistants) are informed if a resident becomes combative or resists care you should back off and request assistance because that's how reportable incidents occur. V1 stated it is plausible if R16 has long fingernails that her hands were caught down in the railings and possibly became wedged during the alleged incident and could have injured her finger that way. V1 stated R16's injury during the incident was a fresh wound on her hand. V6 (Assistant Director of Nursing) stated in the process of being repositioned or turned over it's possible for R16's hand to become wedged in between the mattress and bed rail. V6 agreed it can't be determined if this did or did not occur during the alleged incident. V6 stated the fact that V35 reported that R16's hand was injured while activities of daily living care was being provided is why she came to the conclusion that it's possible that R16's hand became injured in the process of receiving care in the manner in which it was described. R17 is an [AGE] year-old female with a diagnoses history of Stage 3 Chronic Kidney Disease, Dementia, and Other Specified Depression Episodes who was admitted to the facility [DATE]. R17's Quarterly Minimum Data Set, dated [DATE] documents she requires one-person physical assistance and supervision for walking in room, corridor, and ambulating on and off the unit. R17's current care plan documents she is at risk for falls due to Cognitive Deficits, Diagnoses and/or Disorders, Incontinence, Dementia, use of anti-hypertensive and psychotropic medication with interventions including assure resident is wearing eyeglasses; ensure that R17 takes brakes with ambulating and has somewhere to sit near the nurses station when she is there; Monitor for changes in ability to navigate the environment. R17's current fall care plan does not include supervision while ambulating. R17's incident report dated [DATE] documents he was observed sitting in her room on the floor, when asked why she stated she just wanted to sit down, upon assessment it was noted she had swelling on right side of her forehead. R17 was assessed, bed remained in lowest position. Injury included swelling of forehead. R17's progress notes dated [DATE] 07:10AM Post Occurrence Documentation states she was noted setting in her room on the floor, when asked why she was sitting on the floor she stated that she just wanted to sit down, upon assessment it was noted that she had swelling noted on the right side of her forehead. R17's progress notes dated [DATE] at 08:30 AM documents writer called PPHP (Provider Partner's Health Plan) hotline to report new findings from the follow-up on the resident whose right eye is now black and swollen; at 10:36PM writer assessed the resident and observed swollen on the right orbital region (right eye), vitals are stable nurse practitioner notified, ice packed was placed on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 15 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 affected part, Resident complained of slight pain during shift writer continue to placed ice pack on patient affected part. Level of Harm - Actual harm Residents Affected - Few On [DATE] from 12:16 PM - 2:10 PM V1 (Administrator) stated R17's black eye was due to a fall. V1 stated there was no root cause analysis completed for her fall in March, and she doesn't want to guess as to how she fell. V6 (Assistant Director of Nursing) stated R17 has an unsteady gate but isn't sure if this was her status in March. V6 stated R17 ambulates on her own, is very combative at times and walks all day on the unit. V1 stated R17 had a fall in [DATE] and [DATE]. V1 stated a root cause analysis should be done when a resident has a fall which would be documented under a risk management report and it there isn't one for her fall in March. V1 stated whatever is determined from a root cause analysis would be added to the care plan. V6 stated in January R17 fell in front of a nurses station after standing for a long period of time. V6 stated the results of the root cause analysis from that was impaired cognition and balance. V6 stated R17's incident report from March does not document where she was located but the black eye she sustained could have been from hitting her bedside table or dresser during the fall. V6 stated R17 doesn't need consistent supervision however, she refuses care daily and needs consistent redirection throughout the day. V6 stated one person staff supervision means having a staff member present with a resident to observe them directly when they are moving. V6 stated this means staff should have their eyes directly on R17 when she is self-ambulating. V6 stated R17's status of requiring one person staff assistance and supervision according to her quarterly minimum data set assessment from January means someone being present to observe her may have prevented her from falling in March. V1 stated R17 has a BIMS (Basic Interview for Mental Status) of 15 means she was able to pull her call light and if she pulled the call light when she had her fall in March someone could have assisted her. V6 stated R17 does not use her call light. V1 and V6 stated they are not sure if R17 was using her call light to request assistance in March. V1 stated she believes R17's fall was unavoidable because she has the cognition to be able to pull her call light. V1 agreed they would not be expecting her to use her call light for assistance based on her current behavior of not using it. The facility's Fall Management Policy reviewed [DATE] states: The facility is committed to minimizing resident falls or injury so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Plan of care reviewed and updated at time of occurrence, quarterly, and as needed in order to minimize risk for fall incidents. Based on observation, interview and record review, the facility failed to re-evaluate fall care plan interventions for effectiveness after resident falls for residents assessed to be at risk of falling, and failed to have individualized interventions, taking resident cognitive function into account, included in the plan of care to meet specific resident needs to address re-current falls. This failure applied to three (R4, R5, R26) of three residents reviewed for falls and resulted in R4 having multiple falls and sustaining a laceration to the forehead, which required sutures; R5 had a fall which resulted in hospitalization for acute intracranial hemorrhage; and R26 having multiple falls and being observed to wander into other resident rooms unsupervised.The facility failed to keep a resident (R16) free from injury while being provided care by staff and by not implementing effective and personalized fall interventions for a resident (R17) with a history of falls. These failures applied to two (R16, R17) of two residents reviewed for accidents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 16 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 Findings include: Level of Harm - Actual harm R5 is a [AGE] year-old man who resided at the facility from [DATE] to [DATE], with past medical history of Type 2 diabetes, Heart failure, Hyperlipidemia, Essential Primary Hypertension, Dysphagia, Gastro-Esophageal Reflux disease without Esophagitis, etc. Residents Affected - Few Per record review, R25 (RN) documented the following on [DATE], resident fell, speech slurred able to lift right and left arm as well as stick tongue out with no deviation, however no improvement in speech. Resident sent out 911. Hospital record dated [DATE] states in part, [AGE] year-old male with past medical history of .presented from a nursing home after an unwitnessed fall. On arrival, CT head showed large acute intracranial hemorrhage with extension to right basal ganglia and 2mm midline shift. Neurosurgery consulted by emergency room physician, their evaluation pending. On my evaluation patient is obtunded, not following any command, occasionally moans to painful stimuli, systolic blood pressure is above 200. Review of death certificate showed that R5 expired on [DATE], cause of death was listed as non-traumatic intracranial hemorrhage. Care plan initiated [DATE] stated that R5 is at risk for falls related to the use of anti-hypertensive medication, unsteady gait, uses walker, requires assistance with toileting. Interventions include assist resident at night when he needs to go to the bathroom, orient resident to surroundings frequently, including location of bathroom, dining room, bedroom, etc., provide proper well-maintained footwear, etc. The additional intervention after the fall on [DATE] was for resident to request assistance with transfer from staff. Care plan initiated [DATE] stated that resident has limited ability to manage and complete functional tasks due to balance deficit musculoskeletal. Interventions include to assist and instruct resident with all prescribed physician precautions, fall risk education and therapeutic exercises to improve balance ability. Minimum Date Set (MDS) assessment dated [DATE] section G (functional) coded R5 as requiring staff supervision with set up or one-person physical assistance for all ADLs. Section GG (functional abilities) of the same assessment coded resident as requiring supervision or touching assistance to partial to moderate assistance for ADLs. On [DATE] at 4:17PM V45 (LPN) said that she recalls R5 and recalls the last time he fell. R5 needed assistance with ADLs, he is incontinent sometimes but other times he goes to the bathroom. The day R5 fell, V45 said that she was working on the other side of the floor, another resident notified her that R5 was on the floor, resident stated that he was going to the bathroom when he fell. R45 added that she does not know the last time resident was seen by a staff before the fall. On [DATE] at 12:55PM, V25 (RN) said that he recalls R5, he was on break the day resident fell, according to the nurse that was covering for him, resident was grabbing something on his dresser and fell, he did not witness the fall.V25 added that R5 has fallen before and he is a fall risk, V25 said that he did not follow up with the hospital after resident was sent out, he did not complete the incident report either because he did not witness the fall, not sure if resident had any injuries. Fall incident dated [DATE] documented by V26 (LPN) stated that she was made aware resident needed assistance, resident noted sitting next to wall in bedroom with his walker on the floor next to him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 17 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 - Actual harm Residents Affected - Few Resident stated that he was going to the washroom and lost his balance. R5 also had a fall on [DATE] as documented by V26 (LPN) at 00:32, resident sustained an injury to the back of his head and was also sent to the hospital for further evaluation. On [DATE] at 12:24PM, V26 (LPN) said that she recalls R5, he can walk, he gets around on his own but requires staff supervision, she does not recall what resident was doing before the fall, she was notified by another resident. V26 cannot recall the last time herself or the CNA saw the resident before he fell. R26 is a [AGE] year-old female who was admitted to the facility on [DATE] with past medical history of essential primary hypertension, unspecified dementia, iron deficiency anemia, schizophrenia, generalized muscle weakness, etc. On [DATE] from 1:25PM to 1:30PM, observed about five residents sitting in one area in the dementia unit eating lunch and there was no staff in sight monitoring or supervising them. At 1:32PM, a resident came down from the hallway and stated that another resident came to her room while she was eating and did something in the garbage can on her roommate's side of the bed, she stated that she does not know who the resident is or what room she came from. Surveyor followed resident to her room and observed R26 lying down in the first bed, awake but confused and could not answer any questions, Surveyor also observed some yellowish liquid in the garbage can and on the floor in room. On [DATE] at 1:34PM, V6 (ADON) was spotted in the hallway, surveyor presented this observation to her, and she said that R26 is from (another) room, resident wanders. V6 walked resident back to her room, Surveyor notified V6 that there was some yellowish liquid in the garbage can in room (number provided) and the other resident complained that R26 did something in the garbage can, V6 looked in the garbage can and stated, that is urine, I will get housekeeping to take care of that, I bet you the other resident did that and is trying to pin it on R26 I don't think she will do something like that. On [DATE] at 1:37PM, V7 (CNA) was observed guiding resident to her room and told surveyor that this resident does that all the time, she wanders into other residents' rooms, pull her pants down and urinates anywhere, she has taken care of the resident for a while, and she does that all the time. Per facility fall log, R26 has had multiple unwitnessed falls since admission ([DATE] found on the floor in the dining room; [DATE], another resident informed staff that resident was on the floor in the nursing station; [DATE], resident was found on the floor in the hallway and sustained swelling to the right side of her face). MDS assessment dated [DATE] section G coded resident as requiring supervision with set up to one-person physical assistance for ADLs. Fall care plan initiated [DATE] stated that resident is at risk for falls due to poor safety awareness. Interventions include but not limited to encourage resident to keep room free of obstacles, encourage resident to report falls, resident was placed in a unit where she could be more closely monitored and constantly redirected, resident was sent to the hospital for further evaluation, provider was consulted for further evaluation, etc. R4 is a [AGE] year-old female who has resided at the facility since 2022 with past medical history of unspecified dementia, essential primary hypertension, underweight, muscle wasting, restlessness, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 18 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 and agitation, etc. Level of Harm - Actual harm MDS dated [DATE] section G coded R4 as requiring extensive assistance with one-person physical assist for ADLS, section H stated that resident is always incontinent of bowel and bladder. Residents Affected - Few Fall care plan initiated [DATE] stated that R4 is at risk for falls related to having cognitive deficit, incontinence, muscle weakness, poor balance, poor safety awareness, etc. Interventions include assist resident to get up and out of bed when resident is not feeling sleepy, rounding of every two hours and prompt or assist for change in position, toileting, promote placement of call light within reach etc. R4 had an unwitnessed fall on [DATE], sustained a laceration to her forehead, was sent to the hospital and returned to the facility with sutures to her forehead. R4 also had unwitnessed falls on [DATE], [DATE], and [DATE]. On [DATE] at 2:04PM, V44 said that residents who are assessed as needing supervision could be more of cueing, not hands on, and depends on residents. Those who are assessed with weakness or lack of coordination should be monitored frequently, those in the memory care unit should be always monitored all day long. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 19 of 20 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 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review, the facility failed to provide sufficient nursing coverage, per their assessed staffing needs to ensure adequate care and support. This failure has the potential to affect all 151 residents that reside in the building. Findings include: On 10/30/23 at 12:26PM, V20 (Licensed Practical Nurse) was interviewed regarding staffing on unit three. V20 said there are 37 residents on this unit which is a memory care unit. There is currently one nurse and about three certified nursing assistants (CNA's) working on the unit. V20 said majority of these residents are dependent on staff for care and time management is very challenging. V20 said at times there are only two CNA's working the unit and when this is the case, I have to assist with supervision and have to pass medication from the nursing station so I can observe the residents in the dining room. On 11/1/23 at 11:35AM, V29 (Nursing Scheduler) was interviewed regarding staffing. V29 said I am responsible for putting together the schedule for CNA's and nurses. I schedule a total of at least 14 nurses and 24 CNA's per day. The shifts should have a minimum of 8 CNA's and 5 nurses for the day and afternoon shift and at least 6-8 CNA's and 4 nurses for the overnight shift. If a staff member calls off, we attempt to call someone in to cover that shift. We will also pull CNA's from restorative or wound care and nurse managers to work the floor if needed. V29 says we do not use agency staffing at this time. V29 said staff have expressed concern in the past about them having too much to do or they become overwhelmed. At 1:00PM, V25 (Registered Nurse) was interviewed regarding staffing. V25 said I work the day shift and have worked on all units within the facility and I feel as if the facility does not have appropriate staffing coverage for nurses and CNA's to adequately take care of the resident's needs. At 1:35PM V30 (Licensed Practical Nurse) was interviewed regarding staffing and observed to be working on unit three. V30 said there is always one nurse on this unit three and there are currently 37 residents. The residents on this unit have cognitive impairment and need redirection and supervision. V30 says there really should be two nurses here which would allow us to provide more supervision and ensure that we can round more on the residents. Time reports were reviewed for nurses and CNA's from 9/30/23-10/30/23 for weekend shifts. It is to be noted that out of the 10 weekend days reviewed, there were 7 days that did not meet the minimum requirements of 24 CNA's and 14 nurses per V29 (Nursing Scheduler). Time reports were also reviewed for nurses and CNA's from 10/1/23-10/30/23 for the overnight shift. It is to be noted that out of 30 shifts for nurses and CNA's for the overnight shift during this time, there were 26 shifts that did not meet the minimum requirements of 6 CNA's and 4 nurses per V29. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 20 of 20