Health inspection·September 25, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to ensure that residents shower room was free of black substances and failed to ensure that a resident's toilet was in good repair.This applies 16 of 16 residents (R24, R47, R58, R85, R92, R101, R103, R104, R105, R138, R140, R144, R149, R150, R156, and R164) reviewed for homelike environment in the sample of 29. Findings include:1. On September 22, 2025 at 10:20 AM, R58 was in her room alert and oriented and stated that the exhaust fan in the shower down the hall from her doesn't work, and she saw sparks come from it a month ago. R58 stated that there is also mold in the same shower all along the edge of shower. On September 23, 2025 R58 stated she told a Certified Nursing Assistant (CNA) about the mold and the shower but she doesn't know their name. R58 stated the sparks had been there 4-5 months. R58 stated, because the fan hasn't been fixed yet, R58 tells all the staff not to turn on the fan when they help her with a shower. On September 22, 2025 at 10:50 AM, in the shower room down R58's hall, there is a strong musty foul smell odor when you enter the shower room. V33 (CNA) stated each hall on the 2nd floor has its own shower. R58 showed surveyor the 2400 wing shower room. There were small 1x1 inch white tiles in the shower that cover the floor and up to the edges that meet the walls. There was a black substance along the wall and covering caulk and cracks in the tiles. On September 22, 2025 at 10:52 AM, V34 (Housekeeper) stated that he is not assigned to clean that particular shower room and he was not sure what the black substance was. On September 22, 2025 at 11:01 AM, V35 (Director of Maintenance) came into the 2400 wing shower room. V35 turned on the fans. One of the two fan mad a loud screeching sound. V35 went over and looked at it and said that it was broken. Surveyor asked V35 what the black substance was along shower floor and going up the wall. V35 examined the black substance and said, It's mold. I'm not going to lie to you. V35 stated he is responsible for removing mold, but housekeeping is responsible for cleaning the shower room daily. V35 stated someone should have done a work order and V35 would have come up right away and taken care of the mold. V35 stated he has not received a work order for the mold in the shower. On September 23, 2025 at 10:53 AM, V35 stated, he treated the mold yesterday with a specific mold treatment. V35 stated he believed the cause of the sparks that R58 mentioned that were coming from the fan, was the heating element in the fan. R58 stated, he clipped and capped the wires to the heating element in the fan so that shouldn't happen again. R58 stated the fan is very old. The fan was then turned on by V35 and it was still very loud. V35 stated they are going to replace the fan and heating element together. On September 23, 2025 at 3:30 PM, V3 (Assistant Director of Nursing) stated that all the residents that reside in the 2400 wing where R58 reside use the shower in that hall. V3 provided a resident listing report of the residents who use the shower on the 2400 hall and it included the following residents: R47, R58, R85, R92, R101, R103, R104, R105, R138, R140, R144, R149, R150, R156, and R164. 2. On September 22, 2025 at 11:40 AM, R24 was alert and stated his toilet has been leaking urine and water since it was replaced 6 months ago. On September Page 1 of 19 145221 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 22, 2025 at 11:46 AM, V33 (CNA) showed surveyor R24's bathroom where the floor was wet with some slightly brown fluid in front of the toilet and on the right side of the toilet. R24 said to V33, My toilet has been leaking. On September 23, 2025 at 9:09 AM, with V30 (Infection Preventionist) observed R24's bathroom floor was wet in front and on the right side of the toilet. On September 23, 2025 at 2:07 PM, V35 (Maintenance Director) and his only assistant, stated that they had not received any work orders for R24's toilet. On September 24, 2025 at 1:14 PM, V2 (Director of Nursing) stated she expects staff to fill out a maintenance ticket and let the manager know if there is mold in the shower room or a leaking toilet. 145221 Page 2 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a demented male resident from kissing a demented female resident. This applies to 1 of 1 resident (R148) reviewed for abuse in the sample of 29.Findings include: R148's admission record showed her to be a [AGE] year-old female with diagnoses that included unspecified severe dementia with mood disturbances, depression, anxiety and congestive heart failure. R148's Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated July 22, 2025 showed her to be severely cognitively impaired with a BIMS score of zero. R148's care plan showed the following: R148 is disoriented to person, place and time related to dementia diagnosis. R73's admission record showed him to be [AGE] years old with diagnoses that include dementia, bipolar, traumatic brain injury, paranoid schizophrenia. R73'BIMS score of 1, showed him to be severely cognitively impaired. R73 criminal background checks showed he had a history of aggravated domestic battery. On September 23, 2025, at 1:59 PM, R73 walled over to R148 and kissed R148 repeatedly. R148 was seated at a table with two other residents in the dining area. R148 just looked up at R73. V28 (LPN-Licensed Practical Nurse) told R73 to stop and then removed R73 from the area. On September 24, 2025, at 2:18 PM, V26 (Certified Nursing Assistant/CNA) staid she has worked at the facility for over a year and mostly works on the floor where R73 and R148 reside. V26 said that R73 kisses R148 all the time. V26 said that she has never seen R148 initiate a kiss with R73. V26 stated that sometimes R73 will grab R148's head (and she demonstrated on her own head) and force her head to turn with his hand and then kiss her. V26 stated R73 will even go into R148's room and kiss her while she is sleeping. V26 stated that they try to separate them but, we were told they are demented and there is nothing we can do. On September 24, 2025 at 2:27 PM, R148 was asked if she knew who R73 was. R148 said, No, Who is that? Tell me who that is. On September 24, 2025 at 2:31 PM, V27 (CNA) stated she doesn't work often up on the floor where R148 and R73 reside but has been up on the floor for the last couple of weeks. V27 stated that she sees R73 kissing R148 and she will stop it when she sees it. V27 stated she has never seen R148 initiate a kiss with R73. V27 stated that R73 is always initiating kissing R148. While V27 and surveyor were talking at the nurse's station, R73 went over to R148 and started kissing her again on the lips. V27 said, there he goes again, and she went over and separated them. On September 24, 2025 at 3:57 PM, V3 (Assistant Director of Nursing) stated that a person with a Brief Interview for Mental Status (BIMS) score of zero would not be able to consent to sexual or intimate contact. On September 24, 2025 at 4:15 PM, V8 (Social Services) stated they do not have an assessment for the ability to consent for intimate behaviors for R148. V8 stated they would just make that determination based on the residents BIMS score.On September 24, 2025, at 9:39 AM, V1 stated that no one had reported any incidents with R73 to her. On September 25, 2025 at 8:47 AM, V1 (Administrator/Abuse Coordinator) stated that R73's behavior of kissing R148 has been going on for longer than a month. V1 stated she will check the notes to see how long it has been going on. She doesn't know from the top of her head. As of September 23, 2025, at 2:27 PM, R148 did not have a care plan that addresses her risk for being abused, nor was there a care plan addressing her being consistently kissed by R73. R148 also did not have an assessment for a risk for vulnerability to abuse. On September 25, 2025, at 11:01 AM, V31 (Nurse Practitioner) stated that R148 is not able to consent to being kissed. Furthermore, neither is R73. V31 stated this is the first time she has ever heard that R73 is kissing R148, and she has been working at the facility for 4 years. R73's point of care behavioral charting showed he was sexually inappropriate on September 9, 2025 (V32 documentation) and September 24, 2025. On September 25, 2025, at 11:49 AM, V32 (CNA) stated the 145221 Page 3 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R73 has a thing where he likes to get up and kiss other residents specifically to R148 and R85. R85's room is near his. V32 stated, R148, R85, and R73 have dementia. I stop them because I know they aren't supposed to be doing that. V32 stated R148 comes out of his room and looks for R148 and when he doesn't find R148 then he goes to R85 and kisses her. V32 stated she has witness R73 kissing residents since she started in December 2024. V32 stated, R73 tries to kiss R148 and or R85 every day she is working on the floor R73 resides. V32 said, V32 believe that R73 is seeking R148 out when he is awake. V32 said R73 wanders throughout the night. V32 stated she has seen him go into to R85's bedroom and another time in the dining room and kissed her. V32 stated she does not believe R148 nor R85 is able to consent to being kissed. The facility's Abuse prevention policy dated October 2023 showed the following: Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property or who have needs and behaviors that might lead to conflict. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. 145221 Page 4 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that updated PASRR (Preadmission Screening and Record Review) referrals were completed when new psychiatric diagnoses were identified after admission.This applies to for 3 of 3 residents (R10, R35, R61) reviewed for PASRR compliance in the sample of 29.The findings include: 1.R61 was admitted on [DATE]. The PASRR Level I, dated October 30, 2023, indicated: No Level II Required - No SMI/ID/RC (Severe Mental Illness/Intellectual Disability/Related Condition.) The rationale stated: There is no evidence of a PASRR condition. If changes occur or new information refutes these findings, a new screen must be submitted.Review of medical diagnosis showed diagnoses of bipolar disorder, Schizophrenia, and Depression were created on November 03, 2025. No updated PASRR referral was completed.The resident's care plan dated March 18, 2025, showed, Resident is an adult living with chronic mental illness. Resident has been screened through the outside screening agency and found to need long-term care placement/services. History includes anxiety. However, anxiety was not listed in the EMR diagnoses, and the PASRR documentation did not reflect the later diagnoses of bipolar disorder, schizophrenia, or depression.Email correspondence dated November 02, 2023, between marketing and admissions specifically requested that a new PASRR be completed prior to November 05, 2023; however, no referral was submitted.2. R10 was admitted on [DATE]. PASRR Level I, dated October 28, 2022, determined 'No Level II Required - No SMI/ID/RC. EMR (Electronic Medical Record) showed new diagnoses: Unspecified Dementia added October 31, 2022, Major Depressive Disorder, recurrent, mild added May 07, 2025, and Dementia in other diseases classified elsewhere added May 12, 2025. Review of the care plan showed no focus, goal, or interventions addressing the new psychiatric/behavioral diagnoses.No updated PASRR referral was submitted following these diagnoses.3.R35 was admitted [DATE]. PASRR Level I, dated February 15, 2023, determined 'No Level II Required - No SMI/ID/RC,' with instructions to submit a new referral if new diagnoses were identified. EMR showed diagnoses of Major Depressive Disorder, recurrent severe and Generalized Anxiety Disorder were entered on January 17, 2024.PASRR documentation did not include these diagnoses or any recommendations for services. An updated PASRR referral was not completed.On September 23, 2025, at 10:37AM with V13 (Medical Records Director) confirmed that PASRR referrals are generated through an outside agency responsible for PASSR screenings when notified by MDS of a new diagnosis. V13 stated she relies on consultants or notification to initiate a new referral.On September 23, 2025, at1: 1:32PM V9 (MDS) confirmed that diagnoses are entered into the EMR (electronic Medical Records) by herself or V20 (Care Plan Coordinator) and that all new diagnoses are communicated in daily meetings attended by department heads, including V13. Despite this process, no updated PASRR referral was initiated for R61, R10, R35. 145221 Page 5 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 assist residents identified as needing assistance with personal hygiene and bed bath or shower.This applies to 6 of 7 residents (R6, R38, R49, R50, R52 and R137) reviewed for ADL (activities of daily living), in the sample of 29.The findings include:1.According to the Electronic Medical Records (EMR), R137 has multiple diagnoses including cerebrovascular disease (Stroke) with right side paralysis affecting dominant side, abnormality of gait and mobility, Alzheimer's disease and dementia. The (MDS) Minimum Data Set, dated [DATE], showed R137 had severe cognitive impairment and required assistance for personal hygiene, and dressing. R137's Care Plan for (ADL) Activities of Daily Living self-care deficit initiated on March 24, 2025, showed R137 requires moderate to maximum assistance with dressing and grooming tasks. Residents Affected - Some On September 22, 2025, at 11:07 AM R137 was sitting in the dining room in her wheelchair. R137's shirt had crumbs of food, and her fingernails had brown and black substances underneath them. On September 22, 2025, at 12:28 PM, V 19 cut up the food when assisting R137 with her lunch tray set up. R137 picked up the chicken and chocolate brownie with her left hand which had brown and black substances underneath the fingernails. On September 23, 2025, at 12:05 PM AM R137 was sitting in the dining room in her wheelchair. R137's fingernails had brown and black substances underneath. 2. Face sheet shows that R52 is 68 years-old who has multiple medical diagnoses including morbid obesity, and muscle wasting and atrophy, not elsewhere classified, multiple sites. R52's Minimum Data Sheet (MDS) dated [DATE], shows R52 is alert and oriented and requires assistance with activities of daily (ADL) care. On September 22, 2025, at 10:35 AM, R52 was resting in bed resting. R52 appear unkempt and disheveled with overgrown, unruly/unkept mustache and beard and long, uneven, jagged, dirty fingernails (with accumulations of black/brown substances underneath his nails). R52 wants his nails clipped but does not want his facial hair trimmed. On September 23, 2025, at 9:36 AM, R52 was resting in bed. R52 remained unkempt and disheveled looking with long dirty fingernails (with accumulated black/brown substances underneath nails) and untidy mustache and beard. The fitted sheet was soiled with debris of dead skin and other unidentified substances. It was also stained with dry yellow substance which V6 (Certified Nursing Assistant/CNA) identified as fluids that were secreting from R52's skin. V6 provided incontinence care to R52 who was wet with urine. R52's skin has multiple clumps of dead skin spread/scattered all over his back and buttocks which V5 (Wound Care Nurse) described as lump of mixed dead skin, sweat, and previous barrier and other treatment cream. 3. Face sheet shows that R50 is 65 years-old who has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R50's Minimum Data Set (MDS) dated [DATE], shows that R50 is alert and oriented and requires assistance with activities of daily living (ADL) care. On September 22, 2025, at 10:56 AM, R50 was in his bedroom. R50 had overgrown facial hair and overgrown, uneven, jagged and dirty fingernails (with black/brown substance underneath fingernails). R50 stated that it's been a while since they last clipped his nails and shaved his facial hair. 145221 Page 6 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On September 23, 2025, at 9:13 AM, R50 was in his room and was noted with overgrown facial hair and long, jagged, uneven, dirty fingernails. On September 24, 2025, at 3:53 PM, R50 remained with overgrown, uneven, jagged, dirty fingernails. R50's facial hair was shaven, he stated that they gave him a shower earlier, however, they did not clip his nails. R50 said wants his nails clipped. V29 (CNA) confirmed that it needed to be clipped. On September 25, 2025, 09:56 AM V2 [NAME] (DON) stated that bed bath and shower are provided twice a week and as needed to keep resident clean and comfortable. This shower and bed bath also include nail care and facial hair care (shaving, trimming, cleaning). 4. R38 had multiple diagnoses including, Parkinson's disease without dyskinesia and without mention of fluctuations, and muscle wasting and atrophy, based on the face sheet. R38's quarterly MDS dated [DATE], showed that the resident was cognitively intact and required assistance with personal hygiene. On September 22, 2025 at 11:51 AM, R38 was in bed, alert and oriented. R38's fingernails were long with black substances under some of the nails. R38 stated that she wants the staff to trim and clean her fingernails. On September 23, 2025 at 9:37 AM, R38 was in bed, alert and oriented. R38's fingernails were long with black substances under some of the nails. In the presence of V2 (Director of Nursing), R38 stated that she wants the staff to trim and clean her fingernails because it looks very nasty. According to R38 she had requested the staff multiple times for nail care assistance, but no one listened to her request. V2 acknowledged that R38 requires the assistance of the staff for nail care because the resident's fingernails were long with black substances under the nails. R38's active care plan in place last revised on May 21, 2025 showed that the resident has ADL self-care deficit. The same care plan showed multiple interventions including one staff assistance with hygiene tasks and provision of moderate to maximum assistance with grooming tasks. 5. R49 had multiple diagnoses including, Huntington's disease, based on the face sheet. R49's annual MDS dated [DATE], showed that the resident was severely impaired with cognition. The same MDS showed that R49 had functional limitation in range of motion to her bilateral upper extremities and required total assistance from the staff with personal hygiene. On September 22, 2025 at 2:13 PM, R49 was sitting in a reclining wheelchair in-front of the first floor nursing station. R49 was awake but non-verbal. R49 had constant involuntary movement of her bilateral arms and legs. R49's fingernails were long, and some were jagged. On September 23, 2025 at 9:32 AM, R49 was in bed, awake but non-verbal. R49 had constant involuntary movement of her bilateral arms and legs. R49's fingernails were long, and some were jagged. V2 who was present during the observation acknowledged that R49's fingernails were long. According to V2, R49 requires the assistance of the staff for nail care. R49's active care plan in place last revised on July 8, 2025 showed that the resident had ADL self-care deficit. The same care plan had multiple interventions including, Resident is dependent with ADL care; provide total assistance in all aspects of hygiene/dressing. 145221 Page 7 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. R6 has multiple diagnoses including unspecified intellectual disabilities and muscle wasting and atrophy, based on the face sheet. R6's quarterly MDS dated [DATE], showed that the resident was cognitively intact and required assistance with personal hygiene. On September 22, 2025 at 2:23 PM, R6 was sitting in his wheelchair inside the first floor dining room. R6 was alert and oriented. R6 had accumulation of long facial hair. R6 stated that he wanted to be shaven because his facial hair is long. On September 23, 2025 at 10:19 AM, R6 was inside the therapy room, participating in therapy. R6 had accumulation of long facial hair. R6 stated that he wanted the staff to shave him. V2 who was present stated that R6 needs the assistance of the staff with shaving. R6's active care plan last revised on May 17, 2025 showed that the resident has ADL self-care deficit. The same care plan under interventions showed, 1 assist with dressing/hygiene task and moderate to max assist with dressing/grooming tasks. On September 24, 2025 at 8:47 AM, V2 stated that it is part of the facility's care and service to provide assistance to all residents needing assistance with ADL care, including shaving and nail care. V2 stated that assistance with ADL care should be provided to maintain resident's grooming and hygiene. 145221 Page 8 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 thoroughly cleanse a resident's skin prior to application of skin treatment and failed to ensure that psychotropic medication was administered as ordered. This applies to 2 of 2 residents (R52, R121) reviewed for quality of care in the sample of 29. The findings include:1. On September 23, 2025, at 9:36 AM, V4 (Wound Care Nurse) assessed R52's skin while V6 was providing incontinence care. There was multiple striation of redness all over on R52's backside and buttocks. There was a yellow stain noted on the fitted sheet right by R52's upper back. V6 said that the stain came from the fluids that was secreting from R52's skin. There were also clumps of dead skin scattered all over R52's backside and buttocks. V4 said that R52 has history of fungal rash on his back that's why he is receiving Nystatin ointment. V4 applied the Nystatin ointment without ensuring that R52's back was cleansed. Residents Affected - Few On September 23, 2025, at 10:06 AM, V4 and V5 (Both Wound Care Nurses) assessed R52's skin. V4 said R52 was admitted with redness and fungal rash. The Nystatin cream is used to treat his skin because of history of fungal rash. V5 on the other hand stated the small clumps on his skin were dead skin, sweat, and old cream, from previous application, it should have been cleansed more, because it's defeating the purpose of the treatment. R52's physician order summary dated July 16, 2025, shows: Nystatin External Cream 100000 unit/gram. Apply topically to back, buttocks, and groin, for redness. Medication Class: Antifungal. 2. R121 is a [AGE] year-old female with a diagnoses history of schizoaffective disorder and anxiety disorder who was admitted to the facility 03/21/2012. On September 22, 2025 at 10:59 AM, R121 stated she didn't receive her Lorazepam for 6 days, when it was delivered it was the wrong dose and she had to wait until this was fixed, then she finally received it; she has asked the facility not to delay giving her this medication because it messes with her and makes her anxious and angry. On September 23, 2025 at 10:02 AM, R121 stated in the past she had to be put in straight jacket because she was off her medications, and expressed concerns about the consequences of not receiving her psychotropic medications. On September 24, 2025 at 2:07 PM, V2 (Director of Nursing) stated if R121 has an order for Lorazepam it should have been administered as ordered; the facility does keep an emergency supply of Lorazepam and if it was in stock it should have been given to R121; the Lorazepam should have been reordered within a few days of running out. R121's current physician orders document an active order effective 11/17/2022 for one .5 mg Lorazepam tablet twice daily for anxiety. R121's progress notes dated 09/10, 09/11, 09/14, and 09/15 document her prescribed Lorazapam was not available for administration. R121's September medication administration record documents Lorazepam was not administered as 145221 Page 9 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0684 ordered from 09/10 - 09/12 and 09/13 - 09/15. Level of Harm - Minimal harm or potential for actual harm The facility's list of emergency medications received September 24, 2025 from the facility includes .5 mg of Lorazepam. Residents Affected - Few The facility's policy on Administration of Medications received from the facility September 24, 2025 states in part: Medications should be administered within one (1) hour of the prescribed times. 145221 Page 10 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and provide orthotic devices and services to residents, to prevent further reduction in mobility and ROM (range of motion).This applies to 2 of 6 residents (R12 and R123) reviewed for limited ROM, in the sample of 29.The findings include:1. R12 had multiple diagnoses including, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infraction due to thrombosis of left middle cerebral artery and severe morbid obesity due to excess calories, based on the face sheet.R12's annual MDS (Minimum Data Set) dated July 29, 2025 showed that the resident was cognitively intact. The same MDS showed that R12 had functional limitation in ROM to one side of both upper and lower extremities.On September 22, 2025 at 11:20 AM, R12 was in bed, alert and oriented. R12 had right arm and hand weakness. R12 was having a hard time to move her right arm and hand without the help of the left hand. R12 stated that she wants a pillow or a device to support her weak right arm and hand.On September 23, 2025 at 9:24 AM, V2 (Director of Nursing) was brought to R12's room to show the condition of the resident's right arm and hand. R12 was in bed, alert and oriented. R12 had right arm and hand weakness. R12 complained of right shoulder pain and was having a hard time to move her right arm and hand without the help of the left hand. In the presence of V2, R12 stated that she wants a device to help support her right arm and hand. V2 stated that she will request the occupational therapist to screen/assess R12 for a device.On September 23, 2025 at 3:02 PM, V7 (Occupational Therapist) stated that she screened R12 that morning per facility request. V7 stated that based on R12's screening, the resident had no complaint of pain during ROM of the right shoulder and elbow. R12 had weakness on her right hand, her first (thumb) digit and the second (index finger) digit had weakness, while able to open the rest of the right fingers. According to V7, she was recommending for R12 to receive occupational therapy service and to use a palm protector at night, as part of treatment to help open R12's first and second digits to prevent further weakness and for proper positioning.R12's occupational therapy screening form dated September 23, 2025 created by V7 showed that the resident had increasing weakness to the right elbow and hand. 2. R123 had multiple diagnoses including, cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, muscle wasting and atrophy on multiple sites and systemic lupus erythematosus, based on the face sheet.R123's quarterly MDS dated [DATE] showed that the resident was cognitively intact. The same MDS showed that R123 had functional limitation in ROM to one side of the upper extremity.On September 22, 2025 at 11:55 AM, R123 was in bed, alert, oriented and verbally responsive. R123 had weakness on his left arm and hand. R123's left middle and index fingers were extended, while the rest of his fingers on the left hand were bent (cannot open/extend) touching his palm. R123 had no splint or device on his left hand.On September 23, 2025 at 9:59 AM, V2 (Director of Nursing) was brought to R123's room to show the resident's left arm and hand. R123 was sitting in his wheelchair inside the room. R123 had weakness on his left arm and hand. R123's left middle and index fingers were extended, while the rest of his fingers on the left hand were bent (cannot open/extend) touching his palm. R123 had no splint or device on his left hand. R123 stated that he would like to have a splint or any device on his left hand for proper positioning and to prevent further decline of his left hand. During the same observation, V2 stated that she will request the occupational therapist to screen/assess R123 for the need for splint or device.On September 23, 2025 at 3:09 PM, V7 (Occupational Therapist) stated that she screened R123 that morning per request of the facility. V7 stated that R123 had contracture on the left hand. According to V7, based on 145221 Page 11 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R123's screening she is recommending for the resident to use a resting hand splint at all times, as tolerated and may be removed for hygiene. V7 stated that R123 would benefit from the resting hand splint for contracture management, to prevent further contracture and for positioning.R123's occupational therapy screening form dated September 23, 2025 created by V7, documented that the resident has muscle weakness of arms, with left hand joint contracture or is at high risk for developing contracture. On September 24, 2025 at 8:50 AM, V2 stated that she expects the CNAs (Certified Nursing Assistant) to report to the nurses any signs of weakness, stiffness and/or contracture. The nurses are then expected to report those signs to the therapy department, so that the therapist could appropriately screen/assess the resident for any need for therapy services or equipment/devices needed to prevent further decline in the resident's physical status or ROM. 145221 Page 12 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

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. Based on observation, interview, and record review, the facility failed to ensure that residents who smoke and require supervision for smoking were monitored closely during smoking period. In addition, facility also failed to ensure that residents are not keeping their own cigarette lighters. This applies to 6 of 8 residents (R26, R71, R75, R110, R151, R164) reviewed for smoking in the sample of 29. The findings include:On September 23, 2025, at 3:35 PM, V23 (Activity Aide) was in the dining/dayroom near the door of the back patio handing cigarettes to residents during smoke time. V23 was the only staff supervising the smoking period. Glass windows/walls with horizontal window blinds separated the dayroom from the back patio area. However, V23 was only intermittently looking outside through the glass window to monitor the residents who were smoking. R110 was observed in the back patio smoking and carrying a lighter. R110 lit up another cigarette with this lighter and then put the cigarette lighter in her pocket when she finished smoking and walked back inside the facility without surrendering the cigarette lighter to V23.On September 23, 2025, at 3:42 PM, after R110 went back inside the facility, V23 said that residents are not allowed to keep cigarette and cigarette lighter with them or in their bedroom. After this statement, V23 was notified that R110 had a lighter with her, but V23 did not say anything about it.On September 23, 2025, at 3:46 PM, R110 was in her room, she showed her cigarette lighter and said, All the residents have their own lighter. On September 24, 2025, at 9:45 AM, smoking observation was conducted. V24 (Activity Aide) was handing passing cigarettes to residents. There were several residents who were smoking in the back patio including R26, R71, R75, R151, R164. Upon approached, these residents all stated that they keep their own lighters.At 9:51 AM, R164 said that he lights his cigarettes with his own lighter and showed that he was keeping it in the pocket of his pants.At 9:54 AM, R75 said sometimes he needs to bring his own lighter to light his cigarette.At 9:56 AM, R26 has his own lighter. R26 stated he keeps it in his room and use it mostly to help light other people.At 9:57 AM, R71 was smoking and has a lighter with him.At around 10:00 AM, R151 was sitting on his wheelchair, he had a plastic bag with him which contained his lighter. R151 stated that he lights his own cigarette. R151 showed the lighter that was inside the plastic bag.Upon entering the dayroom, V24 was observed away from the back patio entrance and window and was not continuedly observing the residents who were smoking. There was no staff directly monitoring the back patio.At around 10:05 AM, R151 went back inside the dayroom and continued to propel himself to his bedroom without surrendering the lighter to V24.On September 24, 2025, at 10:22 AM, V25 (Activity Director) stated residents are not allowed to keep their lighter with them for safety concerns like potential burning. They don't want residents to be tempted or to try smoking in their bedrooms. The staff should monitor the residents. The facility is supposed to have 2 staff monitoring the residents during smoke time one staff passing the cigarette while the other would be directly monitoring in the patio. However, there were times when there was only 1 staff. Staff should be lighting the cigarettes for the residents. The lighters are to be lock in the cigarette cart.On September 24, 2025, at 10:29 AM, V25 opened the cigarette cart for inspection. There were only 2 lighters in the cart which belonged to R37 and R163. These two residents were not included among the 6 residents that were observed smoking with lighters.The updated smoking assessments of R26, R71, R75, R110, R151, 164, showed that these residents may not be capable of handling/carrying any smoking materials and require supervision when smoking.R26's, R75's, R110's, 164's, most recent smoking care plan showed, Potential for safety hazard and/or injury related to smoking. Resident is non-compliant with turning in smoking materials.R71's and R151's most recent smoking care plan showed, Resident is non-compliant with turning in smoking materials. 145221 Page 13 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to ensure that continuous oxygen therapy was consistently provided and monitored as ordered.This applies to 1 of 2 residents (R35) reviewed for respiratory care in the sample of 29.The findings include: R35's medical diagnosis list created on January 17, 2024, shows multiple diagnosis including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and shortness of breath.The Physician's Order Sheet includes an order dated January 17, 2024, to administer oxygen at 3 liters per minute via nasal cannula continuously every shift to maintain SpO? (Oxygen Saturation) greater than 90% related to COPD. Additional orders included oxygen saturation monitoring and oxygen equipment maintenance.On September 22, 2025, at 10:27 AM, R35 was observed sitting on the edge of the bed watching television with oxygen in place at 3 liters per minute via nasal cannula. When asked about portable oxygen use, R35 stated they did not have a portable tank and that they were supposed to remain on oxygen all the time but could not do so while moving. R35 further stated oxygen is not used when traveling around the building or down to therapy.On September 23, 2025, at 9:42 AM, R35 was observed in room without oxygen on.On September 23, 2025, at 11:55 AM, R35 was observed in bed watching television without oxygen, with the nasal cannula tubing draped across the concentrator.On September 24, 2025, at 9:58 AM, R35 was lying in bed without oxygen, the nasal cannula tubing draped across the bed toward the concentrator.On September 24, 2025, at 11:00 AM, R35 was again observed in bed without oxygen applied.R35 was observed on several occasions between September 22 and September 24, 2025, going to restroom and walking halls without supplemental oxygen. Documented SpO? obtained September 20, 2025, shows R35 SpO? level was 90% on room air. Additional readings throughout the month of September notate that oxygen therapy was not in use during recordings of oxygen saturation. On September 23, 2025, at 9:33AM V12 (Physical Therapy Assistant) stated that R35 is on oxygen 'as needed,' and noted there is an oxygen concentrator in the therapy gym to be used if saturation drops. V12 confirmed she had not seen R35 with a portable tank.On September 24, 2025, at 1:19PM V2 (Director of Nursing) stated that portable tanks are available in the facility's oxygen supply closet and should be used by residents on continuous oxygen during transport. Staff should obtain portable tanks for residents in need.According to facilities Policy & Procedure Oxygen Administration and Storage dated January 01, 2022 the purpose is to ensure staff follow safety guidelines and regulations for storage and use of oxygen. When a resident is leaving the building or will be moving about in such a manner as a concentrator becomes impossible, a tank may be used. Residents Affected - Few 145221 Page 14 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to administer medications as ordered during medication administration observation. There were 25 medication administration opportunities with 2 errors resulting to 8% percent medication error rate.This applies to 2 of 4 residents (R147 and R163) reviewed for medication administration in a sample of 29.The findings include:1.According to the face sheet, R147 has multiple diagnoses including, bilateral secondary cataract, presence of intraocular lense, chronic obstructive pulmonary disease, and heart disease.R147's POS (Physician Order Sheet) dated September 20, 2025, showed an active order for FML Litquifilm Opthalmic Suspension 0.1% (Fluorometholone), instill 1 drop in both eyes one time a day for episcleritis (an inflammation in the eyes).On September 23, 2025, at 9:25 AM, V22 (Registered Nurse) administered the eye drops, FML Litquifilm Opthalmic Suspension 0.1% (Fluorometholone) to R147 in each eye. The eye drops instructions on the medication label showed, shake well before each use. V22 failed to shake the eye drops bottle before applying to R 147's eyes.2. According to the face sheet, R163 has multiple diagnoses including, cellulitis of right lower limb, local infection of skin and subcutaneous tissue, quadriplegia and history of other venous thrombosis and embolism.R163's POS (Physician Order Sheet) dated September 19, 2025, showed an active order for Ceftriaxone Sodium Solution Reconstituted 2 grams (IV) intravenously one time a day for infection of the foot ulcer for 42 days.On September 23, 2025, at 9:02 AM, V22 was programing R163's IV medication pump to administer the IV medication Ceftriaxone Sodium Solution. The IV medication bag label showed the volume of 100 ML to be infused at 100 ML/hour. V22 entered Volume to me infused as 250 (ML) Milliliters and the IV rate, 100 ML/hour and said she was done.On September 24, 2025, at 11:50 AM, V2 (Director of Nursing) said V22 should have followed the physician medication order and instructions on the medication labeling. V2 also added that V22 should have entered the IV medication volume and rate as prescribed to prevent medication error and potential air embolism to the resident.The facility's Policy and Procedure for Administering Medications revised January 2025 showed, Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: . 3. Medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. Residents Affected - Few 145221 Page 15 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure food was prepared, stored, and served under sanitary conditions. This failure applies to 144 residents who are served food from the kitchen. Findings include:On September 25, 2025, at 3:59 PM, V1 (Administrator) stated out of 147 residents in the facility, there are 144 residents receiving food from the kitchen.On September 23, 2025, at 10:39 AM, Upon entering the kitchen V15 (Cook) was standing at the food prep table handling food prep items then donned gloves without performing hand hygiene.On September 23, 2025 at 10:41 AM In the kitchen, V16 (Dietary Aide)collected and rinsed soiled dishes, placed them in a dish rack and into the low temp dishwasher, then collected clean dishes from the dishwasher without performing hand hygiene; after pulling a rack of clean dishes from the dishwasher V16 grabbed a towel from the top of a box of latex gloves sitting in a part of the dish washing machine, wiped the water out of multiple bowls and placed them back inside the dish rack, then placed the towel back on top of the box of latex gloves. V16 collected the dish rack containing the bowls V16 wiped and several other clean bowls and placed the rack on top of two other dish racks sitting on a roller base that contained heavy presence of visible debris and particles and left them to dry. Several dish racks used to clean dishes and for storing clean dishes were heavily stained with a film and substance that was removable when rubbed. The mugs and cups stored in several dish racks contained visible particles. A silverware [NAME] container filled with napkins that were placed on residents' meal trays contained heavy presence of visible stains and film all throughout the upper edges of the container. V14 (Dietary Manager) grabbed napkins from the silverware [NAME] and placed them on multiple trays being prepared for residents. V17 (Dietary Aide) and V18 (Dietary Aide) were performing kitchen duties with their hair exposed and not completed covered by their hairnets.On September 22, 2025, at 11:57 AM, V18 (Dietary Aide) was working in the kitchen with her hair not completely covered and exposed from the sides of her hairnet.The freezer was noted with a sticky spilled substance on the surface of a box of multiple frozen pizzas, the inside and outside of the plastic bag covering the pizzas contained a thick sticky layer of a spilled substance. V14 stated the substance appeared to be soda.On September 23, 2025, at 11:06 AM, Car keys and an eyeglass case were sitting on the bottom level of the food prep table next to a large box of potatoes. A bowl containing white powdered residue was sitting on top of the container of thickener powder, V15 (Cook) stated the bowl was used to scoop thickener from the container; the exterior of the container of thickener contained stains of a sticky yellow substance.On September 23, 2025, at 12:25 PM, in the first and 2nd floor dining rooms nursing aides were serving coffee and juice from large beverage dispensers. The dispensers that contained a heavy presence of dark and red stains covering the rubber lining inside the lids of the dispensers and the surface of the dispensers contained pink stains and sticky dark stains in various areas. Underneath the carts holding the beverage dispensers were two dish racks filled with mugs. These mugs had visible drops of water on their surface and the dish racks storing the mugs contained patches of thick film stains throughout the surface. The beverage carts holding the dispensers contained visible pink stains, particles, and sticky substances on various areas of the surface.On September 23, 2025, at 12:50 PM, A small refrigerator in the kitchen (used for storing multiple yogurts, sandwiches, and juice boxes) contained visible food particles, a thick sticky substance on the inside upper surface, and heavy presence of dark substance buildup on the rim of the door. V14 (Dietary Manager) said the food items in the refrigerator were being used for residents.On September 24, 2025, at 12:28 PM, V14 (Dietary Manager) said that staff should let dishes air dry. A rag 145221 Page 16 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many to dry dish wear should not be used to prevent contamination. V14 also said that storing a dry towel on a box of gloves is not sanitary and they should be stored in a bucket of solution or a sealed plastic bag on the tray line. V14 confirmed that items used to store clean dishes should be clean and free of debris and the beverage carts should not have any buildup of substances or stains. V14 also added that dietary staff should not have exposed hair while working in the kitchen and staff should wash hands between tasks. The small refrigerator holding cold items to be served to residents should be wiped down daily and the small refrigerator should be cleaned. The facility's Food Safety and Sanitation policy on Tray Service received from the facility September 24, 2025 shows in part: Employees will use measures to ensure the sanitation and safety of food provision on the tray line, transportation of meals, and tray delivery. Proper procedures are used so that measured temperatures are accurate, and contamination is prevented:b. An alcohol swab is used to sanitize the thermometer between uses at one meal. Food will be delivered to the residents in a sanitary way to prevent food-borne illness.The facility's Food Safety and Sanitation policies on Cleaning Schedules received from the facility September 24, 2025, documents in part:The purpose of the policy is To assure the kitchen is kept clean and meets state regulations monthly. The cleaning schedule will be used by all staff to assure that the kitchen is maintained with cleanliness and sanitized as needed. The food service department will be cleaned and sanitized on a routine basis according to written cleaning schedules. The facility's Food Safety and Sanitation policy on Storage of Dry Food received from the facility September 24, 2025 states in part: The facility will follow safe handling and storage of dry foods and supplies. Storage bins used (for dry foods) will be kept clean. The facility's Food Safety and Sanitation policy on Handwashing received from the facility September 24, 2025 states in part: Employees will use proper hand washing techniques to prevent the spread of infection, cross contamination, and germs. Employees are required to wash hands:k. After handling soiled dishes and utensils.The facility's Food Safety and Sanitation policy on Employee Health and Personal Hygiene states in part: Personal items will be placed in a designated area away from food preparation. 145221 Page 17 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

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 with regards to hand hygiene during range of motion assessments and administration of insulin. In addition, the facility failed to wear complete PPE (Personal Protective Equipment) during provision of wound treatment and administration of intravenous (IV) medication for residents who are under Enhance Barrier Precaution (EBP). This applies to 5 of 6 residents (R9, R29, R50, R135, R163) reviewed for infection control in the sample of 29. The findings include: 1.According to the face sheet, R163 has multiple diagnoses including, cellulitis of right lower limb, local infection of skin and subcutaneous tissue, quadriplegia and history of other venous thrombosis and embolism. R163's POS (Physician Order Sheet) dated September 22, 2025, showed an active order for a (PICC) Peripherally Inserted Central Line Catheter to (RUE) Right Upper Extremity. Residents Affected - Some On September 23, 2025, at 9:02 AM, V22 (Registered Nurse) was preparing R163's (IV) intravenously medication, Ceftriaxone Sodium Solution on the medication cart in front of R163's room. V22 connected the IV tubing to the IV bag, part of the tubing dropped and touched the floor while V22 was holding the IV bag. V22 proceeded to enter R163' room without replacing the tubing. There was an (EBP) Enhanced Barrier Precaution sign on R163's door which showed that providers and staff must wear gloves and gown when providing high-contact resident care activities including central line device care or use. V22 wore gloves and failed to wear a gown before entering R163's room. V22 primed the medication tubing, cleaned R163's IV access port with an alcohol wipe, flushed and connected the IV tubing to R163's IV access on his right upper extremity. 2.According to the face sheet, R135 has multiple diagnoses including, hypertension, hyperlipidemia, and arthritis. R163's POS (Physician Order Sheet) dated February 28, 2025, showed an active order for Humalog Injection solution (Insulin Lispro), inject per sliding scale subcutaneously for times a day for diabetes Mellitus. On September 23, 2025, at 9:17 AM, V22 drew up R135's insulin in a syringe in front of the resident's room. V22, failed to pull up the needle safety cap built in with the syringe, left the needle exposed and proceeded to enter R135's room. V22 held the insulin syringe with the exposed needle in her hand while she waited for R135 to take his other oral medication. V22 then proceeded to administer R135's insulin. On September 24, 2025, at 11:50 AM, V2 (Director of Nursing) said V22 should have worn gloves and gown before entering the room to administer IV medication to the resident on EBP, and V22 should have gotten a new tubing if the IV tubing touches the floor to prevent infection. V2 also added that V22 should have pulled up the syringe safety cap after drawing up the insulin until when ready to administer the insulin to prevent infection and accidental needle stick that can occur from touching the needle. The facility's Policy and Procedure for Administering Medications revised January 2025 showed, Procedure: .12. Adherence to established facility infection control procedures shall be followed during the administration of medications. 3. On September 23, 2025, at 10:43 AM, V4 and V5 (Both Wound Care Nurses) provided wound care to R29 who has a stage 4 pressure to the sacrum. Both nurses wore gloves during the provision of care, however, they did not wear a gown during the wound treatment. There was a signage posting of EBP (Enhance Barrier Precaution) on R29's door. 145221 Page 18 of 19 145221 09/25/2025 Parc Joliet 222 North Hammes Joliet, IL 60435

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On September 23, 2025, at 2:36 PM, V7 (Occupational Therapist/OT) assessed R50's left hand for range of motion (ROM). V7 touched R50's left hand without wearing a pair of gloves and without hand hygiene prior to assessment. After assessment she went to see R9 (another resident) without hand hygiene. 5. On September 23, 2025, at 2:41 PM V7 (OT) went to see R9 to assess R9's left and right hands for ROM. V7 touched R7's hands during assessment without hand hygiene and without wearing gloves. On September 24, 2025, at 1:00 PM, V30 (Infection Preventionist Nurse) stated the staff must wear PPE (Personal Protective Equipment) if they are providing wound care, administering IV medications. When a staff is assessing a resident, the staff must perform hand hygiene before and after tasks and in between residents, to prevent spread of potential infection. The Enhance Barrier Precaution (EBP) signage posting shows: Wear gloves for the following High-Contact Resident Care Activities; Bathing/Showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, wound care, devices such as central lines. Facility's Policy and Procedure for Hand Hygiene dated November 8, 2022, shows: Purpose: To provide guidelines on proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infection. 145221 Page 19 of 19