Inspection·November 16, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a physician order for a Do Not esuscitate. Residents Affected - Few This applies to 1 of 4 residents (R109) reviewed for advanced directives in the sample of 24. The findings include: R109's EMR (Electronic Medical Record) showed R109 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection, sepsis, respiratory failure, and heart failure. R109's Illinois Department of Public Heath Uniform POLST (Practitioner Order For Life-Sustaining Treatment) Form showed No CPR: Do Not Attempt Resuscitation was selected. The POLST form was signed by R109 and V26 (APRN/Advanced Practice Registered Nurse) on [DATE]. On [DATE] at 3:06 PM, V18 (RN/Registered Nurse) said R109's EMR showed she was a full code, and V18 was unable to view R109's POLST Form in the EMR. V18 said R109 was a full code. On [DATE] at 3:08 PM, V18 (Social Worker) said when R109 was admitted to the facility she was a full code, but then completed a POLST Form on [DATE]. V18 continued to say the POLST Form was signed by V26 and R109. On [DATE] at 2:57 PM, V2 (DON/Director of Nursing) said if a POLST Form is completed for a resident, the social worker uploads the POLST Form to the EMR, and then notifies nursing so nursing can update the order for the resident's code status. On [DATE] at 3:15 PM, V2 (DON/Director of Nursing) said R109's POLST form was uploaded to the EMR on [DATE]. V2 continued to say R109's full code order should have been changed to Do Not Resuscitate right after it was uploaded to the EMR. R109's Order Audit Report, dated [DATE], showed an order dated [DATE], for Full Code. As of [DATE] at 3:00 PM, R109's Full Code order was active. The facility's policy titled, Policy and Procedure for Advanced Directives, dated [DATE], showed, Policy: This policy serves to guide the clinical staff at [the facility] on a standardized approach for identifying patients with advanced directives and educating patients and families on advanced directive options. This policy is based upon current best practice and evidence and focuses on informing, guiding, and supporting staff in management of advanced directives . Procedure: .Completion of the POLST Form .13. If a patient choses to complete a POLST Form, nursing will be notified to assist in the process of notifying the physician of the patient's wishes, placing order in the patients EMR and ensuring all required parties have signed the form . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 2 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview, and record review, the facility failed to follow their policy to remove a staff member from duty after a resident voiced an allegation of verbal abuse. This applies to1 resident (R92) reviewed for abuse in the sample of 24. The findings include: Review of R92's face sheet documents a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include Malignant Neoplasm of Brain, Muscle weakness, Epilepsy, Anxiety Disorder, and Fracture of the Shaft of the Right Tibia and Fibula. R92's Minimum Data Set (MDS) section C, dated 9/30/23, shows she is cognitively intact. On 11/13/23at 1:32 PM, R92 stated V23 (CNA/Certified Nursing Assistant) yells at her all the time when V23 disagrees with her. R92 stated when V23 yells at her, it makes her feel horrible and disrespected. R92 stated the last time V23 yelled at her was last week. R92 stated V23 yells at her in front of other staff also. V1 (Administrator) was notified of the allegation on 11/13/23 at 1:51PM. On 11/13/23 at 4:31 PM, V23 was observed working on the same floor that R92 resides on. V24 (LPN/Licensed Practical Nurse) stated V23 was working a double shift. V24 provided a copy of the assignment sheet at that time, and circled the staff that was working the second floor, and wrote at the bottom in her own hand. V24 stated each floor has the same copy of the assignments. Review of the assignment sheets confirmed V23 was scheduled to work the second shift, and the same assignment that includes R92's room. On 11/16/23 at 9:20 AM, review of V23's timecard shows on 11/13/23, V23 clocked in at 6:24 AM, and clocked out at 10:30 PM. On 11/14/23 at 8:55 AM, V3 (ADON/Assistant Director of Nursing) stated after she learned of the allegation, she went to R92's room on 11/13/23, and told R92 that V23 was no longer going to be taking care of her. V3 stated she did not ask R92 any questions about the alleged verbal abuse. On 11/14/23, at 9:17 AM, V4 (Abuse Coordinator) stated she went to R92's room at about 4:00 PM on 11/13/23, and asked R92 generally how her care was. V4 stated she did not ask any specific questions about the alleged verbal abuse, nor did mention V23's name in the conversation. V4 stated the facility's normal procedure for allegations of abuse is to take the alleged perpetrator off the schedule and put them on leave, for the safety of all the residents. V4 confirmed V23 was not removed from the facility during the abuse investigation, and the facility's policy was not followed. V4 stated she was just trying to get the investigation done. V23 stated she finished her investigation at 8:00 PM on 11/13/23. The facility's Abuse Prevention Program Policy and Procedure, dated 2009-2012, showed the following: Residents are to be free from verbal, sexual, physical and emotional/mental abuse: neglect; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 3 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete self-abuse/self-neglect; medical neglect; misappropriation of resident property; corporal punishment; and involuntary seclusion at all times. All reports of abuse are to be thoroughly investigated by the facility. Residents and staff are to be protected during incident investigations by ensuring: f. Accused employees are removed from resident contact immediately and may be suspended from duty until the results of the investigation are reviewed. Event ID: Facility ID: 145219 If continuation sheet Page 4 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to change the resident's midline dressing to ensure integrity of the catheter and to prevent potential IV (intravenous) site infection per physician's order, plan of care, and per facility's infusion manual. Residents Affected - Few This applies to 1 of 2 residents (R167) reviewed for IV lines in the sample of 24. The findings include: R167 had multiple diagnoses including dislocation of tarsometatarsal joint of left foot, displaced fracture of medial cuneiform of left foot, Charcot's joint (right ankle and foot), diabetes mellitus with diabetic neuropathy, and infection following a procedure, based on the face sheet. On 11/13/23 at 1:04 PM, R167 was sitting in his wheelchair inside his room. R167 had a single lumen left arm midline (IV line). The midline had a transparent dressing, dated 11/10/23. The said dressing was rolled up on the lower inner right side. According to R167, he uses the midline for IV antibiotic due to recent surgery on the left foot. On 11/14/23 at 2:48 PM, V13 (Registered Nurse) was observed coming out of R167's room. According to V13, she was inside R167's room to start the resident's IV antibiotic medication. R167 was sitting in his wheelchair with ongoing IV antibiotic. R167's left arm midline had a transparent dressing, dated 11/10/23. The said dressing was rolled up on the entire lower part, and partly on the right and left sides of the transparent dressing. On 11/15/23 at 9:40 AM, R167 was in bed, alert, oriented, and verbally responsive. R167's left arm midline had a transparent dressing, dated 11/10/23. The said dressing was rolled up on the entire lower part, and partly on the right and left sides of the transparent dressing. V3 (Assistant Director of Nursing) was present during the observation and commented, The dressing is coming off and it needs to be changed. R167's active order summary report, dated 11/12/23, showed an order to administer reconstituted Vancomycin solution intravenously once a day. R167's MAR (medication administration record) showed the resident received the Vancomycin solution intravenously on November 13, 14, 15, 2023 at 6:00 AM. R167's active order summary report, dated 11/10/23, showed an order to administer reconstituted Meropenem solution intravenously three times a day for erythema on the left foot. R167's MAR showed the resident received the Meropenem solution intravenously on November 13 and 14, 2023 at 6:00 AM, 2:00 PM and 10:00 PM, and on November 14, 2023 at 6:00 AM. R167's active order summary report, dated 11/11/23, showed an order which included midline dressing change every Friday and PRN (as needed). R167's active care plan, initiated on 11/13/23, showed the resident had a midline on the left upper extremity. The care plan showed R167 was at risk for catheter migration, infiltration and infection at the insertion site. The care plan showed multiple interventions including, Dressing changes weekly and PRN, per facility protocol. The same care plan showed in-part under interventions, inspect dressing at least every shift to ensure it is secure, clean and intact. On 11/15/23 at 10:12 AM, V2 (Director of Nursing) stated the transparent dressing of the midline (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 5 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete should be changed weekly every Friday morning and as needed when the dressing is falling off or rolling up to prevent exposure of the IV insertion site. V2 stated the midline dressing should always be intact to maintain integrity of the IV site, maintain sterile filled, and to prevent potential exposure and infection of the IV site. The facility's Midline catheter dressing change infusion manual, revised on 7/1/23, showed in-part under considerations, 1. Catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. It showed in-part under the guidance, 1. Sterile dressing change using transparent dressings is performed: .1.3 If the integrity of the dressing has been compromised (wet, loose or soiled). Under the guidance it showed in-part, 5. Assessment of the vascular access site is performed: . 5.3 Before and after administration of intermittent infusions and 5.4 At least once every shift when not in use. Under the same guidance it showed in-part, 6. Assessment of entire arm with indwelling vascular access device (VAD) for infusion related complications is to include, but is not limited to, the absence or presence of: . 6.6 Integrity of transparent dressing. Event ID: Facility ID: 145219 If continuation sheet Page 6 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow menu portion serving sizes for mechanical soft and pureed diets. Residents Affected - Some This applies to 5 of 5 residents (R20, R29, R32, R60, R111) observed for dining in the sample of 24. The findings include: On 11/13/23 at 12:05 PM during lunch meal service in the facility kitchen, V9 (Cook) was at the tray line platting food for the residents. V9 used #12 scoop (green colored scoop) to serve ground chicken to mechanical soft diets. R29 and R111 were observed to receive mechanical soft ground meat. V9 used #10 scoop (cream colored scoop) to serve pureed corn and R20, R32 and R60 received the same. Diet spread sheet for mechanical soft and pureed diets showed serving size for one each for ground chicken and pureed corn. When asked to clarify portion size for these diets, V6 (Dietary Supervisor/Cook) stated they follow the serving size as shown on the recipe. Recipe for Sandwich Chicken Breast Ground (Recipe #12) showed to place a #8 scoop ground meat with one tablespoon of mayonnaise or choice of condiment to moisten the meat and spread into bread and grill. Recipe for Corn Pureed Thick (Recipe #3) showed to serve portion size of #8 scoop of pureed corn. On 11/14/23 at 11:56 AM, V6 stated V9 should have used #8 scoop instead of #12 scoop to serve the ground meat for mechanical soft diets, and the #8 scoop should have been used instead of the #10 scoop to serve pureed corn. On 11/15/23 at 12:02 PM, V16 (Dietitian) stated the meal items should be portioned out correctly as it meets the micro and macro nutrients of the planned diets for the residents. Facility scoops equivalent portion sizes showed #8=4 oz/ounce, #10=3 oz, #12= 2 and 2/3 oz. Fall/Winter Menu for 11/13/23 (Cycle 9) included items of grilled chicken breast sandwich and frozen cut corn. Facility diet order log showed R29 and R111 were on mechanical soft diets, and R20, R32, and R60 were on pureed diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 7 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to provide thickened soup to a resident with swallowing problems, and failed to serve ground barbeque pork for mechanical soft diets. Residents Affected - Some This applies to 5 of 5 residents (R6, R33, R46, R69, and R315) reviewed for dining in the sample of 24. The findings include: 1. R46's diagnoses on face sheet included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, dysphagia, unspecified, and acute respiratory failure with hypoxia. R46's POS (Physician Order Sheet) included diet order of Reduced Carbohydrate diet, Regular texture, Honey consistency (start date 11/1/23). On 11/14/23 at 12:39 PM, R46 was seen eating lunch in dining room on the first floor with V8 (R46's spouse), and was noted to have an occasional cough while eating her soup. R46's diet card showed low sodium, red carb (reduced carbohydrate) honey thick liquid, and R46 received a hamburger, potato chips, thickened coffee, and soup with thin broth. V8 stated R46 should get thickened fluids. This was relayed to V6 (Dietary Supervisor /Cook), who stated R46 should have received thickened soup. On 11/15/23 at 12:54 PM, V17 (Speech Language Pathologist) stated R46 had a recent video swallow study done at the hospital, and she was aspirating on both thin and nectar thick liquids, and had penetration on honey thick liquids. V17 added she put R46 on regular solids and honey thick liquids and thickened soups. 2. On 11/14/23 at 11:41 AM, V7 (Cook) was plating food for lunch at tray line service. V7 served BBQ (barbeque) pork that was shredded in irregular pieces in varying lengths and thickness to both Regular and Mechanical Soft consistency diets. Menu diet spread sheet for lunch (Cycle Day 10) showed to serve #8 scoop of ground BBQ pork sandwich. R6, R33, R69, and R315 received the above shredded BBQ pork in a bun. On 11/14/23 at 11:56 AM, V5 (Food Service Manager) stated the mechanical soft recipe for BBQ pork shows to serve ground pork. The same recipe titled Sandwich Pork BBQ Ground (Recipe #13) showed as follows: Place amount of meat in a food processor. Grind to desired consistency. Place a #8 scoop of ground meat with one tablespoon of BBQ sauce or condiment of choice to moisten meat and spread onto bread. Facility diet order log showed R6, R33, R69, and R315 were on mechanical soft diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 8 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provision of care, and failed to follow enhanced barrier precautions. Residents Affected - Some This applies to 11 of 24 residents (R20, R84, R51, R67, R80, R96, R167, R265, R267, R316 and R317) reviewed for infection control in the sample of 24. The findings include: 1. On 11/15/23 at 9:45 AM, R167 was in bed, alert, oriented, and verbally responsive. V14 (Licensed Practical Nurse/wound care) stated R167 had ongoing IV (intravenous) antibiotic therapy due to erythema of the left foot. V14 provided wound treatment to R167's left foot with the assistance of V15 (Registered Nurse/wound care). With her gloved hands, V14 removed the old dressing from R167's left foot. After removing the old dressing, V14 removed her used gloves and put on a new pair of gloves, without performing hand hygiene (hand washing or use of hand sanitizer) then proceeded to clean all of R167's surgical incision sites on the left foot including the DTI (deep tissue injury) on the resident's left heel. After cleaning the above mentioned sites, V14 removed her used gloves, put on a new pair of gloves, without performing hand hygiene (hand washing or use of hand sanitizer), then proceeded to open multiple betadine swab stick packets, and used those multiple swab sticks to apply the betadine on all the surgical incisions on R167's left foot, including the DTI on the left heel. After the said procedure, V14 removed her gloves put on a new pair of gloves, without performing hand hygiene (hand washing or use of hand sanitizer), then proceeded to apply non-adhering dressing to all surgical incision sites on R167's left foot and a foam dressing on the left heel DTI. On 11/15/23 at 12:29 PM, V4 (Director of Clinical Services) stated she oversees the clinical care of the residents. V4 stated after removing the old dressing, which was considered a dirty procedure, the staff should remove the used gloves, wash hands, then put on a new pair of gloves before proceeding to clean the surgical sites and wounds/pressure injury. V4 stated after cleaning the surgical sites and wounds/pressure injury, the staff should remove the used gloves, wash hands, then put on a new pair of gloves before opening the treatment supplies like the betadine swab stick packets. According to V4, after performing dirty task/procedure and before proceeding to a clean task/procedure, the staff should always remove the used gloves, wash hands then apply new pair of gloves to prevent cross contamination, to maintain infection control and to prevent potential infection. 2. On 11/13/23 at 3:08 PM, V21 (Certified Nursing Assistant/CNA) rendered incontinence care to R20, who had a bowel movement and was wet with urine. V21 cleaned R20's perineum from front to back; she (V21) applied clean incontinence brief, repositioned R20, and straightened linen and sheet, while wearing the same pair of gloves all throughout the provisions of care. On 11/15/23 at 12:35 PM, V4 (Director of Clinical Services) stated staff must perform hand hygiene and change their gloves in between tasks to prevent cross contamination and to maintain infection control. 4. R80's face sheet showed diagnoses of osteomyelitis of vertebra, lumbar region, bacteremia, personal history of other infectious and parasitic diseases, and benign prostatic hyperplasia without lower urinary tract symptoms. R80's POS showed EBP (enhanced barrier precautions) for PICC (peripheral inserted central catheter) care three times a day start, date 10/21/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 9 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm On 11/13/23at 1:22 PM, R80's room door showed signage Enhanced Barrier Precautions: STOP, EVERYONE MUST clean their hands, including before entering and when leaving the room. R80 was resting in bed and V12 (Lab Technician) came in wearing a gown, then put on gloves without performing hand hygiene, and took blood. V12 then removed her gloves and did not perform hand hygiene, and left the room with the same gown on and walked down the hallway. Residents Affected - Some 5. R51's face sheet showed R51 had encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below knee, other chronic osteomyelitis, left ankle and foot, and other idiopathic peripheral autonomic neuropathy. R51's POS showed EBP for wound care/ESBL (extended spectrum bets-lactamase) urine, revised date 11/13/23. On 11/13/23 at 12:10 PM, R51's room door showed signage for EBP. V10 (CNA) was seen delivering a room tray to R51 and set it on bedside table. V10 then left the room and took another tray from the cart in the hallway and continued process of delivering trays to residents eating in their rooms. V10 did not wash hands or use hand sanitizer on entry and exit to R51's room. When asked, V10 seemed not aware of signage of EBP on R51's room door. R51 stated she has a urinary tract infection and has a wound to right heel. 6. R265's face sheet showed retention of urine, unspecified, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, and retention of urine, unspecified. R267's face sheet showed hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, personal history of antineoplastic chemotherapy, hemangioma of intracranial structures, encounter for surgical aftercare following surgery on the digestive system, and secondary malignant neoplasm of brain. R96's face sheet showed urinary tract infection, site not specified, acute kidney failure, unspecified hydronephrosis, overactive bladder, and chronic obstructive pulmonary disease. On November 14, 2023 at 3:03 PM, V11 (CNA) was seen going into R267's and R265's shared room, which showed signage for EBP. V11 did not performing hand hygiene on entrance to the room. V11 had a portable blood pressure equipment with her, and she proceeded to take both R267 and R265's vitals consecutively without performing hand hygiene between residents. V11 then entered R96's room, which also had a signage for EBP on the door, without sanitizing her hands and proceeded to take R96's vitals. V11 stated she only sanitizes the blood pressure equipment initially when she starts taking vitals and when she is done taking all the vitals of the residents. V2, DON (Director of Nursing), provided information that R265 is on EBP as she has a urinary catheter, and therefore her roommate is also on EBP. R96 originally was on EBP for urinary catheter, which is discontinued, and remains on EBP for Escherichia Coli urinary tract infection. On 11/15/23 at 8:49 AM, V2 stated those who enter a resident room that has EBP should follow standard precautions by washing hands or hand sanitization with alcohol prior to entering room and on exit. V2 stated if providing high risk care, then a gown and gloves should be worn. V2 stated hands should be sanitized prior to donning gloves and removal, and gowns should be removed prior to exit from room. V2 added the staff taking vitals should use alcohol hand sanitizer in between patients and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 10 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm wash hands every 3rd person. V2 stated the blood pressure machine should be wiped down as needed with alcohol sanitizer. Facility Policy and Procedure for Preventing the Spread of Multi Drug Resistant Organisms (MDROs), dated 9/1/22, showed as follows: Residents Affected - Some Policy: This policy and procedure is intended to provide guidance for PPE use and room restriction in nursing facilities for preventing transmission of MDROs. For purposes of this policy, the MDROs for which the use of enhanced based precautions applies are based on organisms targeted by the CDC . Standard Precautions: A group of infection prevention practices that apply to the care of all patients, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Procedure: Any patient with an infection or colonization with MDRO when Contact Precautions do not otherwise apply, have a wound and/or indwelling medical devise will be placed in enhanced barrier precautions. 2. Post clear signage on the door or wall outside the patient room indicated the type of precautions and required PPE (example; gown and gloves) and the high-contact resident care activities that require the use of gowns and gloves. The facility's policy and procedure for standard precautions, dated May 2011, showed under policy, Standard precautions will be used in the care of all residents regardless of their diagnoses or suspected or confirmed infections status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucus membranes may contain transmissible infectious agents. Under the policy implementation it showed in-part, 1. Standard precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. Under the procedure it showed in-part, 1. Hand hygiene . d. Wash hands after removing gloves. 2. Gloves .e. Change gloves, as necessary, during the care of a resident to prevent cross contamination from one body site to another site (when moving from a dirty site to a clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 11 of 12 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 145219 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burgess Square Healthcare Ctr 5801 South Cass Avenue Westmont, IL 60559 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 site) . g. Remove gloves promptly after use, before touching non-contaminated items and Level of Harm - Minimal harm or potential for actual harm environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Residents Affected - Some 3. On 11/13/23 at 11:55 AM, V22 (CNA/Certified Nursing Assistant) took R316's food tray into her room and adjusted his bedside tray table, moved a brown drink in a clear container, and exited the room without performing hand hygiene. V22 then went to the food tray tower and took two more food trays. V22 took both of those trays into R67's room. V22 put one tray on R67's bedside table and adjusted it. V22 did not perform hand hygiene. V22 then took the remaining food tray into R317's room, grabbed the bedside table and placed the food tray on it. V22 then put on gloves and emptied R317's urinal. V22 took off his gloves and came out of the room, without performing hand hygiene. V22 then went to the food tray tower pulled the R33's tray out to look at ticket, the cup of fruit cocktail was on the ticket, and V22 moved the fruit cocktail with his un-sanitized hands. V22 stated he didn't know the answer to whether he should perform hand hygiene between passing food trays and after emptying a urinal. V22 stated he is new to the facility, but would go ask the nurse and get back to the surveyor with an answer. On 11/13/23 at 12:02 PM, V22 (CNA) returned and stated he asked the nurse, and she said he should have hand sanitized. V22 stated he believes he had training on infection control and hand hygiene, but he probably forgot he needed to perform hand hygiene. On 11/13/23 at 12:14 PM, V22 (CNA) came out of bathroom with R84, and did not perform hand hygiene when he exited the room and before going into R316's room to turn off the light on a panel inside the room. V22 stated he should have performed hand hygiene after leaving R84's room and before touching anything in R316's room. On 11/15/23 at 2:20 PM, V2, Director of Nursing/DON stated during food tray pass, the staff should perform hand hygiene after passing trays and before entering another resident's room. V2 stated staff should perform hand hygiene after coming into contact the resident's environment. V2 stated after emptying a urinal or providing activities of daily living (ADL) care, staff should perform hand hygiene, preferably washing their hands with soap and water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 12 of 12