Inspection·April 18, 2024

F 0600 (Brief Interview of Mental Status) score of 13 indicating intact cognition. Level of Harm - Immediate jeopardy to resident health or safety R2's Comprehensive Behavioral Health Initial assessment dated [DATE] shows that R2 has a history of aggression and violence; displays frequent Hallucinations/Illusions and almost constant Delusions; Attitude towards Admittance: angry, confused; Adjustment to Placement: Angry over facility placement; resents placement; Copes through display of anger and hostility. Residents Affected - Few No care plan related to R2's need for monitoring due to aggressive behavior documented prior to [DATE], the day of the incident. R2's psychiatry progress note from previous facility dated [DATE] reads in part, Behavior: agitated, restless, combative, stealing from other residents. 3. On [DATE] at 10:42 AM Surveyor approached R2 on the 2nd floor hallway. Surveyor asked about the incident involving him and R1 on [DATE]; however, R2 stated something unintelligibly and walked away. R2 proceeded then to follow surveyor throughout the unit, staring, mumbling unintelligibly, and clinching fists in a threatening way. Surveyor did not observed staff redirecting R2 at any point. R2 is remaining in the facility displaying aggressive and intimidating behaviors as observed by a surveyor and shares a room with another resident at this time. On [DATE] at 10:49 AM Surveyor interviewed R7. R7 resided in the room directly adjacent to R1 and R2's room at the time of the incident. R7 stated, I was awake on the night of [DATE]. The incident happened around 2:00 AM. R1 was howling: Somebody help! while R2 was just beating on him. R1 came into my room, he was bleeding from all over his face. R2 beat R1 terribly. Staff didn't hear them. There was only one nurse that night, V17 (Licensed Practical Nurse), I don't know where all CNAs (Certified Nursing Assistants) were. R2 is still messing with other residents. Everybody knows what happened that day. Nobody talked to me about the incident, you're the first person who asked me about it. After R1 returned from the hospital, he didn't move anymore, didn't come out of his room like he did before. According to R7's MDS (Minimum Data Set) assessment dated [DATE] under section C, R7 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. On [DATE] at 11:29 AM V1 Surveyor interviewed V1 (Administrator/Abuse Coordinator) who stated in summary: I found out about the incident early, around 4.00 am, on [DATE]. V17 (LPN) notified me that R1 had a fall and will be sent out to the hospital. Allegedly, R1 hit his head. While they were waiting for the ambulance, R1 said, My roommate pushed me. Based on that allegation, I initiated abuse investigation. All neighboring residents, in adjacent rooms and rooms across from R1 and R2 room, were interviewed; all of them said they were asleep and didn't hear or see anything. The door to R1 and R2 room was ajar throughout the night. Staff didn't hear or see anything, including V17 (LPN), V11 (CNA), and V15 (Social Worker). We called local police department as part of the abuse investigation procedure, they awoke R2 to interview him, and R2 denied knowing what happened to R1. When police came, R2's behavior changed, he was walking away from them. After that, R2 became agitated and was sent out for psychiatric evaluation. As an outcome of the investigation, we found that R1 had laceration above his right eye but no serious injuries from the incident. When R1 came back from the hospital, he remained in bed, so he wasn't ambulating like before. I spoke to R1's Power of Attorney and discussed moving R1 closer to the nursing station to keep him safe. After few days (on [DATE]), R1 was transferred out to the hospital for a medical reason, and he passed away (on [DATE]). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 2 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 12:43 Surveyor interviewed V12 (Licensed Practical Nurse) who stated in summary: R2 was admitted to the facility on [DATE] around 3:00 PM, close to the change of shift, I was one of the admitting nurses. R2 seemed agitated. When we tried to orient R2 to his room and point to his bed, R2 told us, I want to be where I want to be and said I'm leaving from here. R2 met R1 in the hallway that day but did not display any aggressive behavior towards him at that time. Couple of residents have brought to my attention later that day ([DATE]), that R2 walked up behind them, into their personal space, which made them uncomfortable. R1 was very active, talkative, and friendly, seemed very happy. R1's vision was very impaired. All residents liked R1 and looked out for him due to his vision impairment. I saw R1 after the incident (on [DATE]), the right side of R1's face was very swollen, he couldn't move, he wasn't able to walk or feed himself, or even sit up. R1 has never gone back to his baseline. On [DATE] at 12:59 PM Surveyor interviewed V13 (Housekeeper) who stated in summary: The way R2 talks and looks at me, I don't know, I'm trying not to acknowledge him. It feels like R2 is targeting me, and couple other residents as well. You know how he looked at you when you were in the unit today? R2 does the same to me. It seems like R2 is looking for trouble. It is hard to understood what he's mumbling under his breath too, but I make sure R2 is never behind my back. R2 also writes in his room and on the bathroom walls. I saw R1 after the incident (on [DATE]), and he looked really bad, swollen. Residents are asking me why they (facility staff) are not doing anything about R2, they feel very uncomfortable with him on the unit. Everyone is aware that R2 is aggressive. On [DATE] at 3:28 PM V1 (Administrator) stated that, per V15's (Social Worker) significant other, she is incapacitated and won't be available for an interview during this survey. On [DATE] at 10:02 AM Surveyor interviewed V14 (Resident Care Coordinator) who stated in summary: I performed R1's MDS assessment in section GG on [DATE]. R1 was ambulatory, required partial to moderate assistance with incontinence care, identifying objects, and positioning for safety due to his visual impairment. R1 was able to perform majority of ADLs but staff assistance was required due to his vision impairment and behavior, such as response to internal stimuli, and cognitive incapacity. On [DATE] at 10:38 AM Surveyor interviewed V11 (Certified Nursing Assistant) who stated in summary: On 03/172024, I was working on the night shift (10:00 PM to 7:00 AM). I didn't hear or see anything that happened between R1 and R2 at the time of the incident. V17 (LPN) came to get me, between 3:00 AM and 4:00 AM, asking if I saw R1 recently. V17 (LPN) said R1 has a knot on his head. We both went to see R1. R1 had bloody face, swollen right eye, and swelling of the entire right side of his face. There was blood on R1's bed and the floor. R1 went to the bathroom to wash his face and hands, I assisted him. I didn't see any blood in the bathroom or on the bathroom floor. If I was going to judge where the incident happened, it would have been by R2's bed, that's where the blood was. In the conversation, R1 said he was punched twice in the face and kicked continuously by R2 while he fell to the floor. While I was awaiting an ambulance with R1, R2 kept coming around and asking how is R1 doing, if he's ok, and if his eye was ok. I told R2 to give us privacy, R2 got agitated but went back to his side of the room. I did not assess R2 or looked at his fists. Paramedics came 30 minutes later (around 4:00 AM - 4:30 AM). R2 was in the room the entire time. I usually round the unit every 2 hours. I came in at 10:00 PM, started rounding around 10.30 PM and went every two hours from then on. Last time I saw R1 that night was around 01:30 AM and he was asleep in the bed at that time. R2 was walking throughout the unit most of the night. No one mentioned that R2 required additional monitoring. When there is newly admitted resident in the unit, they should be monitored more frequently. I don't believe there is a specific policy for that, it is my personal experience. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 3 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 11:30 AM Surveyor interviewed V2 (Director of Nursing) who stated in summary: Myself and V5 (Clinical Director) are supposed to be part of the team who makes decision about resident placement in regard to appropriate room and roommate, but we are just told where to place residents. Surveyor clarified why are V2 (DON) and V5 (Clinical Director) excluded from roommate placement decision despite their clinical experience, V2 (DON) said, I have no answer to that. V2 (DON) continued: R2 has a psychiatric background, his referral packet showed past agitation but not violence. Placing R1 and R2 in the same room was not the decision we made. It would be V16 (Admissions Director). New residents should be monitored for the first 72 hours, nurses should be documenting the behavior, or anything abnormal. I was not a part of R1 and R2's incident investigation, I was off one day. I was told R1 had fallen. Upon hospital record review, I found out that something else happened. Medical record alerted me that there was physical assault that occurred. I presented it to V1 (Administrator) and she said that that the outcome of the investigation is that R1 fell. There were no further interventions for abuse because it was concluded it was a fall; therefore, we implemented additional fall precautions for R1. After R1 returned from the hospital (on [DATE]), he wasn't eating, dressing, or ambulating, so there was also referral that was placed for therapy. On [DATE], I was notified that R1 was not himself. When I went up to his room, staff had crash cart at the bedside. R1's oxygen saturation was 80%, he had nonrebreather mask, and his blood pressure was very low. R1's blood sugar read as high which means it was above 600. Nurse practitioner ordered 10 units of insulin before ambulance arrived. EMS took over from there. R1 was admitted with diagnosis of DKA (Diabetic Ketoacidosis). I didn't know he died (on [DATE]), I just found out today. On [DATE] at 11:40 AM Surveyor interviewed V5 (Clinical Director) who stated in summary: V1 (Administrator) has a social service background, so she is qualified to make decision in regard to resident placement. I feel like, when I looked at R2's admission packet, that showed agitation but not violence, I assumed it was safe to have R1 and R2 together, in the same room. We're not always familiar with entirety of residents' behavior. I was not part of R1 and R2 incident investigation, I was not here. After R2 returned from his psychiatric evaluation, he was placed back in the same room, R1 was moved to a private room, both were located on the same floor. R2 was placed on 72 hour checks and was referred to see a psychiatrist. I cannot answer why this resident was placed in the same room with a new roommate. On [DATE] at 12:00 PM Surveyor interviewed V16 (Admissions Director) who stated in summary: I am responsible for resident placement in regard to appropriateness of the room and a roommate. I did not think that R2 should not be placed back in the same room with a new roommate upon his readmission on [DATE]. Surveyor reiterated that R2 assaulted another resident (R1) recently, V16 continued: The focus was to remove R1 and place him in another room, but R2 was assessed as safe to return to the same room with a new roommate. I make my decision based on nurses and social service staff assessments when I make room assignments. On [DATE] at 12:40 PM Surveyor interviewed V17 (Licensed Practical Nurse) who stated in summary: I was doing rounds on [DATE], between 3:00 AM and 4:00 AM, when I found R1 sitting on the edge of his bed with some injuries. I asked him what happened, R1 said that he fell. I did my assessment then and notified the doctor. The doctor ordered to send R1 to the hospital. R1 had injury to his eye and had some bleeding. I assessed the rest of his body and there were no other injuries. R2 was agitated at that time, manic, restless, kept going back and forth all night, and talking to self. He was more agitated than usual. R2 was pacing in the hallway, going back to the room occasionally. I did not hear or see the incident and there were no witnesses at the time. I didn't see any blood on the room's floor, maybe a little on R1's sheet. I notified administrator and family in addition to the doctor. R2 was a new resident. I got a report upon beginning of my shift, but I was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 4 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few not endorsed anything special about R2. When we have a new resident, we should monitor every hour for about 3 days. The monitoring occurs between nurses and CNAs. Surveyor clarified if V17 (LPN) addressed R2's escalating behavior on [DATE] before the incident occurred, V17 said, R2 was sent out to the hospital for behavioral evaluation after the incident. Based on the record review, no documented interventions for R2's maladaptive behavior on [DATE] between 11:00 PM and 4:00 AM noticed. Based on the record review, no documentation of R2's new admission monitoring between [DATE] 2:30 PM and [DATE] 4:10 AM noticed. On [DATE] at 1:15 PM Surveyor interviewed V19 (Licensed Practical Nurse) who stated in summary: I performed R1's assessment on [DATE]. R1 was not responding and not talking, he was lethargic. I had to crush his medications that day. I checked his blood sugar, it was abnormal. I told another nurse, she put him on oxygen, and I went to call 911 and V2 (DON). I've known R1 for a very long time. R1 was almost blind, but he could walk around. R1 could also talk and was able to eat independently. R1 could even go to the bathroom with minimal assistance. All I know in regard to the incident that happened on [DATE], is that they sent R1 to the hospital but not sure why. I went to R1's unit the following day ([DATE]) and one of the resident's said that R1 was beat up by another resident. R1 said to me I was beat up because I was in wrong hand, I don't know what that meant. I've never met R2, but I spoke to one of the CNAs who took care of R2 in another facility, and she said, What is he doing here? (R2) is very dangerous, (R2) bit me up there. On [DATE] at 3:23 PM Surveyor interviewed V27 (Medical Director) who stated in summary: I am a medical director of this facility. I don't know specific details about the incident that occurred between R1 and R2 on [DATE], but I was notified that they had an altercation and R1 suffered laceration to the forehead. R1 was intact in regard to his functional ability before the incident on [DATE]. R1 was alert to self and had history of non-compliant behaviors. He had BIMS of 7, which means severe cognitive impairment. If R2 had BIMS of 13, that means he is not severely impaired and is able to understand and comprehend. Based on the BIMS score it does not seem these two residents are at the same level. If two residents like that are monitored and assisted, their cohorting may be acceptable; however, if there is lack of supervision and monitoring, it would not be appropriate. On [DATE] at 1:30 PM Surveyor interviewed V34 (Primary Metal Health Nurse Practitioner) who stated in summary: R2 was referred to psychiatry post the incident on [DATE]. I assessed R2 on [DATE]. R2 was very aggressive and irritable during my assessment that day. R2 was very guarded, not easy to talk to, and not very friendly. Facility should monitor residents like R2 closely and make sure their roommates are safe. Resident displaying agitation would not be appropriate to be placed in the same room with cognitively and visually impaired roommate. Especially, a resident who is visually impaired might invade others' space and appear as wandering into another's resident private space. That can cause a conflict. I would expect that a resident who displays aggressive behaviors, such as psycho motor agitation, in simple words, when someone is trying to hit, kick, bite, push, but also, call names, clench fists, mumble under their breath, or position in fight stand, should be initially admitted into a private room under close monitoring. Aggressive behavior may also take on indirect form, including walking up behind somebody, into their personal space, it's like bullying. R2 was definitely not appropriate to be placed with his roommate (R1). On [DATE] at 12:19 PM Surveyor interviewed V35 (Certified Registered Nurse Practitioner) who stated in summary: I get report from my company nurse who gets notified of any residents requiring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 5 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few assessment via record review. There is no face to face or phone report, it is exclusively based on record review. I came in and assessed R1 on [DATE], after his hospital readmission. R1 was weak, it was unlike him, usually R1 was able to get up and walk. R1 responded to his name only, unlike before, R1 was able to respond to questions not only to his name. R1 had steri strip and laceration to his right eyebrow. R1 also had some swelling to the right eyebrow. Based on his change in physical condition, I ordered physical therapy. I was told R1 fell, I did not inquire further. I reviewed R1's hospital records, hospital records said it was a physical assault. I asked the nurse on the floor for clarification, she said the incident was documented as a fall but R1 said he was assaulted. Based on R1's injury, it could have been either assault or a fall, but the hospital record read it was an assault; I don't know what was the source of R1's injuries. On [DATE] at 1:28 PM Surveyor interviewed V36 (Licensed Practical Nurse) who stated in summary: On [DATE], R1 was readmitted to the same room as before the incident. R1 complained of pain, so I notified NP, she ordered him pain medication and I gave it to him. R1 had laceration on the right side of his face, had steri strips on his forehead. He also had bruising around his right eye area. I didn't have a chance to assess the rest of his body because he refused due to pain. I didn't ask R1 what happened. He was not able to get up and feed himself. Before the incident he was able to walk and feed himself. I only worked with R2 on [DATE]. I was not told anything specific about him. We check on resident at least every 2 hours. If residents are yelling, have behaviors, or verbal altercation occurs, we notify social workers, check if they have PRN and notify the doctor. If they have physical aggression, we separate them and send them out to the hospital. If a resident is sent out to the hospital for behavioral evaluation, it is usually a behavior that we are not able to manage in the facility. On [DATE] at 11:07 AM, on [DATE] at 10:47 AM, and on [DATE] at 03:08 PM surveyor attempted to call V15 (Social Worker), no answer, voicemail left. Surveyor did not receive call back from V15 (SW) during the course on the investigation. On [DATE] at 12:38 PM Surveyor interviewed V40 (Emergency Department Clinical Lead) who stated in summary: We have certain criteria in the emergency department that we use to determine if trauma response needs to be initiated, some of those criteria are penetrating injury or exposed skull fracture. Team purple is trauma team who responds to patients with trauma triggered injuries. Trauma response is not triggered for falls from standing position, it can be triggered for falls from 10 feet and above. Surveyor clarified that team purple was triggered for R1 upon his admission into emergency department on [DATE], V40 said: If trauma response was initiated in the field, we know that patient's injury met trauma criteria and requires specialty team response, such as trauma team. 4. Progress noted dated [DATE] at 2:30 PM by V12 (Licensed Practical Nurse) reads in part, (R2) arrived on foot by admission staff. (R2) alert X3, confused, aggressive, and hard to redirect. (R2) doesn't want to be touched, don't allow for writer to complete assessment. Facility Reported Incident dated [DATE] reads in part, On [DATE] at approximately 4:00 AM while in his room, (R1), informed the unit nurse (V17 LPN) that he fell while attempting to go to the bathroom. (R2) later alleged to the CNA (V11), that he had an altercation with his roommate (R2). This allegation was unsubstantiated. Abuse is not found in this occurrence and was not substantiated as this allegation and fall appears to be a sign and symptom of his disease process. Progress note dated [DATE] at 4:10 AM written by V15 (Social Worker) reads in part, While doing rounds, (R1's) door was ajar and the writer noticed (R1) sitting on the bed in the middle of the night, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 6 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few the writer walked in (R1's) room and noticed an injury, the writer asked (R1) how did he get the injury but (R1) did not respond. (R1) just pointed to the injury. The nurse and the doctor were notified. Progress note dated [DATE] at 4:10 AM written by V15 (Social Worker) reads in part, The writer tried to speak to the (R2), and (R2) was very agitated, talking to himself, making delusional and very un-redirectable. (R2) was irritable every time anybody approached him. The nurse contacted the doctor, and the doctor ordered to send (R2) to local psychiatric hospital. R1's ambulance sheet dated [DATE] reads in part, Primary impression: Injury of Head; Chief Complaint: Head Trauma; Injury: Assault with bodily force. Initial Patient Acuity: Emergent; Final Patient Acuity: Emergent. (Ambulance) arrived on scene for (R1) A&Ox3 (alert and oriented to person, place, and time) per normal; now is A&O x1 (alert and oriented to person) head trauma. (R1) was assaulted by his roommate (R2). (R1) has swelling, deformity, and bruising. (R1) did state that he was hit 15 times by his roommate's (R2) fists and feet. R1's hospital record dated [DATE] reads in part, (R1) arrives via EMS s/p (status post) possible assault by roommate. Per EMS, (R2) hit (R1) approximately 15 times with hands and feet, (R1) unable to see out of right orbit. Exam: CT heads without intravenous contrasts; Findings: There is a hematoma along the right frontal scalp and right lateral orbital wall; Orbits: increased attenuation in the bilateral orbital globes suggesting vitreous hemorrhage. R2's hospital record dated [DATE] reads in part, Chief complaint: (R2) here via (local fire department) with involuntary petition from nursing home for aggressive undomiciled behavior per nursing home staff (R2) is unable to be redirected and does not follow commands very well, and hence render a threat to himself and others. All history was obtained from nursing home records as (R2) tends to remain agitated and noncooperative. Past medical history known of unspecified encephalopathy, psychoactive substance abuse, schizoaffective disorder, essential hypertension, CC: bizarre/Paranoid Behavior. R2's hospital record dated [DATE] reads in part, (R2), here for an evaluation of Altered Mental Status. History was obtained from nursing home records as (R2) remains agitated and uncooperative. (R2) is awake, restless, agitated, uncooperative, behavior unpredictable, incoherent speech. Police report dated [DATE] reads in part, Upon arrival, reporting officer, spoke with V15 (Social Worker) who stated that R2 had battered R1 in (their) room. The reporting officer spoke to V11 (CNA) who stated that (R1) told him that (R2) punched him in the face twice and knocked him down twice. The reporting officer spoke to V17 (LPN) who informed the reporting officer that R2 will be transported to (local psychiatric) hospital for mental health issues and R1 will be transported to (local) hospital for fractured face. 5. The facility Abuse Policy dated 09/20 reads in part, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. 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 confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Serious Bodily Injury is an injury involving extreme physical pain, involving substantial risk of death; involving protracted loss or impairment of the function of a bodily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 7 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety member, organ, or mental faculty; or requiring [NAME] intervention such as surgery, hospitalization, or physical rehabilitation. As part of social service assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. Residents Affected - Few The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the Immediacy and correct the noncompliance. Corrective Action Taken: 1. A body check was performed on R1 on [DATE] (by V17 LPN) after the alleged abuse occurred and he was noted with injuries that were immediately treated. Family and physician notifications were made (by V17 LPN) on [DATE] - verified with no concerns. 2. A body assessment was performed on resident R2 on [DATE] by V17 LPN. There were no injuries noted verified with no concerns. 3. The plans of care pertaining to the alleged abuse for R1 and R2 were reviewed and revised [DATE] by the Social Services Counselor. The interventions for R1 included 1:1 behavior monitoring until calm. Interventions for R2 included 1:1 behavior monitoring - verified with no concerns. 4. R1 and R2 were promptly sent to the hospital for evaluation on [DATE] - verified with no concerns. 5. R1 was re-admitted to the facility [DATE] and was subsequently transferred to a private room. R2 was re-admitted to the facility [DATE] - verified with no concerns. 6. On [DATE] R1 discharged from the facility and did not return. On [DATE] R2 was discharged to the hospital and remains hospitalized at this time - verified with no concerns. 7. All potential admissions that will have a roommate and room change considerations will be made upon review of their clinical record by Administrator, Clinical Director, Director of Nursing, Asst. Director of Nursing. Considerations to ensure appropriateness of roommates to avoid vulnerable residents being housed with aggressive resident include but not limited to clinical medical condition, cognition, functional ability, and past behavioral health symptoms - verified by staff interview with no concerns. 8. On [DATE] the DON, Administrator, ADON, Nurse Consultant and Medical Director reviewed the facility resources for stress management and policy related to the occurrence: Abuse. No changes were made verified with no concerns. Identifying other residents having the potential to be affected by the same deficient practice: 1.On [DATE] all residents skin was assessed for any physical markings that could potentially be related to physical abuse. This was completed by the assigned nurses - verified with no concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 8 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 2. Interviewable residents were interviewed by the Activity Director [DATE] and completed [DATE]. To determine if there were any concerns related to abuse or mistreatment and there were none - verified with no concerns. 3. At Risk for Abuse Risk Assessments started on all residents on [DATE] (by the Social Services Counselors and Director) and completed on [DATE] with no concerns identified. The plans of care were revised as needed by Social Services Counselors and Director - verified with no concerns. Measures taken to ensure that the problem is corrected and will not recur. 1. All staff and managers are being reeducated on facility abuse policy and abuse prevention, stress management (by the Social Services Director and Activity Director). The reeducation was provided on [DATE] and completed on [DATE]. Educations will continue to be provided for those employees who have not received educations at the start of their shift. This will be ongoing - verified with no concerns. 2. The facility assigned department heads (Social Services Director, Activities Director) to provide pop quizzes to staff about abuse which began on [DATE] and completed [DATE]. Pop quizzes will continue to be provided for those employees who have not received educations at the start of their shift. This process will be ongoing - verified with no concerns. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur. 1. A review of compliance using Quality Assurance Audit tool for abuse started [DATE] (by the Administrator). Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator until goal is attained for 4 months - verified with no concerns. 2. A review of results of audit regarding abuse with the facility's interdisciplinary team started the week of [DATE]. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/designee until goal is attained for 4 months - verified with no concerns. 3. Abuse policy and prevention will be discussed with all new hires upon hire (by the HR Director/Business Office Manager) or Administrator - verified with no concerns. Quality Assurance Plans to monitor facility performance: 1. Audits on all resident's abuse assessment and abuse care plan was reviewed for accuracy. Audits will be done weekly for four weeks, then monthly x 3 months, and then randomly by Administrator/d[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 9 of 37 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 04/18/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 care in accordance with professional standards of quality by a) failing to protect cognitively and visually impaired resident's right to be free from physical abuse from another resident with known history of aggressive behavior; b) failing to provide adequate supervision and monitoring on a resident assessed to be at risk for elopement; c) failing to ensure resident did not leave facility without staff knowledge or supervision; d) failing to follow elopement policy on procedures and reporting; e) failing to conduct pain assessment and provide necessary care and treatment on a resident complaining of chest pain and during change in condition; and f) failing to monitor escalation of maladaptive behavior. These failures affect three (R1, R2 and R5) of 10 residents reviewed for supervision, abuse, behavior, pain and change in condition. This deficiency also has the potential to affect the 157 residents currently residing in the facility. Residents Affected - Many Findings include: Per facility census, there are 157 residents currently residing in the facility. R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Exit Seeking/Wandering/Elopement Risk assessment dated [DATE] documented that R5 is cognitively impaired with deficits in orientation, decision making related to Dementia, severe mental illness, and was assessed at risk for elopement. Community Survival Skills assessment dated [DATE] recorded that R5 is not able to navigate safely on community streets. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. Hospital referral packet dated 10/20/23 recorded that R5 has history of elopement from previous nursing home; and will need placement in a memory care unit. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed the alarm on the back door gone off and sounding. Code [NAME] for elopement was called and headcount on the unit was initiated. One staff went outside to look for a resident who left unattended but reported did not see anybody. Another staff helped with the head count. As staff conducting head count, a staff from another unit received a call that R5 was in the hospital. On 04/08/24 at 2:12 PM, V3 (Certified Nurse Aide, CNA) was asked regarding incident on 04/06/24 with R5. V3 stated, On 04/06/24, I was the CNA on the floor, and she (R5) was my resident at the time. Like around 8:00 to 9:00 PM, I started putting residents on bed. She came to me and asked if I was her CNA. I said yes and asked if she needs something. She said she needed a brief and a blanket. I gave it to her, and she went back to her room. She is not incontinent. Then, I continued to put other residents on bed. Suddenly, the door alarmed. V4 (Licensed Practical Nurse, LPN) called me to check the alarm. He (V4), I and V30 (CNA) checked residents in their rooms and did a head count. V30 went outside and looked for the resident who opened the door. While we were doing the head count, V28 (LPN) came down and said that R5 was in the hospital. We were doing the head count for like less than half an hour. V28 turned off the alarm and we continued to check on everybody. I am not aware that she (R5) has history of elopement. She (R5) was always sitting in her bed during my shift. She is alert, oriented, able to move around without assistance. She has a walker. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 10 of 37 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 04/18/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many V4 was also interviewed on 04/08/24 at 2:45 PM, stated, On 04/06/24, I was the nurse assigned on R5. Around 9:30 PM, I heard an alarm went off from the unit exit door. I asked myself, maybe somebody must have used the door. So, I called Code [NAME] right away. Code [NAME] is for elopement. My staff, V3 and V30 went to the door and went outside. While I do the head count, I found out R5 was missing. That would be like 9:40 PM already. As we were doing the head count, V28 came down and said hospital called, said R5 was in the hospital. I called hospital, was told that she (R5) was with them, in the emergency room. I called V1 (Administrator) and reported the incident. To be honest, R5 is not one of those residents that need to be monitored. She does not have a behavior and very compliant. I was unaware that she has history of elopement. She walked with the use of walker, she walked slowly. That time. she was able to leave facility unnoticed. Unit 3 is on the ground floor. V28 also stated during interview on 04/08/24 at 3:19 PM that she was working on the second unit when the phone rang. V28 continued, That was 10:00 PM, I received a call from the hospital stating that they have a lady in the lobby and wants to know if the lady is from our facility. I asked the name and she gave me R5's name. I went to third unit; the code green was on. I told V4 that she (R5) was in the hospital, and I gave him the hospital phone number. R5 was able to leave facility on 04/06/24 unnoticed, unsupervised. R5 is a resident in the Memory Care Unit, a secured and locked unit in the facility. Observation on 04/09/24 at 10:25 AM showed that the exit door where R5 exited on 04/06/24 has an alarm. The door will alarm when push bar is pressed and when fully opened, a secondary continuous loud alarm will be heard in the entire unit. The hospital is located two blocks east from the exit door. The hospital is situated at the intersection of a busy street. On 04/09/24 at 9:58 AM, V5 (Social Services Director) was interviewed regarding R5. V5 verbalized, She is alert and oriented, sometimes she gets confused. She uses a walker to ambulate. Prior to her coming here, she is already on the list for elopement risk. However, since she'd been here, she never attempted to elope. Basically, it is more on supervision. The staff are made aware of these elopement risk residents. Regarding incident on 04/06/24, I was made aware on Sunday, 04/07/24 that she eloped and was in the hospital. She (R5) is not able to go out by herself, she needs staff or family assistance. She has Dementia, Schizophrenia and Schizo affective disorders. The exit doors have alarms. When staff heard an alarm, they have to attend to the door and redirect resident who wants to go out. She came back last night; she was placed on a 72-hour well-being check; I am sure her physician was notified and she remains in the elopement risk, and we will be monitoring her; on one on one counseling; every 15 minute check; she needs to be supervised all the time. On 04/09/24 at 10:40 AM, R5 was observed sitting in her rollator walker by the nurses' station. She was alert, oriented, wearing a yellow nonskid sock. R5 was asked regarding incident on 04/06/24 when she eloped from the facility and went to the hospital. R5 stated, I was in the hospital down there. I had chest pain and I had pain in the stomach and tooth pain. That time, I told the nurse (don't know his name) that I was having chest pain and he was not paying attention or anything, so I walked down there to the hospital. I was gone for a day. I was scared that I might be having a heart attack, it frightens me. R5 also mentioned during follow up interview, When I went to the hospital, I was on my feet, no socks. I walked on the rocks. A lady passed by, and she said if I needed help. She helped me and brought me to the hospital. I was having extreme pain on my chest, 8 out of 10, (8 meaning severe pain). I had tooth ache as well and pain in my left armpit. I was thinking I was having a heart attack at the time because I had one before and I know how it feels. I was actually short of breath when I get into the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 11 of 37 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 04/18/2024 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 0658 Progress notes dated 04/08/24 time stamped 8:59 PM recorded R5 came back to facility. Level of Harm - Minimal harm or potential for actual harm On 04/09/24 at 11:40 AM, V1 was asked regarding elopement incident on R5. V1 replied, I am the one investigating her elopement. She is alert, oriented to place, able to ambulate using a rollator. She was placed on the elopement risk upon admission. Her referring paperwork stated that she had history of elopement. All the staff were made aware that she is an elopement risk. For her, she had not displayed any exit seeking behaviors since admission, she was placed in the Memory care unit, which is one of our secured units. She is monitored and supervised - CNAs do round every hour and nurses. We also have ambassador rounds wherein we check residents if they have behaviors, concerns and for needs. These are the basic interventions that we implement and should be in the care plan. I was notified last 04/06/24, like little after 10:00 PM by V4, the nurse, that she (R5) had left the building and was in the hospital. I asked him (V4) about the details. He told me that CNA provided her with care around 9:30-9:35 PM and continued with her rounds. The door alarm was activated roughly around 9:45 PM. He said he went down to door where the alarm was and asked other CNAs to come. One went outside to search around but did not see her. They started the headcount, initiated the code green. And that's when she discovered R5 was missing. He was headed to the phone when he was given the information that she (R5) was in the hospital. He made his notification to me, to V2 (Director of Nursing) and V32 (Assistant Director of Nursing). We did the debriefing and started the investigation to find out how it happened. We started to do in-services on staff regarding elopement. We did not do any reporting to local state agency because she was found in less than an hour, probably like 20 minutes and sustained no injuries. I still have no definitive answer to how she (R5) was able to get out that night. Nobody said that they saw her out the door and was never seen when they looked outside. She exited from the exit door at the end of the hallway. This was the only one activated at the time she was missing. And that was the conclusion that it was the main exit point. Residents Affected - Many On 04/09/24 at 1:32 PM, V30 was asked regarding R5's incident on 04/06/24. V30 verbalized, On 04/06/24 about 10:00 PM, I started my shift, I will be working night shift. The moment I was coming in the unit, I headed to the break room. As I enter the break room, V4 came into the breakroom and asked me if I heard an alarm. I didn't hear any sounding alarm, but something sounded like a call light. He (V4) said door alarm was going off, and we need to do a head count. It was me and him (V4) doing the head count, while V3 was doing the head count on the other side of the unit. As I do the head count, I immediately noticed that R5 was not in her room. I told V4. I started to look where the alarm was. I went out of the back door and back of facility, but I did not see her (R5). I searched into the back alley but did not see her (R5). It was only me who went and looked outside. I went back and as I was about to enter the unit again, V28 said R5 was in the hospital. When I came in that time around 10:00 PM, I did not hear any alarm but as I entered Unit 3, the alarm already went off. We did head count first, then I went outside to look. We were told during in services that if we hear an alarm, do a head count first, then search from the door where alarm was going off. R5's Hospital Records dated 04/07/24 recorded in part but not limited to the following: Chief complaint - chest pain History of present illness - presents to emergency department via emergency medical services for evaluation after found wandering in traffic with a walker and without shoes. Patient (R5) resides at a nursing home. Patient (R5) states she has been experiencing left sided chest pain for three days. She describes a fullness at her chest. She has new onset tooth pain, shortness of breath, and left upper extremity pain. She reports alerting nursing home staff of her symptoms. Patient (R5) became concerned due to having history of a heart attack and decided to leave the facility due to not getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 12 of 37 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 04/18/2024 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 0658 proper care. Level of Harm - Minimal harm or potential for actual harm Review of systems: HENT (Head/eye/nose throat): tooth pain; Cardiovascular: Positive for chest pain and leg swelling (chronic); Respiratory: Positive for shortness of breath; Musculoskeletal: Positive for left upper extremity pain Residents Affected - Many Clinical Impression: Chest pain, unspecified type V29 (Physician/Hospital) stated during phone interview on 04/09/24 at 1:27 PM that R5 was found wandering and came to the hospital for chest pain. V29 added, She is alert, oriented to time, place and person. I was told by resident (R5) that she left on her own and she was having chest pain, and she was admitted in the hospital. V10 (Hospital Staff) also stated, I was the nurse assigned to R5. That was last Saturday, 04/06/24, she was found in the middle of the road by a bystander. The bystander called paramedics and she was sent here. She had no shoes at the time, said she was having chest pain. A follow up interview with V4 was conducted on 04/10/24 at 9:51 AM stating that he has no knowledge and awareness that R5 was complaining of chest pain on 04/06/24. On 04/10/24 at 11:24 AM, V2 stated during interview, I believe R5 is on the elopement risk list. The list needs to be updated as needed. The expectation from staff is they do rounds frequently; observe for signs of behaviors like exit seeking and residents should be directed. When door alarms, they should get up and see where it is coming from. If it is a door alarm, they need to go to the door, look outside and around the area. The rest of the staff are already doing the head count. If there is a missing resident, they should call Code Green. V32 just told me today that she (R5) had an incident of elopement last 04/06/24. I was off during the weekend and just came back today. On 04/10/24 at 3:22 PM, V27 (Medical Director) was asked regarding R5 and elopement precautions in the facility. V27 stated, R5 was the one who eloped. I was notified that she just eloped, did not find her, tried to look for her everywhere and found that she was in the hospital. She has no history of elopement from what I have known, not sure if she had one. She was placed in a locked unit. If it is a locked unit, staff wants to make sure it is locked all the time, which means it is secured making sure everybody is safe and secured inside. Keep the place locked, secured. Monitor the flow on who is going and coming. I don't know why it happened because it is a locked unit. We need to do an investigation how it happened. Staff needs in services regarding elopement prevention protocol and see if they follow the protocol, and implement the protocol. Somebody did not follow the process. I am sure there is an elopement protocol that I need to review. She came back, from what I remember on the same day and there were no injuries, nothing significant based from the nurses' notes from the hospital. I was not aware that she had chest pain. I did not know about it. Typically, if a resident complained of chest pain, take vital signs, make them stable and call paramedics to hospital as I ordered. Facility's policy titled, Elopement and Management of Missing Resident dated 03/28/2023 documented in part but not limited to the following: Policy: It is the policy of this facility to report and investigate all reports of missing residents and to minimize risks of elopement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 13 of 37 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 04/18/2024 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 0658 Procedure: Level of Harm - Minimal harm or potential for actual harm 1. Responding to a Door Alarm: Residents Affected - Many a. It is the responsibility of all staff to respond to activated door alarms to determine the reason for the alarm sounding b. If able to determine the reason for the alarm sounding, reset the door alarm and no further action is needed. c. If unable to determine the reason for alarm sounding, CODE GREEN and the location of the CODE GREEN should be announced 3 times over the intercom. 3. Suspected Missing Resident: p. Upon return of the resident to the facility, the Director of Nursing or designee should: vii. If resident sustained injury, a report will be made to local state agency. On 04/11/24 at 10:51 AM, V1 was asked regarding R5's elopement incident notification to local state agency. V1 replied, On 04/06/24, I was notified by V4 that she (R5) was missing. We did not do any reporting to local health agency because she was located within an hour of missing with no injuries. When she came back, we did not do any reporting as well because she has no injuries. I spoke to R5 when she came back and did not mention that she went to the hospital because of chest pain. I called hospital and was told that she went there because of bunch of reasons but not chest pain. R5's Hospital Discharge summary dated [DATE] recorded diagnosis: Atypical Chest Pain. R5's Care Plans (CP) documented the following: At risk for elopement related to physical ability to leave unit/facility, exit seeking behavior at former placement per hospital referral packet (CP dated 03/30/24) - Intervention: Consider potential variables, boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. ADL (activities of daily living) functional performance deficit (CP dated 04/04/24) - Intervention: Monitor for presence of pain, intolerance during ambulation. Potential for altered cardiac function (CP dated 04/04/24) - Intervention: Monitor for changes in status and report to MD (Medical Doctor) as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 14 of 37 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 04/18/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Potential for alteration in health condition (CP dated 04/04/24) - Intervention: Notify MD and family with any changes in condition. On 04/16/24 at 10:14 AM, V32 was asked regarding R5. V32 verbalized, I was notified on 04/06/24 at 10:15 PM regarding her elopement. I was just notified that she got out of the facility, and I notified V1. When a resident is complaining of pain, staff has to do the vital signs, notify physician and sent resident out as ordered. Pain is subjective, we cannot say they are not having it. Whatever resident say if it is pain, it is pain. Facility's policy titled Change of Condition (Resident) dated 09/20 documented in part but not limited to the following: Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition. Facility's policy titled, Pain Management Evaluation dated 09/2020 stated in part but not limited to the following: Purpose: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 2. Acute pain is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness. 4. During the pain evaluation, determine the most workable pain rating scale for the resident. The following scales are available: a. The numeric rating scale (NRS): 1-3 (mild), 4-6 (mod), 7-10 (severe); b. PAINAD scale 1-3 (mild), 4-6 (mod), 7-10 (severe); 5. Pain will be evaluated each shift Findings include: 1. R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus; Peripheral Vascular Disease; Schizophrenia; Hypertension; and Presbyopia. According to R1's MDS (Minimum Data Set) assessment dated [DATE] and 10/10/2023 under section C, R1 has BIMS (Brief Interview of Mental Status) score of 7 indicating severely impaired cognition. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, shows that R1 required supervision/touching assistance or partial moderate assistance with all functional abilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 15 of 37 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 04/18/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section GG, shows that R1 was dependent with all functional abilities. R1's Abuse assessment dated [DATE] shows that R1 is not at risk for abuse, despite Developmental/Intellectual Disability confirmed by R1's BIMS score of 7. Residents Affected - Many R1's care plan dated 03/17/2024 reads in part, Due to vision impairment resident may enter into the wrong room. The behavior may present as wandering. Assist as needed. Check and assure physical comfort. 2. R2 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder; Anxiety Disorder; Encephalopathy; and Hypertension. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R2's Comprehensive Behavioral Health Initial assessment dated [DATE] shows that R2 has a history of aggression and violence; displays frequent Hallucinations/Illusions and almost constant Delusions; Attitude towards Admittance: angry, confused; Adjustment to Placement: Angry over facility placement; resents placement; Copes through display of anger and hostility. No care plan related to R2's need for monitoring due to aggressive behavior documented prior to 03/17/2024, the day of the incident. R2's psychiatry progress note from previous facility dated 02/23/2024 reads in part, Behavior: agitated, restless, combative, stealing from other residents. 3. On 04/09/2024 at 10:42 AM Surveyor approached R2 on the 2nd floor hallway. Surveyor asked about the incident involving him and R1 on 03/17/2024; however, R2 stated something unintelligibly and walked away. R2 proceeded then to follow surveyor throughout the unit, staring, mumbling unintelligibly, and clinching fists in a threatening way. Surveyor did not observed staff redirecting R2 at any point. R2 is remaining in the facility displaying aggressive and intimidating behaviors as observed by a surveyor and shares a room with another resident at this time. On 04/09/2024 at 12:59 PM Surveyor interviewed V13 (Housekeeper) who stated in summary: The way R2 talks and looks at me, I don't know, I'm trying not to acknowledge him. It feels like R2 is targeting me, and couple other residents as well. You know how he looked at you when you were in the unit today? R2 does the same to me. It seems like R2 is looking for trouble. It is hard to understood what he's mumbling under his breath too, but I make sure R2 is never behind my back. R2 also writes in his room and on the bathroom walls. I saw R1 after the incident (on 03/17/2024), and he looked really bed, swollen. Residents are asking me why they (facility staff) are not doing anything about R2, they feel very uncomfortable with him on the unit. Everyone is aware that R2 is aggressive. On 04/10/2024 at 10:38 AM Surveyor interviewed V11 (Certified Nursing Assistant) who stated in summary: On 03/172024, I was working on the night shift (10:00 PM to 7:00 AM). I didn't hear or see anything that happened between R1 and R2 at the time of the incident. The V17 (LPN) came to get me, between 3:00 AM and 4:00 AM) asking if I saw R1 recently. V17 (LPN) said R1 has a knot on his head. We both went to see R1. R1 had bloody face, swollen right eye, and swelling of the entire right side of his face. There was blood on R1's bed and the floor. R1 went to the bathroom to wash his face and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 16 of 37 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 04/18/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hands, I assisted him, and didn't see any blood in the bathroom or on the bathroom floor. If I was going to judge where the incident happened, it would have been by R2's bed. In the conversation, R1 said he was punched twice in the face and kicked continuously while he fell to the floor by R2. While I was awaiting ambulance with R1, R2 kept coming around and asking how is R1 doing, if he's ok, and if his eye was ok. I told R2 to give us privacy, R2 got agitated but went back to his side of the room. I did not assess R2 or looked at his fists. Paramedics came 30 minutes later (around 4:00 AM - 4:30 AM). R2 was in the room the entire time. I usually round the unit every 2 hours. I came in at 10:00 PM, started rounding around 10.30 PM and went every two hours from then on. Last time I saw R1 that night was around 01:30 AM and he was asleep in the bed at that time. R2 was walking through out the unit most of the night. No one mentioned that R2 required additional monitoring. R2 was a new resident at that time, I was not familiar with him. When there is newly admitted resident in the unit, they should be monitored more frequently. I don't believe there is a specific policy for that, it is my personal experience. On 04/10/2024 at 11:30 AM Surveyor interviewed V2 (Director of Nursing) who stated in summary: Myself and V5 (Clinical Director) supposed to be part of the team who makes decision about resident placement in regard to appropriate room and roommate, but we are just told where to place residents. Surveyor clarified why are V2 (DON) and V5 (Clinical Director) excluded from roommate placement decision despite their clinical experience, V2 (DON) said, I have no answer to that. V2 (DON) continued: R2 has a psychiatric background, his referral packet showed past agitation but not violence. Placing R1 and R2 in the same room was not the decision we made. It would be V16 (Admissions Director). New residents should be monitored for the first 72 hours, nurses should be documenting the behavior, or anything abnormal. I was not a part of R1 and R2's incident investigation, I was off one day. I was told R1 had fallen. Upon hospital record review, I found out that something else happened. Medical record alerted me that there was physical assault that occurred. I presented it to V1 (Administrator) and she said that that the outcome of the investigation is that R1 fell. There were no further interventions for abuse because it was concluded it was a fall; therefore, we implemented additional fall precautions for R1. After R1 returned from the hospital (on 03/18/2024), he wasn't eating, dressing, or ambulating, so there was also referral that was placed for therapy. On 04/10/2024 at 12:40 PM Surveyor interviewed V17 (Licensed Practical Nurse) who stated in summary: I was doing rounds on 03/17/2024, between 3:00 AM and 4:00 AM, when I found R1 sitting on the edge of his bed with some injuries. I asked him what happened, R1 said that he fell. I did my assessment then and notified the doctor. The doctor ordered to send R1 to the hospital. R1 had injury to his eye and had some bleeding. I assessed the rest of his body and there were no other injuries. R2 was agitated at that time, manic, restless, kept going back and forth all night, and talking to self. He was more agitated than usual. R2 was pacing in the hallway, going back to the room occasionally. I did not hear or see the incident and there were no witnesses at the time. I didn't see any blood R1 and R2's room floor, maybe a little on R1's sheet. I notified administrator and family in addition to the doctor. R2 was a new resident. I got a report upon beginning of my shift, but I was not endorsed anything special about R2. When we have a new resident, we should monitor every hour for about 3 days. The monitoring occurs between nurses and CNAs. Surveyor clarified if V17 (LPN) addressed R2's manic behavior on 03/17/2024 before the incident occurred, V17 said, R2 was sent out to the hospital for behavioral evaluation after the incident; however, V17 (LPN) did not directly answer surveyor's question. Based on the record review, there is no documented interventions for R2's escalating maladaptive behavior on 03/17/2024 between 11:00 PM and 4:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 17 of 37 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 04/18/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 04/10/2024 at 3:23 PM Surveyor interviewed V27 (Medical Director) who stated in summary: I am a medical director of this facility. I don't know specific details about the incident that occurred between R1 and R2 on 03/17/2024 but I was notified that they had an altercation and R1 suffered laceration to the forehead. R1 was intact in regard to functional ability before the incident on 03/17/2024. However, R1 was involved in therapy after his readmission (on 03/18/2024). R1 then, was sent out to the hospital on [DATE] for hyperglycemia. R1 was alert to self and had history non-compliant behaviors. He had BIMS of 7 which means severe cognitive impairment. If R2 had BIMS of 13, that means he is not severely impaired and is able to understand and comprehend. Based on the BIMS score it does not seem these two residents are at the same level. If two residents like that are monitored and assisted, their cohorting may be acceptable; however, if there is lack of supervision and monitoring, it would not be appropriate. On 04/11/2024 at 1:30 PM Surveyor interviewed V34 (Primary Metal Health Nurse Practitioner) who stated in summary: R2 was referred to psychiatry post the incident on 03/17/2024. I assessed R2 on 04/01/2024. R2 was very aggressive and irritable during my assessment that day. R2 was very guarded, not easy, and not very friendly. Facility should monitor residents like R2 closely and make sure their roommates are safe. Resident displaying agitation would not be appropriate to be placed in the same room with cognitively and visually impaired roommate. Especially, a resident who is visually impaired might invade others' space and appear as wandering into another's resident private space. That can cause a conflict. I would expect that a resident who displays aggressive behaviors, such as psycho motor agitation, in simple words, when some trying to hit, kick, bite, push, but also, call names, clench fists, mumble under their breath, or position in fight stand, should be initially admitted into a private room under close monitoring. Aggressive behavior may also take on indirect form, including walking up behind somebody, into their personal space, it's like bullying. R2 was definitely not appropriate to be placed with his roommate (R1). 4. The facility Abuse Policy dated 09/20 reads in part, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. 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 confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Serious Bodily Injury is an injury involving extreme physical pain, involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring [NAME] intervention such as surgery, hospitalization, or physical rehabilitation. As part of social service assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. The facility Behavior Symptom Tracking, Assessment, and the Behavior Management Program police dated 04/2014 reads in part, Staff will document residents' maladaptive moods and/or behaviors in order to track and utilize data to determine patterns and trends of resident conduct and lead to improved care planning and treatment. Upon witnessing any maladaptive moods and/or behaviors, staff's first priority is to maintain safety of residents, staff, and visitors. Any necessary interventions, as trained, to maintain safety will be performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 18 of 37 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 04/18/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide necessary care and treatment during change in condition on a resident complaining of chest pain; and failed to monitor escalation of maladaptive behavior for two (R2 and R5) of five residents in the sample of 10 reviewed for quality of care. This deficiency resulted in R2 exhibiting increased wandering and pacing, resulted R2 to commit an assault behavior. This deficiency also resulted in R5 experiencing severe chest pain, eloped from the facility to go to the nearest emergency room for further evaluation and treatment. Residents Affected - Few Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Exit Seeking/Wandering/Elopement Risk assessment dated [DATE] documented that R5 is cognitively impaired with deficits in orientation, decision making related to Dementia, severe mental illness, and was assessed at risk for elopement. Community Survival Skills assessment dated [DATE] recorded that R5 is not able to navigate safely on community streets. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. Hospital referral packet dated 10/20/23 recorded that R5 has history of elopement from previous nursing home; and will need placement in a memory care unit. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed the alarm on the back door gone off and sounding. Code [NAME] for elopement was called and headcount on the unit was initiated. One staff went outside to look for a resident who left unattended but reported did not see anybody. Another staff helped with the head count. As staff conducting head count, a staff from another unit received a call that R5 was in the hospital. On 04/08/24 at 2:12 PM, V3 (Certified Nurse Aide, CNA) was asked regarding incident on 04/06/24 with R5. V3 stated, On 04/06/24, I was the CNA on the floor, and she (R5) was my resident at the time. Like around 8:00 to 9:00 PM, I started putting residents on bed. She came to me and asked if I was her CNA. I said yes and asked if she needs something. She said she needed a brief and a blanket. I gave it to her, and she went back to her room. She is not incontinent. Then, I continued to put other residents on bed. Suddenly, the door alarmed. V4 (Licensed Practical Nurse, LPN) called me to check the alarm. He (V4), I and V30 (CNA) checked residents in their rooms and did a head count. While we were doing the head count, V28 (LPN) came down and said that R5 was in the hospital. V4 was also interviewed on 04/08/24 at 2:45 PM, stated, On 04/06/24, I was the nurse assigned on R5. Around 9:30 PM, I heard an alarm went off from the unit exit door. I asked myself, maybe somebody must have used the door. So, I called Code [NAME] right away. Code [NAME] is for elopement. My staff, V3 and V30 went to the door and went outside. While I do the head count, I found out R5 was missing. That would be like 9:40 PM already. As we were doing the head count, V28 came down and said hospital called, said R5 was in the hospital. I called hospital, was told that she (R5) was with them, in the emergency room. I called V1 (Administrator) and reported the incident. To be honest, R5 is not one of those residents that need to be monitored. She does not have a behavior and very compliant. I was unaware that she has history of elopement. She walked with the use of walker, he walked slowly. That time. she was able to leave facility unnoticed. Unit 3 is on the ground floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 19 of 37 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 04/18/2024 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 0684 Level of Harm - Actual harm R5 was able to leave facility on 04/06/24 unnoticed, unsupervised. R5 is a resident in the Memory Care Unit, a secured and locked unit in the facility. Observation on 04/09/24 at 10:25 AM showed that the hospital is located two blocks east from the exit door where R5 exited on 04/06/24. The hospital is situated at the intersection of a busy street. Residents Affected - Few Hospital records dated 04/07/24 recorded that R5's chief complaint was chest pain. According to history of present illness, R5 resented to the emergency department after found wandering in traffic with a walker and without shoes. R5 stated she has been experiencing left sided chest pain for 3 days. She describes a fullness at her chest. She has new onset tooth pain, SOB (shortness of breath and left upper extremity pain. She reports alerting nursing home staff of her symptoms. She became concerned due to having history of a heart attack and decided to leave the facility due to not getting proper care. Hospital records also documented the following: Past Medical History: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris Review of systems: HENT (Head/eye/nose throat): tooth pain Cardiovascular: Positive for chest pain and leg swelling (chronic). Respiratory: Positive for shortness of breath Musculoskeletal: Positive for left upper extremity pain Clinical Impression: Chest pain, unspecified type R5's hospital Discharge summary dated [DATE] indicated: Diagnosis: Atypical Chest Pain On 04/09/24 at 9:33 PM, V10 (Hospital Staff) was interviewed regarding R5. I was the nurse assigned to her (R5). That was last Saturday, 04/06/24, she was found in the middle of the road by a bystander. The bystander called paramedics and she was sent here. She had no shoes at the time, said she was having chest pain. V29 (Physician/Hospital) also mentioned during interview, On 04/06/24, she was found wandering and came for chest pain. She is alert, oriented to time, place and person. I was told by her (R5) that she left on her own and she was having chest pain, and she was admitted . Progress notes dated 04/08/24 time stamped 8:59 PM recorded R5 came back to facility. On 04/09/24 at 10:40 AM, R5 was observed sitting in her rollator walker by the nurses' station. Alert and oriented, R5 was asked regarding incident on 04/06/24 when she eloped from the facility and went to the hospital. R5 stated, I was in the hospital down there. I had chest pain and I had pain in the stomach and tooth pain. That time, I told the nurse (don't know his name) that I was having chest pain and he was not paying attention or anything, so I walked down there to the hospital. I was gone for a day. I was scared that I might be having a heart attack, it frightens me. R5 also mentioned during follow interview, When I went to the hospital, I was on my feet, no socks. I walked on the rocks. A lady passed by, and she said if I needed help. She helped me and brought me to the hospital. I was having extreme pain on my chest, 8 out of 10, (8 meaning severe pain). I had tooth ache as well and pain in my left armpit. I was thinking I was having a heart attack at the time because I had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 20 of 37 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 04/18/2024 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 0684 one before and I know how it feels. I was actually short of breath when I get into the hospital. Level of Harm - Actual harm V1 (Administrator) was also asked regarding R5 chest pain on 04/06/24. V1 verbalized, On 04/06/24, I was notified by V4 that she (R5) was missing. When she (R5) came back, I spoke to her, did not mention that she went to the hospital because of chest pain. I called hospital and was told that she went there because of bunch of reasons but not chest pain. Residents Affected - Few On 04/10/24 at 3:13 PM, V4 was asked if R5 complained of chest pain on 04/06/24. V4 stated, On 04/06/24, I was the nurse assigned on R5. No, she did not complain of any chest pain. I was not aware of her having chest pain. On 04/10/24 at 3:22 PM, V27 (Medical Director) was interviewed regarding R5. V27 replied, I was notified that she just eloped, did not find her, tried to look for her everywhere and found that she was in the hospital. She has no history of elopement from what I have known, not sure if she had one. She was placed in a locked unit. If it is a locked unit, want to make sure it is locked all the time which means it is secured making sure everybody is safe and secured inside. I was not aware that she had chest pain. Typically, if a resident complained of chest pain, take vital signs, make them stable and call paramedics to hospital as ordered. R5's Care Plans (CP) documented the following: At risk for elopement related to physical ability to leave unit/facility, exit seeking behavior at former placement per hospital referral packet (CP dated 03/30/24) - Intervention: Consider potential variables, boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. ADL (activities of daily living) functional performance deficit (CP dated 04/04/24) - Intervention: Monitor for presence of pain, intolerance during ambulation. Potential for altered cardiac function (CP dated 04/04/24) - Intervention: Monitor for changes in status and report to MD (Medical Doctor) as needed. Potential for alteration in health condition (CP dated 04/04/24) - Intervention: Notify MD and family with any changes in condition. On 04/16/24 at 10:14 AM, V32 was asked regarding R5. V32 verbalized, I was notified on 04/06/24 at 10:15 PM regarding her elopement. I was just notified that she got out of the facility, and I notified V1. When a resident is complaining of pain, staff has to do the vital signs, notify physician and sent resident out as ordered. Pain is subjective, we cannot say they are not having it. Whatever resident say if it is pain, it is pain. Facility's policy titled Change of Condition (Resident) dated 09/20 documented in part but not limited to the following: Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 21 of 37 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 04/18/2024 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 0684 Facility's policy titled, Pain Management Evaluation dated 09/2020 stated in part but not limited to the following: Level of Harm - Actual harm Residents Affected - Few Purpose: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 2. Acute pain is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness. 4. During the pain evaluation, determine the most workable pain rating scale for the resident. The following scales are available: a. The numeric rating scale (NRS): 1-3 (mild), 4-6 (mod), 7-10 (severe); b. PAINAD scale 1-3 (mild), 4-6 (mod), 7-10 (severe); 5. Pain will be evaluated each shift Findings include: 2. R2 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder; Anxiety Disorder; Encephalopathy; and Hypertension. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R2's Comprehensive Behavioral Health Initial assessment dated [DATE] shows that R2 has a history of aggression and violence; displays frequent Hallucinations/Illusions and almost constant Delusions; Attitude towards Admittance: angry, confused; Adjustment to Placement: Angry over facility placement; resents placement; Copes through display of anger and hostility. No care plan related to R2's need for monitoring due to aggressive behavior documented prior to 03/17/2024, the day of the incident. R2's psychiatry progress note from previous facility dated 02/23/2024 reads in part, Behavior: agitated, restless, combative, stealing from other residents. On 04/09/2024 at 10:42 AM Surveyor approached R2 on the 2nd floor hallway. Surveyor asked about the incident involving him and R1 on 03/17/2024; however, R2 stated something unintelligibly and walked away. R2 proceeded then to follow surveyor throughout the unit, staring, mumbling unintelligibly, and clinching fists in a threatening way. Surveyor did not observed staff redirecting R2 at any point. R2 is remaining in the facility displaying aggressive and intimidating behaviors as observed by a surveyor and shares a room with another resident at this time. On 04/09/2024 at 12:59 PM Surveyor interviewed V13 (Housekeeper) who stated in summary: The way R2 talks and looks at me, I don't know, I'm trying not to acknowledge him. It feels like R2 is targeting me, and couple other residents as well. You know how he looked at you when you were in the unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 22 of 37 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 04/18/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few today? R2 does the same to me. It seems like R2 is looking for trouble. It is hard to understood what he's mumbling under his breath too, but I make sure R2 is never behind my back. R2 also writes in his room and on the bathroom walls. I saw R1 after the incident (on 03/17/2024), and he looked really bed, swollen. Residents are asking me why they (facility staff) are not doing anything about R2, they feel very uncomfortable with him on the unit. Everyone is aware that R2 is aggressive. On 04/10/2024 at 10:38 AM Surveyor interviewed V11 (Certified Nursing Assistant) who stated in summary: On 03/17/2024, I was working on the night shift (10:00 PM to 7:00 AM). R2 was walking through out the unit most of the night. No one mentioned that R2 required additional monitoring. R2 was a new resident at that time, I was not familiar with him. When there is newly admitted resident in the unit, they should be monitored more frequently. I don't believe there is a specific policy for that, it is my personal experience. On 04/10/2024 at 12:40 PM Surveyor interviewed V17 (Licensed Practical Nurse) who stated in summary: R2 was a new resident. I got a report upon beginning of my shift, but I was not endorsed anything special about R2. When we have a new resident, we should monitor every hour for about 3 days. The monitoring occurs between nurses and CNAs. Surveyor clarified if V17 (LPN) addressed R2's manic behavior on 03/17/2024 before the incident occurred, V17 said, R2 was sent out to the hospital for behavioral evaluation after the incident; however, V17 (LPN) did not directly answer surveyor's question. Based on the record review, there is no documented interventions for R2's escalation in maladaptive behavior on 03/17/2024 between 11:00 PM and 4:00 AM. On 04/11/2024 at 11:09 AM PM Surveyor interviewed V2 (Director of Nursing) who stated in summary: Resident's change in condition is any abnormality in resident's condition, ex. decline in functional ability, change in labs, vital signs, or behavior. The expectation is for the nurse to call the doctor and family to notify of resident's change in condition, monitor, and carry out physician's orders in regard to change in resident's condition. Also, document of any change in condition for 72 hrs or until change if condition has resolved. On 04/10/2024 at 3:23 PM Surveyor interviewed V27 (Medical Director) who stated in summary: I am a medical director of this facility. I don't know specific details about the incident that occurred between R2 and his roommate on 03/17/2024 but I was notified that they had an altercation. R2's roommate was alert to self and had history non-compliant behaviors. He had BIMS of 7 which means severe cognitive impairment. If R2 had BIMS of 13, that means he is not severely impaired and is able to understand and comprehend. Based on the BIMS score, it does not seem these two residents are at the same level. If two residents like that are monitored and assisted, their cohorting may be acceptable; however, if there is lack of supervision and monitoring, it would not be appropriate. On 04/11/2024 at 1:30 PM Surveyor interviewed V34 (Primary Metal Health Nurse Practitioner) who stated in summary: R2 was referred to psychiatry post the incident on 03/17/2024. I assessed R2 on 04/01/2024. R2 was very aggressive and irritable during my assessment that day. R2 was very guarded, not easy, and not very friendly. Facility should monitor residents like R2 closely and make sure their roommates are safe. Resident displaying agitation would not be appropriate to be placed in the same room with cognitively and visually impaired roommate. Especially, a resident who is visually impaired might invade others' space and appear as wandering into another's resident private space. That can cause a conflict. I would expect that a resident who displays aggressive behaviors, such as psycho motor agitation, in simple words, when some trying to hit, kick, bite, push, but also, call names, clench fists, mumble under their breath, or position in fight stand, should be initially admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 23 of 37 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 04/18/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete into a private room under close monitoring. Aggressive behavior may also take on indirect form, including walking up behind somebody, into their personal space, it's like bullying. R2 was definitely not appropriate to be placed with his roommate. The facility Behavior Symptom Tracking, Assessment, and the Behavior Management Program police dated 04/2014 reads in part, Staff will document residents' maladaptive moods and/or behaviors in order to track and utilize data to determine patterns and trends of resident conduct and lead to improved care planning and treatment. Upon witnessing any maladaptive moods and/or behaviors, staff's first priority is to maintain safety of residents, staff, and visitors. Any necessary interventions, as trained, to maintain safety will be performed. Event ID: Facility ID: 145173 If continuation sheet Page 24 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety 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 observation, interviews and record reviews, the facility failed to provide adequate supervision and monitoring on a resident assessed to be at risk for elopement due to history of elopement from previous nursing home; failed to ensure the resident did not leave facility without staff knowledge or supervision; and failed to follow elopement policy on procedures and reporting. These failures affected one (R5) of three residents in a sample of 10 reviewed for elopement risk and supervision. These failures resulted in R5 able to eloped from facility. R5 experienced harm by walking to emergency room without shoes on and having to cross a high-volume traffic intersection at night, while allegedly experiencing chest pain. The Immediate Jeopardy began on 04/06/24 when R5 left facility unnoticed and unsupervised, walked without shoes on to local hospital while crossing a high volume traffic intersection at night while allegedly experiencing chest pain. V1 (Administrator) was notified of the Immediate Jeopardy on 04/15/24 at 11:59 AM. The survey team confirmed by observation, interviews and record reviews that the Immediate Jeopardy was removed on 04/07/24 and the deficient practice was corrected on 04/08/24, and completed on 04/10/24. Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Exit Seeking/Wandering/Elopement Risk assessment dated [DATE] documented that R5 is cognitively impaired with deficits in orientation, decision making related to Dementia, Severe Mental Illness, and was assessed at risk for elopement. Community Survival Skills assessment dated [DATE] recorded that R5 is not able to navigate safely on community streets. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. Hospital referral packet dated 10/20/23 recorded that R5 has history of elopement from previous nursing home; and will need placement in a memory care unit. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed the alarm on the back door gone off and sounding. Code [NAME] for elopement was called and headcount on the unit was initiated. One staff went outside to look for a resident who left unattended but reported did not see anybody. Another staff helped with the head count. As staff conducting head count, a staff from another unit received a call that R5 was in the hospital. On 04/08/24 at 2:12 PM, V3 (Certified Nurse Aide, CNA) was asked regarding incident on 04/06/24 with R5. V3 stated, On 04/06/24, I was the CNA on the floor, and she (R5) was my resident at the time. Like around 8:00 to 9:00 PM, I started putting residents on bed. She came to me and asked if I was her CNA. I said yes and asked if she needs something. She said she needed a brief and a blanket. I gave it to her, and she went back to her room. She is not incontinent. Then, I continued to put other residents on bed. Suddenly, the door alarmed. V4 (Licensed Practical Nurse, LPN) called me to check the alarm. He (V4), I and V30 (CNA) checked residents in their rooms and did a head count. V30 went outside and looked for the resident who opened the door. While we were doing the head count, V28 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 25 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few (LPN) came down and said that R5 was in the hospital. We were doing the head count for like less than half an hour. V28 turned off the alarm and we continued to check on everybody. I am not aware that she (R5) has history of elopement. She (R5) was always sitting in her bed during my shift. She is alert, oriented, able to move around without assistance. She has a walker. V4 was also interviewed on 04/08/24 at 2:45 PM, stated, On 04/06/24, I was the nurse assigned on R5. Around 9:30 PM, I heard an alarm went off from the unit exit door. I asked myself, maybe somebody must have used the door. So, I called Code [NAME] right away. Code [NAME] is for elopement. My staff, V3 and V30 went to the door and went outside. While I do the head count, I found out R5 was missing. That would be like 9:40 PM already. As we were doing the head count, V28 came down and said hospital called, said R5 was in the hospital. I called hospital, was told that she (R5) was with them, in the emergency room. I called V1 (Administrator) and reported the incident. To be honest, R5 is not one of those residents that need to be monitored. She does not have a behavior and very compliant. I was unaware that she has history of elopement. She walked with the use of walker, he walked slowly. That time, she was able to leave facility unnoticed. V28 also stated during interview on 04/08/24 at 3:19 PM that she was working on the second unit when the phone rang. V28 continued, That was 10:00 PM, I received a call from the hospital stating that they have a lady in the lobby and wants to know if the lady is from our facility. I asked the name and she gave me R5's name. I went to third unit; the code green was on. I told V4 that she (R5) was in the hospital, and I gave him the hospital phone number. R5 was able to leave facility on 04/06/24 unnoticed, unsupervised. R5 is a resident in the Memory Care Unit in the facility, which is a secured and locked unit on the first floor. Observation on 04/09/24 at 10:25 AM showed that the exit door where R5 exited on 04/06/24 has an alarm. The door will alarm when push bar is pressed and when door is fully opened, a secondary continuous loud alarm will be heard in the entire unit. The hospital is located two blocks east from the exit door. The hospital is situated at the intersection of a busy street. On 04/09/24 at 9:58 AM, V5 (Social Services Director) was interviewed regarding R5. V5 verbalized, She is alert and oriented, sometimes she gets confused. She uses a walker to ambulate. Prior to her coming here, she is already on the list for elopement risk. However, since she'd been here, she never attempted to elope. Basically, it is more on supervision. The staff are made aware of these elopement risk residents. Regarding incident on 04/06/24, I was made aware on Sunday, 04/07/24 that she (R5) eloped and was in the hospital. She (R5) cannot go out by herself, she needs staff or family assistance. She has Dementia, has Schizophrenia and Schizo affective disorders. The exit doors have alarms. When staff heard an alarm, they have to attend to the door and redirect resident who wants to go out. She (R5) came back last night; she was placed on a 72-hour well-being check; I am sure her physician was notified and she remains in the elopement risk and we will be monitoring her - one on one counseling; every 15 minute check; she needs to be supervised all the time. On 04/09/24 at 10:40 AM, R5 was observed sitting in her rollator walker by the nurses' station. She was alert, oriented, wearing yellow nonskid socks. R5 was asked regarding incident on 04/06/24. R5 replied, I came back from hospital last night. I was in the hospital down there. I had chest pain and I had pain in the stomach and tooth. That time, I told the nurse that I was having chest pain, don't know his name, and he was not paying attention or anything so I walked down there to the hospital. I was scared that I might be having a heart attack, it frightens me. I was gone for a day. Progress notes dated 04/08/24 time stamped 8:59 PM recorded R5 came back to facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 26 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few On 04/09/24 at 11:40 AM, V1 was asked regarding elopement incident on R5. V1 replied, I am the one investigating her elopement. She is alert, oriented to place, able to ambulate using a rollator. She was placed on the elopement risk upon admission. Her referral paperwork stated that she had history of elopement. All the staff were made aware that she is an elopement risk. For her, she had not displayed any exit seeking behaviors since admission, she was placed in the Memory care unit, Unit 3, which is one of our secured units. She is monitored and supervised - CNAs and nurses do rounds every hour. We also have ambassador rounds which we check residents if they have behaviors, concerns and for needs. These are the basic interventions that we implement and should be in the care plan. I was notified last 04/06/24, like little after 10:00 PM by V4, the nurse, that she (R5) had left the building and was in the hospital. I asked him about the details. He told me that CNA provided her with care around 9:30-9:35 PM and continued with her rounds. The door alarm was activated roughly around 9:45 PM. He said he went down to door where the alarm was and asked other CNAs to come. One went outside to search around but did not see her. They started the headcount, initiated the code green. And that's when she discovered R5 was missing. He was headed to the phone when he was given information that she (R5) was in the hospital. He made his notification to me, to V2 (Director of Nursing) and V32 (Assistant Director of Nursing). We did the debriefing and started the investigation to find out how it happened. We started to do in-services on staff regarding elopement. We did not do any reporting to local state agency because she was found in less than an hour, probably like 20 minutes and sustained no injuries. I still have no definitive answer as to how she (R5) was able to get out that night. Nobody said that they saw her out the door and was never seen when they looked outside. She exited from the exit door at the end of the hallway. That was the only one activated at the time she was missing. And that was the conclusion that it was the main exit point. On 04/09/24 at 1:32 PM, V30 was asked regarding R5's incident on 04/06/24. V30 verbalized, On 04/06/24 about 10:00 PM, I started my shift, I will be working night shift. The moment I was coming in the unit, I headed to the break room. As I enter the break room, V4 came into the breakroom and asked me if I heard an alarm. I didn't hear any sounding alarm, but something sounded like a call light. He (V4) said door alarm was going off, and we need to do a head count. It was me and him (V4) doing the head count, while V3 was doing the head count on the other side of the unit. As I do the head count, I immediately noticed that R5 was not in her room. I told V4. I started to look where the alarm was. I went out of the back door and back of facility, but I did not see her (R5). I searched into the back alley but did not see her (R5). It was only me who went and looked outside. I went back and as I was about to enter the unit again, V28 said R5 was in the hospital. When I came in that time around 10:00 PM, I did not hear any alarm but as I entered Unit 3, the alarm already went off. We did head count first, then I went outside to look. We were told during in services that if we hear an alarm, do a head count first, then search from the door where alarm was going off. R5's Hospital Records dated 04/07/24 recorded in part but not limited to the following: Chief complaint - chest pain History of Present Illness - presents to emergency department via emergency medical services for evaluation after found wandering in traffic with a walker and without shoes. Patient (R5) resides at a nursing home. Patient (R5) states she has been experiencing left sided chest pain for three days. She describes a fullness at her chest. She has new onset tooth pain, shortness of breath, and left upper extremity pain. She reports alerting nursing home staff of her symptoms. Patient (R5) became concerned due to having history of a heart attack and decided to leave the facility due to not getting proper care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 27 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of systems: HENT (Head/eye/nose throat): tooth pain; Cardiovascular: Positive for chest pain and leg swelling (chronic); Respiratory: Positive for shortness of breath; Musculoskeletal: Positive for left upper extremity pain Clinical Impression: Chest pain, Unspecified type V29 (Physician/Hospital) stated during phone interview on 04/09/24 at 1:27 PM that R5 was found wandering and came to the hospital for chest pain. V29 added, She is alert, oriented to time, place and person. I was told by resident (R5) that she left on her own and she was having chest pain, and she was admitted in the hospital. V10 (Hospital Staff) also stated, I was the nurse assigned to R5. That was last Saturday, 04/06/24, she was found in the middle of the road by a bystander. The bystander called paramedics and she was sent here. She had no shoes at the time, said she was having chest pain. She told me that facility told her to leave and helped her out the door. I called facility, spoke to V4. V4 said he saw her leaving the facility but then he changed his story that he did not see her leaving, then changed his story that he just heard the door alarm. On 04/10/24 at 9:30 AM, R5 was observed in her room, sitting in her rollator walker. Surveyor made a follow up interview on the night she eloped from facility. R5 stated, When I went to the hospital, I was on my feet, no socks. I walked on the rocks. A lady passed by, and she said if I needed help. She helped me and brought me to the hospital. No one saw me when I left that night, I passed by the nurses' station though. A follow up interview with V4 was conducted on 04/10/24 at 9:51 AM stating that he did not see R5 leaving the facility and did not speak to the hospital staff about seeing her (R5) leaving the unit. V4 also stated that he has no knowledge and awareness that R5 was complaining of chest pain on 04/06/24. R5's care plan dated 03/30/24 documented: R5 is at risk for elopement related to physical ability to leave unit/facility, exit seeking behavior at former placement per hospital referral packet. Interventions: Consider potential variables, boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. On 04/10/24 at 11:24 AM, V2 stated during interview, I believe R5 is on the elopement risk list. The list needs to be updated as needed. The expectation from staff is they do rounds frequently; observe for signs of behavior like exit seeking and residents should be directed. When door alarms, they should get up and see where it is coming from. If it is a door alarm, they need to go to the door, look outside and around the area. The rest of the staff are already doing the head count. If there is a missing resident, they should call Code Green. V32 just told me today that she (R5) had an incident of elopement last 04/06/24. I was off during the weekend and just came back today. On 04/10/24 at 3:22 PM, V27 (Medical Director) was asked regarding R5 and elopement precautions in the facility. V27 stated, R5 was the one who eloped. I was notified that she just eloped, did not find her, tried to look for her everywhere and found that she was in the hospital. She has no history of elopement from what I have known, not sure if she had one. She was placed in a locked unit. If it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 28 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few is a locked unit, staff wants to make sure it is locked all the time, which means it is secured making sure everybody is safe and secured inside. Keep the place locked, secured. Monitor the flow on who is going and coming. I don't know why it happened because it is a locked unit. We need to do an investigation how it happened. Staff needs in-services regarding elopement prevention protocol and see if they follow the protocol, and implement the protocol. Somebody did not follow the process. I am sure there is an elopement protocol that I need to review. She (R5) came back, from what I remember on the same day and there were no injuries, nothing significant based from the nurses' notes from the hospital. I was not aware that she had chest pain. I did not know about it. Typically, if a resident complained of chest pain, take vital signs, make them stable and call paramedics to hospital as I ordered. Facility's policy titled, Elopement and Management of Missing Resident dated 03/28/2023 documented in part but not limited to the following: Policy: It is the policy of this facility to report and investigate all reports of missing residents and to minimize risks of elopement. Procedure: 1. Responding to a Door Alarm: a. It is the responsibility of all staff to respond to activated door alarms to determine the reason for the alarm sounding. b. If able to determine the reason for the alarm sounding, reset the door alarm and no further action is needed. c. If unable to determine the reason for alarm sounding, CODE GREEN and the location of the CODE GREEN should be announced 3 times over the intercom. 3. Suspected Missing Resident: p. Upon return of the resident to the facility, the Director of Nursing or designee should: vii. If resident sustained injury, a report will be made to local state agency. On 04/11/24 at 10:51 AM, V1 was asked regarding R5's elopement incident notification to local state agency. V1 replied, On 04/06/24, I was notified by V4 that she (R5) was missing. We did not do any reporting to local health agency because she was located within an hour of missing with no injuries. When she came back, we did not do any reporting as well because she has no injuries. I spoke to R5 when she came back and did not mention that she went to the hospital because of chest pain. I called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 29 of 37 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 04/18/2024 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 hospital and was told that she went there because of bunch of reasons but not chest pain. Level of Harm - Immediate jeopardy to resident health or safety R5's Hospital Discharge summary dated [DATE] recorded diagnosis: Atypical Chest Pain. Residents Affected - Few Potential for altered cardiac function - Intervention: Monitor for changes in status and report to MD (Medical Doctor) as needed. R5's care plan dated 04/04/24 documented: Facility's policy titled Incident/Accident Reports dated 09/2020 stated in part but not limited to the following: Procedure: 12. The Director of Nursing, Assistant Director of Nursing or Nursing Supervisor must notify: a. (Name of local state agency) of any serious incident or accident. Serious means any incident or accident that causes physical harm or injury to a resident. Note: Physical harm or injury does not include skin tear or bruise or something covered with a band-aid. Physical harm would include a broken bone, or blood flow not stopped by a band-aid or hospital or emergency room treatment that involves more than diagnostic evaluation. The Immediate Jeopardy that began on 04/06/24 was removed on 04/07/24 when the facility took the following actions to remove the immediacy and correct the noncompliance. Corrective Action Taken: 1. Upon readmission R5 was reassessed for elopement risk by social services on 04/08/2024 and deemed an elopement risk. This was completed on 04/08/24, and verified with no concerns. 2. R5 returned to the facility, was readmitted from hospital on [DATE]. Per discharge records from hospital no injuries were noted and no change in orders. Upon return, R5 was placed on the second floor unit observed and verified with no concerns. 3. R5 care plan was updated by Social Services pertaining to elopement on 04/08/2024. This was reviewed and verified with no concerns. 4. On 04/08/2024 the DON, Administrator, ADON, Nurse Consultant and Medical Director reviewed the facility policies related to the occurrence: Elopement, Routine Resident Checks, Exit Seeking, Abuse, and Incidents/Accidents. No changes were made. This was reviewed, verified with no concerns noted. - The Social Services Director and counselors are responsible for the assessments and updating care plans. This was verified with V5 and reviewed with no concerns noted. - The Administrator/designee is responsible for monitoring and reeducation of staff to ensure safety, verified with V1, with no concerns noted. - Resident in question R5 has been assessed every shift for pain. Nurse will immediately address (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 30 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety any identified pain. This was initiated on 04/08/24 and ongoing. This was verified with V36, and confirmed via electronic health records with no concerns noted. - Nurse will monitor all residents for change of condition including new acute onset of pain. If change of condition is identified, primary physician will be notified immediately. This was initiated on 04/08/24 and ongoing. This was verified with no concerns noted. Residents Affected - Few - Resident was provided with appropriately fitting shoes on 04/11/24. This was verified with R5 with no concerns noted. Identifying other residents having the potential to be affected by the same deficient practice: 1. This failure has the potential to affect all residents who experience a change of condition resulting from pain. No other residents were identified to have a change of condition as a result of pain. This was verified with no concerns noted. 2. Resident elopement assessment and careplan updated upon re-admission initiated 04/08/24 and completed on 04/08/24, verified with no concerns noted. 3. All residents were reassessed by the social services staff for elopement risk by social services on 04/08/2024 and completed on 04/10/24. Careplans were updated as needed. These were verified with no concerns noted. 4. All new admissions will have an elopement risk assessment that will be completed within 24 hours by Social Services staff upon admission and interim care plan will be initiated based off the assessment, and will be reassessed every three months, and PRN (as needed) based on behaviors resulting in risk. These were verified with no concerns noted. 5. All residents that are identified as at risk for elopement during admission had a review of their care plan by social services staff and updates were made where applicable, completed on 04/10/24 and ongoing. This was initiated on 04/08/24, and were verified with no concerns noted. 6. On 04/08/24 facility initiated the process of ensuring pictures of at-risk residents were placed in a binder on all nursing stations (1st,2nd,3rd unit) and the receptionist desk which was completed on 04/10/24. This is updated by Clinical Director as needed. Pictures are only privy to staff and placed in a manner that promotes privacy and dignity. These were verified through observation; and interviews with V6 (LPN), V12 (LPN), V36 (LPN), V43 (CNA) and V44 (CNA), with no concerns noted. 7. On 04/08/24 facility initiated the process to ensure the list of residents at risk for elopement is placed at the front desk. Pictures are posted on the bulletin at the front desk. Pictures are only privy to staff and placed in a manner that promotes privacy and dignity. This was completed on 04/10/24 and will be updated as needed by the Clinical Director. This was verified with V24 (Receptionist) with no concerns noted. 8. On 04/09/24 Special Resident Council Meetings were held by the Activity Director educating the residents on the seriousness of safety, informed of the requirement to leave facility out on pass process. Some of the residents are cognitive enough to be educated regarding facility rules/protocols and follow the facility's rules they are not at risk for elopement. This was completed on 04/09/24 and will be ongoing for newly admitted residents. This was verified with no concerns noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 31 of 37 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 04/18/2024 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 Measures taken to ensure that the problem is corrected and will not recur. Level of Harm - Immediate jeopardy to resident health or safety 9. The staff members on duty at the time of the occurrence on 3rd unit included 1 LPN, 2 CNA's received a formal disciplinary action as well as re-education. This was reviewed, and verified with no concerns noted. Residents Affected - Few 10. On 04/08/24 facility initiated the process of ensuring pictures of at-risk residents were placed in a binder on all nursing stations (1st,2nd,3rd unit) and the receptionist desk which was completed on 04/10/24. This is updated by Clinical Director as needed. Pictures are only privy to staff and placed in a manner that promotes privacy and dignity. This was verified through observation and interviews, with no concerns noted. 11. Staff and managers are being reeducated by Administrator, DON, ADON, Clinical Director, Activity Director, Scheduler, Nurse Consultant, Business Office Manager on routine resident checks, exit seeking, incidents/accidents, change of condition, notifications for change of conditions, elopement policy and procedure and where to locate the at risk of elopement binders. The reeducation was provided on 04/07/24 with a completion date of 04/08/24. Educations will continue to be provided for those employees who have not received educations at the start of their shift. Routine checks allow the staff the opportunity to address any identified resident needs, change of condition or medical concerns. These were verified with staff interviews, with no concerns noted. 12. Reeducation provided by Administrator, Psychosocial Coordinator, Clinical Director regarding assessing for elopement risk which was initiated 04/07/24 and completed on 04/08/24. This was verified with no concerns noted. 13. Staff and managers are being reeducated by Administrator, DON, ADON, Clinical Director, Activity Director, Scheduler, Nurse Consultant, Business Office Manager on elopement risk and reporting behaviors or changes in factors related to elopement risk to appropriate discipline. This was started on 04/07/24 and completed on 04/09/24. The reeducation was provided on 04/07/24 by the Administrator and her designees. Educations will continue to be provided for those employees who have not received educations at the start of their shift. These were verified with no concerns noted. 14. Staff and managers are being reeducated by Administrator, DON, ADON, Clinical Director, Activity Director, Scheduler, Nurse Consultant, Business Office Manager regarding door alarms, checking to ensure doors are opening and closing properly, responding to door alarms to ensure it was not triggered by a resident, which started on 04/07/24 with a completion date of 04/09/24. This was verified with no concerns noted. 15. The alarm at the north exit door on third unit was checked to ensure that it was functioning properly on 04/07/24 this was completed on 04/07/24. The facility building manager is assigned to monitor the alarm on all units and lower level on day shift. Manager on duty and charge nurse will monitor the alarms on all units and lower level on all shifts, weekends, nights and overnights. This is ongoing. This was verified upon observation and interviews with no concerns noted. 16. The receptionist will monitor the front entrance door 8am-8pm. All other exit doors will be alarmed. The door leading to the lobby area will remain alarmed. This was verified with no concerns noted. 17. Exterior door alarms will be checked by Maintenance Director, Manager on Duty, Unit Charge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 32 of 37 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 04/18/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Nurse to ensure they are in working order on each shift. QA (Quality Assurance) initiated on 04/07/24 and completed 04/07/24 and is ongoing. This was verified with no concerns noted. Measures or systems the facility will alter to ensure that the problem will be corrected and will not recur. 18. A review of compliance using Quality Assurance Audit tool for elopement was completed by the Clinical Director and completed by her designee and Door Alarm working condition started 04/07/24 by Clinical Director and completed by her designee. The Elopement Audit started on 04/07/24 by the Clinical Director. The Audits will be done weekly for four weeks, then monthly for 3 months, and then randomly by Administrator, DON, until goal is attained in 4 months. This was verified and reviewed with no concerns noted. 19. On 04/08/2024, the facility DON, Administrator and Nurse Consultant reviewed policies and procedures listed below with the Medical Director. This review included but is not limited to staffing, environment, addressing risk factors, and assessing changes in condition related to pain. The following policies were reviewed with no changes made. Changes in Condition - DON/ADON - Elopement - Clinical Director/Activity Director/Business Office Manager - Door Alarm - Maintenance Director/Scheduler/Business Office Manager/Housekeeping Supervisor - Routine Checks - Scheduler/DON/ADON/Business Office Manager - Incident/Accidents - DON/ADON - A review of results of audit regarding elopement and door alarm working condition with the facility's interdisciplinary team started on 04/07/24. Audits will be done weekly for four weeks, then monthly for 3 months, and then randomly by Administrator/designee until goal is attained in. - During orientation of new hires, the new door alarm enhancements and functionality will be discussed and the safety of it. These were verified with no concerns noted. Quality Assurance Plans to monitor facility performance: - The facility Quality Assurance Team/ IDT (including Medical Director, Administrator, Social Services, DON, ADON and facility consultant) shall meet monthly or as PRN. This was verified with no concerns noted. - The QA meeting is held as needed and quarterly. An emergency QA meeting was held on 04/08/24 at 10am by the Administrator with the Interdisciplinary Care Team and Medical Director. The Elopement from facility on 04/06/24 by the Administrator, DON, ADON, and Social Services. This was verified with no concerns noted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 33 of 37 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 04/18/2024 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 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 interview and record reviews, the facility failed to conduct pain assessment and provide necessary care and treatment on a resident complaining of chest pain. This deficiency affect one (R5) of one resident reviewed for pain. This deficiency resulted in R5 experiencing severe chest pain, eloped from the facility without shoes on, to go to the nearest emergency room for further evaluation and treatment. Residents Affected - Few Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed the alarm on the back door gone off and sounding. Code [NAME] for elopement was called and headcount on the unit was initiated. One staff went outside to look for a resident who left unattended but reported did not see anybody. Another staff helped with the head count. As staff conducting head count, a staff from another unit received a call that R5 was in the hospital. On 04/08/24 at 2:12 PM, V3 (Certified Nurse Aide, CNA) was asked regarding incident on 04/06/24 with R5. V3 stated, On 04/06/24, I was the CNA on the floor, and she (R5) was my resident at the time. Like around 8:00 to 9:00 PM, I started putting residents on bed. She came to me and asked if I was her CNA. I said yes and asked if she needs something. She said she needed a brief and a blanket. I gave it to her, and she went back to her room. She is not incontinent. Then, I continued to put other residents on bed. Suddenly, the door alarmed. V4 (Licensed Practical Nurse, LPN) called me to check the alarm. He (V4), I and V30 (CNA) checked residents in their rooms and did a head count. While we were doing the head count, V28 (LPN) came down and said that R5 was in the hospital. V4 was also interviewed on 04/08/24 at 2:45 PM, stated, On 04/06/24, I was the nurse assigned on R5. Around 9:30 PM, I heard an alarm went off from the unit exit door. I asked myself, maybe somebody must have used the door. So, I called Code [NAME] right away. Code [NAME] is for elopement. My staff, V3 and V30 went to the door and went outside. While I do the head count, I found out R5 was missing. That would be like 9:40 PM already. As we were doing the head count, V28 came down and said hospital called, said R5 was in the hospital. I called hospital, was told that she (R5) was with them, in the emergency room. R5 was able to leave facility on 04/06/24 unnoticed, unsupervised. R5 is a resident in the Memory Care Unit, a secured and locked unit in the facility. Observation on 04/09/24 at 10:25 AM showed that the hospital is located two blocks east from the exit door where R5 exited on 04/06/24. The hospital is situated at the intersection of a busy street. On 04/09/24 at 10:40 AM, R5 was observed sitting in her rollator walker by the nurses' station. Alert and oriented, R5 was asked regarding incident on 04/06/24 when she eloped from the facility and went to the hospital. R5 stated, I was in the hospital down there. I had chest pain and I had pain in the stomach and tooth pain. That time, I told the nurse (don't know his name) that I was having chest pain and he was not paying attention or anything, so I walked down there to the hospital. I was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 34 of 37 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 04/18/2024 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 0697 Level of Harm - Actual harm Residents Affected - Few gone for a day. I was scared that I might be having a heart attack, it frightens me. R5 also mentioned during follow up interview, When I went to the hospital, I was on my feet, no socks. I walked on the rocks. A lady passed by and she said if I needed help. She helped me and brought me to the hospital. I was having extreme pain on my chest, 8 out of 10, (8 meaning severe pain). I had tooth ache as well and pain in my left armpit. I was thinking I was having a heart attack at the time because I had one before and I know how it feels. I was actually short of breath when I get into the hospital. On 04/09/24 at 9:33 PM, V10 (Hospital Staff) was interviewed regarding R5. I was the nurse assigned to her (R5). That was last Saturday, 04/06/24, she was found in the middle of the road by a bystander. The bystander called paramedics and she was sent here. She had no shoes at the time, said she was having chest pain. V29 (Physician/Hospital) also mentioned during interview, On 04/06/24, she was found wandering and came for chest pain. She was admitted for chest pain. She is alert, oriented to time, place and person. I was told by her (R5) that she left on her own and she was having chest pain, and she was admitted . Hospital records dated 04/07/24 recorded that R5's chief complaint was chest pain. According to history of present illness, R5 resented to the emergency department after found wandering in traffic with a walker and without shoes. R5 stated she has been experiencing left sided chest pain for 3 days. She describes a fullness at her chest. She has new onset tooth pain, SOB (shortness of breath and left upper extremity pain. She reports alerting nursing home staff of her symptoms. She became concerned due to having history of a heart attack and decided to leave the facility due to not getting proper care. Hospital records also documented the following: Past Medical History: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris Review of systems: HENT (Head/eye/nose throat): tooth pain Cardiovascular: Positive for chest pain and leg swelling (chronic). Respiratory: Positive for shortness of breath Musculoskeletal: Positive for left upper extremity pain Clinical Impression: Chest pain, unspecified type R5's hospital Discharge summary dated [DATE] indicated: Diagnosis: Atypical Chest Pain Progress notes dated 04/08/24 time stamped 8:59 PM recorded R5 came back to facility. On 04/10/24 at 3:13 PM, V4 (Licensed Practical Nurse, LPN) was asked if R5 complained of chest pain on 04/06/24. V4 stated, On 04/06/24, I was the nurse assigned on R5. No, she did not complain of any chest pain. I was not aware of her having chest pain. V1 (Administrator) was also asked regarding R5 chest pain on 04/06/24. V1 verbalized, On 04/06/24, I was notified by V4 that she (R5) was missing. When she (R5) came back, I spoke to her, did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 35 of 37 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 04/18/2024 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 0697 mention that she went to the hospital because of chest pain. I called hospital and was told that she went there because of bunch of reasons but not chest pain. Level of Harm - Actual harm Residents Affected - Few On 04/10/24 at 3:22 PM, V27 (Medical Director) stated during interview, I was not aware that she had chest pain. I was notified that she just eloped. Typically, if a resident complained of chest pain, take vital signs, make them stable and call paramedics to hospital as ordered. V36 (LPN) was interviewed on 04/15/24 at 1:43 PM regarding R5. V36 mentioned, I have taken care of R5. I am not aware of any chest pain complaint, just body pain. If a resident complained of chest pain, if they have an order for Nitro, we give it to them. If no order, I will call physician for order; monitor resident, take vital signs and follow physician's order. On 04/16/24 at 10:14 AM, V32 (Assistant Director of Nursing) was asked regarding chest pain. V32 verbalized, When a resident is complaining of pain, staff must do the vital signs, notify physician and send resident out as ordered. Pain is subjective, we cannot say they are not having it. Whatever residents say if it is pain, it is pain. R5's care plans (CP) documented the following: ADL (activities of daily living) functional performance deficit (CP dated 04/04/24) - Intervention: Monitor for presence of pain, intolerance during ambulation. Potential for altered cardiac function (CP dated 04/04/24) - Intervention: Monitor for changes in status and report to MD (Medical Doctor) as needed. Potential for alteration in health condition (CP dated 04/04/24) - Intervention: Notify MD and family with any changes in condition. Facility's policy titled, Pain Management Evaluation dated 09/2020 stated in part but not limited to the following: Purpose: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 2. Acute pain is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness. 4. During the pain evaluation, determine the most workable pain rating scale for the resident. The following scales are available: a. The numeric rating scale (NRS): 1-3 (mild), 4-6 (mod), 7-10 (severe); b. PAINAD scale 1-3 (mild), 4-6 (mod), 7-10 (severe); 5. Pain will be evaluated each shift Facility's policy titled Change of Condition (Resident) dated 09/20 documented in part but not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 36 of 37 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 04/18/2024 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 0697 limited to the following: Level of Harm - Actual harm Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the resident's change in condition. Residents Affected - Few Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 37 of 37