Inspection·April 5, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident nails are trimmed and cleaned as needed. V17 said resident nails should be cleaned and trimmed to help prevent the spread of germs. and if a resident has a contracted hand, long nails could cut their hand. The facility's Nail Care Review not dated shows if necessary trim nails using a clipper. Check each nail for snags and file until smooth. Based on observation, interview and record review the facility failed to provide incontinence care and nail care to residents who required the assistance of staff for activities of daily living (ADL) for 4 of 20 residents (R92, R42, R25, R56) reviewed for activities of daily living in the sample of 20. The findings include: 1.R92's resident assessment dated [DATE], showed R92 required the extensive assistance of staff for toileting. The assessment showed R92 was always incontinent of bladder and bowel. R92's care plan dated March 28, 2023, showed R92 is incontinent of bladder and bowel . Check for incontinence; change if wet/soiled. R92's progress notes dated March 6, 2023, showed R92 was emergently sent to a local hospital for a change condition where R92 was hospitalized for severe sepsis. R92's progress notes dated March 18, 2023, showed R92 was readmitted to the facility, from the hospital, after receiving treatment for severe sepsis, pneumonia, and UTI (urinary tract infection). On April 3, 2023, at 10:00 AM, R92 was seated in a wheelchair in her room. V7 (Family of R92) was seated next to R92. An odor of urine was noted in R92's room. When R92 was asked about the last time she was toileted, R92 stated, It was before breakfast, around 7:00 AM. On April 3, 2023, at 11:00 AM, R92 was in bed. V7 (Family of R92) remained at R92's bedside. R92's call light was on. V7 stated, We are still waiting for someone to come and take her to the bathroom. This really upsets me. We told them she needed to be checked and toileted every 2 hours. She just got back from the hospital where she was diagnosed with a UTI. The hospital said she got her UTI from laying in her pee. On April 3, 2023, at 11:10 AM, V8 Certified Nursing Assistant (CNA) assisted R92 to the toilet. As V8 CNA was transferring R92 from her wheelchair to the toilet, R92 was urinating on her clothing and legs. R92's incontinence brief was soiled with a large amount of urine. 2. R42's resident assessment dated [DATE], showed R42 required the extensive assistance of staff for toileting. The assessment showed R42 was frequently incontinent of bladder and bowel. On April 3, 2023, at 11:40 AM, R42 was in bed. R42's incontinence brief appeared wet. An odor of stool was noted in R42's room. R42 stated, I can't get up to the bathroom without someone to help me, so I just lay here and pee on myself. On April 3, 2023, at 11:55 PM. V6 CNA entered R42's room. V6 stated the last time she provided incontinence care to R42 was at 8:30 AM. V6 CNA began providing cares to R42. V6 CNA removed R42's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 incontinence brief. R42's incontinence brief was saturated with urine and contained a large amount of stool. Level of Harm - Minimal harm or potential for actual harm On April 4, 2023, at 9:00 AM, V2 Director of Nursing stated incontinence care should be offered and/or provided to residents every 2 hours and as needed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 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 provide the necessary care and services by not reporting a non pressure wound to the appropriate staff for one of 20 residents (R25) reviewed for quality of of care. Residents Affected - Few The findings include: R25's Order Summary Report dated 4/4/23, shows R25 was admitted to the facility on [DATE] with diagnoses including acquired absence of right leg above knee, colon cancer, history of transient ischemic attack, malnutrition, and dementia. R25's MDS (Minimum Data Set) dated 2/22/23 shows R25 requires extensive assistance with bed mobility, transferring, toilet use, and personal hygiene. R25 is always incontinent of urine. On 4/3/23 at 11:03 AM, V11 CNA (Certified Nursing Assistant) performed incontinence care to R25. R25's incontinence brief was saturated with urine, there was a strong urine odor. The was a small open area to R25's sacrum. V11 did not applied any barrier cream or ointment to R25's buttocks. V11 said R25 last received incontinence care on the night shift, about 6:30 AM. R25's Care Plan initiated 9/21/22 shows, Check skin for areas of redness. Report any changes to the nurse. Apply moisture barrier to buttocks. R25's Skin/Wound Noted dated 4/4/23 at 3:30 AM shows, Partial thickness epidermal peeling noted to coccyx measuring 3.0 cm X 1.0 cm. Perform prompt toileting/incontinence care using absorbent products and moisture barrier creams as needed. On 4/05/23 at 11:26 AM, V14 Wound Care Nurse said, the staff let her or the nurse know right away if they find something on residents skin. V14 said she was notified 4/4/23 that R25 had an open area to her buttocks. V14 said that R25 has moisture acquired skin damage to her sacrum. (The day after the open area was observed by the surveyor). On 4/5/23 at 11:29 AM, V2 DON (Director of Nursing said staff should be putting on barrier cream on incontinent residents so the moisture is not irritating to the residents' skin. The facility's Pressure Injury Prevention and Treatment policy effective 3/3/23 shows, The facility must have a system in place to assure that daily monitoring and periodic documentation of measurements and appropriate assessment are implemented consistently throughout the community. To ensure that care staff and licensed nurses are appropriately initiating interventions, treatment, evaluation and documentation to attempt to prevent further deterioration and provided appropriate interventions for healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R56's Order Summary Report dated 4/4/23 shows he was admitted to the facility on [DATE] with diagnoses including history of falling, metabolic encephalopathy, urinary tract infection, pressure ulcer of sacral region stage 4, non pressure chronic ulcer of left heel and midfoot, muscle weakness, cognitive communication deficit, and chronic kidney disease. Residents Affected - Few On 4/3/23 at 2:18 PM, R56's heel were directly on his mattress. There were two green heel boots noted R56's wheel chair underneath linens. R56's dressing to his buttocks was changed by the wound care nurse. The wound care doctor assessed R56's wound and handed R56's heel boots to the wound care nurse. R56's Wound Evaluation and Management Summary dated 3/27/23 by the wound care doctor shows, Recommendations sponge boot. R56's Care Plan initiated on 6/30/22 shows, R56 is at risk for skin breakdown due to decline in mobility, pain, incontinence, and presence of pressure injuries. Provided heel pressure relief as appropriate. Care plan Initiated 2/24/23 shows low air loss mattress, wheelchair cushion, heel lift boots to bilateral feet when in bed. There is no documentation of R56 refusing any care or treatment prior to 4/3/23. The facility's Pressure Ulcer Prevention and Treatment policy revised on 3/3/23 shows, To identify and institute nursing measure needed to care for individuals at risk for impairment of skin integrity. Reposition resident per care plan using pressure relieving devices to prevent bony prominences from rubbing as applicable. Based on observation, interview and record review the facility failed to ensure pressure injury interventions and treatments were in place for 3 of 7 residents (R33, R42, R56) reviewed for pressure injuries in the sample of 20. The findings include: 1.R33's Skin/Wound note dated March 16, 2023, showed R33 was admitted to the facility with a DTI (deep tissue injury) to his left buttock that measured 3.0 cm (centimeters) x 4.5 cm x 0 foam dressing applied. Monitor resident for pain or discomfort. Turn and reposition resident at frequent intervals. R33's Skin and Wound Evaluation report dated April 3, 2023, showed R33's pressure/deep tissue injury remained to his left buttock area. On April 3, 2023, at 9:55 AM, R33 was seated in a wheelchair in his room. A mesh sling from a mechanical lift was noted underneath R33's buttock and lower back, in the wheelchair. R33 stated, My butt hurts. I have been sitting up in this wheelchair since 7:00 AM this morning. I have a wound on my butt. The sling bunches up underneath me and it hurts my butt. They want me to stay in the wheelchair because I have to go to therapy. I just want to get off my butt. On April 3, 2023, at 10:10 AM, R33 was in therapy, seated in his wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On April 3, 2023, at 10:22 AM, R33 was wheeled back to his room by therapy staff. R33 remained in his wheelchair. On April 3, 2023, at 10:52 AM, R33 remained in his wheelchair. V4 Certified Nursing Assistant (CNA) stated, We got (R33) up to his wheelchair around 7:00 AM. We get our hoyer lift (mechanical lift) residents up early. On April 3, 2023, at 11:25 AM, R33 remained seated in his wheelchair, in his room. R33 stated, My butt hurts. I have been up in this chair since 7:00 AM. I can't move on my own. I broke my leg. I can't stand on my leg. V5 Wound Nurse entered R33's room and stated, Can we get you into bed and look at your wounds before lunch? R33 stated, Sure. On April 3, 2023, at 11:41 AM, R33 remained seated in his wheelchair. V5 Wound Nurse stated, I can't find a CNA right now to help me get (R33) into bed so I will look at (R33's) wounds after lunch around 12:30 PM. DTI is another name for pressure injury. I don't see where (R33's) pressure injury (to his left buttock) has been staged yet.(R33) should be repositioned every 2 hours. He shouldn't be up in the wheelchair, on his butt, for more that 2 hours at a time. On April 3, 2023, at 12:21 PM, R33 remained seated in his wheelchair. On April 3, 2023, at 1:00 PM, R33 remained seated in his wheelchair. On April 3, 2023, at 1:20 PM, R33 complained of terrible pain to his buttocks to V8 CNA. R33 remained seated in his wheelchair. On April 3, 2023, at 1:55 PM (approximately 7 hours later), R33 was placed in bed by staff. 2. R42's care plan dated March 16, 2023, showed R42 was admitted to the facility with Stage 4 pressure injuries to his sacrum and right ischium (buttock) area. The plan showed R33 is at risk for developing new pressure injuries and skin breakdown related to osteomyelitis and Stage 4 pressure injury on sacrum region .Interventions .Low air loss mattress .Prompt toileting/incontinence care .Treatment per physician orders . R42's Wound Evaluation and Management Summary dated April 3, 2023, showed R42's Stage 4 sacral pressure injury measured 3.9 cm x 2.6 cm x 1.0 cm. The summary showed a physician order of apply foam border dressing to sacral injury once a day. The summary showed R42's Stage 4 right buttock pressure injury measure 0.7 cm x 1.8 cm x 0.2 cm. The summary showed a physician order of apply gauze and foam border dressing to buttock injury once a day. On April 3, 2023, at 11:40 AM, R42 was in bed. R42's incontinence brief appeared wet. An odor of stool was noted in R42's room. R42 stated, I can't get up to the bathroom without someone to help me, so I just lay here and pee on myself. R33's air mattress (pressure redistribution mattress) was turned off/not working. On April 3, 2023, at 11:55 PM. V6 CNA and V5 Wound Nurse entered R42's room. V5 Wound Nurse walked over to R42's bed and began talking to R42. V5 Wound Nurse looked at R42's mattress, felt the mattress, walked down to the foot of the bed, and turned the air mattress on. V5 Wound Nurse then exited the room. V6 CNA began providing cares to R42. V6 stated the last time she provided incontinence care to R42 was at 8:30 AM. V6 CNA removed R42's incontinence brief. R42's incontinence brief was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few saturated with urine and contained a large amount of stool. No dressings were noted to R42's sacral wound or right buttock wound. Stool was noted on and around R42's golf-ball sized, circular, sacral wound. V6 CNA finished providing cares to R42 and placed him in a clean incontinence brief. No dressings were in place to R42's sacral or right buttock pressure injuries. On April 3, 2023, at 12:04 PM, V5 Wound Nurse stated, The pressure interventions we have in place for (R42) include an air mattress, frequent incontinence care and wound dressings. We need to make sure his air mattress is on so it can help take pressure off his wounds. If there is not a dressing in place, staff should report it immediately to the nurse so one can be reapplied. On April 3, 2023, at 1:47 PM, V5 Wound Nurse stated, No one reported to me that (R42's) wound dressings weren't in place. The facility's Pressure Ulcer Prevention and Treatment policy dated March 3, 2023, showed, Policy: . To ensure that care staff and licensed nurses are appropriately initiating interventions, treatment, evaluation and documentation to attempt to prevent further deterioration and provide interventions for healing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure residents received restorative services and failed to ensure devices were in place to contractures for four of 17 residents (R56, R43, R72, R50) reviewed for restorative programming in the sample of 20. The findings include: 1. R56's Order Summary Report dated 4/4/23 shows he was admitted to the facility on [DATE] with diagnoses including history of falling, metabolic encephalopathy, urinary tract infection, pressure ulcer of sacral region stage 4, non pressure chronic ulcer of left heel and mid-foot, muscle weakness, cognitive communication deficit, and chronic kidney disease. On 4/3/23 at 10:04 AM, R56 was observed in bed. R56's left hand was contracted and R56 had long nails. R56 said that he needed his nails trimmed. There were no devices in place to R56's contracted left hand. R56's MDS (Minimum Data Set) dated 2/18/23 shows R56 did not have any functional limitation in range of motion with his upper extremities. R56's Occupational Patient Discharge Instructions dated 3/8/23 shows, Discharge plan and instructions: Patient discharged to same skilled nursing facility, as above with recommendations including wearing of palm protectors. Staff/patient to be trained. R56's Orders and Care Plan were updated on 4/4/23 to reflect occupational therapy recommendations. 2. R43's Order Summary report dated 4/5/23 shows R43 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, heart disease, history of falling, carpal tunnel syndrome, and foot drop. R43's Occupation Therapy Progress and Discharge summary dated [DATE] shows, The patient did make significant progress toward most goals as above. Patient discharged from occupational therapy at this time with plan for patient to receive restorative program services to maintain range of motion at left upper extremity joints. Post discharge recommendation for patient include follow through, restorative program. Has bilateral wrist splints. R43's Care Plan Revised on 9/16/22 shows, [R43] has a splint to left hand on in AM and off at bedtime. On 4/3/23 at 11:37 AM, R43 was laying in his bed. R43's left hand was contracted. R43's fingers were bent towards the palm of his hand. There was a rolled wash cloth rolled in tape on the top of R43's rolling table. 3. On 4/5/2023, R50's admission Record showed R50 is an [AGE] year-old female resident with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R50's Minimum Data Set (MDS) section C shows R50 as having a BIMs score of 14, cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 4/3/2023 at 11:35AM, R50 was observed in her room sitting up in a wheelchair. R50's right upper extremity was sitting on a padded armrest. R50 said she had a stroke and lost the function of the right side of her body. R50 said the facility does not offer her restorative services. R50 said staff does not do range of motion exercises with R50 to maintain R50's functional ability and strength. On 4/5/2023, R50's Care Plan shows R50 having an ADL/Functional Deficit: R50 requires assistance in ADL functions due to Hx of CVA with right side. R50's Care Plan goal states Resident will achieve maximum functional mobility for safe return to home within 90 days. R50's Occupational Therapy notes reason for discharge shows R50 needing restorative nursing services. R50's task documentation for Restorative - Active Range of Motion Program and Restorative - Passive Range of Motion Program shows no documentation of either task being completed in the last 30 days. 4. On 4/5/2023, R72 admission Record showed R72 is a [AGE] year-old male resident with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R72's MDS shows R72 as having a BIMs score of 9, not cognitively intact. On 4/3/2023 at 10:25AM, R72 was observed near the doorway of his room sitting up in a wheelchair. R72 had his left arm up on a padded armrest secured to the armrest. R72 did not move his left arm. R72 was attempting to roll his wheelchair out of his room. R72's Care Plan shows R72 as having an ADL deficit due to recent medication condition, diagnosis of CVA. On 4/4/2023 at 2:07PM, V2 Director of Nursing (DON) said there is no restorative program in place. V2 said the two restorative aides they had either quit or changed positions within the company. The facility failed to provide any documentation of R50 and R72 receiving restorative services. A list of residents with contractures and decreased range of motion was requested from the facility twice. The facility failed to provide a list of residents with contractures or decreased range of motion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R92's care plan dated February 28, 2023, showed R92 was at risk for falls due to her diagnoses of unsteady gait, weakness, and incontinence. The care plan showed R92 required the assistance of 1-2 staff for toileting and transfers. The care plan showed, Use gait belt as appropriate for all transfers and assisted ambulation . On April 3, 2023, at 11:10 AM, V8 Certified Nursing Assistant (CNA) transferred R92, from her bed to a wheelchair, by holding on the waistband of R92's pants. V8 CNA did not place a gait belt around R92's waist to assist with the transfer. V8 CNA wheeled R92 to the bathroom. V8 CNA again transferred R92 from her wheelchair to the toilet, without the use of a gait belt. 3. R59's care plan dated February 7, 2023, showed R59 was at risk falls due to her diagnoses of unsteady gait and weakness. The care plan showed R59 was incontinent of bowel and required the assistance of staff for toileting and transfers. The plan showed, Use gait belt as appropriate for all transfers and assisted ambulation. On April 3, 2023, at 10:33 AM, V9 Physical Therapy Assistant (PTA) transferred R59, from her wheelchair to the toilet, by holding onto R59's arms. No gait belt was used during the transfer. On April 3, 2023, at 10:35 AM, V9 PTA stated, I didn't use a gait belt to transfer (R59). I should have but she was in a hurry. On April 4, 2023, at 9:00 AM, V2 Director of Nursing stated staff are to use a gait belt to transfer any residents that need assistance with transfers and/or toileting. Based on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place by not locking the wheels on a shower chair and failed to transfer a resident in a safe manner for three of 20 residents (R14, R92, R59) reviewed for safety in the sample of 20. The findings include: 1. On 4/5/2023, R14's admission Record showed R14 was admitted to the facility on [DATE]. On 4/3/2023, R14's progress notes show R14 had a fall on 3/28/2023 while in the shower with facility staff. On 4/5/2023 at 11:24AM, R14 was interviewed in his room. R14 said he fell in the shower. R14 said he leaned forward and slipped off the shower chair. R14 said the chair rolled back away from him. R14 said he landed on his butt and fell back onto his back and hit his head. R14 said he was sent to the hospital for evaluation. R14 said he had soreness after the fall for a couple of days. On 4/4/2023 at 2:30PM, V12 Certified Nursing Assistant (CNA) said she was giving R14 a shower on 3/28/2023. V12 said she asked R14 to lean forward on the shower chair so she could dry off R14s back with a towel. V12 said R14 leaned too far forward and fell off the shower chair. V12 said the shower chair rolled backwards away from the resident. V12 said R14 fell on his butt first, then fell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 backwards onto his back and hit his head. V12 said the back wheels on the shower chair weren't locked and that is why the chair rolled. V12 said the shower chair should be locked. On 4/5/2023 at 11:54AM, V2 Director of Nursing (DON) said the shower chair wheels should be locked while a resident is in the shower chair. V2 said if they wheels aren't locked on the shower chair the chair could possibly move and the resident could fall. On 4/5/2023 at 11:06AM, V15 Medical Doctor said he was notified of R14 falling on 3/28/2023. V15 said he happened to be in the building that day when he was called. V15 said he went to the unit R14 was on and received an assessment from the nurse on duty. V15 said he ordered R14 to be sent out to the hospital because R14 was on blood thinners. V15 said it his policy to send out all residents who hit their head and are on blood thinners to the hospital for further evaluation. V15 said facility staff called 911 and R14 was sent to the hospital for evaluation. V15 said R14 stayed in the hospital for further monitoring due to orthostatic hypotension. On 4/5/2023, R14's progress notes show R14 returning from the hospital to the facility on 3/30/2023 via ambulance. R14's Morse Fall Scale, effective date 2/11/2023, showed R14 of having a fall risk score of 65, category high risk for falling. The Morse Fall Scale shows high risk as 45 and higher. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 ensure appropriate treatment and services were provided to prevent urinary tract infections for two of five residents (R5, R25) reviewed for incontinence care in the sample of 20. The findings include: 1. R5's Order Summary Report dated 4/4/23 shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, hemiplegia and hemiparesis, and muscle weakness. R5's MDS (Minimum Data Set) dated 1/30/23 shows she is not cognitively intact, requires extensive assistance with bed mobility, toilet use, and personal hygiene. R5 is always incontinent of urine and frequently incontinent of bowel. On 4/3/23 at 11:46 AM, V10 CNA (Certified Nursing Assistant) provided incontinence care to R5. There was stool in R5's buttocks. V10 wiped R5's buttocks multiple times with stool still noted on the wet wipe. V10 stopped wiping R5's buttocks and placed a clean brief on her and transferred her into the wheel chair although there was still a moderate amount of stool noted on the last wet wipe. There was no barrier cream applied to R5's peri area. R5's Care Plan initiated on 1/31/23 shows, Cleanse well after incontinence. 2. R25's Order Summary Report dated 4/4/23, shows R25 was admitted to the facility on [DATE] with diagnoses including acquired absence of right leg above knee, colon cancer, history of transient ischemic attack, malnutrition, and dementia. R25's MDS (Minimum Data Set) dated 2/22/23 shows R25 requires extensive assistance with toilet use and personal hygiene. R25 is always incontinent of urine. R25's Care Plan initiated on 9/21/22 shows R25 is always incontinent of bladder, check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier. [R25] is receiving diuretics. On 4/3/23 at 11:03 AM, V11 CNA provided incontinence care to R25. R25's incontinence brief was saturated from front to back. There was a strong urine smell. The incontinence pad that was under R25 was also wet with urine. V11 wiped the left side of R25's buttocks, but did not wiped R25's right side. V11 did not apply any barrier cream. On 4/5/23 at 9:51 AM, V17 CNA said when doing incontinence care, it is important to make sure there is no more stool in the residents buttocks because if stool is left in there, it could cause infection or redness. V17 said both sides of the residents body should be cleanse so skin breakdown does not occur. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to ensure prescription medications were administered according to standards of practice for 1 of 20 residents (R353) reviewed for medication administration in the sample of 20. The findings include: On April 3, 2023, at 10:20 AM, R353 was seated in bed with her bedside table in front of her. Two oblong pills were noted lying on the table. R353 stated, I take so many medications. Those are my morning pills. I couldn't take them all. I will take them later. On April 3, 2023, at 10:40 AM, V3 Registered Nurse (RN) stated, Nurses should watch residents take their medications but (R353) didn't want to take all of her medications this morning. Those pills are her magnesium pill and probiotic. I don't think she has ever been assessed to keep her medications at her bedside or to self-administer her medications. On April 4, 2023, at 9:00 AM, V2 Director of Nursing, Medications cannot be left at a resident's beside unless the resident has been assessed to self-administer medications and has a physician order to do so. Nurses should watch each resident take their medications. R353's medication administration record dated April 3, 2023, showed V3 RN administered 1 tablet of Magnesium Oxide (400 mg/milligram) and 1 capsule of probiotic (250 mg) to R353 on the morning of April 3, 2023. R353's Physician Order report dated April 4, 2023, showed no order to allow medications to be kept at R353's bedside or order to allow R353 to self-administer her medications. R353's medical records dated March 21, 2021 (admission) to April 3, 2023, were reviewed. The records showed that R353 had not been assessed to self-administer her medications. An Assessment for Resident Self Administration of Medications for R353, dated April 4, 2023, showed R353 was assessed to self-administer her medications but was deemed unsafe to do so. The facility's Medication Administration policy dated March 1, 2023, showed, The resident is always observed after administration to ensure that the dose was completely ingested. If the medication is prepared but the resident is unable to take it immediately, the medication should be labeled with the resident's name, covered and returned to medication cart until the resident is able to take the medication or the medication is disposed of residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves in a manner to prevent cross contamination for four of 20 residents (R5, R25, R64, R18) reviewed for infection control in the sample of 20. Residents Affected - Some The findings include: 1. R5's Order Summary Report dated 4/4/23 shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, hemiplegia and hemiparesis, and muscle weakness. R5's MDS (Minimum Data Set) dated 1/30/23 shows she is not cognitively intact, requires extensive assistance with bed mobility, toilet use, and personal hygiene. R5 is always incontinent of urine and frequently incontinent of bowel. On 4/3/23 at 11:46 AM, V10 CNA (Certified Nursing Assistant) provided incontinence care to R5. There was stool in R5's buttocks. V10 wiped R5's buttocks multiple times with stool still noted on the wet wipe. V10 stopped wiping R5's buttocks and placed a clean brief on her and transferred her into the wheel chair although there was still a moderate amount of stool noted on the last wet wipe. There was no barrier cream applied to R5's peri area. V10 did not change her gloves prior to putting a new brief on. R5's Care Plan initiated on 1/31/23 shows, Cleanse well after incontinence. 2. R25's Order Summary Report dated 4/4/23, shows R25 was admitted to the facility on [DATE] with diagnoses including acquired absence of right leg above knee, colon cancer, history of transient ischemic attack, malnutrition, and dementia. R25's MDS (Minimum Data Set) dated 2/22/23 shows R25 requires extensive assistance with toilet use and personal hygiene. R25 is always incontinent of urine. R25's Care Plan initiated on 9/21/22 shows R25 is always incontinent of bladder, check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier. [R25] is receiving diuretics. On 4/3/23 at 11:03 AM, V11 CNA provided incontinence care to R25. R25's incontinence brief was saturated from front to back. There was a strong urine smell. The incontinence pad that was under R25 was also wet with urine. V11 wiped R25's front peri area, helped R25 turn on her side, wiped R25's buttocks and did not change her gloves or perform hand hygiene prior to touching R25. On 4/5/23 at 9:51 AM, V17 CNA said gloves should be changed after removing soiled items and prior to touching clean items so germs don't get transferred. 3. On 4/3/2023 at 12:15PM, V11 Certified Nursing Assistant (CNA) was observed touching R64's hat and clothing. V11 immediately went over to R18 and touched R18's clothing. V11 did not use hand sanitizer or wash her hands between contact with R64 and R18. On 4/3/2023 at 12:21PM, V18 Licensed Practical Nurse (LPN) said hand sanitation with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 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 145602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village at Victory Lakes, The 1055 East Grand Avenue Lindenhurst, IL 60046 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 alcohol-based hand rub or anti-bacterial soap should be used between patient contact. Level of Harm - Minimal harm or potential for actual harm On 4/4/2023 at 1:55PM, V16 Infection Control Nurse (ICP) said facility staff should use hand sanitizer or hand washing between patient contact to prevent cross contamination. Residents Affected - Some R64's Order Summary Report shows an active order for enhanced barrier precautions every shift for MDRO as of 11/7/2022. The facility's Standard Precautions Policy effective 3/1/23 shows, It is our policy to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene should be performed if hands will be moving from a contaminated body site to a clean body site during resident care and after contact with blood, body fluids or excretions, mucous membranes, non intact skin or wound dressings. Change gloves during resident care if the hands will move from a contaminated by site to a clean body site FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145602 If continuation sheet Page 15 of 15