Inspection·September 29, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. R41 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents one-person extensive assistance with toilet use and personal hygiene. Residents Affected - Some On 9/26/23 at 10:38 AM, R41 was observed sitting on a recliner, four feet away from her bed, with the call light in the bed and not within reach. The next day (9/27/23) at 9:38 AM, R41 was observed sleeping in her bed with a call light not within reach. The call light was curled around the chair leg and 3-4 feet from the bed. Based on observation, interview and record review, the facility failed keep call lights accessible to dependent residents. This applies to 7 of 7 residents (R23, R28, R38, R41, R83, R91, and R103) reviewed for accommodation of needs in a sample of 32. The findings include: 1. R91's face sheet showed the following diagnoses of acute respiratory disease, vascular dementia, anxiety disorder, abnormalities with gait and mobility and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R91's MDS dated [DATE] showed that R91's cognition is moderately impaired; R91 needs extensive assistance with two or more person physical assist with bed mobility, toilet use and personal hygiene; total dependence with two or more person physical assist with transfer. R91's care plan (start date 1/21/23) showed that R91 is at risk for falling as a result of decreased endurance, increased weakness with intervention to keep call light in reach at all times. On 9/27/23 at 9:28 AM, R91 was sitting up in bed. R91 said he wanted to be adjusted in bed. R91 could not locate his call light. Surveyor went out to the nurse's station to inform staff. On 9/27/23 at 9:49 AM, V14 (Restorative Aide) said call lights should be next to residents at all times in case they need help or in case of an emergency. On 9/27/23 at 11:30 AM, V2 (DON/Director of Nursing) said call lights should be within residents reach, so they can use it if they need help. The facility's Answering the Call Light (revised 8/2008) states when resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 2. R38's face sheet showed the following diagnoses of vascular dementia, pain in left hip, unsteadiness on feet, anxiety disorder and displaced intertrochanteric fracture of left femur. R38's Minimum Data Set (MDS) dated [DATE] showed that R38's cognition is severely impaired; R38 needs extensive assistance with two or more persons assist with bed mobility and transfers, needs extensive assistance with one person physical assist with toilet use and personal hygiene. R38's care plan (revised 9/6/23) showed that R38 needs extensive assist of one for transfers due to weakness and poor safety with intervention to keep call light within reach. On 9/27/23 at 9:28 AM, R38 was in bed resting. R38's call light was on the floor and not within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 2 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's reach. At 9:50 AM, R38's call light was still on the floor; Surveyor showed V14 Restorative Aide the location of R38's call light. 3. On 9/26/23 at 10:18 AM, R83 was sitting in her wheelchair next to her bed. R83's call light was on the floor behind her, out of reach of the resident. R83 said the facility staff do not bring it closer to her when she's in the wheelchair. R83's face sheet shows R83 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, hypertension, cognitive communication deficit, spinal stenosis, lack of coordination, repeated falls, unsteadiness on feet, weakness, and spinal stenosis. R83's MDS dated [DATE] shows R83 had severe cognitive impairment and required supervision for eating and required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. R83's care plan dated 7/13/23 shows to keep call light within reach. 4. On 9/26/23 at 10:23 AM, R103 was in a seated position, leaning to the right side in her bed. R103's adaptive call light was on the floor on the opposite side and not within reach of the resident. R103 began patting her bed for the call light and said she did not know where her call light was located. R103 requested for someone to come and find her call light for her. R103's face sheet shows R103 was admitted to the facility with diagnoses including bipolar disorder, dementia, weakness, lack of coordination, and fibromyalgia. R103's MDS dated [DATE] shows R103 had moderate cognitive impairment and required supervision for eating, limited assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. R103's care plan dated 9/21/23 shows to keep call light within reach of resident. 5. On 9/26/23 at 11:09 AM, R23 was sleeping in bed. R23's call light was on the floor and out of reach of the resident. On 9/27/23 at 01:06 PM, R23 was sitting in the recliner at the end of the bed. R23's call light was not within reach and was attached to the blanket on the bed. R23's face sheet shows R23 was admitted to the facility with diagnoses including cerebral aneurysm, dementia, difficulty in walking, weakness, and abnormal posture. R23's MDS dated [DATE] shows R23 had severe cognitive impairment and required limited assistance for bed mobility, transfers, eating, and required extensive assistance for dressing, toileting, and personal hygiene. R23's care plan dated 9/21/23 shows to keep call light within reach. 6. On 9/26/23 at 10:37 AM, R28 was sleeping in bed and her call light was on the floor and out of reach of the resident. R28's face sheet shows R28 was admitted to the facility with diagnoses including multiple sclerosis, anemia, dementia, weakness, lack of coordination, repeated falls, epilepsy, and dysarthria. R28's MDS dated [DATE] shows R28 had moderate cognitive impairment and required limited assistance for toileting, and extensive assistance for bed mobility, transfers, dressing, eating, and personal hygiene. R28's care plan dated 7/13/23 shows to keep call light in reach at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 3 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's Physician Order Sheet concurred with a resident's most recent POLST (Practitioner Order for Life-Sustaining Treatment) form. This applies to 1 of 6 residents (R74) reviewed for advanced directives in a sample of 32. The findings include: R74's [DATE] POS (Physician Order Sheet) showed an order dated [DATE] for DNR (Do Not Resuscitate). R74's documents showed two POLST (Practitioner Order for Life-Sustaining Treatment) forms. R74 had a POLST form dated [DATE] for DNR and a POLST form dated [DATE] for full code. On [DATE] at 2:14 PM, V5 (RN/Registered Nurse) said she was the nurse taking care of R74. V5 said if R74 was in cardiac arrest, she would look in the binder on the crash cart. V5 also said she would look at the resident documents to see what the residents' code status was. V5 said she believed R74 was a full code and two weeks earlier; she had a conversation with him where he expressed being a full code. V5 checked R74's orders and said she was unsure why there was an order for DNR, and she would need to confirm with R74 about his code status. V5 checked R74's documents which showed a POLST form dated [DATE], showing full code. On [DATE] at 2:23 PM, V5 went into R74's room and R74 said if he could be revived, he would want that. V5 asked R74 if he would want everything done, to which R74 said I want everything done. On [DATE] at 2:27 PM, V6 (Social Services Director) said R74's guardian witnessed the POLST form on [DATE] and R74 signed the POLST form from [DATE] showing he wanted to be a full code. V6 said R74 would get the final say, even if he has been assigned a guardian. On [DATE] at 03:23 PM, V6 said she had received an email from the guardian on [DATE] because R74 had gone to the hospital with two POLST forms, one indicating DNR status and one indicating full code status. On [DATE] at 2:30 PM, V2 (DON/Director of Nursing) said the facility staff should be following the POLST form that R74 signed on [DATE], indicating he was a full code. R74's face sheet shows R74 was admitted to the facility with diagnoses including paraplegia, osteoporosis, polyneuropathy, cerebral palsy, and abnormal posture. R74's MDS (Minimum Data Set) dated [DATE] showed R74 was cognitively intact and required supervision for eating and extensive assistance for bed mobility, dressing, toileting, and personal hygiene. The facility provided the email sent from R74's guardian to V6 dated [DATE] which documented the following: Apparently there were two POLST forms sent to the hospital yesterday, one listing him Full Code. Please omit the full code one from your system. The facility's Advance Directives policy dated 11/2016 showed Social Service and/or the interdisciplinary care plan team will review the resident's advance directive status as documented in the resident's record at the time of the initial care plan conference and reconfirm that no changes in status are desired. Facility staff will receive training at the time of hire regarding resident rights to formulate advance directives and the facility policy to assure the exercise of such rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 4 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 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 provide incontinent care, facial hair grooming, and nail trimming/grooming to dependent residents. Residents Affected - Some This applies to 5 of 7 residents (R6, R36, R41, R58, and R103) reviewed for activities of daily living (ADL) in a sample of 32. The findings include: 1. R41 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents one-person extensive assistance with toilet use and personal hygiene. On 9/27/23 at 9:38 AM, R41 was sleeping with a strong urine odor on her bed. R41 stated that she hasn't been changed yet. On 9/27/23 at 9:41 AM, V4 (Certified Nursing Assistant/CNA) checked on R41, and R41 was observed with an incontinence pull-up outside of an incontinent brief, and a bigger pad inside the incontinent brief, soaked in urine. 09/27/23 09:41 AM V4 stated, I changed R41 at around 6:30 AM when I started (three hours earlier). I have 11 residents, and incontinent care should be provided every 2 hours and as needed 2. R6's face sheet showed the following diagnoses of dementia, Alzheimer's disease, weakness, abnormal posture, and disorder of the muscle. R6's Minimum Data Set (MDS) dated [DATE] showed that R6's cognition is moderately impaired and needs extensive assistance with one person physical assist with personal hygiene. R6's care plan (revised 8/21/23) showed that R6 requires assist with ADLs related to impaired mobility, weakness, and other comorbidities. On 9/26/23 at 10:31 AM, during initial tour rounds on the second floor, R6 was observed in bed watching television. R6 asked surveyor if the surveyor had scissors or a razor. R6 had several long white hairs on the chin and was pulling on the hair. R6 said she would like the hair on her chin gone, and that was why she asked the surveyor for scissors and razor. R6 said she asked staff, but they have not done it. On 9/27/23 at 3:40 PM, V2 (DON/Director of Nursing) said the CNAs (Certified Nurse Aides) were responsible for ADLs, personal hygiene, bathing, toileting, grooming which includes shaving. 3. On 9/27/23 at 12:52 PM, R36 was sitting in her wheelchair, and she had long fingernails on both hands. R36's nails on her right hand had grown over a half an inch past her fingertips, and the nails on her left hand were varying lengths. R36's left hand thumb, ring finger, and pinky were half an inch past her fingertips, and the index and middle fingers were jagged. R36 said she last had her nails cut three months ago and the facility staff do not ask her if she wants her nails cut. R36 said she did not like having long nails and prefers short nails. R36 said she also does not like keeping her nails long because they crack, and her index finger and middle finger had cracked. On 9/27/23 at 01:49 PM, V10 (Restorative Aide/CNA/Certified Nurse Assistant) said he had never done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 5 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 R36's nails and the residents should not have long nails. Level of Harm - Minimal harm or potential for actual harm On 9/27/23 at 03:35 PM, V7 (CNA) said she takes care of R36, and she does not do nail care. On 9/27/23 at 03:33 PM, V9 (CNA) said residents should not have long nails. Residents Affected - Some On 9/27/23 at 03:41 PM, V9 said the nails should be cut twice a week. V9 said it is her expectation if the nails are long, they should be clipped. On 9/27/23 at 03:44 PM, V9 observed R36's nails and said the length of her nails were not acceptable and offered to clip them, to which R36 said yes. R36's face sheet shows R36 was admitted to the facility with diagnoses including hypertensive heart and chronic kidney disease, stage 5 chronic kidney disease, unsteadiness on feet, dependence on renal dialysis, heart failure, and type 2 diabetes mellitus. R36's MDS (Minimum Data Set) showed R36 was cognitively intact and required supervision for eating, and extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. R36's POS (Physician Order Set) shows an order dated 9/7/23 showing Resident nails should be short at all times. Special Instructions: Make sure resident nail is cut and should always be short. 4. On 9/26/23 at 10:32 AM, R58's nails on her hands were a quarter of an inch past her fingertips. R58 said she wished the facility staff would cut her nails and she does not like the length of her nails. On 9/27/23 at 01:03 PM, R58's nails were the same length and she said they were not cut yet but she would like them to be cut. R58's face sheet shows R58 was admitted to the facility with diagnoses including polyosteoarthritis, weakness, difficulty walking, lack of coordination, and cognitive communication deficit. R58's MDS dated [DATE] showed R58 had moderate cognitive impairment and required supervision for eating, and extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. R58's care plan dated 8/17/23 shows the facility staff should provide assistance for tasks she is unable to complete independently. 5. On 9/26/23 at 10:23 AM, R103's nails had grown approximately one inch past her fingertips on both hands. R103 said she does not like having long nails and would like them hacked off. R103 said the facility staff do not offer to cut her nails. On 9/27/23 at 12:57 PM, R103's nails were still one inch long and R103 said she does want them cut off. R103's face sheet shows R103 was admitted to the facility with diagnoses including bipolar disorder, dementia, weakness, lack of coordination, and fibromyalgia. R103's MDS dated [DATE] shows R103 had moderate cognitive impairment and required supervision for eating, and limited assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. On 9/27/23 at 4:35 PM, V2 (DON/Director of Nursing) said the staff should be checking the nails during shower days or on grooming days. It is part of their ADL (Activities of Daily Living) care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 6 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 The facility's Nail Care Guideline dated 2/23 nail care includes routine cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 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: 145614 If continuation sheet Page 7 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 9/26/23 at 10:52 AM, during initial tour of the first floor, R80 was sleeping on his bed in his room. There was a medium size oxygen cylinder that was by the wall next to his cabinet. It was unsecured and not in a cylinder rack. On 9/27/23 at 1:33 PM, R80 was sleeping on his bed in his room. The same oxygen cylinder remained unsecured. On 9/28/23 at 11:40 AM, surveyor and V2 (DON-Director of Nursing) reviewed R80's September 2023 POS (Physician Order Sheet). There were no orders for any type of oxygen equipment. R24's room was across from R80's room, and R43's room was next to R80's room. On 9/27/23 at 9:50 AM, V2 (DON) stated, Yes, the portable oxygen tanks should be secured in a holder or cannister. If it falls, it can combust. We have oxygen tanks in the oxygen room as well. They should be chained to the wall and secured as well. Facility's policy titled Oxygen Therapy and Devices (Unknown Date) documents the following: Definition of Oxygen: 4.) b. Compressed gas: i. Most common is the E-cylinder. ii. Must be secured at all times to prevent the cylinder from falling over. iii. Secure tanks in a cart or chained to the wall or a cylinder rack. 4. R14's face sheet showed the following diagnosis of acute respiratory disease. R2's physician order sheet (POS) showed an order for oxygen two liters by nasal cannula or mask as needed. On 9/26/23 at 11:02 AM, during initial tour rounds on the second floor, there were two metal oxygen tanks in R14's room by the wall cabinet. The oxygen tanks were not secured in a holder. At 11:48 AM and 12:35 PM, the oxygen tanks were still not in a holder. The next day on 9/27/23 at 9:27 AM, the two oxygen tanks remained in R14's room on the floor and were not secured. At 1:09 PM, the oxygen tanks were still in R14's room not secured. V17 (LPN/Licensed Practical Nurse) said the oxygen tanks should not be on the floor, they should be in a holder when not in use because it is a safety hazard. V17 said there is a room downstairs where oxygen tanks are kept when not in use. On 9/26/23 and 9/27/23, surveyor observed R14's room was in close proximity to R8, R50 and R70's rooms. On 9/27/23 at 11:33 AM, V2 DON said oxygen tanks should be in a holder when not in use, it should not be on the floor for safety reasons. 5. R91's face sheet showed the following diagnoses of acute respiratory disease, vascular dementia, anxiety disorder, abnormalities with gait and mobility and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R91's MDS dated [DATE] showed that R91's cognition is moderately impaired; R91 needs extensive assistance with two or more person physical assist with bed mobility, toilet use and personal hygiene; total dependence with two or more person physical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 8 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 assist with transfer. Level of Harm - Minimal harm or potential for actual harm R91's fall risk care plan (start date 1/21/23) showed that R91 is at risk for falls as a result of decreased endurance, increased weakness, and history of a stroke. A 1/30/23 intervention showed to provide a floor bed (mattress) to promote safety, a 1/23/23 intervention for bilateral bed bolsters, a 1/21/23 intervention to keep his bed in the lowest position with brakes locked, and a 1/22/23 intervention for bilateral floor mats. Residents Affected - Some On 9/27/23 at 9:29 AM, V14 (Restorative Aid) and V15 (CNA) were in R91's room repositioning them in bed. R91 was in a low air-loss mattress and no bolsters were present on the bed. While repositioning R91, V15 noticed R91's incontinence brief needed to be changed. V15 and V14 repositioned R91 on his right side (his stroke-affected side). V15 said there were no briefs by R91's bedside and V15 left the room to get clean briefs. V14 went to the bathroom to gather supplies for incontinence care. R91 was left alone in his bed lying on his right side, holding the partial side rail, and the bed was in a high position. R91 had sunk down into the air mattress and the air mattress was under pressure and higher behind him. R91's floor mattress was against the wall on the right side of the room. Surveyor alerted V14 (who was still in R91's bathroom) and notified her of the safety risk of leaving R91 unattended. V14 said R91 should not have been left unattended and staff should have been there or should have had interventions in place. On 9/27/23 at 3:49 PM, V2 DON said there should be two staff when care is provided for resident on low air-loss mattress for safety reasons because the pressure in the air mattress changes. V2 said the staff should not have left the resident alone, one staff should have stayed or if they had to leave, staff should have lowered the bed and had safety measures in place. 7. On 9/27/23 at 03:12 PM, R33 requested assistance from staff to be transferred from the bed to the wheelchair. V7 (CNA) and V8 (CNA) assisted R33. R33 was laying flat in bed and V7 raised the head of the bed to a sitting position. V8 began to pull her sideways and V7 guided her feet to the ground. R33 said she was dizzy. V8 pulled R33 up by the armpit and R33 stated I have no balance, no control. V7 and V8 did not apply a gait belt to R33 prior to assisting from a sitting to standing position. R33 began to lean on V8. V8 assisted R33 into the wheelchair by holding her under the right armpit and V7 moved the wheelchair closer and held R33 under her left armpit. V7 and V8 pivoted R33 to sit in the wheelchair, then V7 pulled R33 by her pants towards the back of her wheelchair to position her. On 9/27/23 at 03:33 PM, V8 said she should have used the gait belt. V8 said it helped make transferring the resident easier and assisted with balancing the resident. V8 also said it protected the resident from leaning or falling. At 03:35 PM, V7 said R33 told her she could pivot so she did not use the gait belt. V7 said she knew she should use the gait belt. On 9/27/23 at 04:35 PM, V2 (DON/Director of Nursing) said the staff should be using gait belts to transfer residents and should not be pulling the residents by their pants. R33's face sheet showed R33 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following stroke, difficulty in walking, lack of coordination, weakness, and chronic pain. R33's MDS (Minimum Data Set) dated 9/12/23 shows R33 was cognitively intact and required supervision for eating, and extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. R33's care plan dated 9/12/23 shows to provide assistive devices as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 9 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on observation, interview, and record review, the facility failed to supervise residents with aspiration precautions during meals, failed to implement fall interventions, failed to secure oxygen tanks in resident rooms, failed to safely position a resident during incontinence care, and failed to safely transfer residents. This applies to 12 of 12 residents (R2, R8, R14, R24, R33, R43, R50, R55, R70, R80, R91, and R99) reviewed for accidents and supervision in a sample of 32. The findings include: 1. The EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including dysphagia, protein-calorie malnutrition, multiple sclerosis, dementia, acute respiratory failure, and weakness. The MDS (Minimum Data Set) dated 7/19/2023 showed R2 was cognitively intact. The MDS continued to show R2 required supervision assistance of one person physical assistance with eating and extensive assistance of one to two person physical assistance for bed mobility and transfers from facility staff. R2's Physician Order Report dated 9/27/2023 showed an order dated 7/06/2023, for a general diet with pureed consistency and nectar-thickened liquids. The Physician Order Report continued to show an order dated 7/08/2023, for 1:1 feed following strict aspiration precautions. On 9/26/2023 at 12:19 PM, R2 was in bed sleeping. R2 had a plate of untouched pureed food and a cup with a straw and thickened liquid. On 9/26/2023 at 12:28 PM, V18 (Certified Nurse Assistant/CNA), entered R2's room and removed the plate of untouched pureed food. V18 said R2, did not eat a lot. V18 continued to say that R2 can eat by himself. On 9/27/2023 at 9:21 AM, R2 was in bed during lunch. No staff was present. R2 was holding a cup with a thickened liquid. R2 had a plate and a bowl of untouched pureed food. R2 said, I eat with my hands, I do it by myself. R2 was coughing. R2 had spilled thickened liquid on his gown and bed sheets. On 9/27/2023 at 9:41 AM, V17 (Licensed Practical Nurse/LPN), was preparing R2 medications. V17 said R2 received crushed medications to prevent choking and aspiration. V17 continued to say R2 feeds himself and will ask for help if needed. Additionally, R2's Fall Risk Observation dated 7/28/2023, showed R2 was a high risk for falls. R2's Event Report dated 7/26/2023, showed R2 had an unwitnessed fall from the bed without injury. R2's fall risk care plan dated 9/27/2023, showed multiple fall interventions dated 7/26/2023, including bilateral floor mats. On 9/26/2023 at 10:31 AM, R2 was in bed. R2 only had one floor mat, which was located underneath his bed. On 9/27/2023 at 9:21 AM, R2 was in bed. R2 continued to only have one floor mat, and it again was located underneath his bed. R2 said that he fell early during his stay at the facility. R2 said he was trying to turn in bed and rolled on his left side and fell. R2 said sometimes staff helps him turn in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 10 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/27/2023 at 3:47 PM, V2 (DON) said fall interventions should be in place for safety. V2 continued to say that floor mats are interventions to prevent residents from injury. 2. The EMR showed R55 was admitted to the facility on [DATE], with multiple diagnoses including dysphagia, heart failure, dementia, diabetes, repeat falls, osteoarthritis, and weakness. The MDS dated [DATE] showed R55 had moderate cognitive impairment. The MDS continued to show R55 required supervision assistance of one person physical assistance with eating and extensive assistance of one person physical assistance for transfers and toileting. R55's Physician Order Report dated 9/27/2023 showed an order dated 7/13/2023, for a NAS (no added salt) diet with a mechanical soft texture and thin liquids. R55's Speech Therapy Treatment Encounter Note dated 9/25/2023, showed R55 had aspiration precautions and required supervision during meals. On 9/26/2023 at 12:28 PM, R55 was in bed eating for lunch. No staff were present. R55 was sipping on a bowl of applesauce. R55 had a plate of untouched chopped food and an empty soup bowl. R55 had no drink. R55 had spilled noodles on his shirt. On 9/28/2023 at 11:10 AM, V22 (Speech Language Pathologist/SLP) said R55 was at risk for aspiration and required direct supervision with meals. V22 said that R55 required cueing with meals to take small bites, alternate between food and liquid, and finish swallowing food before putting more food in his mouth because he shoved food in his mouth. V22 said any resident with a history of aspiration or receiving an altered diet such as mechanical soft or pureed texture, or thickened liquids was at risk for aspiration. V22 continued to say that residents at risk for swallowing aspiration should be supervised directly by the staff if they are eating in their rooms, and if the staff was not available, the residents should be eating in the dining room. On 9/27/2023 at 3:44 PM, V2 (Director of Nursing/DON) said residents at risk for aspiration should be assisted by the nursing staff. V2 continued to say that residents receiving a dysphagia diet needed to be supervised during meals even if able to feed themselves. The facility's Swallowing Evaluation policy (not dated) showed Policy Specifications: .4. Appropriate information on safe swallow strategies for the resident is readily available to nursing and dining room staff . Additionally, R55's Fall Risk Observation dated 9/26/2023, showed R55 was a high risk for falls. R55's activities of daily living care plan dated 9/27/2023, showed R55 requires assistance from staff with transfers. R55's Physical Therapy Treatment Encounter Note dated 9/22/2023, showed R55 required partial to moderate assistance with toileting transfers. On 9/27/2023 at 10:17 AM, V13 (CNA) had a gait belt slung across her chest. V13 entered the room of R55 to assist him with toileting. V13 did not apply the gait belt on R55. V13 instructed R55 to stand from his wheelchair and hold on to the bathroom rail. V13 proceeded to hold the back of R55's shirt to help him stand. V13 then pulled down his pants. V13 continued to hold the back of R55's shirt while transferring him onto the toilet seat. After R55 was finished using the toilet, V13 held R55's left elbow and instructed him to hold on to the bathroom rail. When standing, R55 started to lose his balance and sat back onto the toilet seat. V13 then again held R55's left elbow and instructed him to hold on to the bathroom rail. V13 then pulled up his pants. V13 proceeded to hold the back of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 11 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 R55's pants to transfer him into the wheelchair. Level of Harm - Minimal harm or potential for actual harm On 9/28/2023 at 8:56 AM, V19 (Therapy Director) said R55's physical ability during transfers fluctuated if R55 was weak. V19 said R55 was at risk for falls because he had a history of falls. V19 continued to say that nursing staff should always use a gait belt when assisting R55 with transfers. Residents Affected - Some On 9/28/2023 at 9:27 AM, V2 (Director of Nursing/DON) said she expected nursing staff to use a gait belt when transferring residents for a smooth safe transfer. V2 said if a gait belt was not used during transfers, falls can occur. The facility's Gait Belt policy dated 02/2023, showed Purpose: A gait belt is a safety device made of cloth that buckles securely around a resident's waist. The device provides a secure grasping surface to aid during transfers and ambulation. Commonly used for those who require assistance during transfer . 3. The EMR showed R99 was admitted to the facility on [DATE], with multiple diagnoses including repeated falls, dementia, psychosis, anxiety, osteoarthritis, chronic obstructive pulmonary disease, and heart failure. The MDS dated [DATE] showed R99 had severe cognitive impairment. The MDS continued to show R99 required extensive assistance of two person physical assistance for bed mobility and transfers from facility staff. R99's Fall Risk Observation dated 7/16/2023, showed R99 was a high risk for falls. R99's Event Report dated 8/04/2023, showed R99 had an unwitnessed fall from his reclining geriatric wheelchair in the dining room. R99 sustained skin tears to his right cheek and right arm. R99's fall risk care plan showed multiple fall interventions dated 8/07/2023, including to apply a Dycem (non-slip material) device to his reclining geriatric wheelchair. On 9/26/2023 at 11:02 AM, R99 was sitting in his reclining geriatric wheelchair in the dining room. R99 was sliding down from his chair and no longer positioned in a sitting position. On 9/27/2023 at 4:14 PM, R99 was sitting in his reclining geriatric wheelchair in the dining room. V21 (Registered Nurse/RN) said R99 had a history of falls. V21 said R99 did not have a Dycem (non-slip material) device placed on his reclining geriatric wheelchair at that time. On 9/28/2023 at 9:12 AM, R99 was sitting in his reclining geriatric wheelchair in the dining room. V13 (CNA) was sitting next to R99. V13 said R99 did not have a Dycem (non-slip material) device placed on his reclining geriatric wheelchair at that time. On 9/28/2023 at 9:27 AM, V2 said R99's fall intervention was a Dycem (non-slip material) device to prevent him from falling from his reclining geriatric wheelchair again. V2 said she expected nursing staff to check the residents' care cards for fall interventions. V2 continued to say if fall interventions were not followed, another fall could occur. The facility's Falls Clinical Protocol policy dated 2005, showed Treatment Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 12 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 (at ordered routes or per the schedule). Residents Affected - Some There were 29 opportunities with 7 errors resulting in a 24.1% error rate. This applies to 4 of 4 residents (R51, R24, R43, R16) observed in the medication pass. The findings include: 1. On 9/27/23 at 08:34 AM during medication pass, V12 (RN/Registered Nurse) was preparing and administering medications for R51. V12 took R51's Aspirin 81 mg (Milligram) chewable tablet and put it in the medication cup, along with R51's other medication. At 08:48 AM, V12 gave R51 her medications and R51 swallowed her medication. R51 did not chew her chewable aspirin. R51's face sheet shows R51 was admitted to the facility with diagnoses including aphasia following stroke, thrombocytopenia, intracerebral hemorrhage, atherosclerosis, stent, and history of transient ischemic attack. R51's POS (Physician Order Sheet) shows an order dated 7/27/23 for aspirin tablet, chewable, 81 mg. 2. On 9/27/23 at 08:54 AM during medication pass, V12 was preparing and administering medications for R24. V12 took R24's Aspirin 81 mg chewable tablet and put it in the medication cup, along with R24's other medication. At 09:03 AM, V12 handed R24 all her medications and R24 swallowed her medication. R24 did not chew her chewable aspirin. R24's face sheet shows R24 was admitted to the facility with diagnoses including diastolic heart failure, hypertension, atrial fibrillation, and hyperlipidemia. R24's POS shows an order dated 3/17/23 for aspirin tablet, chewable, 81 mg. On 9/28/23 at 08:45 AM, V12 said if a medication is ordered as a chewable, it should be chewed. V12 said the chewable medication should be given separately. 3. On 9/27/23 at 09:07 AM during medication pass, V12 was preparing and administering medications for R43. V12 administered oral medications for R43. V12 did not administer Brimonidine eye drops or Polymyxin B Sulfate-Trimethoprim eye drops to R43, which were both due at 9 AM. On 9/27/23 during record review, R43's MAR (Medication Administration Record) showed R43's eye drops were signed off as administered. On 09/28/23 at 08:41 AM, V12 said she did not administer the eye drops for R43 on 09/27/23. V12 said she worked with R43 previously and had not administered eye drops. R43's face sheet shows R43 was admitted to the facility with diagnoses including Sjogren syndrome, osteoporosis, prosthetic heart valve, hyperlipidemia, and gastro-esophageal reflux disease. R43's POS shows an order dated 7/14/23 for Brimonidine drops 0.2% 1 drop to both eyes at 9 AM. The POS also shows an order dated 9/25/23 for polymyxin B sulf-trimethoprim drops 10,000 units 1 drop in each eye at 9 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 13 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On 9/27/23 at 09:17 AM during medication pass, V11 (LPN/Licensed Practical Nurse) was preparing and administering medications for R16. V11 administered several oral medications for R16. V11 did not administer Lasix 40 mg, Famotidine 20 mg, and Diclofenac gel, which were due at 9 AM. On 9/27/23 during record review, R16's MAR showed R16's Lasix 40 mg, Famotidine 20 mg, and Diclofenac gel were signed off as administered. On 9/28/23 at 09:10 AM, V11 said she did not administer medications to R16 after being observed for medication pass. V11 said she did not administer the Lasix 40 mg and Diclofenac gel, and was unable to remember if she administered the Famotidine 20 mg. V11 said all medications should be administered when ordered. V11 also said if she did not administer a medication, she should look for the medication and call the doctor to notify if unavailable. R16's face sheet shows R16 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, hemiplegia, difficulty in walking, pain in left knee, hypertension, and gastro-esophageal reflux disease. R16's POS shows an order dated 4/1/22 for Lasix 40 mg at 9 AM, Famotidine 20 mg at 9 AM, and Diclofenac sodium gel 1% at 9 AM. On 9/29/23 at 09:22 AM, V24 (Pharmacist) said if the medications are on the eMAR (Electronic Medication Administration Record), the nurses should be administering the medication. V24 also said if the staff are not administering the medication, a prescriber needs to be consulted and the nurses should be documenting in the eMAR. V24 said the staff should not sign off on medications if they have not administered the medication. V24 said if a resident misses a dose of Lasix, they could have elevated blood pressure or swelling. V24 said if a resident misses a dose of Famotidine, they could have heartburn. V24 said if a resident misses a dose of Diclofenac gel, it could cause increased swelling or pain. V24 said Brimonidine eye drops are used for ocular pressure, so missing a dose could cause an increase in ocular pressure, and the polymyxin B sulfate-trimethoprim drops were an antibiotic eye drop and not receiving it could prolong the healing of the eye infection. On 9/28/23 at 09:24 AM, V25 (ADON/Assistant Director of Nursing) said chewable medications should be placed in a separate cup and chewed. V25 also said scheduled medications should be given at the scheduled time, and the nurses should not be signing off the medications if they are not administering the medication. The facility's Administration Procedures for All Medications policy dated 10/25/14 showed To administer medications in a safe and effective manner. Review 5 Rights (3) times. Check MAR/TAR for order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 14 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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: label and date resident food, remove expired food items, complete temperature logs, and keep thermometers inside resident personal refrigerators. Residents Affected - Some This applies to 11 of 11 residents (R29, R34, R35, R41, R43, R50, R51, R52, R80, R110, R112) reviewed for personal room refrigerators. The findings include: On 9/26/23 at 10:00 AM, initial tour was conducted on the first floor. The following observations were made: 1. At 10:36 AM, inside R51's fridge there was a can of whipped cream and 1 package of pudding. There was no temperature log on her fridge. 2. At 10:41 AM, R110's refrigerator had the June temperature log sheet in a plastic sleeve in front of refrigerator. It was missing temperatures for June 4th, 17-23, 26, 27, and 30th. There was no current log sheet for September 2023. 3. At 10:52 AM, inside R80's fridge there were 2 hydrolyte thickened waters, 2 old donuts in a plastic bag that were not labeled or dated, and a package of chocolate candy. R80 stated he was unsure of when his fridge was last checked by staff. R80 did not know what the donuts in the plastic bag were and when they were put there. R80 did not have a temperature log sheet on his fridge. 4. At 10:57 AM, R43's fridge had no temperature log. 5. At 11:02 AM, R29's fridge contained an unknown food item wrapped in aluminum paper that was not labeled or dated. Inside the fridge, there was 1 package of shortbread cookies, 6 plastic bottles of water, a package of mini chocolate chip muffins, and 3 cartons of chocolate milk. R29 had no thermometer inside and there was no temperature log. 6. At 11:23 AM, inside R112's fridge there were 4 plastic containers of old Chinese food and a carton of rice. They were not dated or labeled. The fridge had not been closed all the way. There was no thermometer inside and there was no log sheet. 7. At 11:27 AM, inside R35's fridge there was one 1/2 pint carton of reduced fat milk. It was best by 7/24/23 (two months earlier). R35 only had the temperature log for April 2023, and it was missing dates for April 17-23, and 26-30. 8. At 11:29 AM, inside R34's refrigerator there were 2 yogurts. One was best by 11/20/22 and the other one was best by 8/28/23 (one month earlier). There was a 1/2 pint milk carton that expired 10/31/22 (almost a year ago). There was no thermometer inside. In the front of the refrigerator, there was a temperature log for June 2023. R34 stated she has never seen staff check her refrigerator. 9. At 2:00 PM, inside R52's refrigerator, there were 2 half-pint cartons of milk, 5 cans of root beer, and one bar of chocolate candy. There was no temperature log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 15 of 16 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 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chateau Nrsg & Rehab Center 7050 Madison Street Willowbrook, IL 60521 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 0813 Level of Harm - Minimal harm or potential for actual harm On 9/26/23 at 1:06 PM, V2 (DON-Director of Nursing) stated, Each resident has a Guardian Angel who is a manager. They are supposed to check the resident's refrigerators. Each fridge has to have a thermometer in it. They have to check the temperature and log it on the log sheet, which should be in the plastic sleeve in front of the refrigerator door. During the time, they check the refrigerators, they are also responsible for making sure the food items are labeled and dated, and if anything is expired, they have to remove it. Residents Affected - Some On 9/26/23 at 1:40 PM, surveyor asked V1 (Administrator) for the current and previous months refrigerator temperature log sheets for the resident refrigerators. V1 stated that he would have to check. On 9/26/23 at 1:45 PM, V1 came back and stated that he couldn't verify if the temperatures were taken prior and was unable to provide temperature log sheets for the past year. Facility's policy titled Use and Storage of Food Brought to Residents (November 2016) shows: 2. Unlabeled food items or those exceeding a manufacturer expiration date will be discarded. On 9/26/23 at 2:00 PM, V2 stated she did not have a policy on residents having thermometers in their refrigerators and that it is the residents' Guardian Angels task to check the thermometer and log it. 10. On 9/27/23 at 9:41 AM, R41 was observed with a personal refrigerator in her room without having a thermometer or temperature log and having six milk cartons expired (one carton expired on 8/21/23, two cartons expired on 9/18/23, and three cartons expired on 9/23/23). R41 is a [AGE] year-old female with mild cognitive impairment per Minimum Data Set (MDS) dated [DATE]. On 9/27/23 at 9:41 AM, V4 (Certified Nursing Assistant) stated that the fridge shouldn't have stored expired foods. 11. On 9/26/23 at 11:05 AM, the refrigerator in R50's room contained two cartons of fat free milk that expired on 9/5/23, one carton of two-percent milk that expired 6/12/22 (over a year ago), one carton of fat free milk that expired on 8/16/22 (over a year ago), and one carton of pomegranate-berry thickened water that expired on 4/5/23 (five months ago). The temperature log on the refrigerator was from April 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 16 of 16