Inspection·December 11, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1. V9 added that he was focusing on his work with his computer, and he neither saw the incident nor heard exactly the wording V4 was saying. On 12/10/24 at 10:30 AM, V10 (Unit Clerk/CNA) stated that on 11/20/24, she heard someone in the dining room call the 'F' word. V10 added that she could hear from her office, and the nurse told her that staff member V4 (CNA) was the one calling the 'F' word to R1. On 12/10/24 at 11:15 AM, V2 (Director of Nursing / DON) stated, I can't remember the date of the incident between V4 and R1. V4 was holding a tray in the dining room; R1 hit the tray, and the food fell on the floor. V4 said an explicit word, 'F word' out loud. I pulled V4 from the unit and sent her home immediately as she was disruptive to our unit. It was not explained to me as verbal Abuse and, hence, was not reported to the abuse coordinator on the same day. On 12/10/24 at 2:15 PM, V1 (Administrator/Abuse Coordinator) stated, A resident has the right to be free from verbal Abuse. On 11/20/24, ADON got a text message from V6 saying that V4(CNA) was cursing on the unit; the DON (V2) went to the unit and asked the CNA and interviewed persons who witnessed the incident. V2 determined that the CNA was not exhibiting good customer service and decided to send her home. V2 determined it was not an abuse. They told me V4 was cursing on the unit, and it was not reported to me that V4 was calling the 'F' word to R1 on 11/20/24. A review of the facility presented Abuse Prevention Policy (undated) document: This facility affirms the right of our residents to be free from Abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment .Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its abuse prevention policy by not reporting a verbal abuse allegation to state agency. This applies to 1 of 3 residents (R1) reviewed for abuse reporting in a sample of 3. The Findings include: R1 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis including vascular dementia. A review of the Minimum Data Set (MDS) dated [DATE] documents that R1 has severe cognitive impairment. On 12/10/24 at 10:10 AM, V5 (Registered Nurse / RN) stated, When I came back from vacation on 12/4/24, I heard from V6 (RN) and V7 (Licensed Practical Nurse / LPN) about the verbal Abuse from V4 to R1. R1 is very confused, and I heard V4 called R1 something with the 'f_ _ k' word. On 12/10/24 at 10:15 AM, V7 stated, On 11/20/24 during lunchtime, I was sitting in the nurse's station and could see R1 in the dining room. V4 took R1's tray away, and R1 raised her hand and hit the tray, causing the coffee cup to fall off the tray along with other food items. V4 put the tray on the table, got in the face of R1, and told her loudly, 'If you do this again, I will f_ _k you up.' V4 literally got down and said it on R1's face. I was not her nurse; V6 was the nurse. V6 was next to me with her medication cart. On 11/20/24, V6 notified V3 (Assistant Director of Nursing) about the verbal abuse, and V2 (Director of Nursing) came to me and asked me what happened. I explained to her that V4 was verbally abusive to R1. On 12/10/24 at 11:00 AM, V6 (Registered Nurse/RN) stated, The CNA (V4) called R1 something with the 'F' word. V4 said to R1, 'If you put your hand on me, I am going to f_ _ k you up.' I did report to ADON (V3) in detail via text. I texted her on 11/20/24 at 12:40 PM and still have the text on my phone. I believe V2 talked to V7 after I reported the abuse to V3. V2 didn't ask anything to me. V4 was sent home before her shift ended, but she came back the next day. On 12/10/24 at 11:35 AM, V3 stated that she was told/texted that V6 thinks V4 was loud to R1, and V6 never mentioned to V3 that V4 called R1 with an 'F' word. V3 continued that she reported the incident to V2, and V2 sent V4 home before V4's shift ended as V4 was disruptive to the unit residents. On 12/10/24 at 11:15 AM, V2 (Director of Nursing / DON) stated, I can't remember the date of the incident between V4 and R1. V4 was holding a tray in the dining room; R1 hit the tray, and the food fell on the floor. V4 said an explicit word, 'F' word' out load. I pulled V4 from the unit and sent her home immediately as she was disruptive to our unit. It was not explained to me as verbal abuse and, hence, was not reported to the abuse coordinator on the same day. A couple of days later, V1 (Administrator) asked me about the incident, as he had heard from others, and I explained it to him. On 12/10/24 at 2:15 PM, V1 (Administrator/Abuse Coordinator) stated, On 11/20/24, ADON got a text message from V6 saying that V4(CNA) was cursing on the unit; the DON (V2) went to the unit and asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145614 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm the CNA and interviewed persons who witnessed the incident. V2 determined that the CNA was not exhibiting good customer service and decided to send her home. V2 determined it was not an abuse. V1 stated that the staff told him that V4 was cursing on the unit. According to V1 staff did not report that V4 was calling R1 the F word. V1 stated the incident of 11/20/24 was not reported. V1 also stated that all abuse allegations should be reported within 24 hours to the state agency. Residents Affected - Few On 12/10/24 at 10:13 AM, R1 stated in the presence of V5 (Registered Nurse / RN), It's been a while since someone called me with the 'F' word. But I don't know who or when. A review of the last six months reportable indicates that the abuse allegation from V4 to R1 that happened on 11/20/24 was not reported to the state agency. A review of the facility presented Abuse Prevention Policy (undated) document: Employees, without fear of retaliation, may also independently report to state survey agency any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property, and to local law enforcement or state agency if they have suspicion that a crime was committed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145614 If continuation sheet Page 4 of 4