Health inspection·December 22, 2022

F 0677 for toileting. Level of Harm - Minimal harm or potential for actual harm R54's active care plan last revised on November 6, 2022 showed that the resident is incontinent of bladder function. The same care plan showed in-part under intervention, Incontinent: Check every room rounds, upon request, as needed for incontinence. Residents Affected - Some On December 21, 2022 at 9:28 AM, V3 (Assistant Director of Nursing) stated that the residents should be checked and changed at least every 2 hours and as needed to ensure cleanliness and comfort especially for residents needing assistance from the staff. V3 also stated that it is part of the nursing care to ensure that resident's fingernails are clean and trimmed. V3 added that it is especially important for R54's fingernails to be trimmed and cleaned because the resident needs the assistance of the staff with regards to hygiene related to R54's mental disability. 2. R49's face sheet diagnoses include has multiple diagnoses which includes rhabdomyolysis, generalized muscle weakness, lack of coordination, abnormal posture, and macular degeneration. R49's quarterly MDS dated [DATE] showed that the resident is cognitively intact. The same MDS showed that the resident required limited assistance from the staff with regards to personal hygiene. On December 19, 2022 at 3:49 PM, R49 was sitting in her wheelchair in-front of the nursing station. R49 was alert, oriented and verbally responsive. R49 had accumulation of long facial hair on her chin and on her upper lip. R49 stated that she wanted the staff to shave her facial hair. V4 (Nurse) was present during the observation and was aware of R49's request to be shaven. R49's active care plan last revised on November 2, 2022 showed that the resident has ADL self-care performance deficit related to weakness. The same care plan showed under intervention, Personal hygiene: The resident requires extensive assistance by staff with personal hygiene and oral care. On December 20, 2022 at 1:04 PM, R49 was sitting in her wheelchair inside her room. R49 was alert, oriented and verbally responded. R49 stated, Thank you for telling the nurse about my facial hair. Now I look like a woman instead of a man. On December 21, 2022 at 9:28 AM, V3 (Assistant Director of Nursing) stated that it is part of the nursing care to ensure that unwanted facial hair of the residents especially the female resident be removed, to maintain personal hygiene and grooming. V3 stated that though R49 is able to do some ADLs on her own, shaving requires the assistance of the staff for safety. 3. R3 has multiple medical diagnoses which include generalized muscle weakness and lack of coordination. R3's minimum data set (MDS) dated [DATE] shows that she is alert and oriented and requires extensive assistance for grooming and hygiene. On 12/19/22 at 12:46 PM, R3 was in the sitting on her wheelchair by the nurses' station. R3 displays facial hairs to upper lip and chin. R3 has long nails with polish, however, underneath some of her nails were accumulation of unidentified substances. On 12/20/22 at 1:04 PM, V5 and V10 (Both CNAs) provided care to R3. R3 remains with facial hair and long fingernails with substances underneath. When R3 was asked if she wants to be shaven, R3 agreed. When asked about her nails she said that it was just done yesterday (nail polish). The nails polish looked new, however, there were still the accumulated substances and/or debris underneath some of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 2 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 0677 her nails. Level of Harm - Minimal harm or potential for actual harm R3's care plan active shows that she has an ADL self-care performance deficit related to weakness. R3 requires extensive assistance from staff with personal hygiene and oral care. Residents Affected - Some 4. R31 has multiple diagnoses which include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, blindness on one eye, generalized muscle weakness, and abnormalities of gait and mobility. MDS shows dated 9/15/22 shows that R31 is cognitively impaired and requires extensive assistance for grooming and hygiene. On 12/20/22 at 2:05 PM, R31 was sitting on his bed, with facial hair growth but R31 refused to be shaven. His nails were somewhat long with black substance underneath, when asked if he wanted to clean and clipped his nails, R31 agreed. V23 (CNA) stated that R31 is diabetic so she can't do it, but someone usually comes to clean their nails. R31's care plan shows that R31 has an ADL self-care performance deficit and requires extensive assistance by staff with personal hygiene. On 12/21/22 at 3:05 PM, V24 (Clinical Resource Nurse Manager) stated that if a resident is diabetic the CNA and the nurses can clean their nails but it's only the nurses who can clip the nails. The CNA staff must notify the nurse if the nails need clipping. 5. R32's EMR (electronic medical record) included diagnoses of personal history of traumatic brain injury, other abnormalities of gait and mobility, other lack of coordination, difficulty in walking, dysphagia, oral phase. R32's Quarterly MDS dated [DATE] included that R32 was severely impaired in cognition and required extensive two-person physical assistance for personal hygiene. On 12/19/22 at 11:29 AM, R32 was lying in bed and appeared disheveled and noted to have facial hair and his arms had very dry and scaly skin. R32 was alert and able to communicate clearly and stated that he is mostly blind with some vision in his right eye. R32 remarked I need a shave and haircut. It's been more than a week since I was shaved. They haven't put any lotion on. R32's fingernails were noted to be about half inch long with blackish substance underneath. R32 stated They have to cut and clean it. On 12/19/22 at 12:50 PM, this information was relayed to V9 (Licensed Practical Nurse) who stated He gets shaved on shower days and will let the barber know about haircut. He needs to be oiled up. On 12/19/22 at 12:34 PM, R32 received a bedside tray and noted to take a few bites of his peanut butter jelly sandwich and his fingernails were still long with blackish substance underneath it. V10 (Certified Nursing Assistant) who came into the room was notified that R32 would like to have his fingernails cleaned and cut. On 12/20/22 at 09:49 AM, R32 was seen seated at the nurses station in a reclining chair. R32 noted to still have facial hair and his fingernails remained long with blackish substance underneath them. R32 stated They still haven't done anything. V9 (Licensed Practical Nurse) who was in the vicinity was again reminded of R32's requests. R32's nursing care with target date of 1/1/2023 included that R32 has potential impairment to skin integrity due to decreased mobility and ADL (activities of daily living) self-care performance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 3 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 0677 deficit. Interventions included that R32 requires extensive assistance by staff with personal hygiene and oral care and for R32 to avoid scratching and to keep fingernails short. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 4 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to fasten a seat belt of a resident while providing transportation in facility's bus and failed to provide supervision resulting in the residents fall. This applies to 1 of 2 residents (R77) reviewed for fall incidents in the sample of 22. The findings include: R77's face sheet included diagnoses including acute respiratory failure with hypoxia, dependence on renal dialysis, chronic kidney disease, stage 4 (severe), unspecified abnormalities of gait and mobility, unsteadiness on feet, other lack of coordination, unspecified intellectual disabilities. Quarterly MDS (minimum data set) dated 9/23/22 included that R77 was moderately intact in cognition and required extensive one person assistance with transfers, and locomotion off unit. Fall incident report dated 12/01/22 included that R77 slid out of his wheelchair while he was taken to a doctor appointment in the facility's bus and slid unto his knees when the bus brakes were used. IDT (Interdisciplinary Team) note included that R77 did not hit his head and that no injuries were reported. Intervention include that the bus driver was educated on properly securing residents on the bus with seat belt with return demonstration. R77's Fall Risk Assessment post fall 12/01/22 included that R77 is High Risk with fall score of 75. (Morse Fall scoring: High risk if 45 or higher). This assessment also included that R77 has had previous falls and has impaired gait and inability to walk unassisted. On 12/20/22 at 11:07 AM, R77 stated The driver did not put the seat belt on me. I need help with putting it on. The driver slammed the brakes on, and I fell out of my wheelchair and fell forward on my knee. My knees hurt but did not break anything. The CNA (Certified Nursing Assistant) was sitting in front of me, and she helped me get up. On 12/20/22 at 10:56 AM, V7 (Bus Driver) stated I had strapped R77 in with 4 latches that holds the wheelchair in place and makes sure it doesn't move. I thought I had fastened the seat belt across R77. There was a section on the road where 3 cars ahead of me slammed on the brakes. So, I had to correct the bus to prevent it from moving forward and moved it over to the side (shoulder) of the road. I heard a sound and when I looked back, R77 was holding on to the top of the head rest in front of him. He did not have his seatbelt on. The other lady I was also transporting was strapped in. Usually, we have a CNA accompany us, unless I am dropping the resident off with a family member meeting us there (for the appointment). R77 had a CNA with him, and she was one seat ahead of him. On 12/20/22 at 11:26 AM, V8 (Certified Nursing Assistant) stated I was accompanying two residents for a doctor appointment. We had gotten on to the bus and I saw the driver hooking the safety belts and at that point I thought that all the safety belts were on. The driver came to an abrupt stop down the street, and I noticed R77 come forward and he landed on the floor because the bus driver [V7] had not put a strap across him. The bus driver is responsible for checking if all straps are on when the residents are on the bus. On 12/20/22 at 11:31 AM, V2 (Director of Nursing) stated that during R77's fall incident of 12/01/22, R77's seat belt was not on. V2 stated that it is the bus driver's responsibility for strapping residents on when in the bus and it's the CNA's role to accompany the resident to the appointment. V2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 5 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 stated that CNAs are there to ensure that the residents are safe on route to the appointment. Level of Harm - Minimal harm or potential for actual harm On 12/20/22 at 11:41 AM, V1 (Administrator) stated that the bus driver is employed by the facility. Facility policy titled Transportation Bus Procedure revised 12/1/22 included as follows: Residents Affected - Few 1) Make sure all residents are secure in a seat or wheelchair. 3) Make sure all safety belts are applied and locked. 4) Make sure all safety belts are in proper working order. 5) Make sure all residents are secure and comfortable before the bus is moving. 6) Make sure to frequently look to assure all passengers are secure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 6 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 incontinence care and catheter care in a manner that would prevent infection and maintain hygiene. This applies to 3 of 3 residents (R37, R54 and R74) reviewed for incontinence care and urinary catheter care in the sample of 22. The findings include: 1. R54 diagnoses includes chronic diastolic (congestive) heart failure, generalized muscle weakness, presbyopia, and profound intellectual disabilities, based on the face sheet. R54's quarterly MDS (minimum data set) dated December 5, 2022 showed that the resident is severely impaired with cognitive skills for daily decision making. The MDS showed that R54 required extensive assistance from the staff with most of her ADLs (activities of daily living) including personal hygiene and toilet use. The same MDS showed that R54 is incontinent of both bowel and bladder functions. On December 20, 2022 at 1:20 PM, V5 (Certified Nursing Assistant/CNA) provided incontinence care to R54 with the assistance of V4 (Nurse). R54's disposable brief was wet with urine. V5 used three disposable cleansing wipes (at the same time) and wiped R54's right groin area, then from the pubic area down with one stroke and then the left groin area. V4 wiped R54 in this manner using the same cleansing wipes without changing side or folding the wipes. During the procedure, V5 did not separate the labial folds to clean the area. R54's active care plan last revised on November 6, 2022 showed that the resident has ADL self-care performance deficit related to intellectual disabilities. The same care plan showed that R54 requires extensive assistance from the staff for toileting. On December 21, 2022 at 9:28 AM, V3 (Assistant Director of Nursing) stated that when providing incontinence care, staff should use one disposable cleansing wipe every time they clean the different part of the perineum. The used cleansing wipe or part of the used cleansing wipe should not be re-used to clean the resident to prevent cross contamination and potential infection, as well as to maintain hygiene. The facility's policy and procedure regarding perineal care dated February 2018 showed, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The same policy and procedure showed in-part that for female resident, b. Wash perineal are, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to the thighs, Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. 2. R74's medical diagnoses include muscle wasting and atrophy, weakness, and malaise. R74's minimum data set (MDS) dated [DATE] shows that she requires assistance with toileting. On 12/20/22 at 12:52 PM, R74 was resting in bed. R74 was observed with indwelling urinary catheter. V5 and V10 (Both CNA) rendered incontinence care to R74 who was wet with urine (urinary catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 7 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 leaked). V5 and V10 assisted R74 into a side-lying position, then V10 proceeded to clean R74's posterior perineum, applied clean incontinence brief and assisted R74 back on supine position. V10 did not clean the anterior portion of R74's peri-area (which is the vulva) and the urinary catheter. 3. R37's medical diagnoses include generalized muscle weakness and lack of coordination. R37's minimum data set (MDS) dated [DATE] shows that she requires extensive assistance for toileting. On 12/20/22 at 1:55 PM, V10 and V23 (Both CNA) provided incontinence care to R37. V23 cleaned R37's peri-area from front to back. However, during the process V23 did not separate the inner labia to clean the folds. On 12/21/22 at 2:08 PM, V19 (Clinical Nurse Manager) stated that when staff is providing incontinence care for a female resident the expectation is that they must follow the proper steps of cleaning the peri-area, such as cleaning from front to back, separate the labial folds and clean side to side. If the resident has a catheter treat it as part of the resident's body, which means include the catheter tube with the cleaning procedure. This is to prevent infection. Facility Policy and Procedure for Urinary Catheter Care shows: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control: 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. a. Do not clean the peri-urethral area with antiseptics to prevent catheter-associated urinary tract infections (UTI) while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. Steps in the Procedure: 15. For female: Use a washcloth with warm water and soap to cleanse around the labia. Use one area of the washcloth for each downward cleansing stroke. 17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 8 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow the rate of infusion of the gastrostomy tube (g-tube) feeding as prescribed by a physician to meet a resident's nutrition needs. This applies to 1 of 1 resident (R74) reviewed for enteral feeding in the sample of 22 residents. Residents Affected - Few The findings include: R74's medical diagnoses which include dysphagia, gastrostomy status, muscle wasting and atrophy, weakness, and malaise. On 12/19/22 at 1:25 PM, R74 was resting in bed. R74 was awake but non-verbally responsive. R74 was observed with g-tube feeding (brand name of feeding) 1.5 Cal which was infusing at 60 ml/hr. (milliliter per hour). On 12/21/22 at 9:59 AM, R74 was lying in bed with g-tube feeding running at 60 ml/hour. On 12/21/22 at 11:39 AM, R74's g-tube feeding remained at 60 ml/hr. V9 and V21 (Both Nurses) stated that R74's g-tube feeding is supposed to be running at 62 ml/hr. The surveyor, V9 and V21 went to R74's bedroom to check the g-tube pump, and it showed that the enteral feeding was running at 60 ml/hr. V21 stated that she did not notice it because the enteral feeding was hung and set-up by the night shift. On 12/21/22 at 1:27 PM, V20 (Registered Dietitian) stated she last saw R74 on 12/16/22 and the order was to infuse feeding at 62 ml/hr. R74 is NPO (nothing by mouth) and was receiving enteral feeding at 60 ml/hr, however, V20 recommended to increase the feeding to 62 ml/hr due to R74's weight loss and to meet R74's nutritional need and hydration. V20 stated she expects that facility to follow her recommendation and physician's order to infuse the right amount of g-tube feeding. R74's POS (Physician Order Sheet) shows an order for enteral feeding dated 11/28/2022 to administer (brand name of feeding) 1.5 at 62 ml/hr. for 16 hrs/day (for total infusion of 992 cc). On at 0500 AM, off at 9:00 PM as tolerated. Dietary Notes dated 12/16/22 documents: V20 observed R74 who was non-verbal. V20 observed (brand name of feeding\ 1.5 infusing per prescription. R74 appears to have lost weight as the region of the eye appears to be hollowing and meets the guidelines of malnutrition. Nutrition status is expected to decline due to intolerance of tube feeding. Interventions to slow expected decline: NPO (Nothing per oral). Tube feeding prescription: (brand name of feeding) 1.5 at 62 ml/hr. x 16 hrs. water flush of 50 cc x 16 hrs. RX (prescription) provides 992 cc, 1440 kcal, 86 gm protein, 754+800=1554 cc free water, 1 kcal: 1 cc ratio, 22.6 kcal/kg body weight (BW). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 9 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 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 by a physician. There were 2 medication errors out of the 25 opportunities which resulted to 8% medication error rate. This applies to 1 of 7 residents (R44) reviewed for medication pass. Residents Affected - Few The findings include: On 12/19/22 at 3:55 PM, V18 (Nurse) checked R44's blood glucose level (BGL) and it showed 312 mg/dl (milligram/deciliter). V18 stated that she will be giving Humalog 10 units as a regular dose plus additional Humalog 12 per sliding scale which would total to 22 units. On 12/19/22 at 4:10 PM, V18 stated that she only had two medications to give R44 at that time, Rytary ER 48.75-195 mg cap and Humalog. V18 gave R44 the Rytary ER 2 capsules. Then V18 proceeded to draw the Humalog from the vial. State representative checked the syringe and observed that the plunger was in the line of 24 units, however, the syringe showed that there were air bubbles inside the syringe. The surveyor prompted V18 to recheck the syringe and she removed air and aspirated from the vial again. This was repeated two more time and, on the 3rd try the syringe showed that there were 7 units air and with 16 units of Humalog. Surveyor prompted V18 recheck it, but she gave the medication to R44 as is. On 12/19/22 at around 4:20 PM, when the surveyor inquired about the Novolog, V18 stated that she thought she removed all the air in the syringe, and that she didn't see it clearly because of the goggles that she was wearing. On 12/21/22 at around 12:45 PM, R44's medication administration record was reviewed. It showed in the administration history with time included that V18 signed that she had given Rytary ER 48.75-195 mg cap (2 caps) and Furosemide 20 mg tablet at 4:07 PM, and Novolog 10 units plus 12 units equivalent to 22 units at 3:58 PM. On 12/21/22 at 12:50 PM, V24 (Clinical Resource Nurse) confirmed that V18 signed Furosemide 20 mg at 4:07 PM, and for Novolog V18 documented that she gave a total of 22 units of this insulin. On 12/21/22 at 2:14 PM, V19 (Clinical Nurse Manager) stated that when administering medication, the staff must ensure that they follow physician's order, the staff must follow the right medication, right person, right route, right time, right dose to ensure that there's no medication error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 10 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to serve portion sizes for the mechanical soft diets as shown in the menu spread sheet for the lunch meal service. This applies to 4 of 5 residents (R10, R25, R39, R64) observed for dining in the sample of 22. The findings include: Facility daily menu spreadsheet (Week 1: Monday) showed that the main entree for the lunch meal was BBQ [Barbeque] meatloaf (2 oz/ounce protein=2-1/2 oz serving). The column for serving portion for mechanical soft diets included ground BBQ meat lf/sce (12 scoop + 1 oz sce). [lf/sce=loaf/sauce]. On 12/19/22 on 12:05 PM, V15 (Cook) was seen at the tray line platting the lunch meal which included meat loaf with gravy as the main entree. V15 used a #16 scoop to serve ground meat loaf to the residents on mechanical soft diet. R64's tray card showed mechanical soft, double portion protein and received two #16 scoops of ground meat loaf. R10's tray card included mechanical soft diet with double portions and received two #16 scoops of ground meat loaf. R25 and R39's tray cards showed mechanical soft, and each person received one #16 scoop of ground meat respectively. When V15 was asked why #16 scoop was used instead of the #12 scoop,V15 stated that they (facility) do not have a #12 scoop and therefore he is using a larger #16 scoop which is a 2 oz portion to serve the residents mechanical soft meat. V15 added that based on the spreadsheet the 12 scoop is only 1 oz. V15 was notified that the spreadsheet was showing to use #12 scoop for ground meat + 1 oz sauce. V15 stated that he was under the impression that the 1 oz that appeared near #12 scoop meant that #12 scoop = 1 oz. On 12/19/22 at 12:27 PM, V11 (Culinary Director) showed a scoop size chart posted on the wall and stated that according to this chart #16 scoop =2 oz, #12 scoop =2 and 2/3 oz. V11 stated that based on this chart, the #12 is a bigger portion. On 12/21/22 at 01:24 PM, V20 (Registered Dietitian) stated that the facility should follow the menu spreadsheets to serve portion sizes as indicated. Facility Diet Orders listed on Diet List Report printed on 12/19/22 included that R10, R25, R39, and R64's are on mechanical soft diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 11 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 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. Based on observation, interview, and record review, the facility failed to ensure that the dishes are washed in a clean and sanitary environment and failed to maintain sanitizing solutions in sanitation buckets within recommended sanitation concentrations. This applies to all 91 residents that receive oral diets from the facility kitchen. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated 12/19/22 showed that the census of the facility was 92. Facility provided documentation that there was only one resident on NPO (Nothing by mouth) status on 12/19/22. 1. On 12/19/22 at 09:44 AM, the initial tour of the facility kitchen was done in the presence of V11 (Culinary Director). At the dish machine, V12 (Dietary Server) was seen loading the used dishes on the left side of the dish machine and V13 (Dietary Server) was pulling the clean dishes off the racks from the right side. The clean side of the dish machine was noted to have marked food deposits and scum, and the back splash of this area had blackish/brownish spots/substance. When this backsplash was wiped with a paper towel, brownish black substance came off to the surface of the paper towel. V11 stated that this blackish brown substance is the dirt from the paint that is chipping off from the walls. When standing by the dish machine, water was noted to be dripping from the ceiling above the dish machine unto racks of newly washed dishes and the floor surrounding it. To catch these drips, there were two yellowish colored rags that were soaked with liquid placed on top of the dish machine. V11 stated that the leak in the ceiling started last Thursday when it was raining outside and that she notified V14 (Environmental Service Director) the same day. V11 continued, that the facility is only one storied and there is no bathroom above this ceiling. V11 was notified that the cleaned dishes that were pulled from the dish machine on to the soiled area and those dishes that were stored under the dripping from the ceiling cannot be used for the meal service. V11 was also notified that the use of this dish machine to wash dishes under the current conditions has to be with the direction of facility management. On 12/19/22 at 10:52 AM, the concern of leakage above the dish machine was reported to V1 (Administrator) who stated that she was not aware of the leak from the ceiling. V1 stated that V14 (Environmental Service Director) handles all work orders. On 12/19/22 at 10:59 AM, after the inspection of the dish machine area, V1 verified that there is no patient care area above the ceiling. V1 stated that the affected dishware will be rewashed, and the storage of dishes relocated, and the area will be cleaned and sanitized. V1 stated We have to investigate where the leak is. V11 was present during this interaction. On 12/19/22 at 11:42 AM, V14 stated that this has been a recurrent issue whenever there is heavy rain. V14 stated that the wind created by the rain tends to blow into the discharge vent of the dishwasher on the roof. V14 stated that the water drippings are from the condensation of the dish machine steam that is supposed to go out of the vent. V14 stated that he was notified on Thursday and put in a work order on Friday and the roofers said that they will come as soon as they can to replace the entire vent. On 12/20/22 at 09:42 AM, the facility kitchen was visited again and noted that the ceiling still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 12 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 0812 Level of Harm - Minimal harm or potential for actual harm had peeling paint with condensation and continued drips to the floor from the same. The yellow-colored water-soaked rags were still on top of the dish machine. V16 (Dietary Server) who was in the area stated, it's always been there. The clean side of the conveyor belt had food debris collecting at base of the rack that held clean dishes. The back splash was still covered in areas with blackish/brownish spots. This was again relayed to V11 who stated that she will ensure that this area is cleaned again prior to washing dishes. Residents Affected - Many On 12/20/22 at 11:22 AM, V14 stated the roofing company came by and stated that there were no issues with the roof. V14 continued that he had the Plumbing and Piping company come in and they stated that the belt that makes the fan spin to remove the condensation was broken which is causing the steam to be trapped and causing the leak. V14 stated that once the belt is fixed, he will cut out the dry wall and put in a new one to fix all the leaks and also clean and repaint the blackened area of the backsplash on the conveyor belt of the dish machine. 2. On 12/19/22 at 9:51 AM, V15 (Cook) was seen wiping the counter tops of the steam table with a cloth from a sanitizing bucket. When the sanitizing strength of the sanitizer was checked with a test strip, it showed a light green color on the color chart registering at 50 ppm/parts per million. V11(Culinary Director) stated that the sanitizer used is a QUATS [Quaternary Ammonia Cation] should test between 150-200 ppm. Facility Sanitizer Test Strip labels/dish machine procedure dated 6/10/22 included as follows: Using sanitizer test strips are one way to confirm levels are achieved to protect against food borne illnesses. A quat disinfectant must be 150-300 PPM to be considered effective. It's no longer considered to be an effective disinfectant at levels below 100 ppm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 13 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow standard infection control practices during provisions of care related to hand hygiene, gloving and proper use of mask. The facility also failed to ensure catheter tubing was not touching the floor. This applies to 4 of 5 residents (R19, R37, R44, R74) reviewed for infection control in the sample of 22. Residents Affected - Some The findings include: 1. On 12/19/22 at 3:55 PM, V18 (Nurse) administered medication to R44 while her mask was covering only her mouth and her nose was totally exposed. V18 talked to R44 and was only an arm's length away from R44. 2. On 12/20/22 at 12:52 PM, V5 and V10 (Both Certified Nursing Assistants/CNAs) provided incontinence care to R74 who was wet with urine. V10 wiped R74's posterior perineum, applied clean incontinence brief, repositioned, and straightened R74's clothes and bedding while wearing same soiled gloves. 3. On 12/20/22 at 1:55 PM, V10 and V23 (Both CNAs) provided incontinence care to R37. V23 cleaned R37's peri-area from front to back, then she applied barrier cream and clean incontinence brief, and repositioned R37 while wearing same soiled gloves. On 12/21/22 02:11 PM, V19 (Clinical Nurse Manager) stated that the staff must wash hands before donning gloves, perform hand hygiene and change gloves between dirty to clean task, and perform hand hygiene after completing care to prevent spread of infection. 4. During this survey, the facility had residents with Covid-19. On 12/20/22 at 1:49 PM, V25 and V26 (Both Housekeepers) entered the facility without a mask. They walked through a unit corridor where resident bedrooms were, and they reached the nurses' station and asked a nurse for the mask. There were several residents sitting in wheelchairs parked around the nurses' station. These residents were not wearing mask. The nurse along with V25 and V26 went somewhere and came back to the nurses' station with a box of mask. V25 and V26 applied their mask at the nurses' station. The surveyor asked a staff the names of V25 and V26. A few minutes later V25 and V26 approached the surveyor. V26 was angry and in a loud (yelling) voice asked the surveyor why their name was asked. The surveyor informed them of the observation. V26 stated that it's not her fault that there was no mask available by the facility's door when they entered the facility. On 12/20/22 at 2:35 PM, V1 (Administrator) and V14 (Environmental Service Director) both stated that staff must put a mask on before they enter the facility and must always wear it inside the facility. They also added the staff must wear it appropriately as part of their infection prevention process. Facility's Policy and Procedure for Hand Hygiene shows: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Procedure: 7. Use alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 14 of 15 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 145536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Bourbonnais,the 20 Briarcliff Lane Bourbonnais, IL 60914 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 the following situations: Level of Harm - Minimal harm or potential for actual harm h. Before moving from a contaminated body site to a clean body site during resident care. j. After contact with blood and body fluids. Residents Affected - Some 9. The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 5. R19's diagnoses on EMR (electronic medical records) included unspecified intellectual disabilities, acute kidney failure, obstructive and reflux uropathy, kidney transplant status. R19's POS (Physician Order Sheet) included Suprapubic catheter #16FR [French] related to obstructive and reflux uropathy. On 12/19/22 at 11:36 AM, R19 was seen seated in a wheelchair in his room and noted to have catheter tubing on the floor under R19's wheelchair. One end of the tubing was tucked into the leg of R19's pants and the other end with the catheter bag in a privacy bag. R19 was not able to answer queries adequately and stated ya ya to all queries. R19 was seen wheeling himself back at forth in his room with the tubing dragging on the floor underneath the wheelchair. On 12/19/22 at 12:47 PM, V9 (Licensed Practical Nurse) was notified about R19's catheter tubing on the floor. V9 stated He [R19] has a suprapubic catheter. The catheter tubing should not be on the floor. On 12/21/22 at 03:30 PM, V3 (Assistant Director of Nursing) stated that the catheter tubing should not be on the floor because of cross contamination from things from the floor to patient. Facility policy and procedure titled Catheter Care, Urinary (revised September 2014) included as follows: Infection Control: b) Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145536 If continuation sheet Page 15 of 15