Health inspection·February 11, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some re-opened the investigation. The report shows small charges from a vending machine were made to the missing credit card on 2/1/25, 2/2/25, and 2/3/25. Utilizing the credit card charge times, the facility was able to identify a temporary agency employee that worked all the shifts and units where the missing credit cards were reported. The facility also confirmed a charge was identified to have taken place at a restaurant 0.7 miles from the temporary agency employee's home address. The facility immediately notified the temporary agency and the police investigating the original theft reports. Final Reportable, dated 2/3/25, shows R1 had a recent hospital stay and on 1/30/25, R1 received a text message from her credit card company asking her to verify a purchase at a convenience store for $11.00. R1 checked her bank account and identified a fraudulent charge attempt on her account. R1 contacted her daughter V3 (Family) who contacted V1 (Administrator) to assist R1 in canceling her credit card. V1 assisted R1 in canceling her credit card and began a facility investigation. R1 searched her purse and identified her credit card as missing. V1 assisted R1 in filing a police report. During the investigation, three additional residents on the 500 unit reported missing credit cards or small amounts of cash, and one resident located on the 2500 unit. An additional police report was made to include the additional information of missing items. During the investigation, the facility reviewed staffing and identified one staff who worked both units in the time frame of the missing items. Review of the employee's work history showed the employee worked 1/21/25-1/28/25 but did not show up for her scheduled shift on 1/31/25 and 2/1/25 resulting in automatic termination. Final reportable shows the facility reviewed the hiring of the employee and a criminal background check was conducted prior to hire and was clear. The healthcare registry form was reviewed prior to hire and the staff was eligible to work as a CNA. The residents were reimbursed any missing cash and the missing credit card was deactivated. Residents were encouraged to send valuable items home with trusted family or friends. If residents wish to keep their valuable items they have the option of having it locked up in a secure closet in the administrator office. Residents do continue to have the choice of keeping valuables with them at the bedside if they choose. Review of facility staffing schedules, dated 1/19/25 to 2/2/25, show V4 worked caring for R1-R4 during her worked shifts. 2. Face sheet, dated 2/10/25, shows R2's diagnoses include fracture of greater trochanter of left femur, fracture of third lumbar vertebra, falls, hypotension, chronic obstructive pulmonary disease, respiratory failure, asthma, polyneuropathy, sick sinus syndrome, anemia, takotsubo syndrome, rheumatoid arthritis, and depression. MDS, dated [DATE], shows R2's cognition was intact. On 2/10/25 at 1:44 PM, R2 stated on 2/3/25, she checked her bank account to look for a charge she was expecting. R2 stated she noticed there were approximately nine charges on her account that she did not recognize, including some that she was told by the credit card company were vending machine charges. R2 stated she called the bank to report the fraud, and also reported it to the Administrator. R2 stated when she looked in her purse, she was missing a cash card and another credit card. R2 stated she was also missing $40. R2 stated she was as admitted to the facility on [DATE] and kept her purse in the top drawer in her room. R2 stated she provided V1 with the time and amounts of the fraudulent charges and the following day she received a text from the credit card company that another fraudulent charge of $125 was attempted at a gas station on her credit card which was blocked by the company. R2 stated there were four unauthorized charges on 2/1/25, four unauthorized charges on 2/2/24, and one more unauthorized charge on 2/3/25 for vending machine food she believed was here at the facility. R2 stated she provided the times of the charges to V1 so V1 could check the cameras by the vending machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 2 of 4 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 02/11/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Progress note, dated 2/4/25, shows, Pt (patient) reported to Writer that her credit card, bank card and $40.00 was stolen from upstairs. Write reported it to AM supervisor and Administrator. Resident grievance, dated 2/4/25, shows R2 was missing a debit card, credit card, and two $20 bills from her purse. Residents Affected - Some 3. Face sheet, dated 2/10/25, shows R4's diagnoses include urinary tract infection, acidosis, hypo-osmolality and hyponatremia, anemia, muscle weakness, diabetes, hypertension, and Norwalk virus. MDS, dated [DATE], shows R4's cognition was intact. On 2/10/25 at 2:10 PM, R4 stated on 2/2/25 R4 looked in her purse and discovered she was missing one credit card and $48.00 in cash. R4 stated she reported the missing items items to the facility and to the police. R4 stated she discovered the following unauthorized charges on her credit card: 1/28/25 Four snack vending charges - $1.10, $1.10, $1.10, $1.85 1/31/25 Uptown Smoke Zone $61.16 1/31/25 Windy City Gyros $28.74 2/1/25 Three $5.00 snack vending charges Grievance, dated 2/2/25, shows R4 reported she was missing her credit card and $48 dollars from her wallet. 4. Face sheet, dated 2/10/25, shows R3's diagnoses include intertrochanteric fracture of right femur, fall, diabetes, heart failure, depression, and osteoporosis. MDS, dated [DATE], shows R3's cognition was intact. On 2/10/25 at 1:30 PM, R3 stated after she heard her roommate, R4, had items stolen, she asked staff to look in an envelope in her drawer where she was keeping $43.00 and the staff found her money was missing from the envelope. R3 stated the night prior, she was resting in bed and groggy when her roommate, R4, was assisted to the bathroom by a staff member. R3 described the staff member as Caucasian, tall, slim with a slim face, and had tattoos on her arm. R3 stated after she helped R4 to the bathroom, the staff pulled the curtain between the resident beds and R3 heard the staff member rummaging in the dressers between the resident beds. R3 stated the room was dark and the curtain was drawn so she did not see the staff take anything, but R3 stated it was odd she was rummaging through the dressers while R4 was in the bathroom. R3 stated it was the next day she and R4 discovered there were items missing from their room. Grievance, dated 2/2/24, shows R3 reported missing $43 as of 2/1/25. 5. On 2/11/25 at 9:34 AM, V1, Administrator, stated she was contacted by a nursing supervisor who reported R6 was contacted via text by V4. V1 stated V4 told R6 she was experiencing personal hardships and was in need of money. V1 stated she reported the contact to the police. On 2/11/25 at 11:53 AM, screen shots of text messages between R6 and V4 show V4 told R6 she needed $300 because she was being evicted due to being fired, her spouse beat her, her son was taken by her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 3 of 4 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 02/11/2025 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mother in law, her family will not communicate with her, and she needed help to stay at her residence or return to her home state. Resident statement, provided 2/10/25, shows V4 provided R6 her personal cell phone number after telling R6 that V4's child was ill. The statement shows R6 later texted V4 to ask how her child was doing and V4 responded asking for $300. Employee statement, dated 2/10/25 by V5 (Nurse), shows V5 was passing medication when R6 showed her text messages from V4 and V5 reported the messages immediately after instructing R6 to block the number and not respond. Facility document, dated 2/10/25, shows R1 experienced five fraudulent transactions totaling $253.70, R2 experienced nine fraudulent transactions totaling $13.70 and $40 cash taken, R3 experienced $43 cash taken , and R4 experienced eight fraudulent transactions totaling $158.05. Facility Abuse Prevention Program Policy and Procedure, dated 2012, shows Resident are to be free from . misappropriation of resident property . and all times. Misappropriation of Property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Examples include, but are not limited to, stealing cash or property; misuse of checks, credit cards, or accounts; forgery of a signature; identity theft. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145219 If continuation sheet Page 4 of 4