Inspection·September 27, 2024

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few also hung it on 9/24/24. V4 said she cleaned the hub of the PICC (Peripherally Inserted Central Catheter), flushed it with 10 ML (Milliliters) of normal saline, checked for blood return, and hung her antibiotics. At 1:04 PM, V4 disconnected the IV tubing from the hub, wiped the hub with an alcohol wipe, and flushed 10 ML of normal saline. 3. On 9/24/24 at 10:16 AM, R321 had a PICC line on the right arm and the dressing was clean, dry, and intact. On 9/25/24 at 9:54 AM, R321 had a bag of Sodium Chloride IV fluids running at 80 ML/Hour. On 9/25/24 at 12:26 PM, V4 said she hung R321's Sodium Chloride maintenance fluids around 9:45 AM, and signed it off in the MAR after she started it. R321 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following surgery on the digestive system and adjustment and management of vascular access device. R321's MDS (Minimum Data Sheet). dated 9/13/24, showed R321 was cognitively intact. R321's POS (Physician Order Sheet) showed an order, dated 9/7/24, for central/midline care to the right upper extremity, and an order for one liter of Sodium Chloride started on 9/25/24. R321's September 2024 MAR (Medication Administration Record) showed R321 was given Sodium Chloride by V4 on 9/25/24 at 10 AM. On 9/26/24 at 1:55 PM, V24 (LPN) said she does not hang IV's because she is an , and they were not allowed to. V24 said if she had a resident with an IV, she would ask an RN (Registered Nurse) to hang the IV antibiotic. The facility's document titled Job title: LPN states the LPN performs various patient test and administers medications within the scope of practice and requires knowledge and skills related to medical/operational systems to successfully maintain excellent nursing care. The facility's Central Vascular Access Device (CVAD) Flushing and Locking policy (revised 6/1/21) states the nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. The National Library of Medicine article titled Nursing Advance Skills dated 2023 said a midline is a long and deep peripheral catheter inserted in the veins of the upper arms, not a short intravenous catheter inserted by a percutaneous venipuncture into a peripheral vein. The Illinois Nurses Act (section 1330.240) amended on June 14, 2019, shows the scope of practice for LPNs which does not include initiating the administration of IV medications through a midline (long peripheral catheter) or central lines, nor reconstituting IV antibiotic medication solutions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 2 of 17 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 09/27/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 3. On 09/25/24 at 09:27 AM, R45 was sleeping in his bed. An unsecured portable oxygen tank was on the floor on the left side of his dresser across his bed. It did not have any holder to prevent the tank from tipping over. R45's portable oxygen tank was full. R45 shared the room with R26. R45's room was near R41 and R84's room. On 9/26/24 at 11:39 AM, V2 (DON-Director of Nursing) said, Portable tanks are stored in 2200 hallway of the facility. Portable tanks are also stored and secured behind resident's wheelchair. Portable oxygen needs to be secured for safety reasons and so they will not tip over and blow up. The facility's Oxygen Management Policy and Procedure, dated 4/22/2015, documented the following: If the resident uses oxygen, a portable container may be kept in the room. The portable oxygen container should be protected from falling over when not in use. Based on observation, interview, and record review, the facility failed to safely reposition a resident and failed to secure oxygen tanks to prevent them from falling and combusting. This applies to 9 of 9 residents (R14, R2, R32, R371, R379, R26, R41, R45, and R84) reviewed for accidents and supervision in a sample of 31. The findings include: 1. R14 was re-admitted to the facility on [DATE], with diagnoses including Parkinson's disease, dementia, muscle weakness, altered mental status, osteoporosis, malignant melanoma of skin, and history of falling. R14's MDS (Minimum Data Set) was not available, but the Significant Change Assessment completed on 9/20/24 showed R14 had moderate cognitive impairment. R14's GG Assessment, dated 9/23/24 showed R14 was dependent on staff for all activities of daily living. On 9/25/24 at 3:23 PM, V8 (CNA/Certified Nurse Assistant) came to R14's room to assist V13 (Wound Care Nurse) and V14 (Wound Care Nurse) with fixing R14's bed height. R14 was lying in bed and the head of the bed was elevated, and R14's upper body was leaning towards the left side. V8 fixed R14's bed, and then came around to R14's right side, and pulled the resident by the upper arm, by placing her hands under his armpit to straighten him out. V8 did not ask V13 or V14 to assist with repositioning R14. On 98/25/24 at 3:51 PM, V8 (CNA) said she should not have pulled R14's arm, and should have asked for assistance to reposition R14. V8 said she should have used the draw sheet and pillows to reposition R14. V8 said the resident could have been bruised by the way he was pulled. On 9/25/24 at 3:23 PM, V14, who had observed V8 reposition R14, said V8 should not have pulled R14 and should have asked for assistance to help reposition him. On 9/25/24 at 3:48 PM, V12 (CNA) said, To reposition a resident, you ask for help by using a draw sheet to straighten them out. Staff should not pull the resident by their arms because the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 3 of 17 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 09/27/2024 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 0689 are often fragile, and it could break their arm. Level of Harm - Minimal harm or potential for actual harm On 9/25/24 at 3:55 PM, V9 (CNA) said if a resident was leaning, she would not pull the resident, but would use other staff assistance and a draw sheet. Residents Affected - Some On 9/25/24 at 3:58 PM, V10 (OT/Occupational Therapist) said staff should use the draw sheet to prop the resident up and V11 (PTA/Physical Therapist Assistant) said he would use the draw shift as well, and then use pillows to prop them up. V10 and V11 said the staff should not be pulling the resident to straighten them out. On 9/25/24 at 4:06 PM, V2 (DON/Director of Nursing) said V8 should have repositioned R14 gently, with two staff assistance because R14 required maximal assistance from staff. V2 also said the staff should have used the draw sheet. The facility's Repositioning Policy, revised May 2013, showed, Use two people and a draw sheet to avoid shearing while turning or moving the resident up in bed. 2. The Electronic Medical Record (EMR) showed R32 had diagnoses of acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease. R32's Order Summary Report, dated 9/26/2024, showed an order for oxygen via nasal cannula 4-8 LPM (liters per minute). On 9/24/2024 at 12:30 PM, there were two metal oxygen tanks at the entrance of R32's room. The oxygen tanks were not secured in a holder to prevent them from tipping over. On 9/25/2025 at AM 9:03 AM and 9/26/2024 at 9:00 AM, the oxygen tanks were still in the same location and not secured in a holder. On 9/26/204 at 9:05 AM, V18 (Respiratory Therapist/RT) said the oxygen tanks should not be placed directly on the floor for safety. V18 said oxygen tanks should be placed on oxygen holders to prevent them from tipping over. On 9/24/2024, 9/25/2024, and 9/26/2024, R14's room was in close proximity to R379, R2, and R371's rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 4 of 17 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 09/27/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide proper catheter care, secure catheter tubing placement, and safely anchor the catheter drainage bag. This applies to 2 of 3 (R374 and R45) reviewed for urinary catheters in a sample of 31. The findings included: 1. The EMR (Electronic Medical Record) showed R374 had diagnoses of urinary retention and urinary tract infection. R374's EMR continued to show she required the use of an indwelling catheter. R374's MDS (Minimum Data Set), dated 9/2/2024, showed R374 was incontinent of bowel and dependent on facility staff for toileting hygiene care. On 9/25/2024 at 9:15 AM, V26 (Certified Nurse Assistant/CNA) was rendering toileting care to R374 after having a bowel movement. V26 did not provide catheter care to R374. V26 then assisted R374 into her wheelchair and placed her catheter drainage bag on the floor. On 9/25/24 at 3:20 PM, R374 was in bed with her catheter's drainage bag loosely hanging over the right side of her bed not secured. V19 (CNA) was asked to provide catheter care to R374. R374's catheter tubing was located underneath her right thigh, and the tubing contained urine. V19 turned R374 on her left side, which caused her catheter to pull to the right side. V19 proceeded to provide catheter care. V19 wiped R374's catheter with multiple upstrokes towards R374's urethra, and then downstrokes using the same wipe. V19 then said she would change R374's incontinence brief because it was stained with yellow fluid drainage. Then when V19 was done rendering incontinence care, she left R374's catheter tubing placed underneath her right thigh, and drainage bag unsecured hanging over the right side of the bed. 2. The EMR showed R45 had diagnoses of urinary retention, neuromuscular dysfunction of the bladder, and urinary tract infections. R45's EMR continued to show he required the use of an indwelling catheter. R45's MDS, dated [DATE], showed R45 was incontinent of bowel and dependent on facility staff for toileting hygiene care. On 9/25/2024 at 4:15 PM, R45 was in bed. V12 (CNA) was asked to provide catheter care to R45. V12 proceeded to render catheter care to R45. V12 used one wet washcloth to clean R45's catheter. V12 cleaned the catheter with multiple upward and downward strokes. Then V12 used the same washcloth to clean R45's penis area and scrotum, and then again cleaned R45's catheter with the same washcloth. On 9/26/2024 at 12:00 PM, V2 (Director of Nursing/DON) said catheter care should be provided every shift and during incontinence care. V2 said catheters for male and female residents should be cleaned by wiping them down, away from the urethra. V2 said catheter drainage bags should not be placed on the floor and should be safely secured not hanging loosely. V2 continued to say catheter tubing should also be checked to ensure they are not kinked, and residents should not be lying on top of the tubing to prevent obstruction. V2 said she expects nursing staff to provide proper catheter care for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 5 of 17 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 09/27/2024 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 0690 infection control and to provide proper hygiene care. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Urinary Catheter Care Policy and Procedure, dated 9/18/2019, showed, The purpose of this policy to ensure the safe insertion of catheters to prevent resident injury and reduce the risk of catheter-related infections .Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks .Infection Control .2. Maintain a clean technique when handling or manipulating the catheter, tubing, or drainage bag .Routine hygiene .Be sure the catheter tubing and drainage bag are kept off the floor . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 6 of 17 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 09/27/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to verify Percutaneous Endoscopic Gastrostomy tube (PEG tube) placement prior to administering medications through PEG-tube and failed to properly administer water flushes and medications via the G-tube. This applies to 1 of 1 resident (R171) reviewed for medication administration via PEG-tube in a sample of 31. The findings include: R171's Physician Order shows the following orders: PEG tube three times a day flush 30 cc (ml) prior to med admin, 10-15 cc between each med flush, 30 cc flush post med admin. Potassium Chloride Oral Solution 20MEQ/15 ML (10%) give 15 ml via PEG tube one time a day for supplement. On 9/25/24 at 9:00 AM, V15 (Registered Nurse/RN) went to R171's room to administer his morning medications via the PEG-tube. V15 placed a stethoscope on R171's abdomen injected 30ml (milliliters) of air using the piston syringe through the port. V15 used the stethoscope to auscultate to check for PEG-tube placement. V15 failed to check the gastric content. V15 flushed R171's PEG-tube with 60 ml of water before administering medications, flushed with 20 ml of water in between each medication, and flushed with another 60 ml of water after administering medications. V15 failed to dilute liquid Potassium Chloride prior to administering it via the PEG-tube. On 9/26/24 at 10:15 AM, V2 (Director of Nursing/DON) said nurses check G-tube placement by pushing air in PEG-tube and auscultating or by measuring the tube. V2 said the nurse should follow the physician order for water flushes and liquid potassium should be diluted with 4 to 8 ounces of water to prevent gastrointestinal irritation. The facility's Manufacturer's Guideline for Potassium Chloride Oral Solution 20MEQ/15 ml states to dilute prior to administration. Warnings and Precautions: Gastrointestinal Irritation dilute before use. The facility's Administering Medications through an Enteral Tube (3/16/22) states to verify placement of feeding tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 7 of 17 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 09/27/2024 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 residents' PICC (Peripherally Inserted Central Catheter) dressings, measure arm circumferences, and external catheters as ordered for intravenous catheters. Residents Affected - Few This applies to 2 of 4 residents (R374 and R424) reviewed for intravenous catheters in a sample of 31. The findings include: 1. On 9/24/24 at 10:37 AM, R424 had an intravenous (IV) PICC catheter to right upper arm. R424's PICC line catheter had transparent dressing, with no date; the bio-patch dressing, and butterfly outer catheter was covered in dry blood, dressing was soiled. On 9/25/24 at 10:55 AM, R424's PICC line dressing still soiled with dry blood. R424's Physician Order states PICC line (single lumen) care to right upper extremity one time a day every Friday and as needed, dressing change and change of caps. 2. The Electronic Medical Record (EMR) showed R374 had diagnoses of discitis of the lumbar region and urinary tract infection. R374's EMR showed R374 was receiving daily IV antibiotic therapy for her infections via her right upper arm PICC. R374's Order Summary Report, dated 9/26/2024, showed an order for PICC LINE care to RUE one time a day every Fri and prn, measure arm circumference, external catheter measurement, dressing change, and changing of caps. On 9/25/2024 at 9:15 AM, R374 had an intravascular central catheter (PICC) to her right upper arm. R374's PICC line had a transparent dressing, dated 9/18/2024. On 9/26/2024 at 9:39 AM, R374 had the same transparent dressing, dated 9/18/2024. On 9/26/2024 at 11:40 AM, V2 (Director of Nursing/DON) said central venous catheter dressings should be changed every 7 days or if soiled, and dated for infection control prevention. V2 said she expects nurses to be assessing PICC line dressing routinely. V2 said R374's PICC line dressing was not changed because she went to the hospital, and when she returned it was missed. The facility's Central Vascular Access Device (CVAD) Dressing Change, dated 6/01/2021, showed, 1. Central vascular access devices (CVADs) included: 1.1 Peripherally inserted central catheter (PICC) .2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection .Guidance: 1. Perform sterile dressing changes using Standard-ANTT: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean, dry and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label 1.1.1.1 Upper arm circumference with PICC, and external catheter length measurements must still be completed as part of the initial assessment 1.2 At least weekly 1.3 If the integrity of the dressing has been compromised (wet, loose, or soiled) .7. Assessment of the vascular access site is performed .7.3 Before and after administration of intermittent infusions 7.4 At least once every shift when not in use .8. Assessment of indwelling vascular access insertion site, an entire arm with PICC, for infusion related complications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 8 of 17 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 09/27/2024 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 is to include .8.2 Drainage 8.6 Integrity of transparent dressing . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 9 of 17 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 09/27/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based in observation, interview, and record review, the facility failed to get an order for oxygen for a resident receiving oxygen. Residents Affected - Few This applies to 1 of 1 resident (R322) reviewed for oxygen administration in a sample of 31. The findings include: R322 was admitted to the facility on [DATE], with diagnoses including hypertensive encephalopathy, type 2 diabetes mellitus, dementia, hypertension, constipation, osteoarthritis, gait and mobility, cognitive communication deficit, need for assistance with personal care, and history of falling. R322's admission Social History Progress Note, dated 9/20/24, showed R322 had moderate cognitive impairment. R322's POS (Physician Order Sheet), dated 9/26/24 at 2 PM, did not show an order for oxygen administration. On 9/24/24 at 11:22 AM, R322 was lying in bed and was receiving between 3.5 to 4 liters of oxygen via the nasal cannula. On 9/25/24 at 10:07 AM, R322 was wearing oxygen via the nasal cannula, and she was still receiving between 3.5 to 4 liters of oxygen. On 9/26/24 at 1:46 PM, V16 (LPN/Licensed Practical Nurse) said residents who are on oxygen need an order. V16 said R322 was receiving oxygen. V16 checked R322's POS (Physician Order Sheet) and said V16 did not have an order for oxygen. On 9/26/24 at 12:12 PM, V2 (DON/Director of Nursing) said when residents are receiving oxygen should have an order from the physician. R322's oxygen saturation vitals showed R322 required and had been receiving oxygen from 9/19/24. The facility's Oxygen Management Policy and Procedure, dated 4/22/15, showed, All residents that receive oxygen in the facility will have a physician order that designates the number of liters the resident should receive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 10 of 17 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 09/27/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to verify the counting logs accuracy for residents with controlled medications, and failed to dispose of controlled medications per facility policy. Residents Affected - Few This applies to 2 out of 2 (R377 and R378) residents reviewed for control medications in a sample of 31. Findings include: 1. R377's Order Summary Report, dated 9/26/2024, showed an order, dated 9/23/2024, for Alprazolam Oral Tablet 0.25 MG (Alprazolam) give 0.5 tablet by mouth every 12 hours as needed for anxiety. On 9/25/2024 at 3:46 PM, V22 (Licensed Practical Nurse/LPN) was asked to review the controlled box for storage in the 300-hall medication cart. R377's Controlled Substances Proof of Use sheet was stored inside the controlled box (not in the cart's narcotic control counting log binder), and had two tablets in separate individualized packages stapled to the sheet. One package was sealed with one whole tablet, and the other package that was not sealed had a cut half tablet that was loose. The packages said they contained Alprazolam 0.25 mg (milligrams) tablets. R377's Controlled Substance Proof of Use sheet, dated 9/21/2024, did not indicate the name of the medication, dosage, nor the medication order administration instructions. 2. R378's Controlled Substance Proof of Use sheet was stored inside the controlled box in the 300-hall medication cart (not in the cart's narcotic control counting log binder). R378's sheet had one tablet in an individualized package stapled to the sheet, which said it contained Tramadol 50 mg. R378's Controlled Substance Proof of Use sheet, dated 8/20/2024, did not indicate the ordered medication administration instructions. R378's Order Summary Report, dated 9/26/2024, did not show an active order for Tramadol. V22 (Licensed Practical Nurse/LPN) was present during R377 and R378's observations. V22 said they frequently pre-pull controlled medications from the facility's narcotic convenience box to have them available if needed for new admissions. V22 was not able to explain why the Controlled Substance Proof of Use sheets were not in the cart's narcotic control counting log binder. On 9/26/2024 at AM, V2 (Director of Nursing/DON) said, All individualized Controlled Substance Proof of Use sheets should be kept inside the narcotic control sign-off binder to ensure all controlled medications are accurately accounted for. The Controlled Substance Proof of Use sheets should have proper documentation to ensure the safety and correct administration of controlled medications. Controlled medications should be obtained from the facility's convenient controlled box at the time they are needed, not pre-pulled. Opened controlled medications should be disposed of accordingly and not be placed back into the package once open to prevent diversion. The facility's policy titled Controlled Substance Policy and Procedure, dated 12/2022, showed, The facility shall comply with all laws, regulations, and other requirements related to handling, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 11 of 17 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 09/27/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete storage, disposal, and documentation of s II and other controlled substances .If the count is correct, an individual resident controlled substance record must be made for each resident who will be receiving a controlled substance .This record must contain .The name and strength of the medication; quantity received .Name of physician; Prescription number; Name of issuing pharmacy .When a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tables or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container. Nursing staff must count controlled medications at the beginning and end of each shift .They must document and report any discrepancies to the Nurse Manager . Event ID: Facility ID: 145219 If continuation sheet Page 12 of 17 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 09/27/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safely store medications. This applies to 5 of 5 residents (R373, R171, R425, R272, and R274) reviewed for medication storage in the sample of 31. Findings include: 1. R373's Oder Summary Report, dated [DATE], showed orders for Mirabegron ER (extended-release) 50 mg (milligrams) daily for stress incontinence, Sertraline 100 mg daily for anxiety, and Wellbutrin XL (extended-release) 300 mg daily for depression On [DATE] at 3:46 PM, V22's (Licensed Practical Nurse/LPN) medication cart was checked for medication storage. V22's cart had 3 pills that were loose in an unlabeled clear medication cup. V22 said her shift had just started, and she was not sure whose medications they were, nor what the pills were. V22 said opened and unlabeled medications should have been stored inside the medication cart. On [DATE] at 12:00 PM, V2 (Director of Nursing/DON) said R373's morning nurse on [DATE] prepared her 9 AM medications, but forgot to administer them, and stored them in the medication cart. V2 said she expects nurses to prepare medications at the time they are being administered. V2 continued to say medications removed from their original packages should not be stored in the medication cart once opened to ensure safe medication storage and administration. 4. On [DATE] 11:52 AM, R272 had an unlabeled tube of glucose tablets on top of his bedside table, and another tube of glucose tablets on his nightstand on the left side of his bed. He said he self-administers it when he sees his blood sugar level is low. R272 had an unlabeled Ipratropium Bromide Nasal Solution 0.03% on top of his bedside table. He said he self-administers it twice a day, one to two sprays to each nostril every morning and every evening. R272 had an unlabeled tub of Hemp EMU relief cream on the windowsill on the right side of his bed; he said he administers it to himself and applies it on his thighs when it hurts as needed. All medications are unlabeled. On [DATE] at 9:54 AM, same unlabeled medications were observed on his bedside table. Review of R272's POS (Physician Order Sheet) showed no order to keep medication by bedside. There were no orders for glucose tablets, Ipratropium Bromide Nasal Solution 0.03%, and Hemp EMU relief cream. 5. On [DATE] at 11:35 AM, R274 had Cortizone-10 cream on her bedside table that was in front of her. It was not labeled. She said she applies it herself to her arms when it itches. Review of R274's POS showed no order for medication at the bedside and no order for Cortizone-10. On [DATE] at 11:39 AM, V2 (DON-Director of Nursing) said, Currently, there are no residents in the facility that have an order to have medication by the bedside and order to self-administer medication. Before an order for medication by the bedside and order to self-administer is obtained, assessment needs to be done to determine if resident is competent. If resident is competent, order is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 13 of 17 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 09/27/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm obtained, resident is given a lock box with a key to store the medication in. The resident is given a sign out sheet to document when they take medication so nurses can check it. If family brings in medication from outside, they are instructed to give it to the nurses, and nurses administer it as house stock if there is an order. All medications should be kept under lock and key with the nurse. If there is no order for medication, nurses should call family to inform them that medication will be returned to family or disposed. Residents Affected - Some The facility's policy titled Storage of Medications, dated 11/2020, showed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . The facility's policy titled Administering Medications, dated 12/2017, showed, Medications shall be administered in a safe and timely manner, and as prescribed .3. Medications must be administered in accordance with the orders, including any required time frame . 2. On [DATE] at 10:45 AM, there was a bottle of generic eye drops, Clear Eyes Triple Relief on R425's bedside table. There was a Ventolin HFA (Hydrofluoroalkane) Albuterol Sulfate Inhalation Aerosol inhaler, and two tablets of Children's allergy medication, expired 02/2023, in a clear bag on R425's bedside dresser. At 12:12 PM, R425 said she uses the eyedrops when her eyes gets dry, and she uses the inhaler because she has asthma and COPD (Chronic Obstructive Pulmonary Disease). Review of R425's physician order shows an order for Albuterol Sulphate Inhalation Aerosol Powder Breath Activated 108 (90 base) mcg, 2 puff inhale orally every four houses as needed for wheezing and shortness of breath. There is no order for the Children's allergy medication, eye drops or to have medications stored at the resident room. 3. On [DATE] at 8:50 AM, during medication pass, there was ampule of Ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5 mg/3 mg (milligram) on R171's bedside table. R171 also pointed to Spiriva Respimat Tiotropium Bromide Inhalation inhaler on the bedside dresser. R171 told V15 (Registered Nurse/RN) that his daughter brought it because the facility did not have it in stock. V15 said the nebulizer treatment and the inhaler should not be in the resident's room. Review of R171's physician orders shows order for Ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5 mg/3 mg; there was no order for Spiriva Respimat Tiotropium Bromide Inhalation inhaler or to have medications stored in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 14 of 17 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 09/27/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control practices for residents on transmission-based precautions. Residents Affected - Some This applies to 5 of 5 residents (R325, R324, R62, R45, R374) reviewed for infection control in a sample of 31. The findings include: 1. R325 was admitted to the facility on [DATE], with diagnoses including urinary tract infection, cellulitis of right lower limb, severe dementia, and need for assistance with personal care. R325's POS (Physician Order Sheet) showed R325 had an order for contact isolation for a diagnosis of MDRO (Multi-Drug Resistant Organism) urine. R325's admission Social History Progress Note, dated 9/25/24, showed R325 was cognitively intact. On 9/26/24 at 10:15 AM, R325's room door had a sign showing she was on contact precautions. R325 had an isolation bin outside her room with gowns, masks, face shields, red bags, and blue bags. V5 (CNA/Certified Nurse Assistant) was in R325's room with no gown on, and said she was providing R325 patient care and was finishing providing a bed bath for the resident. On 9/26/24 at 1:40 PM, V5 said R325 was on isolation for burns and so the CNAs and nurses needed to wear PPE (Personal Protective Equipment) such as a gown, gloves, and a mask to go into the room. On 9/26/24 at 1:46 PM, V16 (LPN/Licensed Practical Nurse) said for residents on contact isolation, the staff should wear a gown, gloves, and optionally could wear a mask. V16 said the PPE (personal protective equipment) is worn to protect themselves as well as the patient. V16 said any part of the staff body that could touch the resident should be covered. On 9/26/24 at 1:55 PM, V24 (LPN) said the staff should wear a gown and gloves to go into contact isolation rooms. On 9/26/24 at 12:12 PM, V2 (DON/Director of Nursing) said for residents on contact precautions, the staff should wear gowns and gloves if they are going into contact precaution rooms. The facility's Policy and Procedure for the Prevention and Control of Infection Disease Outbreaks, revised on 6/1/21, showed to Implement appropriate isolation precautions (i.e. contact, droplet, etc.). Wear personal protective equipment to include gloves, gown, and mask upon entry to the room and when in contact with the symptomatic resident. The facility's undated Contact Precautions signage showed Put on gown before room entry. 2. R324 was admitted to the facility on [DATE], with diagnoses including an unstageable pressure ulcer of the sacral region, methicillin resistant staphylococcus aureus infection, local infections of the skin and subcutaneous tissue, and extended spectrum beta lactamase resistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 15 of 17 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 09/27/2024 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 R324's Social History Progress Note, dated 9/23/24, showed R324 had moderately impaired cognition. Level of Harm - Minimal harm or potential for actual harm R324's POS (Physician Order Sheet) showed an order, dated 9/24/24, for a new central/midline order and an order for Ertapenem Sodium Injection Solution Reconstituted 1 gram. Residents Affected - Some R324's September 2024 MAR (Medication Administration Record) showed R324 was given Ertapenem by V4 on 9/24/24 and 9/25/24. On 9/24/24 at 11:01 AM, R324's door had signage for EBP (Enhanced Barrier Precautions), and there were gowns located outside of her room. On 9/25/24 at 1:04 PM, V4 (LPN) went to R324's room to disconnect her from her IV (Intravenous) antibiotic administration, and did not apply a gown while providing IV maintenance. On 9/26/24 at 1:46 PM, V16 (LPN) said for residents under EBP, any time the staff was in direct contact with the resident, they are supposed to wear a gown and gloves, including with IV management. On 9/26/24 at 1:55 PM, V24 (LPN) said staff going into resident rooms on EBP should have gloves and a gown on and could choose to wear a mask. 3. R62 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, dementia, hypertension, and atherosclerotic heart disease. R62's MDS (Minimum Data Set), dated 8/30/24, showed R62 was cognitively intact. On 9/24/24 at 12:09 PM, R62's room door had signage for EBP. V7 (Housekeeping) was providing linen change and bed making for R62's bed, and had only a pair of gloves on, no gown. V7 placed the dirty linen directly on the ground, touched R62's bed with the same gloves, picked up the linen off the ground, placed the dirty linen onto the bed, and then grabbed the dirty linen against her clothing and walked out of the room. V7 said R62's room was not under any kind of isolation or precautions. 4. R45's Oder Summary Report, dated 9/26/2024, showed an order for Enhanced Barrier Precautions due to his urinary catheter. R45's Care Plan, dated 9/26/202,4 said R45 had an indwelling catheter and was at risk for infections. The care plan had multiple interventions including Enhanced Barrier Precautions. On 9/25/2024 at 4:15 PM, R45's room door had an Enhanced Barrier signage posted with instructions for staff to apply proper PPE when rendering direct care. V12 (CNA) entered R45's room and applied clean gloves to provide urinary catheter care to R45. V12 did not perform hand hygiene nor applied a PPE gown. V12 proceeded to render urinary catheter care to R45. On 9/26/24 at 10:29 AM, R45's room door had signage for EBP. V23 (Housekeeping) was observed making R45's bed and only had gloves on, no gown. V23 said she changed his bed sheets every day. V23 said R45 was not on any isolation or precautions, and when shown the EBP signage, said only the aide needed to wear a gown and gloves. 5. R374's Order Summary Report, dated 9/26/2024, said an order for Enhanced Barrier Precautions due to her PICC (Peripheral Intravenous Central Catheter) and urinary catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 16 of 17 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 09/27/2024 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 Residents Affected - Some R374's Care Plan, dated 9/26/2024, said R374 was at risk for infections and required enhanced barrier precautions due to her indwelling medical devices. The care plan had multiple interventions including PPE to be worn when caring for the resident to protect themselves and the resident. On 9/25/2024 at 3:20 PM, R374's room door had an Enhanced Barrier signage posted with instructions for staff to apply proper PPE (Personal Protective Equipment) when rendering direct care. V19 (CNA) entered R374's room and applied clean gloves to provide urinary catheter and incontinence care to R374. V19 did not perform hand hygiene nor applied a PPE gown. V19 proceeded to render urinary catheter and incontinence care to R374. On 9/26/2024 at 12:00 PM, V2 (Director of Nursing/DON) said staff are expected to wear proper PPE when entering rooms with transmission-based precautions and when providing high-contact care for residents under enhanced barrier precautions. V2 said high-contact activities where PPE was required for those under enhansed barrier precautions included intravenous catheter care, incontinence care, catheter care, linen changing. V2 said proper use of PPE and hand hygiene needs to be followed to prevent the transmission of infections. The facility's signage titled Enhanced Barrier Precautions said everyone must Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for following High-Contact Resident Care Activities. The signage said high-contact resident care activities included bathing, showering, changing linens, providing hygiene, changing briefs, or assisting with toileting, and device care or use of central lines and urinary catheters. The facility's policy titled Policy and Procedure for Preventing the Spread of Multidrug Resistant Organisms (MDROs), dated 9/1/2022, showed, Patients in nursing facilities are at increased risk of becoming colonized and developing infection with MDROs .This policy and procedure is intended to provide guidance for PPE use and room restriction in nursing facilities for preventing transmission of MDROs. For purpose of this policy, the MDROs for which the use of enhanced based precautions applies are based on organisms targeted by the CDC .Contact Precautions: .Contact Precautions require the use of gown and gloves on every entry into a patient's room .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 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 17 of 17