Health inspection·March 27, 2024

F 0600 Level of Harm - Actual harm Residents Affected - Few sure the soap was all gone. R55 added that he made her feel uncomfortable. On 12/12/2023, V1 interviewed V8 who admitted to patting R55 on her bottom, did not consider it inappropriate because R55 wears a sanitary napkin inside her pull up and he pats the area to make sure everything is in its place. V8 denied calling R55 a fat ass but said that he groaned after transferring resident from bed to wheelchair, R55 asked him why he groaned, and he said to resident, your weight is 1/2 of mine, so you are not a light weight, your weight is heavy. V8 denied telling resident that he was going to kiss her or making any kissing noises. On 3/19/2024 at 11:10AM, R55 was observed in her room, awake, alert and oriented and stated that she is doing okay. Surveyor asked the resident about the incident that happened with a staff in December of 2023. R55 said, you mean the guy? Surveyor said, yes. R55 said that this staff will pat her on her bottom after changing her incontinence brief, and she does not think that he should be doing that. Surveyor asked resident how that made her feel. R55 said, it makes her angry, it is not appropriate for him to be doing that. R55 also said, The staff member identified as V8 called her a 'fat ass' and that was wrong of him, no one should be addressed like that. R55 reported the incident to a nurse because it makes her feel uncomfortable. R55 added, she has not seen the staff recently, she thinks he got another job, she has not had any issues with any other residents or staff. On 03/20/24 12:04 PM, V1 (Administrator) said that she investigated the abuse allegation for R55, resident is alert and oriented X3 and has never made any abuse allegation towards any staff or resident. V1 interviewed the resident who told her that staff (V8) called her a fat ass, pats her on her bottom after changing her incontinence brief and touched her breast during showering. V8 was suspended during the investigation, and he did not return to the facility because he was terminated. V1 said that she did not substantiate abuse because the staff (V8) was able to explain the patting on resident's bottom, it is not the appropriate thing to do because it could be interpreted as uncomfortable for the resident, staff are not supposed to make residents uncomfortable. V1 said that she did not consider this abuse, but staff was terminated due to customer service, he could have used better judgement when providing care, and she felt it was better to part ways. On 03/20/24 02:10PM, V4 (Executive Director) said, residents are screened for abuse risk upon admission and every 6 months. Those at risk will be identified and referred to nursing and social worker for follow-up. Those identified at risk will have a care plan, at risk residents are those with psych issues, aggressive behavior, history of abuse and substance abuse. Dependent residents may potentially be at risk for abuse, but they don't have an abuse care plan. If there is an allegation of abuse and it is not substantiated, the resident will not have a care plan because no abuse occurred. The Administrator investigates all abuse and does a good job, if she said abuse did not occur, then there is no abuse. On 03/20/24 02:38 PM, V30 (LPN) said, she is familiar with R55, has worked with her since she was admitted , she was the nurse that the resident reported the abuse to. She came to work on second shift and the resident told her that she wanted to speak to her. R55 said that it was private and asked her to close the door. R55 said to V30, He was here today and helped another staff get me up. V30 asked resident who is he and she mentioned V8 and said that V8 called her a fat ass. V30 immediately called V1 who happened to be on grounds, she came up to the floor and spoke to the resident. V30 stated that she reported the incident immediately to V1 because she considers it abuse. Abuse policy revised /7/2018 states in part that the facility affirms that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to community staff, other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 2 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0600 Level of Harm - Actual harm Residents Affected - Few residents, consultants, contractor, etc. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Under prevention of abuse, neglect and exploitation, the policy states 1. Assess, monitor, and develop appropriate plan of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with history of aggressive behavior, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. Facility's policy titled, Abuse, Neglect and Exploitation dated 03-07-2018 documented in part but not limited to the following: Policy: (Name of Ministries) affirms that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but it not limited to: freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to: community staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Purpose: To ensure that a comprehensive program exists in all aspects of community operations involving the prevention, identification, reporting, and investigation of abuse. Prevention of Abuse, Neglect and Exploitation 1. The community will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: k. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. l. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care and/or are totally dependent on staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 3 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 report an allegation of rough handling/mistreatment made by one resident (R38) regarding an employee (CNA/V6); failed to prevent further instances of rough handling/mistreatment initially reported to V9/RN on 2/6/24 who failed to recognize the alleged abuse, failed to report the alleged abuse; and failed to immediately remove alleged abuser from further contact with the resident. This failure affected one resident (R38) of 6 residents reviewed for abuse in the sample of 69. This failure resulted in R38 to experience severe pain to her left shoulder as a result of V6's rough treatment and continues to express feelings of pain, fear, anguish, and intimidation when V6 returns to roughly handle the resident even after repeated requests to be gentle in providing care. Findings include: R38 is an alert and oriented [AGE] year-old resident with diagnoses including chronic diastolic congestive heart failure, osteoarthritis, scoliosis, and spondylosis with radiculopathy. Care Plan dated 2/9/24 reads in part, The resident has limited physical mobility related to disease Process (arthritis, pain, and chronic wounds.) The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions: Invite The resident to activity programs that encourage arm movement or gentle arm exercises as tolerated. Monitor/document/report any signs/symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Provide gentle range of motion as tolerated with daily care. There were no care plans related to R38's susceptibility to abuse and/or preventing abuse. On 03/18/24 at 11:55 AM, R38 stated that on 2/6/24 during care, V6/CNA was very rough with her, ignored her requests to be slow and gentle in moving her arm as it was painful if done too quickly. V6 ignored her requests to not be handled roughly and snapped back at the resident saying to her that she'd been a CNA for 11 years, knows what she is doing, and doesn't need to be told what to do. Resident indicated her shoulder was hurt due to V6's careless actions and caused her extreme pain after the incident of 2/6/24 so she informed V9 (RN) about what had happened to her between V6 and to call her doctor for x-rays. V9 called the doctor who ordered x-rays and pain medication but failed to alert the doctor or immediate supervisor about the incident. R38 indicated that she reported to V9 RN about V6 always wearing and talking on an earpiece and does not pay attention to her but is more focused on her phone calls. Resident said she is afraid if she complained further that they will get another rotating aide that does not know what they are doing and does not want to get on this cycle of aides that she has to orient to her particular care needs, so she tolerates V6 who continues to be rough to cause further pain during care. R28 said that this CNA V6 has been assigned to her numerous times after the 2/6/24 incident even after she reported it to the nurse (V9). R38 indicated she was also concerned about others who can't speak up like the residents on the second floor who she knows V6 floats to. On 3/19/24 at 2:45 PM, V9 (RN) stated, I know (R38), and she is mostly on her bed. She is alert times 4 (cognitively intact with no confusion). Surveyor asked if he recalled R38 complaining about arm/shoulder pain, V9 stated, She complained her shoulder was hurt by V6 CNA because she was rough with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 4 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 her. Surveyor asked to recall the incident of 2/6/24, V9 stated, I recall her shoulder was in a lot of pain, so I asked what happened and she told me that the CNA was rough with her arm and hurt her shoulder. I then asked if she wanted any pain medication, so I called the doctor who ordered x-ray and told him that the resident was in extreme pain. Surveyor asked what he did when R38 told him that V6 was rough and hurt the resident's shoulder, V9 stated, I asked the resident first what happened, if V6 was rough and how it happened whether it was when she was turned in bed or whatever and she said it was during a bed bath I think is what she said. I also talked to (V6) about what happened, and she didn't say anything that the resident was in pain, I just remember that I documented that the CNA told me to see her because she claimed the resident was in pain. Surveyor asked if he informed anyone else about the incident, V9 stated, I can't recall but I think I told V2 (DON), but I did not document that in the notes, just that I called the doctor. Surveyor asked if an incident such as what R38 described and what steps or procedures he should do? V9 stated that if a resident had a problem with a CNA assigned to them, they would just swap out that CNA with another one the resident liked. Surveyor asked if this was what he did in this situation that occurred on 2/6/24, V9 stated, No I didn't do that. Surveyor asked if he perceived this rough handling by V6 as potential abuse, V9 stated, I didn't think that at the time but if the resident told me V6 hurt her, then I guess it was. Surveyor asked when he received any abuse training, V9 indicated that he had a refresher this month. Surveyor asked what the facility's procedures were of any suspected or reported abuse, V9 stated, We do an abuse assessment on the resident and report what happened to the DON. We are to report any abuse incident, assess and interview the resident and report it but I missed the reporting part of it, I'm sorry. Surveyor clarified if V6 finished her shift taking care of R38 or if he reassigned V6, V9 stated, No sir, she finished her shift with R38. After the interview with V9 (RN), Surveyor showed V9 the progress notes he entered pertaining to the incident and to confirm whether he wrote the entry, V9 stated, Yes I wrote that. V9's nursing notes read in part, 2/7/2024 at 21:45 Health Status Note. Note Text: Late entry: Around 4PM yesterday, CNA called NOD (nurse on duty) to report that resident is in pain. Checked resident, noted facial grimace and was holding her shoulder, reporting of pain. When asked what happened, she said that CNA lifted her shoulder when asked to adjust her blouse on the back. Resident requested to have her shoulder massaged, provided relief. Resident informed both NOD and CNA that her both shoulders has limited ROM, especially the left one. Offered pain pill, resident declined. CNA kept resident comfortable. At bedtime, checked resident, she reported that pain is tolerable but still there. She added that she will inform MD about in on Thursday. Surveyor asked if there was anywhere in the documentation, he wrote informing either the DON or any supervisor of the incident involving V6 and the resident R38, V9 stated, No sir. I did not do that, so I didn't put that in there. On 3/19/24 at 2:55 PM, V6/CNA stated to surveyors during interview, I've worked here since September and applied for an open position. Surveyor asked if she used to work as an agency CNA prior to her hire, V6 stated No I haven't. V6's statement however did not align with her personnel file showing her previous position was an agency CNA. Surveyor asked about R38 and if she recalled the incident of 2/6/24 where the resident complained of shoulder pain, V6 stated, Yes I know (R38) and I remember her complaining about her shoulder, so I told the nurse, but I'm not frequent on her floor. I generally work the second floor. Surveyor asked the type of floor the second floor was, V6 stated, It's dementia mostly. Surveyor asked if there was anything she could recall of the incident of 2/6/24 other than the resident complaining of shoulder pain, V6 stated, (R38) is very particular about her care and she verbally tells me how she wants things all the time, she likes her phone to be near her. She's also particular about her sheets going up close to her neck when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 5 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 she's in bed, and she needs her gown changed and clean. Surveyor asked if these were unreasonable requests, V6 indicated they were not. Surveyor asked if she could recall during the incident of 2/6/24 if there was any discussion about slowing down or being gentle with her, V6 stated, I'm always gentle with my residents. Surveyor clarified that the question was if there was any discussion by the resident for her to be gentle when moving her arm or any other body part, V6 stated, Yes I think she mentioned something like that. Surveyor asked when she was told to slow down and be gentle what she did, V6 stated, I don't remember. Surveyor asked if she could recall if the nurse V9 asked her what happened, V6 stated, Yes he just asked me what happened, and I told him she was in pain. Surveyor asked if there was any argument on 2/6/24 with R38 or if the resident asked her not to be too rough with her in any manner, V6 stated, No I never argued with her and like I said she (R38) is very particular with how she wants things. Surveyor asked how long she'd been a CNA, V6 stated, I've been a CNA 11-12 years. Surveyor asked if she ever mentioned this fact to the resident, V6 stated, No, I don't have conversations with residents, I just do my job. Surveyor asked if there was anything out of the ordinary that may have occurred on 2/6/24 during her care of R38 or during anytime she'd been assigned to R38 V6 stated, No, she's not a difficult resident, she's just particular but (R38) has a way she talks to other people in a condescending manner. Surveyor asked how that made her feel, V6 stated, I just try to ignore it. Surveyor asked if she'd had any other issues with any other residents she'd care for, V6 paused and then stated, No but earlier this year one of the resident's family complained about my care so the administrator suspended me and when I got back the DON V2 gave me a 1:1 about general care and respecting patients. Surveyor asked if she knew what the specific complaint was that the family alleged, V6 stated, I don't know. Surveyor asked the rationale for her being provided 1:1 training about general care and respecting residents as she mentioned, V6 stated, I can't answer that. Surveyor asked if she'd been trained on the topic of abuse, V6 stated that she received one upon hire and she did an online training in the past November. On 3/19/24 at 3:35 PM, surveyors asked V2/ DON if she knew about the incident of 2/6/24, V2 stated, I don't recall V9 tell me anything about R38 or I do not recall it. I believe I was not in the building, but it may have been my previous assistant, but she no longer works here but I don't know who he spoke to. Surveyor asked if she knew about R38's shoulder/arm pain, V2 stated, I am not aware of anything about her shoulder. (R38) is very alert x 4 and she's able to make her needs known. She's particular and has particular preferences. There's certain staff she gravitates to and likes the normal CNA's or the regular CNA's and does not like any of the agency CNA's we had. She likes CNA's who are assigned to the unit that are the permanent on the unit because over time they have gotten to know her. Surveyor asked if these were reasonable requests, V2 indicated that they were. Surveyor asked about V6 and her work record with residents, V2 stated, I've never had any issues with (V6). Surveyor asked if V6 had any history with any other residents that resulted in any disciplinary action, V2 hesitated and stated, I've never had any issues with her except one time recently I think in January there was something about another resident and their care from V6, so we ended up putting her on administrative leave. Surveyor asked what the administrative leave was about, V2 stated, It was about some customer service issue some family had with V6. Surveyor clarified if that administrative leave was a suspension or personal leave, V2 stated, She was suspended. Surveyor asked what specific customer service issue V6 was suspended for, V2 stated, I think the family alleged that their mom was left cold and wet (urine) and wasn't given a blanket or something like that. Surveyor asked how leaving a resident wet and cold was a customer service issue, V2 stated, Well it was also a care issue. Surveyor asked what units V6 normally worked on, V2 stated that V6 worked all throughout the facility including the dementia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 6 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 unit. Surveyor asked if any of the residents on the dementia unit were interviewable or could voice any concerns to anyone, V2 stated, No most of them are confused. V2 paused and stated, Oh I see what you mean. I gave V6 in-service training, and she's been a CNA for a while, and I trust her. On 3/19/24. 2:00 PM. V13 (Director of Resident Services) stated, I'm responsible for the abuse in service training portion in our skills fair and we had our latest one in November. We try to capture all the staff for the campus in these skills fairs that touch on various subjects, one is abuse which I do. I make it a point during training that anything you hear or see, you have to report immediately to your immediate supervisor, who will then report it to V1(Administrator). I tell them about the 8 types of abuse, and anyone can report abuse including family, the resident themselves, and any staff. I tell staff that even idle gossip staff may hear about regarding residents being mistreated should be reported right away to their supervisor. I know we don't like to gossip but a lot of that gossip may include clues about some staff member that may be abusing a resident. Staff shouldn't determine themselves whether it's just a customer service issue because they should report it and let the supervisor and administrator determine this with their investigation whether it is actual abuse or just a service failure. Surveyor asked V13 a hypothetical question about if a CNA was being rough with a resident and that was reported to the nurse what the next step would be, V13 stated, They should immediately remove that person from the resident, and let their immediate supervisor know and also the administrator so they can investigate. It's not up to that individual to do this, they just need to separate the resident from that individual and report it right away. On 3/19/24 at 2:35 PM, V11 RN stated, I know R38 very well because she is on my unit and it's my permanent floor. Sometimes she said she likes mostly the morning people. Sometimes if she doesn't like somebody, I try to change CNA. She mostly complains about them talking on the phone when they're working with the resident, but they should not be talking on the phone. I talked to CNA's at once if they talk on the phone. Surveyor asked if she heard about the incident that occurred on 2/6/24 involving R38 and V6, V11 stated, I hear someone was rough with her (R38) but it's not on my shift. I hear that from the CNA amongst themselves too. The CNA's talk that somebody was rough with her and not nice with her. It was a few months ago, I think. I know for example who it was generally, and I try to figure out who, so I try to ask CNA's. Sometimes you know when she's not happy, so I tell V12/Administrative assistant not to schedule a particular CNA (V6). Surveyor asked if she informed the Administrator or DON about what she heard, V11 stated, I don't tell Administrator or anyone, just V12. If there's any problem with any CNA, I Usually I tell V12. Surveyor asked if V12 was her immediate supervisor who she reported problems to, V11 stated, No. Surveyor asked if she discovered who the CNA was, she heard about involved with R38's rough treatment, V11 stated, What I hear was about (V6). I hear that she (R38) doesn't like her because the resident told me herself that (V6) was always rough with her. She tells me V6 doesn't know too much what to do and how to care for her. I heard this again today, but I was busy. Surveyor asked V11 if she told anyone else other than V12, V11 stated, No I don't tell anybody, I'm sorry. On 3/19/24 at 11: 00 am V12, stated. I'm a scheduler for nurses and CNA's but my title is administrative assistant. I recall talking to R38 because I followed up with the resident because of (V6). I try to see residents twice a week but I remember that I followed up with her I think last month about V6 because the resident said that the CNA wasn't familiar with her routines so the resident herself walked through it with the CNA so she can follow the steps. She has a routine that she likes. Surveyor asked if the resident or any other residents complained about the CNA, V12 stated, I'm not sure. I come in at 7 AM and I usually go on the floor and make sure the CNAs are there and then I go in to say hello to most of the residents. I see (R38) because she likes to give me (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 7 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 feedback. The only thing she told me about V6 was that she wasn't aware of her routine and that was all she told me. Surveyor asked if R38 requested a different CNA, V12 stated, No but we try not to put (V6) with the resident and she works mostly the second floor or wherever we need her. On 3/20/24 at 11:45 AM, V1 (Administrator) and V2 (DON) presented information to survey team indicating that they had met with R38 last night to address the resident's concerns voiced on 2/6/24. This type-written response reads in part (V1) and (V2) met with (R38) at 6:35 PM on 3/19/24. V1 said to R38, I heard you need to report to me about someone hurting you. R38 went on to relay that V6 had given her a bed bath and after the bath she asked V6 to boost her up so she could pull her nightgown down in back. R38 reported that V6 wears earbuds a lot and was not sure how much she heard her. V6 proceeded to grab R38's left arm and pulled it to the side and R38 called out telling V6 she was in pain. R38 reported it to my nurse (V9) and waited until Thursday for V39 (attending physician) to come and examine the resident and then ordered an x-ray. The interview goes on to state that (V6) tends to have an unpleasant attitude with R38. The written report goes on to conclude that R38 stated that V6's actions were unintentional and received education regarding being fully engaged with residents during care with no external distractions such as cell phones and ear buds and to engage with residents verbally during care regardless of ability to reciprocate. This report fails to indicate any re-in-service education on abuse prevention. On 3/20/24 at 1:30 PM, surveyors re-interviewed R38 to verify the meeting the resident had with V1 and V2. R38 stated to surveyors that V1 Administrator and V2 DON came to see her abruptly after dinner when she was already in bed last night around 7 PM and asked her about V6. R38 indicated that V1 asked if V6 was rough with her, and she told her that she was. R38 stated, the Administrator did most of the talking and I felt pressured to say that the CNA's (V6) actions were not willful because she kept emphasizing and repeating the word willful and that V6's intentions were not willful. R38 indicated to surveyors that she didn't agree with this but in order to pacify administration, R38 stated that she gave in and agreed with them even though she felt V6 intentionally and repeatedly ignored her and was rough each time she came. R38 informed surveyors that she still felt pain in her arm and shoulders after the incident and also every time when V6 returned on numerous occasions. R38 added that yesterday (3/19/24) V6 was assigned to her but was abruptly removed from her assignment which she was relieved to find out. R38 indicated that prior to yesterday, V6 continued to ignore her and provided rough care which caused her more pain. R38 stated that she brought concerns to the administrator on numerous occasions about the quality of staff in general, but the administrator's response would be to pass the buck as a corporate issue. R38 stated that she felt even more vulnerable now with administration by complaining stating, When the Administrator came in the room, she had this look on her face that she was annoyed with me and that Oh it's her complaining again, but R38 didn't expect any real changes to come as she'd been dealing with the same issues for a while with no improvement. On 3/21/24 at 4:30 PM V39 (Attending Physician) stated to surveyors, (R38) is a very fragile patient and she has to be handled in a very delicate manner as she is brittle and has a complete rotator cuff tear and underlying severe arthritis that would worsen if it were exacerbated in any way. This was the reason I had ordered X-rays for that day when I got a call from a nurse telling me there was some incident that happened that caused the patient severe pain, so I suspected further injury to her shoulders. Surveyor asked if it was about the 2/6/24 incident, V39 stated, I don't know the exact date, I just know it happened a month ago. Surveyor asked if how he was informed of the incident involving his patient (R38) and V6, V39 stated, I found out from the resident that some staff person was careless and rough with her, but the nurse made no mention of any incident with R38's CNA being rough, it was the resident herself who informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 8 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 when I came to see her. Level of Harm - Minimal harm or potential for actual harm Facility policy dated, 3/7/2018 titled Abuse, Neglect, and Exploitation reads in part but not limited to, Facility affirms that each resident has the right to be free from abuse and neglect. Residents must not be subjected to abuse by anyone, including but not limited to community staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Abuse means the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. Prevention of Abuse: Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. Recognize signs of burnout, frustration and stress in associates that may lead to abuse. Provide education on what constitutes abuse, and neglect. React to all allegations or questions of abuse by residents, family members, associates or visitors. Take appropriate actions when abuse is suspected. Provide instructions to staff on care needs of residents. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, or ignoring residents while giving care. Identification of alleged abuse, neglect and exploitation: The community will consider factors indicating possible abuse, neglect following possible indicators: Resident, staff or family report of abuse, physical injury of a resident, Verbal abuse of a resident overheard. Physical abuse of a resident observed. Psychological abuse of a resident observed. Failure to provide care needs such as, bathing, dressing, turning and positioning. Response and reporting of abuse, neglect: Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect is suspected, the licensed nurse should: Respond to the needs of the resident and protect them from further incident and document response. Notify the director of nursing and executive director/administrator immediately and document notification. Initiate an investigation immediately. Notify attending physician, resident's family/legal representative and Medical Director and document notification. Prohibit and prevent retaliation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 9 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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** Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions to promote wound healing for one of three Residents (R18) reviewed for pressure ulcer and pressure ulcer interventions, in a total sample of 69 residents. Residents Affected - Few Findings include: R18 is a cognitively impaired [AGE] year-old resident with diagnoses listed in part, but not limited to, hemiplegia and hemiparesis, gastrostomy, heart failure, and a stage four pressure ulcer of the sacral region. A wound evaluation and management summary report dated 03/19/2024 showed R18 with a wound described as stage four with a duration greater than 1,049 days and measuring 3.0 x 1.8 x 0.3 cm. The facility pressure injury report dated 01/06/2024 states the wound was acquired, In House. Three skin observation tool forms found in R18's Electronic Health Record, dated 03/02/2024, 03/09/2024, and 03/16/2024 lack any describable wound documentation, such as wound site, type, measurement, and stage; instead containing the words, No new area, No new area noted, and no new skin issue noted. R18's nursing care plan dated 03/15/2024, R18 is to be turned and repositioned, as needed to aid in comfort and provide off-loading. R18's nursing care plan dated 03/15/2024, documents it is the staff's responsibility to keep R18's skin free of moisture. On 03/18/2024 at 10:09am, surveyor observed R18 lying in bed on her air mattress, asleep, her torso raised, and backside facing the wall. After over two hours of continuous observation, at 12:20pm, surveyor observed R18 laying on the air mattress with her backside facing the wall, torso raised, asleep, with no change in position. During continuous observation, surveyor observed R18 with perspiration on her face, and two blankets covering her body. On 3/19/2024 continuous observation from 10:05am to 12:20pm surveyor observed R18 asleep in bed, laying on air mattress, on her back with several blankets atop her body. V10 (CNA) said R18 is a total assist and V10 repositions her every two hours. V10 also said she provides clean sheets for R18 at the start of all her shifts, showers R18 once per week, and gives R18 a bed bath once per week, or as needed. On 03/19/24 at 11:50am V33 (Family Member) said, R18 needs round-the-clock nursing care, being bathed, brushed, and sanitary needs. V33 said R18 struggles in the past at the facility led to bed sores. V33 said bed sores were acquired at the facility five years ago and never closed and R18 uses an air mattress around-the-clock. On 03/20/24 11:45am, V1 (Administrator) said there was an MDS on file that said R18's chronic stage four pressure ulcer was originally a stage one pressure ulcer that R18 had upon arrival at the facility in 2013. V1 did not recall when R18's pressure ulcer changed from a stage one to a four, adding she would have to look through ten years' worth of documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 10 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 03/20/2024 at 1:40pm, V11 (RN) said she was performing afternoon wound care, along with V10, for R18, who was laying on her back on her air mattress bed. Surveyor asked to observe R18's wound. V11 and V10 proceeded to move R18 onto her left side to expose the stage four wound site of the sacral region, which was covered with a dressing. As V10 held R18 to the side, V11 took the dressing off, revealing a hole slightly smaller than a golf ball. When asked to describe the area, V11 hesitated and paused, saying it looked a little green. A few seconds later, fluid began to leak from R18's urinary catheter, running vertically down the left buttocks area, near the wound site. The area around R18's wound site was visibly moist. R18 had a linen sheet on top of her air mattress, folded over four times under her back. Surveyor also observed the air mattress pump on static mode. When asked V11 about the air mattress pump, V11 said she did not change the pump's settings at all, preferring to leave it as is. On 03/21/24 at 10:18am, V2 (Director of Nursing) said she was not sure if the wound nurse or the facility's environmental services sets the settings of the air mattress pump, adding the pump has a locking mechanism in place. On 03/21/2024 at 1:46pm, V38 (Medical Director) said R18's wound is not new and has been ongoing for a while. V38 said he discusses only newly acquired wounds with the facility, and that stage three wounds and above are discussed in detail. V38 said he does not usually discuss wounds with the wound doctor, unless it is his patient. V38 said repositioning, offloading, and turning every two hours are considered general principles for pressure wound care. On 03/21/2024 at 3:54pm, V29 (Wound Doctor) said he started seeing R18 in March of 2021 for the wound. V29 said repositioning every two hours, offloading, providing incontinence care, keeping the wound area clean, and following with daily dressing changes is the typical recommendation. V29 also said from his experience, individual repositioning was important to the healing process of pressure wounds, adding some of the aides at long term care facilities won't turn the individual, thinking that the air mattress is doing the turning and the mattress does it on its own. V29 said, standard air mattress bed preparation includes not utilizing fitted sheets, not placing too many pads and diapers, minimal would be advisable. Lastly, V29 said he described R18's stage four pressure wound as, unavoidable based on the lab results from R18's hospitalization in February instead of R18's long term care facility lab results January 11, 2024, which included a pre-albumin result of 23.8, within normal range. V29 said he was referring to what the hospital's admission lab results said to designate R18's wound, unavoidable. Surveyors clarified with V29 if the wound was avoidable or not, V29 affirmed that it was avoidable since R18 was able to heal other wounds. Facility policy with an effective date 06/01/2023, and titled, Management and Treatment of Pressure Ulcers-SNF reads in part, In order to heal any wound, including pressure ulcers, some basic principles need to be followed. These are: Protect the wound from infection, trauma, and cold. Protecting the wound from trauma includes the proper support surface. The air mattresses' owner's manual states in part, it is designed to assist in the prevention and treatment of pressure ulcers. The same manual also indicates there are two modes, alternate and static. Static mode turns off Alternating Pressure Therapy. Multiple layering of linens or under pads beneath the resident can negatively affect the mattresses' pressure management capabilities and should be avoided unless recommended by a caregiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 11 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain consent prior to administering a psychotropic medication to one resident (R42) of three residents reviewed for unnecessary medications in a sample of sixty-nine. Findings include: According to electronic medical records, R42 is an [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses that include but are not limited to: Alzheimer's disease, major depressive disorder, psychotic disorder with delusions, vascular dementia - unspecified severity- with agitation, generalized anxiety disorder and unspecified psychosis. Medication order dated 05/24/2022 Lorazepam 0.5 mg give one tablet by mouth three times a day related to psychotic disorder with delusions due to known physiological condition. Consent for this medication has an effective date of 11/04/2022 that was electronically signed by the nurse on 12/01/2022 and signed by resident's representative on 3/12/2024. Medication was initiated prior to having consent to give medication per medication administration record for June 2022. On 03/21/2024 at 10:16 am, V2 (DON) stated the consents she provided for R42 were all the consents she had on file for the resident regarding psychotropic medications. V2 stated, the policy states consent should be obtained prior to administration if not we would be out of practice. V2 stated, that some things that could happen to a resident if given a psychotropic medication prior to obtaining consent would be adverse reactions and mental status changes. On 03/21/2024 at 11:32 am V3 (Infection Preventionist/Psychotropic Nurse) stated, he took over the psychotropic medications about three months ago. He started doing an audit at that time and provided in-service education to staff regarding psychotropic medications. V3 stated, facility should always obtain consent prior to giving psychotropic medications and he has not seen any instances in the facility where psychotropic medications were given before consent even after his audit. When presented with the preceding information, V3 stated that happened prior to him (V3) starting and he (V3) was unaware of the situation of the medication being given prior to consent being obtained. Psychotropic Medication Policy with an effective date of 09/01/2022. The policy states 2. All psychotropic medications prior to administration must have a signed consent completed by the resident and or representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 12 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review, the facility failed to ensure stock medications were labeled with open and expiration date, failed to ensure opened vaccine vial, nasal sprays, inhalers, and insulins were labeled with open and discard dates, and failed to store an inhaler with a pharmacy label. These failures affected six (R6, R7, R12, R25, R42, R50) residents reviewed for medication storage and labeling and have the potential to affect residents receiving medications from the second-floor east side medication cart and first-floor rosewood medication cart. On [DATE] at 1:00pm, Surveyor and V40 RN (Registered Nurse) inspected the second-floor medication cart for rooms 201 through 228. The following observations were made: V40 stated, Floor Stock meds should be labeled with open date and manufacturers expiration date. Surveyor asked V40 do you use the manufacturers expiration date if the medication has been opened. V40 stated, yes (referring to the manufactures stamped expiration date). R6, Ipratropium Bromide Nasal Solution, open date [DATE] no expiration date. V40 stated, I go by the manufacturers expiration date which is 12/25. R6 open Nasal Saline Bottle with no expiration date Opened Arnuity Ellipta 200 mcg (30 dose) inhaler with no expiration date and without the name of resident on inhaler. R42 opened vial of Genteal Tears mod liq drops no expiration date. R12 Lantus Solostar 100u/ml inj opened [DATE] expiration date [DATE]. V40 stated, I do not give that on my shift, that should not be on the cart. Surveyor asked V40 if medication has expired. V40 stated, yes it should not be on the cart. We put expired medication in a different place. R7 eye drops Brimonidine Tart 0.2% 5ml opened [DATE] expiration date [DATE]. Proheal Critical Care Liq protein 30 fl ounce opened [DATE], no expiration date. V40 stated, it is good until [DATE] (manufacturers date). Surveyor reviewed instructions on back of bottle which shows, discard within 60 days after opening. Medication Room Refrigerator: Tuberculin purified protein derivative, diluted aplisol opened [DATE] no expiration date. V40 stated, it should have an expiration date. On [DATE] at approximately 2:00pm surveyor and V2 (DON) reviewed 1st floor Rosewood 1 HCC medication cart for rooms 101-109. Surveyor asked V2 how medication stored on the med cart should be labeled. V2 stated, all meds should be labeled with open date and expiration date. Nurses are expected to put open date and expiration date on all meds. The following observations were made: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 13 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R25, Fluticasone Propionate 50mcg nasal spray opened. Bottle with date of [DATE]. Surveyor asked V2 does the date of [DATE] refer to open date or expiration date. V2 stated, I am not sure what the date means. R50 Fluticasone 50mcg nasal spray dated [DATE]. V2 stated, I am not sure if that is the open date or the expiration date. Proheal Critical Care Liq protein 30 fl ounce opened 2/28/ no year noted, no expiration date. V2 stated, it is good until [DATE] (manufacturers date). Surveyor reviewed instructions on back of bottle which shows, discard within 60 days after opening. V2 stated, nurses should put an open date and expiration date. Facility Policy Medication Labeling and Storage revised February 2023 Policy Interpretation and Implementation Medication Storage in part documents 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. d. expiration date, when applicable; e. resident's name; 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 14 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 administration failed to take appropriate action to ensure the safety of 2 (R38, R55) of 3 residents reviewed for abuse in the sample of 69. The facility administration failed to protect residents from harmful actions inflicted by staff, failed to conduct a thorough investigation of allegations of abuse, and failed to honor the requests of the resident(s) to remain safe and free from harm. This failure has the potential to affect all 69 residents currently residing in the facility. Residents Affected - Many Findings include: On 3/18/24 at 9:50 AM, V1 (administrator) presented survey team with a census roster showing 69 total residents. 1. R38 is an alert and oriented [AGE] year old resident with diagnoses including chronic diastolic congestive heart failure, osteoarthritis, scoliosis, and spondylosis with radiculopathy. On 3/18//2024 at 11:55 AM, R38 stated that on 2/6/24 V6/CNA, while giving her a bed bath, was very rough and caused her arm/shoulder pain and possible injury. R38 stated that V6 is usually talking on her earpiece and does not pay attention or focus on her but instead on her phone calls. The resident also asked V6 not to wear them but V6 ignores her repeatedly. R38 stated that she asked V6 to be gentle in moving her body and arms while conducting any care but V6 disregarded her requests with repeated responses of I've been a CNA for 11 years and I don't need you to tell me what to do. V6 continued pulling her clothes off over her shoulder in a rushed and rough manner as she screamed in pain during the process, yet V6 continued on. R38 stated she informed her nurse V9 (RN) about the incident after several days of experiencing extreme pain and expected the nurse to report it to her doctor and to administration, but she did not hear anything back from anyone. R38 was expecting that she would get some resolution to the conflict. R38 stated V6 was never removed from her care and continued to care for her numerous times after the incident and that this CNA continued to be careless and rough in her care. R38 stated that she saw herself as an advocate not only for herself, but for others who couldn't speak up for themselves. She worried that V6 acted in the same manner with other residents on the dementia unit where she knew V6 had worked. On 3/19/24 at 2:45 PM, V9 (RN) stated, I know (R38), and she is mostly in her bed. She is alert times 4 (cognitively intact with no confusion). She would complain about care especially if it's someone who doesn't know her routine, if her food is delivered late, she will complain, and if she does not get a bath from certain CNA's. Surveyor asked if the resident's requests seemed reasonable, V9 stated, Yes. Surveyor asked if he recalled R38 complaining about arm/shoulder pain, V9 stated, She complained about her shoulder and that a CNA was rough with her. It was V6 and she's on this floor now if you want to talk with her. Surveyor asked V9 to recall the incident, I recall her shoulder was in a lot of pain and so I asked her what happened, and she told me about it. I asked if she wanted any pain medication for that, so I called the doctor who ordered an x-ray. Surveyor asked what else he did when told of the incident with the CNA, V9 stated, I asked the resident first what happened, if it happened when the CNA turned her and I asked her which CNA and she told me V6, so I also talked to the CNA about what happened. Surveyor asked if he informed anyone else about the incident, V9 stated, I think I told V2 (DON), but I did not document that in the notes, just that I called the doctor. Surveyor asked if any incident like what R38 described what he was supposed to do? V9 stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 15 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many if a resident had a problem with a CNA assigned to them, they would just swap out that CNA with another one the resident liked. Surveyor asked when the last time he received abuse training, V9 indicated that he had a refresher this month. Surveyor asked what the facility's procedures were of any suspected or reported abuse, V9 stated, We do an abuse assessment on the resident and report what happened to the DON. We are to report any abuse incident, assess and interview the resident and report it. I missed the reporting part. Surveyor asked if he separated V6 from the resident and V9 stated, No. On 3/19/24 at 2:55 PM, V6/CNA stated to surveyors during interview, I've worked here since September and applied for an open position. Surveyor asked if she used to work as an agency CNA prior to her hire? V6 stated No I haven't. V6's statement however did not align with her personnel file showing her previous position was an agency CNA. Surveyor asked about R38 and if she recalled the incident of 2/6/24 where the resident complained of shoulder pain? V6 stated, Yes I know (R38) and I remember her complaining about her shoulder, so I told the nurse, but I'm not frequent on her floor. I generally work the second floor. Surveyor asked the type of floor the second floor was? V6 stated, It's dementia mostly. Surveyor asked if there was anything she could recall of the incident of 2/6/24 other than the resident complaining of shoulder pain? V6 stated, (R38) is very particular about her care and she verbally tells me how she wants things all the time, she likes her phone to be near her. She's also particular about her sheets going up close to her neck when she's in bed, and she needs her gown changed and clean. Surveyor asked if these were unreasonable requests, V6 indicated they were not. Surveyor asked if she could recall during the incident of 2/6/24 if there was any discussion about slowing down or being gentle with her? V6 stated, I'm always gentle with my residents. Surveyor clarified that the question was if there was any discussion by the resident for her to be gentle when moving her arm or any other body part, V6 stated, Yes I think she mentioned something like that. Surveyor asked when she was told to slow down and be gentle what she did, V6 stated, I don't remember. Surveyor asked if she could recall if the nurse V9 asked her what happened? V6 stated, Yes he just asked me what happened, and I told him she was in pain. Surveyor asked if there was any argument on 2/6/24 with R38 or if the resident asked her not to be too rough with her in any manner, V6 stated, No I never argued with her and like I said she (R38) is very particular with how she wants things. Surveyor asked how long she'd been a CNA, V6 stated, I've been a CNA 11-12 years. Surveyor asked if she ever mentioned this fact to the resident, V6 stated, No, I don't have conversations with residents, I just do my job. Surveyor asked if there was anything out of the ordinary that may have occurred on 2/6/24 during her care of R38 or during anytime she'd been assigned to R38? V6 stated, No, she's not a difficult resident, she's just particular but (R38) has a way she talks to other people in a condescending manner. Surveyor asked how that made her feel, V6 stated, I just try to ignore it. Surveyor asked if she'd had any other issues with any other residents she'd care for, V6 paused and then stated, No but earlier this year one of the resident's family complained about my care so the administrator suspended me and when I got back the DON V2 gave me a 1:1 about general care and respecting patients. Surveyor asked if she knew what the specific complaint was that the family alleged, V6 stated, I don't know. Surveyor asked the rationale for her being provided 1:1 training about general care and respecting residents as she mentioned, V6 stated, I can't answer that. Surveyor asked if she'd been trained on the topic of abuse, V6 stated that she received one upon hire and she did an online training in the past November. On 3/19/24 at 3:35 PM, surveyors asked V2/ DON if she knew about the incident of 2/6/24? V2 stated, I don't recall V9 telling me anything about R38 or I do not recall it. I believe I was not in the building and it may have been my previous assistant; but she no longer works here and I don't know who he spoke to. Surveyor asked if she knew about R38's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 16 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many shoulder/arm pain? V2 stated, I am not aware of anything about her shoulder. (R38) is very alert x 4 and she's able to make her needs known. She's particular and has particular preferences. There's certain staff she gravitates to and likes the normal CNA's or the regular CNA's and does not like any of the agency CNA's we had. She likes CNA's who are assigned to the unit that are the permanent on the unit because over time they have gotten to know her. Surveyor asked if these were reasonable requests, V2 indicated that they were. Surveyor asked about V6 and her work record with residents, V2 stated, I've never had any issues with (V6). Surveyor asked if V6 had any history with any other residents that resulted in any disciplinary action, V2 hesitated and stated, I've never had any issues with her except one time recently I think in January there was something about another resident and their care from V6, so we ended up putting her on administrative leave. Surveyor asked what the administrative leave was about, V2 stated, It was about some customer service issue some family had with V6. Surveyor clarified if that administrative leave was a suspension or personal leave, V2 stated, She was suspended. Surveyor asked what specific customer service issue V6 was suspended for, V2 stated, I think the family alleged that their mom was left cold and wet (urine) and wasn't given a blanket or something like that. Surveyor asked how leaving a resident wet and cold was a customer service issue, V2 stated, Well it was also a care issue. Surveyor asked what units V6 normally worked on, V2 stated that V6 worked all throughout the facility including the dementia unit. Surveyor asked if any of the residents on the dementia unit were interviewable or could voice any concerns to anyone, V2 stated, No most of them are confused. V2 paused and stated, Oh I see what you mean. I gave V6 in-service training, and she's been a CNA for a while, and I trust her. On 3/19/24. 2:00 PM. V13 (Director of Resident Services) stated, I'm responsible for the abuse in service training portion in our skills fair and we had our latest one in November. We try to capture all the staff for the campus in these skills fairs that touch on various subjects, one is abuse which I do. I make it a point during training that anything you hear or see, you have to report immediately to your immediate supervisor, who will then report it to V1(Administrator). I tell them about the 8 types of abuse, and anyone can report abuse including family, the resident themselves, and any staff. I tell staff that even idle gossip staff may hear about regarding residents being mistreated should be reported right away to their supervisor. I know we don't like to gossip but a lot of that gossip may include clues about some staff member that may be abusing a resident. Staff shouldn't determine themselves whether it's just a customer service issue because they should report it and let the supervisor and administrator determine this with their investigation whether it is actual abuse or just a service failure. Surveyor asked V13 a hypothetical question about if a CNA was being rough with a resident and that was reported to the nurse what the next step would be, V13 stated, They should immediately remove that person from the resident, and let their immediate supervisor know and also the administrator so they can investigate. It's not up to that individual to do this, they just need to separate the resident from that individual and report it right away. On 3/19/24 at 2:35 PM, V11 RN stated, I know R38 very well because she is on my unit and it's my permanent floor. Sometime she said she likes mostly the morning people. Sometimes she doesn't like somebody, I try to change CNAs. She mostly complains about them talking on the phone when they are working with the resident. They should not be talking on the phone. I talk to CNA at once if they talk on the phone. Sometimes I hear someone being rough with her (R38) but it's not on my shift. I hear that from the CNA amongst themselves. The CNA's talk that somebody was rough with her and not nice with her. It was a few months ago I think, I heard someone was not nice to her. I know for example who it was generally, and I try to figure out who, so I try to ask CNA's. Sometimes you know when she's not happy, so I tell V12/Administrative Assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 17 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not to schedule a particular CNA (V6). Surveyor asked if she informed the administrator or DON about what she heard, V11 stated, I don't tell administrator or anyone, just V12. If there's any problem with any CNA, I Usually I tell V12. That CNA I hear about is (V6). I hear that she (R38) doesn't like her because the resident told me herself. She tells me V6 doesn't know too much what to do, how to care for her. I heard this again today, but I was busy. Surveyor asked V11 if she told anyone else other than V12, V11 stated, No I don't tell anybody. I don't tell anybody. I'm sorry. V1 (Administrator) and V2 (DON) presented information to survey team indicating that they had met with R38 last night to address the resident's concerns voiced on 2/6/24. This type-written response reads in part (V1) and (V2) met with (R38) at 6:35 PM on 3/19/24. V1 said to R38, I heard you need to report to me about someone hurting you. R38 went on to relay that V6 had given her a bed bath and after the bath she asked V6 to boost her up so she could pull her nightgown down in back. R38 reported that V6 wears earbuds a lot and was not sure how much she heard her. V6 proceeded to grab R38's left arm and pulled it to the side and R38 called out telling V6 she was in pain. R38 reported it to my nurse (V9) and waited until Thursday for V39 (attending physician) to come and examine the resident and then ordered an x-ray. The interview goes on to state that (V6) tends to have an unpleasant attitude with R38. The written report goes on to conclude that R38 stated that she felt V6's actions were unintentional and (V9) received education regarding being fully engaged with residents during care with no external distractions such as cell phones and ear buds and to engage with residents verbally during care regardless of ability to reciprocate. This report fails to indicate any re-inservice education on abuse prevention. On 3/20/24 at 1:30 PM, surveyors re-interviewed R38 to verify the meeting the resident had with V1 and V2. R38 stated to surveyors that V1 Administrator and V2 DON came to see her abruptly after dinner when she was already in bed last night around 7 PM and asked her about V6. R38 indicated that V1 asked if V6 was rough with her, and she told her that she was. R38 stated, the Administrator did most of the talking and I felt pressured to say that the CNA's (V6) actions were not willful because she kept emphasizing and repeating the word willful and that V6's intentions were not willful. R38 indicated to surveyors that she didn't agree with this but in order to pacify administration, R38 stated that she gave in and agreed with them even though she felt V6 intentionally and repeatedly ignored her and was rough each time she came. R38 informed surveyors that she still felt pain in her arm and shoulders after the incident and also every time when V6 returned on numerous occasions. R38 added that yesterday (3/19/24) V6 was assigned to her but was abruptly removed from her assignment which she was relieved to find out. R38 indicated that prior to yesterday, V6 continued to ignore her and provided rough care which caused her more pain. R38 stated that she brought concerns to the administrator on numerous occasions about the quality of staff in general, but the administrator's response would be to pass the buck as a corporate issue. R38 stated that she felt even more vulnerable now with administration by complaining stating, When the administrator came in the room, she had this look on her face that she was annoyed with me and that Oh it's her complaining again, but R38 didn't expect any real changes to come as she'd been dealing with the same issues for a while with no improvement. On 3/21/24 at 4:30 PM V39 (Attending Physician) stated to surveyors, (R38) is a very fragile patient and she has to be handled in a very delicate manner as she is brittle and has a complete rotator cuff tear and underlying severe arthritis that would worsen if it is exacerbated in any way. This was the reason I had ordered X-rays for that day when I got a call from a nurse telling me there was some incident that happened that caused the patient severe pain, so I suspected further injury to her shoulders. Surveyor asked if it was about the 2/6/24 incident? V39 stated, I don't know the exact date, I just know it happened a month ago. Surveyor asked if how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 18 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many he was informed of the incident involving his patient (R38) and V6, V39 stated, I found out from the resident that some staff person was careless and rough with her, but the nurse made no mention of any incident with R38's CNA being rough, it was the resident herself who informed me when I came to see her. 2. R55 is a [AGE] year-old female who has resided at the facility since 6/1/2022 with past medical history including, but not limited to ataxia, age-related osteoporosis, thoracogenic scoliosis, thoracic region, overactive bladder, pain in right leg, pain in left hip. On 3/9/2024 at 11:10 AM, R55 was observed in her room, awake, alert and oriented and stated that she is doing okay. Surveyor asked the resident about the incident that happened with a staff in December of 2023, and she said, you mean the guy? Surveyor said yes and resident said that staff will pat her on her bottom after changing her incontinence brief, she does not think that he should be doing that. Surveyor asked resident how that makes her feel and she said it makes her angry, it is not appropriate for him to be doing that. R55 also said that the staff member identified as V8 (former aide) called her a fat ass and that was wrong of him, no one should be addressed like that. R55 reported the incident to a nurse because it makes her feel uncomfortable. R55 added that she has not seen the staff recently, she thinks he got another job, she has not had any issues with any other resident or staff. Minimum Data Set (MDS) assessment dated [DATE], section C (Cognitive) documented that R55 has a BIMs (Brief Interview for mental Status) score of 13, section GG (functional abilities and goals) of the same assessment indicated that R55 requires substantial/maximal assistance from staff for most activities of daily living (ADLS). Facility reported incident (initial) dated 12/11/2023 documented that R55 reported to her nurse and the administrator that a C.N.A made inappropriate comments to her and slapped her. She could not recall the exact times, but it was over the course of the last few months. The perpetrator put on administrative leave pending investigation. The final report documented that V1 (Administrator) interviewed R55 on 12/11/2023 and resident stated that V8 (C.N.A) hit her on her behind and called her a fat ass. Resident stated that the last time V8 hit her on the behind was last Thursday, he used to do it more often, it quit for a while and then started again. R55 added that when V8 called her a fat ass, she said to him, no I am not a fat ass. R55 also reported to V1 that one time she was coming out of the shower with V8, and he said, I was going to kiss you back there, and R55 said no, R55 added that V8 went on to make some kissing noises as they were walking down the hall. On 12/13/2023, V1 received an email from R55's sister indicating that she spoke to R55 last night and she reported that after drying her in the shower, V8 will touch her breast to make sure there was no soap left. V1 followed up with R55 the same day and she stated that while showering, V8 will put his bare hand under her armpit and under her breast to make sure the soap was all gone. R55 added that he made her feel uncomfortable. 03/20/24 12:04 PM, V1 (Administrator) said that she investigated the abuse allegation for R55, resident is alert and oriented X 3 and has never made any abuse allegation towards any staff or resident. V1 interviewed the resident who told her that staff (V8) called her a fat ass, pats her on her bottom after changing her incontinence brief and touched her breast during shower. V8 was suspended during the investigation, he did not return to the facility because he was terminated. V1 said that she did not substantiate abuse because the staff (V8) was able to explain the patting on resident's bottom, it is not the appropriate thing to do because it could be interpreted as uncomfortable for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 19 of 20 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete resident, staff are not supposed to make residents uncomfortable. V1 said that she did not consider this an abuse, staff was terminated due to customer service, he could have used a better judgement when providing care, and she felt it was better to part ways. 03/20/24 02:10 PM, V4 (Executive Director) said that residents are screened for abuse risk upon admission and every 6 months, those at risk will be identified and referred to nursing and social worker for follow-up. Those identified at risk will have a care plan, at risk residents are those with psych issue, aggressive behavior, history of abuse and substance abuse. Dependent residents may potentially be at risk for abuse, but they don't have an abuse care plan, if there is an allegation of abuse and it is not substantiated, the resident will not have a care plan because no abuse occurred. The administrator will determine whether any abuse is willful and investigates all abuse and does a good job, if she said abuse did not occur, then there is no abuse. Event ID: Facility ID: 145724 If continuation sheet Page 20 of 20