Inspection·April 9, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their maintenance and housekeeping policy and procedures by not maintaining a clean, sanitary, and comfortable environment that is in good repair and by not providing a television for a resident who had been moved to a new room for three weeks. This failure applied to nine of nine residents (R17, R36, R100, R104, R108, R112, R119, R143, and R303) reviewed for environment. Findings include: On 4/6/2025 at 1:05PM, R303 said the facility is overall unsanitary and not in good condition. R303 said I admitted to the facility on [DATE] and many things in my room are broken or not in working condition. The sheets were stained, my television does not work, the bathroom looks as if there is water damage on the floor, and there is a hole in my wall next to my bed. At 1:15PM, R303 and R100 were interviewed in their room. Observed hole next to R303's head of bed, handles missing off of wardrobe, and large red stain on privacy curtain between beds. R303 and R100 said it gets so hot in here and the windows do not open. Observed windows knobs to be off and not in working order. Touched window curtain surface and noted to have dust and grime on curtains. Observed R303 television to be mounted on wall with chord hanging and not plugged in. R100 said this television has been broken since August of 2024. R303 said it is upsetting because I just admitted Friday and they placed me in this room with nothing in working order. Observed bathroom between residents room to have broken grab bar on one side of toilet. Also observed baseboard on wall to be missing and water damage noted to wall. It is to be noted that R100, R303, R112, and R119 all share a bathroom. R100 said this has been like this for a very long time. Sometimes when I go to the bathroom, water drips on my head from the ceiling. Observed ceiling tiles to be discolored and dark yellow in color. On 4/7/2025 at 12:30PM, V5 (Regional Maintenance Support) said rooms should be in working order before new residents are admitted . Maintenance logs dated January 2025-April 2025 show multiple maintenance requests that are outstanding and not resolved. R143 is 52 years and was admitted to the facility on [DATE], medical history includes, but not limited to hypertensive heart disease with heart failure, syncope and collapse, orthostatic hypotension, type 2 diabetes, insomnia, hyperlipidemia, other seizures, essential primary hypertension, etc. On 04/06/25 11:30AM, R143 was observed in his room, awake and alert and stated that he is doing okay but certain things are not going okay, he was moved to this new room about three weeks ago and has been asking for a television. Resident stated that all he does is stare at the blank walls, he have spoken to several staff but gets a run around, Resident said that last week a staff came and told him that all he needed was to find a mount for a television and he will come back, staff never returned, R143 said he is tired of asking and it is so frustrating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/7/2025 at 9:40AM, V4 (Maintenance Manager) said that he is aware that R143 needs a television in his room, resident informed V4 last week and he informed his supervisor who completed a work order and ordered a new television. Currently they do not have any television in the facility. V5 (Regional Maintenance Director) who came to the room while surveyor was speaking to V5 said that V4 is new and still in training, V5 normally go to the facilities to train new staff and have not been to this facility to train V4, there is another maintenance staff that work with V4 but that one is new too. On 4/7/2025 at 12:25PM, V5 (Regional Maintenance Director) was observed in resident's room with a television mounted on the wall. Surveyor asked V5 when the television arrived, and he said that V4 is not really familiar with where to find some items. V5 said that he was cleaning the storage and found 2 televisions, there is no work order for the resident's room, but he will put in a work order today. The facility's Maintenance Policy and Description of Building Manager Responsibilities dated 03/2014 states in part but not limited to the following: Building Manager will assure that maintenance services are provided to all areas of the building, grounds, and equipment in a prompt and professional manner. The Building Manager is responsible for assuring that the following functions are performed as necessary for the safety and comfort of residents, staff, and visitors: Maintaining the building in good repair and free from hazards. Establishing priorities in providing repair service. Providing routinely scheduled maintenance services to all areas. The facility's Housekeeping Policy received 04/08/2025 states: The facility will follow an effective plan to maintain a clean, safe, and orderly environment. Unpleasant odors within the responsibility of Housekeeping and Maintenance will be controlled through proper cleaning of the environmental surfaces and proper ventilation. Floors will be maintained as clean and free of slipping and tripping hazards. R36 is a [AGE] year-old male with a diagnoses history of Paranoid Schizophrenia, Bipolar Disorder, Generalized Anxiety Disorder, Unspecified Mood Affective Disorder, Psychotic Disorder with Hallucinations, Restlessness and Agitation, Depression, and Violent Behavior who was admitted to the facility 07/26/2024. On 04/06/25 at 10:41 AM R36 stated they don't clean his room enough. Observed holes in R36's wall and he stated he would like them repaired. Observed chipped paint on the floor by R36's window, the pin board over R36's bed with multiple stains, his room sink with stains and residue around the faucet and on the back of the sink, his room radiator vents with buildup, his clothes cabinet with multiple stains and spills, and his room floors dirty. R104 is a [AGE] year-old female with a diagnoses history of Dementia, Schizophrenia, and Bipolar Disorder who was admitted to the facility 10/13/2022. On 04/06/25 at 10:46 AM Observed a urine odor in R104's room, observed the window next to R104's bed with splattered insulation foam and with multiple broken blinds. R104 stated she would like the blinds repaired and the foam in her window fixed if they can. Observed holes in the wall behind R104's bed. Observed the baseboard next to R104's bathroom peeled from wall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heather Health Care Center 15600 South Honore Street Harvey, IL 60426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm R108 is a [AGE] year-old male with a diagnoses history of Recurrent Major Depressive Disorder who was admitted to the facility 12/14/2022 On 04/07/25 at 08:25 AM R108 stated there are holes in the wall in his room and maintenance is aware of it. Residents Affected - Some On 04/07/25 at 08:53 AM Observed R108's bathroom vent with heavy buildup of dust, observed holes and cracks in the wall underneath the window in R108's room. R17 is a [AGE] year old male with a diagnoses history of Schizophrenia, Schizoaffective Disorder, COPD, Spinal Stenosis, and Heart Failure who was admitted to the facility 09/18/2017. On 04/07/25 at 08:56 AM R17 pointed at the baseboard behind his bed. Observed the baseboard behind R17's ed was peeled away from the wall. R17 communicated that the maintenance man knows but hasn't done anything. On 04/07/25 at 08:59 AM Observed the floors underneath the sink in R36's room cracked and with buildup and with the baseboard peeling. Observed R36's clothes cabinet and sink with the same stains and spills present yesterday. Maintenance log reports from December 2024 - April 2025 documents on unknown dates R17's room has detached wall base board, missing window screen and window won't close, has a cracked sink and hole in the wall, and the light not working, R36's room has holes in the wall, R104's room has missing wall baseboard. On 04/08/25 at 03:09 PM V4 (Maintenance/Building Manager) stated he has been in the facility approximately 3 weeks. V4 stated V26 (Painter) typically patches holes, baseboards, and paints in residents rooms. V4 stated he uses the nurses logs to identify when these repairs are needed. V4 stated he walks around daily and performs preventive maintenance checks but doesn't observe all the residents rooms. V4 he mainly observes the halls, main doors, windows, exit doors, fire systems, and nurses station when performing these maintenance checks. V4 stated sometimes repairs are not listed in the logs and the nurses will call and report needed repairs. On 04/09/25 at 11:14 AM When asked by surveyor how often are resident's rooms cleaned? V1 (Administrator) responded, daily. When asked by surveyor should there be any visible spills, stains, or residue left on the residents room furniture, sink, or floors after housekeeping for more than one day? V1 responded, no. When asked by surveyor how often are bathroom vents cleaned? V1 responded, daily and as needed. When asked by surveyor should there be any visible signs of heavy buildup at any time on a residents bathroom vent? V1 responded, no. When asked by surveyor if the resident's room's show signs of disrepair such as exposed foam around their window seals, broken blinds, peeling or chipped paint, baseboards peeling from the wall, holes or cracks in the walls etc.; should staff be aware of this and should they report this to maintenance? V1 responded, yes. When asked by surveyor should maintenance monitor resident's room condition and identify these signs of disrepair? V1 responded, yes. On 04/09/25 at 12:36 PM When asked by surveyor if there should be any detectable unpleasant odors in residents rooms? V1 (Administrator) responded, not unless there is a recent happening like an incontinence episode and recent rounds. When asked by surveyor what should be done to remedy or prevent unpleasant odors? V1 responded, proper attention to the situation for example clean up the episode. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that staff administered scheduled medications on time for residents. This failure affected five (R65, R71, R79, R112 and R119) of five residents reviewed for medication administration and has the potential to affect all 31 residents in the west wing of unit 1 at the facility. Findings include: On 4/6/2025 at 10:30AM, observed medication administration for R71 with V25 (LPN). R71 received among other treatments, Keppra 500mg by mouth and Lamotrigine 100mg 1 tablet by mouth. Per physician order, both medications were scheduled to be given two times a day at 0900 and 1700. Medication administration record (MAR) showed both medications signed of at 0900, medication audit dated 4/6/2025 showed that both medications were given at 10:40AM. On 4/6/2025 at 10:40AM V25 was observed administering medication to R79. Resident received among other treatments: Metformin 100mg tablet, Metoprolol 100mg tablet, Gabapentin 300mg tablet, Hydralazine 25mg tablet, Enalapril 10mg tablet, Cyclobenzaprine 5mg tablet, Apixaban 5mg tablet and Magnesium Oxide 400mg tablet. Review of physicism order showed that these medications are scheduled or two or three times a day, all medications are documented as given at scheduled 0900 in MAR. Review of medication audit showed that these medications were charted between 11:01 and 13:50. On 4/06/2025 at 11:00 AM R71 said, I have received my medications late today, and I take medication for seizures. I am concerned about my health and want my medication on time. On 4/06/2025 at 11:10 AM R79, said, I received my medications late today, I take blood pressure medications and I want to keep my blood pressure down. Ob 4/6/2025 at 12:45PM, surveyor asked V25 how many residents she still must give medications and she said four residents, Surveyor asked V25 if she could ask for help when she is running behind with medication administration and she said yes. R65 received the following medications from V25, Lasix 20 mg tablet two times a day, Dicyclomine 10 mg tablet three times a day, Gabapentin 300mg three times a day, The above medications were signed off as given at 0900 per MAR, medication audit for 4/6/025 showed that they were administered at 12:54. R112 received the following medications as documented in MAR, Flonase allergy relief, 1 [NAME] in both nostrils twice a day, Metoprolol 25mg one time a day, Procardia XL extended-release tablet, by mouth one time a day. These medications were signed off as given at 0900, medication audit showed that they were given at 12:01. R119 received the following medications from V25, Clopidogrel 75 mg tablet one time a day, Carvedilol 25mg by mouth two times a day, Furosemide 40mg by mouth two times a day, metformin 500mg by mouth two times a day, Hydralazine 25mg by mouth three times a day, Ofloxacin ophthalmic solution, one drop in both eyes, four times a day, Ketorolac Tromethamine ophthalmic solution , on drop in both eyes four times a day, Prednisolone ophthalmic solution 1 drop in both eyes four times a day. These (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medications were signed off as given at 0900, medication audit review showed that they were charted at 13:00 to 13:18 by V25. On 4/8/2025 at 3:15PM V2 (DON) said that late medication administration is unacceptable and there should not be any reason for that, medications should be given an hour before or an hour after, giving medication ordered two or three times a day late will affect the next dose that will be administered too close together. V2 added that she constantly in-service the nurses about giving medication on time, if a nurse is running late, they can ask for assistance. V2 also said that when a medication is administered late, a prudent nurse should notify he physician and get an order to reschedule or skip the next dose. Medication administration policy dated 03/2021 states in part: to ensure that medications are administered safely as prescribed. Under procedure, the document states #8. Medications are administered within (1) hour of prescribed time. Unless otherwise specified by the physician, routine medications are administered according to established medication administration schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145173 If continuation sheet Page 6 of 6